Fecal incontinence is the most psychologically and socially humiliating symptom that can occur in an otherwise healthy person. This symptom consists of the involuntary passage of hard or liquid stools. The condition is caused by loss of control of the external anal sphincter or its dysfunction.
This symptom should be distinguished from other situations associated with uncontrolled stool. For example, stool leakage may be associated with hemorrhoids, anal warts, fistulas, and rectal prolapse. Insufficient control of stool elimination is also possible due to inflammatory bowel disease, laxative abuse, and infection.
Causes of fecal incontinence
The content of the article
The incidence of fecal incontinence in the general population is estimated at 2-3%. It is greatest in women over 70 years of age. Predisposes to fecal incontinence:
- elderly age;
- severe depression;
- urinary incontinence;
- complicated vaginal birth.
This problem occurs in 13-25% of women within 3-6 months after childbirth, regardless of the type of birth. Six months after giving birth, about 7% of women suffer from fecal incontinence at least once a month.
An increase in the incidence of fecal incontinence in older women has been associated with previous perineal trauma and atrophy of the external anal sphincter and fronto-rectus muscle.
Loss of complete control over bowel movements may be due to:
- sphincter dysfunction;
- impaired ability of the rectum to adapt to the amount and consistency of accumulated stool;
- impaired sensitivity in the rectum.
Loose or loose stools with gas and inflammation of the rectum speed up bowel movements or increase the frequency of the urge to defecate.
Classification
Depending on the severity, there are 3 degrees of encopresis:
- First. Uncontrolled excretion of feces during the passage of intestinal gases. Typically a small amount of discharge (staining laundry).
- Second. Periodic involuntary discharge of a large volume of liquid feces.
- Third. The sphincter gapes, and solid fecal matter passes out of the rectum in an unregulated manner.
There are 3 forms of the disease:
- Partial. Incontinence occurs during significant physical exertion, severe fear, and occurs simultaneously with emptying the bladder.
- Uncontrollable. The urge persists, the patient cannot slow down the act of defecation.
- Regular. There are no urges. This type is typical for severely bedridden patients.
Diagnostics
Diagnosis
When evaluating a patient with fecal incontinence, a thorough history should be obtained. First, it is necessary to determine whether fecal incontinence is actually present or whether the patient complains of excessive and too frequent urge to defecate.
The gastroenterologist needs to understand how long the symptoms last, whether the patient has diarrhea, how much stool is passed, and whether there is an urgency to it. It is also necessary to determine whether the patient has undergone surgery in the past in the perineal area (in the case of women, we are talking about complicated vaginal births), whether radiation therapy was prescribed in this area, and whether the patient suffers from neurological diseases or diabetes.
This is followed by a thorough physical examination with perineal and rectal examination, including bilateral rectal reflex examination. The absence of this reflex indicates an interruption of the reflex arc.
Prevention of encopresis in adults
The disease brings considerable discomfort to a person’s life. If its first symptoms are noticed, special attention must be paid to nutrition and lifestyle. By eliminating prohibited foods from the diet and giving up alcohol and smoking, the patient significantly improves his or her prognosis for recovery. If symptoms persist, you do not need to lead an active lifestyle; you should temporarily give up sports and going to the pool. Before leaving the house, you must visit the toilet. You should always take wet wipes and a change of underwear with you. This will help you avoid getting into an awkward situation.
Additional Research
Depending on the symptoms accompanying fecal incontinence (diarrhea or constipation), additional tests are performed that are recommended in these situations. Other tests to consider include electromyography and transrectal (endorectal) ultrasound.
- Electromyography.
Electromyography is performed using surface or needle electrodes. Its purpose is to determine the overall myoelectric activity of the external sphincter and frontorectalis muscles at rest, conscious contraction of the sphincter, and the act of pressing on the stool. - Transanal ultrasound.
Transanal ultrasound (TAUS), including three-dimensional ultrasound, evaluates structural abnormalities in the anal sphincters, puborectal muscles, and rectal wall. For the test, endorectal probes with a frequency range of 10-16 MHz are used. This is a simple and relatively minimally invasive test.
TAUS is most useful when the history and anorectal manometry findings suggest occult sphincter injury. The results of transrectal ultrasound have a decisive influence on the choice of treatment.
A morphological defect of the sphincters exceeding 1/3 of their circumference indicates the failure of conservative treatment.
Common causes of constipation:
- change in nutritional pattern
- starting kindergarten
- trip with mode change
- hospital stay for any reason
- uncomfortable toilet (outdoors)
Often constipation goes unnoticed at first, especially if the child has already gone to the toilet on his own, falling out of the parent’s control zone. But there is also a kindergarten where parents usually cannot control anything...
As a result, problems are identified already at the stage of constantly soiled panties.
a special visual scale to evaluate stool in a conversation with parents and child :
- Amsterdam AISS Baby Stool Scale for the youngest diaper wearers
- Bristol scale for older children
Children are better oriented using the modified Bristol scale mBSFS (there are only five options instead of seven in the usual adult version).
Another source of confusion is a phenomenon called paradoxical diarrhea : looser stool due to inflammation in the intestine begins to flow around the fecal debris. As a result, parents complain of strange diarrhea, which turns out not to be diarrhea at all, but constipation.
The reasons for non-retentive stool are unclear to doctors, since in such children the volume of the intestine, the sensitivity of the anus, and the speed of feces movement through the colon are normal.
It is very important for the doctor to understand as early as possible the type of calomania - retention or non-retention.
A lot depends on this:
- the prognosis will be different - non-retentive calomasation much more often goes away on its own with age
- There will be different treatments (the most important thing is whether laxatives will help or not)
Here is a table from the International Association for Child and Adolescent Psychiatry and Allied Professions , which compares both types of encopresis and makes life easier for the doctor and the patient.
I would like to draw your attention to ultrasound signs.
Usually, if you have constipation, I almost never refer you for an ultrasound. The technique is good, but not for this situation.
But in some situations, when it is not possible to immediately understand the type of stool, you can send the child for an ultrasound and check the diameter of the rectum.
If the diameter is increased, then this is a clear hint that you cannot do without laxatives.
Conservative treatment
- Diet and lifestyle
. With nonspecific conservative treatment, it is important to change eating habits. This will reduce the frequency of bowel movements and improve the consistency of bowel movements. Well-formed stools are easier to control. It is important to understand that hard stool stuck in the rectum increases fecal incontinence, so it is necessary to promptly remove the stool remaining in the rectum. - Pharmacotherapy.
In standard situations, the following are used: loperamide, codeine and diphenoxylate. Patients who tend to pass stool uncontrollably after meals may benefit from anticholinergic medications taken before meals. For idiopathic fecal incontinence, amitriptyline is prescribed. - Sacral nerve stimulation.
This is a relatively new treatment method. Electrical stimulation of the sacral nerve roots can restore bowel retention in patients with intact muscle structure. After a successful 3-week treatment, the stimulation device is implanted subcutaneously.
Encopresis in the elderly
Relatives of elderly people who suffer from encopresis often come to our clinic. This is a common problem caused by age-related brain disorders. The cortical center, which is responsible for the act of defecation, begins to function incorrectly. This problem is not congenital and develops gradually with age. We are developing an individual treatment program for encopresis, consisting of many components, including the most effective methods and approaches.
Elderly people often experience psychological discomfort due to the inability to control bowel movements. They begin to avoid communication with friends and relatives and become voluntary hermits in their home. If a pensioner previously went to work, he can quit so that no one witnesses his “inconvenient” illness.
Such situations can occur up to 5 times a day. Patients are prescribed medication, as well as consultations with a psychiatrist and psychotherapist. It is important not only to eliminate the problem at the physiological level, but also to remove the consequences of psychological trauma. Often, marasmus is treated in parallel; inability to control bowel movements is a concomitant disease in some cases. In this case, the patient does not understand and does not remember what exactly happened to him.
How can a doctor help a child with colomasia?
The basis of treatment for retentional stool is to relieve the child of chronic constipation.
The methods have long been known and simple.
The main medications are laxatives (usually macrogol or lactulose) in sufficient doses for a sufficiently long period. The key word is enough !
The main mistakes of parents and even doctors:
- give a certain dose of laxative and not realize that the dose must be further adjusted according to the child’s reaction
- prescribe treatment for too short a period (unfortunately, constipation that has lasted for years cannot be cured in a month)
The value of other drugs (probiotics, choleretic drugs) is usually very small; their effect can be easily replaced with a slightly larger dose of a laxative.
Is diet (eating high in fiber) important?
I usually talk about a diet that is beneficial for stool (fruits, vegetables, whole grains), but in a real situation, when constipation is so severe that stools occur, the diet in treatment is of minimal importance. Talking about proper nutrition is more important for the future, when the stage of gradual abandonment of laxatives comes. Then nutrition will be part of the prevention of relapses, and then a component of the formation of a healthy lifestyle.
The defecation schedule is a very important part of working with stool.
The main recommendation is to put your child on the potty/toilet regularly soon after eating .
Why after eating?
We use for our own purposes the gastrocolic reflex , which everyone has to one degree or another. When food enters the stomach, a reflex signal goes to the large intestine - it’s time to make room for a new portion :-).
Schoolchildren are also advised to sit on the toilet after returning from school.
To consolidate your bowel habits, you can use a diary .
For parents of my youngest patients, I recommend using a beautiful, visual calendar. The child marks the day when he was able to fully relieve himself by gluing a smiley face or a star. If you collect a certain number of emoticons, you will receive a pre-agreed “bonus” from your parents. Motivation is awesome!
Treatment of non-retentive calomasia.
This option is much less treatable.
Laxatives are useless - there is no constipation at the heart of this type of constipation.
All that remains is the bowel movement regime and keeping a diary .
Sometimes medications that slow motility and improve the tone of the internal anal sphincter can be useful (they are often prescribed for diarrhea).
The most famous such drug is loperamide.
Unfortunately, experience with the use of loperamide in children is limited; close, confidential contact with the doctor is required when attempting to use it.
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