diease

Bowel Incontinence


OVERVIEW OF Bowel Incontinence :

Faecal incontinence refers to the involuntary bowel movemnets that cannot be controlled. Stool passes spontaneously without any planned action.


EPIDEMIOLOGY :

people of age more than 65 years of age is prone for the disease.

young children physical activity also are the victim to bowel incontinence


CAUSES :

Faecal incontinence occurs due to the damage in the digestive dract and chronic diseases. The women who are having the vaginal delivery has higher chances for bowel incontinence.

Diarrhoea:

The loosy stools can be present over longer period of time in the rectum. This often leads to bowel incontinence

The following are the common diseases which present as a diarrhoea

Irritable bowel diseases

Irritable bowel syndrome

Proctitis.

Constipation:

The harder stools results in muscle fatigue leading in difficulty to pass the stools.

Muscle injury or weakness:

The muscle presenting in the anus,rectum if they get  injured or weakened, they feel difficult to pass the hard stools and the loosy stools are passed very easily. These muscles can be injured or weakened by

          Doing surgery to,

    • removing cancer in the anus or rectum
    • removing haemorrhoids
    • treating anal abscess and fistulas

trauma to the specific organs

 

Nerve damage:

If the muscles supporting the rectum , pelvic floor, anal canal is damaged it might results in difficulty in passing the stools . nerves may get  dysfunction or get damaged due to the following reasons:

 A long time habit of passing the stool with strain

Brain damage

Spinal damage

Neuronal Damage:

The diseases which is affecting the anus, pelvic floor and the rectum can result in neuronal damage. The following are the diseases which might include:

           Dementia

           Multiple scelerosis

                  Parkinson’s diseas

                  Stroke

            Type 2 diabetes mellitus.

 

Loss of stretch in the rectum:

If the rectum gets scarred or inflammed extremely the muscle gets fatigue and tightens and the stool is difficult to pass. Rectal surgeries , radiation therapy, an inflammatory bowel diseases results in loss of stretch to the anal and rectal muscle causing the stools difficulty to pass.

Haemorrhoids:

Haemorrhoids leads to the closure of rectal canal and this results in passage of small stools or mucus might leak.

Rectal prolapse:

In rectal prolapse the rectum comes into contact with the anal canal and the closure of anal cavity occurs which might also leads to the leaky mucus.

Physical inactivity:

The person who is sitting or lying down for more amount of time might store the more amount of stool in their rectum which in turn might leads to constipation and stiffness of the surrounding mescles. These actions might results in faecal incontinence or loosy stools might be able to pass from those areas.

Childbirth by vaginal delivery:

     Childbirth by vaginal delivery causes closure of anal sphincter and these problems might have higher chances in the following reasons:

  • your baby was large
  • forceps were used to help deliver your baby
  • you had a vacuum-assisted delivery
  • the doctor made a cut, called an episiotomy, in your vaginal area to prevent the baby’s head from tearing your vagina during birth

 

Rectocoele:

 Rectocele is the passage of the rectum through the vagina and rectum comes out of the vagina. The stool might get difficult to pass and causes some pain.

 

 

Faecal incontinence in children:

For children older than age 4, the most common cause of fecal incontinence is constipation with a large amount of stool in the rectum. When this happens, a child may not be able to sense when a new stool is coming into the rectum. The child may not know that he or she needs to have a bowel movement. A large amount of stool in the rectum can cause the internal anal sphincters to become chronically relaxed, which lets soft stool seep around hard stool in the rectum and leak out.

Birth defects of the anus, rectum, or colon, such as Hirschprung disease, can cause fecal incontinence in children. These birth defects may weaken pelvic floor muscles or damage nerves in the anus or rectum. Injuries to the nerves in the anus and rectum can also cause fecal incontinence, as can spinal cord injuries and birth defects of the spinal cord.

 


PATHOPHYSIOLOGY :

Faecal incontinence occurs when the normal anatomic and physiologic function of the body gets interrupted. Incontinence usually occurs from the multiple fcarors and it is not concerned to the single factor. The internal anal sphincter function is to cause the pressure during the resting phase and also it enhances the action of external sphincter , the anal mucosal folds, and the anal endovascular cushions. Disruption of the external sphincter results in urge related disorder or diarhhoea related disorder. Damage to the endovascular cushions results in dysfunction of the anal seal and sampling reflex. The ability of the rectum to perceive the presence of stool leads to the rectoanal contractile reflex response, an essential mechanism for maintaining continence.Pudendal  neuropathy can diminish rectal sensation and lead to excessive accumulation of stool, causing  faecal impaction, mega-rectum, and fecal overflow. The puborectalis muscle plays an integral role in maintaining the anorectal angle. Its  nerve supply is independent of the sphincter, and its precise role in maintaining continence needs to be defined. Obstetric trauma, the most common cause of anal sphincter disruption, may involve the EAS, the IAS, and the pudendal nerves singly or in combination. It remains unclear why most women who sustain obstetric injury in their 20s or 30s typically do not present with fecal incontinence until their 50s. There is a strong need for prospective, long-term studies of sphincter function in nulliparous and multiparous women


COMMON CLINICAL SIGNS AND SYMPTOMS :

loosy stool

difficulty in passing the stool

pain while evacuating 

excessive straining to pass the stool

Bloating and gas


DIAGNOSTIC :

Blood test,urine test  and stool test might be used to detect the dysfunction of bowel.

                   Blood test- can show signs of anaemia,inflammation and infection.

  • Stool tests can show the presence of blood and signs of infection and inflammation.
  • Urine test – diseases such as Diabetes mellitus type 2

Bowel function diseases:

It involves the Inspection of the anal,pelvic floor and rectum .

  • anorectal manometry—a test that checks how sensitive your rectum is, how well it works, and how well the anal sphincter work
  • defecography—an  xray  of the area surrounding the anus and rectum to see how well you can hold and release stool
  • Electromyography—a test that checks how well the muscles and nerves of your anus and pelvic floor are working

Endoscopy

Endoscopy helps to look inside your anus, rectum, and colon  for signs of inflammation and digestive tract functions problems that may be causing your fecal incontinence. Endoscopies for fecal incontinence include

  • Anoscopy
  • colonoscopy
  • flexible sigmoidoscopy
  • rectoscopy—a procedure similar to an anoscopy to look inside your rectum

Imaging tests

To look for problems in the anus, pelvic floor, or rectum that may be causing your fecal incontinence, your doctor may perform an imaging test such as

  • Lower Gastrointestinal series
  • Magnetic resonance imaging
  • ultrasound


TREATMENT AND PROGNOSIS :

Depending on the cause of fecal incontinence, options include:

  • Anti-diarrheal drugs : loperamide hydrochloride (Imodium A-D) and diphenoxylate and atropine sulfate (Lomotil)
  • Bulk laxatives such as methylcellulose (Citrucel) and psyllium (Metamucil), if chronic constipation is causing your incontinence

Exercise and other therapies

If muscle damage is causing fecal incontinence, your doctor may recommend a program of exercise and other therapies to restore muscle strength. These treatments can improve anal sphincter control and the awareness of the urge to defecate.

Options include:

  • Kegel exercises. Kegel exercises strengthen the pelvic floor muscles, which support the bladder and bowel and, in women, the uterus, and may help reduce incontinence. To perform Kegel exercises, contract the muscles that you would normally use to stop the flow of urine.

Hold the contraction for three seconds, then relax for three seconds. Repeat this pattern 10 times. As your muscles strengthen, hold the contraction longer, gradually working your way up to three sets of 10 contractions every day.

  • Biofeedback. Specially trained physical therapists teach simple exercises that can increase anal muscle strength. People learn how to strengthen pelvic floor muscles, sense when stool is ready to be released and contract the muscles if having a bowel movement at a certain time is inconvenient. Sometimes the training is done with the help of anal manometry and a rectal balloon.
  • Bowel training. Your doctor may recommend making a conscious effort to have a bowel movement at a specific time of day: for example, after eating. Establishing when you need to use the toilet can help you gain greater control.
  • Bulking agents. Injections of nonabsorbable bulking agents can thicken the walls of your anus. This helps prevent leakage.
  • Sacral nerve stimulation (SNS). The sacral nerves run from your spinal cord to muscles in your pelvis, and regulate the sensation and strength of your rectal and anal sphincter muscles. Implanting a device that sends small electrical impulses continuously to the nerves can strengthen muscles in the bowel.
  • Posterior tibial nerve stimulation (PTNS/TENS). This minimally invasive treatment stimulates the posterior tibial nerve at the ankle. In a large study, however, this therapy didn't prove to be significantly better than a placebo.
  • Vaginal balloon (Eclipse System). This is a pump-type device inserted in the vagina. The inflated balloon results in pressure on the rectal area, leading to a decrease in the number of episodes of fecal incontinence.
  •  Radiofrequency therapy. Known as the Secca procedure, this involves delivering temperature-controlled radiofrequency energy to the wall of the anal canal to help improve muscle tone. Radiofrequency therapy is minimally invasive and is generally performed under local anesthesia and sedation. However, this procedure isn't always covered by insurance.

Surgery

      Treating fecal incontinence may require surgery to correct an underlying problem, such as rectal        prolapse or sphincter damage caused by childbirth. The options include:

  • Sphincteroplasty. This procedure repairs a damaged or weakened anal sphincter that occurred during childbirth. Doctors identify an injured area of muscle and free its edges from the surrounding tissue. They then bring the muscle edges back together and sew them in an overlapping fashion, strengthening the muscle and tightening the sphincter. Sphincteroplasty may be an option for patients trying to avoid colostomy.
  • Treating rectal prolapse, a rectocele or hemorrhoids. Surgical correction of these problems will likely reduce or eliminate fecal incontinence. Over time, the prolapse of the rectum through the rectal sphincter damages the nerves and muscles of the sphincter. The longer the prolapse goes untreated, the higher will be the risk of fecal incontinence not resolving after surgery.
  • Colostomy (bowel diversion). This surgery diverts stool through an opening in the abdomen. Doctors attach a special bag to this opening to collect the stool. Colostomy is generally considered only after other treatments haven't been successful.


PROGNOSIS :

The prognosis is good when the triggering factor is made to subside.


PREVENTION :

Intake  lots of water and other fluids. You may be able to treat diarrhea at home using over-the-counter medications, such as loperamide

stay hydrated

practise physical exercises

reduces the stress and practise yoga

avoid the foods that results in constipation mainly junk foods

be physically active

 


Recovery Period :

It might take more than a week for the recovery and the recovery also depends upon the lifestly changes.

 


Medicines used in the Treatment :

  • loperamide hydrochloride (Imodium A-D)
  • diphenoxylate and atropine sulfate (Lomotil)
  • Bulk laxatives such as methylcellulose (Citrucel) and psyllium (Metamucil),


REFERENCE :

https://www.mayoclinic.org/diseases-conditions/fecal-incontinence/diagnosis-treatment/drc-2

https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/diagnosi

https://www.medicalnewstoday.com/articles/165583

https://my.clevelandclinic.org/health/diseases/14574-fecal-bowel-incontinence

https://www.nhs.uk/conditions/bowel-incontinence/