Incontinence

What is Incontinence?

Incontinence of stool means the inability to control the passage of stool or gas. Some people have mild trouble controlling gas whereas others have severe loss of control of liquid and formed stools. Incontinence is a miserable problem that many people have trouble talking about. People are frequently embarrassed and afraid there is no help. However, treatment is available. Colorectal surgeons are specially trained physicians who care for this problem frequently.

How Common is Incontinence?

One study showed that over 2% of the population suffers from incontinence. More than 30% of nursing home patients are incontinent. It affects more women than men, and it becomes more common as people age and their sphincter muscles lose tone.

What Causes Incontinence?

Normal control of the passage of stool depends on many factors. A problem in any of the following areas can contribute to lack of control. One factor is the time it takes for stool to pass through the bowel. If stool moves through the bowel too quickly, a person may not have enough warning and may have an accident. This happens most commonly to people with irritable bowel syndrome or inflammation of the bowel (colitis). The consistency of the stool affects the ability to control its passage. Loose or watery stool is difficult for anyone to control. Anything that causes diarrhea, such as infection, inflammation, and food intolerance, can lead to incontinence.

There are a variety of benign anal conditions that frequently lead to mild forms of incontinence. Many patients with prolapsed internal hemorrhoids complain of fecal soiling.  The hemorrhoids can prevent complete closure of the anus and allow leakage of fecal matter onto the skin.  Patients with an anal fistula can have drainage that is often interpreted by the patient as incontinence.  Both of these conditions can be remedied with proper treatment.

Normally the rectum will stretch to hold stool or gas entering it, giving the person time to make it to the bathroom. If the rectum is full of stool or an abnormal growth, it may not be able to expand further to hold additional stool. If this happens, loose stool may leak out. To prevent leakage one must be able to tell that stool or gas is present in the rectum. People with neurologic problems, such as a stroke, may not have normal sensation in the rectum. They will not be able to sense that gas or stool has come into the rectum and therefore have no warning to go to the bathroom.

The sphincter muscle, a circle of muscle around the anus (rectal opening), keeps the anus closed. It needs to function properly in several ways for adequate control. It needs to hold the anus closed at rest and squeeze to tighten the anus when stool or gas enter the rectum. As people age, the muscle gradually loses strength. The sphincter muscle can also be injured during a childbirth or during a rectal operation. If the injury is recognized and repaired, the muscle usually heals properly. If it does not, there may be a gap in the circle of muscle so it is unable to close off the anus. For some people this gap is small and only becomes a problem when the muscle weakens with age.

Two nerves stimulate the sphincter muscle. If the nerves are injured, the sphincter muscle may become weak. The nerves may be injured through stretching during pregnancy or childbirth or from excessive straining to move one's bowels. Rectal prolapse, tissue that repeatedly comes out through the anus, can also stretch or injure the nerve. In these situations, the muscle is intact but it does not work properly, resulting in incontinence.

What Tests are Available?

First, the doctor will ask questions about the patient's symptoms, bowel habits, and other medical problems. The patient will then be examined with particular attention paid to the sphincter muscle, rectum, and lower colon. The doctor may know the cause of the incontinence at that point. If not, the patient may need to have some additional tests. During one test (manometry), a catheter is placed into the anus to record pressures as patients tighten and relax the sphincter muscle. Another test may also be done to test for proper nerve function. An ultrasound probe inserted into the anus can provide a picture of the muscles, which would show any area of injury. The patient may need an x-ray to check for rectal prolapse.

How is Incontinence Treated?

If possible, the underlying problem is corrected. If a medical illness, such as inflammation of the bowel, infection, or irritable bowel syndrome, is causing the incontinence, medication may be prescribed. Diarrhea and constipation are treated with dietary changes, usually emphasizing a high-fiber diet. If incontinence continues despite these changes, the treatment depends on the cause. Incontinence caused by an injury to the sphincter muscles may require surgery. The muscles and nerves will be tested before surgery to help predict the results of surgery. If the muscle is intact but functions poorly, dietary changes may help. Biofeedback* or sphincter training may also be recommended. This program teaches people to consciously identify and exercise their sphincter muscles. New methods of replacing the sphincter muscles are currently being investigated and hold promise for the future. Finally, for patients with severe incontinence, a colostomy improves their lifestyle greatly.

If the underlying cause of incontinence cannot be completely corrected, there are measures to make the problem more manageable. Regular bowel movements help to keep the rectum empty, which decreases the chances of accidental leakage. A high-fiber diet and/or fiber supplements will usually improve constipation. Fiber also helps people with diarrhea by absorbing the water and making the stool more formed. The doctor may also recommend medication to control diarrhea. Many people are concerned about leaving home because of incontinence. Enemas or rectal irrigation can be used to empty the rectum to reduce the chance of leakage. Many patients find these useful prior to leaving home.

For people with incontinence one troubling aspect is the painful skin irritation that may occur. There are many methods of preventing or improving skin irritation and the details should be discussed with the doctor. The general principle is to keep the skin as dry as possible. After cleansing, the skin should be gently dried. Many people use a hair dryer. A protective barrier cream is applied lightly and the skin is covered with rolled cotton gauze. This should be done even if one needs to wear a protective pad or garment. Many people find that carrying a kit with the necessary supplies reduces their anxiety about episodes that may occur away from home.

Patients with incontinence are encouraged to speak with their doctors. Help is available.

Fairfax Colon & Rectal Surgery and Fecal Incontinence

Many patients come to our office with this complaint and are fearful that there will be no hope of a solution or that a major operation will be required.  As stated above, there are many conditions that can cause incontinence. The majority of the patients do not need an operation to repair their sphincter muscle.  Obviously, an accurate diagnosis as to the cause is essential.  A thorough history and careful examination is required as a first step.  Our doctors have the expertise to piece together what the patient is experiencing with the physical findings to determine the likely cause and what further evaluation and treatment are needed.  If manometry, anal ultrasound or other anorectal physiology tests are needed, these can be promptly scheduled in our office for the next office visit.   

If it is determined that a course of biofeedback may improve the continence, our physicians will submit the appropriate referral to a nearby therapist trained in this modality.