Fecal incontinence

What is fecal incontinence?

With fecal incontinence, a person loses control of their bowel contents. This can be intestinal gas, intestinal mucus or bowel movements. The bowel then empties itself without the affected person being able to influence this voluntarily. Fecal incontinence is colloquially known as “bowel weakness”. The medical term for this is anorectal incontinence. Another well-known condition is bladder weakness or urinary incontinence, in which those affected lose urine involuntarily.

Fecal incontinence and severity

Fecal incontinence is not the same for everyone. Experts have created a points system that makes it easier to assess the severity. Many doctors around the world use the Vaizey Wexner system to measure the extent of faecal incontinence. Doctors award points for the frequency and type of incontinence events (loss of gas, liquid or solid stool). Patients can achieve a total of between 1 and 20 points. The higher the number, the more severe the fecal incontinence.

There are also other scales that doctors use to determine the severity of fecal incontinence:

• Grade 1: Only intestinal gas escapes uncontrolled. Solid and liquid stools are easy to hold.
• Grade 2: Those affected can no longer hold back intestinal gas and liquid stool. Only solid stools can still be controlled.
• Grade 3: Bowel movements can no longer be controlled at all. Even a firm chair can no longer be held and involuntarily falls off. There is complete fecal incontinence.

Fecal incontinence – frequency and age

Very few people like to talk about faecal incontinence. But it doesn’t seem to be that rare. Experts estimate that around five percent of the population in Western countries suffer from it to varying degrees. Some do not consult a doctor out of shame or do so late. Fecal incontinence can occur at any age. But it particularly often affects older people. And women are around four to five times more likely to suffer from bowel weakness than men. There are various reasons for this:

• Age: With increasing age, the strength and elasticity of the pelvic floor muscles, which play an important role in holding the stool in place, diminish. In addition, the sphincter muscle usually loses strength. Many senior citizens also suffer from diseases in old age that increase the risk of faecal incontinence. These include, for example, a stroke or dementia.
• Female gender: Due to their anatomy, women have weaker pelvic floor muscles and a weaker sphincter. Pregnancies and vaginal births also further weaken both. The risk of fecal incontinence is significantly higher in women than in men.

Fecal incontinence: causes and risk factors

There are many causes of fecal incontinence. Often there is not just “one” cause, but several factors probably play together and trigger fecal incontinence. Doctors distinguish between primary and secondary faecal incontinence, each of which can have different underlying causes.

Primary fecal incontinence – the reasons

Primary faecal incontinence is caused by direct damage to the nerves (neurons) that help control bowel movements. This is why it is also called neurogenic fecal incontinence. Diseases that are associated with such nerve damage are, for example:

• Stroke (cerebral infarction, stroke)
• Herniated disc (disc prolapse) that presses on the nerves
• Brain tumors
• Paraplegia
• Neurological diseases such as Parkinson’s disease (Parkinson’s disease, shaking palsy), multiple sclerosis, dementia (e.g. Alzheimer’s disease, Alzheimer’s disease) or the long-term diabetes mellitus (it not only damages the blood vessels in the long term, but also the nerves)
• Operations in the pelvic area that affect the nerves
• Congenital spinal malformations, such as the “open back” (spina bifida)

Secondary faecal incontinence – the causes

In the case of secondary faecal incontinence, it is not the nerves that are directly damaged, but other illnesses that trigger the bowel weakness. These include, for example:

• Damaged anal sphincter: This can tear during childbirth (perineal tear) or be damaged during an operation (e.g. anal fistulas or hemorrhoids). Even with anal prolapse, the sphincter sometimes no longer functions as it should.
• Weakened pelvic floor: Childbirth, overweight andobesity or old age weaken the pelvic floor. In general, the muscles and connective tissue lose their elasticity with increasing age. However, you can prevent and counteract this with targeted pelvic floor training.
• Diseases associated with frequent diarrhea, e.g. chronic inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis
• Chronic constipation that lasts longer than three months
• Some mental illnesses and psychological factors (e.g. trauma)
• Long-term abuse of laxatives

Symptoms: Fecal incontinence

Fecal incontinence is usually indicated by the following symptoms:

• Intestinal gases escape again and again unintentionally and their release cannot be controlled.
• Light soiling can always be found in the underwear because small amounts of intestinal mucus or stool leak out.
• Liquid stool can no longer be held.
• Eventually, even solid stools can no longer be held and controlled.

Even if you are uncomfortable with faecal incontinence – always consult a doctor promptly. She or he can find out what exactly is behind it if you can no longer control your bowel gases or stool.

Fecal incontinence: Diagnosis with us

It is best to consult your family doctor first, who will then refer you to a specialist, such as a proctologist. However, specialists in neurology or geriatricians are also good places to go. They are usually also familiar with the clinical picture of fecal incontinence.

At the beginning we will ask you a few questions about your medical history (anamnesis), for example:

• When did you first notice faecal incontinence?
• How often do intestinal gases or stools pass undesirably?
• Do you only lose stool when it is liquid or also solid stool?
• Do you feel an urge to defecate beforehand or does the loss happen without warning?
• If you have an urge to defecate as an “advance warning”: How much time do you have to reach the toilet in time?
• Do you have other digestive complaints such as diarrhea, constipation, flatulence or abdominal pain?
• Do you suffer from urinary incontinence?
• Do you have any known diseases? If yes: Which ones?
• Have you recently undergone an operation?
• Are you taking any medication, if so, what kind and since when?
• Have you had any pregnancies or births? When and how many?
• What kind of food do you eat?

This is followed by a physical examination. We carefully palpate the anus, sphincter and rectum with a finger to detect any abnormalities and changes. This method is called a digital rectal examination.

An endoscopy sheds light on the anal canal(proctoscopy) or the rectum. This examination is called a rectoscopy. Sometimes a colonoscopy is also necessary. A gastroenterologist examines the entire colon for possible changes. A flexible instrument is used, which is equipped with a small camera and provides images from the inside of the bowel. At the same time, we can take tissue samples from the anal or intestinal mucosa (biopsy) as part of the colonoscopy. These cells are then analyzed under a microscope by a pathologist in the laboratory.

A pressure measurement can be used to determine whether the anal sphincter is functioning adequately. We use a measuring probe to electronically record the pressure conditions in the area of the sphincter muscle.

Sometimes imaging procedures are also used to find the cause of fecal incontinence. These include, for example:

• Ultrasound (sonography), for example rectal ultrasound of the rectum
• X-ray examination of the bowel with the aid of contrast medium (defecography)
• Magnetic resonance imaging (MRI = magnetic resonance imaging): This method works with strong magnetic fields and produces detailed cross-sectional images of organs and tissues.

Fecal incontinence: prevention, early detection, prognosis

Fecal incontinence has many different causes. This is often due to age or certain illnesses and cannot be prevented. However, pelvic floor exercises are an effective way of preventing this. It is probably familiar to most women after pregnancy and childbirth. You then train your pelvic floor and strengthen it again. But men can also strengthen their pelvic floor in a targeted way.

In general, it can be said that faecal incontinence that is discovered early and is not yet so severe can be treated better. Then the progression can sometimes be halted.

Fecal incontinence – course and prognosis

In the long term, faecal incontinence can lead to many psychological and social problems. Many are ashamed and afraid of attracting attention due to unpleasant odors or sudden “accidents”. The result is often a social withdrawal into one’s own four walls. However, there are some treatment options that can alleviate fecal incontinence. Modern aids can also often be used to conceal bowel weakness.

Fecal incontinence: treatment with various strategies

There are various treatment options for fecal incontinence. The exact choice depends on the cause and degree of bowel weakness. Sometimes the cause can be remedied or we can at least mitigate the consequences of fecal incontinence. The aim of treatment is always to get bowel movements under control again (no constipation, no diarrhea) and to strengthen the pelvic floor muscles. In case of a surgical intervention, the Institute of Anesthesiology will select the anesthesia procedure that is individually adapted to you.