Updated | July 8, 2022 Authors : Patrícia Motta Lima e José Assunção Gonçalves Also called fecal incontinence , this devastating clinical condition affects quality of life and personal, work and social commitments of patients. It is estimated that 5%-18% of the population suffer from some degree of bowel incontinence. It is likely that the value is higher, as the disease is often lived in silence, due to shame and embarrassment. It affects both sexes but is more common in women and the incidence tends to increase with age. Causes and risk factors for bowel incontinence The mechanism of bowel continence is complex and depends on the integrated function of several factors: Volume and consistency of stool; Preserved and functioning sphincters; Cognition; Intestinal motility; Sensitivity and rectal capacity; Neurological circuits and intact reflexes. The disturbance of one or more of these factors associated with the insufficiency of compensation mechanisms leads to the loss of the ability to control the moment of evacuation . Therefore, the cause of bowel incontinence is multifactorial. The main risk factors associated with the development of bowel incontinence are: Related with gestation : obstetric trauma, childbirth laceration, newborn weight, prolonged delivery time, advanced age of the mother, among others; Surgical trauma : proctological surgeries, namely those that treat perianal fistula, hemorrhoids and anal fissure, other perineal surgeries that can cause anal sphincter injury, as well as abdominal and pelvic surgeries; Age : hormonal and degenerative factors that can worsen anorectal functions with advancing age; Neurological and psychiatric diseases : neurodegenerative diseases and depression; Inflammatory bowel disease : Crohn disease and ulcerative colitis; Metabolic diseases : diabetes, obesity and hyperthyroidism; Medications : side effects of drugs that interfere with bowel motility and stool consistency, such as antidiabetics and antibiotics; Others : radiation proctitis (rectal inflammation after treatment with pelvic radiotherapy), irritable bowel syndrome, intestinal infections, food intolerance, among others. Types of bowel incontinence Bowel incontinence is classified into 3 types: Passive incontinence When the patient does not feel the presence of feces or gases, which pass through the anus unnoticed, without arousing the need to evacuate; Urge incontinence When the patient recognizes the need to defecate but is unable to voluntarily maintain continence until reaching the toilet; Mixed incontinence It is the association of passive incontinence and urge incontinence. Investigation of bowel incontinence A patient with bowel incontinence should undergo a thorough clinical investigation. Although not rare, this disease is not usually addressed in a routine consultation. Anyone who suffers from bowel incontinence complaints should be encouraged to share them with their doctor . In a bowel incontinence consultation, the patient will be asked about the characteristics and duration of symptoms, frequency of episodes, stool consistency, lifestyle, presence of other pathologies, medication use, diet, gestational history and previous surgeries. Quality of life questionnaires, incontinence scores and diaries may be applied to record episodes. Diagnostic tests Diagnostic tests complement the investigation, screen out other diseases and allow an objective classification of anal incontinence. Each exam has its specific indications and is requested by the doctor according to the patient complaints. Functional exams : these are minimally invasive exams, quick to perform without any sedation. They provide detailed information about the functioning of the anus and rectum (anal pressures, nerve preservation, reflexes, sensitivity, compliance, etc.). Examples: anorectal manometry, balloon expulsion test. Imaging tests : These are tests that assess the integrity of anatomical structures and the physiological interaction of pelvic organs. Examples: endoanal ultrasound, pelvic MRI, MRI defecography, colonic transit time. Endoscopic exams : these are exams that analyze the mucosa of the colon and rectum, allow for biopsies and are important for screening for other diseases that may be associated with bowel incontinence, such as inflammatory bowel diseases, proctitis and even cancer. Examples: rectosigmoidoscopy, total colonoscopy. Laboratory tests : blood and/or stool tests that complement the investigation. Multidisciplinary approach Bowel incontinence may be present alone, but is usually associated with other disorders , namely urinary incontinence and pelvic organ prolapse. Thus, a multidisciplinary approach is imperative and, according to complaints, patients may need to be evaluated by professionals from other specialties such as gynecology, urology, physiatry, neurology, physiotherapy, psychology, nutrition, nursing. Treatment of bowel incontinence The treatment of bowel incontinence is aimed at relieving symptoms and improving quality of life . It is essential to create a relationship of trust between the doctor, patient and family. As it is a chronic disease with multiple causes, the therapy must be directed to the main complaint of the patient, to what most restricts and limits his life. It is important to manage expectations regarding treatment results , which will not always reach an immediate and complete resolution. General guidelines on lifestyle habits, tobacco and coffee, diet and supportive measures may be sufficient to resolve complaints. The prescription of antidiarrheal drugs, constipation or rectal emptying stimulants is indicated in some cases of bowel incontinence. Pelvic rehabilitation : these are rehabilitation sessions that promote pelvic muscles strength and teach postural techniques, correct evacuation position, hypopressive gymnastics, abdominal-diaphragmatic breathing, specific exercises for the pelvic floor muscles, sensitive training and rectal and cognitive-behavioral techniques. Biofeedback and electrical stimulation are the main modalities and involve different techniques, methodologies and equipment, and must be performed by a qualified professional. Surgery : the surgical approach should be the last treatment option for bowel incontinence. The anatomical correction does not necessarily lead to the functional correction of the symptoms and must be complemented with the measures mentioned above. Currently, the following types of surgery are available: Anal sphincteroplasty; Injection of volume expanders; Radiofrequency; Artificial sphincter; Dynamic graciloplasty; Stoma creation. Sacred neuromodulation is currently the procedure of choice in the treatment of bowel incontinence, being the technique with the best results in the short, medium and long term. It is a minimally invasive procedure in which a neurostimulator is implanted in the sacral and gluteal region. Direct stimulation of the nerves leaving the spinal cord modulates the functioning of the pelvic floor muscles, especially the anal sphincter. This treatment is also beneficial in patients with urinary incontinence. Anal incontinence is much more common than you might think. Despite its negative impact on quality of life, most people who suffer from this condition do not complain to their doctor, but they should. After an adequate evaluation, the available treatments can promote a significant improvement of the symptoms and reduce the limitations and restrictions of patient life. Anal incontinence is a disease evaluated by gastroenterology and general surgery specialties . Meet the gastroenterology and general surgery clinical team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
