Fecal incontinence: symptoms and treatment
Stool incontinence (or encopresis) is a disorder in which the ability to control a defecation act is lost. Incontinence, the symptoms of which are mainly observed in children, manifested in adults, is usually associated with the relevance of a particular pathology of organic scale (tumor formation, trauma, etc.).
Under the incontinence of stool, as we noted, is understood the loss of control over the process of emptying the bowels, which, accordingly, indicates the inability to delay the defecation until the moment it becomes possible to visit the toilet for this purpose. As an incontinence stool is also considered an option in which there is an involuntary leakage of stool (liquid or solid), which, for example, can occur during the passage of gases.
In almost 70% of cases, fecal incontinence is a symptom (disorder) that occurs in children from 5 years of age. Often its occurrence is preceded by stool retention (the chair here and hereinafter — an interchangeable synonym for the definition of «feces»). As for the predominant sex in terms of the development of encopresis, the disease is more often observed in males (with an approximate ratio of 1.5: 1). When considering adult statistics, this disease, as already noted, also does not have to be excluded.
There is an opinion that the incontinence of stool is a violation, common for the onset of old age. Despite some common facets, it is not true. At the moment, there are no facts that would indicate that, without exception, people at age lose the ability to control fecal excretion through the rectum. Many believe that fecal incontinence is an old disease, but in reality the situation looks somewhat different. So, about half of patients, if you look at certain statistics on this account — people of the middle-aged group, and this age, respectively, ranges from 45 to 60 years.
Meanwhile, this disease also has to do with old age. So, it is this reason, following dementia, that is becoming second in importance in that elderly patients adhere to social exclusion, therefore, fecal incontinence in the elderly and is a specific problem that belongs to the framework of age-related problems. In general, regardless of age, the disease, as you can understand, adversely affects the quality of life of patients, leading not only to social exclusion, but also to depression. Because of the incontinence of stool, sexual attraction is subject to changes, against the background of the general picture of the disease depending on each aspect, this picture is a component, there are problems in the family, conflicts, divorces.
Defecation: the principle of action
Before we go on to consider the characteristics of the disease, let us dwell on how the intestine controls defecation, that is, how it occurs at the level of its physiological characteristics.
Management of bowel defecation is carried out through the coordinated functioning of nerve endings and muscles concentrated in the rectum and in the anus, this occurs through a delay in the exit of the stool or, conversely, through its exit. Fecal confinement is provided at the expense of the final department in the large intestine, that is, due to the rectum, which must for this purpose be in a certain voltage.
Cal at the time of hitting the final department basically already has a sufficient density. The sphincter, based on the circular type of muscles, is in a tightly compressed state, so it provides a tight ring in the terminal part of the rectum, which is the anus. In the compressed state, they stay until the moment that the stool is prepared for the exit, which, accordingly, occurs within the framework of the act of defecation. Due to the muscles of the pelvic floor, the intestine tone is maintained.
Let us dwell on the features of the sphincter, which plays an important role in the disorder we are considering. The pressure in its region is on the average about 80 mm Hg. Although the variants are considered as a norm within the range of 50-120 mm Hg. Art.
This pressure in men is higher than in women, with time it undergoes changes (decrease), which, meanwhile, does not cause a problem in patients directly related to incontinence (if, of course, there are no factors , This pathology provoking). The anal sphincter is constantly in a tonus (both during the day and during the night rest), does not exhibit electrical activity during defecation. It should be noted that the anal inner sphincter acts as an extension of the circular smooth muscle in the rectum, for this reason, control over it is carried out by the autonomic nervous system, it can not be consciously (or arbitrarily) controlled.
Stimulation of an adequate act of defecation occurs due to the stimulation exerted on the mechanoreceptors in the rectal wall, which occurs as a result of the accumulation of fecal masses in its ampoule (with a preliminary entry from the sigmoid colon). As a response to such irritation, it is necessary to adopt the appropriate position (sitting, squatting). With simultaneous contraction of the muscles of the abdominal wall and the closing of the glottis (which is determined by the so-called Valsalva reflex), intra-abdominal pressure increases. This, in turn, accompanies the inhibition of segmental contractions from the rectum, which ensures the advance of stool in the direction of the rectum.
The previously noted musculature of the pelvic floor is subject to relaxation, because of which its descent occurs. Sacral-rectum and pubic-rectum muscles open their anorectal angle when relaxed. Being exposed to irritation from fecal masses, the rectum provokes relaxation of the internal sphincter and sphincter of the external, as a result of which stools are released.
Of course, there are situations in which defecation is undesirable, impossible for certain reasons, or inappropriate, because this was initially taken into account in the defecation mechanism. In the above cases, the following occurs: the external sphincter and pubic-rectum muscles begin to contract arbitrarily, which leads to the closure of the anorectal angle, the anal canal begins to tightly compress, thus ensuring the closure of the rectum (exit from it). In turn, the rectum, in which the fecal masses are located, undergoes expansion, which becomes possible due to a decrease in the degree of wall tension, the urge to act of defecation, respectively, passes.
Causes of incontinence
The impact on the defecation mechanism determines the principles of manifestation of the disorder of interest to us, therefore, for this reason, we should elaborate on the causes that provoke it. These are:
- muscle weakness, muscle damage;
- nerve impairment
- decreased muscle tone of the rectum area
- dysfunctional pelvic floor disorder
Let us dwell on the reasons listed above.
Constipation. Under the constipation in particular, this state is implied, which is accompanied by the number of acts of defecation less than three times per week. The result of this, respectively, and can become incontinence stool. In some cases, in the rectum during constipation, a significant amount of solidified feces is formed and subsequently stuck. At the same time, a watery stool may accumulate, which begins to leak through a stiff stool. If constipation lasts for a considerable period of time, this can cause stretching of the sphincter muscles and their weakening, which in turn becomes the result of a decrease in the retention capacity of the rectum.
Diarrhea. Diarrhea can also cause a patient to develop a stool incontinence. The filling of the rectum with liquid stool occurs much faster, while maintaining it is accompanied by considerable difficulties (in comparison with a hard stool).
Muscle weakness, muscle damage. If the muscles of one of the sphincters (or both sphincters, external and internal) are affected, incontinence may develop. With weakening or damage to the muscles of the internal and / or external anal sphincter, the inherent strength is lost, respectively. As a result, holding the anus in the closed position while preventing leakage of the stool is greatly complicated or even impossible at all. As the main reasons contributing to the development of muscle weakness or muscle damage, we can distinguish the transfer of injuries in this area, surgery (for example, with hemorrhoids or with cancer), etc.
Insolvency of nerves. If the nerves that control the muscles of the inner and outer sphincters are not working properly, they can not be compressed and relaxed accordingly. Similarly, a situation is considered in which nerve endings reacting to the degree of stool concentration in the rectum begin functioning in a disturbed mode, whereby the patient does not feel the need to visit the toilet. Both variants testify, as it is understandable, about the inconsistency of nerves, against which, in turn, the incontinence of feces can also develop. Under the main sources provoking such incorrect work of nerves, we understand their following variants: childbirth, stroke, diseases and traumas that affect the activity of the central nervous system, the habit of ignoring body signals for a long time, indicating the need for defecation, etc.
Reduced muscle tone of the rectum area. In the normal (healthy) state, the rectum may, as we discussed in the description of the section on the defecation mechanism, stretch, and, thus, retain the stool until the moment within which defecation becomes possible. Meanwhile, certain factors can cause the appearance of scarring on the wall of the rectum, as a result of which it loses its inherent elasticity. As such factors, various types of surgical interventions (rectal area), intestinal diseases accompanied by characteristic inflammation (ulcerative colitis, Crohn’s disease), radiation therapy, etc. can be considered. Accordingly, on the basis of the urgency of such an effect, it can be said that the rectum Loses its ability to adequately stretch its muscles while holding the stool, which in turn provokes an increase in the risk associated with the development of incontinence.
Dysfunctional disorder of the pelvic floor. Fecal incontinence may develop as a result of abnormal functioning of the nerves or muscles of the pelvic floor. This, in turn, can contribute to certain factors. In particular, this is:
- lowering the sensitivity of the rectal area to the stool filling it;
- decreased compressive capacity of muscles that are directly involved in defecation;
- rectocele (pathology, within the framework of which the rectum wall protrudes into the vagina), prolapse of the rectum;
- Functional relaxation of the pelvic floor, as a result of which it becomes weak and tends to sag.
In addition, pelvic floor dysfunction often develops after childbirth. In particular, the risk increases if obstetric forceps were used in the context of labor (with the help of which it is possible to extract the baby). No less significant degree of risk is assigned to the procedure of episiotomy, in which the operative dissection of the perineum is performed as a measure to prevent the formation of arbitrary forms of vaginal ruptures in a woman giving birth, as well as the child’s cerebral trauma. In such cases, incontinence in women is manifested either immediately after delivery, or several years after this.
Hemorrhoids. With external hemorrhoids, the development of which occurs in the area of the skin surrounding the anus, the actual pathological process can act as a reason not to completely block the muscles of the sphincter anus. As a result, a certain amount of mucus or liquid stool may leak through it.
Stool incontinence: Species
Stool incontinence, depending on age, is determined by differences in the nature of the occurrence and in the types of disorder. So, on the basis of the features we have already considered, it can be distinguished that incontinence can be manifested in the following variants:
- Regular allocation of stools without concomitant urge to defecate;
- stool incontinence with a preliminary urge to defecate;
- partial manifestations of incontinence resulting from certain loads (physical activity, tension during coughing, sneezing, etc.)
- stool incontinence, arising from the effects of degenerative processes associated with aging of the body.
Stool incontinence in children: symptoms
Stool incontinence is in this case an unconscious release by a child aged 4 years and older of the feces, or in its inability to withhold until the appearance of conditions in which defecation becomes permissible. It should be noted that before the child reaches the age of 4 years, fecal incontinence (and urine incontinence) is a completely normal phenomenon, despite certain inconveniences and stress that may accompany it. The point is, in this case, in the gradual acquisition of skills related to the excretory system as a whole.
Symptoms of incontinence in children are also often noted against the background of previous constipation, the nature of which we have generally considered above. In some cases, as the cause of constipation in children during the first years of their life is an excessive insistence on the part of parents in terms of training the child to the pot. Some children have a problem of insufficiency of the contractile function of the intestine.
The urgency of the accompanying incontinence of the stool of a mental disorder can be considered in frequent cases when the bowel is emptied in conditions of unapproved places (the allocation has a normal consistency). In some cases, fecal incontinence is associated with problems associated with impaired development in the child’s nervous system, including with his inability to withhold attention, with impaired coordination, hyperactivity and easy distraction.
A separate case examines the occurrence of this disorder in children from disadvantaged families in which parents do not timely teach them the required skills and generally do not devote sufficient time. This may be accompanied by the fact that children, confronted with the persistence of this disorder, simply do not recognize the characteristic feces of smell and do not react in any way to the fact that it departs.
Encopresis in children may be primary or secondary. Primary encopresis is associated with the practical lack of skills in the child for defecation, while the secondary encopresis appears suddenly, predominantly against the background of previous stress (the birth of another child, conflicts in the family, divorce of parents, commencement of visiting the kindergarten or school, change of place of residence and etc.). The peculiarity of the secondary incontinence of the stool is that this frustration arises with already acquired practical skills for defecation and the ability to control them.
Most often, fecal incontinence is noted in the daytime. When it occurs at night, the forecast is less favorable. In some cases, incontinence can be accompanied by urinary incontinence (enuresis). More rarely, as a cause of incontinence of feces, the actual bowel diseases are considered.
Often the problem of incontinence in children arises from the deliberate retention of the stool before. As a cause of stool retention in this case, one can consider, for example, the occurrence of unpleasant emotions in the training of using the toilet, the constriction that occurs when a public toilet is needed. Also, the reasons may be that children do not want to interrupt the game or are experiencing fear associated with the possible occurrence of unpleasant sensations or soreness in defecation.
Stool incontinence, the symptoms of which, above all, are based on the act of defecation in places for which it is inappropriate, is accompanied by the voluntary or involuntary excreta allocation (on the floor, in clothing or in bed). By frequency, such emptying is manifested at least once a month, for a period of at least six months.
An important aspect in the treatment of children is the psychological aspect of the problem, it is with psychological rehabilitation that treatment should begin. It is, first of all, in explaining to the child that the problem that is happening to him is not his fault. Naturally, in relation to the child against the background of the existing problem of incontinence of stool, in no case should there be intimidation or ridicule, any humiliating comparisons on the part of the parents.
This may seem strange, but listed options for the approach of parents — not uncommon. Everything that happens to the child causes them not only a certain discomfort, but also an irritation that splashes in some form or another onto the child. It should be remembered that this approach only aggravates the situation in which, we repeat, the child is not to blame. Moreover, due to this, there is a risk of development in the near future of the child of a number of psychological problems, varying degrees of severity and the disputable possibility of their correction and complete elimination. Taking this into account, it is important for parents not only to focus on solving the child’s problem, but also to carry out certain work on self-restraint, acceptance of the situation and search for a solution to it. The child needs help, support and encouragement, only because of this, any treatment can be effective with minimal loss.
Behavioral treatment of incontinence in a child consists in observing the following principles:
- The child should be seated on the pot after each meal for 5-10 minutes. Due to this, the reflex activity of the intestine is strengthened, the child accustoms himself to tracking the urge to defecate in his own body.
- If it was noticed that the feces are «skipped» at a certain time during the day, it should be planted on the pot a few before such «passes».
- Again, it is important to encourage the child. Do not put it on the pot against your will. Children at the age of 4 years, as a rule, react positively to the invention of any games, therefore, in case of actual encopresis, this approach can be used. So, you can, for example, apply a certain scheme of encouragement, acting with the agreement of the child to sit down on the potty. Accordingly, when allocating stool for such squats, it is advisable to increase the reward somewhat.
By the way, the listed variants of the approach to the child will allow not only to teach the baby the acquisition of adequate toilet skills, but will also determine the possibility of eliminating possible stagnation of stool (constipation).
In diagnosing the disorder, the physician takes into account the patient’s medical history, the medical examination and the data obtained during the diagnostic tests (a survey on important points related to the existing problem). In addition, a number of instrumental diagnostic techniques are used.
- Anorectal manometry. For its implementation, a pressure sensitive tube is used, the use of which determines the sensitivity of the rectum and features associated with its functioning. Also, this method allows to determine the actual compression force on the part of the anal sphincter, the ability to adequately respond to emerging neural signals.
- MRI (magnetic resonance imaging). Due to the influence of electromagnetic waves, this method allows you to obtain detailed images relating to the area under investigation, the muscles of soft tissues (in particular, with incontinence, the emphasis in this study is on studying the muscles of anal sphincters by obtaining such an image).
- Proctography (or defectography). Radiological examination method, which determines the amount of feces that the rectum can contain. In addition, the features of its distribution in the rectum are determined, the features of the effectiveness of the defecation act are revealed.
- Transrectal ultrasound. The method of ultrasound examination of the rectum and anus is realized by introducing a special sensor into the anus region (transducer). The procedure is absolutely safe, without concomitant soreness.
- Electromyography. The procedure for studying the muscles of the rectum and pelvic floor, focused on the study of the correct functioning of the nerves controlling these muscles.
- Recto-rheumoscopy A special flexible tube equipped with an illuminator is inserted into the anus (and then to the other lower sections in the large intestine). Due to its use, it is possible to examine the rectum from the inside, which in turn determines the possibility of identifying local comorbid causes (tumor formation, inflammatory process, scars, etc.)
Treatment of fecal incontinence in adults and children (in addition to the noted positions considered in the corresponding paragraph), depending on the factors causing the disease, is based on the following principles:
- adjusting the diet;
- use of drug therapy measures
- Intestinal training
- pelvic floor muscles training (special exercises)
Each of the points is worked out only on the basis of a visit to a specialist and only in accordance with his specific instructions, based on the results of the research measures taken. We will dwell on surgical intervention, which, quite possibly, will interest the reader. This measure is used if the improvement does not occur with the implementation of other measures listed, and also if the incontinence of the feces is triggered by trauma to the anal sphincter or pelvic floor area.
As the most common method of surgery, sphincteroplasty is considered. This method is aimed at rejoining the sphincter muscles that have undergone separation because of a rupture (for example, during labor or trauma). Such an operation is performed by a general practitioner, colorectal surgeon or surgeon-gynecologist.
There is another method of surgical intervention, consisting in placing an inflatable cuff in the anus («artificial sphincter») with a subcutaneous implantation of a «pump» of small dimensions. The pump is activated by the patient (this is done to inflate / lower the cuff). This method is used infrequently, is performed with the control of a colorectal surgeon.
Tips for patients with incontinence
Stool incontinence, as one can understand, can cause a number of problems, ranging from banal embarrassment to deep depressions against this background, a sense of loneliness and fear. Therefore, the implementation of certain practical methods is extremely important for improving the quality of life of patients. The first and basic step, of course, is to turn to a specialist. This barrier is necessary to move, despite the possible embarrassment, a sense of shame and other emotions, due to which a trip to a specialist in itself looks like a problem. But the problem itself, which is the incontinence of feces, is mostly solved, but only if patients do not «drive themselves into a corner» and do not react to everything by waving their hand and choosing for themselves a position of seclusion.
So, here are some tips, adhering to which, with the urgency of incontinence, you can in some way control this problem in conditions that are least conducive to an adequate response to the situation:
- leaving the house, go to the toilet, trying, thus, to empty the intestines
- again, when leaving, care should be taken for the availability of replacement clothing and materials, with which you can quickly eliminate the «malfunction» (napkins, etc.)
- Try to find in the place where you are, the toilet before you need it, this will reduce a number of related inconveniences and quickly navigate
- If there is a suggestion that loss of control of the gut is a possible situation, then it is better to wear underwear if disposable;
- Use tablets that help reduce the intensity of the odor of gases and feces, such pills are available without a prescription, but it is better to trust the doctor’s advice in this matter.
With incontinence, you can first turn to the doctor (therapist or pediatrician), he will refer you to a specific specialist (proctologist, colorectal surgeon, gastroenterologist or psychologist) on the basis of consultation.