The media frequently cover urinary incontinence. What doesn't get reported on is the other type of incontinence—even though it affects nearly 18 million American adults.

The inability to control bowel movements, known as bowel incontinence, is more common in older adults (over age 65), but it can affect adults of all ages. It is both uncomfortable and embarrassing-so much so that many people never discuss it with their doctors. Too often, those who do ask for help are told that it's just a natural part of getting older." The fact is, there is nothing natural about bowel incontinence. Fortunately, it's always caused by an underlying, and usually treatable, problem.

What Goes Wrong

You should see your primary care physician or a gastroenterologist if you're having difficulty controlling your bowel movements. No one should have trouble "holding" his/her bowel movements except in unusual situations, such as when you have diarrhea. Main causes…

  • Constipation. Paradoxically, this is a common cause of bowel incontinence.

Here's why: Patients who are frequently constipated may develop an impaction, the accumulation of stool inside the rectum. Impacted stool can stretch the rectum, leading to seepage of liquid stool and creating overflow incontinence.

  • Weak pelvic floor. The pelvic floor muscles control bowel movements and urination. These muscles tend to get weaker with age, particularly in those who typically strain to have a bowel movement. Pregnancy and childbirth also can weaken or harm these muscles.
  • Damage to the rectum. This is generally a side effect of medical treatments.

Example: Men who have had radiation for prostate cancer may develop rectal scarring, which reduces the amount of stool that the rectum can hold and diminishes its ability to stretch. Decreased capacity to store stool leads to urgency. Inflammatory bowel diseases such as Crohn's disease can have similar effects.

  • Damage to the anal sphincters (rings of muscle that control bowel movements) also can be involved. In men, this damage sometimes occurs during prostate women, it may be caused by childbirth, particularly when the birth requires an episiotomy (creating a surgical incision to enlarge the vaginal opening) or the use of forceps. Hemorrhoids can prevent the anal sphincters from completely closing.
  • Nerve damage. Nerve damage can reduce your ability to tighten the sphincters-or even to sense when stool is about to come out. Nerve damage can result from diabetes, diseases such as multiple sclerosis or

a lifetime of straining during bowel movements.

For Better Control

It is difficult for someone with bowel incontinence to determine the cause, so it is crucial to seek medical treatment.

When you see a doctor for bowel incontinence, it's important to receive a digital rectal exam. It is among the most effective ways to identify possible causes. For example, your doctor may feel a stool impaction or weakness in the sphincter muscles.

Doctors who don't perform a digital exam are more likely to depend on tests that may not be necessary, such as rectal sonograms or anal manometry, in which a narrow tube with a small balloon at the tip is inserted into the rectum to measure the sensitivity and function of the rectum and anus.

Some patients with bowel incontinence require surgery, such as repair of the anal sphincter muscles, but the majority do not.

Best treatments…

  • Removal of excess stool. This is sometimes the only treatment needed if impacted stool is causing the problem. The doctor will use his gloved fingers to break apart and remove the excess stool. This is followed by an enema and then a laxative to fully empty the colon, which can be done at home or in the doctor's office. Some bowel incontinence patients recover completely after the treatment, but only if they have regular bowel movements every day or every other day-or, when necessary, with additional enemas or laxatives.
  • Laxatives. Doctors used to discourage patients from using stimulant laxatives, such as bisacody (Dulcolax) or senna extracts. However, recent research shows that these products are not as harmful to the colon as previously believed. They can prevent stool impaction as well as constipation. You can use them daily or every other day, depending on your doctor's advice. If you prefer, you can try a bulk laxative, such as psyllium (Metamucil).
  • Moderate fiber intake. In my experience, patients with rectal damage-for example, from radiation or inflammatory bowel disease-often do better when they consume less dietary fiber. That's because fiber increases the amount of stool that's produced. This is helpful for healthy adults, but it may not be so for people with bowel incontinence.

Because people vary in how they react to dietary fiber, it's wise to ask your doctor whether you should be on a low-or high-fiber diet.

  • Habit training. This is a behavioral approach for patients with poor sphincter control or for those who can't feel when a bowel movement is imminent. Patients are instructed to go to the toilet at specific times-for example, 15 to 30 minutes after breakfast or right after drinking a cup of coffee.

The goal is to establish a regular routine so that you work with your body's natural rhythms and bowel movements become more predictable.

  • Medication. Loperamide (Imodium) is an antidiarrheal medication that can help if your stools tend to be loose or watery. It slows the passage of stools and makes them firmer and less likely to leak out.

Loperamide works best when it's taken before you have problems. Someone who tends to have accidents in the morning, for example, should take the medication an hour before breakfast. You can also take it to prevent problems when you won't have easy access to a bathroom. Ask your doctor about the best times to take it. Side effects are rare but can include constipation.

Helpful: Patients with minor leakage due to anal sphincter weakness can insert a cotton ball, twisted into a "tampon" shape, into the anal opening. It's less expensive than pads or adult diapers-and, if your accidents involve only a little leakage, just as effective.

Also helpful: If sphincter muscles are weak, you can strengthen them by performing anal Kegel exercises-tighten and release muscles several times a day.

Breakthrough Approach

Approved by the FDA in 2011, InterStim Therapy is effective for patients with severe bowel incontinence (or urinary incontinence) caused by muscle damage that can't be corrected surgically.

How it works: Surgically implanted electrodes stimulate the sacral nerves where they exit the spinal cord. These nerves activate the pelvic floor and sphincter muscles. Delivering electricity to these nerves helps them function properly.

Patients who are candidates for InterStim are first given a temporary device. If it's effective, a permanent, stopwatch-sized power pack is implanted under the skin in the lower back.

Recent finding: A study published in Diseases of the Colon & Rectum found that 86% of patients who used InterStim had at least 50% fewer bowel incontinence episodes. Forty percent had total remission of bowel incontinence.

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