The Poop Problem No One Talks About: Understanding and Managing Fecal Incontinence

This might rank among the top of health issues you’d rather not discuss. Like ever. It’s awkward at best, embarrassing for sure — and quite frankly, a little gross. But we are going to talk about fecal incontinence and here’s why: First, it’s more common than you think. In a large, population-based survey, one in seven people reported experiencing this not-so-pleasant bowel issue. And perhaps even more important: As distressing and disruptive as fecal incontinence is, it’s also very treatable. Read on to learn about what causes fecal incontinence and how you can help manage symptoms with exercise, pelvic floor physical therapy, lifestyle changes, and other treatments.

What Is Fecal Incontinence?

Fecal incontinence — also called bowel incontinence or bowel leakage — is the inability to control bowel movements, which causes stool (feces, or poop) to leak from your rectum without warning. It can range from an occasional leak while passing gas or during a bout of diarrhea to the complete loss of bowel control.  There are two types of fecal incontinence:

• Urge incontinence. You know you need to pass stool, but you can’t control or stop it before reaching the toilet. Urge incontinence can occur if your anal sphincter or pelvic floor muscles are too weak to hold in stool or gas.

• Passive incontinence. This is when leakage happens without you knowing. With passive incontinence, your body may not be able to sense when your rectum is full and you need to pass stool. 

You may experience both fecal incontinence and urinary incontinence because the same pelvic floor muscles that control urinary function also control bowel function.

Symptoms of Fecal Incontinence

The symptoms of fecal incontinence may seem pretty hard to ignore, but some may be more subtle, or you may not realize that these “normal” issues are actually signs of fecal incontinence:

• Passing stool before you can reach the toilet. 

• Leaking stool when you pass gas or cough.

• Leaking stool during physical activity or everyday exertions.

• Soiling your underwear with stool or mucus.  

What Causes Fecal Incontinence?

Passing stool involves multiple systems in the body, including muscles and nerves. Pelvic floor muscles stretch from your pubic bone in the front to your tailbone in the back. Like the foundation of a house, they help support structures above, like the bowel and bladder. When stool collects in the rectum (at the end of your colon), nerves located between your rectum and anus signal to your brain that it’s time to go. Muscles of your pelvic floor and anus keep the poop in place until you get to the bathroom; then they relax to help the stool pass. If your pelvic floor and anal muscles are weak, it can affect your ability to hold in stool and gas. Pelvic floor dysfunction can lead to fecal incontinence. Other causes of fecal incontinence can include:

• Muscle damage. If the rings of muscle at the end of the rectum (called the anal sphincter) are injured or weakened, they may not be able to keep the anus closed, letting stool leak out. Injury to these muscles can occur from surgery to remove hemorrhoids, cancer in the anus or rectum, or a trauma.

• Nerve damage. Injury to the nerves that sense stool in your rectum or those that control your anus, pelvic floor, and rectum can lead to fecal incontinence. Many things can damage these nerves, such as repeated straining during bowel movements, a brain or spinal cord injury, or conditions like diabetes or stroke.

• Childbirth injuries. Vaginal deliveries sometimes cause injuries to the anal sphincter, which can lead to fecal incontinence. The chances are greater if your baby was large, forceps were used to help deliver the baby, you had a perineal tear, or (less common) if the doctor made a cut (called an episiotomy) in your vaginal area to make more room for the baby’s head during birth.

• Loss of stretch in the rectum. Scarring, sclerosis, and inflammation from rectal surgery, radiation therapy in the pelvic area, or inflammatory bowel disease can cause the rectum to become stiff. If it can’t stretch as much to hold stool, your rectum can fill up quickly and stool may leak out.

• Chronic constipation. Large, hard stools are difficult to pass. Over time, straining from constipation can weaken pelvic floor muscles and stretch rectal muscles, allowing watery stools that build up behind the hard stool to leak out.

• Diarrhea. Loose, liquid stools can fill your rectum quickly, and are harder to “hold in” than solid stools.

• Hemorrhoids. Swollen veins in the rectum can keep the muscles around your anus from closing completely, which lets small amounts of stool or mucus leak out.

• Rectal prolapse. When the rectum drops down from its usual position and protrudes into the anus or presses into the vagina (rectocele), it can lead to fecal incontinence.

• Intestinal conditions. While they may not cause fecal incontinence, you may have a higher risk if you have irritable bowel syndrome, Crohn’s disease, inflammatory bowel syndrome, or ulcerative colitis.

Physical Therapy for Fecal Incontinence

When weak pelvic floor muscles contribute to fecal incontinence, pelvic floor physical therapists (PTs) can help. To improve bowel control, a pelvic floor physical therapist may recommend:

• Kegel exercises to strengthen the muscles in the pelvic floor, anus, and rectum. Your PT can help you learn the proper way to perform Kegel exercises. 

• Biofeedback therapy to help you sense when stool is filling your rectum and ready to be released. It can also help you contract your muscles (hold your poop in) if it’s not a good time to go to the bathroom.

• Bowel training to help establish more bowel control through a routine. Your PT may recommend you make a conscious effort to go number two at a specific time every day, such as after breakfast. 

You can see a physical therapist in person or use a program like Hinge Health to access a PT via telehealth/video visit.

More Ways to Manage and Treat Fecal Incontinence

Depending on the cause of your fecal incontinence, your healthcare provider may also suggest one or more of these treatment options as part of your plan:

Dietary changes. You may be able to help regulate your bowel movements and gain better control with these diet changes:

• Keep a food diary. What you eat and drink affects your digestive tract and the consistency of your stool. Foods that cause diarrhea or gas can worsen fecal incontinence. Keep track of your diet for a few days. You may start to see a connection between certain foods and bouts of incontinence. Once you've identified problem foods, try removing them from your diet to see if your incontinence improves.

• Fill up on fiber. If constipation or hemorrhoids are causing your fecal incontinence, your doctor may recommend eating more fiber-rich foods, such as fruits, vegetables, and whole-grain breads and cereals. Fiber helps make stool soft and easier to control.

• Drink more water. There’s no hard-and-fast rule for how much water you need. But a general recommendation is to aim for half your body weight in ounces of water. (That means a 150-pound person should drink 75 ounces.) This can help keep stools soft and formed.

Medications. Over-the-counter options for diarrhea or constipation can help reduce or relieve fecal incontinence. If those aren’t helping symptoms, your healthcare provider may prescribe stronger medicines to treat the cause of your incontinence. Bulking agents. Injections of non-absorbable substances can thicken the walls of the anus to help it close better and prevent leakage. Barrier devices. Anal plugs and vaginal inserts can provide physical pressure against the rectum to protect against leaks.

Electrical stimulation. Devices that send mild electronic pulses may be used externally or surgically implanted near nerves that help manage bowel movements. Surgery. This may be an option if symptoms fail to improve with other treatments, or if your fecal incontinence is caused by injuries to the pelvic floor muscles or anal sphincters. Anal sphincter surgery or colostomy (diversion of your colon to an external opening in your abdomen) are some of the surgical procedures you may discuss with your healthcare provider. 

Dealing with Incontinence: How You Can Cope

Let’s be real: Feeling like you can’t control your bowels is not a good feeling — like, at all. For some, the fear and embarrassment of not making it to the bathroom in time can really impact your everyday life. Those worries are not going to go away overnight. But as you work toward treating the issues contributing to your condition, try these steps to help you better manage your symptoms:

• Use the toilet before going out.

• Locate the closest public restroom wherever you go, before you need it.

• Wear an absorbent pad or disposable undergarment to prevent soiling when you go out.

• Carry a bag with cleanup supplies and a change of clothes, just in case.

• Talk to your doctor about using fecal deodorants (over-the-counter medications that minimize the smell of your stool and gas).

Fecal incontinence is stressful. But it doesn’t have to control you. There are plenty of ways you can take control and get back to living your life to the fullest.

PT Tip: It’s Not You, It’s Your Muscles

“It can feel incredibly difficult to speak up about symptoms of fecal incontinence, but with education and exercise you can improve,” says Kandis Daroski, PT, DPT, a Hinge Health pelvic floor physical therapist. “Knowing that muscles are often part of the reason for fecal incontinence can give you confidence that exercise is an effective treatment. It starts with the courage and bravery to ask for help.” 

Learn More About Hinge Health for Pelvic Symptom Relief

If you have pelvic pain or symptoms that are affecting your quality of life, you can get the relief you've been looking for with Hinge Health’s online exercise therapy program.

The best part: You don’t have to leave your home because our program is digital. That means you can easily get the care you need through our app, when and where it works for you.

Through our program, you’ll have access to therapeutic exercises and stretches for your condition. Additionally, you’ll have a personal care team to guide, support, and tailor our program to you.

See if you qualify for Hinge Health and confirm free coverage through your employer or benefit plan here.

This article and its contents are provided for educational and informational purposes only and do not constitute medical advice or professional services specific to you or your medical condition.

References

1. Andy, U. U., Harvie, H. S., Pahwa, A. P., Markland, A., & Arya, L. A. (2017). The relationship between fecal incontinence, constipation and defecatory symptoms in women with pelvic floor disorders. Neurourology and Urodynamics, 36(2), 495-498. doi: 10.1002/nau.22964

2. Bochenska, K., & Boller, A. M. (2016). Fecal incontinence: Epidemiology, impact, and treatment. Clinics in Colon and Rectal Surgery, 29(03), 264-270. doi: 10.1055/s-0036-1584504

3. Definition & Facts of Fecal Incontinence | NIDDK. (2017, July). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/definition-facts

4. Menees, S. B., Almario, C. V., Spiegel, B. M. R., & Chey, W. D. (2018). Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey. Gastroenterology, 154(6), 1672-1681.e3. doi:10.1053/j.gastro.2018.01.062

5. Bharucha, A. E., Rao, S. S. C., & Shin, A. S. (2017). Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 15(12), 1844–1854. doi:10.1016/j.cgh.2017.08.023