Fecal Incontinence Health Article

Physical examination

The physical examination begins with a visual inspection of the anus and the area lying between the anus and the genitals (the perineum) for hemorrhoids, infections, and other conditions that might explain the patient's difficulties. During this phase of the examination the doctor asks the patient to bear down. Bearing down enables the doctor to check whether rectal prolapse or certain other problems exist. Rectal prolapse means that the patient's rectum has been weakened and drops down through the anus. Next, the doctor uses a pin or probe to stroke the perianal skin. Normally this touching causes the anal sphincter to contract and the anus to pucker; if it does not, nerve damage may be present. The final phase of the examination requires the doctor to examine internal structures by carefully inserting a gloved and lubricated finger into the anal canal. This allows the doctor to judge the strength of the anal sphincter and a key muscle (the puborectalis muscle) in maintaining continence; to look for abnormalities such as scars and rectal masses; and to learn many other things about the patient's medical situation. At this point the doctor performs the anal wink test again and asks the patient to squeeze and bear down.

Laboratory tests

Information from the medical history and physical examination usually needs to be supplemented by tests that provide objective measurements of anal and rectal function. Anorectal manometry, a common procedure, involves inserting a small tube (catheter) or balloon device into the anal canal or rectum. Manometry measures, among other things, pressure levels in the anal canal, rectal sensation, and anal and rectal reflexes. Tests are also available for assessing nerve damage. An anal ultrasound probe can supply accurate images of the anal sphincter and reveal whether injury has occurred. Magnetic resonance imaging, which requires the insertion of a coil into the anal canal, is useful at times.

Treatment

Fecal incontinence arising from an underlying condition such as diabetic neuropathy can sometimes be helped by treating the underlying condition. When that does not work, or no underlying condition can be discovered, one approach is to have the patient use a suppository or enema to stimulate defecation at the same time every day or every other day. The goal is to restore regular bowel habits and keep the bowels free of stools. Medications such as loperamide (Imodium) and codeine phosphate are often effective in halting incontinence, but only in less severe cases involving liquid stools or urgency. Dietary changes and exercises done at home to strengthen the anal muscles may also help.

Good results have been reported for biofeedback training, although the subject has not been properly researched. In successful cases, patients regain complete control over defecation, or at least improve their control, by learning to contract the external part of the anal sphincter whenever stools enter the rectum. All healthy people have this ability. Biofeedback training begins with the insertion into the rectum of a balloon manometry device hooked up to a pressure monitor. The presence of stools in the rectum is simulated by inflating the balloon, which causes pressure changes that are recorded on the monitor. The monitor also records sphincter contraction. By watching the monitor and following instructions from the equipment operator, the patient gradually learns to contract the sphincter automatically in response to fullness in the rectum. Sometimes one training session is enough, but often several are needed. Biofeedback is not an appropriate treatment in all cases, however. It is used only with patients who are highly motivated; who are able, to some extent, to sense the presence of stools in the rectum; and who have not lost all ability to contract the external anal sphincter. One specialist suggests that possibly two-thirds of incontinence sufferers are candidates for biofeedback.

Some people may require surgery. Sphincter damage caused by childbirth is often effectively treated with surgery, however, as are certain other kinds of incontinence-related sphincter injuries. Sometimes surgical treatment requires building an artificial sphincter using a thigh muscle (the gracilis muscle). At one time a colostomy was necessary for severe cases of incontinence, but is now rarely performed.

Prognosis

Fecal incontinence is a problem that usually responds well to professional medical treatment, even among elderly and institutionalized patients. If complete bowel control cannot be restored, the impact of incontinence on everyday life can still be lessened considerably in most cases. When incontinence remains a problem despite medical treatment, disposable underwear and other commercial incontinence products are available to make life easier. Doctors and nurses can offer advice on coping with incontinence, and people should never be embarrassed about seeking their assistance. Counseling and information are also available from support groups.