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Addressing Some Common Questions About Fecal Incontinence

Elisa Birnbaum, MD, discusses a common condition that patients often feel distressed or embarrassed to ask about.

Written by Rachel Sauer on April 14, 2023

It’s not uncommon for patients to approach their health care providers in blushes and whispers, burdened by the weight of perceived taboos.

Certain symptoms can feel distressing or embarrassing to talk about, including the stool leakage or loss of bowel control that may be symptoms of fecal incontinence.

Elisa Birnbaum, MD, a professor of GI, trauma, and endocrine surgery in the University of Colorado School of Medicine, has worked not only to advance a multidisciplinary approach to surgical treatment for fecal incontinence, especially in women, but to destigmatize the condition so that patients feel less embarrassed to approach their doctors about it.

Further, her research has explored innovative treatments for fecal incontinence, working toward improved outcomes and improved quality of life for patients. She recently addressed some common questions about fecal incontinence.

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What is fecal incontinence?

Fecal incontinence is loss of control of bowel movements. It can occur on a spectrum, from occasional stool leakage to complete loss of control. It can affect as many as one in 10 people, so it’s not uncommon to have some form of incontinence. It can be extremely distressing, but also something that people may feel hesitant or embarrassed to talk about because of certain social taboos.

What are some causes of fecal incontinence?

A common cause is injury or damage to the muscle at the end of the rectum, which is the sphincter, that holds in stool. This kind of damage can occur during childbirth, especially in the case of an episiotomy or forceps use. Nerve damage also can cause fecal incontinence, which again can happen during childbirth but also can be caused by stroke, diabetes, and other conditions, or long-term constipation. Repeated straining during bowel movements also can cause nerve damage.

Chronic constipation can be a factor in fecal incontinence and so can hemorrhoids, because they can prevent the anus from completely closing. Diarrhea or loose stool also can make fecal incontinence worse.

Are there certain people who are more likely to experience fecal incontinence?

Typically, fecal incontinence is seen in categories of people, and more often in women. It’s more likely to happen as you age. A common history in fecal incontinence is women who have had vaginal births with episiotomies, tears, or forceps delivery. These can lead to certain pelvic floor dysfunctions and fecal incontinence. We also see it sometimes with people who have had anal surgery – fistulostomies or hemorrhoidectomies – and experience lack of bowel control after surgery. These are two of the most common causes of fecal incontinence.

It also sometimes occurs with patients who’ve had radiation for rectal cancer or for prostate cancer and experience injury to the lining of their colon from treatment. Also, patients who’ve had prior colonic resections and have a shortened colon may experience looser stools that are harder to control.

Some patients experience more urgency incontinence, which we see sometimes with diarrheal diseases, and with Crohn’s or ulcerative colitis, and this can be temporary incontinence or more long-term. There’s also another group of patients who experience overflow incontinence, those who experience constipation or who haven’t been able to evacuate well.

At what point should a person seek medical care rather than just deal with it at home?

If it’s something you’re worried about, ask your doctor. Even if it ends up not being serious enough to require surgical intervention, anything that’s sudden or happening a lot and causing you concern is something to talk about with your health care provider. Some people may feel distressed to bring it up or embarrassed talking about it, so as clinicians our goal is to help patients feel comfortable and to trust us to come up with the best treatment plan for them.

How is fecal incontinence commonly treated?

There’s a range of treatment from diet interventions and physical therapy to surgery, but we definitely want to start with medical management before progressing to surgical options. Patients may look at changing their diets to include more fiber and increase the amount of water they drink every day. There also are medications that help patients have more regular bowel movements or better bowel control.

Because it’s something that we see with women who’ve had episiotomies during childbirth, the urogynecology program in the CU School of Medicine has embarked on a program where anyone who’s had third- and fourth-degree episiotomies is recommended for pelvic floor therapy, which can be a really important intervention for fecal incontinence.

We consider surgical intervention for patients who are experiencing more significant and ongoing fecal incontinence – for example, passing a formed stool on a regular basis, as often as several times a week, for a period of time. Surgery either involves anal sphincter reconstruction, which I do if there’s no muscle or peroneal body between the anus and vagina. If the patient has an intact perineum but the muscle’s not functioning, then we may think about placing an InterStim sacral nerve stimulator, which stimulates the roots of certain nerves that are important for bladder and bowel function.

Is there anything people can do to prevent fecal incontinence?

Because it can be associated with muscle damage, with aging, or with certain conditions or diseases, some causes are going to be outside a person’s control. But drinking plenty of water and eating more high-fiber foods can help, and there’s evidence showing that Kegel exercise can, too. These things can help reduce the need to strain during bowel movements, which can damage nerves and weaken the sphincter muscles.

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Elisa Birnbaum, MD