Fecal Incontinence in Elderly Adults: What You Need to Know

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 in elderly adults.

Healthy bowel function is controlled by three body functions:

• Rectal sensation
• The digestive system’s ability to accommodate waste
• Control of the anal sphincter muscles

Malfunction of one or more of these 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 to the rectum. In response, rectal walls stretch. This tells the brain it’s time for a bowel movement. Two anal sphincter muscles — an involuntary inner muscle and a voluntary outer seal — hold the stool in the rectum until a toilet is reached. Then a person relaxes to release the stool. If a signal is misinterpreted, the sphincter muscles are damaged, or the toilet isn’t reached in time, fecal incontinence may occur.

One or more of the following physical causes can result in fecal incontinence in the elderly:

• Nerve damage. Since our nerves let us know when it’s time for a bowel movement, damage can lead to incontinence. This damage can result 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 loose 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, which can lead to bowel leakage.
• Rectal inelasticity. Rigid rectal walls can lead to loss of storage capacity. This stiffening of the rectal walls can be due to scarring from surgery. It may also be related to radiation treatment or inflammatory bowel disease (IBD).
• Surgery. Surgeries can cause muscle and nerve damage that leads to fecal incontinence. For instance, surgical procedures to remove hemorrhoids can cause injury to the tissues. Operations around the rectum or anus can increase the risk of bowel incontinence in the elderly.
• Rectal prolapse. Prolapse means part of the rectum drops down into the anus. This is often caused by chronic straining to move the bowels. Over time, constipation and straining can lead to this condition.
• Rectocele. Similar to rectal prolapse, rectocele occurs when the rectum bulges into the vagina rather than the anus. It can lead to fecal incontinence in elderly adults. In addition, it can also cause reproductive and feminine health problems.
• Chronic laxative abuse. Overuse of laxatives can lead to FI later in life. Laxative misuse can cause a number of bowel problems, including diarrhea, gas, chronic constipation, and bowel obstruction, which are risk factors for bowel incontinence.

There are a number of different reasons why an elderly person may experience incontinence. Being aware of what has caused the problem may give seniors some idea of how to manage it. However, it’s not always possible to pinpoint a single cause.

Let our care assessment guide you

In addition to the physical causes described above, the following factors often contribute to the loss of bowel control in seniors.

• Age. Fecal incontinence can occur at any age. However, it’s more common in older adults and often worsens with age.
• Stress or fear. Adjusting to a new environment can be stressful. It can also lead to temporary loss of bowel control. Keep this in mind if your loved one experiences a change in their digestion or bowel pattern around the same time they’re navigating big life changes.
• Menopause and hormone therapy. Women who are past their childbearing years are at a higher risk of bowel incontinence. Low estrogen levels after menopause can lead to fecal incontinence, according to a 2017 study published in the journal Gastroenterology.^[01] The research also suggests that hormone replacement therapy throughout life may lead to FI in seniors.
• Physical disability. Having difficulties reaching a toilet in time can be a cause of FI. Older people may have experienced falls or have physical limitations that impair their mobility or speed.
• Dementia. Seniors in the progressing stages of Alzheimer’s Disease or other forms of dementia may have difficulty controlling their bowels. In some cases, they forget to go. Other times, the brain has trouble interpreting messages from the body that it’s time to find a bathroom. 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. This is due to injury to the muscles and nerves in the perineal area. Risk rises with the number of deliveries.

As you can see, older adults are at increased risk for fecal incontinence simply because of their age. In fact, it’s estimated that around 8% of seniors in the United States suffer from fecal incontinence.^[02]

If you or an elderly loved one is experiencing FI, talk to a doctor. Usually, a general practitioner will provide a referral 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’ll 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 asking questions, the doctor may do a physical examination. They’ll likely check for hemorrhoids, infection, or other abnormalities. They may look at the anus and perineum, the area between the anus and the genitals. Doctors may also schedule one or more of these common tests:

• Anal manometry. This test involves inserting a thin tube into the rectum. The tip has an inflatable balloon with pressure sensors. These sensors can detect sensation, strength, and response in the anus.
• Anorectal ultrasound. This ultrasound uses a wand-like instrument, called a transducer, which sends sound waves that bounce 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. It can help the doctor see if there is any prolapse. Patients must cleanse their bowels using an enema before the procedure. Then a radiologist inserts a soft paste in the rectum. The patient will then try to simulate a bowel movement while an X-ray is taken.
• Anal sphincter electromyography (EMG). This test uses a thin needle electrode to measure electrical activity around the pelvic floor and anus. It shows how the nerves and muscles are working. This helps the doctor identify any injury or nerve damage.
• Flexible sigmoidoscopy. Similar to a colonoscopy, this test uses a long, slender, flexible tube with a video camera. It can explore the rectum and lower colon for abnormalities.

The type of test needed will depend on a number of factors. A doctor will consider a patient’s symptoms and past medical history before recommending a specific test.

Talk with a Senior Living Advisor

Mild incontinence may be managed at home, but seniors with more severe symptoms can benefit from biofeedback training, prescription medication, or surgery. It’s important to note that fecal incontinence in elderly adults may have serious emotional effects. These can contribute to anxiety, depression, and even social isolation. Mental health is one reason that bowel control is so important for seniors.

At-home incontinence management

After a diagnosis, a doctor may recommend any of the following treatments and lifestyle modifications as a first step.

• Diet. Staying hydrated helps with bowel regularity. Also, eating high-fiber fruits, vegetables, and whole grains can regulate bowel movements. Water and fiber also help prevent both diarrhea and constipation.
• Kegel exercises. Pelvic floor exercises strengthen the muscles of the anus, too. In a Kegel exercise, the pelvic, gluteal, 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. For people who are unable to feel the need to defecate, scheduling several visits to the toilet throughout the day can prevent leakage and overflow.
• Increased hygiene. Cleaning fecal matter from the skin reduces odor and irritation. Regularly changing absorbent products is crucial. Keeping up on personal care and hygiene may not decrease minor FI, but it will reduce secondary discomfort.
• Over-the-counter (OTC) medicine. Doctors may suggest medicine to manage fecal incontinence. This is particularly true when incontinence is related to constipation or diarrhea. Below are some of the OTC medicines commonly used to prevent bowel incontinence.
  • Anti-diarrheal drugs, such as Imodium, Lomotil (diphenoxylate and atropine), Lotronex (alosetron), and Pepto-Bismol, prevent watery stools.
  • Laxatives like milk of magnesia relieve temporary constipation.
  • Stool softeners, such as Colace and Dulcolax, prevent stool impaction, which causes constipation.

Trying one or more of these may offer some relief. However, some cases may not respond to these treatments. For persistent incontinence, more aggressive treatments may be necessary.

Biofeedback therapy

Biofeedback exercises are a noninvasive therapy that can reduce incontinence symptoms in a large percentage of people.^[03] Through biofeedback therapy, patients learn to control body processes that are normally involuntary. Biofeedback exercises may require the assistance of a registered nurse or doctor with special training. Once learned, they can be continued at home independently.

During biofeedback therapy, a small electrode is placed in or near the anus. This sends signals to a computer. As pelvic muscles tighten and relax, an image on the screen or 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 FI. It could even eliminate symptoms in some cases. Common surgical options to discuss with a doctor include:

• Sphincteroplasty. This is the most common fecal incontinence surgery. It reconnects the ends of sphincter muscles torn by injury or childbirth.
• Artificial anal sphincter. This operation involves placing an inflatable cuff around the anus. A small pump is implanted beneath the skin, and the person can inflate or deflate the cuff to close or open the opening.^[04]
• “Nonabsorbable bulking agent” injections. Anal bulking agents such as silicone or collagen products can be injected into the anus wall. This narrows the opening so the sphincter muscles can close more easily.^[05] This is a less invasive outpatient procedure that doesn’t require general anesthesia.
• “Bowel diversion” surgery. The bottom half of the small intestine or colon is moved to a hole in the stomach. To collect stool, an external pouch, sometimes known as a colostomy bag, is placed over the opening. The bags are emptied and cleaned regularly.

It’s important to remember that surgery is often a last resort. Also, not everyone is a surgical candidate. Each patient must work with their doctor to determine the best course of treatment for their unique situation.

If your elderly family member is experiencing fecal incontinence, simple planning can help avoid complications, such as odors, accidents, and skin rashes.

• Be prepared. Always carry a bag with fresh clothing and clean-up supplies when leaving home. Prior to outings, try to identify public bathrooms in advance, and suggest using the restroom before leaving the house. Also, plan meals accordingly.
• Respect the person’s dignity. Seniors may feel embarrassed and avoid going out or participating in activities. Refer to disposable undergarments as underwear (not diapers). Fecal deodorant tablets can help reduce smells and are available over the counter or with a prescription.
• 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.
• Ask for help. If fecal incontinence is keeping your loved one isolated, affecting their relationships, or interfering with their favorite pastimes, talk to them about treatment options. Also, encourage them to see a doctor. Communication is key.

Understanding the many causes of fecal incontinence can help seniors explore lifestyle changes, medical treatments, and surgical interventions to manage their symptoms. Although discussing the topic may be difficult, open communication with family members and medical professionals can lead to solutions and greatly improve a senior’s quality of life.