Faecal incontinence

Faecal incontinence refers to the inability of someone to control their own bowel motions. It varies from minor soiling such as staining the underwear with faeces despite having cleaned ones self after toileting to complete loss of control of bowel motions. Continence itself is a very complicated process involving together the bowel, the nervous system, the muscles of the pelvis and back passage and the person’s emotions. Normally once the bowel fills up the sensory mechanism will inform the brain and the relevant muscles to control the motion until it is convenient to open the bowels. At that time the brain starts the process and the bowel pushes the bowel motion in coordination with the muscles which relax and allow for the expulsion of stools. Any problem with any of these systems can lead to problems with continence.

Symptoms

Any degree of faecal incontinence can be very unpleasant and significantly affect a person’s quality of life. It can affect up to 1 in 20 women younger than 40 and up to 1 in 4 women over the age of 50, while it affects up to 1 in 10 of men of all ages. There are two main types of faecal incontinence, “urge” incontinence where there is a very urgent call to go to the toilet but people do not make it on time and “passive” incontinence where soiling just happens without people being aware of it happening.

There are many potential causes of faecal incontinence most times due to a combination of factors. These include:

1. an abnormality of the structures around the back passage caused by trauma from childbirth, previous surgery such as open haemorrhoidectomy, anal fistula, abscess, haemorrhoids, rectal prolapse or rectocele,
2. conditions affecting the nerves such as multiple sclerosis, stroke, spinal cord injury,
3. a loose bowel consistency/diarrhoea related to overflow from constipation or to a condition such as inflammatory bowel disease or irritable bowel and
4. conditions affecting the brain or behaviour such as dementia and learning difficulties
5. conditions affecting the capacity of the rectum such as post radiotherapy or due to inflammatory bowel disease

Diagnosis

A careful and extensive history will be taken and examination of the anus, rectum and sometimes the vagina will be required. Investigations will be directed towards excluding any other serious pathology depending on your symptoms and tests to confirm the diagnosis. These tests usually include anorectal physiology tests with endoanal ultrasound. A defecating proctogram, an x-ray or MRI of the lower part of the bowel while it expels a paste, may also be needed.

Treatment options

These will be directed by the cause of the symptoms. In most occasions dietary advice, with or without the use of some medication and/or persistent pelvic floor exercises with biofeedback should be able to improve your symptoms and quality of life. Regular colonic and rectal irrigation may also help a lot of people. In some occasions tibial nerve stimulation may be helpful in 50% of people.

Surgery is rarely required when all of the above measures have not managed to improve your symptoms. Surgical options include repair of a potential defect in the back passage muscle (sphincter) called sphincteroplasty, anal sphincter augmentation which involves the injection of a prosthetic material into the internal sphincter in people with passive incontinence, rectal prolapse repair and haemorrhoid treatment. A very small number of people may require sacral nerve stimulation, an artificial sphincter or a different type of sphincter repair with a muscle flap and these patients will be referred to the appropriate international centre. As a last resort some patients may need diversion of the bowel motions and formation of a stoma. The most appropriate treatment option will be discussed with you at the clinic at an individualised basis.