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Bowel incontinence can be difficult to talk about, as it can be very distressing and embarrassing for those experiencing it, and many people are reluctant to seek medical help.
Bowel control is a natural body function that most people take for granted, as it is learned at a very young age. When a person has problems controlling their bowels, it can have negative effects on their quality of life that can result in depression and social isolation. Individuals who live with this condition are often reluctant to come forward and seek help due to the stigma associated with bowel incontinence, even though their quality of life is severely affected.
It is estimated that approximately 0.5%–1% of adults regularly experience bowel incontinence. With more than 15% of over-85-year-olds living at home having bowel incontinence, this figure is higher for those living in residential or nursing homes, at 10%–60%, according to the Royal College of Nursing (RCN).
However, because of the stigma and sensitivities around the issue, it is difficult to know with any accuracy exactly how common bowel incontinence is. Various research studies have suggested that about 10% of adults soil their underwear regularly, but the true prevalence remains hidden.
What is bowel incontinence?
Bowel incontinence may also be referred to as faecal incontinence or anal incontinence; it is not being able to control bowel movements. Those with bowel incontinence may have an unintentional loss of liquid or solid stools. Faecal matter leaks from the rectum without warning, and can range from an occasional leakage of faeces while passing wind, to a complete loss of bowel control. This leakage can occur with or without a person’s knowledge.
The bowel is part of the digestive system and it works to digest the food eaten, absorb the goodness and nutrients into the bloodstream, and then process and expel the waste that the body cannot use.
The digestive system works by pushing food through the intestines which usually takes between 24 to 72 hours. Muscular contractions squeeze (peristalsis) the food through the different sections of the intestine. These different sections are separated by bands of muscles, or sphincters, which act as valves. The passage of food from one area of the intestines to another is coordinated so that food stays in a specific area for long enough for the gut to do a particular job, that is to absorb fluids and nutrients, or to process and expel waste.
Once the bowel has done its work and absorbed nutrients from food, the waste travels to the rectum which stretches, triggering a message to the brain to say that the bowel is full and needs to be emptied.
The pelvic floor muscles, when well-toned, ensure the anus remains closed until it is time to go to the toilet. When we need to go to the toilet, the brain tells the anal sphincter muscles, via the nerves, to relax. As the muscles relax, the anus opens and the rectum empties.
The anal canal is about 3–4cm long in women and sometimes slightly longer in men. The internal and external sphincters form two concentric rings which run along the length of the anal canal. The internal anal sphincter (IAS) is made of smooth muscle and we do not have voluntary control of this muscle. It works automatically to keep the anus closed until we are ready to have a bowel movement. The external anal sphincter (EAS) is made of striated muscle, the same as the pelvic floor muscles, and we do have voluntary control over the EAS allowing us to hold on if we are aware of wind or diarrhoea.
The pelvic floor muscles are layers of muscle stretched like a sheet from the pubic bone in the front, to the bottom of the backbone, the coccyx. There are three openings through the pelvic floor in women and two in men – the anus (back passage), the vagina in women (birth canal) and the urethra (bladder outlet). The muscles support these three openings, but if they are weakened or not in a good condition, they cannot support the openings effectively.
Through a series of reflexes and signals the nerves in the bowel are coordinated with the pelvic floor muscles and anal sphincters in order to store bowel contents until there is an appropriate time and place to go to the toilet and then to allow complete bowel emptying once on the toilet.
This coordination ensures that the sphincters remain closed, opening only during defecation. So, when the rectum fills, and the pressure inside it increases, the nerves sense the pressure and tell the brain about it. The brain then sends signals via the nerves to keep the external sphincter closed. Normally, this prevents leakage and is called the guarding reflex.
When any part of this process is not working correctly, then bowel incontinence can occur. Some people with bowel incontinence feel the urge to have bowel movements but are unable to wait to reach a toilet. Other people don’t feel the sensation of a pending bowel movement, passing faecal matter unknowingly.
What are the signs and symptoms of bowel incontinence?
Bowel incontinence can affect people in different ways. For some people, bowel incontinence may occur during an occasional bout of diarrhoea; however, for others, bowel incontinence happens a lot. People with this condition may not be able to stop the urge to defecate.
It may come on so suddenly that they can’t make it to the toilet in time – this is called urge incontinence. People who are not aware of the need to defecate but who do so unknowingly, suffer from passive incontinence.
Signs and symptoms of bowel incontinence may include:
- Having sudden urges to empty your bowel that you cannot control.
- Soiling yourself without realising you needed the toilet.
- Sometimes leaking faecal matter, for example when passing wind.
- Faecal matter leaks out due to physical activity / daily life exertions.
- Complete loss of bowel regulation.
- Frequent constipation.
- Frequent diarrhoea.
- Excessive flatulence (passing wind).
- Abdominal pain or cramping.
- The anus is irritated or itchy.
- Urinary incontinence.
Episodes may occur daily, weekly or monthly and can be a relatively small problem, resulting in the occasional soiling of underwear, or it can be devastating, with a total lack of bowel control.
Who is at risk of bowel incontinence?
Bowel incontinence can affect men, women and children. However, it happens more often in women than in men, and also happens more often among older people. It can be a very common problem in children that may start as an occasional ‘accident’ but without treatment can occur more frequently.
Independent risk factors of developing bowel incontinence can include but are not limited to:
- Advancing age – It is more common in adults over 65.
- People who suffer from diarrhoea or urinary incontinence.
- Women who have undergone multiple childbirths, particularly vaginal delivery with sphincter tear.
- Women who take menopausal hormone replacement therapy have a moderately increased risk.
- Children and adults with physical disabilities and/or learning disabilities.
- People with rectal or pelvic organ prolapse.
- People with neurological problems or spinal disease, for example, stroke, multiple sclerosis, spina bifida or spinal injury.
- People with late-stage Alzheimer’s disease and dementia.
What are the causes of bowel incontinence?
Several factors affect the ability to regulate bowel movement, and bowel incontinence can occur for a number of reasons:
- Muscle damage – Childbirth can be a significant factor because the muscles of the anal sphincters can be stretched or even torn during vaginal birth. There can also be nerve damage due to stretching of the nerve or a combination of direct muscle damage and nerve trauma. This usually occurs when the birth is difficult or when instruments have been used to assist delivery.
- Nerve damage – Injury to the nerves that sense faecal matter in the rectum or those that control the anal sphincter can lead to bowel incontinence.
Many things can damage these nerves, including:
– Repeated straining during bowel movements.
– Long-lasting constipation.
– Spinal cord injury.
– Multiple sclerosis (MS).
– Spina bifida.
- Anal fissure – This is a tiny tear in the skin around the anus, often caused by the area being stretched by a large stool. It can be uncomfortable and can bleed a little when defecating.
- Constipation – Chronic constipation may cause a dry, hard mass of faecal matter to form in the rectum and become too large to pass. This is known as faecal impaction. The muscles of the rectum and intestines stretch and eventually weaken. This allows watery faecal matter from further up the digestive tract to move around the impacted faecal matter and leak out. Long-lasting constipation also may cause nerve damage that leads to bowel incontinence.
- Diarrhoea – Solid faecal matter is easier to hold in the rectum than loose stools, so the loose stools of diarrhoea can cause or worsen bowel incontinence.
- Haemorrhoids – These are swollen veins in the rectum. These swollen veins can keep the anus from closing completely, letting faecal matter leak out.
- Loss of storage capacity in the rectum – Usually, the rectum stretches to accommodate faecal matter. If the rectum is scarred or stiff it can’t stretch as much as it needs to, and excess faecal matter can leak out. Things such as surgery, radiation treatment or inflammatory bowel disease (IBD) can stiffen and scar the rectum.
- Inflammatory bowel disease (IBD) – Such as Ulcerative Colitis or Crohn’s disease. These are long-term conditions that involve inflammation of the gut. IBD can cause diarrhoea which may come on suddenly.
- Irritable bowel syndrome (IBS) – IBS is a chronic condition that affects the large intestine, causing symptoms like cramping, bloating, gas, abdominal pain, diarrhoea and constipation. Bowel incontinence is one of the more common symptoms of IBS.
- Surgery – Particularly involving the rectum and anus, such as haemorrhoid removal, can cause muscle and nerve damage that leads to bowel incontinence.
- Rectocele – In women, a rectocele is a bulge (hernia) that occurs in the front wall of the rectum and pushes it into the vagina. This condition can cause bowel incontinence.
- Lifestyle and environmental issues – Such as poor toilet facilities, diet, dependence on a carer for mobility and difficulty with managing clothing can all be associated with bowel incontinence.
What are the treatments for bowel incontinence?
It is important to get medical advice if you have or suspect that you have bowel incontinence because treatment can help. Don’t be embarrassed about talking to someone about it; your GP will be used to seeing people with it, so it is not something to be ashamed of. Treatment can help improve bowel incontinence and reduce the impact it has on your life.
Depending on the cause of bowel incontinence, treatment can include one or more of the following approaches:
- Dietary changes – Think about what and when you eat. You may have noticed that eating stimulates the urge to defecate, so changing the timing of your meals and their size may help to reduce the possibility of anal leakage. For some people, eating more fibre to bulk up the faecal matter helps.
- Bowel retraining – Your GP may refer you to a continence specialist for bowel retraining, a treatment programme that involves creating a regular routine for going to the toilet and learning ways to help you empty your bowels.
- Pelvic floor exercises – These are exercises, taught by a physiotherapist or specialist nurse, that can help strengthen the muscles used to control the opening and closing of your bowels.
- Medications – The GP may prescribe medicines to reduce constipation or diarrhoea.
- Incontinence products – These can help stop you soiling your clothes, and can be useful as a short-term measure, but they do not deal with the underlying problem and are not a long-term solution on their own.
- Surgery – Surgery for bowel incontinence will only be considered if other treatments do not help.
There are several procedures including:
– A sphincteroplasty – An operation to repair damaged muscles in your anus
– Sacral nerve stimulation – Placing a small electronic device under your skin that helps the muscles and nerves in your anus work better
– Injectable bulking agents – Injecting a substance such as silicone into the muscles in your anus to help make them stronger
– A colostomy – This is only considered in rare cases. Your bowel is diverted through a hole made in your stomach so your faecal matter can be collected in a bag, externally.
Bowel incontinence is not life-threatening or hazardous, but it can affect a person’s quality of life, emotional and mental health, and self-esteem. Losing control over bodily functions can lead to feeling uneasy about being out in public. It is common for people with bowel incontinence to try to hide the problem or to avoid social engagements.
Although it may feel like an embarrassing problem to discuss with anyone, it is an issue that GPs can help with, providing treatments that help restore bowel control or reduce its severity.
Organisations providing help and support for sufferers, families and carers include:
- Bladder & Bowel Community.
- The Continence Product Advisor – A collaboration between International Consultation on Incontinence (ICI), International Continence Society (ICS), University of Southampton and University College London helping healthcare professionals, individuals and their carers to identify products and combinations to suit needs, lifestyles and preferences.
- Age UK Advice Line 0800 678 1602.
- ERIC the national charity dedicated to improving children’s bowel and bladder health FREEPHONE 0808 1699 949.
- Bowel Research UK 020 3540 8694.