Bowel leakage or fecal incontinence is a surprisingly common problem. But as common as it is, the fact that it’s also a solvable issue 90% of the time isn’t as well known. Bowel leakage affects tens of millions of Americans, and it varies a great deal in its severity. Treatments for fecal incontinence likewise vary to match the severity of a person’s experience. If you’re one of them, it’s important to understand the pros and cons of current treatments for bowel leakage.
Managing Symptoms of Bowel Leakage
The severity of bowel leakage varies considerably. Some people have an annoying leakage only when they exercise, and they later find embarrassing spots when they’re doing laundry. But for these individuals, bowel leakage doesn’t bother them beyond that. Over time, however, the problem becomes worse, and many people find themselves having to address their condition by wearing wear pads, changing undergarments often, or carrying an extra set of underwear with them. Worst of all, some people start avoiding the great things that make life fun, like visiting with other people, exercising, and attending events. If it’s severe, the skin around the anal area can become seriously chafed and damaged, leading to fungal or bacterial infections.
Changes to Diet
The solutions start with changes in diet, home exercises, oral medications, ointment for the skin, and fiber. The reason we start there is that loose consistency stools or diarrhea can be very hard for anyone to control. With loose or liquid bowel consistency, lots of people will have little or no warning time to get to the bathroom. That same person, however, has plenty of warning time to get to the bathroom if the stools are firmer. The strategy is to figure out what change in your diet can be made for firmer stools.
For some people, it’s identifying certain foods that cause diarrhea. A common example is dairy products for a person who doesn’t realize they are lactose intolerant. The first place to start is by keeping a food journal for a couple of weeks and writing down the bowel movements of that day along with the consistency of the stools. You should also note if there was an accident or leakage.
Hardening the stools can sometimes occur with diet or by adding powdered fiber in the form of Citrucel or similar products. An important thing to remember here is that no two people are quite alike. I always advise my patients to consider this an experiment for a few weeks.
Step two is the use of common medications to firm up the stools: Imodium (loperamide) and Lomotil. These are often helpful and usually something to at least try for a few weeks. But every medication can have side effects. Imodium binds to a type of opioid receptor in the intestines, slowing down the muscle contractions of the intestines. Some people experience dizziness or drowsiness, constipation, dry mouth or fatigue. Lomotil has two active ingredients, and one of them is in a class of drugs that you’ll hear more about if you see my other articles, posts, or videos about continence. This class of drugs, called anticholinergics, has a lot of side effects, especially in older people. The side effects include dry mouth, constipation, dry mucous membranes everywhere including dry eyes, and difficulty emptying the bladder. Worst of all, in older people these drugs cause confusion, memory loss, and depression. We try to avoid these drugs in people over, say, 50 years of age for that reason.
Exercises to strengthen the anal sphincters and pelvic floor have been shown to help somewhat. These can be done at home with Kegel exercises, along with exercises such as squats and kneeling leg lifts. There are online tutorials, and there are more formal training sessions with a therapist that can also help.
Biofeedback is a form of exercise in which additional information is gained based on monitoring the muscle activity to help the person better engage the pelvic floor and sphincter muscles. We try to encourage every patient to use these techniques and modalities, and our experience has been that they are helpful as an adjunct therapy but are rarely sufficient as a standalone treatment.
Most people consult us after the first-tier methods of diet, fiber, exercises and anti-diarrheal medication have not worked. And here’s the good news – because of better treatments, today we can still almost always solve, or dramatically mitigate, the problem of bowel leakage.
Sacral Nerve Modulation
The number one most effective treatment for fecal incontinence, and probably the best-kept secret in all of medicine, is sacral nerve modulation (SNM). This therapy has been evolving for 25 or 30 years and was the brainchild of bioengineers who thought they could replicate the amazing success of cardiac pacemakers by making a “pacemaker“ for the pelvic floor and sphincter muscles. It turns out that they were 100% correct. The same idea of restoring the transmission lines, or nerve signals, to the pelvic floor muscles and sphincters of the rectum and bladder causes correction of the leakage and accidents. This treatment is very much like the placement of a pacemaker, meaning that it is today a minor procedure performed with local anesthetic.
SNM is at least 90% successful in resolving bowel leakage. Medicare and virtually every insurance plan covers it, and the tiny device is placed under the skin in 45 minutes with a single Band-aid. The newest devices have a battery life of a whopping 15 years.
Another treatment includes the use of a viscous filler material, or bulking agent, injected directly into the tissues of the anal sphincter. Several years ago, the FDA approved a specially designed dextranomer filler material called Solesta, and the treatment works moderately well. The injection is performed in the office, and surprisingly, it’s not usually painful. This treatment usually does not complete solve the problem all by itself, although for some people it does. The substance is inert and not thought to cause any harm, but the body does eventually dissolve it over time, usually anywhere from six months to two years. There are rare reported cases of infection, but it’s a pretty benign therapy.
Lastly, there is reconstructive surgery. Amazingly, during my career, surgery to reconstruct the anal sphincters has become rare in treating fecal incontinence, mainly because sacral nerve modulation works so well. Twenty years ago, it was not uncommon for a person to undergo a complex procedure and then work on rehab for months. Today, that is very rarely necessary.
As you can imagine, this type of surgery is quite painful, and recovery can be very slow. Wound complications are common. It has been a tremendous improvement to have sacral nerve modulation as an alternative option, because it often eliminates the need for this type of reconstructive surgery.
It must also be said that there are patients for whom no solution provides an answer and for whom the only good answer is to create a colostomy. This surgery brings the large intestine out to the skin of the abdominal wall and a pouch is worn under one’s clothes. Today, that’s a last resort and rarely needed. Some cases of severe cancers and radiation still require a colostomy, but far fewer than in years past.
In summary, the treatments for bowel leakage have become simpler, safer, easier, less invasive, and much more effective in recent years. For most people, diet, exercises, and anti-diarrheal medications are the first steps. If those don’t solve the bowel leakage problem, then the most effective treatment is sacral nerve modulation. The Continence Center here at Sasse Surgical in Reno, Nevada, can answer all of your questions about this treatment and whether you’d be a good candidate. Contact us today to learn more. There’s no reason to endure fecal incontinence any longer.