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Fecal Incontinence Information and Elderly Assistance

Last Updated: April 4, 2013

In 1985, while giving birth to her son, Nancy Norton received a fourth-degree laceration of her external sphincter muscle. Since that injury, Norton has managed her own fecal incontinence-the involuntary leaking of stool.

"Within an instant my life had changed dramatically and I had no idea how I was going to get through life with fecal incontinence," recalls Norton, who in 1991 founded the International Foundation for Functional Gastrointestinal Disorders (IFFGD) to address the lack of public information on fecal incontinence.

Fecal incontinence, often enshrouded in social stigma, affects up to 17 million people in the United States, according to the IFFGD. Obstetrical injuries such as Norton's are the number one cause and result in about 60 percent of cases, according to Dr. Satish Rao, professor of gastroenterology and hepatology at University of Iowa Health Care. Fecal incontinence is the second most common reason for committing the elderly to nursing homes. About one third of elderly under institutional care have it, and some estimates go as high as 47 percent.

Definition

Fecal incontinence is the inability to control bowel movements. The condition can range from an occasional leakage of stool while passing gas to a complete loss of bowel control.

"Between a third and half of the patients have impaired awareness of stool in the rectum," says Rao, "what we call an impaired rectal sensation. If you're not aware that the stool is there, by the time you know it's too late and the stool leaks out."

Healthy bowel function is controlled by rectal sensation, rectal accommodation, and anal sphincter muscles. A malfunction in one or more of these things may result in fecal incontinence. As feces move from the last part of the large intestine, called the sigmoid colon, they enter the rectum. As rectal walls stretch, they signal the need to have a bowel movement. The two anal sphincter muscles-an involuntary inner and a voluntary outer-hold the feces in the rectum until a toilet can be reached, at which time they relax and release the stool. People who suffer from fecal incontinence may not sense a full rectum and, if so, may not be able to hold feces because of damaged nerves and sphincter muscles.

Causes and Symptoms

Fecal incontinence is commonly the result of muscle or nerve injuries that accelerate the natural aging process of pelvic muscles and tissues in the elderly. It is important to note that it is not an inevitable consequence of aging, but that it may indicate a more serious condition, such as:

• Alzheimer's disease: Those suffering from late-stage Alzheimer's commonly experience fecal incontinence because of its effect on the nervous system.
• Chronic laxative abuse:Long-term, frequent reliance on laxatives to maintain regularity may cause fecal incontinence.
• Constipation:Constipation is one of the more common causes of fecal incontinence, especially in the elderly. When stools become hardened in the rectum-"impacted"-the looser, watery stool must move around the drier mass and often leaks from the anus.
• Diarrhea:Especially in cases of sphincter muscle and nerve damage, the loose stools of diarrhea are more challenging to retain in the rectum.
• Muscle damage:Damage to sphincter muscles can occur during rectal surgery or in childbirth in which episiotomy or forceps are used. In cases of damaged sphincter muscles, fecal incontinence may not show up until later in life. "[Women] have healthier tissues that compensate for lack of muscle function and so on," says Rao. "A woman who would normally become incontinent at age 80, once she has an obstetrical injury may become incontinent at age 45."
• Nerve damage:Childbirth may cause nerve damage and limit a woman's rectal sensation. Prolonged, severe straining over a lifetime may also damage nerves.
• Neurological conditions:Many diseases besides Alzheimer's that affect the nervous system may also cause fecal incontinence. Examples are multiple sclerosis, various forms of dementia, diabetes, spinal cord tumors, and spinal injuries.
• Rectal cancer:Cancer of the rectum affects the lining of the rectal walls and can lead to abnormal tissue growth that eventually harms the muscle walls or nerves that signal the need for bowel movements.
• Rectal inelasticity:Scarring from radiation or surgery can harden rectal walls, diminishing their ability to hold stool.
• Rectal prolapse:A condition usually caused by severe and chronic straining to move the bowels, it occurs when the rectum drops through the anus, or through the vagina in women.
• Stress:The stress of being in an unknown environment may contribute to an older person's lack of bowel control.
• Surgery:Virtually any operation involving the rectum and anus, including hemorrhoid removals, risks damaging the sphincter muscles.

Diagnosis

The diagnosis of fecal incontinence begins with a visit to a physician, who may refer the patient to a specialist. The physician typically asks about the patient's current and past living environments, including bowel habits. A small physical examination may follow in which the anus and perineum (the area between the anus and genitals) are examined for abnormalities such as hemorrhoids or infections. The doctor may touch the skin in these areas using a probe, testing for the normal anal response to such stimulation. A digital exam may then follow, using a gloved, lubricated finger to check anal strength and rectal walls.

A number of ways can be used to determine the exact cause of your loved one's fecal incontinence:

• Anal manometrytests anal strength and rectal response by the insertion of a tube and inflatable balloon into the rectum through the anus. Rectal sensation is tested by delicately inflating and deflating the balloon. According to Rao, manometry is the most accurate and effective tool to determine the cause and severity of fecal incontinence.
• Anorectal ultrasonographyevaluates the structure of the sphincter with a wand-like instrument inserted into the anus and rectum. The wand emits sound waves used to create an image of the rectum.
• Defecography(or proctography) uses X-rays to view the shape and position of the rectum during defecation.
• Anal electromyography (EMG)tests the nerve function in the muscles around the anus by using tiny needle electrodes.
• Flexible sigmoidoscopy/colonoscopyuses a long, slender, flexible tube with a video camera attached to explore the last two feet of the colon for abnormalities.