Stephanie Chambers, APRN, C.N.P., D.N.P.
Gastroenterology & Hepatology (Digestive Care)
Fecal incontinence: Does your underwear have more than a small brown streak?
Pelvic floor issues are much more common than you might think. Fecal incontinence affects 2% to 7% of the U.S. population, although this number may be much higher, as many people are reluctant to discuss this issue with their health care team.
For some people, including children, fecal incontinence is a minor problem, limited to the occasional soiling of their underwear. For others, the condition can be devastating due to a complete lack of bowel control.
Fecal incontinence is categorized in two ways.
- Minor incontinence
Involuntary loss of gas or liquid stool is considered minor incontinence.
- Major incontinence
The involuntary loss of solid stool is major incontinence.
Fecal incontinence can damage a person's self-confidence, leading to anxiety and social isolation. People with fecal incontinence should discuss their symptoms openly and honestly with their health care team. With treatment, symptoms can be lessened in most cases, and incontinence can often be cured entirely.
What are pelvic floor muscles?
Pelvic floor muscles are a group of muscles that make up the bottom of the pelvic region. The anal sphincters and pelvic muscles surround the end of the digestive tract. Together, these muscles and the puborectalis muscle ensure controlled movement of digestive tract contents.
The pelvic floor muscles play an important role in continence by supporting the pelvic organs, stabilizing the pelvis and participating in sexual activity. They are like any other muscle in the body. They can be weak, stretched out, strong or tight. Generally, pelvic floor weakness and tension lead to pelvic muscle dysfunction. Weakness is a common cause of incontinence, and tension often leads to pelvic pain.
The anal and rectal areas contain specialized muscles that regulate the proper passage of bowel movements. Normally, when stool enters the rectum, the anal sphincter muscle tightens to prevent the passage of stool at an inconvenient time. If this muscle is weak or does not contract in a timely way, incontinence occurs.
Fecal incontinence can be caused by:
- Damage to the anal sphincters
- Neurologic causes
- Fecal impaction
- Decreased distensibility of the rectum
- Idiopathic incontinence, which is when the cause cannot be identified
Tests to determine cause of incontinence
The underlying cause of fecal incontinence can often be established with a combination of medical history, physical examination and diagnostic tests.
A few types of tests can be performed to determine the root of the problem. Anorectal manometry, or anorectal motility test, is a common, noninvasive test. The safe, low-risk procedure evaluates patients with constipation or fecal incontinence. The test measures how strong the sphincter muscles in the rectal and anus are and whether they relax as they should while passing stool.
During the procedure, a gastroenterologist analyzes pressures of the anal sphincter muscles, sensation in the rectum, and neural reflexes associated with regular bowel movements. Patients do not need to be sedated during the test. They may experience slight discomfort but no pain as the tube is inserted.
After the tube is in place, the exposed end is attached to a machine that will record the pressure changes of muscle contractions and relaxation for 10–20 minutes.
Other diagnostic tests include colonoscopy, flexible sigmoidoscopy, anoscopy, ultrasound, MRI or stool tests.
Is treatment available for fecal incontinence?
Because fecal incontinence can be distressing, it is important to take steps to manage it. You should discuss potential treatment options with your health care team.
What you eat and drink affects the consistency of your stools. If constipation is causing fecal incontinence, you should drink plenty of fluids and eat fiber-rich foods.
If diarrhea contributes to the problem, high-fiber foods can add bulk to your stools and make them less watery. Fiber bulks the stool, making it softer and easier to pass regularly. It is recommended that adults consume 20–35 grams of fiber per day. Sources of fiber include fruits, vegetables and whole grains.
You can try an over-the-counter fiber powder product to help bulk stools. Examples include Citrucel, Metamucil and Benefiber. Pill forms of fiber also are available.
Consuming large amounts of fiber can cause abdominal bloating or gas. You can minimize this by starting with a small amount and slowly increasing until stools become softer and more frequent. Make sure you are drinking plenty of water when increasing your fiber intake. It is recommended adults drink eight 8-ounce glasses of water every day.
Depending on the cause of fecal incontinence, medications such as anti-diarrheal, bulk laxatives or injectable bulking agents can be used. If constipation does not respond to medications, or if constipation has been present for multiple years, the problem may be related to pelvic floor dysfunction.
Over-the-counter antidiarrheals reduce stool frequency. Loperamide (Imodium) also can increase the tightness of the anal sphincter muscles. It is important to let your health care team know if you are taking any over-the-counter antidiarrheals and to take the medication only as directed on the package.
If you are struggling with fecal incontinence, it is important to avoid foods and drinks that may cause loose or more frequent stool, which can worsen fecal incontinence. This may include dairy products, spicy foods, fatty or greasy foods, caffeinated beverages, diet foods or drinks, sugar-free gum or candy, and alcohol.
If you are experiencing significant rectal discomfort without being diagnosed with fissures or hemorrhoids, or if you experience more than a slight yellow leak of stool or a brown streak in your underwear, schedule a visit with your primary care provider or a gastroenterologist.
If muscle damage is causing fecal incontinence, your health care professional may recommend an exercise program and other therapies to restore muscle strength. Your clinician may refer you to a physical therapist specializing in pelvic floor dysfunction. Biofeedback uses anal manometry testing and special exercises of the pelvic floor muscles to strengthen the muscles and improve sensation.
Biofeedback is a technique that helps you focus on controlling your body's functions by receiving feedback from electrical sensors. Patients are taught how to strengthen pelvic floor muscles, sense when stool is ready to be released, and how to contract the muscles if having a bowel movement at a particular time is inconvenient.
It is important to take steps to manage your symptoms. Treatment can improve your quality of life and raise your self-esteem.
Stephanie Chambers is a nurse practitioner in Gastroenterology and Hepatology in Mankato, Minnesota.