How does retention work and what is broken?
At rest, the lumen of the anus is closed by the internal sphincter, which works independently of consciousness. We control the external sphincter and pelvic floor muscles voluntarily and can hold the contents until the appropriate moment. The rectum plays the role of a reservoir, and its mucous membrane distinguishes gas, liquid and solid stool. Incontinence occurs when muscle damage, loss of sensation, decreased bowel compliance after surgery and radiation, or simply when stool is too loose and difficult for even healthy muscles to hold.
- Damage to the external or internal sphincter
- Nervous regulation disorder
- Decreased reservoir function of the rectum
- Loose stools and urgency
- Fullness of the rectum due to chronic constipation
- Pelvic organ prolapse and rectal prolapse
Causes and risk factors
In women, the leading cause remains obstetric trauma: third- and fourth-degree perineal ruptures, forceps, large fetus. Such an injury may not appear immediately, but over the years, when age-related muscle weakening is added. In men, operations for fistulas, hemorrhoids and fissures are more often important. A separate group is neurological causes: diabetic neuropathy, stroke, multiple sclerosis, spinal injuries. Often it all starts with banal chronic constipation in an elderly person, when liquid contents leak around the fecal plug.
- Perineal lacerations during childbirth, obstetric forceps
- Operations on the anus and rectum
- Age-related weakening of the pelvic floor muscles
- Diabetes mellitus and neuropathy
- Stroke, multiple sclerosis, spinal cord injury
- Chronic diarrhea, inflammatory bowel disease
- Constipation with fecal impaction and paradoxical leakage
Symptoms and degrees
Manifestations vary in severity: from the inability to hold in gases and traces of feces on underwear to complete loss of control over bowel movements. Many people describe urgency as having to run to the toilet in seconds, which limits travel, work and socializing. Perineal skin irritation, itching and diaper rash are often associated. People hide the problem for years and do not see a doctor, although early treatment gives the best treatment results.
- Gas incontinence
- Soiling of laundry, smudging
- Leakage of liquid stool
- Failure to retain a formed stool
- Sudden imperative urges
- Irritation and itching of the skin of the perineum
Diagnostics
The proctologist asks in detail about the nature and frequency of episodes, stool consistency, childbirth and previous operations; it is useful to keep a stool diary. During the examination, the condition of the perineum, reflexes, sphincter tone and the strength of its voluntary compression are assessed. Next, endorectal ultrasound is used to look for muscle defects and anorectal manometry to assess pressure and sensitivity. A colonoscopy is needed to rule out tumors, inflammatory bowel disease, and other causes of diarrhea.
- Examination and digital rectal examination
- Anoscopy and sigmoidoscopy
- Endorectal ultrasound of the sphincter
- Anorectal manometry
- Colonoscopy for diarrhea and blood in stool
- Coprogram and tests to find the cause of diarrhea
Treatment and rehabilitation
They start with the simplest and most effective thing - giving the stool the desired consistency: dietary fiber, diet, and, if necessary, drugs that slow down the intestines, as prescribed by the doctor. The second mandatory component is training the pelvic floor muscles, preferably under the supervision of a specialist and using biofeedback. They form the habit of having bowel movements at the same time, and in case of fecal impaction, they cleanse the intestines. If a sphincter defect is identified, its surgical restoration is discussed. There are also neuromodulation methods.
- Regulating stool consistency and diet
- Exercises for the pelvic floor muscles
- Biofeedback training
- Treating diarrhea or constipation as the underlying cause
- Surgical restoration of the sphincter after injury
- Perineal skin care and protection