Treating Fecal Incontinence

Fecal incontinence can be treated, and it is up to you and your doctor to decide which treatment is best for you. Choices range from bowel training regimens to extensive surgery. The approach you select will depend on the cause and severity of your fecal incontinence. In most cases, treatment begins with nonsurgical options. To help you gain the best possible control, physicians often recommend a combination of approaches.

Diet and medication

The good news is that your diet can have a major impact on your bowel function, changing the consistency of the stool and the predictability of your bowel movements. That means there are potentially beneficial changes that you can make, such as increasing the fiber content of your diet or eliminating foods that irritate your system. Depending on your symptoms, your doctor may suggest diet changes to improve bowel control or make your condition easier to manage.

Virtually everyone can derive some benefit from dietary advice. For example, people with sphincter problems can gain better control by taking steps to eliminate diarrhea. Symptoms of irritable bowel syndrome can be helped by identifying and eliminating specific irritating foods.

Controlling diarrhea

Diarrhea is the most common aggravating factor in fecal incontinence. If you tend to have loose stools, you may be able to make them firmer and easier to control by adding fiber to your diet or by taking a bulking agent or fiber supplement such as Citrucel or Konsyl. Because high-fiber diets are often recommended for people with constipation, it may seem counterintuitive to add fiber if you already have diarrhea. But dietary fiber can absorb up to 30 times its weight in water, thereby producing formed but soft stools. Good sources of dietary fiber are bran cereals, uncooked fruits and vegetables, whole-grain breads and pasta, and brown rice. This will "normalize" your bowels.

Specific foods trigger diarrhea in some people. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has identified a number of foods to try eliminating from your diet to see if your symptoms improve. According to the NIDDK, potential sources of trouble may include caffeine, cured or smoked meats, spicy foods, alcohol, dairy products, fruits, fatty and greasy foods, and sweeteners (such as sorbitol, xylitol, mannitol, and fructose) that are found in many diet drinks, fruit drinks, sugarless gum, and candies.

Your physician may also advise a change in the medications you take for other conditions, in case they are contributing to diarrhea and incontinence problems. As an example, the antidiabetic drug metformin (Glucophage) may result in chronic diarrhea that begins long after starting the drug. Orlistat (Xenical), a medication used to treat obesity, decreases the absorption of fat from the digestive tract. Side effects include several distressing bowel symptoms, including oily seepage from the rectum, fecal urgency, and fecal incontinence (in less than 10% of users). Serious gastrointestinal side effects, including fecal incontinence, have resulted when people using orlistat consumed snack foods that contained the fat substitute Olestra.

If food seems to move through your digestive system rapidly, your doctor may suggest an antidiarrheal medicine such as loperamide (Imodium) or diphenoxylate and atropine (Lomotil) to solidify your stools and make them less frequent. Loperamide has the side benefit of increasing muscle tone in the internal anal sphincter, which may also help with incontinence. The tricyclic antidepressant amitriptyline also reduces the number of bowel movements and has been successfully used to improve fecal incontinence, although not in a controlled study.

Managing constipation

If your fecal incontinence is related to constipation, your health professional may suggest ways to train yourself to have regularly timed bowel movements. These may include increasing your fiber and fluid intake and using various stimuli (from a warm drink to an enema, depending on need) to encourage a bowel movement at set times.

Pelvic muscle exercises and biofeedback

No matter what causes your fecal incontinence, you may be advised to use Kegel exercises (see "Pelvic floor exercises") to strengthen your pelvic floor and sphincter muscles. Although there are not good data comparing pelvic muscle exercises to other treatments (or to no treatment at all), the exercises are a good first step and can be combined with other treatments.

Biofeedback training may help fecal incontinence in two ways — by helping you strengthen and coordinate the action of your sphincter muscles and by improving your ability to sense the presence of stool in the rectum.

During a biofeedback session aimed at strengthening your pelvic muscles, the practitioner inserts a slim sensor into your rectum (in women, it is sometimes placed in the vagina, or an additional sensor is used). Other electrodes on your abdomen help record muscle contractions there. A computer screen provides feedback about the strength of your contractions and whether you are using the correct muscles.

If the biofeedback training is aimed at improving your ability to sense stool in the rectum, the practitioner will use anorectal manometry equipment to vary the pressure in your rectum.

Whether biofeedback will help depends on the cause and severity of your incontinence and your ability to learn and practice the exercises. According to an international consensus panel that met in 1999, biofeedback helps about 75% of people with fecal incontinence, providing complete relief for about 50%. Some controlled trials demonstrated only modest improvements, but biofeedback and exercise are so safe they are usually recommended prior to more invasive treatments. You are most likely to benefit if your incontinence is due to nerve damage caused by vaginal deliveries, but biofeedback also aids some people with minor structural defects in their sphincters.

Pelvic muscle conditioning without exercise. Electrical stimulation (see "Conditioning without exercise") is sometimes used to treat fecal incontinence. Although there are numerous reports of its value, no controlled studies have clearly demonstrated its relative effectiveness in comparison with biofeedback or no treatment. In one 2006 British study, electrical stimulation modestly improved bowel control, but so did a placebo treatment of low-level electrical stimulation. When biofeedback supplemented with electrical stimulation was compared with biofeedback alone in treating postpartum fecal incontinence, both groups benefited equally. Nationally, Medicare does not require or prohibit coverage for this treatment for fecal incontinence. Local carriers make the decision.

Magnetic stimulation of the pelvic floor muscles (see "Conditioning without exercise"), already FDA-approved for treating urinary incontinence, improved patient ratings and pressure measurements related to bowel control in a pilot study on fecal incontinence.

Surgical treatments

Different surgical approaches are used for fecal incontinence, depending on the cause of the symptoms and your response to previous treatments. Some have been around for years, although the techniques are always being modified to improve results. If fecal incontinence is caused by damage to the anal sphincter, perhaps from a tear during vaginal delivery, a fracture, or a past operation, surgery may help to repair it. Other surgeries help repair defects in the pelvic floor muscles. When there is extensive nerve damage as well as sphincter problems, a surgeon can use a transplanted piece of muscle or an artificial sphincter to create a mechanism for fecal control.

Sphincteroplasty

If your anal sphincter was damaged during childbirth, another trauma, or anal surgery, your physician may suggest a sphincteroplasty to repair it. The external anal sphincter forms a ring around the anus, so if there is a breech or interruption in the ring of muscle, you may not be able to close it tightly enough to keep stool in. During a sphincteroplasty, the surgeon will reattach the damaged ends and stitch them together to create a complete ring of muscle, restoring the anus to its proper shape. Sphincteroplasty has been used for decades and is the most common surgery used to treat fecal incontinence. Careful evaluation before surgery is important because sphincteroplasty is mainly effective in patients without nerve damage.

If sphincter damage is severe, your surgeon may perform a temporary colostomy, in which your colon is attached to an opening in your abdomen covered with a colostomy bag, to avoid exposing your anus to stool while it heals. You will also use a catheter to urinate for a day or so. You may be in the hospital for several days and need a month or more of recovery after the colostomy is undone before you regain normal bowel habits and return to your usual activities.

While healing, you may have quite a bit of discomfort, bruising, and swelling in the wound area. Wound infections are common after sphincteroplasty and all surgeries in the anorectal area. Be scrupulous about postoperative instructions on cleaning and caring for the wound.

Sphincteroplasty is initially successful in up to 75% of carefully selected patients with intact nerve function. However, there have been discouraging reports about deteriorating function over time. In two separate studies, surgeons contacted patients 4–12 years after sphincter repair. At one center, all of the repairs were for obstetric injuries; the other involved a more diverse group of traumatic injuries. At least half of the patients were experiencing urinary or fecal incontinence, had required further surgery, or had developed other bowel problems.

If incontinence is still a problem after the surgery, your surgeon may recommend biofeedback. Some surgeons suggest it for all patients as soon as the wound is healed, in order to maximize the chance of a good outcome.

Pelvic floor surgeries

Your clinician may recommend pelvic floor surgery if your sphincter muscle is not damaged but sagging pelvic floor muscles are causing your fecal incontinence. This operation surgically repositions the pelvic floor muscles to restore the normal angle between the colon and rectum.

In a posterior anal repair, the surgeon makes an incision behind the anus and places sutures to tighten up the pelvic floor muscles. Unfortunately, this procedure is not very successful over the long term, and many patients require repeated surgeries. For that reason, it is rarely performed in the United States, except in combination with an anterior levatorplasty, which approaches the muscles from an incision in front of the anus.

The combination of the two procedures is called a total pelvic floor repair. The surgeon may also perform a sphincteroplasty during the operation. More than half of patients seem to improve after this major surgery, but the results are sometimes disappointing. You are not likely to be offered this surgery unless biofeedback has failed to improve your symptoms and you have serious nerve and muscle damage to the pelvic floor.

Dynamic graciloplasty

If your sphincter is damaged and there is nerve damage as well, the surgeon can wrap a piece of the gracilis muscle, from the inner thigh, around the anus to substitute for the damaged sphincter. To keep the anus closed, preventing stool from leaking out, an electrode is implanted in the muscle to send it signals to stay contracted. Although the idea of using the gracilis has been around since the 1950s, success was minimal until the development of the implanted stimulator.

In a report in Diseases of the Colon and Rectum in 2002, researchers from the Cleveland Clinic Florida found that two years after this surgery, patients needed half as many pads to control their incontinence. The number of incontinent episodes involving solid stool dropped from 9.3 to 1.3 per week. And those involving liquid were reduced from 9.1 to 3.5.

Persistent complications following dynamic graciloplasty can include obstructed defecation and ongoing pain or swelling in the donor leg.

Artificial sphincter

If other surgery fails or if nerve damage is severe, an artificial sphincter may be inserted. In 2001, the FDA approved the Acticon Neosphincter, an implanted device that keeps the anus closed until the patient squeezes a control pump to open it and allow a bowel movement to pass. For a male patient, the control pump is implanted in the scrotum; for a female patient, in the labia. Afterward, the cuff gradually closes, in much the same way as the artificial urinary sphincter does (see "Artificial sphincters").

In follow-up studies, the use of an artificial sphincter significantly improved quality of life in patients who had the device successfully implanted. However, up to half of patients require repeat surgery or removal of the device for various complications, including infection.

To be a candidate for this operation, you must have the manual dexterity to work the pump. After it is implanted, you will not be able to deliver a baby vaginally or engage in anal intercourse, either of which could damage the cuff.

Colostomy

Usually as a last resort, elimination can be entirely diverted from the rectum and anal canal through a surgically created opening. In a colostomy, the surgeon sutures the end of the bowel to an opening on the surface of the body, usually on the abdomen. The surgery is performed under general anesthesia and requires several days of hospitalization.

After a colostomy, you will need to wear a small pouch outside your body to collect waste material, and to care for the opening on the skin (called the ostomy). Modern ostomy bags are not visible when you are dressed, and they control odor so effectively that others need not be aware you have had the surgery.

Sacral neuromodulation

In Europe, InterStim sacral nerve stimulation is used to treat fecal as well as urinary incontinence (see "Surgery for urge incontinence"). In a study of 34 patients treated in European centers, the frequency of incontinence episodes decreased from an average of 16.4 per week to 3.1 at one year and 2.0 at two years. In the United States, a multicenter trial is testing whether InterStim can aid fecal incontinence by providing continuous low-level stimulation to sacral nerves controlling the rectal and sphincter muscles through a surgically implanted electrode.