Bowel Leakage
What is Fecal Incontinence (FI) or Accidental Bowel Leakage (ABL)?
The involuntary passage of stools beyond one’s control is known as fecal incontinence or accidental bowel leakage.
This problem is very common and very distressing. Nearly 20% of women aged over 45 years reported ABL women. The highest incidence of incontinence is reported in nursing home populations, where rates of ABL can reach as high as 50%. FI is the second leading cause for nursing home placement in the United States.
The prevalence is predicted to increase from 10.6 million affected individuals in 2010 to 16.8 million affected individuals in 2050. It occurs 8 times more often in women than in men.
Sadly, fewer than one third of women with accidental bowel leakage discuss their symptoms with a health care professional. Further, many patients with fecal incontinence who have attempted to seek care report that their health care providers either dismissed their concerns or did not provide hope or did not offer solutions.
What is worse is that fewer than 3% of patients with self-reported fecal incontinence receive a clinical diagnosis of fecal incontinence.
Bowel Leakage in Women: Causes, Symptoms, and Treatment Options
Bowel leakage, also called accidental bowel leakage (ABL) or fecal incontinence, is when stool passes unexpectedly or when you’re unable to fully control a bowel movement. It can happen at any age, but certain factors like childbirth and changes to the pelvic floor can increase your risk.
Bowel leakage can range from occasional staining in your underwear to a sudden urge to have a bowel movement that you cannot control. Some women also experience leakage without realizing it has happened.
What Causes Bowel Leakage in Women?
For normal bowel control, the muscles and nerves of the pelvic floor, anal sphincter, and rectum must work together. If part of this system is not functioning properly, leakage can occur.
Potential causes and contributing factors include:
- Pelvic floor or anal sphincter damage from childbirth
- Chronic diarrhea or constipation
- Irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD)
- Previous rectal or anal surgery
- Pelvic organ or rectal prolapse
- Diabetes
- Neurologic conditions
- Weakness or poor coordination of the pelvic floor muscles
For some women, more than one factor contributes to bowel leakage.
What Are the Symptoms of Bowel Leakage?
Symptoms can look different from one woman to another. You may experience:
- Stool leaking unexpectedly
- Difficulty reaching the bathroom in time
- Leakage of liquid or solid stool
- Staining or soiling of underwear
- Difficulty completely emptying your bowels
- Constipation or frequent loose stools
- Irritation of the skin around the anus
Even occasional bowel leakage is worth discussing with your doctor, especially if it is interfering with your daily activities or quality of life.
How Is Bowel Leakage Treated?
Your treatment will depend on the cause of the leakage and the severity of your symptoms. At Advanced Urogynecology of Michigan, evaluation might include a pelvic and rectal examination, stool diary, and specialized testing to get a clear understanding of how your rectum, pelvic floor, and anal sphincter are functioning.
Many women start with nonsurgical treatment. Depending on your needs, options may include dietary changes, fiber or medications to improve stool consistency, and pelvic floor physical therapy. For persistent symptoms, treatments such as sacral neuromodulation may be considered. In some cases, a damaged anal sphincter can be surgically repaired.
We know that bowel leakage can be difficult to talk about, but you don’t have to face it alone. Identifying the cause is the first step toward finding a treatment that can help you regain better bowel control and improve your quality of life.
What are the risk factors for ABL?
- Prior pelvic floor damage related to childbirth.
- Surgery such as hemorrhoidectomy
- Diabetes
- Neurologic conditions
- Anoreceptive intercourse
- Urinary incontinence (UI)
- Obesity
- disorders of chronic bowel disturbance, including irritable bowel syndrome, inflammatory bowel disease, and chronic diarrhea or constipation
- Constipation: reported in up to 60% of patients with FI
What is the normal physiology of bowel continence or control?
The lowest part of the large bowel called the anal canal is surrounded by two sphincter muscles called internal and the external sphincter and another sling called the puborectalis sling. These three together help in maintaining continence. Above this, the rectum has a storage area called the rectal ampulla which allows for storage of stools until the time is right for its evacuation.
If there is dysfunction in the bowel motility or the storage of the rectal ampulla or weakness of the anal sphincter complex, accidental bowel leakage can occur.
How do we assess for ABL in our practice at AUGM
- Pelvic examination: A thorough vagina and rectal examination helps us identify any vaginal prolapse or rectal prolapse. It also helps understand the strength of the anal sphincter muscle and if there is any constipation.
- Stool Diaries are important as they help determine the consistency of the stools that the patient typically passes. If the patient has loose stools, then the likelihood of fecal incontinence is higher, and this can be corrected simply by improving the consistency of the stools.
- Specific bowel tests:
- Anorectal manometry:
- Records the pressure of the anal sphincter at rest and at squeeze.
- Records the holding volumes of the rectal cavity.
- Balloon expulsion test.
- Patient is told to push a water filled balloon out of the rectum into the toilet similar to having a bowel movement.
- This assesses the coordination of the rectum and the anal canal especially to see if the sphincter muscle relaxes during expulsion.
- Endoanal ultrasound
- identifies defects in the internal and external anal sphincter muscles.
- Anorectal manometry:
How do we manage ABL in our practice at AUGM:
- Due to irritation from constant fecal seepage, moisturizers that also provide a skin barrier, such as dimethicone, lanolin, and petrolatum, and perineal products for adults should be considered.
- Food diaries can also help identify triggers that should be avoided if the patient has loose stools and fecal hurry or urgency.
- For patients with loose stools, daily fiber intake of 25 g for adult women under the age of 50 and 21 g for women aged 50 years or older should be considered.
- Loperamide may also be considered to help improve the stool consistency if the patient mainly has loose stool leakage.
- Pelvic floor therapy done by our dedicated pelvic floor Physical therapist helps improve the strength of the rectal sphincter and coordinates the function of the rectum and the anal canal. This is typically done once a week for 4-6 weeks. Pelvic floor therapy does the following:
- Improves rectal sensation
- Improves anal sphincter tone
- Improves coordination between rectum and anal canal, and
- Allows for a better abdominal force to initiate a strong rectal pressure while relaxing the anal sphincter.
- Sacral neuromodulation (SNM):
- delivers pulsatile electrical current through an electrode placed in the third sacral (S3) nerve as it exits the sacral foramen at the tail bone.
- The initial stage could be done in the doctor’s office and then the final stage is done in an outpatient center. The procedure takes about 20’ to perform
- Anal sphincter repair: In some cases, anal sphincter repair is beneficial for the management of fecal incontinence. The repair of a torn anal sphincter can help restore continence.
- Other treatment options: A bowel control device such as Eclipse or an anal plug may be tried in certain situations.
Accidental bowel leakage (ABL) is very common especially in the elderly but can happen at any age especially if due to childbirth. It is simple to diagnose, and the first-line therapy is always nonsurgical with sacral neuromodulation being an effective secondary option.
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