Incontinence

Incontinence is the impaired ability to control gas or stool. Its severity can range from a mild occasional loss of control of gas to a frequent loss of control of either liquid or formed stools. Incontinence to stool is a common problem (more than 2% of the population may have some form of incontinence), seen more commonly in females, but often not discussed due to embarrassment. Fecal incontinence tends to increase with age and many times can be seen simultaneously with urinary incontinence.

Continence

Normal control of the passage of stool depends on a number of factors:

• Transit time of stool through the bowel -- If stool moves through the bowel too quickly, a person may not have enough warning and may have an accident. This can be seen in patients with irritable bowel syndrome or inflammation of the bowel (colitis).
• Consistency of the stool -- Loose or watery stool is difficult for anyone to control. Anything that causes diarrhea, such as infection, inflammation, or food intolerance, could lead to incontinence.
• Compliance and capacity -- Normally the rectum will stretch (compliance) 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. Inflammation may also lead to both a decreasein compliance and capacity.
• Intact sphincter muscle--the external sphincter muscles circle around the anus (the rectal opening to the outside world), keeping the anus closed. They need to function properly to hold the anus closed at rest as well as to squeeze to tighten the anus when stool or gas enter the rectum to prevent passage of gas or stool at an inopportune time. The internal sphincter muscle maintains the baseline tone of the anal canal.
• Intact Nerves and sensation--To prevent leakage one must be able to tell that stool or gas is present in the rectum. Additionally, nerves to the sphincter muscles help them to maintain their function.

Causes of Incontinence

• Injury during childbirth is a more common cause, although this may not become symptomatic until years later. 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.
• The nerves supplying the anal muscles may also be injured at the time of childbirth. As with the sphincter muscle, some nerve injuries may be recognized immediately following childbirth, while others may go unnoticed and not become a problem until later in life. In these situations, past childbirth may not be recognized as the cause of incontinence. 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. Additionally, some people with nerve root compression of the low back may exhibit symptoms of incontinence.
• Anal operations or injury to the tissue surrounding the anal region similarly can damage the anal muscles or nerves thereby hindering bowel control.
• Infections around the anal area may destroy muscle tissue leading to problems of incontinence.
• As people age, they experience loss of strength in the anal muscles. As a result, a minor problem in a younger person may become more significant later in life.
• Rectal prolapse, where the rectal lining protrudes through the anus can lead to both neurologic and sphincter muscle problems.

Evaluation of Incontinence

When you come to our office, your doctor will ask questions about the your symptoms, bowel habits, other medical problems, past obstetrical history (where applicable), as well as what medications you currently take. You will then be examined with particular attention paid to the sphincter muscles, rectum, and lower colon. This evaluation will help establish the degree of control difficulty and its impact on your quality of life as well as your lifestyle.

Additional studies may be required to define the anal area more completely, and may include a flexible sigmoidoscopy or colonoscopy, depending upon your history. Additionally, specific tests to evaluate the sphincter muscles and nerves may be required. A number of these studies are performed either at our Colon and Rectal Center at Mercy Medical Center or at St. Agnes Hospital. These would include:

• Manometry--here a small catheter is placed into the anus to record pressure as patients relax and tighten the anal muscles. This test can demonstrate how weak or strong the muscle really is.
• Pudendal Nerve Terminal Motor Latency-- conducted to determine if the nerves that go to the anal muscles are functioning properly.
• Endorectal Ultrasound--an ultrasound probe is inserted into the to provide a picture of the muscles and show areas in which the anal muscles may be disrupted.

Treatment

• Mild problems may be treated very simply with dietary changes, bulking agents and the use of some constipating medications. This management is used more often for patients whose sphincter muscle is intact, but not working well. Your doctor also may recommend simple home exercises (Kegel exercises) that may strengthen the sphincter muscles.
• In other cases, Biofeedback can be used to help patients sense when stool is ready to be evacuated and help strengthen the muscles. This is typically taught at the Colon and Rectal Center, with home teaching apparatus available.
• Injuries to the anal muscles may be repaired with surgery, most commonly with sphincter muscle repair. But other surgery may be necessary depending upon the underlying problem.
• Diseases which cause inflammation in the rectum, such as colitis, may contribute to anal control problems. Treating these diseases also may eliminate or improve symptoms of incontinence.
• Sometimes a change in prescribed medications may help.

Remember: In our practice, everything we do is custom tailored for each patient. Therefore, while two patients may exhibit similar symptoms, their individual management may be very different.

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