Fecal Incontinence in Northern Virginia

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Fecal incontinence, also called accidental bowel leakage, is the unplanned loss of stool, and it is far more common than most people realize. It is also one of the symptoms people are least likely to mention to a physician. That silence is understandable, but it means many people manage leakage on their own for years when treatment could help. This guide explains what fecal incontinence is, why it happens, how a gastroenterologist evaluates it, and the range of treatments available, most of which are simple and low risk.

This article is general education, not medical advice. The right approach depends on the cause, how often leakage happens, and your overall health, so talk with your physicians about your own situation.

What fecal incontinence is

The American College of Gastroenterology (ACG) defines fecal incontinence as the involuntary loss of solid or liquid stool, including staining of underwear. Its 2021 clinical guideline on benign anorectal disorders (Wald and colleagues), which remains the ACG's current guideline on the topic, notes that some patients prefer the term accidental bowel leakage. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) uses both names.

Bowel control depends on several parts working together: the muscles of the anus and pelvic floor, the rectum's ability to stretch and hold stool, the nerves that sense when the rectum is full, and the consistency of the stool itself. A problem with any one of these can lead to leakage, and often more than one is involved.

Two types of fecal incontinence

• Urge incontinence. You feel a strong need to have a bowel movement but cannot reach a toilet in time. The NIDDK describes this as the most common type. The ACG guideline notes it is often linked to weaker squeeze strength in the outer anal sphincter muscle or a rectum that holds less stool.
• Passive incontinence. Leakage happens without warning, because the body does not sense that the rectum is full. The ACG notes it is often linked to lower resting pressure in the inner anal sphincter muscle.

Which type you have is one of the first clues a physician uses to find the cause, so it is worth noticing whether you feel the urge before an accident or not.

How common fecal incontinence is

The ACG guideline reports an age-adjusted prevalence of about 9 percent in U.S. community surveys, rising with age. The NIDDK estimates that 7 to 15 out of 100 adults living at home have fecal incontinence, and that it affects about 1 in 3 people seen in primary care. In nursing homes, the NIDDK puts the figure at 50 to 70 out of 100.

The ACG adds that most people with fecal incontinence have it less than once a month, or have only staining of underwear, and that women are slightly more likely than men to report it, by a difference of only 1 to 2 percentage points. It also notes that only a small share of people with fecal incontinence ever discuss it with a physician, which is why the guideline encourages physicians to ask.

Common causes of fecal incontinence

The ACG guideline makes an important point: there is rarely a single cause. Several risk factors usually combine, and the more that are present, the more likely leakage becomes. That is good news for treatment, because improving even one factor, such as firming up loose stool, can be enough to restore control.

Diarrhea and loose stool

Loose, watery stool fills the rectum quickly and is much harder to hold than formed stool. The NIDDK calls diarrhea the most common risk factor for fecal incontinence in people living at home. That makes the cause of the diarrhea part of the evaluation. Conditions such as irritable bowel syndrome, inflammatory bowel disease, microscopic colitis, and lactose intolerance can all cause leakage that improves once the underlying problem is treated. Our guide to chronic diarrhea covers the wider list. The NIDDK also lists having had your gallbladder removed as a risk factor.

Constipation and overflow leakage

It surprises many people that constipation can cause leakage. The NIDDK explains that hard stool that stays in the rectum stretches and weakens the muscles over time, and watery stool can then seep around it. This overflow pattern is especially common in frail older adults who are less active. Our guide to chronic constipation explains how it is evaluated and treated. Opioid pain medicines can set this up too; see opioid-induced constipation.

Childbirth and muscle injury

Vaginal childbirth can injure the anal sphincter muscles. The NIDDK lists a large baby, forceps or vacuum delivery, and an episiotomy as factors that raise the chance of injury. The ACG notes something many women do not expect: fecal incontinence related to childbirth more often begins two to three decades after delivery than right after it, as muscles weaken with age. Surgery for hemorrhoids, anal fissures, abscesses, or fistulas can also affect the sphincter muscles. Our guide to anal fissures and other anorectal conditions discusses that trade-off.

Nerve and other medical conditions

The ACG guideline names dementia, stroke, diabetic nerve damage, spinal cord injury, and inflammatory bowel disease among the conditions associated with fecal incontinence. The NIDDK adds multiple sclerosis and Parkinson's disease, along with conditions that make the rectum stiff, such as pelvic radiation or rectal surgery. Hemorrhoids and rectal prolapse can keep the anus from closing completely and cause small amounts of leakage or mucus. MedlinePlus, from the National Library of Medicine, notes that antacids and laxatives can also contribute, especially in older adults.

How fecal incontinence is evaluated

The ACG states that the aim of the evaluation is to identify every factor contributing to leakage and then address the easiest ones to change first. Most of that starts with conversation.

The history

A gastroenterologist will ask how often leakage happens, how much, whether it is solid or liquid, and whether you feel urgency beforehand. The ACG guideline notes that these details strongly predict how much fecal incontinence affects daily life. Your physician may also ask you to describe your stool using the Bristol Stool Form Scale, a set of pictures of stool types, or to keep a short bowel diary. The NIDDK encourages people to be as specific as they can, and reminds patients that a physician will not be shocked or surprised by anything they describe.

The physical exam

The ACG guideline calls a careful rectal exam mandatory for everyone with fecal incontinence. It checks muscle tone at rest and during a squeeze, looks for a rectal mass or impacted stool, and assesses how the pelvic floor moves. Depending on your age and symptoms, a colonoscopy or blood and stool tests may be part of the workup, especially when diarrhea or bleeding is involved.

Testing for fecal incontinence

Not everyone needs specialized testing. The ACG notes that people with mild symptoms who improve with simple measures may not need any. For those who do not improve, the guideline says testing should begin with anorectal manometry, a test that uses a thin, flexible probe to measure the pressure of the anal muscles at rest and during a squeeze, along with rectal sensation. A balloon expulsion test checks how well the rectum empties. When muscle weakness is found, especially if surgery is being considered, an endoanal ultrasound or MRI can show whether the sphincter muscles are torn or scarred.

Treatment for fecal incontinence

Most people start with conservative treatment, and many need nothing more. The ACG describes these measures as safe, inexpensive, and often effective. The NIDDK reports that simple treatments improve symptoms by about 60 percent and stop fecal incontinence altogether in about 1 out of 5 people.

First steps: stool consistency, diet, and exercises

• Treating diarrhea. When leakage comes with loose stool, the ACG strongly recommends antidiarrheal medicines such as loperamide, along with other options a physician may prescribe, including bile acid binders. Firmer stool is easier to hold.
• Fiber. Fiber supplements such as psyllium can add bulk to loose stool and also help when constipation is the problem. MedlinePlus suggests aiming for about 30 grams of fiber a day. Ask your physician what amount is right for you.
• Diet changes. MedlinePlus lists caffeine, alcohol, fatty or spicy foods, dairy for people who are lactose intolerant, and sugar substitutes such as sorbitol as foods that can worsen leakage in some people. A food diary can show which ones matter for you.
• Treating constipation. When overflow is the problem, clearing and preventing constipation with fiber or laxatives can stop the leakage. The ACG notes this approach has the strongest evidence in children and older adults.
• Pelvic floor exercises. Tightening and relaxing the pelvic floor muscles many times a day can strengthen them. The NIDDK notes that a physician can help make sure you are doing the exercises correctly.

The ACG guideline notes that these measures are most effective when a health care professional teaches them and follows up, rather than handing over a list. With that support, up to 20 percent of patients may need no further treatment.

Biofeedback therapy

For people who do not improve with education and conservative measures, the ACG strongly recommends biofeedback. Biofeedback is a form of pelvic floor training that uses sensors and a screen or sound to show you, in real time, how your anal and pelvic floor muscles are working. Depending on the problem, it can strengthen the sphincter, help you sense stool sooner if you have passive leakage, or help you hold off urgency. In one trial cited by the ACG, among patients who had not responded to medicines and education, 76 percent reported adequate relief with biofeedback compared with 41 percent with pelvic floor exercises alone. The guideline notes that biofeedback causes no harm, and that it is most effective for motivated patients and may be less effective with memory problems.

Devices and injections

For selected people who still have symptoms after conservative treatment and biofeedback, the ACG suggests considering:

• Anal inserts and vaginal balloon devices. These act as physical barriers to leakage. The evidence is limited, and some people find inserts hard to tolerate, but they help some patients.
• Injectable bulking agents. A gel injected into the wall of the anal canal can help the opening close more completely. In one trial cited by the ACG, 52 percent of patients had at least a 50 percent reduction in episodes, compared with 31 percent with a placebo injection.

Nerve stimulation and surgery

For moderate to severe fecal incontinence that has not responded to conservative measures, biofeedback, and other low-risk options, the ACG strongly recommends sacral nerve stimulation. A small implanted device sends mild electrical pulses to the nerves that control the anus and rectum. Patients try a temporary device first, and only those who improve receive the implant. In the main North American study, 86 percent of people with the implant had at least a 50 percent reduction in weekly episodes three years later, and 40 percent were fully continent. Implant-site pain, tingling, and infection were the most common side effects.

The ACG suggests surgical repair of the anal sphincter, called sphincteroplasty, mainly for injuries recognized soon after childbirth or another injury. Results tend to fade over time: the guideline notes that early improvement in up to 85 percent of patients falls to about 50 percent after four to five years. For severe fecal incontinence that has not responded to any other treatment, the ACG suggests discussing a colostomy or ileostomy, and notes that most people who choose one report it restricts their life little or not at all and would choose it again.

Living with fecal incontinence while treatment works

Treatment often takes weeks to months to show its full effect. In the meantime, the NIDDK suggests practical steps that make daily life easier:

• Using the toilet before leaving home, and knowing where restrooms are before you need one.
• Carrying a small bag with cleanup supplies and a change of clothes.
• Wearing absorbent pads or disposable underwear, which the NIDDK notes can make a big difference for milder leakage.
• Protecting the skin by washing gently after a bowel movement, keeping the area dry, and using a moisture-barrier cream.
• Choosing breathable clothing and underwear.

The NIDDK also offers a reminder worth repeating: fecal incontinence is a medical problem, not something to be ashamed of, it is not always a normal part of aging, and it usually does not go away on its own.

When to see a gastroenterologist for fecal incontinence

MedlinePlus advises reporting any bowel leakage in an adult, day or night, to a physician, along with skin irritation or sores caused by leakage or severe diarrhea. The NIDDK adds that it is time to see a physician when leakage is frequent or severe or is affecting your quality of life or causing emotional or social distress. Leakage that comes with rectal bleeding, a change in bowel habits, or weight loss deserves prompt evaluation; our guides to blood in the stool and when to see a gastroenterologist explain how to tell a scheduled concern from an urgent one.

The ACG clinical guideline on benign anorectal disorders and the NIDDK's guide to bowel control problems are both available for those who want more detail.

Fecal incontinence care in Northern Virginia with GC of NoVA

Gastroenterology Center of Northern Virginia sees adults across Arlington, Annandale, and the surrounding communities for bowel control problems, whether they come to us on their own or are referred by a primary care physician or gynecologist. Our physicians take the time to understand what is happening, look for treatable causes such as diarrhea, constipation, or inflammation, start the conservative measures that help most people, and coordinate anorectal testing, pelvic floor therapy, or surgical referral when they are needed. We see patients at our Arlington office, next to VHC Health, and our Annandale office, in the Woodburn Medical complex.

If this is your first visit, our guide to your first gastroenterologist visit explains what to bring. For fecal incontinence, a one or two week bowel diary noting how often leakage happens, how much, and whether you felt urgency is especially useful, along with a list of your medications. To schedule, contact our Arlington office at (703) 522-7476 or our Annandale office at (703) 560-6106, or learn more at gcofnova.com.

This article is for general education and is not medical advice. Talk with a qualified gastroenterologist about your symptoms, diagnosis, and treatment options.