Modern medicine now sees continence as a highly complex interaction between the nervous system, the gastrointestinal tract, pelvic floor muscles, and emotion. The lower bowel must recognise when faeces is entering it and the pelvic floor must be able to keep the anus closed if defaecation is not convenient. When it is convenient to pass a bowel motion, the same muscles that are keeping the anus closed must be able to relax in a coordinated manner while the bowel above contracts to expel its contents.
In basic terms, faecal incontinence is the inability to control one’s bowel movements. Some patients have very minor soiling, usually presenting as a streak of faeces noted in their underwear after they are sure that they have cleaned themselves properly. At the other end of the spectrum, the problem may be so severe that the entire bowel contents can be evacuated involuntarily at once, causing great distress.
There are two main types of faecal incontinence. One is known as “urge” incontinence. Normally continent people get a feeling that they will need to defecate soon (known as a “call to stool”). In some people, rather than this just being a vague sensation, the feeling is of an extreme need to get to the toilet quickly. In a few of these people, their anal muscles are not strong enough to keep the anus squeezed tight, and if they do not get to the toilet in time, they will be incontinent of a variable amount of faeces. The other type is known as “passive” incontinence. This is where a patient will be incontinent of faeces without even realising they needed to go to the toilet, and faeces just presents itself in the underwear. Again, these are highly stressful experiences.
Faecal incontinence invariably ends up controlling the lives of those who suffer from it. Most people with faecal incontinence get to know where the toilets are on their daily route. They dare not catch a bus in case they are caught short, and frequently carry a change of clothes with them. Others avoid social activities so that they do not have to eat, because of the subsequent risk of needing to go to the toilet. People with severe bowel incontinence are likely to become completely housebound and have very poor quality of life.
This distressing condition is much more common than people might think. About six in every 100 women under the age of 40 years suffer from faecal incontinence. In older women, this figure rises to above 15%. Even more surprising is that 10% of men of any age suffer from some form of faecal incontinence. Certainly, the risk of faecal incontinence increases as people get older.
Faecal incontinence should be seen as a symptom rather than a condition in itself. There are many causes of faecal incontinence. Normally two or more causes are needed to overcome the normal continence mechanism. These causes can be divided into five main groups:
Group 1 – an abnormality of the anus or lower bowel arising from the trauma of child birth, surgical trauma, the presence of an anal fistula or abscess, or rectal prolapse
Group 2 – neurological conditions, including multiple sclerosis, spinal cord injury, stroke and spina bifida
Group 3 – constipation and overflow diarrhoea
Group 4 – memory and behavioural problems, such as dementia and learning difficulties
Group 5 – diarrhoea associated with inflammatory bowel disease and irritable bowel syndrome.
Some cases are classified as idiopathic, where no obvious cause can be found, but the person suffers considerably with the problem. There is hardly ever just one reason why someone suffers from faecal incontinence. It is the complex interplay between muscles, nerves, cognition, and the consistency of stools, so it is a case of “one size does not fit all”. Faecal incontinence is truly one symptom where the health professional has to be completely holistic and tailor treatment to the patient’s specific needs.
If you are suffering from faecal incontinence, you should see a colorectal surgeon who specialises in both pelvic floor conditions and faecal incontinence. An extensive history will be taken and an examination performed. This will include examining the abdomen initially. Your surgeon will examine the perineum, anus, rectum, and perhaps also the vagina. You will be asked to squeeze and relax your pelvic floor muscles to help your surgeon make an initial assessment.
An experienced surgeon will have a very good idea about the possible causes of your faecal incontinence from the examination alone. However, other investigations may be required. The staff conducting these investigations are highly professional, and most patients report that their tests were not as bad as they thought they were going to be.
The first investigation is an anal ultrasound scan. This involves a small probe being placed in the anus and an ultrasound image being created of the anal muscles. This will look for any damage to these muscles.
The second investigation is anorectal physiology, which looks at your sensation in the lower bowel and ability to squeeze the anal muscles. This is performed by inserting a small balloon into the anus.
The third investigation is a defecating proctogram where an X-ray medium is instilled into the rectum and the patient is required to pass a bowel motion behind an X-ray screen. Another way to do this is in the MRI scanner, this is known as a magnetic resonance proctogram. This investigation shows the structure of the pelvis in great detail, and surgeons find this useful to help work out what is going on and what therapies may help. Understandably, patients can find the prospect of this investigation rather daunting, but for those with severe faecal incontinence, any reluctance tends to disappear when people realise that this test may well identify a treatment that will work for them.
Conservative and medical
We have made great strides recently in the treatment of faecal incontinence, and most patients do not need surgery. For the vast majority, improving stool consistency with dietary or medical help is a good first step. Pelvic floor physiotherapy and biofeedback is very useful, but does not work overnight. It takes hard work and dedication on the part of both the patient and the physiotherapist to re-engage muscles that have been damaged and to encourage new neuromuscular pathways to develop and strengthen.
Some patients do extremely well with colonic and rectal irrigation. There are many good and convenient systems available, allowing patients to clear their lower bowels every day or every other day. Half of the patients prescribed this therapy do extremely well and say that it dramatically changes their lives for the better.
For those people who suffer from faecal incontinence associated with irritable bowel syndrome, extensive measures may need to be taken. These treatments include the FODMAP diet (www.ibsgroup.org/brochures/fodmap-intolerances.pdf), probiotics, or specific medications.
Percutaneous tibial nerve stimulation is an exciting new therapy that helps over half our patients with faecal incontinence. It is very simple and involves placing an acupuncture-type needle near the ankle for half an hour each week for 12 weeks. Top-up therapies can be offered thereafter.
Quality of life can be improved dramatically for most people using these non-surgical measures, and very few need to go on to have surgery.
A colorectal surgeon with a specialist interest in faecal continence will think of surgery as the last line of treatment. However, this does not mean that surgery is not successful. Research has shown that the classic idea of repairing a damaged anal sphincter muscle in a person with bowel incontinence is not effective in the long run. However, it is still an option, although rarely done.
If a rectal prolapse is contributing to faecal incontinence, then this should be repaired. There are a variety of ways to do this, but the gold standard is a ventral mesh rectopexy or similar operation.
Sacral nerve stimulation, also known as sacral neuromodulation, is a good treatment for faecal incontinence in the right situation. Once a prolapse has been dealt with and there is still damage to the pelvic floor, sacral nerve stimulation becomes even more useful. Sacral nerve stimulation involves the implantation of wires through the lower back near to the pelvic nerves. These wires are then connected to a pacemaker battery that is implanted in the abdominal wall. The battery itself needs to be replaced every 5–8 years, but if successful, sacral nerve stimulation returns the patient’s quality of life to a near normal level.
Anal bulking is another option, and works best when there is a defect in the internal anal muscles and passive faecal incontinence. This technique involves injection of synthetic material into the anal muscles.
For more information on Faecal Incontinence, please visit www.pelvicphysiotherapy.com