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Incontinence, bowel Content Supplied by NHS Choices
Introduction

Bowel incontinence is an inability to control bowel movements, resulting in involuntary soiling. It's also sometimes known as faecal incontinence.

The experience of bowel incontinence can vary from person to person. Some people feel a sudden need to go to the toilet but are unable to reach a toilet in time. This is known as urge bowel incontinence.

Other people experience no sensation before soiling themselves, known as passive incontinence or passive soiling, or there might be slight soiling when passing wind.

Some people experience incontinence on a daily basis, whereas for others it only happens from time to time.

It's thought one in 10 people will be affected by it at some point in their life. It can affect people of any age, although it's more common in elderly people. It's also more common in women than men.

Why bowel incontinence happens

Bowel incontinence is a symptom of an underlying problem or medical condition.

Many cases are caused by diarrhoea, constipation, or weakening of the muscle that controls the opening of the anus.

It can also be caused by long-term conditions such as diabetes, multiple sclerosis and dementia.

Read more about the causes of bowel incontinence.

Seeking advice and treatment

Bowel incontinence can be upsetting and hard to cope with, but treatment is effective and a cure is often possible, so make sure you see your GP.

It's important to remember that:

  • Bowel incontinence isn't something to be ashamed of - it's simply a medical problem that's no different from diabetes or asthma.
  • It can be treated - there's a wide range of successful treatments.
  • Bowel incontinence isn't a normal part of ageing.
  • It won't usually go away on its own - most people need treatment for the condition.

If you don't want to see your GP, you can usually make an appointment at your local NHS continence service without a referral. These clinics are staffed by specialist nurses who can offer useful advice about incontinence.

Read more about diagnosing bowel incontinence.

How bowel incontinence is treated

In many cases, with the right treatment, a person can maintain normal bowel function throughout their life.

Treatment will often depend on the cause and how severe it is, but possible options include:

  • lifestyle and dietary changes to relieve constipation or diarrhoea
  • exercise programmes to strengthen the muscles that control the bowel
  • medication to control diarrhoea and constipation
  • surgery, of which there are a number of different options

Incontinence products, such as anal plugs and disposable pads, can be used until your symptoms are better controlled.

Even if it isn't possible to cure your bowel incontinence, symptoms should improve significantly.

Read more about treating bowel incontinence.



Causes of bowel incontinence

Bowel incontinence is usually caused by a physical problem with the parts of the body that control the bowel.

The most common problems are:

  • problems with the rectum - the rectum is unable to retain poo properly until it's time to go to the toilet
  • problems with the sphincter muscles - the muscles at the bottom of the rectum don't work properly
  • nerve damage - the nerve signals sent from the rectum don't reach the brain

These problems are explained in more detail below.

It's important to discuss any bowel problems with your GP as there's a small chance they could be a sign of a more serious condition, such as bowel cancer.

Problems with the rectum

Constipation

Constipation is a leading cause of bowel incontinence.

In cases of severe constipation, a large, solid stool can become stuck in the rectum. This is known as faecal impaction. The stool then begins to stretch the muscles of the rectum, weakening them.

Watery stools can leak around the stool and out of the bottom, causing bowel incontinence. This is called overflow incontinence and happens most commonly in elderly people.

Repeated straining caused by constipation or faecal impaction can also lead to rectal prolapse, when part of your lower intestine falls out of place and protrudes from your bottom. Rectal prolapse may also lead to bowel incontinence.

Diarrhoea

It's difficult for the rectum to hold liquid stools (diarrhoea), so people with diarrhoea (particularly recurring diarrhoea) can develop bowel incontinence.

Conditions that can cause recurring diarrhoea include:

These conditions can also cause scarring of the rectum, which can lead to bowel incontinence.

Haemorrhoids

Haemorrhoids (piles) are enlarged blood vessels inside or around the bottom (the rectum and anus). Symptoms include discomfort, itching, bleeding or a lump hanging down outside of the anus.

In severe cases, haemorrhoids may lead to bowel incontinence.

Problems with the sphincter muscles

The sphincter muscles at the bottom of the rectum control the bowel. Bowel incontinence happens if these muscles become weakened or damaged.

Childbirth is a common cause of damage to the sphincter muscles and a leading cause of bowel incontinence. During a vaginal birth, the sphincter muscles can become stretched and damaged, particularly as a result of a forceps delivery. Other causes include a large baby, the baby being born with the back of their head facing the mother's back (occipitoposterior position) and a long labour.

Sphincter muscles can also become damaged through injury, or damage from bowel or rectal surgery.

Nerve damage

Bowel incontinence can also be caused by a problem with the nerves connecting the brain and the rectum. A nerve problem can mean your body is unaware of stools in your rectum, and may make it difficult for you to control your sphincter muscles.

Damage to these nerves is related to a number of conditions, including:

An injury to these nerves, such as a spinal injury, can also lead to bowel incontinence.

Other health conditions

In some cases, bowel incontinence may result from a health condition such as dementia or a severe learning disability that causes the person to lose bowel control.

A physical disability can also make it difficult to get to the toilet in time.



Diagnosing bowel incontinence

Your GP will begin by asking you about the pattern of your symptoms and other related issues, such as your diet.

You may find this embarrassing, but it's important to answer as honestly and fully as you can to make sure you receive the most suitable treatment. Let your doctor know about:

  • any changes in your bowel habits lasting for more than a few weeks
  • rectal bleeding
  • stomach pains
  • any changes to your diet
  • any medication you're taking

Your GP will usually carry out a physical examination. They'll look at your anus and the surrounding area to check for damage and carry out a rectal examination, inserting a gloved finger into your bottom.

A rectal examination will show whether constipation is the cause, and check for any tumours in your rectum. Your GP may ask you to squeeze your rectum around their finger to assess how well the muscles in your anus are working.

Depending on the results, your GP may refer you for further tests.

Further tests

Endoscopy (sigmoidoscopy)

During an endoscopy, the inside of your rectum (and in some cases your lower bowel) is examined using a long, thin flexible tube with a light and video camera at the end (endoscope). Images can also be taken of the inside of your body.

The endoscope checks whether there's any obstruction, damage or inflammation in your rectum.

An endoscopy isn't painful, but it can feel uncomfortable, so you may be given a sedative to relax you.

Anal manometry

Anal manometry helps to assess how well the muscles and nerves in and around your rectum are working.

The test uses a device that looks like a small thermometer with a balloon attached to the end. It's inserted into your rectum and the balloon is inflated. It may feel unusual, but it's not uncomfortable or painful.

The device is attached to a machine, which measures pressure readings taken from the balloon.

You'll be asked to squeeze, relax and push your rectum muscles at certain times. You may also be asked to push the balloon out of your rectum in the same way you push out a stool. The pressure-measuring machine gives an idea of how well your muscles are working.

If the balloon is inflated to a relatively large size but you don't feel any sensation of fullness, it may mean there are problems with the nerves in your rectum.

Ultrasound

An ultrasound scan can be used to create a detailed picture of the inside of your anus. Ultrasound scans are particularly useful in detecting underlying damage to the sphincter muscles.

Defecography

Defecography is a test used to study how you pass stools. It can also be useful in detecting signs of obstruction or prolapse that haven't been discovered during a rectal examination.

During this test, a liquid called barium is placed into your rectum. The barium helps make it easier to highlight problems using an X-ray. Once the barium is in place, you'll be asked to pass stools in the usual way while scans are taken.

This test is occasionally carried out using a magnetic resonance imaging (MRI) scanner instead of an X-ray.



Treating bowel incontinence

Treatment for bowel incontinence depends on underlying cause and the pattern of your symptoms.

Trying the least intrusive treatments first, such as dietary changes and exercise programmes, is often recommended.

Medication and surgery are usually only considered if other treatments haven't worked.

The various treatments for bowel incontinence are outlined below. You can also read a summary of the pros and cons of the treatments for bowel incontinence, allowing you to compare your treatment options.

Continence products

You may find it helpful to use continence products until your bowel incontinence is better controlled. Most continence products are available for free on the NHS.

Anal plugs are one way to prevent involuntary soiling. An anal plug is made of foam and designed to be inserted into your bottom. However, they can be uncomfortable and they're not really a long term solution.

If the plug comes into contact with moisture from the bowel, it expands and prevents leakage or soiling. Anal plugs can be worn for up to 12 hours, after which time they are removed using an attached string.

Disposable body pads are contoured pads that soak up liquid stools and protect your skin. They can be used in cases of mild bowel incontinence.

Single-use silicone inserts, which form a seal around the rectum until your next bowel movement, are also being investigated as a treatment option for moderate to severe bowel incontinence.

Your local NHS continence service can offer help and advice about continence products, and you don't usually need a referral from your GP to make an appointment. These clinics are staffed by nurses who specialise in continence treatment.

Read more about incontinence support on the NHS.

When you're out

  • Wear trousers or skirts that are easy to undo and have elasticated waistbands rather than buttons.
  • Disability Rights UK offers access to 9,000 disabled toilets around the UK with a Radar NKS key. The key costs 4.50 and is only sold to people who require use of toilet facilities due to a disability or health condition.

Dietary changes

Bowel incontinence associated with diarrhoea or constipation can often be controlled by making changes to your diet.

It may be beneficial to keep a food diary to record the effect of your diet on your symptoms.

Diarrhoea

The National Institute for Health and Care Excellence (NICE) has published dietary advice for managing diarrhoea in cases of irritable bowel syndrome (PDF, 39Kb). These guidelines can also be applied to people with diarrhoea associated with bowel incontinence.

The advice from NICE includes the following:

  • limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds)
  • avoid skin, pips and pith from fruit and vegetables
  • limit fresh and dried fruit to three portions a day and fruit juice to one small glass a day (make up the recommended 'five a day' with vegetables)
  • limit how often you have fizzy drinks and drinks containing caffeine
  • avoid foods high in fat, such as chips, fast foods and burgers

Constipation

A high-fibre diet is usually recommended for most people with constipation-associated bowel incontinence. Your GP can tell you if a high-fibre diet is suitable for you.

Fibre can soften stools, making them easier to pass. Foods that are high in fibre include:

  • fruit and vegetables
  • beans
  • wholegrain rice
  • wholewheat pasta
  • wholemeal bread
  • seeds, nuts and oats

Drink plenty of fluids because this can help to soften your stools and make them easier to pass.

Pelvic floor muscle training

Pelvic floor muscle training is a type of exercise programme used to treat cases of bowel incontinence caused by weakness in the pelvic floor muscles.

A therapist, usually a physiotherapist or specialist nurse, will teach you a range of exercises. The goal of pelvic floor muscle training is to strengthen any muscles that may have been stretched and weakened.

You'll probably be required to carry out the exercises three times a day, for six to eight weeks. After this time, you should notice an improvement in your symptoms.

Exercises to try

Check with your health professional before trying these at home.

First, pretend you're trying to hold in a bowel movement. You should feel the muscles around your anus tighten.

Next, sit, stand, or lie in a comfortable position with your legs slightly apart.

  • Squeeze your pelvic floor muscles for as long as you can, then relax. Repeat five times.
  • Squeeze the muscles as hard as you can, then relax. Repeat five times.
  • Squeeze the muscles quickly, then relax. Repeat five times.

If you find these exercises too difficult, try fewer repetitions at first and build them up. If they get too easy, try doing more repetitions. You can do the exercises without anyone knowing about them, so they should be easy to fit into your daily routine.

Bowel retraining

Bowel retraining is a type of treatment for people with reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation.

There are three goals in bowel retraining:

  • to improve the consistency of your stools
  • to establish a regular time for you to empty your bowels
  • to find ways of stimulating your bowels to empty themselves

Changes to your diet usually improve stool consistency (see above).

Establishing a regular time to empty your bowels means finding the most convenient time when you can go to the toilet without being rushed.

Ways to stimulate bowel movements can differ from person to person. Some people find a hot drink and meal can help. Others may need to stimulate their anus using their finger.

Biofeedback

Biofeedback is a type of bowel retraining exercise that involves placing a small electric probe into your bottom.

The sensor relays detailed information about the movement and pressure of the muscles in your rectum to an attached computer.

You're then asked to perform a series of exercises designed to improve your bowel function. The sensor checks that you are performing the exercises in the right way.

Medication

Medication can be used to help treat soft or loose stools or constipation associated with bowel incontinence.

Loperamide is a medicine widely used to treat diarrhoea. It works by slowing down the movement of stools through the digestive system, allowing more water to be absorbed from the stools. Loperamide can be prescribed in low doses to be taken regularly over a long period of time.

Laxatives are used to treat constipation. They're a type of medicine that helps you to pass stools. Bulk-forming laxatives are usually recommended. These help your stools to retain fluid. This means they're less likely to dry out, which can lead to faecal impaction.

Enemas or rectal irrigation

Rectal irrigation or enemas are used when bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool from the rectum.

These procedures involve a small tube that is placed into your anus. A special solution is then used to wash out your rectum.

Surgery

Surgery is usually only recommended after all other treatment options have been tried.

The main surgical treatments used on the NHS are sphincteroplasty and sacral nerve stimulation. Other treatments - such as tibial nerve stimulation, endoscopic heat therapy and artificial sphincter surgery - can also be used, but their availability on the NHS is limited.

An operation called a colostomy is more widely available on the NHS, but it's only used if other treatments are unsuccessful.

These treatments are outlined in more detail below.

Sphincteroplasty

A sphincteroplasty is an operation to repair damaged sphincter muscles. The surgeon removes some of the muscle tissue and the muscle edges are overlapped and sewn back together. This provides extra support to the muscles, which makes them stronger.

Sacral nerve stimulation

Sacral nerve stimulation is a treatment used for people with weakened sphincter muscles.

Electrodes are inserted under the skin in the lower back and connected to a pulse generator. The generator releases pulses of electricity that stimulate the sacral nerves, which causes the sphincter and pelvic floor muscles to work more effectively.

At first, the pulse generator is located outside your body. If the treatment is effective, the pulse generator will be implanted deep under the skin in your back.

The most commonly reported complications of the procedure are infection at the site of surgery and technical problems with the pulse generator, which require additional surgery to correct.

See the NICE guidelines on Sacral nerve stimulation for faecal incontinence.

Tibial nerve stimulation

Tibial nerve stimulation is a fairly new treatment for bowel incontinence.

A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve. It's not known exactly how this treatment works, but it's thought to work in a similar way to sacral nerve stimulation.

NICE concludes that the procedure appears to be safe, although there are still uncertainties about how well it works.

See the NICE guidelines on Treating faecal incontinence by stimulating the tibial nerve.

Injectable bulking agents

Bulking agents, such as collagen or silicone, can be injected into the muscles of the sphincter and rectum to strengthen them.

The use of bulking agents in this way is a fairly new technique, so there's little information about their long-term effectiveness and safety.

You should discuss the possible advantages and disadvantages of this type of treatment in full with your treatment team before deciding whether to proceed.

See the NICE guidelines on Treating faecal incontinence with injectable bulking agents.

Endoscopic heat therapy

Endoscopic radiofrequency (heat) therapy is a fairly new treatment for bowel incontinence.

Heat energy is applied to the sphincter muscles through a thin probe, to encourage scarring of the tissue. This helps tighten the muscles and helps to control bowel movements.

The National Institute for Health and Care Excellence (NICE) recently produced guidelines on this procedure. NICE concluded that the procedure appears to be safe, although there are still uncertainties about how well it works.

As well as the uncertainties surrounding this procedure, it is also expensive. Therefore, it is usually only used on the NHS during clinical trials.

See the NICE guidelines on Treating faecal incontinence using endoscopic radiofrequency therapy.

Artificial sphincter

An artificial sphincter may be implanted if you have bowel incontinence caused by a problem with your sphincter muscles.

This operation involves placing a circular cuff under the skin around the anus. The cuff is filled with fluid and sits tightly around the anus, keeping it closed.

A tube is placed under the skin from the cuff to a control pump. In men, the pump is placed near the testicles, in women it's placed near the vagina. A special balloon is placed into the tummy, and this is connected to the control pump by tubing that runs under the skin.

The pump is activated by pressing a button located under the skin. This drains the fluid from the cuff into the balloon, so your anus opens and you can pass stools. When you are finished, the fluid slowly refills the cuff and the anus closes.

The use of an artificial sphincter is a relatively new procedure, so there isn't much good-quality information about its long-term effectiveness and safety.

Possible problems include infection, injury during surgery and the cuff becoming dislodged. In some cases, further surgery is required to correct problems.

See the NICE guidelines on Treating faecal incontinence with an artificial sphincter inserted through a cut in the abdomen.

Colostomy

A colostomy is usually only recommended if other surgical treatments are unsuccessful.

A colostomy is a surgical procedure in which your colon (lower bowel) is cut and brought through the wall of your stomach to create an artificial opening. Your stools can then be collected in a bag, known as a colostomy bag, which is attached to the opening.



 
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