THE CONDITION NO-ONE WANTS TO TALK ABOUT
Fecal incontinence (FI) is the most debilitating condition of all pelvic floor dysfunctions. The psychological impact is dramatic and if you suffer this condition, you may be reluctant to report your symptoms or to seek help. Even healthcare providers can be reluctant to enquire about this condition, which can leave you feeling lost and alone. Embarrassment and shame can hinder you from finding the help you need. This further emphasises the importance of the #BreakthePFDtaboo campaign.
So what are the symptoms? Sometimes if you get sick and have severe diarrhea, you may experience the unintentional leakage of runny poo. This could be considered Functional FI as it is related to an illness rather than to weakness in your pelvic floor. Functional FI will most likely clear when the illness is gone. With Fecal incontinence, however, leakage happens under “normal” conditions.
At its mildest, fecal incontinence equals flatulence, where you are unable to control your gas. This doesn’t mean that you have FI if you fart a lot. The average person farts 14 times per day. It is the inability to hold in a fart at an inopportune moment that highlights you may have some inefficiency in your external anal sphincter. When FI becomes more severe, leakage can be anything from a small amount of poop to complete emptying of the bowel. There is a high prevalence of depression amongst women with FI with many claiming to “succumb” to the condition. We don’t want you to succumb, we want you to fight back and regain control, and to know that you are not alone.
THE PROCESS OF POOING
Your anus is the end of a long pipe that runs from your mouth to your bottom. In between your mouth and your bottom, the food you eat gets broken down by billions of microbes (bacteria) that are part of your microbiome which forms a large part of your immune system. Food is moved by the smooth muscle that forms the digestive tract (stomach, intestines etc).
By the time the food you have eaten makes it to your rectum, it has been heavily processed by your digestive system, leaving waste (mostly fibre and substances that cannot be digested). Your pelvic floor creates a barrier to prevent your poop from coming straight out of your body, allowing it to accumulate into a sufficient “poop-sausage” before initiating the reflex that lets you know its time to empty (intrinsic myenteric defecation reflex). This first reflex moves the poop towards your anus letting you know, poo time is here. Your external anal sphincter is responsible for holding the anus closed.
THE ROLE OF THE PELVIC FLOOR IN POOING
The intrinsic myenteric defecation reflex moves your poop towards your external anal sphincter, however, it meets with the resistance of your pelvic floor, more specifically the puborectalis muscle which is part of your Levator ani. This muscle puts a kink in your rectum which slows the decent of poop that is headed towards the exit (your anus). This kink creates the anorectal angle. The external anal sphincter should hold the rectum closed until the stretch receptors in the rectum trigger the urge to empty.
Of course, just like the process of urination, you learned as a child to control the external anal sphincter allowing you to hold your poop until a toilet could be found. Once a toilet is found, you squat down (hopefully!), relaxing your external anal sphincter and allowing the poop to exit the body. In the book, we explore the process of defecation in more detail to gain valuable insights which are utilised in the whole life, whole mind, whole body approach to rehabilitation.
SO HOW DOES FECAL INCONTINENCE OCCUR?
FI is a complex condition with many impacting factors, so let’s focus solely on the role of pelvic floor. The mechanism of continence is dependent on both the puborectalis (which creates a kink in the rectum), and the external anal sphincter, both of which are under your voluntary control. Weakness in the pelvic floor can result in laxity and atrophy of these and other muscles of the pelvic floor.
A weak pelvic floor typically sit lower providing less support for the organs of the pelvis (bladder, uterus and rectum). If you have read the urinary incontinence and pelvic organ prolapse pages, you will be familiar with the impact of weak pelvic floor muscles. In respect of the puborectalis and levator ani, weakness results in a decrease in the anorectal angle. This can increase the risk of FI as a reduction in this angle allows more, if not all of the fecal content to weigh down on the external urethral sphincter. This reduction in angle is important when you need to poo. Squatting to poo reduces the angle significantly allowing for a faster evacuation.
Weakness in the external anal sphincter is the real killer though. The external anal sphincter needs to have sufficient strength to hold tightly closed. You have voluntary control of the muscle so when it is sufficient in strength, you can maintain the closure. Lack of strength means that the pressure of feces bearing down will be greater than the pressure holding the muscle closed. This will result in a leakage. The muscle can be weak due to atrophy, or in many cases, it can be weak due to injury. If tearing during childbirth is severe, this can cause a sphincter tear. Depending on the quality of repair and on the subsequent muscle rehabilitation, you will have more or less strength in this muscle.
Sometimes fecal incontinence can occur after the bowel has been emptied, if it had failed to empty fully. This can happen due to a rectocele, where weakness in the pelvic floor and the back vaginal wall (posterior) allows the rectum to prolapse into the vagina. You can read more on rectocele and treatments in the pelvic organ prolapse section of the knowledge portal.
HOW CAN I KNOW THE SEVERITY OF MY FECAL INCONTINENCE (FI)?
Unlike urinary incontinence with the Sandvik Test, there is currently no standard qualification method to define the severity of FI. For this reason, we have created an adapted version of the Sandvik Test to help you assess the severity of your FI. When you meet with a pelvic health specialist, you can share your results with them.
MY SUI IS SEVERE, DOES THIS MEAN THAT PELVIC FLOOR MUSCLE TRAINING (PFMT) WON’T WORK?
No, the severity of your SUI is not directly connected to the effectiveness of PFMT. You should have a PFMT program that is tailored to you based on the condition of your pelvic floor muscles. Studies show that women who have weaker pelvic floor muscles to start with have the greatest percentage improvement in symptoms from PFMT. Consistency is key. Your pelvic floor physiotherapist can help you to set goals that are achievable.
WHAT IS PELVIC FLOOR MUSCLE TRAINING (PFMT)?
Traditional PFMT involves exercising pelvic floor muscles to restore muscle function and strength. These exercises are often referred to as Kegel’s – named after Dr. Arnold Kegel who identified the importance of exercising the pelvic floor to maintain continence. Learning how to perform Kegel’s properly is imperative to the success of your treatment.
IS THERE ANYTHING ELSE I SHOULD DO COMBINED WITH MY PFMT?
Yes, PFMT is localised to your pelvic floor muscles and will help with creating localised strength, however, your pelvic floor muscles do not work in isolation. Taking a whole body, whole life, whole mind approach will improve your chance of success.
When it comes to Fecal Incontinence, it is almost as important to assess your diet, which is one of the reasons we included the additional question regarding the consistency of your normal poo in the severity test. If your “normal” poo leaves you with constipation or loose stools/diarrhoea, it is imperative that you make changes to your diet. Constipation and diarrhoea have a detrimental impact on your pelvic floor and can lead to FI if they are chronic. Look for a local nutritionist in our Specialist directory. Let us know if you fail to find someone in your area and we will try to help.
When you consider that your diet plays a major role in digestion and that constipation and diarrhoea increase your risk of developing FI, you should take your diet seriously. Probiotics can help to boost your microbiome with lots of healthy bacteria. It is important to have your bloods checked to ensure you are sufficient in essential vitamins and minerals. A good nutritionist can advise you on the best diet for your specific condition.
Did you know that for every additional unit increase in your BMI, your risk of developing urinary incontinence increases by 1%? In fact, obese people have a double the risk for developing urinary incontinence. The severity of incontinence is also more severe if you are obese and lowering the BMI has been shown to lower the severity. Given that 20% of women who suffer urinary incontinence will also suffer fecal incontinence, you should strive to keep a healthy BMI.
Your pelvic health specialist or nutritionist may ask you to keep a diary of your food intake and bowel movements over a couple of months to identify your patterns. You can do this using pen and paper or alternatively use an app such as Tummy Lab which was created to track Irritable Bowel Syndrome (IBS) and other digestive issues. In this app, you can track the food you eat, your bowel movements, your symptoms and many other data-points that may be of interest. Your pelvic health specialist might suggest bowel retraining if your pattern of movements is highly irregular.
Your pelvic floor has relationships with surrounding muscles. In recent years, Biomechanists, structural integrators, movement therapists and yoga teachers have been expanding pelvic floor rehabilitation programs to include other key muscle groups that have a direct relationship to the pelvic floor (such as the diaphragm, core and gluteus muscles). By working on a range of functional movements, in combination with Kegels, the pelvic floor can become more stable. This should help to improve your overall fitness level as well as reducing the symptoms of your FI.
Posture and alignment impact the stability of your pelvic floor and should be assessed as part of your rehabilitation. Your connective tissue (fascia) holds your body in its normal posture. Advancements in fascial research has created a much clearer understanding on how load is distributed through your body. When you view your pelvic floor muscles in isolation, you are viewing just a small part of the puzzle. Working with a myofascial release therapist or structural integrator is a wonderful addition to your rehabilitation.
The psychological aspect to fecal incontinence is substantial. The condition can leave you afraid to even leave home, mapping toilet locations when you do so as not to get caught unawares. Self-esteem greatly suffers and depression and anxiety are often reported with the severity of depression increasing along with the severity of FI. It is imperative that you seek help as soon as possible. Speaking to a therapist can help you deal with the negative impact of living with FI. Meditation can also be of benefit as you undertake your rehabilitation. Please realise that you are not alone. You can connect to others that have FI in our community.
A randomised study that evaluated the effects of PFMT for stress incontinence in two groups, one that did PFMT at home, and the other that did PFMT at home combined with a group training session once per week, showed that the group who underwent group training showed significant improvement over the home trained group. With FI, you are probably less reluctant to go outside, but the sense of community and support when you train with others might boost your self-esteem and prevent you from feeling isolated. If your pelvic health physiotherapist does not offer a weekly group session, try to find a pilates, yoga or hypopressive class focusing specifically on training the pelvic floor.
An important lifestyle choice connected to fecal incontinence relates to anal sex. A 2016 study which included 2070 women concluded that anal intercourse can be a contributing factor with anal incontinence. In the book, anal sex is explored from the perspective of the pelvic floor as there are some considerations that can help to reduce the impact on your pelvic health if anal sex is your thing. You should definitely pause the activity if your incontinence is severe and take time to heal before resuming.
MEASURING YOUR PROGRESS
You should always start with establishing your baseline before beginning training as this allows you to properly assess your progress. There are a number of different ways in which to measure your progress. You can retake the FI Severity test every few months to reassess your incontinence and monitor your body’s response to the training. Biofeedback can also be used to track the strength of your pelvic floor. If you purchase a biofeedback device, you can also use it as part of your training. It is usual for pelvic health physios and other specialists to use biofeedback testing as well as ultrasound to directly see the activation of the pelvic floor. In some cases, a three dimensional pelvic ultrasound machine may be used to get a more accurate picture of what is happening through the entire pelvic floor.
There are numerous products available to manage the symptoms of fecal incontinence from pants to squatty potties. There are also devices to aide pelvic floor muscle training with probes that are specifically for the anal passage. Reviews of these products will be covered on our YouTube channel. If there is a specific product that you would like to see reviewed, just contact us and we will review. The images below link to the products on in your local amazon store.*
* I am an affiliate of amazon, iTunes and other affiliate services and may receive a small commission should you purchase through links on TheFlowerEmpowered.com
CONSERVATIVE TREATMENTS HAVE NOT WORKED FOR ME, WHAT NEXT?
You should give conservative treatments time to take effect. The more severe your FI, the longer it will may take. A “can do” attitude really helps. Consistency is key with any strength training program. It can also take time to find the diet that is right for your unique microbiome. I recommend you give yourself at least one year of consistent steady training and dietary adjustments before considering the more invasive options of bulking agents or surgery. Your pelvic floor physical therapist can refer you to a specialist surgeon to explore further treatments if the conservative treatments fail.
WHAT OTHER TREATMENT OPTIONS DO I HAVE?
If your condition is connected to Pelvic Organ Prolapse or Rectocele, you should review the advice given on the POP page with regards to the treatments available for those conditions. If you condition is not connected to POP, there are some other alternatives that are listed below. Pessaries and urethral blocking are for management of the condition rather than permanent cure. All treatments that involve putting something into the body, including bulking agents, laser treatment and surgery, carry more risks than the conservative options.
Anal Incontinence plugs are designed to function in a similar way to a tampon. They are made from an absorbable foam covered by a thin film that dissolves when it comes in contact with bodily fluids. Once the film has dissolved, the absorbable material expands to seal the rectum. The foam itself is porous to allow gas to pass through. Like a tampon, the plug has to be passed sufficiently high into the rectum for correct and comfortable positioning. If the plug expands in the lower part of the rectum, it can be extremely uncomfortable while adding unnecessary pressure to the internal and external sphincters.
A 2005 study found that anal plugs can be “difficult to tolerate, however, if they are tolerated, they can be helpful in preventing incontinence”. Another study from the Nursing Times (2008) found that patient uptake was low until correct placement was demonstrated in a clinic setting. If used correctly, the anal plug can be useful to manage the symptoms of FI while working on pelvic floor rehabilitation.
Many medications can aggravate the digestive system thus changing the consistency of your poo. It is important to carefully consider everything that goes into the mouth as it will eventually make some level of an appearance at the other end of your digestive pipe.
Medication for treatment of FI tends to be for symptom control and is typically used over the short term. If loose stools or diarrhoea are contributing, drugs like Imodium may be offered. If constipation is contributing, bulking laxatives such as Psyllium may be offered. Aside from these medications, which focus on changing the consistency of your poo, there are one or two other medications that can be given. Amitriptyline can be used to decrease rectal contractions. A low dose of Clonidine can be used to reduce rectal sensation and urgency.
All medications come with side effects and typically treat the symptom and not the root cause. Try to find the root cause of your issue and work from there.
Everyone is familiar with the trout pout, and most likely, also familiar with the injections to bulk the lips in order to exaggerate the trout pout. A similar treatment is available to add bulk to the tissues surrounding the anal sphincter. This treatment was first introduced for FI in 1993. There have been limited trials into the efficacy of these bulking agents, and no long term trials exist. The trials that have been run have shown a reduction in symptoms for the treated group compared to the controls as well as an increase in quality of life scores. In the same way that the lip fillers break down over time returning the lips to their normal state, bulking agents will also break down over time meaning that a repeat treatment will be required at some point.
Transcutaneous Prosterior Tibial Nerve Stimulation (TPTNS) is stimulation of the tibial nerve with skin surface electrodes. This treatment is the least invasive of the nerve stimulation options. The treatment is preformed by placing two skin electrodes above and below the ankle where the tibial nerve is located. Whereas PTNS (Prosterior Tibial Nerve Stimulation) is performed in clinic by a doctor, TPTNS can be preformed at home using a TENS (Transcutaneous Electrical Nerve Stimulation) device. This is the same device that is used to perform electrical stimulation of the sphincter with an anal probe, you just connect skin electrodes instead. There have been limited studies into TPTNS, however, completed studies have shown that it can relieve the symptoms of fecal incontinence.
PTNS is a slightly more invasive version of tibial nerve stimulation. Instead of using two skin electrodes, one of the skin electrodes is replaced with a needle which is inserted into the inner ankle. You sit in a chair with your legs elevated. The needle is inserted about the width of three fingers above the malleolus (ankle bone). The skin electrode is placed under the foot in the calcaneus. It is normal for the big toe to flex during treatment. Some studies say you should feel the contraction of your pelvic floor during treatment, although this is not always the case. A 2014 study reviewing the outcome of PTNS in patients with FI found that patients had sustained improvement in symptoms for up to 42 months.
Sacral Nerve Stimulation (SNS) is the most invasive of the nerve stimulation treatments for Fecal Incontinence. It involves implanting a pacemaker type device under the skin of the buttock with an electrode that is fed into the S3 sacral nerve root. The exact mechanism that makes this an effective treatment is not understood. However, studies have demonstrated improvements in anal resting and squeeze pressures and changes in rectal sensitivity.
The device is 2 inches wide and quarter inch thick. Battery is expected to last 5 years, however, the manufacturer emphasises that the more you use it, the quicker it will run out. Changing the battery involves a subsequent surgery. You can have a two week trial before device implantation which is quite unique. During this trial period, you will have probes going into your sacral nerve but will have a small device strapped to your waist instead of the implant.
A Cochrane review in 2015 evaluated the available studies into SNS for FI and found that it was unsuitable for those with constipation.
Obstetric injuries (from vaginal delivery) are the most prevalent sphincter injuries amongst women. Surgery to restore the muscle to its original anatomical form is often performed after injury. A 2012 systemic review into to assess long term outcomes of sphincter repair reported that initial outcome was subjectively reported as “good” but declines were common in long term follow-up. Sphincter repair on its own may not be sufficient and should be followed with a program of PFMT to rehabilitate the newly repaired muscle.
There are a number of other surgical alternatives for repair of the anal sphincter, however most of them have higher risks or are experimental. One treatment, the graciloplasty, involves taking the Gracilis muscle from inside the leg and rotating it to come up and wrap around the sphincter. The muscle is then fitted with a nerve stimulator to increase the tone for sphincter contractions. The surgery is complicated and, according to a 2013 study, is no-longer performed in the US due to the unavailability of the nerve stimulater.
Other treatments involve implantation of inflatable devices or magnets to act as an artificial urethral sphincter. The efficacy of these devices has yet to be confirmed with long term studies.
I’VE BEEN TOLD I NEED SURGERY, WHAT SHOULD I KNOW BEFOREHAND?
All surgeries carry risks, even those considered to be “minimally invasive”. Carefully consider your options and make sure surgery only carried out a last resort.
SET APPROPRIATE EXPECTATIONS
It is important to have realistic expectations if you are going for surgery, and to ensure that both you and your surgeon are on the same page. Successful surgery according to you might not be the same as successful surgery according to your surgeon. Studies into the surgical treatment of FI typically measure success either as object cure rate, subjective cure rate or a combination of the two. Within a single study, the objective and subjective cure rates can vary greatly. A good example of this is this study from 2003 evaluating the outcome of implantation of artificial anal sphincters into 25 people. According to the scoring system used to assess objective cure, of the 19 patients for whom the sphincter was successfully activated, all were 100% continent. However, 36.8% of the patients reported emptying difficulties with some requiring regular enemas and laxatives to allow for satisfactory emptying meaning that subjectively the surgery could not be considered 100% successful for those patients.