Is fecal incontinence caused by “holding”? — Actually, it’s not that simple!

Author: Lou Wenjia, attending physician at Peking Union Medical College Hospital

Reviewer: Zhu Lan, Professor, Chief Physician, Peking Union Medical College Hospital, Doctoral Supervisor

When it comes to fecal incontinence, many people think that it is a condition that only children have, and that adults can "hold it in". But is this really the case?

1. What is fecal incontinence?

Fecal incontinence is the inability to control the passage of gas or feces. If a person is over 3 years old and has continuous or repeated involuntary passage of more than 10 ml of intestinal contents at least once a month, then this is considered to be fecal incontinence.

Fecal incontinence can be roughly divided into two types: one is called urgency fecal incontinence, which means that even if you feel the urge to defecate, you cannot control it and have to defecate directly; the other is called passive fecal incontinence, which means that there is no urge to defecate before the stool is discharged.

The two types of fecal incontinence have different pathogenesis, but both have a great impact on the patient's body and mind. Some patients are too embarrassed to seek medical treatment, which leads to long-term suffering in their lives.

What are the causes of fecal incontinence?

The physiological process of defecation is a series of complex and coordinated physiological reflex activities of the human body. Due to various factors, pathological changes in different anatomical levels and different tissue structures will cause different degrees of fecal incontinence.

Common causes of fecal incontinence include the following 5 types.

1. Secondary to systemic diseases: intestinal infections caused by bacteria, viruses, parasites, etc.; endocrine diseases such as diabetes and hyperthyroidism; immune diseases such as ulcerative colitis or Crohn's disease; brain or spinal cord injuries caused by trauma, tumors, bleeding, etc., all of which may cause fecal incontinence.

2. Abnormal anatomical structure: Rapid vaginal delivery, large fetus, forceps delivery or episiotomy can cause anal sphincter rupture and pelvic floor muscle loss of nerve control. Surgical operations such as anal fistula repair and hemorrhoidectomy can damage the sphincter and cause fecal incontinence.

3. Functional intestinal disorders: such as functional diarrhea, irritable bowel syndrome, etc. causing fecal incontinence.

4. Anorectal malformations: such as cloacal malformations, which mainly occur in female infants and are often accompanied by varying degrees of sacral hypoplasia. Poor bowel control ability and overflow of feces may also occur due to rectal dilatation [1].

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5. Advanced age: Aging is also an important factor leading to an increased incidence of fecal incontinence. The rectal capacity of the elderly is lower, which can easily cause rectal dilation and anal sphincter relaxation, and their defecation sensory threshold and maximum tolerance are reduced.

In addition, special circumstances such as misuse of laxatives, obesity, frailty, physical disabilities leading to limited mobility, severe cognitive impairment, and learning disabilities may also lead to fecal incontinence.

Once symptoms of fecal incontinence appear, you need to seek medical attention promptly, complete various examinations, and determine the specific cause.

3. What tests do people with fecal incontinence need?

In addition to a detailed medical history and physical examination, patients with fecal incontinence also require the following auxiliary examinations.

1. Anal ultrasound: This is the best method to detect sphincter defects. If the ultrasound result is inconclusive or of poor quality, magnetic resonance imaging can be considered.

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2. Electromyographic evaluation: neuromuscular function of the internal and external anal sphincters and pelvic floor neuropathy.

3. Anal manometry: mainly uses water-infused manometry catheters or water-infused balloons. The resting pressure of the anal canal reflects the function of the internal anal sphincter. When the anal canal is actively contracted to the maximum extent, the pressure of the lower anal canal reflects the function of the external sphincter. However, the anal canal pressure is affected by many factors, and its evaluation function is limited.

4. Proctoscopy: It can be performed alone or simultaneously with colonoscopy or fiber sigmoidoscopy.

Medical imaging examinations make it easier for doctors to determine the specific cause of the disease. Patients can communicate more with doctors and choose a more appropriate examination plan. Only after the cause of the disease is accurately determined can effective treatment be achieved.

4. What are the current treatment options for fecal incontinence?

The treatment options for patients with different causes are also different. Currently, the commonly used treatment options include the following 5 types.

1. General treatment: mainly for patients with fecal incontinence related to stool characteristics, symptoms can be improved by adjusting dietary habits, fluid intake, defecation habits, etc. Changing improper dietary habits can identify and avoid foods that cause diarrhea or gastrointestinal emergencies.

Common irritating foods include spicy foods, coffee, caffeinated beverages, beer, liquor, and citrus fruits. Lactose-intolerant patients should avoid dairy products or add lactase. Increasing fiber intake can increase the volume and density of stool and make it clump, thereby improving fecal incontinence. Remember to replenish water while supplementing fiber to avoid fecal impaction.

2. Drug therapy: This method can be used as the initial treatment for mild to moderate patients. The main purpose of drug therapy is to improve stool characteristics and slow down intestinal peristalsis, but excessive use of drugs may cause complications such as constipation, intestinal obstruction and ischemic colitis [2].

Currently, there is still a lack of sufficient clinical evidence on how to choose appropriate drugs to treat fecal incontinence.

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3. Biofeedback: Biofeedback therapy is a painless, non-invasive cognitive training of the pelvic floor muscles, which is particularly effective for patients with intact anal sphincter and decreased rectal sensory function [2].

4. Neurostimulation: When biofeedback therapy is not effective, invasive treatments such as sacral nerve stimulation (SNS), tibial nerve stimulation (TNS) and pudendal nerve stimulation (PNS) can be tried [2].

At present, the effect of neurological treatment is quite good, but the disadvantages are that it is prone to complications and the cost is relatively high.

5. Surgical treatment: When non-surgical treatment is ineffective, surgical treatment can be considered. A specialist doctor is required to choose the appropriate surgical method based on the actual situation and cause of the disease.

Many people are embarrassed to see a doctor when they encounter problems with fecal incontinence, but if they allow it to develop, it will cause them physical and mental suffering and bring many inconveniences to their lives.

In fact, fecal incontinence can be treated, and there is no need to endure inferiority for it. Seek medical treatment in time, identify the cause, fully communicate with the doctor, and find a treatment plan that suits you, so as to effectively avoid embarrassment, restore a beautiful mood and normal social interaction.

References

[1] Fan Xiaohua, Jiang Yajun, Lin Zhenbin. The current status and pathogenic factors of fecal incontinence. Journal of Colorectal and Anal Surgery, 2021, 27(5): 419-421.

[2]Yao Yibo, Xiao Changfang, Wang Chen. Research progress on non-surgical treatment of fecal incontinence. Journal of Colorectal and Anal Surgery, 2021, 27(5): 423-426.