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Anatomy of the rectum and anus.
Fecal incontinence is the inability to control your bowels. When
you feel the urge to have a bowel movement, you may not be able to
hold it until you can get to a toilet. Or stool may leak from the
More than 5.5 million Americans have fecal incontinence. It
affects people of all ages--children as well as adults. Fecal
incontinence is more common in women than in men and more common in
older adults than in younger ones. It is not, however, a normal part
Loss of bowel control can be devastating. People who have fecal
incontinence may feel ashamed, embarrassed, or humiliated. Some
don't want to leave the house out of fear they might have an
accident in public. Most try to hide the problem as long as
possible, so they withdraw from friends and family. The social
isolation is unfortunate but may be reduced because treatment can
improve bowel control and make incontinence easier to manage.
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Fecal incontinence can have several causes:
- damage to the anal sphincter muscles
- damage to the nerves of the anal sphincter muscles or the
- loss of storage capacity in the rectum
- pelvic floor dysfunction
Constipation is one of the most common causes of fecal
incontinence. Constipation causes large, hard stools to become
lodged in the rectum. Watery stool can then leak out around the
hardened stool. Constipation also causes the muscles of the rectum
to stretch, which weakens the muscles so they can't hold stool in
the rectum long enough for a person to reach a bathroom.
Fecal incontinence can be caused by injury to one or both of the
ring-like muscles at the end of the rectum called the anal internal
and/or external sphincters. The sphincters keep stool inside. When
damaged, the muscles aren't strong enough to do their job, and stool
can leak out. In women, the damage often happens when giving birth.
The risk of injury is greatest if the doctor uses forceps to help
deliver the baby or does an episiotomy, which is a cut in the
vaginal area to prevent it from tearing during birth. Hemorrhoid
surgery can damage the sphincters as well.
Fecal incontinence can also be caused by damage to the nerves
that control the anal sphincters or to the nerves that sense stool
in the rectum. If the nerves that control the sphincters are
injured, the muscle doesn't work properly and incontinence can
occur. If the sensory nerves are damaged, they don't sense that
stool is in the rectum. You then won't feel the need to use the
bathroom until stool has leaked out. Nerve damage can be caused by
childbirth, a long-term habit of straining to pass stool, stroke,
and diseases that affect the nerves, such as diabetes and multiple
Normally, the rectum stretches to hold stool until you can get to
a bathroom. But rectal surgery, radiation treatment, and
inflammatory bowel disease can cause scarring that makes the walls
of the rectum stiff and less elastic. The rectum then can't stretch
as much and can't hold stool, and fecal incontinence results.
Inflammatory bowel disease also can make rectal walls very irritated
and thereby unable to contain stool.
Diarrhea, or loose stool, is more difficult to control than solid
stool that is formed. Even people who don't have fecal incontinence
can have an accident when they have diarrhea.
Abnormalities of the pelvic floor can lead to fecal incontinence.
Examples of some abnormalities are decreased perception of rectal
sensation, decreased anal canal pressures, decreased squeeze
pressure of the anal canal, impaired anal sensation, a dropping down
of the rectum (rectal prolapse), protrusion of the rectum through
the vagina (rectocele), and/or generalized weakness and sagging of
the pelvic floor. Often the cause of pelvic floor dysfunction is
childbirth, and incontinence doesn't show up until the midforties or
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The doctor will ask health-related questions and do a physical
exam and possibly other medical tests.
- Anal manometry checks the tightness of the anal sphincter and its ability
to respond to signals, as well as the sensitivity and function of the rectum.
- Anorectal ultrasonography evaluates the structure of the anal sphincters.
- Proctography, also known as defecography, shows how much stool the rectum
can hold, how well the rectum holds it, and how well the rectum can evacuate
- Proctosigmoidoscopy allows doctors to look inside the rectum for signs
of disease or other problems that could cause fecal incontinence, such as
inflammation, tumors, or scar tissue.
- Anal electromyography tests for nerve damage, which is often associated
with obstetric injury.
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Treatment depends on the cause and severity of fecal
incontinence; it may include dietary changes, medication, bowel
training, or surgery. More than one treatment may be necessary for
successful control since continence is a complicated chain of
Food affects the consistency of stool and how quickly it passes
through the digestive system. If your stools are hard to control
because they are watery, you may find that eating high fiber foods
adds bulk and makes stool easier to control. But people with
well-formed stools may find that high fiber foods act as a laxative
and contribute to the problem. Other foods that may make the problem
worse are drinks containing caffeine, like coffee, tea, and
chocolate, which relax the internal anal sphincter muscle.
You can adjust what and how you eat to help manage fecal
- Keep a food diary. List what you eat, how much you eat, and when
you have an incontinent episode. After a few days, you may begin to see
a pattern involving certain foods and incontinence. After you identify foods
that seem to cause problems, cut back on them and see whether incontinence
improves. Foods that typically cause diarrhea, and so should probably be
- cured or smoked meat like sausage, ham, or turkey
- spicy foods
- dairy products like milk, cheese, and ice cream
- fruits like apples, peaches, or pears
- fatty and greasy foods
- sweeteners, like sorbitol, xylitol, mannitol, and fructose, which
are found in diet drinks, sugarless gum and candy, chocolate, and fruit
- Eat smaller meals more frequently. In some people, large meals
cause bowel contractions that lead to diarrhea. You can still eat the same
amount of food in a day, but space it out by eating several small meals.
- Eat and drink at different times. Liquid helps move food through
the digestive system. So if you want to slow things down, drink something
half an hour before or after meals, but not with the meals.
- Eat the right amounts of fiber. For many people, fiber makes stool
soft, formed, and easier to control. Fiber is found in fruits, vegetables,
and grains. You'll need to eat 20 to 30 grams of fiber a day, but add it
to your diet slowly so your body can adjust. Too much fiber all at once
can cause bloating, gas, or even diarrhea. Also, too much insoluble, or
undigestible, fiber can contribute to diarrhea. So if you find that eating
more fiber makes your diarrhea worse, try cutting back to two servings each
of fruits and vegetables and removing skins and seeds from your food.
- Eat foods that make stool bulkier. Foods that contain soluble,
or digestible, fiber slow the emptying of the bowels. Examples are bananas,
rice, tapioca, bread, potatoes, applesauce, cheese, smooth peanut butter,
yogurt, pasta, and oatmeal.
- Get plenty to drink. You need to drink eight 8-ounce glasses of
liquid a day to help prevent dehydration and to keep stool soft and formed.
Water is a good choice, but avoid drinks with caffeine, alcohol, milk, or
carbonation if you find that they trigger diarrhea.
Over time, diarrhea can rob you of vitamins and minerals. Ask
your doctor if you need a vitamin supplement.
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Examples of foods that have fiber include
|Breads, cereals, and beans
|1/2 cup of black-eyed peas, cooked
|1/2 cup of kidney beans, cooked
|1/2 cup of lima beans, cooked
|Whole-grain cereal, cold
- 1/2 cup of All-Bran
- 3/4 cup of Total
- 3/4 cup of Post Bran Flakes
|1 packet of whole-grain cereal, hot
|1 slice of whole-wheat or multigrain bread
|1 medium apple
|1 medium peach
|1/2 cup of raspberries
|1 medium tangerine
|1 cup of acorn squash, raw
|1 medium stalk of broccoli, raw
|5 brussels sprouts, raw
|1 cup of cabbage, raw
|1 medium carrot, raw
|1 cup of cauliflower, raw
|1 cup of spinach, cooked
|1 cup of zucchini, raw
If diarrhea is causing the incontinence, medication may help.
Sometimes doctors recommend using bulk laxatives to help people
develop a more regular bowel pattern. Or the doctor may prescribe
antidiarrheal medicines such as loperamide or diphenoxylate to slow
down the bowel and help control the problem.
Bowel training helps some people relearn how to control their
bowels. In some cases, it involves strengthening muscles; in others,
it means training the bowels to empty at a specific time of day.
- Use biofeedback. Biofeedback is a way to strengthen and coordinate
the muscles and has helped some people. Special computer equipment measures
muscle contractions as you do exercises--called Kegel exercises--to strengthen
the rectum. These exercises work muscles in the pelvic floor, including
those involved in controlling stool. Computer feedback about how the muscles
are working shows whether you're doing the exercises correctly and whether
the muscles are getting stronger. Whether biofeedback will work for you
depends on the cause of your fecal incontinence, how severe the muscle damage
is, and your ability to do the exercises.
- Develop a regular pattern of bowel movements. Some people--particularly
those whose fecal incontinence is caused by constipation--achieve bowel
control by training themselves to have bowel movements at specific times
during the day, such as after every meal. The key to this approach is persistence--it
may take a while to develop a regular pattern. Try not to get frustrated
or give up if it doesn't work right away.
Surgery may be an option for people whose fecal incontinence is
caused by injury to the pelvic floor, anal canal, or anal sphincter.
Various procedures can be done, from simple ones like repairing
damaged areas, to complex ones like attaching an artificial anal
sphincter or replacing anal muscle with muscle from the leg or
forearm. People who have severe fecal incontinence that doesn't
respond to other treatments may decide to have a colostomy, which
involves removing a portion of the bowel. The remaining part is then
either attached to the anus if it still works properly, or to a hole
in the abdomen called a stoma, through which stool leaves the body
and is collected in a pouch.
The skin around the anus is delicate and sensitive.
Constipation and diarrhea or contact between skin and stool
can cause pain or itching. Here's what you can do to relieve
- Wash the area with water, but not soap, after a bowel movement.
Soap can dry out the skin, making discomfort worse. If possible,
wash in the shower with lukewarm water or use a sitz bath. Or try
a no-rinse skin cleanser. Try not to use toilet paper to clean up--rubbing
with dry toilet paper will only irritate the skin more. Premoistened,
alcohol-free towelettes are a better choice.
- Let the area air dry after washing. If you don't have time, gently
pat yourself dry with a lint-free cloth.
- Use a moisture barrier cream, which is a protective cream to help
prevent skin irritation from direct contact with stool. However,
talk to your health care professional before you try anal ointments
and creams because some have ingredients that can be irritating.
Also, you should clean the area well first to avoid trapping bacteria
that could cause further problems. Your health care professional
can recommend an appropriate cream or ointment.
- Try using nonmedicated talcum powder or corn starch to relieve
- Wear cotton underwear and loose clothes that "breathe." Tight
clothes that block air can worsen anal problems. Change soiled underwear
as soon as possible.
- If you use pads or disposable undergarments, make sure they have
an absorbent wicking layer on top. Products with a wicking layer
protect the skin by pulling stool and moisture away from the skin
and into the pad.
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Because fecal incontinence can cause distress in the form of
embarrassment, fear, and loneliness, taking steps to deal with it
is important. Treatment can help improve your life and help you
better about yourself. If you haven't been to a doctor yet, make
- Take a backpack or tote bag containing cleanup supplies
and a change of clothing with you everywhere.
- Locate public restrooms before you need them so you know
where to go.
- Use the toilet before heading out.
- If you think an episode is likely, wear disposable undergarments
or sanitary pads.
- If episodes are frequent, use oral fecal deodorants to
add to your comfort level.
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If your child has fecal incontinence, you need to see a doctor to
determine the cause and treatment. Fecal incontinence can occur in
children because of a birth defect or disease, but in most cases
it's because of chronic constipation.
Potty-trained children often get constipated simply because they
refuse to go to the bathroom. The problem might stem from
embarrassment over using a public toilet or unwillingness to stop
playing and go to the bathroom. But if the child continues to hold
in stool, the feces will accumulate and harden in the rectum. The
child might have a stomachache and not eat much, despite being
hungry. And when he or she eventually does pass the stool, it can be
painful, which can lead to fear of having a bowel movement.
A child who is constipated may soil his or her underpants.
Soiling happens when liquid stool from farther up in the bowel seeps
past the hard stool in the rectum and leaks out. Soiling is a sign
of fecal incontinence. Try to remember that your child did not do
this on purpose. He or she cannot control the liquid stool and may
not even know it has passed.
The first step in treating the problem is passing the built-up
stool. The doctor may prescribe one or more enemas or a drink that
helps clean out the bowel, like magnesium citrate, mineral oil, or
The next step is preventing future constipation. You will play a
big role in this part of your child's treatment. You may need to
teach your child bowel habits, which means training your child to
have regular bowel movements. Experts recommend that parents of
children with poor bowel habits encourage their child to sit on the
toilet four times each day (after meals and at bedtime) for 5
minutes. Give rewards for bowel movements and remember that it is
important not to punish your child for incontinent episodes.
Some changes in eating habits may be necessary too. Your child
should eat more high-fiber foods to soften stool, avoid dairy
products if they cause constipation, and drink plenty of fluids
every day, including water and juices like prune, grape, or apricot,
which help prevent constipation. If necessary, the doctor may
It may take several months to break the pattern of withholding
stool and constipation. And episodes may occur again in the future.
The key is to pay close attention to your child's bowel habits. Some
warning signs to watch for include
- pain with bowel movements
- hard stool
- refusal to go to the bathroom
- soiled underpants
- signs of holding back a bowel movement, like squatting,
crossing the legs, or rocking back and forth
- They were potty-trained too early.
- They refuse to have a bowel movement (because of painful
ones in the past, embarrassment, stubbornness, or even a
dislike of public bathrooms).
- They are in an unfamiliar place.
- They are reacting to family stress like a new sibling or
their parents' divorce.
- They can't get to a bathroom when they need to go so
they hold it. As the rectum fills with stool, the child may
lose the urge to go and become constipated as the stool
dries and hardens.
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American Academy of Family Physicians
International Foundation for Functional Gastrointestinal
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