Fecal Incontinence: Causes, Symptoms & Treatment Options

What Is Fecal Incontinence?

Fecal incontinence is the inability to control bowel movements, causing stool to leak unexpectedly from the rectum. It ranges from occasional leakage when passing gas to complete loss of bowel control. This condition affects approximately 7-15% of community-dwelling adults and becomes more common with age.

Fecal incontinence, also medically known as bowel incontinence or accidental bowel leakage (ABL), refers to the involuntary passage of fecal material through the anal canal. The condition exists on a spectrum from minor soiling and inability to control gas, to complete loss of bowel control. While this condition is often considered embarrassing and many people avoid discussing it even with their doctors, it is surprisingly common and highly treatable in most cases.

The rectum serves as the final portion of the gastrointestinal tract and functions as a storage reservoir for stool until it is convenient to have a bowel movement. Two muscles called the anal sphincters work together to keep the anus closed. The internal anal sphincter operates involuntarily and remains contracted most of the time, while the external anal sphincter can be voluntarily controlled and is the muscle you squeeze when you consciously hold back a bowel movement. Nerves running from the brain through the spinal cord to these muscles coordinate their function, allowing you to maintain continence under most circumstances.

When any component of this complex system fails whether it's the sphincter muscles, the nerves controlling them, the rectum's capacity to store stool, or the stool consistency itself fecal incontinence can result. Understanding that this condition has specific, identifiable causes is the first step toward finding effective treatment.

Types of Fecal Incontinence

Fecal incontinence manifests in different ways depending on the underlying cause and severity. Recognizing which type you experience helps guide appropriate treatment.

Urge incontinence occurs when you feel a sudden, intense need to have a bowel movement but cannot reach the toilet in time. This type often indicates problems with the external sphincter or rectal capacity. People with urge incontinence typically know they need to go but simply cannot hold it long enough.

Passive incontinence happens when stool leaks without any awareness or sensation. This type usually indicates damage to or dysfunction of the internal sphincter or sensory nerves in the rectum. People with passive incontinence may not know they have soiled themselves until they notice the stool.

Fecal seepage refers to small amounts of stool leaking after an otherwise complete bowel movement. This may result from hemorrhoids, rectal prolapse, or incomplete evacuation leaving residual stool near the anal opening.

What Causes Fecal Incontinence?

Fecal incontinence results from damage to the anal sphincter muscles, nerve injuries affecting bowel control, chronic diarrhea, rectal prolapse, aging-related muscle weakness, or neurological conditions like stroke or dementia. Childbirth injury is the most common cause in women, while surgery and aging are major factors for both sexes.

Multiple factors can contribute to fecal incontinence, and many people have more than one underlying cause. The anal sphincters, rectum, pelvic floor muscles, and the nerves controlling them must all work together harmoniously for normal continence. Disruption of any component can lead to leakage problems.

Age-Related Changes

As people age, typically starting around age 50-60, the sphincter muscles naturally weaken. The internal sphincter loses some of its resting tone, and the external sphincter may not squeeze as strongly as it once did. Additionally, the nerves supplying the rectum and anal sphincters may function less efficiently with age. These changes explain why fecal incontinence becomes increasingly common in older adults, affecting up to 50% of nursing home residents.

The rectal wall may also become less compliant with age, reducing its capacity to stretch and store stool. This means the rectum signals the need to defecate at lower volumes, giving less warning time before urgency becomes critical. Combined with reduced sphincter strength, these age-related changes create a perfect storm for incontinence.

Sphincter Muscle Damage

Direct injury to the anal sphincter muscles represents one of the most common and well-understood causes of fecal incontinence, particularly in women. The sphincter muscles can be damaged through several mechanisms:

Childbirth injury is the leading cause of sphincter damage in women. During vaginal delivery, the sphincter muscles may tear, a condition called sphincter rupture or obstetric anal sphincter injury (OASI). Even when tears are recognized and repaired immediately after delivery, some degree of sphincter weakness may persist. Nerve damage during childbirth can also impair sphincter function. Many women develop incontinence symptoms years or decades after the initial injury, often when age-related changes combine with the pre-existing damage.

Anorectal surgery for conditions such as hemorrhoids, anal fissures, fistulas, abscesses, or rectal cancer may inadvertently damage the sphincter muscles. While surgeons take great care to preserve sphincter function, some procedures necessarily involve cutting through or near the sphincter muscles.

Other forms of trauma, including sexual assault involving the anus or accidental injuries, may also damage the sphincter muscles and lead to incontinence.

Nerve Damage

The nerves controlling the anal sphincters and rectum can be damaged through various mechanisms. Pudendal nerve injury during childbirth is common and may contribute to incontinence even without obvious sphincter muscle damage. Spinal cord injuries, depending on their level and completeness, can severely disrupt bowel control. Conditions affecting the spine such as herniated discs or spinal stenosis may compress nerves and impair their function.

Systemic diseases that damage nerves throughout the body can also affect bowel control. Diabetes mellitus, when it causes diabetic neuropathy, may impair the nerves to the rectum and sphincters. Multiple sclerosis and other demyelinating diseases can interrupt nerve signals at multiple points. Stroke and other brain injuries may damage the centers that coordinate voluntary sphincter control.

Diarrhea and Stool Consistency

Loose or liquid stool is much more difficult to control than formed stool. Even people with normal sphincter function may experience leakage during episodes of severe diarrhea. Chronic conditions causing persistent loose stools significantly increase incontinence risk:

• Inflammatory bowel disease: Ulcerative colitis, Crohn's disease, and microscopic colitis all cause chronic inflammation and diarrhea
• Irritable bowel syndrome (IBS): Particularly the diarrhea-predominant type can overwhelm sphincter control
• Infections: Gastroenteritis with severe diarrhea may cause temporary incontinence
• Malabsorption: Conditions like celiac disease or lactose intolerance causing chronic loose stools
• Medications: Many drugs including some antibiotics, metformin, and NSAIDs can cause diarrhea

Rectal Prolapse and Structural Issues

Rectal prolapse occurs when part or all of the rectum protrudes through the anus. This stretches the sphincter muscles and damages the nerves, commonly leading to incontinence. The prolapse may be visible externally or may remain internal (intussusception) while still causing symptoms. Other structural abnormalities such as rectocele (bulging of the rectum into the vagina) or enterocele may also contribute to incomplete evacuation and subsequent leakage.

Radiation Therapy

Radiation treatment to the pelvis for cancers of the prostate, cervix, uterus, or rectum can damage the rectum and sphincter muscles. Radiation proctitis causes inflammation of the rectal lining that may persist long after treatment ends. The radiation can also damage nerves and muscles directly, leading to both urgency and weakness.

When Should You See a Doctor for Bowel Leakage?

See a doctor if you experience any involuntary loss of stool, even if occasional. Seek prompt medical attention for sudden changes in bowel habits, blood in stool, severe or persistent diarrhea, or if incontinence significantly affects your daily life. Many effective treatments are available, and early intervention leads to better outcomes.

Many people delay seeking help for fecal incontinence due to embarrassment, believing nothing can be done, or assuming it's a normal part of aging. However, this condition is not a normal or inevitable consequence of growing older, and significant improvements are possible for most people. Healthcare providers regularly treat this condition and can offer compassionate, effective care.

You should contact a healthcare provider if you experience any of the following:

• Any involuntary leakage of stool, even if minor or infrequent
• Inability to control gas
• Frequent urgency to have bowel movements
• Staining of underwear without awareness
• Skin irritation around the anus from stool contact
• Avoidance of social activities or work due to fear of accidents

How Is Fecal Incontinence Diagnosed?

Diagnosis begins with a detailed medical history and physical examination including digital rectal exam. Tests may include anorectal manometry to measure sphincter pressures, endoanal ultrasound to visualize muscle structure, colonoscopy to evaluate the colon, and defecography to assess evacuation mechanics. The specific tests recommended depend on your symptoms and suspected underlying cause.

A thorough evaluation helps identify the underlying causes of fecal incontinence and guides treatment selection. Your healthcare provider will begin by asking detailed questions about your symptoms, their frequency and severity, and how they affect your daily life. Many doctors use standardized questionnaires to assess severity and track changes over time.

Medical History Questions

Your doctor will ask about several aspects of your condition and general health. Expect questions about the consistency of leaked stool (solid, liquid, or both), how often leakage occurs, whether you sense the urge before it happens, and specific triggers you've noticed. Information about your overall bowel habits, diet, medications, surgical history, and for women, obstetric history including details of vaginal deliveries, helps paint a complete picture.

Physical Examination

The physical examination includes a digital rectal exam, where the doctor inserts a gloved, lubricated finger into the rectum. This allows assessment of resting sphincter tone and squeeze strength, detection of any masses or abnormalities, and evaluation of the pelvic floor muscles. While many people find this examination uncomfortable or embarrassing, it provides essential information that cannot be obtained any other way.

Visual inspection of the perianal area may reveal skin changes from chronic stool exposure, hemorrhoids, fissures, fistulas, or signs of rectal prolapse. The doctor may ask you to bear down or squeeze to observe sphincter function.

Specialized Diagnostic Tests

Depending on initial findings, additional tests may be recommended:

Anorectal manometry measures the pressure generated by the anal sphincters at rest and during squeezing. A small pressure-sensing catheter is inserted into the rectum to record these measurements. The test also assesses rectal sensation and the reflexes coordinating defecation. This test is painless and provides objective data about sphincter function.

Endoanal ultrasound uses sound waves to create images of the anal sphincter muscles. A small ultrasound probe inserted into the anal canal can detect tears, thinning, or scarring of the sphincter muscles that may not be apparent on physical examination. This imaging study is particularly useful for identifying sphincter defects that might benefit from surgical repair.

Electromyography (EMG) evaluates the function of the nerves supplying the sphincter muscles by measuring electrical activity. This test helps determine whether nerve damage contributes to the incontinence.

Defecography is an imaging study that assesses what happens during defecation. After filling the rectum with contrast material, X-ray or MRI images are taken while you squeeze and strain. This reveals problems with evacuation mechanics, rectal prolapse, rectocele, or coordination abnormalities.

Colonoscopy may be recommended to evaluate the colon for conditions such as inflammatory bowel disease, tumors, or polyps that might contribute to diarrhea and incontinence.

What Can You Do Yourself to Manage Fecal Incontinence?

Self-care measures include dietary modifications to firm stool consistency, establishing regular bowel habits, performing pelvic floor exercises daily, staying physically active, and protecting perianal skin. Many people experience significant improvement with these lifestyle changes alone, though it may take several weeks to see full benefits.

Conservative self-management forms the foundation of fecal incontinence treatment. Many people achieve substantial improvement through lifestyle modifications alone, and these strategies complement other treatments when needed. Consistency is key these approaches require daily attention for best results.

Dietary Modifications

What you eat directly affects stool consistency and can significantly impact continence. The goal is generally to produce stool that is soft but formed, as this is easiest to control.

Fiber supplementation can help bulk up loose stools. Soluble fiber products like psyllium absorb water and add substance to stool. Start with a low dose and increase gradually to avoid gas and bloating. Adequate fluid intake is essential when taking fiber supplements they need water to work properly.

Identify and limit foods that trigger loose stools for you. Common culprits include:

• Fatty and greasy foods
• Caffeine (coffee, tea, cola, chocolate)
• Alcohol
• Artificial sweeteners, especially sorbitol and mannitol
• Spicy foods
• Gas-producing foods like beans, onions, cabbage, and carbonated beverages
• Dairy products if you have lactose intolerance

Keeping a food diary can help identify your personal triggers. Record what you eat and drink along with any incontinence episodes, then look for patterns. Eating meals at regular times helps establish predictable bowel patterns.

Establishing Regular Bowel Habits

Training your bowels to move at predictable times can reduce unexpected accidents. The gastrocolic reflex naturally stimulates bowel activity after meals, especially breakfast. Try sitting on the toilet for 10-15 minutes after meals, particularly after your morning meal. Don't strain adopt a relaxed posture and allow your body time.

When you feel the urge to defecate, respond promptly. Repeatedly ignoring the urge can diminish rectal sensation over time. Take adequate time for complete evacuation rather than rushing, as incomplete emptying can lead to later seepage.

Pelvic Floor Muscle Training

Regular pelvic floor exercises, sometimes called Kegel exercises, can strengthen the external anal sphincter and improve control. These exercises are most effective when performed correctly and consistently over time.

To identify the correct muscles, try to squeeze as if you're holding back gas or stopping a bowel movement. You should feel a lifting and tightening sensation around the anus. Avoid tightening your stomach, buttock, or thigh muscles focus only on the pelvic floor.

Practice two types of contractions:

• Quick squeezes: Contract and release the muscles rapidly 10-15 times. These help with urgency control.
• Sustained holds: Contract and hold for 5-10 seconds, then relax for equal time. Repeat 10 times. Gradually increase hold duration as you get stronger.

Perform these exercises 3-4 times daily. You can do them anywhere sitting, standing, or lying down since no one can tell you're exercising. Improvement typically becomes noticeable after 6-12 weeks of consistent practice. Consult a healthcare provider or pelvic floor physiotherapist if you're unsure whether you're performing the exercises correctly.

Physical Activity

Regular exercise benefits bowel function by promoting normal intestinal transit and regular bowel movements. Find activities you enjoy and can sustain. If you worry about leakage during exercise, start with low-impact activities and know where restrooms are located at your exercise venue. Using protective pads during workouts can provide peace of mind.

Skin Care

Stool contact irritates perianal skin, causing redness, itching, and discomfort. Proper skin care prevents these complications:

• Clean gently after bowel movements using soft, unscented toilet paper or moist wipes
• Wash with mild, fragrance-free soap and water don't over-clean, as this can increase irritation
• Pat dry rather than rubbing
• Apply a barrier cream or ointment (zinc oxide, petroleum jelly, or other protective products) to create a moisture barrier
• Change soiled undergarments promptly

How Is Fecal Incontinence Treated?

Treatment options include fiber supplements and anti-diarrheal medications, biofeedback therapy to improve sphincter coordination, anal plugs and incontinence products, sacral nerve stimulation, injectable bulking agents, and surgical repair of sphincter defects. Treatment is tailored to each person's specific causes and severity, often combining multiple approaches for best results.

Treatment for fecal incontinence follows a stepwise approach, beginning with conservative measures and progressing to more invasive options if needed. The specific treatment plan depends on the underlying cause, severity, and individual patient factors. Most people experience significant improvement with appropriate treatment, though complete cure may not always be possible.

Medications

Several medications can help manage fecal incontinence, primarily by altering stool consistency or reducing bowel motility:

Loperamide (Imodium) is an anti-diarrheal medication that slows intestinal transit and firms stool. It can be taken regularly or as needed for predictable control, such as before social outings. When used as directed, it is safe for long-term use in appropriate patients. Your doctor can help determine the right dosing schedule.

Fiber supplements such as psyllium (Metamucil) or methylcellulose (Citrucel) add bulk to stool, making it more formed and easier to control. They also help with incomplete evacuation. Drink plenty of fluids when using fiber supplements.

Cholestyramine binds bile acids that may cause diarrhea, particularly in people who have had gallbladder removal or certain intestinal surgeries.

If underlying conditions cause diarrhea contributing to incontinence, treating those conditions is essential. This might include medications for inflammatory bowel disease, antibiotics for bacterial overgrowth, or enzyme supplements for pancreatic insufficiency.

Biofeedback Therapy

Biofeedback is a specialized form of pelvic floor muscle training that uses electronic monitoring to provide visual or auditory feedback about your muscle activity. During biofeedback sessions, a small sensor is placed in the rectum to detect sphincter contractions. You watch a screen or listen to audio cues that indicate when you're squeezing correctly and how strongly.

This technique helps you learn to identify and strengthen the correct muscles, improve coordination between sphincter squeeze and rectal distension, and develop strategies for preventing urgency-related accidents. Multiple sessions over several weeks to months are typically needed. Research shows biofeedback improves symptoms in 50-75% of patients and works best when combined with home exercises.

Incontinence Products

Various products can help manage symptoms and protect against accidents:

Anal plugs are small, disposable devices inserted into the rectum to prevent leakage. They expand to create a barrier and are removed when you need to have a bowel movement. While not suitable for everyone, they can provide security during specific activities or social situations.

Absorbent pads and underwear protect clothing and skin from leakage. Modern products are discreet, comfortable, and highly absorbent. Choose appropriate absorbency for your leakage level and change promptly when soiled.

Transanal Irrigation

Transanal irrigation (TAI) involves using water to flush out the rectum and lower colon at scheduled times. This empties stool from these areas, reducing the amount available to leak before the next irrigation session. TAI is performed at home using specialized equipment and typically done every 1-2 days. It requires initial training from a healthcare provider but can significantly improve quality of life for selected patients.

Nerve Stimulation Therapies

Percutaneous tibial nerve stimulation (PTNS) delivers mild electrical impulses to the nerves controlling pelvic floor function through a small needle inserted near the ankle. Weekly 30-minute sessions over 12 weeks, followed by maintenance treatments, can improve symptoms in some patients. The treatment is well-tolerated with minimal side effects.

Sacral nerve stimulation (SNS) involves surgical implantation of a small device that delivers continuous electrical stimulation to the sacral nerves controlling bowel function. An initial trial period with temporary leads helps predict whether permanent implantation will be effective. SNS has shown good results for patients who don't respond to conservative treatments, with improvement rates of 50-90% in appropriate candidates.

Injectable Bulking Agents

Various substances can be injected into the tissue around the anal canal to bulk up the area and improve closure. These include dextranomer microspheres, polyacrylamide hydrogel, and other materials. The injections are performed as an outpatient procedure and may provide improvement for mild to moderate incontinence. Effects may diminish over time, requiring repeat injections.

Surgical Options

When conservative measures and less invasive treatments fail, surgery may be considered:

Sphincteroplasty repairs a torn or damaged sphincter muscle by overlapping and suturing the ends together. This surgery is most effective when a defined sphincter defect, such as from childbirth injury, can be identified. Results are often good initially but may diminish over years.

Muscle transposition uses muscle from the thigh (gracilis) to create a new sphincter when the original is severely damaged. This complex surgery is reserved for severe cases.

Artificial bowel sphincter is an implanted device consisting of an inflatable cuff around the anal canal, controlled by a pump in the scrotum or labia. While effective, it has significant complication rates and is used selectively.

Colostomy diverts stool to a bag on the abdominal wall, bypassing the anus entirely. While this is a significant change, some people with severe, treatment-resistant incontinence find a colostomy greatly improves their quality of life by providing predictable, manageable control.

How Does Fecal Incontinence Affect Daily Life?

Fecal incontinence significantly impacts quality of life, causing social isolation, anxiety, depression, and avoidance of work and activities. Many people experience embarrassment and shame that prevents them from seeking help. With proper treatment and management strategies, most people can regain confidence and return to normal activities.

The impact of fecal incontinence extends far beyond the physical symptoms. The unpredictability and social stigma associated with bowel accidents can profoundly affect emotional wellbeing, relationships, work, and overall quality of life. Recognizing and addressing these effects is an important part of comprehensive care.

Many people with fecal incontinence restrict their activities, avoiding travel, social events, exercise, and intimate relationships out of fear of accidents. This social withdrawal can lead to isolation and loneliness. Depression and anxiety are common, as is damage to self-esteem and body image. Some people miss work or even leave jobs they loved due to their symptoms.

The financial burden can be substantial, with costs for incontinence products, laundry, skin care supplies, and healthcare visits adding up over time. Sleep disruption from nocturnal leakage affects daytime functioning. Caregivers of people with incontinence also experience significant burden.

Coping Strategies

While working on treatment, several strategies can help you maintain quality of life:

• Know where restrooms are located wherever you go
• Carry supplies (wipes, changes of clothes, plastic bags) for emergencies
• Wear dark-colored clothing that doesn't show stains as readily
• Plan outings around bathroom availability
• Consider support groups connecting you with others who understand
• Talk to a counselor if anxiety or depression develops

Most importantly, remember that you are not alone and effective treatments exist. Seeking help is the first step toward reclaiming your life.