Dr Mark Wong, Senior Consultant & Director, SGH Pelvic Floor Disorder Service; Director, SGH Gastrointestinal Functional Lab shares the causes of faecal incontinence and more.
Faecal incontinence: A real-life story of dignity restored
Faecal incontinence refers to the recurrent and involuntary loss of solid or liquid stools in socially inappropriate situations. This is due to the inability to control one’s anal muscles. If left untreated or mismanaged, faecal incontinence can lead to severe skin irritation as well as depression, causing affected individuals to withdraw from their families and society.
Madam Tan (real identity withheld) is a 69-year-old grandmother who has a five-year history of progressively worsening faecal incontinence. She has well-controlled diabetes and hypertension, with two prior vaginal deliveries.
Her worsening symptoms of involuntary stool leakage have forced the fiercely independent woman to curtail much of her social life, with routine activities of daily living presenting a significant challenge. She admits to ‘toilet-mapping’, which means she carefully plans her route to ensure that there are toilets nearby at all times whenever she goes out. She also wears sanitary pads daily and severely restricts her out-of-home activities.
Physical examination revealed an otherwise healthy lady with weakened anal muscles. She was started on a high-fibre diet and anti-diarrhoeal medications to improve stool consistency, and concurrently trained on specialised pelvic floor exercises called anorectal biofeedback. Follow-up revealed encouraging results with Madam Tan reporting a gradual reduction in her ‘leaks’ over the subsequent months.
At the latest review twelve months into treatment, she felt contented for the first time in five years, as her ‘leaks’ had significantly reduced. She had gradually resumed her normal routine of shopping for groceries and other social activities. Her restored confidence even allowed her to take her first overseas trip in ten years.
While up to 60 per cent of patients with faecal incontinence can improve with conservative treatments as outlined above, the remaining 40 per cent, including those who have more severe degrees of incontinence, will require surgical modalities to achieve an optimal quality of life.
Faecal incontinence is often overlooked as a part of ageing
Based on international data, it is estimated that between 1 to 18 per cent of the adult Western population suffers from faecal incontinence, with women and the elderly being the most at risk.
In Singapore and Asia as a whole, there is little information and awareness regarding the condition. As a result, most sufferers are unaware of the available treatment options, and the resulting negative effects on their overall physical and psychosocial well-being are often overlooked.
In addition, the accompanying embarrassment and fear of social stigmatisation cause the afflicted (most of whom are elderly) to suffer in silence, setting up a vicious cycle that perpetuates the misinformed notion that faecal incontinence is simply ‘part-and-parcel’ of growing old. Consequently, sufferers are relegated to a suboptimal quality of life, when they should instead be enjoying their ‘golden years’.
Singapore has one of the most rapidly ageing populations in the world, and up to 20 per cent of our population is expected to be more than 65 years old by 2030. In a sobering report released by the Asian Development Bank, published in the Straits Times on 30 September 2011, Singapore was identified as likely to be the hardest hit by the burden of a greying population.
According to the first study on the prevalence of faecal incontinence in Singapore conducted by SGH, an estimated 4.7 per cent of the population suffers from this condition. This translates to approximately 200,000 citizens.
As the country faces an inevitable ‘silver tsunami’, there is greater impetus for the healthcare sector and government to identify and treat the affected individuals.
What causes faecal incontinence?
The most common cause is injury to the anal muscles or sphincters or the nerves supplying these structures.
In women, faecal incontinence is most commonly caused by delivery, with up to 30 per cent of first-time vaginal deliveries resulting in sphincter injury. This risk is increased with instrument-assisted delivery (e.g. forceps and vacuum-assistance), large birth weight and a prolonged second stage of labour.
In men, anal sphincter injuries are more often due to anorectal procedures including surgery for conditions such as haemorrhoids, anal fissures / fistula or colorectal cancer. Radiation treatment for conditions like prostate cancer also contributes significantly to faecal incontinence in males.
The condition can also arise following major surgery for colorectal cancer or benign conditions, in which part of or the entire rectum is removed. The problem then stems from the reduction or removal of the rectum’s storage capacity and the disruption of important nerve pathways. Function can be further worsened when chemotherapy and/or radiation are added to the treatment regimen.
Trauma to the perineum or pelvis, such as pelvic fractures after road traffic accidents or penetrating injuries, can result in significant damage to the anal sphincter and surrounding tissues. Occasionally, injuries associated with sexual assault can result in faecal incontinence.
How is faecal incontinence investigated?
A detailed medical history is taken to identify risk factors, followed by a thorough physical examination. For those over 50 years old, a colonoscopy is suggested to exclude colorectal cancer that can present with faecal incontinence.
Further specialised tests performed can include anorectal manometry (anal canal pressures are measured to identify muscle weakness and incoordination) and anorectal ultrasound (to identify tears in the muscle). Specific MRI scans may be ordered if pelvic floor weakness is suspected.
Read on to find out about the treatment options for faecal incontinence.