Fecal Incontinence
Fecal Incontinence, characterized by an inability to control bowel movements, can occur for many reasons. It may be caused by an abscess or inflammation in the rectum, anus or perianal area. Other causes include damage to the anal sphincter from trauma, complications during childbirth, or the result of a previous operation. It can stem from an injury or disorder of the nervous system. Fecal impaction or muscle atrophy in an elderly patient can also lead to incontinence. While age-onset incontinence is less responsive to surgical treatment, surgical correction can be performed in some instances, especially if the underlying cause of the incontinence is anal sphincter abnormality.

This is a common, embarrassing, and socially isolating constellation of symptoms. You may have loss of control of gas, liquid stool or solid stool. You may be wearing pads to absorb leakage. You may be rerouting your life to avoid situations in which a commode is not easily available, or packing additional clothing and pads in case an 'accident' occurs. This problem affects of women under the age of 45, but increases to x% of women greater than xx. Women are affected at a greater rate, but men are not exempt, with X% affected under the age of 45, and X% over the age of xx. Many nursing home residents are affected by this problem, which may cost our economy over $1 billion/year in incontinence pads alone.

While it is often thought that this is an issue of the elderly and infirm, the most common group of individuals affected are those woman having suffered an injury related to childbirth. An episiotomy is an incision from the vagina to the area of the anus, allowing the newborn's head to emerge without an uncontrolled tear into or through the anal sphincter muscles. If the repair becomes infected or if a tear occurs, the sphincter muscles are at risk for injury, thus affecting continence. The use of forceps, large birthweight infant, or prolonged labor may also contribute to injury of the muscles, but also to the nerves to this area. Other possibilities for injury include trauma from anorectal surgery, inflammatory bowel disease, diseases which cause nerve injury, such as diabetes, etc.

After a careful history to elicit some of these possibilities, your physician will complete a careful examination of your anus, perineum, and rectum. Several diagnostic studies may be requested to further delineate your anatomy, the possibility of nerve injury, the possibility of alternative pathology. Anorectal manometry quantitates the ability of your sphincter muscles to squeeze, at both a resting and conscious squeezing state. A thin probe is inserted into your anorectum, and measurements of your sphincter muscles are taken. The probe may also identify a specific area of weakness. Evaluation of the ability of your rectum to stretch to accommodate a fecal bolus, the ability to pass the probe with a balloon filled with water, simulating a fecal bolus may also be evaluated. Anal ultrasound may be used to look at the anatomy of the sphincter muscles. Particularly, in woman who have had birth associated injuries, the sphincter muscle located nearest to the vagina may be very thin or absent. The scar can also be examined. The nerves must also be evaluated, since evidence of injury of one or both pudendal nerves has, in some studies, been associated with a less successful outcome following sphincter repair, also known as sphincteroplasty. Pudendal nerve motor terminal latency or electromyelogram will be used to assess residual nerve function. In pudendal nerve assessment, a probe is connected to a gloved finger, and an electrical impulse is generated. The duration of time required for the nerve to sense the impulse and generate a muscular contraction is measured as a 'latency'. If this examination is not available, an electromyelogram or "EMG" may be required to determine the nerve function. This test involves placement of tiny needle electrodes around the anus. Though slightly uncomfortable, the examination gives additional information regarding the neuromuscular units. Finally, corollary examinations such as defecography may be necessary. In this exami nation, pastelike material is injected into your anus, and expulsion of the material is viewed using fluoroscopy. Such an examination may delineate internal prolapse, rectocele. Colonoscopy, sigmoidoscopy or anoscopy may be necessary as screening examinations to ensure that growths or inflammatory pathology is not responsible for your symptoms.

Treatment for this problem is varied and depends on the nature and severity of the symptoms. Mild incontinence may be treated with dietary changes and medicines, which may thicken the stool and permit better control. If diarrhea or colitis ("inflammation of the colon") is responsible for your symptoms, treatment of the underlying disorder may alleviate your incontinence. If the incontinence is based on injury to the anal sphincter muscles, surgical repair may be warranted. If the nerves are injured and/or there is an injury to the muscles, newer techniques including nerve stimulation or implantation of an artificial sphincter mechanism may be helpful. Biofeedback may be utilized to teach you how to sense the presence of stool or gas, and may be used to teach you how to strengthen the muscles you have. Finally, if all else fails, a colostomy may be warranted.

Though this problem can be devastating, there are many avenues of investigation and treatment which can now be offered. The first step is to recognize your symptoms, and to have your physician direct you to a specialist committed to dealing with this challenging array of problems.