Bowel Incontinence

What is bowel incontinence?
Bowel or faecal incontinence is the inability to control bowel movements, including stool and flatus (wind), from the anal canal (back passage). For some people this can happen with no feeling or warning and is known as passive incontinence. Others have an urgent need to have a bowel movement but are unable to hold onto it, which is known as urgent bowel incontinence.

It can be very distressing to experience these symptoms and many people do not go to their doctor for help and advice as they feel embarrassed. There are however many different options available to help manage and improve bowel incontinence symptoms so that it does not limit everyday life.

What causes bowel incontinence?
Bowel incontinence is not a disease, but it can develop as a consequence of other medical or physical problems including:

• a weakness of the anal sphincter muscles
• a weakness of the rectum
• and or damage to the nerves that control our ability to pass stool

The anal sphincter muscles work in combination with the pelvic floor muscles to maintain control of bowel movements. These muscles are normally contracted and held closed, relaxing only when the nerve signal is received that the rectum is full and a bowel motion is needed. When these muscles become weak they are unable to hold close as tightly and stool or flatus (wind) may seep out without warning or control. Weakness may occur as a result of hormonal changes, the effects of childbirth, obesity and chronic straining.

Chronic straining due to constipation can also cause weakness to the muscle wall of the rectum. The rectum is the bowels storage area at the end of the large bowel and stretches to accommodate stool until it is convenient to have a bowel motion. If the stool is constipated and hard to pass, straining increases the pressure on the rectum muscles, which over time weakens them, sometimes causing the rectum to prolapse down and out of the anal canal. Liquid stool can pass over the top of the constipated stool (overflow diarrhoea) and can leak out of the bottom.

Stool motion that is loose or liquid (diarrhoea) is harder for the weakened muscles of the pelvis to control. Certain medications, a high fibre diet and conditions of the bowel including irritable bowel diseases and coeliac disease can cause the stool to be loose or watery (diarrhoea).

What tests might I have?
In order to help understand the cause of your bowel incontinence and treat you correctly, your specialist may advise that you have certain tests. These may include any or all of the following:

• Blood tests – to check the thyroid gland is working correctly and check your calcium levels.
• Physical examination – your specialist will examine both your tummy and perform an internal finger examination of your back passage putting a gloved finger into your bottom. They may ask you to squeeze your anal canal so they can assess your anal tone (strength of your muscles).
• Ano-rectal physiology (manometry) – a catheter probe with a small balloon is inserted into the anal canal. The other end is attached to a machine which measures the pressure in the balloon as you are asked to squeeze and relax the muscles in your rectum. The balloon is also filled gradually to measure the volume and compliance of the rectum. This gives information as to how toned the muscles in your rectum and anal canal are and how well the muscles and nerves work together to co-ordinate a bowel motion.
• Endoanal ultrasound – an internal probe is passed into the anal canal and uses ultrasound to image the anal sphincter muscles.
• Defaecating Proctogram – a special barium paste enema which shows up on x-rays is inserted into the anal canal. A series of x-rays are then taken as the enema is passed naturally into a specially designed toilet. Although the test can cause embarrassment it may be necessary to provide information to help to understand your constipation symptoms and every effort will be taken to maintain your dignity and privacy.
• Flexible sigmoidoscopy/Colonoscopy/CT Colonoscopy – a fine endoscopic tube is passed into the anal canal and examines the inner lining of the bowel. Either the full length of the bowel is viewed (colonoscopy) or the examination is limited to the rectum and last section of the large bowel (flexible sigmoidoscopy). This test is used to eliminate any other problems within the bowel.

What is the treatment for bowel incontinence?
It is important to understand the cause of the bowel incontinence in order to treat it correctly however for many people it is possible to improve symptoms through dietary and lifestyle changes.

• Reduce intake of caffeine (coffee, tea, cola) and fizzy drinks as these stimulate the bowel to work quicker and cause the stool to be loose.
• Reduce intake of insoluble fibres that are not digested by the bowel. These include seeds, wholegrain breads, bran, high fibre cereals, nuts and skins on fruit and vegetables. Soluble fibre is needed as it helps to absorb water in the bowel helping the stool to bind together and not be as loose. Oats are a good source of soluble fibre.
• Limit or avoid foods high in fat as these can cause diarrhoea.

Non-surgical management of bowel incontinence includes:
Biofeedback
This is a 12 week course of specialist physiotherapy to retrain the pelvic floor muscles and is performed in the physiotherapy department. Biofeedback uses a combination of exercises and specially designed sensors to help stimulate the muscles within the pelvic floor helping you to both locate and strengthen or relax them. Approximately 60% of patients report a significant improvement in their symptoms with Biofeedback alone. It is also used before any surgery is undertaken to improve the overall outcome.
Rectal irrigation
This involves washing out the anal canal and rectum with water. It is performed after a bowel motion to remove any stool that has not been passed naturally. A small, soft tube is gently introduced inside the anal canal. The tube is attached to a bag containing water. Water is slowly introduced into the anal canal, the tube is removed and the water passed into the toilet with any stool remaining in the rectum. This can be done after each bowel motion to make sure the rectum is fully clear; on a daily basis or whenever you feel it is needed. If your health professional advises rectal irrigation therapy you will be taught to use the equipment at home by a trained bowel specialist who will visit and support you. Afterwards you will be able to perform the procedure by yourself in the privacy of your own bathroom.

Other available support:
National Key Scheme (NKS) – a key that gives you access to disabled toilets nationwide. This can be purchased from Disability Rights UK. You can contact them on: 020 72508181 or visit https://www.disabilityrightsuk.org/
Just can’t wait toilet card improves your access to toilets in different locations without the need for explanation. The card can be purchased through the Bowel and bladder foundation. You can contact them on: 0845 345 0165

For more support or information on any of the above, please contact the Colorectal Functional Nurse Specialist on 01274 365554. This number is available Monday – Friday, between the hours of 8.00am and 4.00pm. Outside of these times a voicemail message service is available. Please leave your details and your call will be returned within the next 2 working days.