Fecal incontinence

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Fecal incontinence ( Latin: Incontinentia alvi , also called bowel incontinence , anorectal incontinence or anal incontinence ) is the inability to hold back one's stool or winds at will. It affects people of all ages, but is more common in the elderly. The psychological stress associated with the symptoms is enormous; see Psychosocial Aspects of Fecal Incontinence . The organ responsible for stool continence is the continence organ .

The related problem in children is called encopresis .

causes

The causes of fecal incontinence can be diverse and several factors must come together to trigger fecal incontinence. If only one of the mechanisms for controlling defecation fails, this is usually compensated for by so-called compensation mechanisms. In addition, subjective impressions play a role. The following causes can trigger fecal incontinence:

Impulse processing disruption:
Interruption of pulse transmission:
Sensory disorder:
  • Hemorrhoids (protrusion of extensive hemorrhoids outward with loss of sensitive perception)
  • Diarrhea
  • Rectal prolapse (eversion of the intestinal mucosa outwards with loss of sensitive perception)
  • Inflammation of the colon ( colitis )
Muscular disorder:
Medication:
  • Psychotropic drugs
  • Laxatives in high doses (e.g. paraffin)
Mental / psychiatric disorder:
  • Relapse into infant behavior ( psychosis )
  • Conflicts with caregivers

Frequency and severity

After all, about 1 to 3 percent of the population suffer from faecal incontinence, in the Federal Republic of Germany at least 800,000 people. All cohorts are affected by this, but the frequency increases sharply with age. Whether the prevalence is women or men is controversial and depends heavily on the definition of fecal incontinence. If only stool loss is taken into account, a higher prevalence can be found in women. If soiling (stool smearing) is included, men are more affected due to their longer anal canal.

There are different classifications of fecal incontinence. Park's simple clinical classification of faecal incontinence into three grades is most commonly used:

Grade 1: Light form
  • Uncontrolled departure of winches
Grade 2: Medium form
  • Uncontrolled discharge of thin stool
Grade 3: Severe form
  • Uncontrolled discharge of formed stool

The frequency of stool losses and the patient's quality of life are not taken into account in this classification. There are other classifications for this. However, completely different manifestations of faecal incontinence can have the same total score, which limits the meaningfulness of the classifications.

Forms of fecal incontinence

There are different types of fecal incontinence. In many cases, several of the factors come together and form the clinical picture of faecal incontinence. Incontinence can be both congenital and acquired.

Faecal incontinence due to rectal coprostasis or constipation is triggered by the length of time the stool remains in the large intestine and especially in the rectal ampoule. Due to the high absorptive capacity of the colon mucous membrane, so much fluid is withdrawn from the stool that the stool thickens in individual segments and this can result in fecal stones . The resulting mechanical obstacle to passage leads to the development of a stool impaction, a clinically relevant disease that requires treatment. The main location of stool impaction is the rectum. However, stool impactions are possible throughout the colon. The full picture of a coprostasis is given when the passage path is largely blocked by the accumulation of the stool mass and spontaneous emptying is no longer possible.

Above the relevant large intestinal stenosis, secretory processes are activated with the body attempting to functionally bypass the obstacle to passage by liquefying the stool. The stool that is liquid on the bottom of this mechanism passes the mechanical obstacle and is mistakenly classified as diarrhea. A situation that can be detrimental for the patient in the anamnesis .

Incontinence due to impaired rectal memory function . The storage function of the rectal ampoule can also be disrupted after operations. In rectal cancer surgery, more and more sphincter-preserving operations have been introduced, which allow the intestine to be reconnected to the internal sphincter opening after the tumor has been removed, but scarring in the area and the lack of the special expansion of the rectal ampoule lead to frequent bowel movements and to incontinence. Chronic inflammatory bowel diseases ( Crohn's disease , ulcerative colitis ), which lead to changes in the rectal wall over the years, can also be the cause of a loss of storage function.

A sensory fecal incontinence occurs when the sensitive perception of the mucous membrane is disturbed the anal canal. This can be the case, for example, with neurological diseases, such as unconsciousness or a stroke , but also when the mucous membrane of the anal canal is turned outwards, such as in the case of an anal or rectal prolapse, and thus loses perceptual sensitivity. If the anal canal is not created in the case of anal atresia, or if corrective operations using the pull-through procedure result in partial or complete loss of the anal mucosa, there is also a lack of sensitive perception, so that in turn the clinical picture of sensory fecal incontinence results.

In the case of muscular faecal incontinence , the anal sphincter is damaged, the sensitive perception through the anal canal mucous membrane is intact. The most common cause of damage to the sphincter apparatus is vaginal delivery with a tear in the perineum . Impaling injuries (climbing over sharp fences) are also common among children. Furthermore, complex damage can result from insufficient functionality of the pelvic floor muscles in what is known as pelvic floor insufficiency. The combination with rectal prolapse is often found here, especially in older women. But also fistulas and fistula operations, especially in the case of high-reaching ischio-rectal fistulas, can result in partial or complete destruction of the circular muscle (sphincter ani internus). Scarred healing of the defect does not lead to a complete loss of sphincter strength, but the expansion of the sphincter muscle reduces the strength. In old age, faecal incontinence can develop when the tissue elasticity decreases.

The combination of sensory and muscular fecal incontinence can best be illustrated using the example of rectal prolapse. If the rectal wall slides through the muscular sphincter, this leads to a loss of perceptual sensitivity and to permanent overstretching of the sphincter due to the prolapsed part of the intestine, so that its function gradually becomes weaker.

In neurogenic fecal incontinence , the cause of the functional disorder is mostly cerebral: stroke, metastases / tumor, dementia or degenerative diseases; or spinal: multiple sclerosis , metastases / tumor , degenerative diseases, cauda equina syndrome (squeezing of the horseshoe-shaped nerve fiber bundle at the end of the spinal cord), peripheral neuropathy (nerve damage), spinal cord dizziness, spina bifida (cleft formation in the lower spine).

Investigations

At the beginning of the diagnosis of faecal incontinence there is a detailed anamnesis, with which the beginning of the complaint, the frequency of the stool, the condition of the stool, the circumstances of the involuntary stool, but also existing systemic diseases, previous therapies, the number and course of births, operations, etc. are recorded.

This is followed by the inspection of the anal region, in which z. B. irritations, inflammatory or ulcerative changes in the perianal skin, fissures , scars, hemorrhoids or fistulas can be detected. The following rectal-digital examination in the left-side position enables, among other things, a reliable assessment of the sphincter anatomy and, when the pinching pressure is released, an assessment of the closing force of the sphincter.

These examinations are supplemented by manometric examinations such as draft manometry or measurement of the filling pressure values. In addition, a proctoscopy and a rectoscopy are performed on the left side. The examinations are usually painless, but are occasionally found to be uncomfortable because they involve privacy. Sphincter manometry and anal ultrasound are often required. The examinations are then listed again here.

  • Proctological examination with the finger and anuscopy / proctoscopy
  • Intestinal examination with rectoscopy and colonoscopy
  • Pressure measurement of the anal occlusion apparatus at rest and when pinching
  • Measurement of the muscles' ability to pinch and the duration of the hold
  • Electromyography of muscles to delineate nerve damage
  • Ultrasound examination of the anus to delimit injuries, severing of the sphincter muscles and the pelvic floor muscles.
  • X-ray examination of the rectum (defecography)
  • If necessary, X-ray examination of the large intestine ( colon contrast enema )
  • Examination of stool holding ability and emptying behavior
  • Computed tomography of the sphincters

therapy

The cause is critical to the treatment of fecal incontinence, such as: B. inflammation of the bowel is often treated with drugs. Through operations you can z. B. ablate tumors, eliminate a prolapse of the mucous membrane or intestinal wall, tighten the pelvic floor , repair damage to the sphincter or use an artificial sphincter.

A newer method is the " sacral nerve stimulation ". The basic idea of ​​the procedure is based on the principle of the pacemaker and was first used by urologists for the treatment of urinary incontinence. Here, electrical impulses from a pacemaker unit stimulate the nerve plexus in front of the sacrum (os sacrum) via electrodes that are inserted through a puncture under fluoroscopic control. Originally it was assumed that this would stimulate the nerves of the sphincter muscle and thus regain sufficient muscle strength. Today we know that there is also an influence on perception, primarily by generating an increased level of activity in the sacral plexus. The procedure is particularly suitable for neurologically caused incontinence. The best way to predict the chances of success is by means of a test stimulation, in which the pacemaker is not initially implanted but worn on the belt. In recent years, experience has shown that effects similar to those achieved with sacral nerve stimulation can also be achieved by stimulating nerves in the leg (tibial nerve , peripheral tibial nerve stimulation, PTNS ), which is performed according to a special treatment protocol as part of outpatient treatments in in practice. Non-invasive, even non-contact, stimulation of the pelvic floor (Levator Ani) and the sphincter muscle (Sphincter Ani) can be achieved by magnetic stimulation ( Extracorporeal Magnetic Innervation, ExMI ). The patient sits fully clothed in an armchair and goes through a 20-minute training program.

With physiotherapy you can strengthen the muscles in the pelvic floor, e.g. B. by pinching the sphincter several times a day or with the help of electrical stimulation. For pain around the anus , ointments with zinc or cod liver oil help.

The consistency of the stool can be influenced by medication in such a way that unexpected bowel movements are not to be expected. So you give z. B. Laxatives in the form of suppositories or enemas to empty the bowel at a specific time. With dietary fiber such as B. Indian flea seeds and drugs that inhibit intestinal motor skills such. B. loperamide or tincture of opium can also improve continence.

Toilet training for fecal incontinence is basically carried out in a similar way to urinary incontinence . The only difference is that the patient only tries to defecate once a day and always at the same time. At the beginning, the stool evacuation can be supported with the help of purgative suppositories, whereby the first few weeks suppositories with bisacodyl (e.g. Dulcolax) are used and if successful, suppositories with glycerine (e.g. Glycilax) are used. After 2 to 3 weeks, the first should Auslassversuch without Abführzäpfchen be carried out, since by then the intestinal mostly to the regularity of bowel movements have become accustomed. It is also helpful here to keep a stool diary, which is kept similar to the micturition log . Words of appreciation from the nursing staff have a positive influence on the success of toilet training.

Incontinence care

There are a lot of incontinence aids available these days that can help alleviate the inconvenience of everyday life. So are z. B. diapers , anal tampons and irrigation are available to restore part of the quality of life to those affected and enable them to lead an almost normal life. The affected persons should already be provided with appropriate incontinence aids during the diagnosis and treatment; the selection of the suitable incontinence aid is of particular importance. The provision of suitable aids is particularly important for patients who have no prospect of improvement or cure for their incontinence.

Criteria for the selection of incontinence aids:
  • How much security should be given?
  • What type of incontinence (urinary and / or fecal incontinence) is present?
  • What is the amount and nature of the excretion?
  • When does incontinence occur (e.g. only at night)?
  • How is the mobility of the person concerned?
  • Is the person concerned able to provide incontinence care by themselves based on their mental and physical condition?
  • What is the skin quality of the person affected?
Requirements for incontinence care:
  • As tight as possible against excretions and odors
  • Low-noise and optically inconspicuous aid
  • Skin-friendly material
  • Pick up excretions safely
  • Maintain the independence of the person concerned as much as possible (easy handling)
Absorbent incontinence aids:
Other incontinence aids:

Psychosocial aspects of fecal incontinence

Although it is a widespread condition, especially among older people, there are also younger people who are affected by the symptoms. It is all the more regrettable that faecal incontinence is still a taboo subject in public that nobody likes to talk about. The uncontrolled departure of winds or chairs and the smells and noises associated with them are extremely embarrassing for everyone involved and filled with shame and disgust. The negative feelings are intensified by the fact that the symptoms signal a clear loss of control and the affected person feels thrown back to an early stage of their development, which corresponds to that of a small child who is not yet “clean”.

While in the area of urinary incontinence a slight loosening of the social approach to the topic can be observed today (for example, corresponding aids are advertised much more openly than in previous decades), such a taboo has not yet been removed in the area of ​​fecal incontinence.

If someone becomes incontinent, his life changes dramatically. Feelings of embarrassment and shame lead to the fact that the disease is often kept secret for as long as possible. Many patients do not even confide in their doctor because they do not dare to speak openly about stool-smeared underwear or defecation. One can therefore assume a high number of unreported cases.

A study by the University of Landau provides the first clues about the various stresses and impairments of stool incontinent people.

Keeping secret and hiding leads to the fact that many incontinent people live in constant fear of being discovered. Self-confidence and self-esteem are damaged, often resulting in insecurity, anxiety and depression, but also grief, anger and anger about one's own fate. The result is that many of those affected withdraw from their environment, isolate themselves, limit their social contacts and avoid going out of the house.

The psychological stress is increased when the social environment reacts negatively. It may well happen that even close family members and good friends withdraw, not because they no longer like the person who has become incontinent, but because they are insecure, overwhelmed and unable to cope with the problem.

Fecal incontinence also puts a relationship, partnership or marriage to the test - especially if it is not possible to communicate openly. Here the area of ​​sexuality plays a particularly important role. Fears of losing stool during sexual intercourse and uncertainties about how the partner would react to it often lead to a complete cessation of sex life.

In summary, it can be said that the psychosocial stresses of stool incontinent people can be very diverse and impairing. The lives of many become empty and monotonous, desolate and empty of content. And yet people succeed time and again in breaking the vicious circle, accepting incontinence and regaining their zest for life, so that the question arises as to how one can learn to live with fecal incontinence. The following aspects play a central role:

  1. Early clarification of causes and treatment options by a specialist;
  2. Info about and search for suitable reliable continence remedies;
  3. Good planning and preparation of leisure activities and travel;
  4. Appropriate design of the apartment;
  5. Find people to talk to about incontinence and the stress it brings;
  6. Looking for ways of being able to live a fulfilled relationship and sexuality despite incontinence;
  7. Use supportive offers (self-help groups, psychological counseling / therapy, relaxation training);
  8. Clarification of the assumption of the costs for therapeutic measures and aids by insurance carriers.

The main goal of future activities should be to increase the wellbeing and quality of life of stool incontinent persons and their relatives through education, information and advice, but also to support medical and nursing staff in their work.

Affected patients can receive help from the Deutsche Kontinenz Gesellschaft eV, a non-profit patient self-help association. Founded in 1987, it represents a forum for interdisciplinary and interprofessional collaboration in the care of all incontinence patients.

See also

literature

  • A. Herold, B. Sprockamp, ​​GE Dlugosch: Fecal incontinence - The counselor . Weingärtner Verlag, Berlin 2005, ISBN 3-9804810-4-2 .
  • Michael Probst, Helen Pages, Jürgen F. Riemann , Axel Eickhoff, Franz Raulf, Gerd Kolbert: Fecal incontinence . In: Dtsch Arztebl Int . No. 107 (34-35) , 2010, pp. 596-601 ( Article ).

Web links

Individual evidence

  1. ^ Amy L. Halverson: Nonoperative management of fecal incontinence . In: Clinics in Colon and Rectal Surgery . tape 18 , no. 1 , February 2005, ISSN  1530-9681 , p. 17-21 , doi : 10.1055 / s-2005-864077 , PMID 20011335 , PMC 2780124 (free full text).
  2. ↑ Vanessa C. Costilla, Amy E. Foxx-Orenstein, Anita P. Mayer, Michael D. Crowell: Office-based management of fecal incontinence . In: Gastroenterology & Hepatology . tape 9 , no. 7 , July 2013, ISSN  1554-7914 , p. 423-433 , PMID 23935551 , PMC 3736779 (free full text).
  3. ↑ Arzu Ilce: Fecal Incontinence . In: Fecal Incontinence - Causes, Management and Outcome . InTech, 2014, ISBN 978-953-511-241-9 , doi : 10.5772 / 57502 ( intechopen.com [accessed November 21, 2019]).
  4. ↑ Home :: German Continence Society. Retrieved November 21, 2019 .