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Saturday, August 23, 2025

Bowel incontinence


Bowel Incontinence (Fecal Incontinence)

Introduction

Bowel incontinence is the involuntary loss of stool (solid or liquid) or flatus (gas). It affects about 2–7% of the general population, more common in older adults and women (due to childbirth-related pelvic floor injury).

It may be:

  • Urge incontinence: Sudden need to defecate, inability to reach toilet in time.

  • Passive incontinence: Leakage without awareness.

  • Soiling: Minor leakage after normal defecation.

Pathophysiology

Normal continence requires:

  • Intact anal sphincter muscles (internal + external).

  • Proper rectal sensation and compliance.

  • Functional pelvic floor muscles.

  • Normal stool consistency.

  • Neurological control (spinal cord and brain).

Incontinence occurs when one or more of these mechanisms fail.

Causes of Bowel Incontinence

1. Anal Sphincter Injury

  • Obstetric trauma (forceps delivery, episiotomy).

  • Anal surgery (fistula repair, hemorrhoidectomy).

  • Traumatic injury.

2. Neurological Causes

  • Spinal cord injury.

  • Stroke.

  • Multiple sclerosis.

  • Diabetic neuropathy.

  • Dementia.

3. Gastrointestinal Disorders

  • Chronic diarrhea (IBS, infections, inflammatory bowel disease).

  • Constipation with overflow leakage.

  • Rectal prolapse.

  • Hemorrhoids (interfere with closure).

4. Age-Related Factors

  • Weak sphincter muscles.

  • Reduced rectal compliance.

  • Impaired sensation.

5. Miscellaneous

  • Radiation damage to rectum.

  • Congenital malformations (spina bifida, imperforate anus).

  • Severe systemic illness.

Clinical Features

  • Involuntary leakage of stool (solid, liquid, mucus) or gas.

  • Frequency: occasional → daily.

  • Urgency, inability to hold stool.

  • Soiling of underwear.

  • Associated: diarrhea, constipation, abdominal pain, rectal prolapse, hemorrhoids.

  • Psychological: embarrassment, social withdrawal, depression.

Diagnostic Approach

1. History

  • Duration, severity, stool type (Bristol chart).

  • Associated bowel symptoms (diarrhea, constipation).

  • Obstetric or surgical history.

  • Neurological disease history.

  • Medications (laxatives, antibiotics).

2. Examination

  • Perianal inspection: skin irritation, scars, prolapse, hemorrhoids.

  • Digital rectal exam: sphincter tone, fecal impaction, masses.

  • Neurological exam (perineal sensation, reflexes).

3. Investigations

  • Stool tests: Infection, inflammation, parasites.

  • Blood tests: CBC, thyroid function, glucose, electrolytes.

  • Colonoscopy / sigmoidoscopy: Polyps, tumors, colitis.

  • Anorectal manometry: Anal sphincter pressures, rectal sensation.

  • Endoanal ultrasound / MRI: Detect sphincter defects.

  • Defecography (X-ray/MRI): Rectal prolapse, pelvic floor dysfunction.

Management and Treatment

Treatment depends on severity, cause, and patient preference. It includes lifestyle, medications, physiotherapy, devices, and surgery.

A. General / Lifestyle Measures

  • Regular bowel habits.

  • Diet:

    • High-fiber foods (20–30 g/day) to bulk stool.

    • Avoid caffeine, alcohol, spicy foods if they worsen symptoms.

  • Fluid balance: adequate hydration.

  • Bowel diary to track symptoms.

  • Perianal skin care (barrier creams to prevent dermatitis).

B. Pharmacological Treatment

1. Antidiarrheal Agents (if loose stools)

  • Loperamide: 2–4 mg orally after each loose stool (max 16 mg/day).

  • Diphenoxylate–atropine: 2.5–5 mg orally three to four times daily.

2. Stool Bulking Agents (for loose stool or mild incontinence)

  • Psyllium husk: 3.4 g orally 1–3 times daily with water.

  • Methylcellulose: 2 g orally once or twice daily.

3. Osmotic Laxatives (for constipation with overflow)

  • Lactulose: 15–30 mL orally once or twice daily.

  • Polyethylene glycol (PEG): 17 g dissolved in water daily.

4. Antibiotics (if infective diarrhea cause)

  • Ciprofloxacin 500 mg orally twice daily × 5–7 days.

  • Metronidazole 400 mg orally three times daily × 7 days (for C. difficile, anaerobic infection).

5. Bile Acid Sequestrants (for bile acid diarrhea after gallbladder surgery)

  • Cholestyramine: 4 g orally once or twice daily.

6. Neuromodulators (reduce bowel urgency, pain)

  • Amitriptyline 10–25 mg orally at night.

C. Pelvic Floor and Physiotherapy

  • Pelvic floor (Kegel) exercises: Strengthen anal sphincter muscles.

  • Biofeedback therapy: Improves awareness of rectal sensation and sphincter control.

  • Electrical stimulation: Adjunct for refractory cases.

D. Devices and Minimally Invasive Options

  • Anal plugs / inserts: For patients with severe soiling.

  • Sacral nerve stimulation (SNS): Implantable device stimulating sacral nerves, improves sphincter control.

  • Radiofrequency energy therapy: To strengthen anal sphincter.

E. Surgical Options (for severe / refractory cases)

  • Sphincteroplasty: Repair of torn anal sphincter (usually obstetric injury).

  • Injectable bulking agents: Collagen or synthetic material injected into anal canal.

  • Gracilis muscle transposition: Muscle graft around anus.

  • Artificial bowel sphincter (rare).

  • Stoma (colostomy): Last resort for uncontrollable cases.

Complications

  • Social isolation, embarrassment.

  • Anxiety, depression.

  • Perianal dermatitis, infections.

  • Anal fissures due to chronic leakage.

  • Malnutrition (if associated with chronic diarrhea).

Prognosis

  • Mild cases: Improve with diet, fiber, and antidiarrheal therapy.

  • Moderate cases: Often respond to biofeedback, pelvic floor therapy, loperamide.

  • Severe cases: May require surgery or nerve stimulation, but quality of life can be significantly improved.

Patient Education

  • Bowel incontinence is common and treatable — not a sign of weakness.

  • Maintain regular toilet routine and high-fiber diet.

  • Perform pelvic floor exercises daily.

  • Take medications as prescribed to regulate stool consistency.

  • Seek medical help if:

    • New-onset incontinence.

    • Associated with blood in stool, weight loss, or severe diarrhea.

    • After childbirth or anal surgery.



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