Fecal Incontinence in Elderly Adults: What You Need to Know

Fecal incontinence (FI) affects up to 17 million people in the United States, according to the International Foundation for Functional Gastrointestinal Disorders. It’s also the second most common reason older adults make the decision to go into assisted living or long-term care facilities. Even though fecal incontinence is common, it can be embarrassing or upsetting for seniors to talk about, and often goes unchecked.

The good news is that, in most situations, elderly fecal incontinence is treatable or manageable. Learn about common bowel incontinence causes and treatment plans, and how to talk to a doctor about your elderly loved one’s FI.

What is fecal incontinence?

Fecal incontinence is the inability to control bowel movements. The condition can range from an occasional leakage of stool to a complete loss of bowel control.

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Healthy bowel function is controlled by rectal sensation, the ability of the digestive system to accommodate waste, and the anal sphincter muscles. A malfunction in one or more of these things may result in fecal incontinence, according to Dr. Satish Rao, a gastroenterology specialist at Augusta University Health in Augusta, Georgia. Nearly half of those with FI have “impaired rectal sensation,” which means they aren’t aware of the need to use the restroom, says Rao.

During the digestive process, feces moves from the large intestine — also called the sigmoid colon — into the rectum. In response, rectal walls stretch, signaling the need for a bowel movement. The two anal sphincter muscles  —  an involuntary inner muscle and a voluntary outer seal  — hold the stool in the rectum until a toilet is reached, at which time you relax to release the stool. If the signal is misinterpreted, the sphincter muscles are damaged, or a toilet isn’t reached in time, fecal incontinence may occur.

Physical causes of fecal incontinence in the elderly

Sometimes, FI is related to chronic conditions — other times, surgical and medical procedures are at fault. Common conditions that may lead to bowel incontinence include:

Nerve damage. Since our nerves let us know when it’s time for a bowel movement, damage can lead to incontinence. This damage can come from surgery, spinal injury, or a chronic condition, like diabetes or multiple sclerosis.

Muscle damage. Lack of muscle control may make it difficult to hold in stool. The muscle at the end of the rectum, called the anal sphincter, can be damaged during accidents, prostate surgeries, or childbirth.

Chronic constipation. Continuing constipation can cause impacted stool to form in the rectum over time. This stool may become too large to pass. Rectal muscles and intestines will stretch to accommodate the blockage, and eventually weaken, allowing looser stool from further up the intestines to leak around the impacted stool. Chronic constipation can also lead to muscle and nerve damage.

Diarrhea. Loose stool can worsen existing fecal incontinence, since it’s more difficult to retain in the rectum. Also, needing the bathroom immediately increases the likelihood of not making it in time.

Hemorrhoids. Hemorrhoids are swollen veins in the lower rectum. They can keep the anus from closing completely, allowing leakage.

Rectal inelasticity. Rigid rectal walls can lead to loss of storage capacity. This stiffening of the rectal walls can be due to scarring, surgery, radiation, or inflammatory bowel disease (IBS).

Surgery. Surgeries can cause muscle and nerve damage that leads to fecal incontinence — especially surgical procedures to remove hemorrhoids or other operations around the rectum or anus.

Rectal prolapse. Prolapse occurs when the rectum drops down into the anus. This is often caused by chronic straining to move the bowels.

Rectocele. Similar to rectal prolapse, rectocele occurs when the rectum protrudes from the vagina rather than the anus. This can lead to fecal incontinence, in addition to reproductive and feminine health problems.

Chronic laxative abuse. Overuse of laxatives can lead to FI later in life.

Contributing factors to bowel incontinence in elderly adults

Age. Fecal incontinence can occur at any age, but it’s more common in older adults, and often progresses with age.

Stress or fear. Adjusting to a new environment can be stressful and lead to temporary fecal incontinence.

Menopause and hormone therapy. Low estrogen levels after menopause can lead to fecal incontinence, according to a 2017 study published in the journal Gastroenterology. Also, hormone replacement therapy throughout life may lead to FI in seniors, the research suggests.

Physical disability. Having difficulties reaching a toilet in time can be a cause of FI. Older people may have experienced falls or have medical conditions that limit their mobility or speed. It often takes time to adjust to the need to plan for extra time to get to a bathroom.

Dementia. Fecal incontinence often accompanies late-stage Alzheimer’s disease and other types of dementia.

Childbirth. Vaginal deliveries — especially those assisted by forceps, vacuums, or episiotomies — increase the likelihood of fecal incontinence later in life. Risk rises with the number of deliveries.

Diagnosing senior fecal incontinence

If you or an elderly loved one is experiencing FI, talk to a doctor. Usually, a general practitioner will refer you to a specialist, who may ask questions about living arrangements, diet, and current and past bowel function, according to Rao.

A patient may also be asked to bring a record of fecal incontinence to their first visit, or to create one between appointments.

In this journal, they will likely record:

• Types of food and drinks consumed
• How many times, and when, they defecated throughout the day
• Documentation of irregular stools
• Notes about their accidents, including frequency

After gathering information, the doctor may do a physical examination of the anus and perineum, the area between the anus and the genitals, to check for hemorrhoids or infection. They may also schedule one or more of these common tests:

• Anal manometry
  It involves inserting a thin tube tipped with an inflatable balloon and pressure sensors into the rectum through the anus to test rectal sensation, strength, and response. It also tests the tightness of the anal sphincter muscles
• Anorectal ultrasound
  An ultrasound uses a wand-like instrument, called a transducer, to bounce soundwaves off organs to create an image of their structures. In this case, the ultrasound focuses on the anus and rectum
• Proctography or defecography
  This test uses X-rays to view the shape and position of the rectum during defecation, and can identify rectal prolapse or rectocele. The patient will cleanse their bowels with enemas before the procedure, then simulate defecation on a toilet in an X-ray machine using a soft paste inserted by the radiologist
• Anal sphincter electromyography (EMG)
  This tests the pelvic floor muscles and the muscles around the anus, as well as the nerves that control those muscles. A thin needle electrode measures electrical activity from the muscles, allowing the doctor to assess nerve damage
• Flexible sigmoidoscopy
  Similar to a senior’s standard annual colonoscopy, this test uses a long, slender, flexible tube with a video camera attached to explore the rectum and lower colon for abnormalities

Anatomy of anal canal

Treatment and management of fecal incontinence and bowel leakage

Fecal incontinence may have severe emotional effects, which can contribute to anxiety, depression, and even social isolation. This is one reason management of FI is so important for seniors, who are already at increased risk of isolation and mental illness.

Minor incontinence may be managed at home, while more severe incontinence can benefit from biofeedback training, prescription medication, or surgery.

At-home incontinence management

After a diagnosis is made, the doctor may suggest minor changes as a first step of treatment for bowel incontinence in the elderly:

• Diet
  Staying hydrated and eating high-fiber fruits, vegetables, and whole grains can regulate defecation and prevent diarrhea and constipation
• Kegel exercises
  Pelvic floor exercises strengthen the muscles of the anus. In a Kegel exercise, the pelvic, buttocks, and anal muscles are contracted and held for a slow count of five. A series of thirty of these three times daily generally improves or resolves incontinence, according to Rao
• Scheduled toileting
  The average amount of time for a proper bowel movement is nine minutes, but seniors and caregivers often rush the process, according to the Family Caregiver Alliance. For people who are unable to feel the need to defecate, several visits to the toilet throughout the day can prevent leakage and overflow
• Increased hygiene
  Cleaning fecal matter from skin reduces odor and irritation. Regular changing of absorbent products is crucial. Following these steps may not decrease minor FI, but it will reduce secondary discomfort and symptoms
• Over-the-counter (OTC) medicine
  Occasionally doctors suggest OTC medicine to manage fecal incontinence — especially when it’s caused by constipation or diarrhea. Typical suggested OTC medications include:
  • Anti-diarrheal drugs that prevent watery stools, such as Imodium®, Lomotil® (diphenoxylate and atropine), Lotronex® (alosetron), and Pepto-Bismol®
  • Laxatives like milk of magnesia that relieve temporary constipation
  • Stool softeners such as Colace and Dulcolax that prevent stool impaction, which causes constipation

Biofeedback therapy

Biofeedback exercises are a nonsurgical, non-invasive therapy option shown to reduce incontinence symptoms in a large percentage of people, according to the International Foundation for Functional Gastrointestinal Disorders. Through biofeedback therapy, patients learn to control bodily processes that are normally involuntary.

• Biofeedback therapy generally begins with the assistance of a registered nurse or doctor with expertise in the procedure, but can be continued at home with the proper equipment. A small electrode is placed in or near the anus, and sends signals to a computer
• As the pelvic muscles tighten and relax, an image on the screen or a noise that fluctuates in volume responds. Based on this feedback, a patient can tell when their muscles are engaged, even if they can’t feel it. This feedback is used to learn muscle control

Surgical options for fecal incontinence management

If other treatment methods don’t work, surgery may help reduce — or eliminate — FI. Surgical options to discuss with a doctor include:

• Sphincteroplasty
  This is the most common fecal incontinence surgery, which reconnects the ends of a sphincter muscle torn by childbirth or another injury.
• Artificial anal sphincter
  This surgery involves placing an inflatable cuff around the anus and implanting a small pump beneath the skin that the person activates to inflate or deflate the cuff.
• Nonabsorbable bulking agent injection
  Nonabsorbable bulking agents can be injected into the wall of the anus to bulk up the surrounding tissue. This makes the opening of the anus narrower to help the sphincters close more easily. This is a less invasive outpatient procedure, performed without general anesthesia.
• Bowel diversion
  This operation diverts the lower part of the small intestine or the colon to an opening in the abdominal wall — the area between the chest and the hips. An external pouch, or colostomy bag, is attached to the opening to collect stool. The colostomy bag must be regularly emptied and cleaned.

Incontinence care tips for families

If your elderly family member suffers from fecal incontinence, thorough care and planning can help avoid complications such as skin rashes, odors, and accidents.

• Be prepared
  Always carry a bag with fresh clothing and clean-up supplies when leaving home. If you and your aging relative plan to be in a public place, identify bathrooms in advance. Suggest using the restroom before leaving the house, and plan meals accordingly.
• Consider dignity
  Fecal incontinence can be embarrassing to seniors. Refer to undergarments as underwear (not diapers). Fecal deodorant pills, which are available either OTC or by prescription, can reduce the smell of stool to help prevent embarrassment.
• Avoid falls
  Slip-and-fall accidents can happen easily when a senior is getting to the restroom. Try to make the bathroom as accessible as possible at home, and install grab bars by the toilet. Use pads and protective garments until you find a successful treatment.
• Ask for help
  If elderly fecal incontinence is keeping your loved one isolated and unable to enjoy their favorite pastimes, talk to them about treatment options and encourage them to see a doctor.

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