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A B O U T   B O W E L  P R O B L E M S

About Fecal (Bowel) Incontinence

What is fecal incontinence?

Incontinence is the impaired ability to control gas or stool. Its severity ranges from mild difficulty with gas control to severe loss of control over liquid and formed stools. Incontinence to stool and gas is a common problem for women and can be associated with other pelvic floor problems such as urinary incontinence and prolapse. Both bladder and bowel incontinence are problems that tend to increase with age.

What causes incontinence?

There are many causes of incontinence. Injury during childbirth is one of the most common causes. These injuries may cause a separation in the anal muscles and decrease in muscle strength. The nerves supplying the anal muscles may also be injured. While some injuries may be recognized immediately following childbirth, many 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.

Anal operations or injury to the tissue surrounding the anal region similarly can damage the anal muscles and hinder bowel control. Infections around the anal area may destroy muscle tissue leading to problems of incontinence. In addition, 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.

How is the cause of incontinence determined?

Many clues to the origin of incontinence may be found in patient histories. For example, a woman's history of past childbirths is very important. Multiple pregnancies, large weight babies, forceps deliveries, or episiotomies may contribute to muscle or nerve injury at the time of childbirth. In some cases, medical illnesses and medications play a role in problems with control.

A physical exam of the anal region should be performed. It may readily identify an obvious injury to the anal muscles.

Causes of incontinence:

  • Obstetric injuries
  • Injury to anal muscles
  • Anal infections
  • Diminished muscle strength with age
  • Neurologic disorders (nerve injuries, diabetic neuropathy)

Frequently, additional studies are required to define the anal area more completely. Anorectal physiology testing has been instituted to better assess patients with defecation disorders. We use anorectal manometry to record pressure as patients relax and tighten the anal muscles. This test can demonstrate the strength of the anal muscles. Electromyography is used to determine if the nerves that go to the anal muscles are functioning properly, endoanal ultrasound to assess sphincter anatomy, and defecography to evaluate rectal anatomy and pelvic floor muscle coordination. These tests are used in conjunction with clinical assessment to better evaluate and plan for treatment of incontinence, constipation and prolapse.

What can be done to correct the problem?

After a careful history, physical examination and testing to determine the cause and severity of the problem, treatment can be addressed. Mild problems may be treated very simply with dietary changes, the use of some constipating medications, and simple home exercises that may strengthen the anal muscles to help in mild cases.

In other cases, biofeedback can be used to help patients sense when stool is ready to be evacuated and help strengthen the muscles. Injuries to the anal muscles may be repaired with surgery. Diseases that 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 ay help. New surgical treatments to restore normal bowel functioning have been developed for patients with fecal incontinence that has resulted from sphincter disruption or nerve damage. These new methods include transplanting skeletal muscles and implanting an electrical nerve stimulation device; artificial sphincters, which simulate the natural function of the anal sphincter muscles, giving the patient, control over bowel movements; and direct sacral nerve stimulation. If bleeding accompanies lack of bowel control, consult your physician. Current research into the development of an artificial anal sphincter and the use of radio frequency ablation techniques may soon find a place in treating patients with incontinence.

Treatment of incontinence may include:

  • Dietary changes
  • Constipating medications
  • Muscle strengthening exercises
  • Biofeedback
  • Surgical muscle repair
  • New techniques (artificial sphincter, radio frequency ablation)

An initial discussion of the problem with your physician will help establish the degree of control difficulty, its impact on your lifestyle, and treatment options.

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What is Constipation

Constipation is a symptom that has different meanings to different individuals. Most commonly, it refers to infrequent bowel movements, but it may also refer to a decrease in the volume or weight of stool, the need to strain to have a movement, a sense of incomplete evacuation, or the need for enemas, suppositories or laxatives in order to maintain regularity.

For most people, it is normal for bowel movements to occur from three times a day to three times a week; other people may go a week or more without experiencing discomfort or harmful effects. Normal bowel habits are affected by diet. The average American diet includes 12 to 15 grams of fiber per day, although 25 to 30 grams of fiber and about 60 to 80 ounces of fluid daily are recommended for proper bowel function. Exercise is also beneficial to proper function of the colon.

Eating foods high in fiber, including bran, shredded wheat, whole grain breads and certain fruits and vegetables will help provide the 25 to 30 grams of fiber per day recommended for proper bowel function.

About 80 percent of people suffer from constipation at some time during their lives, and brief periods of constipation are normal. Constipation may be diagnosed if bowel movements occur fewer than three times weekly on an ongoing basis. Widespread beliefs, such as the assumption that everyone should have a movement at least once each day, have led to overuse and abuse of laxatives.

What causes constipation?

There may be several, possibly simultaneous, causes for constipation, including inadequate fiber and fluid intake, a sedentary lifestyle, and environmental changes. Constipation may be aggravated by travel, pregnancy or change in diet. In some people, it may result from repeatedly ignoring the urge to have a bowel movement.

More serious causes of constipation include growths or areas of narrowing in the colon, so it is wise to seek the advice of a colon and rectal surgeon when constipation persists. Constipation may rarely be a symptom of other medical conditions.

Can medication cause constipation?

Many medications, including painkillers, antidepressants, tranquilizers, blood pressure medication, diuretics, iron supplements, calcium supplements, and aluminum containing antacids can cause or worsen constipation.

Furthermore, some people who are not actually constipated may become dependent on laxatives in an attempt to have daily bowel movements, and many cause themselves harm through laxative abuse.

How can the cause of constipation be determined?

Constipation may have many causes, and it is important to identify them so that treatment can be as simple and specific as possible. Your doctor will want to check for any anatomic causes, such as growths or areas of narrowing in the colon.

Additionally, physiologic tests to evaluate the function of the anus and rectum, similar to those performed for incontinence and x-ray studies to evaluate the transit time of swallowed "markers" help to determine the possible causes of constipation. In many cases, no specific anatomic or functional causes are identified and the cause of constipation is said to be nonspecific.

How is constipation treated?

The vast majority of patients with constipation are successfully treated by adding high fiber foods like bran, shredded wheat, whole grain breads and certain fruits and vegetables to the diet, along with increased fluids. Your physician may also recommend lifestyle changes. Fiber supplements containing undigestible vegetable fiber, such as bran, are often recommended and may provide many benefits in addition to relief of constipation.

Designating a specific time each day to have a bowel movement also may be very helpful to some patients. Biofeedback, a form of physical therapy for the sphincters may help to retrain a poorly functioning anal sphincter.

UCSF Center for Pelvic Physiology

Currently UCSF Center for Pelvic Physiology is expanding to accommodate the increasing number of patients that require evaluation for fecal incontinence, constipation and pelvic floor prolapse. This center was established in 1995 and was the only center of its kind in northern California. Over the past seven years we have evaluated and treated hundreds of patients with pelvic floor dysfunction. In addition, we have used endoanal/endorectal ultrasound to diagnose and stage rectal cancers and evaluate complex anal fistulas. Our new center will have 1) the latest state-of-the-art technology for physiologic testing, 2) comprehensive evaluations performed by a trained nurse and colorectal surgeon and 3) resources to provide a multidisciplinary approach to patients with complex pelvic floor disorders. We provide recommendations for medical or surgical treatment and offer biofeedback therapy. We also offer innovative surgical therapies for fecal incontinence such as radiofrequency ablation, artificial sphincters and sacral stimulation for those patients who have failed more conventional treatments.

Reference: Patient Information, American Society of Colon and Rectal Surgeons Website. (www.fascrs.org)

 

Questions or comments about this Web site may be sent to
coe@obgyn.ucsf.edu. Last updated: 09/11/2009

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