Getting to the bottom of Faecal Incontinence

Key Points:

  • Accidental bowel leakage can be managed, or cured by lifestyle changes under the guidance of specialised pelvic physiotherapists and dieticians.
  • Physiotherapy can address poor muscle performance of the anal sphincter muscles and pelvic floor, in order to optimise the continence mechanism.
  • Stool manipulation if often an important part of managing bowel dysfunction. Our Physiotherapists work collaboratively with our in-house Dietician to optimise digestion as well as muscle function.

What is Faecal Incontinence?

Faecal incontinence is the involuntary loss of stool from the back passage, otherwise known as accidental bowel leakage. Leakage of faecal material might occur on the way to the toilet, after the bowel motion, or even without your conscious awareness.

Understandably, faecal incontinence has to be a front runner for THE MOST distressing type of pelvic floor dysfunction. It takes a lot of courage to seek help, but know that you are not alone and there is a lot we can do to conservatively manage and resolve faecal incontinence.

THINKING POINT: Flatus incontinence is the involuntary loss of wind from the back passage. Can you hold onto wind when it catches you unexpectedly on the elevator/treadmill/yoga class? If you answer “No” to this question, pelvic floor muscle retraining could help you.

How Common is Faecal Incontinence?

The Continence Foundation of Australia estimates that faecal incontinence affects 5-10% Australians. However, this is likely to be a big underestimation as many people are too embarrassed to seek treatment.

Risk Factors:

  • Birth trauma such as 3rdand 4thdegree perineal tears during vaginal delivery
  • Weak anal sphincter and pelvic floor muscles
  • Pelvic radiation
  • Colorectal surgery
  • Fascial and ligament laxity that cause incomplete bowel emptying e.g. rectocele, intersucception, rectal prolapse
  • Suboptimal stool type e.g. runny stools = running to the toilet!
  • Reduced tone or sensation in the anal canal
  • Being post-menopausal
  • Constipation leading to an overflow of mucus as your body tries to lubricate hard stools
  • Neurological conditions e.g. multiple sclerosis, spina bifida, dementia
  • Irritable bowel syndrome or Crohn’s Disease
  • Medications 
  • Malignancy

Important Anatomy

Nutrient Absorbtion
Nutrient Absorbtion

When food leaves the stomach it enters the small intestine allowing the amazing nutrients of the meal to be absorbed. When the food reaches the large intestine, it is the consistency of pea-and-ham soup and is now mainly waste. Upon entering the large intestine (starting at the ascending colon) the waste moves through the colon where water is absorbed until it creates a nice sausage formation.

Too long in the colon = too much water absorbed = hard dry constipated motions. 
Too fast through the colon = not much water absorbed = liquid motions.

When the stool drops into the rectum that is when we should feel the need to defecate otherwise known as ‘the call to stool.’ It triggers an automatic reflex, which relaxes our inner anal sphincter priming the body for evacuation. In order to not poo ourselves on the spot, our outer sphincter and deep pelvic floor squeeze the anal canal shut until we are ready to sit on the toilet. 

Anal Sphincter Anatomy
Anal Sphincter Anatomy

The internal anal sphincter (IAS) contributes primarily to anal resting tone – keeps the door shut! The IAS will switch off when the stool drops into the rectum.
The external anal sphincter (EAS) is under our control. We can squeeze this muscle we need extra pressure – e.g. when we want to hold onto a bowel motion or wind, or with coughing/sneezing etc.

Types of Faecal Incontinence

The first thing to understand about faecal incontinence, is that there are three different classifications, all with very different treatment approaches. So the first step towards improving/resolving your problem is to understand what is driving it.

  1. Urge faecal incontinence– bowel leakage in association with an urge to defecate, despite trying to hold onto the motion. CAUSE: weakness in the external anal sphincter +/- pelvic floor muscles. Worsened by loose bowel motions. TREATMENT: targeted pelvic floor muscle retraining, holding on programs, and stool manipulation.
  2. Post-defecatory soiling– bowel leakage or staining on the underwear after an otherwise normal bowel motion. Usually noticed within half an hour. CAUSE: Poor sphincter closure following defecation and/or incomplete evacuation. TREATMENT: correct toileting technique, postural awareness, muscle retraining, splinting/supporting the descending tissue, and stool manipulation.
  3. Passive faecal incontinence– involuntary loss of stool, not felt by the individual and not associated with an urge to defecate. May happen several times per day. . May be a small bit of liquid, a soft blob, a formed bowel motion or somewhere in between. CAUSE: reduced anal pressure resting tone, reduced sensation. TREATMENT: stool manipulation, addressing constipation if that is an issue, pelvic floor muscle retraining, rectal electrical stimulation, anal plugs.

DID YOU KNOW: Constipation can actually cause Faecal Incontinence. When our bowels are super clogged up, our body creates a mucus to try and lubricate the stool, and that mucus can make its way out and onto your underwear! This is called overflow.

How Can Physiotherapy Help?

At Physiotherapy we will get to “the bottom” of your problems by asking you questions about your bowel history and habits.

We may do an objective pelvic floor and/or anal sphincter assessment using real time ultrasound or an internal assessment if needed (and you are comfortable).

We will select a range of treatment types to address your individual problem:

Treatment Examples

  • Defecation dynamics – we will teach you the correct way to pass a bowel motion, using an abdominal muscle strategy to generate rectal pressure that optimises pelvic floor muscle relaxation and minimises descent of your pelvic organs.
  • Pelvic floor muscle retraining– we will assess your muscle system and teach you the best ways to activate your anal sphincters and deep pelvic floor. Your muscle retraining program will be individualised to your circumstances.
  • Electrical stimulation– using a rectal probe we can directly stimulate your pelvic floor and anal sphincter muscles if you are not able to feel a contraction on your own. It can also help build some resting tone in the back passage.
  • Anal plugs– can be used as a short term management strategy to allow you to enjoy your day without worrying about leakage. We can help you choose the right type for your needs.
  • Balloon retraining– this is a type of ‘defecation simulation’ biofeedback and can be useful when patients are struggling to identify a normal sensation in the rectum, as well as helping to retrain the coordination of their defecation muscles.
  • Stool manipulation– fluid and fibre can be manipulated to achieve a desired stool type.
  • Non-physiotherapy treatment– may include seeing a specialist to discuss surgery and sacral stimulation if conservative treatment fails.

If you suffer with any of the symptoms mentioned in this article, please come and see one our expertly trained pelvic physiotherapists to regain control and improve the quality of your life. 

Author

Karly Coltman
Physiotherapist – Learn More

 

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