Faecal Incontinence

In simple terms, faecal incontinence is the involuntary or accidental loss of solid or liquid stool, or gas (wind).

This loss of control can range widely:

• Mild: Occasional leakage or staining of underwear, often only involving gas or liquid stool.
• Severe: Complete inability to control the urge to pass stool, leading to significant loss of formed stool.

It’s important to understand that bowel control is a complex process involving strong muscles around the anus (sphincters), healthy nerves that send messages to the brain, and a rectum (the end of the large intestine) that can stretch and hold waste until it is time to go to the toilet. When any part of this system is damaged or stops working correctly, incontinence can occur.

Incidence and Epidemiology in Singapore

Faecal incontinence is often considered a "silent affliction" in Asia, meaning many people do not report it due to embarrassment. This makes getting exact figures challenging, but research shows it is a significant concern, especially as Singapore’s population ages.

• Prevalence: A cross-sectional study conducted in Singapore found that the overall prevalence of faecal incontinence in the local adult population was around 4.7%. While this might seem low, it translates to a substantial number of citizens affected.
• Risk Groups: Like global trends, the risk of developing FI in Singapore is significantly associated with:
  • Increasing Age: As we get older, muscles naturally weaken, and the nerves can become less responsive.
  • Female Gender: Women are found to be three times more likely to suffer from FI than men, largely due to childbirth-related injuries.
• The Ageing Challenge: Given that Singapore has a rapidly ageing population, the number of people requiring specialist treatment for FI is projected to rise, making public awareness and early intervention critical.

FI is not a single disease, but a symptom caused by underlying issues. The main culprits usually fall into four categories: 

If you seek help, your doctor will first have a detailed discussion about your symptoms, diet, and medical history. Depending on the severity and suspected cause, they may recommend specialized tests:

• Physical Examination: A doctor performs an internal examination to assess the strength of the anal sphincter muscles and check for physical abnormalities, like rectal prolapse (where the rectum drops down).
• Anorectal Manometry: This test uses a small, flexible tube with a balloon and pressure sensors to measure the strength of the anal sphincter muscles and the sensitivity of the rectum. It checks how well the nerves and muscles work together.
• Endoanal Ultrasound: An ultrasound probe is gently inserted into the anal canal to create detailed pictures of the sphincter muscles. This is the gold standard for identifying tears or defects in the muscles, particularly those resulting from childbirth.
• Defecography: a special type of X-ray or MRI scan to look at the position and movement of the pelvic organs (rectum, uterus and bladder) during the process of defecation.

The good news is that most cases of faecal incontinence can be successfully treated or significantly managed, often without surgery. Treatment plans are tailored to the specific cause and severity.

Conservative (First-Line) Treatments

1. Dietary and Lifestyle Changes:
   • Stool Consistency: Adjusting fibre and fluid intake to achieve a soft, formed stool that is easy to pass and easier to hold.
   • Trigger Avoidance: Identifying and avoiding foods or drinks that cause diarrhoea (e.g., excess caffeine, dairy if lactose intolerant, or artificial sweeteners).
2. Medications:
   • Anti-Diarrhoeals: Drugs like Loperamide can slow down the gut and firm up stools.
   • Laxatives or Fibre Supplements: Used if constipation or overflow incontinence is the cause.
3. Bowel Retraining: Establishing a regular schedule for going to the toilet (e.g., after breakfast) to train the body to empty the bowels predictably.
4. Pelvic Floor Physical Therapy & Biofeedback:
   • Pelvic Floor Exercises (Kegels): These exercises help strengthen the muscles that support the rectum and control the anus.
   • Biofeedback: A specialized form of physical therapy where sensors are used to give you visual or audio feedback on your sphincter muscle contractions. This helps you learn how to correctly identify and strengthen these muscles.

Advanced and Surgical Treatments

If conservative methods fail, your specialist may consider:

• Nerve Stimulation:
  • Sacral Neuro-Modulation (SNM): A small device is implanted near the tailbone that sends mild electrical pulses to the nerves that control the bowel and sphincter. This can greatly improve bowel control and awareness.
• Transanal Irrigation (TAI): This involves flushing the large bowel with water using a tube inserted into the rectum. This helps empty the bowels completely and predictably, reducing the chance of leakage between sessions.
• Rectal Prolapse Surgery: If rectal prolapse is found to be the main cause for faecal incontinence, surgical options such as a Delorme's procedure or Rectopexy may be offered to straighten or pull up the rectum to restore its original position.
• Sphincteroplasty: Surgical repair of a torn sphincter muscle, most often performed for damage caused by childbirth.
• Faecal Management Systems: Devices like specialised rectal drainage tubes (such as the Flexiseal system) can be used for temporary management in specific patient groups to safely contain and divert stool output.
• Colostomy: This is an option for severe cases where other treatments have failed. A colostomy creates an opening in the abdomen to divert stool into a bag, providing complete control over bowel management.

The Multidisciplinary Approach: Treating the Pelvic Floor

Faecal incontinence rarely happens in isolation. It is often linked to other Pelvic Floor Disorders, such as Urinary Incontinence or Pelvic Organ Prolapse (where organs like the uterus or rectum slip from their normal position).

Because of this interconnectedness, treatment often requires a coordinated multidisciplinary approach, involving several specialists working together for a holistic plan:

• Colorectal Surgeon or Gastroenterologist: Leads the diagnosis, performs investigations (manometry, ultrasound), and manages surgical options.
• Urologist / Urogynaecologist: Specializes in urinary incontinence and pelvic organ prolapse, treating issues that overlap with FI.
• Pelvic Floor Physiotherapist: Provides essential biofeedback and targeted exercises to strengthen and re-coordinate the pelvic floor muscles.
• Dietitian: Advises on fibre, fluid, and dietary changes to optimize stool consistency.
• Nurse Continence Specialist: Offers support, practical advice on managing hygiene, and training for bowel retraining programmes.

By treating the entire pelvic floor system, not just the single symptom of faecal incontinence, patients receive the most comprehensive and effective care possible.