If you have problems with bowel control, you have problems with involuntary leakage of stool and/or gas. This problem is commonly named fecal incontinence (FI) or accidental bowel leakage (ABL). Your symptoms usually impact your quality of life and patients are embarrassed and feel it is difficult to talk about. Some people have mild trouble holding gas; while others have severe trouble holding stool. ABL is a miserable problem that many people have trouble talking about. Treatment is however available!
We are not sure how frequent accidental bowel leakage is in the population. Some studies have indicated that 2-5% of the population suffers from this problem, while another recent study demonstrated that almost 20% of women above the age of 45 years old.
Why does accidental bowel leakage happen?
Normal bowel control is complex and is influence by several factors. Therefore, bowel leakage can happen when one or several of these factors don’t work as well as they should.
The anal sphincters (control muscles) are located around the anal canal (lower rectum) and they should stay closed at all times except when we have a bowel movement. Injuries to these muscles, or their innervations, may therefore impact the bowel control. Unfortunately, muscles tend to get weaker with age. The anal sphincters may be injured at childbirth or at rectal surgery. This injury (sphincter tear) may be small or sometimes large. If there is an identifiable injury, it can potentially be surgically repaired or treated with one of the other treatment alternatives (see below).
Rectal prolapse can impact your bowel control. Therefore, surgical repair of the prolapse can help patients with this condition.
Bowel control also depends on the function of the small bowel and the colon. For instance, if stool moves through the bowel too quickly, a person may not have warning and may have an accident. This may happen in patients with for instance with irritable bowel syndrome (IBS) or colitis (inflammation). of the bowel (colitis). The consistency of the stool is difficult for anyone to control. Any condition that result in loose stools or diarrhea, can lead to bowel control problems.
Specialized tests for accidental bowel leakage
As always, our practitioner will start asking questions about your medical history. We are especially interested in your bowel function and what type of leakage you have, learning about possible diseases that can cause bowel problems, medications that may have side effects that impact your bowel function, your last colonoscopy, etc. Thereafter the practitioner will perform a careful examination, with particular attention paid to the sphincter muscle, rectum, and lower colon.
With a careful history and physical, the practitioner may have a good “hunch” what the problem may be. However, we frequently will also suggest additional specialized testing, which may include:
Anal ultrasound. Visualizes the anal sphincters and can document sphincter injuries.
Anorectal manometry. Measures the strength in the anal sphincters
Defecography. Visualizes possible prolapse and other rectal conditions.
Treatment of accidental bowel leakage
Our providers are recognized experts in this field and they are in the forefront in developing new treatment options for patients with accidental bowel leakage. They have initiated and participated in studies evaluating the novel treatment options that have recently been introduced for this condition. Our providers also teach these techniques to other physicians at national and international meetings. Our practitioners will be pleased to discuss which treatment option may be the best for you.
Sacral nerve stimulation. Sacral nerve stimulation (SNS) targets the communication between the brain and the bowel. This is performed with a small im,plntable stimulator. One of the advantages with this treatment is that you can try if the treatment works for you during a 1-2 weeks test period. If the treatment is effective during the test period, a permanent stimulator can be implanted.
Solesta. This therapy bulks up the tissues in the lower rectum (anal canal) by injecting a gel into this region. The Solesta gel is made from natural materials. The injections can be given in our clinic without anesthesia since they are almost painless.
Sometimes, accidental bowel leakage is caused by an injury to the anal sphincters that can be surgically repaired. Our doctors are specialized in this kind of surgical repair and they teach this surgery to other physicians.
There are new promising treatment options for fecal incontinence on the horizon. Our practitioners are involved in studies evaluating new treatment options for accidental bowel leakage.
Non-surgical treatment of accidental bowel leakage
Frequently, our treatments will start with less invasive non-surgical options. Our practitioners will strive to identify correctable medical conditions that may impact your bowel function. For instance, medications for inflammation of the bowel or irritable bowel syndrome may improve/resolve your symptoms.
Pelvic floor training/biofeedback may also help your symptoms. With this program you will meet a practitioner who helps you to identify and exercise their pelvic floor muscles.
If the treatment of your bowel problem does not provide complete relief of your symptoms, we try to give advise that may reduce the impact of your symptoms.
Regular and normal bowel movements may improve your ability to empty the rectum and therefore decrease the stool leakage. Dietary advice and sometimes fibers can help with this. Medications to control loose stools may also be helpful.
Stool leakage may impact your possibilities to leave the house, because of the fear of having accidents in public. A small enema before leaving the house can decrease the likelihood for an accident happening.
If the stool leakage causes skin irritation, proper skin management is important. Dry skin is better than moist skin. A cream that protects the skin may be helpful. We recommend that you discuss skin treatment options with one of our providers.
Altemeier’s procedure removes the prolapsed rectum “from below” and can be done without an abdominal incision. The procedure is ideally suited for elderly patients or patients with an incarcerated or infected prolapse. The addition of a pelvic floor repair (levatorplasty) can possibly decrease the risk for the prolapse to come back.
Posterior rectopexy involves an abdominal operation at which the rectum is mobilized and pulled upwards and attached to the tailbone (sacrum). The rectum can be secured sutures or other techniques. Postoperatively, some patients will have persisting/worsened constipation symptoms. Sometimes a bowel resection is added in an effort to decrease the risk for constipation after the repair. The procedure can be performed with open, laparoscopic or robotic technique.
Ventral rectopexy involves pulling up the rectum into its normal anatomical position. A piece of mesh is stitched to the front of the rectum and is secured to the sacrum. The procedure is often performed with minimally invasive technique; laparoscopically or robotically.
Ventral rectopexy is a new surgical method and long term follow/up is therefore limited. Early evaluations indicate improved rectal function in a majority of patients.
This surgical technique requires implant of a mesh in the pelvis and this carries a risk for complications. Your doctor will discuss in detail about treatment alternatives and potential risks with the procedure, including possible mesh complications.
Delorme’s procedure removes the lining (mucosa) of the prolapsed rectum. The prolapsed rectum is thereafter plicated resulting in a repair of the prolapse. The procedure can be done without an abdominal incision and is ideally suited for elderly patients with less extensive rectal prolapse.
External rectal prolapse presents as a protrusion of the rectum out of the anus. It occurs when the upper part of the rectum telescopes itself inside out through the rectal opening. If the telescoping is less severe, the patient may have an internal prolapse of the rectum. The protrusion is then limited to the “inside” and there is no protrusion out of the rectal opening.
Rectal prolapse is frequently associated with constipation and straining and that this may weaken the attachments of the rectum. However, rectal prolapse can also be found in patients with any constipation symptoms and the cause of the prolapse is unknown in many patients.
The most common symptom of rectal prolapse is a feeling of tissue coming out of the rectum. Initially, many patients experience that they have a frequent urge to go to the restroom. As the prolapse progresses, the rectum may start coming out with bowel movements and initially it usually returns inside by itself. As the prolapse gets more advanced, the prolapse starts occurring with activity. Subsequently, the prolapse may come out spontaneously when the patient stands up. It may become necessary to push the rectum inside with a hand and sometimes it may fall out again immediately. At this stage man patients also have problems with accidental bowel leakage. Mucus drainage and bleeding are two other common rectal prolapse symptoms.
Diagnosis of rectal prolapse
A significant external rectal prolapse is usually easy to diagnose with a clinical examination. Sometimes, the prolapse only come out with pushing in the sitting position and the doctor there may need to examine you in the sitting position on a commode pushing.
Frequently we refer patient for a specialized x-ray to study the prolapse further. X-ray pictures are then taken while the patient is passing contrast instilled in the rectum and the vagina. These images can help in the diagnosis of the rectal prolapse and possible other abnormalities or dysfunction in the pelvic floor. A similar study can also be performed with MRI technique.
Some patients with rectal prolapse may also have prolapse problems “in the front”. Therefore, we refer several of our patients for a consultation with a urogynecologist to determine this before we proceed with surgical repair. In this way, we can determine whether you need more than repair of the rectal prolapse at the time of surgery.
Treatment of rectal prolapse
Rectal prolapse can be repaired either with a smaller, rectal repair or with a larger abdominal repair. A rectal repair is a smaller surgery, but the risk that the prolapse comes back is higher. These methods are therefore usually chosen fort older patients. Abdominal repair is usually chosen for younger and fit patients.