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Bowel incontinence is a condition whereby an affected person is unable to prevent involuntary passage of gas (flatus) or stools from the anus. This can be very distressing as soilage around the anus can lead to itching or burning sensations. Furthermore, the affected person may feel anxious of others noticing the soilage. Sometimes, the sufferers are so traumatized that they withdraw socially from their friends and family.
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Normal bowel continence is maintained by coordination of the nerves and muscles of the pelvic floor and anus. Nerves of the pelvis allow a person to sense the presence of stools or gas in the rectum (end part of the large intestine before the anus) as well as stimulate the pelvic floor muscles to contract and shut the anus. Muscles of the pelvic floor consist of voluntary and involuntary muscles. Voluntary muscles can be controlled by the will of the person, such as the pelvic floor muscle (otherwise known as levator ani muscle) and external anal sphincters. Involuntary muscles are controlled autonomously by specialized nerves which regulate normal bodily functions such as temperature, blood pressure and gut movements. In the anus, the internal anal sphincter surrounding the anus is an involuntary muscle.
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When there is damage to sensory nerves of the pelvis, the affected person may not sense the gas or stools and that can lead to leakage of content from the anus. Damage to motor nerves can weaken the muscles of the pelvic floor and the affected person is therefore unable to hold back the urge to pass a bowel movement. Muscles of the anus and pelvic floor can be weakened by age, damaged by trauma or surgery to the anus or even difficult childbirth.
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In many cases with bowel incontinence, it is difficult to pinpoint the exact cause as the traumatic event could have been decades before or it is multi-factorial.
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- Traumatic childbirth – This is the commonest cause of bowel incontinence in women. It can be difficult to diagnose early as the tearing of the anus muscles are not visible from the outside and a woman can overcome the weakness of the damaged muscle by using other pelvic muscles to compensate. It only becomes evident with age as the rest of the pelvic muscles weaken.
- Ageing – The general weakening of muscles of the pelvic floor and anus with age can lead to inability to shut the anus tight.
- Nerve damage – Pelvic nerves can be damaged by surgery in the spine or pelvis, primary nerve disorders or frequent and excessive stretching (such as chronic constipation or obesity).
- Diabetes Mellitus – One of the complications of prolonged diabetes or poor diabetic control is damage to autonomic nerves, such as sensory nerves of the anus and nerves to the internal anal sphincter muscle.
- Anal sphincter damage – This usually happen secondary to surgery of the anus or anal trauma.
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It is important to know that this condition is treatable and not a natural part of ageing. Treatment is based on the severity of the problems and cause of bowel incontinence. Treatment may involve dietary and lifestyle changes, medications, physiotherapy or surgery.
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It is important to note that surgery is not commonly required for treatment of bowel incontinence unless it is very severe. The treatment involves modifications of lifestyle and diet as well as anorectal biofeedback (a form of pelvic floor rehabilitation physiotherapy) first. Medications are sometimes helpful to ensure a patient does not have overly hard stools or diarrhoea.
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The range of surgeries are enormous but most can be performed as day surgery procedures or involve only a few days hospitalization. Most patients recover quickly and are back to their normal activities within a week. Complications are not common and very rarely life-threatening.
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It is important to determine the cause(s) of bowel incontinence in an affected person in order to target the best treatment. It is also important to rule out other bowel conditions that may present almost like bowel incontinence.
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A specialized set of tests called the anorectal physiology measurements (ARM) are available for this purpose. These tests include:
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- Anorectal manometry – This is a non-invasive outpatient test that determines the strength of the anus muscles.
- Pelvic Nerve Study – This studies the quality of the nerves controlling muscles of the anus.
- Anorectal Ultrasound – This test allows the doctor to map out the anus muscles to determine whether surgery is needed to repair the muscle.
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Our specialist will perform the tests and craft a treatment program tailored to each patient.
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