Fecal Incontinence National Digestive Diseases Information Clearinghouse What is fecal incontinence? more common among women. Having any of the following can increase the risk: Fecal incontinence, also called a bowel control problem, is the accidental passing • diarrhea, which is passing loose, watery of solid or liquid stool or mucus from the stools three or more times a day U.S. Department rectum. Fecal incontinence includes the of Health and • urgency, or the sensation of having very Human Services inability to hold a bowel movement until little time to get to the toilet for a bowel reaching a toilet as well as passing stool into movement NATIONAL one’s underwear without being aware of it INSTITUTES OF HEALTH happening. Stool, also called feces, is solid • a disease or injury that damages the waste that is passed as a bowel movement nervous system and includes undigested food, bacteria, • poor overall health from multiple mucus, and dead cells. Mucus is a clear chronic, or long lasting, illnesses liquid that coats and protects tissues in the digestive system. • a difficult childbirth with injuries to the pelvic floor—the muscles, ligaments, Fecal incontinence can be upsetting and and tissues that support the uterus, embarrassing. Many people with fecal vagina, bladder, and rectum incontinence feel ashamed and try to hide the problem. However, people with fecal incontinence should not be afraid or What is the gastrointestinal embarrassed to talk with their health care (GI) tract? provider. Fecal incontinence is often caused The GI tract is a series of hollow organs by a medical problem and treatment is joined in a long, twisting tube from the available. mouth to the anus. The movement of muscles in the GI tract, along with the Who gets fecal release of hormones and enzymes, allows incontinence? for the digestion of food. Organs that make up the GI tract are the mouth, esophagus, Nearly 18 million U.S. adults—about one stomach, small intestine, large intestine— 1 in 12—have fecal incontinence. People of which includes the appendix, cecum, colon, any age can have a bowel control problem, and rectum—and anus. The intestines are though fecal incontinence is more common sometimes called the bowel. The last part in older adults. Fecal incontinence is slightly of the GI tract—called the lower GI tract— consists of the large intestine and anus. 1Whitehead WE, Borrud L, Goode PS, et al. Fecal incontinence in U.S. adults: epidemiology and risk factors. Gastroenterology. 2009;137(2):512–517. How does bowel control work? Esophagus Bowel control relies on muscles and nerves of the rectum and anus working together to Stomach • hold stool in the rectum • let a person know when the rectum Large is full intestine • release stool when the person is ready Small intestine Circular muscles called sphincters close tightly like rubber bands around the anus Colon until stool is ready to be released. Pelvic floor muscles also help with bowel control. Cecum Sigmoid colon Appendix Anus Rectum Rectum The lower GI tract The large intestine absorbs water and any External sphincter remaining nutrients from partially digested food passed from the small intestine. The large intestine then changes waste from liquid to stool. Stool passes from the External Internal sphincter sphincter colon to the rectum. The rectum is located between the last part of the colon—called the sigmoid colon—and the anus. The Internal rectum stores stool prior to a bowel sphincter movement. During a bowel movement, stool moves from the rectum to the anus, the Anus opening through which stool leaves the body. The external and internal anal sphincter muscles 2 Fecal Incontinence What causes fecal The type of constipation that is most likely to lead to fecal incontinence occurs when incontinence? people are unable to relax their external Fecal incontinence has many causes, sphincter and pelvic floor muscles when including straining to have a bowel movement, often • diarrhea mistakenly squeezing these muscles instead of relaxing them. This squeezing makes it • constipation difficult to pass stool and may lead to a large • muscle damage or weakness amount of stool in the rectum. This type of constipation, called dyssynergic defecation • nerve damage or disordered defecation, is a result of • loss of stretch in the rectum faulty learning. For example, children or adults who have pain when having a bowel • childbirth by vaginal delivery movement may unconsciously learn to • hemorrhoids and rectal prolapse squeeze their muscles to delay the bowel movement and avoid pain. • rectocele • inactivity Muscle Damage or Weakness Injury to one or both of the sphincter Diarrhea muscles can cause fecal incontinence. If Diarrhea can cause fecal incontinence. these muscles, called the external and Loose stools fill the rectum quickly and internal anal sphincter muscles, are damaged are more difficult to hold than solid stools. or weakened, they may not be strong enough Diarrhea increases the chance of not to keep the anus closed and prevent stool reaching a bathroom in time. from leaking. Constipation Trauma, childbirth injuries, cancer surgery, Constipation can lead to large, hard stools and hemorrhoid surgery are possible causes that stretch the rectum and cause the internal of injury to the sphincters. Hemorrhoids are sphincter muscles to relax by reflex. Watery swollen blood vessels in and around the anus stool builds up behind the hard stool and and lower rectum. may leak out around the hard stool, leading to fecal incontinence. 3 Fecal Incontinence Nerve Damage Hemorrhoids and Rectal The anal sphincter muscles won’t open and Prolapse close properly if the nerves that control External hemorrhoids, which develop under them are damaged. Likewise, if the nerves the skin around the anus, can prevent that sense stool in the rectum are damaged, the anal sphincter muscles from closing a person may not feel the urge to go to the completely. Rectal prolapse, a condition bathroom. Both types of nerve damage can that causes the rectum to drop down through lead to fecal incontinence. Possible sources the anus, can also prevent the anal sphincter of nerve damage are childbirth; a long-term muscles from closing well enough to prevent habit of straining to pass stool; spinal cord leakage. Small amounts of mucus or liquid injury; and diseases, such as diabetes and stool can then leak through the anus. multiple sclerosis, that affect the nerves that go to the sphincter muscles and rectum. Rectocele Brain injuries from stroke, head trauma, Rectocele is a condition that causes the or certain diseases can also cause fecal rectum to protrude through the vagina. incontinence. Rectocele can happen when the thin layer Loss of Stretch in the Rectum of muscles separating the rectum from the vagina becomes weak. For women Normally, the rectum stretches to hold with rectocele, straining to have a bowel stool until a person has a bowel movement. movement may be less effective because Rectal surgery, radiation treatment, and rectocele reduces the amount of downward inflammatory bowel diseases—chronic force through the anus. The result may disorders that cause irritation and sores on be retention of stool in the rectum. More the lining of the digestive system—can cause research is needed to be sure rectocele the rectal walls to become stiff. The rectum increases the risk of fecal incontinence. then can’t stretch as much to hold stool, increasing the risk of fecal incontinence. Inactivity Childbirth by Vaginal Delivery People who are inactive, especially those who spend many hours a day sitting or lying down, Childbirth sometimes causes injuries to have an increased risk of retaining a large muscles and nerves in the pelvic floor. The amount of stool in the rectum. Liquid stool risk is greater if forceps are used to help can then leak around the more solid stool. deliver the baby or if an episiotomy—a cut in Frail, older adults are most likely to develop the vaginal area to prevent the baby’s head constipation-related fecal incontinence for from tearing the vagina during birth—is this reason. performed. Fecal incontinence related to childbirth can appear soon after delivery or many years later. 4 Fecal Incontinence How is fecal incontinence People may want to keep a stool diary for several weeks before their appointment diagnosed? so they can answer these questions. A Health care providers diagnose fecal stool diary is a chart for recording daily incontinence based on a person’s medical bowel movement details. A sample history, physical exam, and medical test stool diary is available on the Bowel results. In addition to a general medical Control Awareness Campaign website at history, the health care provider may ask the www.bowelcontrol.nih.gov. following questions: The person may be referred to a doctor • When did fecal incontinence start? who specializes in problems of the digestive • How often does fecal incontinence system, such as a gastroenterologist, occur? proctologist, or colorectal surgeon, or a doctor who specializes in problems of the • How much stool leaks? Does the stool urinary and reproductive systems, such as a just streak the underwear? Does just a urologist or urogynecologist. The specialist little bit of solid or liquid stool leak out will perform a physical exam and may suggest or does complete loss of bowel control one or more of the following tests: occur? • anal manometry • Does fecal incontinence involve a strong urge to have a bowel movement or does • anal ultrasound it happen without warning? • magnetic resonance imaging (MRI) • For people with hemorrhoids, do • defecography hemorrhoids bulge through the anus? Do the hemorrhoids pull back in by • flexible sigmoidoscopy or colonoscopy themselves, or do they have to be • anal electromyography (EMG) pushed in with a finger? Anal manometry. Anal manometry uses • How does fecal incontinence affect daily pressure sensors and a balloon that can life? be inflated in the rectum to check the • Is fecal incontinence worse after eating? sensitivity and function of the rectum.