Victor Forge
Losing control of your bowels, also known as faecal or bowel incontinence, can be an embarrassing and distressing problem. Faecal incontinence occurs when stool leaks out from the rectum accidentally, often due to a weak anal sphincter muscle. This muscle surrounds the anal canal and, under normal circumstances, prevents stool from leaving the rectum until a bowel movement occurs. There are several factors that can cause the anal sphincter to weaken, including direct damage to the muscle, nerve damage, rectal prolapse, rectal surgery, childbirth, and chronic constipation or diarrhoea.
| Characteristics | Values |
|---|---|
| Faecal incontinence | The most common reason for incontinence is that the anal sphincter becomes too weak to hold the stool in the rectum. |
| Childbirth | The most common cause of damage in women. |
| Ageing | All our body muscles tend to weaken as we grow older. |
| Heavy straining | Damage or injury to the sphincter muscles due to heavy straining can lead to faecal incontinence or leakage. |
| Rectal surgery | Damage or injury to the sphincter muscles due to rectal surgery can lead to faecal incontinence or leakage. |
| Chronic constipation | Can lead to hardened stool, making it difficult to pass. |
| Pelvic floor dysfunction | Muscles and nerves in the pelvic floor fail to coordinate correctly to have a bowel movement. |
| Hypertonic pelvic floor | Muscles that usually hold in stool fail to relax when trying to have a bowel movement. |
| Paradoxical contraction | Muscles that usually hold in stool tighten instead of relaxing when trying to have a bowel movement. |
| Impaired rectal sensation | Inability to feel the urge to poop. |
| Nerve damage | Damage to the pudendal nerves is a common cause of sphincter muscle damage. |
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What You'll Learn
Childbirth
Obstetric injuries during childbirth can cause both neurological and muscular damage to the pelvic floor. The internal anal sphincter (IAS) is composed of smooth muscle that maintains resting anal pressure, while the external anal sphincter (EAS) contracts voluntarily and during specific maneuvers. Damage to the EAS can lead to urge-related or diarrhea incontinence, while IAS dysfunction affects continence during rest.
Episiotomy, a surgical cut between the vagina and anus, is a common procedure during childbirth. However, it can increase the risk of third or fourth-degree anal sphincter tears, which are more severe and challenging to repair. Forceps delivery and longer pushing durations are also risk factors for EAS injuries and anal incontinence. Additionally, maternal age is a factor, with rates of EAS injury and fecal incontinence increasing with maternal age after 18 years.
The impact of anal incontinence after childbirth can be significant. Studies show that one in four women report a persistently negative quality of life two years after delivery. Women may experience anxiety, depression, embarrassment, and a negative body image due to fecal incontinence. Bowel urgency, which involves a short time between the urge to have a bowel movement and the need to pass stool, is also common in the first few months after vaginal delivery.
Treatment options for anal incontinence caused by childbirth include physical therapy, biofeedback techniques, and surgery. Physical therapy aims to strengthen the pelvic floor muscles and improve bowel control. Biofeedback uses electrodes to sense physiological parameters like muscle tension, guiding patients through muscle-activating and tension-relieving strategies. Surgery may be considered for severe cases, including procedures to repair, tighten, or reconstruct the sphincter muscles.
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Heavy straining
During heavy straining, the sphincter muscles can be damaged or weakened, leading to a loss of their normal function. This can manifest as leakage of gas, liquid, or stools, which can occur during activities such as strenuous exercise, lifting heavy weights, or even walking. The leakage may vary in amount and duration, ranging from a few minutes to several hours.
One of the primary functions of the anal sphincter muscles is to "snap shut" after defecation, sealing off the back passage and preventing any further leakage. When these muscles are weakened due to heavy straining, they may not close immediately or completely, resulting in the aforementioned symptoms. This can also make it challenging to wipe clean after using the toilet.
To improve bowel control and reduce leakage, it is essential to strengthen the anal sphincter muscles. This can be achieved through specific exercises that target these muscles. One such exercise involves sitting comfortably with the knees slightly apart and squeezing the muscles around the back passage, as if trying to prevent the passage of gas. It is important to isolate the correct muscles, ensuring that the buttocks, tummy, and legs remain relaxed during the exercise.
By performing these exercises consistently and correctly, individuals can improve the strength and function of their anal sphincter muscles, reducing the impact of heavy straining and improving their overall bowel control.
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Rectal surgery
One such surgery is a lateral internal sphincterotomy, which involves making a lateral incision into the internal anal sphincter muscle to treat chronic anal fissures. This procedure is performed when excess tension in the muscle prevents healing and causes complications. Sphincter-sparing colorectal surgery is another type of rectal surgery, but it aims to protect the sphincter muscles while removing diseased tissue in the rectum. This procedure is often recommended for patients with colorectal cancer or inflammatory bowel disease (IBD).
During a lateral internal sphincterotomy, a surgeon makes a small cut into the internal anal sphincter muscle to relieve excess tension. This type of surgery is considered safe and effective for treating chronic anal fissures that have failed to heal. The surgery has a high success rate and a low rate of complications. It is important to note that rectal surgery is not the only cause of sphincter muscle weakness. Other factors, such as heavy straining, external hemorrhoids, rectal prolapse, and rectocele, can also contribute to faecal incontinence.
In summary, rectal surgery can lead to the loss of sphincter muscle function and faecal incontinence. However, rectal surgeries like lateral internal sphincterotomy and sphincter-sparing colorectal surgery are designed to treat specific conditions while minimising damage to the sphincter muscles. It is important to weigh the risks and benefits of any surgical procedure and explore alternative treatments, such as physiotherapy and biofeedback techniques, to improve sphincter muscle strength and function.
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Accidental damage during an anal or rectal operation
The evaluation and management of anorectal trauma are well-defined, and the operative management of rectal injuries has evolved with a combination of surgical techniques, the advice of experienced surgeons, and well-controlled clinical studies. Historically, the lack of high-quality studies has led to management decisions being influenced by dogma and personal experience.
The primary repair of a rectal injury can often be accomplished with minimal dissection, such as through transanal repair or during the repair of genitourinary structures with pelvic exposure. Drainage has been a controversial topic, with some studies showing benefits and others showing no improvement. Distal rectal washout, popularized after a 1971 report of outcomes in Vietnam, is also controversial, with suggestions that it may stress the repair or worsen the injury.
Biofeedback is a successful, minimally invasive method of treating faecal incontinence resulting from anal sphincter muscle damage. This method is painless and safe, and it helps patients improve the voluntary contraction of the external anal sphincter and puborectalis muscles. It also aims to improve the coordination of the internal and external anal sphincters in response to rectal distention.
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Ageing
Faecal incontinence is defined as the inability to control bowel movements, causing accidental, unintentional loss of solid or liquid stool from the rectum. It can have a devastating effect on quality of life and is a cause for institutionalisation in the elderly. It is also more common in women, with childbirth-related injury to the anal sphincter being another important risk factor.
Studies using a female rabbit model have shown age-related alterations in the structure and function of the external anal sphincter (EAS) muscle. These studies are the first to demonstrate age-related changes in sphincter muscle morphology and function using multiple parameters.
The Wnt/β-catenin signalling pathway has been recently recognised as the major molecular pathway involved in age-related skeletal muscle atrophy and fibrosis. The exact pathophysiology of age-related alterations in sphincter muscle morphology and function and the underlying mechanisms are still unclear.
Pelvic floor exercises (Kegel exercises) may help reduce faecal incontinence. These involve contracting (squeezing) the anal sphincter several times per day or whenever one feels fullness in the rectum. However, these exercises must be performed daily to be effective.
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Frequently asked questions
Faecal incontinence is when stool leaks out from the rectum accidentally.
The most common cause of faecal incontinence is the anal sphincter becoming too weak to hold the stool in the rectum. This can be due to direct damage to the muscle or damage to the nerves that cause the muscle to contract normally. Other causes include rectal prolapse, rectocele, childbirth injuries, constipation, and neurologic diseases.
Treatments for faecal incontinence include biofeedback therapy, surgery, sacral nerve stimulation, and sphincteroplasty. Medications such as anti-diarrhoeal drugs and laxatives can also be used to manage the condition.
Faecal incontinence is not uncommon, and it can affect people of all ages. However, it is more likely to occur in the elderly, frail, or immobile individuals.
If faecal incontinence is frequent or severe, or if it is affecting your quality of life, you should consult a doctor. Embarrassment surrounding the condition may cause delays in seeking medical help, but it is important to remember that treatment options are available and can provide significant relief.
