Bowel Incontinence

Bowel incontinence is an inability to control bowel movements, resulting in the involuntary passage of stools.

It is also sometimes known as faecal incontinence.

The experience of bowel incontinence can vary from person to person. Some people feel a sudden, urgent need to go to the toilet, and incontinence occurs because they are unable to reach a toilet in time. This is known as urge bowel incontinence.

Other people may experience no sensation before passing a stool, known as passive incontinence or passive soiling, or they may pass a small piece of stool while passing wind.

Some people experience incontinence on a daily basis, whereas for others the problem only occurs from time to time.

Who is affected

Bowel incontinence is much more common than most people realise: it's thought 1 in 10 people will be affected by it at some point in their life.

It can affect people of any age, although the problem is more common in elderly people. It is more common in women than men.

Why bowel incontinence happens

Bowel incontinence is not a condition in itself. It is a symptom of an underlying problem or medical condition.

Many cases are caused by diarrhoea, constipation, or weakening of the ring of muscle that controls the opening of the anus.

Bowel incontinence can also be caused by long-term conditions such as diabetes, multiple sclerosis and dementia.

Causes

Bowel incontinence is usually caused by a physical problem with the parts of the body that control the passage of stools.

The most common problems are:

Problems with the rectum: the rectum (where stools are held) is unable to store stools properly until it is time to go to the toilet.
Problems with the sphincter muscles: the muscles at the bottom of the rectum do not work properly.
Nerve damage: the nerve signals sent from the rectum do not reach the brain.
These problems are explained in more detail below.

Problems with the rectum
Constipation
Constipation is a leading cause of bowel incontinence.

In cases of severe constipation, a large, solid stool can become stuck in the rectum. This is known as faecal impaction. The stool then begins to stretch the muscles of the rectum, weakening them.

Watery stools can then leak around the stool and out of the bottom, causing bowel incontinence. This is called overflow incontinence and occurs most commonly in people who are elderly and frail.

Diarrhoea
It is more difficult for the rectum to hold liquid stools (diarrhoea) than solid stools, so people with diarrhoea (particularly recurring diarrhoea) can develop bowel incontinence.

Conditions that can cause recurring diarrhoea include:

Crohn's disease – a condition that causes inflammation of the digestive system
irritable bowel syndrome – a condition that causes a range of digestive symptoms, such as diarrhoea and bloating
ulcerative colitis – a condition that causes inflammation of the large bowel
These conditions can also cause scarring of the rectum, which can lead to bowel incontinence.

Medications such as lansoprazole and metformin can also cause loose stool.

Problems with the sphincter muscles
The sphincter muscles at the bottom of the rectum control the passage of stools. Bowel incontinence can occur if these muscles become weakened or damaged.

Childbirth is one of the most common causes of damage to the sphincter muscles and a leading cause of bowel incontinence. During a vaginal delivery of a baby, the sphincter muscles can become stretched and damaged, particularly as a result of a forceps delivery.

Sphincter muscles can also become damaged through injury, or damage that arises as a complication of bowel or rectal surgery.

Nerve damage
Bowel incontinence can also be caused by a problem with the nerves connecting the brain and the rectum. A nerve problem can mean your body is unaware of stools in your rectum, and may make it difficult for you to control your sphincter muscles.

Damage to these nerves is related to a number conditions, including:

diabetes
multiple sclerosis (a condition of the central nervous system)
stroke
spina bifida (birth defects that affect the development of the spine and nervous system)
An injury to these nerves, such as a spinal injury, can also lead to bowel incontinence.

Other health conditions
Bowel incontinence does not always result from physical damage to a part of the bowel or the nerves. In some cases, it may result from a health condition such as dementia or a severe learning disability that causes the person to lose the ability to control their bowel properly.

A physical disability can also make it difficult to get to the toilet before passing a stool.

Seeking advice and treatment

Bowel incontinence can be extremely upsetting and hard to cope with, but effective treatments are available and a cure is often possible, so make sure you see your GP.

It is important to remember that:

• Bowel incontinence is not something to be ashamed of – it is simply a medical problem that is no different from diabetes or asthma.
• It can be treated – there is a wide range of successful treatments.
• Bowel incontinence is not a normal part of ageing.
• It will usually not go away on its own – most people will need treatment for the condition.

If you don't want to see your GP, you can usually make an appointment at your local NHS continence service without a referral. These clinics are staffed by specialist nurses who can offer useful advice about incontinence.

Your GP will begin by asking you about the pattern of your symptoms and other related issues, such as your diet.

You may find this embarrassing, but it is important to answer as honestly and fully as you can because this will help to ensure that you receive the most suitable treatment.

It is likely that your GP will carry out a physical examination. First they will look at your anus and the surrounding area to check for any damage. Your GP will then perform a rectal examination, where they gently insert their finger into your bottom.

Carrying out a rectal examination allows the GP to check whether constipation is causing your symptoms, and checks if there are tumours in your rectum. Your GP may ask you to squeeze your rectum around their finger to assess how well the muscles in your anus are working.

Depending on the results of your examination, your GP may refer you for further tests.

Further tests

Endoscopy (sigmoidoscopy)

During an endoscopy, the inside of your rectum (and in some cases your lower bowel) is examined internally using a long, thin flexible tube with a light and video camera at the end. Images can be taken of the inside of your body and sent to an external monitor.

The endoscope is inserted into your bottom to check whether there is any obstruction, damage or inflammation in your rectum.

Although an endoscopy is not painful, it can feel uncomfortable, so you may be given a sedative to relax you.

This procedure is also called a sigmoidoscopy.

Anal manometry

Anal manometry helps to assess how well the muscles and nerves in and around your rectum are working.

The test uses a device that looks like a small thermometer with a balloon attached to the end. This is inserted into your rectum and the balloon is inflated. It may feel unusual, but it is not uncomfortable or painful.

A machine is attached to the device, which measures pressure readings taken from the balloon.

During the test you will be asked to squeeze, relax and push your rectum muscles at certain times. You may also be asked to push the balloon out of your rectum in the same way that you push out a stool. The information is sent to the pressure-measuring machine, and gives an idea of how well your muscles are working.

The balloon can also be inflated to different sizes to determine when your rectum feels full. If the balloon is inflated to a relatively large size but you do not feel any sensation of fullness, it may mean there are problems with the nerves in your rectum.

Ultrasound

An ultrasound scan can be used to create a detailed picture of the inside of your anus. Ultrasound scans are particularly useful in detecting underlying damage to the sphincter muscles.

Defecography

Defecography is a test used to study exactly how you are passing stools. It can also be useful in detecting any signs of obstruction or prolapse that have not been discovered during a rectal examination.

During this test, a liquid called barium is placed into your rectum. The barium helps make it easier to detect problems using an X-ray. Once the barium is in place, you will be asked to pass stools in the usual way while scans are taken.

This test is occasionally carried out using a magnetic resonance imaging (MRI) scanner instead of an X-ray.

How bowel incontinence is treated

In many cases, with the right treatment, a person can maintain normal bowel function throughout their life.

Treatment will often depend on the cause and severity of the condition, but possible options include:

• lifestyle and dietary changes to relieve constipation or diarrhoea
• exercise programmes to strengthen the muscles that control the passage of stools
• medication to control symptoms of diarrhoea and constipation
• surgery, of which there are a number of different options

Incontinence products, such as anal plugs and disposable pads, can be used until your symptoms are better controlled.

Even if a complete cure for bowel incontinence is not possible, most people's symptoms improve significantly and they achieve a better quality of life.

If you have bowel incontinence, your treatment plan will depend on your underlying condition and the pattern of your symptoms.

Trying the least intrusive treatments first, such as dietary changes and exercise programmes, is often recommended.

Medication and surgery are usually only considered if other treatment options are unsuccessful.

Continence products

You may find it helpful to use continence products until your bowel incontinence is better controlled.

Anal plugs are one way to prevent involuntary soiling. An anal plug is made of foam and designed to be inserted into your bottom. However, these plugs can be uncomfortable and only a few people find them to be a long term solution.

If the plug comes into contact with any moisture from the bowel, it expands and prevents any leakage or soiling. Anal plugs can be worn for up to 12 hours, after which time they are removed using an attached string.

Disposable body pads are contoured pads that soak up liquid stools and protect your skin. They can also be used in cases of mild bowel incontinence.

Most continence products are available for free on the NHS.

Your local NHS continence service can offer help and advice about continence products, and you don't usually need a referral from your GP to make an appointment. These clinics are staffed by nurses who specialise in continence treatment. The Bladder & Bowel Foundation can help you find your local service.

Read more about incontinence support on the NHS.

Dietary changes

In cases of bowel incontinence associated with diarrhoea or constipation, it is often possible to control your symptoms by making changes to your diet.

It may be beneficial to keep a food diary to record the effect of your dietary changes on your symptoms.

Diarrhoea

The National Institute for Health and Care Excellence (NICE) has published dietary advice for managing diarrhoea in cases of irritable bowel syndrome (PDF, 39Kb). These guidelines can also be applied for people with diarrhoea associated with bowel incontinence.

The advice from NICE includes the following:

• limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds)
• avoid skin, pips and pith from fruit and vegetables
• limit fresh and dried fruit to three portions a day and fruit juice to one small glass a day (make up the recommended ‘five a day’ with vegetables)
• limit how often you have fizzy drinks and drinks containing caffeine
• avoid foods high in fat, such as chips, fast foods and burgers

Constipation

A high-fibre diet is usually recommended for most people who have constipation-associated bowel incontinence. Your GP can tell you if a high-fibre diet is suitable for you.

Fibre can soften stools, making them easier to pass. Foods that are high in fibre include:

• fruit and vegetables
• beans
• wholegrain rice
• wholewheat pasta
• wholemeal bread
• seeds, nuts and oats

Drink plenty of fluids because this can help to soften your stools and make them easier to pass.

Pelvic floor muscle training

Pelvic floor muscle training is a type of exercise programme used to treat cases of bowel incontinence caused by weakness in the pelvic floor muscles.

A therapist, usually a physiotherapist or specialist nurse, will teach you a range of exercises. The goal of pelvic floor muscle training is to strengthen any muscles that may have been stretched and weakened.

You will probably be required to carry out the exercises three times a day, for six to eight weeks. After this time, you should notice an improvement in your symptoms.

Exercises to try

Check with your health professional before trying these at home.

First, pretend you're trying to hold in a bowel movement. You should feel the muscles around your anus tighten.

Next, sit, stand, or lie in a comfortable position with your legs slightly apart.

• Squeeze your pelvic floor muscles for as long as you can, then relax. Repeat five times.
• Squeeze the muscles as hard as you can, then relax. Repeat five times.
• Squeeze the muscles quickly, then relax. Repeat five times.

If you find these exercises too difficult, try fewer repetitions at first and build them up. If they get too easy, try doing more repetitions. You can do the exercises without anyone knowing about them, so they should be easy to fit into your daily routine.

Bowel retraining

Bowel retraining is a type of treatment for people who have reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation.

There are three goals in bowel retraining:

• to improve the consistency of your stools
• to establish a regular time for you to empty your bowels
• to find ways of stimulating your bowels to empty themselves

Improving stool consistency is usually achieved by modifying your diet (see above).

Establishing a regular time to empty your bowels involves assessing your daily routine and finding the most convenient time when you can go to the toilet without being rushed.

For some people, this may involve waking up early so that they can spend time going to the toilet after breakfast, while other people may prefer to set aside some time in the evening after dinner.

Ways to stimulate bowel movements can differ from person to person. Some people find that a hot drink and meal can help. Others may need to stimulate their anus using their finger.

Biofeedback

Biofeedback is a type of bowel retraining exercise that involves placing a small electric probe into your bottom.

The sensor relays detailed information about the movement and pressure of the muscles in your rectum to an attached computer.

You are then asked to perform a series of exercises designed to improve your bowel function. The sensor checks that you are performing the exercises in the right way.

Medication

Medication can be used to help treat soft or loose stools or constipation associated with bowel incontinence.

Loperamide is a medication widely used to treat diarrhoea. It works by slowing down the movement of stools through the digestive system, while allowing more water to be absorbed from the stools. Loperamide can be prescribed in low doses to be taken regularly over a long period of time.

Laxatives are used to treat constipation. They are a type of medication that helps you to pass stools. Bulk-forming laxatives are usually recommended. These help your stools to retain fluid. This means they are less likely to dry out, which can lead to faecal impaction.

Enemas or rectal irrigation

Rectal irrigation or enemas are used in cases where bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool from the rectum.

These procedures involve a small tube that is placed into your anus. A special solution is then used to wash out your rectum.

Surgery

Surgery is usually only recommended for the treatment of bowel incontinence after all other treatment options have been tried.

The main surgical treatments used on the NHS are sphincteroplasty and sacral nerve stimulation. Other treatments – such as tibial nerve stimulation, endoscopic heat therapy and artificial sphincter surgery – can also be used, but their availability on the NHS is limited.

An operation called a colostomy is more widely available on the NHS, but it is only used if other treatments are unsuccessful.

These treatments are outlined in more detail below.

Sphincteroplasty

A sphincteroplasty is an operation to repair damaged sphincter muscles. The surgeon removes some of the muscle tissue and the muscle edges are overlapped and sewn back together. This provides extra support to the muscles, which makes them stronger.

Sacral nerve stimulation

Sacral nerve stimulation is a treatment used for people with weakened sphincter muscles.

Electrodes are inserted under the skin in the lower back and connected to a pulse generator. The generator releases pulses of electricity that stimulate the sacral nerves.

The stimulation causes the sphincter and pelvic floor muscles to work more effectively, helping to decrease episodes of incontinence.

At first, the pulse generator is located outside your body. If the treatment is effective, the pulse generator will be implanted deep under the skin in your back.

The most commonly reported complications of the procedure are infection at the site of surgery and technical problems with the pulse generator, which require additional surgery to correct.

See the NICE guidelines on Sacral nerve stimulation for faecal incontinence.

Tibial nerve stimulation

Tibial nerve stimulation is a fairly new treatment for bowel incontinence.

A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve. It is not known exactly how this treatment works, but it's thought to work in a similar way to sacral nerve stimulation.

NICE concludes that the procedure appears to be safe, although there are still uncertainties about how well it works.

See the NICE guidelines on Treating faecal incontinence by stimulating the tibial nerve.

Injectable bulking agents

Bulking agents, such as collagen or silicone, can be injected into the muscles of the sphincter and rectum to strengthen them.

The use of bulking agents in this way is a fairly new technique, so there is little information about the long-term effectiveness and safety of this type of treatment.

You should discuss the possible advantages and disadvantages of this type of treatment in full with your treatment team before deciding whether to proceed.

See the NICE guidelines on Treating faecal incontinence with injectable bulking agents.

Endoscopic heat therapy

Endoscopic radiofrequency (heat) therapy is a fairly new treatment for bowel incontinence.

Heat energy is applied to the sphincter muscles through a thin probe, to encourage scarring of the tissue. This helps tighten the muscles and helps to control bowel movements.

The National Institute for Health and Care Excellence (NICE) recently produced guidelines on this procedure. NICE concluded that the procedure appears to be safe, although there are still uncertainties about how well it works.

As well as the uncertainties surrounding this procedure, it is also very expensive. Therefore, it is usually only used on the NHS during clinical trials.

See the NICE guidelines on Treating faecal incontinence using endoscopic radiofrequency therapy.

Stimulated graciloplasty

A stimulated graciloplasty is an operation to replace your sphincter muscles. The surgeon takes a small piece of muscle from your thigh and uses it to create a new sphincter muscle.

Electrodes are inserted into the new sphincter, which are attached to a pulse generator placed inside your abdomen.

The pulse generator runs an electrical current through the implanted muscles, which gradually changes the way the muscles work to make them act like natural sphincter muscles.

As with sacral nerve stimulation, the most common complications of stimulated graciloplasty are infection at the site of surgery and technical problems with the pulse generator.

Nowadays, this procedure is less commonly used than many of the other surgical options for bowel incontinence.

See the NICE guidelines on Stimulated graciloplasty for faecal incontinence.

Artificial sphincter

An artificial sphincter may be implanted if you have bowel incontinence caused by a problem with your sphincter muscles.

This operation involves placing a circular cuff under the skin around the anus. The cuff is filled with fluid and sits tightly around the anus, keeping it closed.

A tube is placed under the skin from the cuff to a control pump. In men, the pump is placed near the testicles, in women it’s placed near the vagina. A special balloon is placed into the abdomen (tummy), and this is connected to the control pump by tubing that runs under the skin. 

The pump is activated by pressing a button located under the skin. This drains the fluid from the cuff into the balloon, so your anus opens and you can pass stools. When you are finished, the fluid slowly refills the cuff and the anus closes.

The use of an artificial sphincter is a relatively new procedure, so there isn't much good-quality information about the long-term effectiveness and safety of this type of treatment yet.

Possible problems from this operation include infection, injury during surgery and the cuff becoming dislodged. In some cases, further surgery is required to correct problems.

See the NICE guidelines on Treating faecal incontinence with an artificial sphincter inserted through a cut in the abdomen.

Colostomy

A colostomy is usually only recommended if other surgical treatments are unsuccessful.

A colostomy is a surgical procedure in which your colon (lower bowel) is cut and brought through the wall of your stomach to create an artificial opening. Your stools can then be collected in a bag, known as a colostomy bag, which is attached to the opening.