Accidental Bowl Leakage or Constipation
Trouble controlling bowels
Bowel control problems can be embarrassing. However, they are more common than you may realize. About 18 million adults in the U.S may be affected, and this number is probably even higher as most people are too embarrassed to report this condition. That means that at least one out of every 12 people struggle with controlling their bowels. This problem can happen to women of all ages.
Bowel control problems can include:
• Accidental bowel leakage (ABL): the involuntary loss of solid or liquid stool or flatus.
• Constipation
Bowel control problems can affect people of every age.
Older women experience these problems more than others, but ABL can happen at any age and to men as well. This problem can lead to embarrassment and concerns about odor or hygiene. Some women start to avoid exercise, social activities, or other things as a result.
Certain health conditions such as frequent diarrhea, hemorrhoids, diabetes, multiple sclerosis and a history of a stroke can put you at higher risk for bowel control problems.
People who have had surgery or radiation to the pelvic area are also at risk. Women are particularly at risk because of injuries to the pelvic floor that can result from having children. If the muscles, ligaments, tissues or nerves of the pelvic floor are damaged, women can experience troubles with bowel movements shortly after childbirth, or years later.
Bowel control problems can be extremely distressing and cause many feelings of embarrassment.
Unfortunately, many women are too embarrassed to talk about them with a health care provider. However, there are medical and surgical options to help women with this problem, and new treatments coming out recently have been shown to be very helpful. Speaking up and talking about these problems is the first step toward having healthy bowel habits. Seek out care from a urogynecologist, a physician specially trained in treating pelvic floor disorders, to take the first step toward bowel control.
Bowel control disorders affect the normal pattern of emptying your bowels.
There are many factors that contribute to normal bowel movements, including the consistency of your stools, diet, medical problems, surgical history, ability of the rectum to hold stool and the coordination of various pelvic muscles to allow emptying.
What is normal?
That’s hard to say exactly. When it comes to bowels, we are all different. You don’t have to have a bowel movement every day. On average, normal stool frequency is at least 3 bowel movements a week, and no more than 3 stools per day. Stool consistency often varies based on what you’re eating, how much water you drink, and how much exercise you get. The first stop is to pay attention to your OWN normal.
You may want to keep a diary of your bowels to take with you to your doctor’s appointment – chart out the day, time, and consistency of the stools you pass, including any episodes of leakage.
Accidental Bowel Leakage
Accidental bowel leakage (ABL), also known as fecal incontinence, is the loss of normal control of the bowels, leading to leakage of solid or liquid stool or gas. About 8 out of every 100 women struggle with ABL. The number of women affected increases with age. And, researchers think that in reality, the total number of women is likely much higher, but many are too embarrassed to seek treatment.
Causes of Accidental Bowel Leakage
There are many causes of accidental bowel leakage, including injury caused during childbirth, damage to the anal sphincter or nerves, pelvic organ prolapse, fistula, medical problems and abnormal stool consistency.
Childbirth Injury
Pregnancy can increase the risk of accidental bowel leakage. It is more common in women who deliver vaginally than women who have a C-section. However, research also suggests that just carrying a pregnancy can increase your risk of these changes as well.
Delivering a large baby vaginally, especially if forceps are used, poses more risk than having a smaller baby. An episiotomy or significant tear of the tissues around the vagina and rectum can result in damage to the nerves, muscles, and tissues around the rectal canal. This can result in a tear of the anal sphincter muscles that help to hold in stool, but also some of the surrounding tissues that are important as well.
Anal Sphincter Injury
There are two main circular muscles, or sphincters, that help to hold in stool near the anal opening. During vaginal childbirth, the anal sphincter muscles can be damaged or torn. These muscles allow us to control bowel movements. It is estimated that as many as 40% of women experience muscle injuries in this area during childbirth. Some of these tears are recognized and repaired, but some are hidden. Injury is more common after episiotomy or forceps delivery.
The anal sphincter muscles can also become weakened for other reasons, such as diabetes or neurologic conditions. They can also be damaged during other surgeries, such as surgery to fix an anal fissure or hemorrhoids. This can cause decreased strength resulting in problems controlling passage of bowel movements.
Ultrasound can help to detect these injuries. Depending on the extent of the injury and the length of time from when it occurred (for example, how long ago you delivered your baby), surgery can repair the damage. If the damage occurred in the past, surgery may not be able to help.
Nerve Injury
Injury to the anal sphincter nerves can cause decreased sensation and muscle strength, both of which can contribute to ABL. Vaginal delivery, chronic constipation, or illnesses that affect the nerves such as diabetes and spinal cord injury can result in nerve damage. For some women, nerve damage that occurs during vaginal delivery improves on its own one or two years after childbirth.
Prolapse
Several types of prolapse can affect bowel control.
Rectocele: A rectocele is a hernia of the bowel upward into the vaginal canal. It causes a vaginal bulge that can sometimes result in difficulty emptying the bowels.
Rectal prolapse: Rectal prolapse is a condition where the rectum slides out through the anal opening. This causes a bulge coming from the anus, not from the vagina. Distortion of the anal opening can result in damage to the sphincter muscles and bowel leakage.
Hemorrhoids: Hemorrhoids are caused by enlarged blood vessels near the anal opening. Sometimes they can cause small bulges near the anal opening. These can make it difficult to clean near the anus, resulting in seepage of bowel contents. There are many treatments for hemorrhoids, ranging from medicines to surgery to remove them. However, if hemorrhoids are removed, one out of every 10 women will end up with fecal incontinence.
Fistula
Abnormal openings or connections (tracts or tunnels) known as “fistulas” can develop between the bowel and vagina, or the bowel and the skin. Fistulas can occur:
After vaginal delivery or vaginal surgery. This is more likely if a large tear occurred during delivery but is still unusual.
Spontaneously as a result of diverticulitis or other bowel conditions, including Crohn’s disease.
In patients who have had radiation in the pelvis.
Abnormal Stool Consistency
Bowel movements with normal consistency are easiest to control. Ideally, stools should be like toothpaste. Abnormal stool consistency (either loose or hard stools) may contribute to ABL:
Diarrhea or loose bowel movements are more difficult to control. This can also increase the sensation of needing to pass stool, called fecal urgency.
Severe constipation. People who have significant problems passing stool can experience a hard lump of stool with diarrhea that develops around it.
Constipation
Everyone is different, but most women normally have bowel movements at least every other day and no more than twice daily. Having a bowel movement less than three times per week, along with straining to produce a hard bowel movement, is called constipation. Constipation is very common, affecting about 1 in 3 women.
Causes of Constipation
Constipation occurs for several reasons. It may be related to diet or changes in the nerves that control the pelvic floor muscle functioning that can affect the bowels. Lifestyle choices, medicines, or supplements, pelvic floor disorders, lack of exercise, and other health problems may also impact bowel movements.
Dietary Problems
The most common reason for constipation is not having enough fiber in your diet. This is very common in women who eat a typical American diet and getting enough fiber to fix this problem often requires planning and supplementation. The general recommendation is to aim for 25-35 gram/day of fiber between food and supplements.
Some foods, especially those high in starch such as white rice, pasta, or white bread, are more likely to lead to constipation.
Constipation may also be due to lack of fluids in your diet. Some women do not drink enough fluids to keep their stool soft. When there is not enough fiber or water in your diet, bowel movements are more likely to be hard or irregular. However, excessive fluid will not help constipation, especially if there is another underlying dietary problem. Discuss with your provider what the right amount of fluid is for you.
Medicines and Supplements
Talk with your doctor about the medicines and supplements you take, as many can cause constipation. Ask about alternative medicines without constipating effects. Medicines that treat bladder urgency, depression, blood pressure, and pain (especially narcotic medicines) commonly cause constipation. Iron and calcium supplements can do this also.
Pelvic Floor Disorders
Pelvic pain may prevent relaxation of pelvic floor muscles, leading to problems having bowel movements. Straining excessively with bowel movements may lead to pelvic floor disorders. Rectoceles do not cause constipation. Prolapse, including rectoceles and rectal prolapse, can make constipation worse.
Medical Conditions
Irritable bowel syndrome, chronic pain, kidney disease, colitis, thyroid disorders, neurological conditions (such as multiple sclerosis or spinal cord injuries), and cancer are other medical conditions that can impact the bowels. Talk with your doctor if you have these conditions or are concerned about them.
Diagnosis
Talk with your doctor about any changes in your usual bowel habits, including trouble controlling gas or stool. Be honest and open about all of your symptoms.
If you notice blood in your stool, definitely ask your doctor for further evaluation.
For a thorough evaluation of your symptoms, seek the care of a specialist such as a Urogynecologist, colorectal surgeon who specializes in female pelvic floor disorders, or a gastroenterologist. Sometimes you need a team of doctors to help manage different aspects of these conditions. The evaluation should always begin with discussion of your symptoms and a physical examination.
Be ready to discuss when you have bowel problems – how often, how long this has been going on, and what provokes your symptoms. Consider doing a diary of your stools and what you eat. Bring a list of your medications, medical conditions, and prior surgeries.
In addition to a review of your medical history and a physical exam, the doctor may recommend tests such as:
Colonoscopy / Sigmoidoscopy:
Colonoscopy is a procedure done with light anesthesia using a flexible camera to directly visualize and examine the entire colon. Sigmoidoscopy examines only the last part of the bowel near the rectum. These tests help your doctor investigate polyps, areas of narrowing, or even a possible blockage due to cancer or other masses. These tests can also locate a fistula or gastrointestinal disorder such as colitis of Crohn’s disease, which is causing your bowel symptoms. You should be getting these regularly to look for cancer, but if you are having a bowel problem, you may need another test.Nerve Testing / Anal Manometry:
Nerve testing evaluates possible injury to the nerves, which can cause decreased strength and sensation. Anal manometry is one type of nerve testing. It checks for normal or abnormal sense of bowel filling. It helps your doctor evaluate contraction and relaxation of the pelvic floor muscles. It also examines the sphincter muscle that surrounds the anus and identifies defects in that muscle which might be a part of your problem.Defecography:
During this test, the mechanics of how you defecate are visualized with radiological studies. This can be done using either x-ray (called fluoroscopy) or magnetic resonance imaging (MRI). A paste is placed into the rectum and sometimes you are given other contrast material through an IV. You then sit on a commode and try to defecate normally. This study can seem unusual, but it is the best study to help the doctors see what is happening on the inside when you defecate.Magnetic Resonance Imaging (MRI):
This is the best study to look at the muscles near the bowels in the pelvis. It can help your doctor see how the bowels move when you strain
Depending upon your symptoms and evaluation findings, other tests that are sometimes necessary include:
Endoanal Ultrasound: Evaluates the anal sphincter muscles.
Barium enema: X-ray study used to look for masses that block the intestines. Doctors look to see how long the contrast stays in your bowels, and sometimes are able to identify a concern for pelvic floor prolapse using this study.
CT (Computed Tomography) scan: Used to look at the intestines or surrounding tissues for causes of constipation such as masses within or around the intestines.
Transit Time/Sitz Marker study: Evaluates the time it takes food to move through your bowels. For this study, you swallow a capsule and then several images are taken in the days afterward to see how far some markers have moved through your bowels.
Treatments
Once your doctor identifies the cause of your bowel control problem, you can discuss the best treatment for you. The type of treatment depends on the cause and severity of the problem.
Many women find that dietary fiber helps them to keep bowel control problems, both accidental bowel leakage and constipation in check. Fiber brings most bowel problems back into a better place. Talk with your doctor about starting an over-the-counter fiber supplement. But go slow when you start fiber! A rapid increase in the amount of fiber in your diet can cause bloating and discomfort, so be sure to slowly increase your fiber by a few grams every day to avoid this. The goal is 25-35 grams of fiber each day. Also, it is important to drink enough water, especially when using fiber, to keep the stools soft.
In addition, physical therapists who specialize in pelvic floor problems can work with you to strengthen the pelvic floor muscles and on different positions that might make defecating easier. In some cases, they perform biofeedback to improve the pelvic floor muscle strength, tone, endurance and sensation. In the difficult cases of pelvic muscle spasm, a trained physical therapist can be extremely helpful to break those spasms. See your doctor for a referral or look at www.apta.org.
For both kinds of bowel control problems—accidental bowel leakage and constipation—the following treatment options are conservative (non-surgical) options:
Lifestyle and Behavior
Diet and fitness
Try eating a high fiber diet. Most experts recommend eating between 25-35 grams of fiber a day. Increase fiber slowly as it can cause gas and bloating.
Try to eat your meals at a predictable time each day and eat roughly the same quantity of food day-to-day at each meal. If you will not be near a toilet about 30-60 minutes after you eat, consider eating less to stimulate the bowels less.
It’s especially important for your bowels to eat breakfast – this will stimulate the bowels to start moving.
Drink little or no caffeine, which is a diuretic and also increases bowel motility. It can leave your stools hard and difficult to pass.
Coffee often stimulates the bowels – if you have problems with urgency or ABL, stop drinking coffee.
Exercise daily. Try to do this at the same time every day.
If you have loose stools or diarrhea, try to avoid offending foods. Certain foods may worsen diarrhea and accidental bowel leakage such as lactose, artificial sweeteners, carbonated beverages, and spicy or greasy foods. Keep a food diary to help recognize foods which may be worsening your symptoms.
Hygiene
Dry toilet paper can irritate the skin. If you have ABL, overcleaning and rubbing the anal area with dry toilet paper can stimulate more seepage of stool. Try alcohol-free moist wipes instead. Try to pat dry instead of wiping vigorously.
If you have ABL, doing two tap-water enemas before you leave home will clean out the rectum and prevent accidents.
Wear cotton underwear to allow the skin to breath.
If you are getting skin irritation, try using cotton pads, or try not using pads at all. Apply a barrier cream such as zinc oxide and calamine lotion to the skin to help avoid getting infections or sores.
Pelvic floor muscle exercises (Kegels)
Strengthening your pelvic floor muscles may help with your symptoms.
Biofeedback and electrical stimulation may be used as part of this to help improve the effect.
If your problem is constipation, you may need to learn how to relax your pelvic floor muscles. A pelvic floor physical therapist can help you with different positions that make defecating easier.
Bowel Training
Try to keep your bowels of a regular schedule. Find a consistent time after a meal every day to try to have a bowel movement when you are not rushed. If you empty your bowels early in the day, this may help. The best time to try having a bowel movement is 20 to 30 minutes after eating breakfast. Sit on the toilet for 10 minutes and relax. Try using a stool in front of the toilet to elevate your feet and keep your knees bent. This may help the pelvic muscles relax and allow the bowel movement to pass. Do not strain. If you do not have a bowel movement, go back to your normal activities. It may take a few days to get into a regular pattern.
Change your position on the toilet: Put a stool or a stack of books in front of the toilet. Place your feet on that, elevating the knees above the hips. This can make defecating easier if you have trouble.
Physical therapy for the pelvic floor with biofeedback
Pelvic floor physical therapists are specially trained to help with pelvic floor disorders. See your doctor for a referral or check www.apta.org.
Devices
There are a number of devices that may be helpful in treating your bowel control problems.
Eclipse™ Vaginal Insert
The Eclipse™ Vaginal Insert is a small balloon device that is inserted into the vagina and inflated so that it puts pressure onto the rectal area. This helps with better bowel control. You need to be fitted for this in a doctor’s office, but then you will be taught how to manage it on your own. This was recently approved for use to treat fecal incontinence and therefore it may only be available in some physician offices. It continues to be evaluated to determine which women it may help the most.
Adhesive Patches
There are several available patches that help contain the stool during certain activities. For example, you can wear one during exercise, and then remove it. One example of these is Butterfly® pads, which can be ordered online.
Anal Plugs
This is a silicone anal insert or foam cup used to temporarily occlude the anal canal to prevent stool leakage. Examples of these include Renew® inserts and Peristeen® products.
Medications
Accidental Bowel Leakage Medicines
Taking these medications just before going out can help you control your bowels. Your doctor may recommend medicine to treat or prevent diarrhea, decreasing the frequency or looseness of bowel movements.
Fiber supplementation: over the counter medicine
Loperamide (Imodium®): over the counter medicine.
Diphenoxylate and atropine (Lomotil®): Prescription medicine.
Amitriptyline: Prescription medicine
Other medicines that may help with incontinence include cholestyramine, hyoscyamine, clonidine, and topical phenylephrine. Sometimes an enema, which is performed prior to leaving the house, may be helpful. Emptying the rectum like this prevents there from being stool present to leak out while you are away from the toilet.
Constipation Medicines
When fiber supplements are not enough, your doctor can recommend medications such as stool softeners or laxatives. And, if your constipation is due to irritable bowel syndrome, additional prescription medicines may be needed.
Medicines for constipation include:
Bulk-forming laxatives (Benefiber®, Metamucil®, Citrucel®): Softens stool by absorbing water.
Stimulant Laxatives (senna, bisacodyl): Cause the bowel wall to contract more to move the stool along.
Lubricants (mineral oil): Coat the wall of the bowel so the stool can pass more easily.
Osmotic laxatives (MiraLax®, lactulose): Work by drawing water back into the intestines.
Saline Laxatives (milk of magnesia): Work by drawing water into the intestines.
Stool softener (docusate sodium): Allow water and fat to pass into stool to soften it, making bowel movements easier to pass.
Surgery
Many women find relief through diet changes and medicines. Sometimes women may need surgery to obtain relief from accidental bowel leakage, such as to repair a torn anal sphincter muscle. Rarely, doctors treat constipation with surgery.
ABL Procedures & Surgery
Nerve Stimulation
Sacral nerve stimulation (SNS): (Axonics or Interstim)
an implantable system (similar to a heart pacemaker) that sends mild electrical impulses to the sacral nerves. It can be helpful for both ABL and chronic constipation in patients who have failed other options. It typically involves a one- to two-week trial prior to placement of the permanent lead (a thin wire) and stimulator. If the trial period is not successful, the permanent device will not be implanted. Because the device is metal, you would not be able to have MRIs in this area if the device is implanted.
Fecal incontinence: Studies found that women who had SNS experienced fewer episodes of fecal incontinence compared to women who were treated with other medical therapies. Some women even regained full control of the bowels. Risks of this procedure include infection and pain/discomfort of the lead or stimulator. Some women require additional surgeries.
Constipation: SNS helps to speed transit time of feces through the colon. SNS may also reduce the abdominal pain and bloating of constipation.
Read more about nerve stimulation for pelvic floor disorders.
Overlapping Anal Sphincteroplasty
Some women have injury to the anal sphincter muscles following vaginal delivery. Repair of torn anal sphincter muscles with surgery is possible for some women. However, for many women this surgery has a low success rate. Therefore, it is not an option for everyone. For example, an overlapping anal sphincteroplasty is more successful when the nerves are working properly.
Other Surgeries
Rectocele Repair
A rectocele is a prolapse of the rectum upward into the vagina, similar to a hernia. If stool is getting “trapped” in the rectocele pouch, it can seep out later. Repairing the rectocele surgically can sometimes lead to improved bowel emptying.
If a fistula (abnormal connection between the bowel and vagina) is present, closing the fistula is generally curative when there are no other factors contributing to the anal incontinence.