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Incontinence, bowel

Introduction

Bowel incontinence can be extremely upsetting and hard to cope with, but effective treatments are available and a cure possible, so make sure you see your GP.

Bowel incontinence is an inability to control bowel movements, which means that stools can leak uncontrollably from the rectum (bottom).

Bowel incontinence is also sometimes known as faecal incontinence.

Some people may just pass a small piece of stool when passing wind, while others may have a complete loss of bowel control (see Bowel incontinence - symptoms).

It can severely affect a person’s quality of life, self-esteem and emotional wellbeing.

Bowel incontinence is much more common than most people realise. This is possibly because many people are unwilling to discuss the condition with family and friends.

Who is affected

Bowel incontinence is not a condition in itself. It is a symptom of an underlying problem or medical condition, such as muscle and nerve damage or dementia.

It can affect people of any age, although the condition is more common in elderly people. It is thought to be slightly more common in women than men. This could be because many cases of bowel incontinence develop as a complication of pregnancy.

The importance of seeking treatment

Many people with bowel incontinence do not seek medical treatment for their condition. This may be because of common misconceptions. Some of these are explored below.

  • Bowel incontinence is not something to be ashamed of. Bowel incontinence is simply a medical problem that is no different from diabetes or asthma.
  • Bowel incontinence can be treated. There is a wide range of successful treatments for bowel incontinence.
  • Bowel incontinence is not a normal part of ageing.
  • Bowel incontinence will not always go away without treatment. Bowel incontinence may go away without treatment in a minority of cases, but most people will need treatment to control their symptoms.

Outlook

In many cases, with the right treatment, a person can maintain normal bowel function throughout their life.

Treatment options include:

  • lifestyle and dietary changes
  • exercise programmes
  • medication
  • surgery

For more information, see Bowel incontinence - treatment.

Even if a complete cure for bowel incontinence is not possible, most people's symptoms improve significantly and they achieve a better quality of life.

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Symptoms

The experience of bowel incontinence can vary from person to person.

Some people feel a sudden, urgent need to go to the toilet, and incontinence occurs because they are unable to reach a toilet in time. This is known as urge bowel incontinence.

Other people may experience no sensation before passing a stool. This is known as passive soiling.

Experiences can vary from person to person, and may include:

  • passing a small piece of stool while passing wind
  • passing liquid stools
  • passing solid stools

Bowel incontinence may be experienced on a daily, weekly or monthly basis.

Additional symptoms

Some people with bowel incontinence also have additional symptoms. These include:

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Causes

There are three main factors that can affect normal bowel function and cause bowel incontinence.

These are:

  • Problems with the rectum: the rectum (where stools are held) is unable to store stools properly until it is time to go to the toilet.
  • Problems with the sphincter muscles: the muscles at the top and bottom of the rectum do not work properly.
  • Nerve damage: the nerve signals sent from the rectum do not reach the brain.

These problems are each explained in more detail below.

Problems with the rectum

Constipation

Constipation is a leading cause of bowel incontinence.

In cases of severe constipation, a large, solid stool can become stuck in the rectum. This is known as faecal impaction. The stool then begins to stretch the muscles of the rectum, weakening them.

Watery stools can then leak around the stool and out of the bottom, causing bowel incontinence.

Diarrhoea

It is more difficult for the rectum to hold liquid stools (diarrhoea) than solid stools, so people with diarrhoea (particularly recurring diarrhoea) can develop bowel incontinence.

Conditions that can cause recurring diarrhoea include:

These three conditions can also cause scarring of the rectum, which can lead to bowel incontinence.

Rectal cancer

Cancerous tumours that develop inside the rectum can sometimes cause bowel incontinence.

Problems with the sphincter muscles

The sphincter muscles at the top and bottom of the rectum act like gates, opening and closing as necessary.

You do not have control of the internal sphincter (at the top), which opens automatically to let stools pass into your rectum.

Once your rectum is full, nerve endings in your rectum send a signal to your brain to ‘tell’ you that you need to pass a stool.

You normally have control over your external sphincter (at the bottom), so this stays closed until you find a convenient time to go to the toilet, at which point your external sphincter will open and stools will pass out.

Childbirth

Childbirth is one of the most common causes of damage to the sphincter muscles and a leading cause of bowel incontinence.

During a vaginal delivery of a baby, the sphincter muscles can become stretched and damaged, particularly as a result of a forceps delivery.

Other causes

Sphincter muscles can also become damaged through injury, or damage that arises as a complication of bowel or rectal surgery.

Nerve damage

A number of conditions can damage the nerves that connect the rectum to the brain, causing bowel incontinence. These conditions include:

Any injury to the nervous system, such as spinal injury, can also lead to bowel incontinence.

Complete loss of bowel control

In a number of other health conditions, there is no physical damage but a person loses their ability to control their bowel properly.

These conditions include:

Are bowel problems a sign of something more serious?

Your bowel problems may be a sign of bowel cancer or another serious condition. Your chances of survival are greater the earlier you are diagnosed, so make sure you discuss them with your GP.

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Diagnosis

Your GP will begin by asking you about the pattern of your symptoms and other related issues, such as your diet.

You may find this embarrassing, but it is important to answer as honestly and fully as you can because this will help to ensure that you receive the most suitable treatment.

It is likely that your GP will carry out a physical examination. First they will look at your anus and the surrounding area to check for any damage. Your GP will then perform a rectal examination, where they gently insert their finger into your bottom.

Carrying out a rectal examination allows the GP to check whether constipation is causing your symptoms, and checks if there are tumours in your rectum. Your GP may ask you to squeeze your rectum around their finger to assess how well the muscles in your rectum and bowels are working.

Depending on the results of your examination, your GP may refer you for further testing.

Further testing

Endoscopy

During an endoscopy, the inside of your rectum (and in some cases your lower bowel) is examined internally using a long, thin flexible tube with a light and video camera at the end. Images can be taken of the inside of your body and sent to an external monitor.

The endoscope is inserted into your bottom to check whether there is any obstruction, damage or inflammation in your rectum.

Although an endoscopy is not painful, it can feel uncomfortable, so you may be given a sedative to relax you.

Anal manometry

Anal manometry helps to diagnose bowel-related problems by assessing:

  • how well your sphincter muscles (above and below the rectum) are working
  • how well the muscles of your rectum are working
  • whether the nerves in your rectum are working properly

Anal manometry uses a device that looks like a small thermometer with a balloon attached to the end. The device is inserted into your rectum and the balloon is inflated. This may feel unusual, but is not uncomfortable or painful.

A machine is attached to the device, which measures pressure readings taken from the balloon.

During the test you will be asked to squeeze, relax and push your rectum muscles at certain times. You may also be asked to push the balloon out of your rectum in the same way that you push out a stool. The information is sent to the pressure-measuring machine, and gives an idea of how well your muscles are working.

The balloon can also be inflated to different sizes to determine when your rectum feels full. If the balloon is inflated to a relatively large size but you do not feel any sensation of fullness, it may mean there are problems with the nerves in your rectum.

Ultrasound

An ultrasound scanner can be used to build up a detailed picture of the inside of your rectum. Ultrasound scans are particularly useful in detecting underlying damage to the sphincter muscles.

Defecography

Defecography is a test used to study exactly how you are passing stools. It can also be useful in detecting any signs of obstruction, such as faecal impaction, that have not been discovered during a rectal examination.

The test involves you drinking a slightly radioactive but harmless liquid called barium. Barium is used because it shows up on X-rays. After you have drunk the barium, you will be asked to pass a stool in the usual way while X-rays are taken.

Anal electromyography

Anal electromyography is a test that checks for any damage to the nerves running from your rectum to your brain.

During anal electromyography, a small set of electrodes are inserted in the muscles around your anus. A small electrical current is then sent through the electrodes into the muscles and associated nerves.

The electrodes are connected to a computer, which tracks how the electrical signals are transmitted through your muscles and nerves. Any delay in the transmission of the electrical signal can be used to pinpoint where nerve damage has occurred.

Tell your doctor ...

  • About any changes in your bowel habits that have persisted for a few weeks or more.
  • Whether or not you have had rectal bleeding with no obvious cause.
  • If you have stomach pains.
  • If you have changed your diet.
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Treatment

If you have bowel incontinence, your treatment plan will depend on the underlying cause of your condition and the pattern of your symptoms.

As a general principle, healthcare professionals recommend trying the least intrusive treatments first, such as dietary changes and exercise programmes.

More intrusive treatments, such as medication or surgery, are usually considered only if other treatment options are unsuccessful.

Continence products

You may find it helpful to use continence products until your symptoms of bowel incontinence are better controlled.

Anal plugs are a good way to prevent episodes of soiling. An anal plug is made of foam and designed to be inserted into your bottom. This can feel strange at first, but most people get used to it.

If the plug comes into contact with any moisture from the bowel, it expands into a mushroom shape and prevents any leakage or soiling. Anal plugs can be worn for up to 12 hours, after which time they are removed using an attached string.

Disposable body pads are contoured pads that soak up liquid stools and protect your skin. They can also be used in cases of mild bowel incontinence.

Most continence products are available for free on the NHS.

Dietary changes

In cases of bowel incontinence associated with diarrhoea or constipation, it is often possible to control your symptoms by making changes to your diet (see below).

A low-fibre diet may be beneficial if you have soft or loose stools.

You may be asked to keep a food diary to record the effect of your dietary changes on your symptoms.

Diarrhoea

The National Institute for Health and Clinical Excellence (NICE) has published dietary advice for managing long-term diarrhoea in cases of irritable bowel syndrome (PDF, 39Kb). These guidelines can also be applied for people with diarrhoea associated with bowel incontinence.

The advice from NICE includes the following:

  • limit insoluble fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds)
  • avoid skin, pips and pith from fruit and vegetables
  • limit fresh and dried fruit to three portions a day and fruit juice to one small glass a day (make up the recommended ‘five a day’ with vegetables)
  • limit intake of foods high in ‘resistant starch’, such as pulses, whole grains, sweetcorn and green bananas
  • avoid foods high in fat, such as chips, fast foods and burgers

Constipation

A high-fibre diet is usually recommended for most (but not all) people who have constipation-associated bowel incontinence. Your GP can tell you if a high-fibre diet is suitable for you.

Fibre can soften stools, making them easier to pass. Foods that are high in fibre include:

  • fruit
  • vegetables
  • beans
  • wholegrain rice
  • wholewheat pasta
  • wholemeal bread
  • seeds
  • nuts
  • oats

Drink plenty of fluids because this can help to soften your stools and make them easier to pass. For most people, drinking at least 1.5 litres (2.5 pints) of fluid (preferably water) a day is recommended.

Medication

Medication can be used to help treat soft or loose stools or constipation associated with bowel incontinence.

Loperamide is a medication widely used to treat diarrhoea. It works by slowing down the movement of stools through the digestive system, while allowing more water to be absorbed from the stools. Loperamide can be prescribed in low doses to be taken regularly over a long period of time.

Laxatives are used to treat constipation. They are a type of medication that helps you to pass stools. Bulk-forming laxatives are usually recommended. These help your stools to retain fluid. This means they are less likely to dry out, which can lead to faecal impaction.

Pelvic floor muscle training

Pelvic floor muscle training is a type of exercise programme used to treat cases of bowel incontinence that develop after childbirth.

A therapist, usually a physiotherapist, will teach you a range of exercises. The goal of pelvic floor muscle training is to strengthen any muscles that may have been stretched and weakened during childbirth.

You will probably be required to carry out the exercises three times a day, for six to eight weeks. After this time, you should notice an improvement in your symptoms.

Exercises to try

Check with your health professional before trying these at home.

First, pretend you're trying to hold in a bowel movement. You should feel the muscles around your anus tighten.

Next, sit, stand or lie in a comfortable position with your legs slightly apart.

  • Squeeze your pelvic floor muscles for as long as you can, then relax. Repeat five times.
  • Squeeze the muscles as hard as you can, then relax. Repeat five times.
  • Squeeze the muscles quickly, then relax. Repeat five times.

If you find these exercises too difficult, try fewer repetitions at first and build them up. If they get too easy, try doing more repetitions. You can do the exercises without anyone knowing about them, so they should be easy to fit into your daily routine.

Bowel retraining

Bowel retraining is a type of treatment for people who have reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation.

There are three goals in bowel retraining:

  • to improve the consistency of your stools
  • to establish a regular time for you to empty your bowels
  • to find ways of stimulating your bowels to empty themselves

Improving stool consistency is usually achieved by modifying your diet (see above).

Establishing a regular time to empty your bowels involves assessing your daily routine and finding the most convenient time when you can spend 20-30 minutes on the toilet without being rushed.

For some people, this may involve waking up early so that they can spend time going to the toilet after breakfast, while other people may prefer to set aside some time in the evening after dinner.

Ways to stimulate bowel movements can differ from person to person. Some people find that a hot drink and meal can help. Others may need to stimulate their anus using their finger.

Biofeedback

Biofeedback is a type of bowel retraining exercise that involves placing a small electric probe into your bottom.

The sensor relays detailed information about the movement and pressure of the muscles in your rectum to an attached computer.

You are then asked to perform a series of exercises designed to improve your bowel function. The sensor checks that you are performing the exercises in the right way.

Enemas

Enemas are used in cases where bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool from the rectum.

An enema is a small tube that is placed into your anus. A special solution is then used to wash out your rectum.

Surgery

Surgery is usually only recommended for the treatment of bowel incontinence after all other treatment options have been tried.

Endoscopic heat therapy

Endoscopic radiofrequency (heat) therapy is a fairly new treatment for bowel incontinence.

Heat energy is applied to the sphincter muscles through a thin probe, to encourage scarring of the tissue. This helps tighten the muscles and helps to control bowel movements.

The National Institute for Health and Clinical Excellence recently produced guidelines on this procedure. NICE concludes that the procedure appears to be safe, although there are still uncertainties about how well it works.

Read the 2011 NICE guidelines on Treating faecal incontinence using endoscopic radiofrequency therapy.

Sphincteroplasty

A sphincteroplasty is an operation to repair damaged sphincter muscles. The surgeon removes some of the muscle tissue and the muscle edges are overlapped and sewn back together. This provides extra support to the muscles, which makes them stronger.

Stimulated graciloplasty

A stimulated graciloplasty is an operation that replaces your sphincter muscles.

The surgeon takes a small sample of muscle from your thigh and uses it to create an artificial sphincter muscle.

Electrodes are inserted into the artificial sphincter, which are attached to a pulse generator placed inside your abdomen.

The pulse generator runs an electrical current through the implanted muscles, which gradually changes the way the muscles work to make them act like natural sphincter muscles.

As with all surgery, stimulated graciloplasty carries a risk of complications. The most commonly reported complications of the procedure are:

  • infection at the sight of surgery
  • technical problems with the pulse generator, which require additional surgery to correct

Injectable bulking agents

Bulking agents, such as collagen or silicone, can be injected into the muscles of the sphincter and rectum to strengthen them.

The use of bulking agents in this way is a fairly new technique, so there is little information about the long-term effectiveness and safety of this type of treatment.

You should discuss the possible advantages and disadvantages of this type of treatment in full with your treatment team before deciding whether to proceed.

Sacral nerve stimulation

Sacral nerve stimulation is a treatment used for people with weakened sphincter muscles.

Electrodes are inserted under the skin in the lower back and connected to a pulse generator. The generator releases pulses of electricity that stimulate the sacral nerves.

The stimulation causes the sphincter muscles to contract so that stools cannot pass out of your rectum. When you want to pass a stool, you use a magnet to interrupt the pulses of electricity, which will open up your sphincter muscles.

At first, the pulse generator is located outside your body. If the treatment is effective, the pulse generator will be implanted deep under the skin in your back.

As with stimulated graciloplasty, the most common complications of sacral nerve stimulation are infection at the site of surgery and technical problems with the pulse generator.

Tibial nerve stimulation

Tibial nerve stimulation is a fairly new treatment for bowel incontinence.

A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve. It is not known exactly how this treatment works, but it's thought to work in a similar way to sacral nerve stimulation.

The National Institute for Health and Clinical Excellence recently produced guidelines on this procedure. NICE concludes that the procedure appears to be safe, although there are still uncertainties about how well it works.

Read the 2011 NICE guidelines on Treating faecal incontinence by stimulating the tibial nerve.

Colostomy

A colostomy is usually only recommended if other surgical treatments are unsuccessful.

A colostomy is a surgical procedure in which your colon (lower bowel) is cut and brought through the wall of your stomach to create an artificial opening called a stoma. Your stools can then be collected in a bag, known as a colostomy bag, which is attached to the opening.

See the topic on colostomy for more information about the procedure.

When you are out

  • Wear trousers or skirts that are easy to undo and have elasticated waistbands rather than buttons.
  • The Bladder & Bowel Foundation can provide you with an 'urgency card', which explains to shop owners or others in a queue that you need to use the facilities urgently. To get a card, call 01536 533 255.
  • RADAR, the disability network, offers access to 7,000 disabled toilets around the country. A small charge is made to cover costs.

Get specialist help at your local NHS continence service

NHS continence services are staffed by specialist nurses. You can usually book an appointment without a referral from a GP. The Bladder & Bowel Foundation can help you find your local service.

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