Incontinence (bowel)

Bowel incontinence, also known as faecal incontinence, is the involuntary loss of bowel control resulting in unexpected leakage of stool or gas. This condition can vary from occasional soiling to complete loss of control over bowel movements. It is often distressing for patients, affecting their physical, emotional, and social well-being.

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Causes of Bowel Incontinence

Bowel incontinence can occur due to multiple factors, including structural, neurological, or functional issues.

• Muscle Damage

  • Injury to the anal sphincter muscles, often due to childbirth, anal surgery, or trauma.

• Nerve Damage

  • Damage to the nerves that sense stool or control the anal sphincter, commonly seen in conditions such as diabetes, spinal cord injury, multiple sclerosis, or stroke.

• Chronic Constipation

  • Leads to stretching and weakening of the rectum and anal muscles.

  • May also cause impaction, leading to overflow diarrhoea.

• Diarrhoea

  • Loose stools are harder to control than formed stools.

  • Gastrointestinal infections, inflammatory bowel disease (IBD), or irritable bowel syndrome (IBS) can contribute.

• Rectal Conditions

  • Rectal prolapse or rectocele.

  • Reduced rectal compliance in radiation proctitis or post-surgical states.

• Age-related Changes

  • Weakening of pelvic floor muscles.

  • Reduced rectal capacity and sensation.

• Other Contributing Factors

  • Cognitive impairment (e.g., dementia).

  • Mobility limitations that delay access to the toilet.

  • Side effects of medications such as laxatives, antibiotics, or chemotherapy.

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Symptoms of Bowel Incontinence

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

• Urgency with inability to reach the toilet in time.

• Staining of underwear.

• Soiling associated with diarrhoea or constipation.

• Skin irritation and soreness around the anus.

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Diagnosis

Diagnosis is based on history, clinical examination, and specialised investigations:

• History and Symptom Diary

  • Frequency, type of stool leakage, triggers, and associated bowel habits.

• Physical Examination

  • Inspection and digital rectal examination to assess sphincter tone and rectal abnormalities.

• Investigations

  • Anal manometry (measuring anal pressure and muscle function).

  • Endoanal ultrasound or MRI to assess sphincter integrity.

  • Colonoscopy if there are alarm features (e.g., blood in stool, weight loss).

  • Nerve conduction studies in suspected neurological causes.

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Management and Treatment

1. Lifestyle and Behavioural Interventions

• Dietary Modifications

  • Increase fibre intake for formed stools (e.g., psyllium, methylcellulose).

  • Avoid diarrhoea-inducing foods (caffeine, alcohol, fatty or spicy foods, lactose in intolerant patients).

• Fluid Intake

  • Adequate hydration but avoid excess caffeinated or alcoholic beverages.

• Toilet Training and Bowel Retraining

  • Scheduled bowel movements after meals.

• Pelvic Floor Muscle Training (PFMT)

  • Kegel exercises to strengthen pelvic floor muscles.

• Biofeedback Therapy

  • Improves coordination of pelvic floor and anal muscles.

2. Medications

• Antidiarrhoeal agents

  • Loperamide 2–4 mg up to 16 mg/day, reduces stool frequency and improves consistency.

• Stool-bulking agents

  • Psyllium husk or methylcellulose to improve stool form.

• Anticholinergics or tricyclic antidepressants (in selected cases of diarrhoea-predominant IBS).

• Topical barrier creams (zinc oxide, petroleum jelly) to protect perianal skin.

3. Treatment of Underlying Cause

• Management of constipation (laxatives, enemas, stool softeners).

• Treatment of infections (antibiotics for bacterial enteritis).

• Management of inflammatory bowel disease with anti-inflammatory or immunosuppressive agents.

• Surgical repair in rectal prolapse or sphincter injury.

4. Surgical and Procedural Options

• Sphincteroplasty – repair of anal sphincter if damaged.

• Injectable bulking agents – increase anal canal resistance.

• Sacral Nerve Stimulation (SNS) – improves sphincter control via neuromodulation.

• Colostomy – last resort for severe, refractory cases.

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Precautions and Self-care

• Regular perianal hygiene to avoid skin breakdown.

• Wearing absorbent pads or incontinence products if leakage is frequent.

• Keeping a bowel diary to track triggers and improvements.

• Psychological support or counselling to address embarrassment and social withdrawal.

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Prognosis

Bowel incontinence can be controlled or significantly improved in many cases with combined lifestyle, medical, and sometimes surgical approaches. Early assessment and tailored treatment improve outcomes and quality of life.