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Incontinence

The Non-Surgical Treatment of Faecal Incontinence

This general guide is designed to provide background information but may not deal with some areas that are of particular concern to you.  These can be dealt with individually and you should feel free to ask about any aspect of your care including the up to date operations which can be offered for incontinence.

What is Faecal Incontinence?

Faecal incontinence is the involuntary passage of wind (flatus) or stool from the anus.  It can range from an intermittent, minor social inconvenience to a constant debilitating condition that makes patients become social recluses.

The Principals that Underlie the Management of Faecal Incontinence

Imagine an upside down balloon that contains a mixture of solid, liquid and air.  The reason this mixture does not fall out the bottom of the balloon is that it is sealed with an elastic band (the anal sphincter muscle).  Provided the tightness in the band is greater than the pressure in the balloon, the mixture will not leak out the bottom.  Leakage normally occurs for two reasons.  First, the pressure in the balloon rises abnormally high and above the tightness of a normal elastic band.  At some point the pressure in the balloon (the bowel) will become so high it overcomes the normal pressure in the band (the anal sphincter) and leakage occurs.  Alternatively, the tightness in the band may fall so low it cannot retain the contents of the balloon even at normal pressure.

The principals that underlie the treatment of faecal incontinence are to determine why there is an imbalance between the pressure in the balloon and the tightness of the band.  This requires a full clinical evaluation and may require special x-rays and other tests to determine the exact cause of the incontinence.  Almost all patients initially require non-surgical treatment in the first instance and for many patients there is no role for surgery
which may even make the situation worse.

Causes

In broad terms the common causes are:-

    Problem
    Cause
    Weak pelvic floor or damage to the anal sphincter muscles childbirth and / or anal operations
    Damage to the nerves of the pelvic floor muscles childbirth, spinal injury, nervous diseases (eg multiple sclerosis), prolonged straining, diabetes infection, inflammatory bowel disease, irritable bowel syndrome, previous bowel resection, diet, constipation, immobility, inflammatory bowel disease
    Liquid or loose stool
    Rigid or irritable rectum (loss of storage)

The Anal Sphincters

The most common cause of faecal incontinence is damage or weakness to one or both of the anal sphincter muscles.

A weak external sphincter muscle typically causes urge incontinence.  This is the need to rush to the toilet as soon as the need to defaecate is felt,
and there is a risk of being accidentally incontinent if the toilet is not reached in time.  This occurs because the weak muscle cannot squeeze hard
or long enough to hold in the stool.

A damaged internal anal sphincter typically causes passive soiling as soft stool, or small pellets of stool, just leak out.  There may be great difficulty in wiping clean after emptying the bowel.  Sometimes there is damage to both the sphincter muscles, and this may lead to leakage without awareness, as well as urgency and urge incontinence.

Stool Consistency

The stool consistency is greatly influenced by what we eat and drink.  If your stool is too soft it will ‘break up’ during defaecation and smear to cause an itching bottom. Firmer stool will be easier to control if the sphincter muscles are weak. Here is some general dietary advice which largely looks like avoiding some foods you have always been told are good for people (including fibre, fruit and fluids)!

    Fluids

    You should drink no more than 1 litre of fluid per day.  Excess fluid will tend to make your stool softer.  Alcohol may make the stool loose.  Because of its volume and yeast, beer is often worse than other drinks.

    Caffeine

    Caffeine is found in coffee, tea, cola drinks and chocolate.  Caffeine stimulates the bowel and as the stool then passes through faster, less fluid is absorbed and the stools are looser. Caffeine also relaxes the anal sphincter.  Exclude caffeine from your diet and see if you improve.

    Artificial Sweeteners

    Artificial sweeteners are sugars that are not absorbed by your body.  Some non-absorbable sugars are used as a laxative.  Not surprisingly artificial sweeteners may make the stools loose, or even cause diarrhoea.  It may be worth eliminating all artificial sweeteners and seeing if this helps.  Artificial
    sweeteners are found in most foods and drinks branded as ‘low calorie’, including ‘Diet’ drinks and low sugar chewing gum.

    Fibre

    Although fibre is good, it can make incontinence worse as it keeps fluid in the bowel and makes the stools loose and more likely to leak.  As fibre stimulates the bowel you have to visit the toilet more often.  Initially you should omit foods, which are obviously high in fibre.  Soluble, or digestible fibre (eg bananas, potatoes, rice, pasta, oatmeal) is less likely to cause a problem. Spicy or hot food can simulate the bowel to empty with reduced warning.  Other foods, such as some biscuits, marshmallows and bananas can help to bulk the stool.

    Other  foods

    Some people find specific foods make matters worse.  Try excluding food in sequence over a few days and see how you are affected.  Foods that are often implicated include smoked products, fatty and dairy foods.

    Medications

    Many medications influence the stool consistency either increasing or decreasing the bowel frequency.

Medications

Medicines for incontinence may be used to solidify a soft stool, to make the bowel squeeze less strongly or to ensure the rectum empties fully.  Some
may increase the tone of the sphincter muscles.  If diarrhoea is present, reating this should lessen frequency and urgency and make incontinence less
likely.  If you are opening your bowels more than once each day and have soft or loose stool you may benefit from the use of such medications.

    Suppositories

    Often best used first thing in the morning, it will usually be able to hold in the suppository for 20-30 minutes.  This will then give a good bowel action that should not require you to linger on the toilet, nor require you to strain.  The rectum will then be empty and should not contain any stool to leak out during the day.

    Loperamide (Imodium)
    Codeine phosphate


    These drugs slow the passage of stool through the colon.  More water is then absorbed and the stool becomes firmer and so less likely to leak.  It is usually best to take these medicines before food rather than after.

    Loperamide makes the stool firmer to reduce the passive seepage of loose stool.  The ideal dose needs to be individually determined as it is difficult to predict the dose that will be effective, but not cause constipation.

    Codeine phosphate has a similar, but more powerful effect.  Some people find one or other of these drugs works best for them, or that a lower dose, but in combination, is better.  You should experiment to find the regime that suits you best which may be easier by using syrup if one tablet has too powerful effect.

    Bulking agents

    If the stools are very loose, especially if there seems to be a lot of mucus, medications such as Fybogel can absorb excess fluid and produce a more formed stool.

Pelvic Floor Exercises

Sphincter exercises can help to reduce the effects of a weakened pelvic floor.  These exercises strengthen the external anal sphincter to help you to hold both flatus and stool.  Women may be familiar with these exercises if they practised them during  pregnancy.  A physiotherapist will show you the exercises, but they will only work if you perform them frequency and completely.  Overall the aim is to strengthen pelvic muscles and improve the sequence of their contraction.

 

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