Bowel Elimination

Objectives

• Discuss the role of gastrointestinal organs in digestion and elimination.

• Describe three functions of the large intestine.

• Explain the physiological aspects of normal defecation.

• Discuss psychological and physiological factors that influence the elimination process.

• Describe common physiological alterations in elimination.

• Assess a patient’s elimination pattern.

• List nursing diagnoses related to alterations in elimination.

• Describe nursing implications for common diagnostic examinations of the gastrointestinal tract.

• List nursing interventions that promote normal elimination.

• List nursing interventions included in bowel training.

• Discuss nursing care measures required for patients with a bowel diversion.
• Use critical thinking in the provision of care to patients with alterations in bowel elimination.

Key Terms

Bowel training, p. 1110

Cathartics, p. 1091

Clostridium difficile, p. 1092

Colostomy, p. 1093

Constipation, p. 1091

Diarrhea, p. 1092

Effluent, p. 1109

Endoscopy, p. 1091

Enema, p. 1107

Fecal occult blood test (FOBT), p. 1099

Flatulence, p. 1092
Hemorrhoids, p. 1092

Ileostomy, p. 1093

Impaction, p. 1091

Incontinence, p. 1092

Laxatives, p. 1091

Paralytic ileus, p. 1091

Polyps, p. 1094

Stoma, p. 1093

Valsalva maneuver, p. 1089

Wound ostomy continence nurse (WOCN), p. 1109

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Regular elimination of bowel waste products is essential for normal body functioning. Alterations in
bowel elimination are often early signs or symptoms of problems within either the gastrointestinal (GI)
or other body systems. Because bowel function depends on the balance of several factors, elimination
patterns and habits vary among individuals.

Understanding normal bowel elimination and factors that promote, impede, or cause alterations in
elimination help manage patients’ elimination problems. Supportive nursing care respects the patient’s
privacy and emotional needs. Measures designed to promote normal elimination also need to minimize
discomfort for the patient.
Scientific Knowledge Base

The GI tract is a series of hollow mucous membrane–lined muscular organs. These organs absorb fluid
and nutrients, prepare food for absorption and use by body cells, and provide for temporary storage of
feces (Fig. 46-1). The GI tract absorbs high volumes of fluids, making fluid and electrolyte balance a key
function of the GI system. In addition to ingested fluids and foods, the GI tract also receives secretions
from the gallbladder and pancreas.

image

FIG. 46-1 Organs of gastrointestinal tract (with heart as reference point).

Mouth

Digestion begins in the mouth and ends in the small intestine. The mouth mechanically and chemically
breaks down nutrients into a usable size and form. The teeth masticate food, breaking it down into a
size suitable for swallowing. Saliva, produced by the salivary glands in the mouth, dilutes and softens the
food in the mouth for easier swallowing.

Esophagus

As food enters the upper esophagus, it passes through the upper esophageal sphincter, a circular muscle
that prevents air from entering the esophagus and food from refluxing into the throat. The bolus of food
travels down the esophagus and is pushed along by peristalsis, which propels it through the length of
the GI tract.

As food moves down the esophagus, it reaches the cardiac or lower esophageal sphincter, which lies
between the esophagus and the upper end of the stomach. The sphincter prevents reflux of stomach
contents back into the esophagus.

Stomach

The stomach performs three tasks: storing swallowed food and liquid; mixing food, liquid, and digestive
juices; and emptying its contents into the small intestine. It produces and secretes hydrochloric acid
(HCl), mucus, the enzyme pepsin, and the intrinsic factor. Pepsin and HCl facilitate the digestion of
protein. Mucus protects the stomach mucosa from acidity and enzyme activity. The intrinsic factor is
essential for the absorption of vitamin B12.
Small Intestine

Segmentation and peristaltic movement in the small intestine facilitate both digestion and absorption
(Fig. 46-2). Chyme mixes with digestive juices (e.g., bile and amylase). Resorption in the small intestine is
so efficient that, by the time the chyme reaches the end of the small intestine, it is pastelike in
consistency.

image

FIG. 46-2 Segmented and peristaltic waves.

The small intestine has three sections: the duodenum, the jejunum, and the ileum. The duodenum is
approximately 20 to 28 cm (8 to 11 inches) long and continues to process the chyme from the stomach.
The jejunum is approximately 2.5 m (8 feet) long and absorbs carbohydrates and proteins. The ileum is
approximately 3.7 m (12 feet) long and absorbs water, fats, certain vitamins, iron, and bile salts. The
duodenum and jejunum absorb most of the nutrients and electrolytes. The intestinal wall also absorbs
nutrients across the mucosa and into lymph fluids or blood vessels. Substances, such as plant fiber, that
the small intestine cannot digest empty into the cecum at the lower right side of the abdomen. The large
intestine begins at the cecum.

Impairment of the small intestine alters the digestive process. For example, conditions such as
inflammation, surgical resection, or obstruction disrupt peristalsis, reduce the area of absorption, or
block the passage of chyme. Electrolyte and nutrient deficiencies then develop.

Large Intestine

The lower GI tract is called the large intestine (colon) because it is larger in diameter than the small
intestine. The large intestine is shorter (1.5 to 1.8 m [5 to 6 feet]) but much wider than the small
intestine. The large intestine is divided into the cecum, colon, and rectum (Fig. 46-3). The large intestine
is the primary organ of bowel elimination. It is positioned like a question mark, partially encircling the
small intestine.

image

FIG. 46-3 Divisions of large intestine.

Chyme enters the large intestine by waves of peristalsis through the ileocecal valve, a circular muscular
layer that prevents regurgitation. The colon is divided into the ascending, transverse, descending, and
sigmoid colons. The muscular tissue of the colon allows it to accommodate and eliminate large
quantities of waste and gas (flatus). It has three functions: absorption, secretion, and elimination. The
large intestine absorbs water, sodium, and chloride from the digested food that has passed from the
small intestine. Healthy adults absorb more than a gallon of water and an ounce of salt from the colon
every 4 hours. The amount of water absorbed from chyme depends on the speed at which colonic
contents move. Chyme is normally a soft, formed mass. If peristalsis is abnormally fast, there is less time
for water to be absorbed, and the stool is watery. If peristaltic contractions slow, water continues to be
absorbed; and a hard mass of stool forms, resulting in constipation (JBI, 2008).

The secretory function of the colon aids in electrolyte balance. The colon secretes bicarbonate in
exchange for chloride. The colon also excretes about 4 to 9 mEq of potassium daily. Therefore serious
alterations in colon function (e.g., diarrhea) cause severe electrolyte disturbances.

Slow peristaltic contractions move contents through the colon. Intestinal content is the main stimulus
for contraction. Mass peristalsis pushes undigested food toward the rectum. These mass movements
occur only three or four times daily, with the strongest during the hour after mealtime.

The rectum is the final portion of the large intestine. Here bacteria convert fecal matter into its final
form. Normally the rectum is empty of waste products (feces) until just before defecation. It contains
vertical and transverse folds of tissue that help to temporarily hold fecal contents during defecation.
Each fold contains an artery and vein that can become distended from pressure during straining. This
distention often results in hemorrhoid formation.

Anus

The body expels feces and flatus from the rectum through the anal canal and anus. Contraction and
relaxation of the internal and external sphincters, innervated by sympathetic and parasympathetic
stimuli, aid in the control of defecation. The anal canal is richly supplied with sensory nerves that help to
control continence.

Defecation

The physiological factors critical to bowel function and defecation include normal GI tract function,
sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and adequate
rectal capacity and compliance. Normal defecation begins with movement in the left colon, moving stool
toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal
sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter
relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
(Huether and McCance, 2008). Sometimes people use the Valsalva maneuver to assist in stool passage.
The Valsalva maneuver exerts pressure to expel feces through a voluntary contraction of the abdominal
muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular
disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for
cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid
straining to pass the stool. Normal defecation is painless, resulting in passage of soft, formed stool.

Nursing Knowledge Base

Factors Influencing Bowel Elimination

Many factors influence the process of bowel elimination. Knowledge of these factors helps to anticipate
measures required to maintain a normal elimination pattern.

Age

Developmental changes affecting elimination occur throughout life. An infant has a small stomach
capacity and less secretion of digestive enzymes. Food passes quickly through an infant’s intestinal tract
because of rapid peristalsis. The infant is unable to control defecation because of a lack of
neuromuscular development. This neuromuscular development usually does not take place until 2 to 3
years of age.

Systemic changes in the function of digestion and absorption of nutrients result from changes in older
patients’ cardiovascular and neurological systems rather than their GI system. For example,
arteriosclerosis causes decreased mesenteric blood flow, thus decreasing absorption from the small
intestine (Meiner, 2011). In addition, peristalsis decreases, and esophageal emptying slows. Older adults
often experience changes in the GI system that impair digestion and elimination (JBI, 2008) (Table 46-1).

TABLE 46-1

Normal Age-Related Changes in the Gastrointestinal Tract

Image

Older adults also lose muscle tone in the perineal floor and anal sphincter (Holman et al., 2008).
Although the integrity of the sphincter remains intact, they often have difficulty controlling bowel
evacuation and are at risk for incontinence. In addition, nerve impulses to the anal region slow, causing
some individuals to become less aware of the need to defecate. Older adults, especially residents in
long-term care facilities, sometimes develop irregular bowel movements and an increased risk for
constipation (Kyle, 2007a).

Diet

Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber, the
nondigestible residue in the diet, provides the bulk of fecal material. Bulk-forming foods such as whole
grains, fresh fruits, and vegetables help flush the fats and waste products from the body with more
efficiency (Holman et al., 2008). The bowel walls stretch, creating peristalsis and initiating the defecation
reflex. With stimulation of peristalsis, bulk foods pass quickly through the intestines, keeping the stool
soft. Ingestion of a high-fiber diet improves the likelihood of a normal elimination pattern if other factors
are normal. Diets high in vegetables and fruits have been linked to decreased risk of colorectal cancer
(ACS, 2011b).

Gas-producing foods such as onions, cauliflower, and beans also stimulate peristalsis. The gas formed
distends intestinal walls and increases colon motility. Some spicy foods increase peristalsis but also
cause indigestion and watery stools.

Food intolerance is not an allergy but rather a particular food that causes the body distress within a few
hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cow’s
milk and have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk
sugar lactase and therefore are lactose intolerant. Another condition called celiac disease is a syndrome
in which the patient has a hypersensitivity to protein in certain cereal grains and gluten.

Fluid Intake

An inadequate fluid intake or disturbances resulting in fluid loss (such as vomiting) affect the character
of feces. Fluid liquefies intestinal contents, easing its passage through the colon. Reduced fluid intake
slows passage of food through the intestine and results in hardening of stool contents. Unless there is a
medical contraindication, an adult needs to drink at least 1100 to 1400 mL of fluid daily. An increase in
fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases
the risk of constipation because of greater resorption of fluid in the colon, resulting in hard, dry stools
(Kyle, 2007a).

Physical Activity

Physical activity promotes peristalsis, whereas immobilization depresses it. Encourage early ambulation
as illness begins to resolve or as soon as possible after surgery to promote maintenance of peristalsis
and normal elimination. Maintaining tone of skeletal muscles used during defecation is important.
Weakened abdominal and pelvic floor muscles impair the ability to increase intraabdominal pressure
and control the external sphincter. Muscle tone is sometimes weakened or lost as a result of long-term
illness, spinal cord injury, or neurological disease that impairs nerve transmission. As a result of these
changes in the abdominal and pelvic floor muscles, there is an increased risk for constipation.

Psychological Factors

Prolonged emotional stress impairs the function of almost all body systems (see Chapter 37). During
emotional stress the digestive process is accelerated, and peristalsis is increased. Side effects of
increased peristalsis are diarrhea and gaseous distention. A number of diseases of the GI tract are
associated with stress, including ulcerative colitis, irritable bowel syndrome, certain gastric and
duodenal ulcers, and Crohn’s disease. If a person becomes depressed, the autonomic nervous system
slows impulses; peristalsis decreases, resulting in constipation.

Personal Habits

Personal elimination habits influence bowel function. Most people benefit from being able to use their
own toilet facilities at a time that is most effective and convenient for them. A busy work schedule
sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting
regular habits and causing possible alterations such as constipation. Individuals need to recognize the
best time for elimination.

Chronically ill and hospitalized patients are not always able to maintain privacy during defecation. In a
hospital or extended care setting, patients sometimes share bathroom facilities with a roommate with
different hygienic habits. In addition, chronic illness limits a patient’s balance, activity tolerance, or
physical activity and requires the use of a bedpan or bedside commode. The sights, sounds, and odors
associated with sharing toilet facilities or using bedpans are often embarrassing. This embarrassment
often causes patients to ignore the urge to defecate, which begins a vicious cycle of constipation and
discomfort.

Position During Defecation

Squatting is the normal position during defecation. Modern toilets facilitate this posture, allowing the
person to lean forward, exert intraabdominal pressure, and contract the thigh muscles. For the patient
immobilized in bed, defecation is often difficult. In a supine position it is impossible to contract the
muscles used during defecation. If the patient’s condition permits, raise the head of the bed to assist the
patient to a more normal sitting position on a bedpan, enhancing the ability to defecate.

Pain

Normally the act of defecation is painless. However, a number of conditions such as hemorrhoids, rectal
surgery, rectal fistulas, and abdominal surgery result in discomfort. In these instances the patient often
suppresses the urge to defecate to avoid pain, contributing to the development of constipation.

Pregnancy

As pregnancy advances, the size of the fetus increases, and pressure is exerted on the rectum. A
temporary obstruction created by the fetus impairs passage of feces. Slowing of peristalsis during the
third trimester often leads to constipation. A pregnant woman’s frequent straining during defecation or
delivery results in formation of permanent hemorrhoids.

Surgery and Anesthesia

General anesthetic agents used during surgery cause temporary cessation of peristalsis (see Chapter 50).
Inhaled anesthetic agents block parasympathetic impulses to the intestinal musculature. The action of
the anesthetic slows or stops peristaltic waves. The patient who receives a local or regional anesthetic is
less at risk for elimination alterations because this type of anesthesia generally affects bowel activity
minimally or not at all.

Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition,
called paralytic ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat
after surgery, return of normal bowel elimination is further delayed.
Medications

Some medications have certain expected actions on the bowel (e.g., there are medications to promote
defecation or control diarrhea). In addition, medications prescribed for acute and chronic conditions
often have secondary effects on the patient’s bowel elimination patterns (Table 46-2).

TABLE 46-2

Medications and the Gastrointestinal System

MEDICATIONS ACTION

Dicyclomine HCl (Bentyl) Suppresses peristalsis and decreases gastric emptying

Opioid analgesics Slow peristalsis and segmental contractions, often resulting in constipation
(Lehne, 2010)

Anticholinergic drugs such as atropine or glycopyrrolate (Robinul) Inhibit gastric acid secretion
and depress gastrointestinal (GI) motility (Lehne, 2010) (Although useful in treating hyperactive bowel
disorders, anticholinergics cause constipation.)

Antibiotics Produce diarrhea by disrupting the normal bacterial flora in the GI tract (An increase in
the use of fluoroquinolones in recent years has provided a selective advantage for the epidemic of
Clostridium difficile) (Vonberg et al., 2008)

Nonsteroidal antiinflammatory drugs Cause GI irritation that increases the incidence of bleeding with
serious consequences to older adults; rectal bleeding is often observed with GI irritation (Lehne, 2010)

Aspirin Prostaglandin inhibitor; interferes with the formation and production of protective mucus and
causes GI bleeding (Lehne, 2010)

Histamine2 (H2) antagonists Suppress the secretion of hydrochloric acid and interfere with the
digestion of some foods

Iron Causes discoloration of the stool (black), nausea, vomiting, constipation (diarrhea is less
commonly reported), and abdominal cramps (Lehne, 2010)

Laxatives and cathartics soften the stool and promote peristalsis. Although similar, laxatives are milder
in action than cathartics. When used correctly, laxatives and cathartics safely maintain normal
elimination patterns. However, chronic use of cathartics causes the large intestine to become less
responsive to stimulation by laxatives. Laxative overuse can also cause serious diarrhea, leading to
dehydration and electrolyte depletion. Mineral oil, a common laxative, decreases fat-soluble vitamin
absorption. Laxatives often influence the efficacy of other medications by altering the transit time (i.e.,
the time the medication remains in the GI tract and is available for absorption).

Diagnostic Tests

Diagnostic examinations involving visualization of GI structures often require a prescribed bowel

preparation (e.g., medications, cathartics, and/or enemas) to ensure that the bowel is empty. In
addition, the patient cannot eat or drink several hours before the examinations such as an endoscopy,
colonoscopy, or other testing that requires visualization of the GI tract. Following the diagnostic
procedure, changes in elimination such as increased gas or loose stools often occur until the patient
resumes a normal eating pattern.

Common Bowel Elimination Problems

Caring for patients who have or are at risk for elimination problems because of emotional stress (anxiety
or depression), physiological changes in the GI tract such as surgical alteration of intestinal structures,
inflammatory diseases, prescribed therapy, or disorders impairing defecation is common in the practice
of nursing.

Constipation

Constipation is a symptom, not a disease (Box 46-1). Improper diet, reduced fluid intake, lack of
exercise, and certain medications can cause constipation. For example, patients receiving opiates for
pain after surgery often require a stool softener or laxative to prevent constipation. The signs of
constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools,
excessive straining, inability to defecate at will, and hard feces (McWilliams, 2010). When intestinal
motility slows, the fecal mass becomes exposed over time to the intestinal walls, and most of the fecal
water content is absorbed. Little water is left to soften and lubricate the stool. Passage of a dry, hard
stool causes rectal pain (Fig. 46-4).

Box 46-1

Common Causes of Constipation

• Irregular bowel habits and ignoring the urge to defecate

• Chronic illnesses (e.g., Parkinson’s disease, multiple sclerosis, rheumatoid arthritis, chronic bowel
diseases, depression, diabetic neuropathy, eating disorders (McWilliams, 2010)

• Low-fiber diet high in animal fats (e.g., meats, dairy products, eggs) (McWilliams, 2010)

• Low fluid intake, which slows peristalsis (Holman et al., 2008)

• Anxiety, depression, cognitive impairment (McWilliams, 2010)

• Lengthy bed rest or lack of regular exercise (McWilliams, 2010)

• Laxative misuse (Durston, 2009)

• Slowed peristalsis, loss of abdominal muscle elasticity, and reduced intestinal mucus secretion
experienced by older adults (Durston, 2009)

• Neurological conditions that block nerve impulses to the colon (e.g., spinal cord injury, tumor) (Kyle,
2007c)

• Illnesses such as hypothyroidism, hypocalcemia, or hypokalemia

• Medications such as anticholinergics, antispasmodics, anticonvulsants, antidepressants,

antihistamines, antihypertensives, antiparkinsonism drugs, bile acid sequestrants, diuretics, antacids,
iron supplements, calcium supplements, and opioids slow colonic action (Lehne, 2010)

Constipation is a significant health hazard. Straining during defecation causes problems for the patient
with recent abdominal, gynecological, or rectal surgery. The effort to pass a stool often causes sutures to
separate, reopening the wound. In addition, patients with histories of cardiovascular disease, diseases
causing elevated intraocular pressure (glaucoma), and increased intracranial pressure need to prevent
constipation and avoid using the Valsalva maneuver.

Impaction

Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the
rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid
colon. If not resolved or removed, severe impaction often results in intestinal obstruction. Patients who
are debilitated, confused, or unconscious are most at risk for impaction. They are dehydrated or too
weak or unaware of the need to defecate, and the stool becomes too hard and dry to pass.

An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to
defecate (Chien and Bradway, 2010). You suspect impaction when a continuous oozing of diarrhea stool
occurs. The liquid portion of feces located higher in the colon seeps around the impacted mass. Loss of
appetite (anorexia), nausea and/or vomiting, abdominal distention and cramping, and rectal pain often
accompany the condition. If an impaction is suspected, gently perform a digital examination of the
rectum and palpate for the impacted mass (Steggall, 2008).

Diarrhea

Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is
associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal
contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid
and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become
watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and
effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the
hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of
contamination and risk of skin ulceration (Gray, 2007).

Excess loss of colonic fluid results in serious fluid and electrolyte or acid-base imbalances. Infants and
older adults are particularly susceptible to associated complications (see Chapter 41). Because repeated
passage of diarrhea stools also exposes the skin of the perineum and buttocks to irritating intestinal
contents, meticulous skin care and containment of fecal drainage is necessary to prevent skin
breakdown (see Chapter 48).
Many conditions cause diarrhea. Antibiotic use via any route of administration alters the normal flora in
the GI tract (Vonberg et al., 2008). Patients receiving enteral nutrition are also at risk for diarrhea.
Consult a dietitian when diarrhea occurs (Tabloski, 2009). See Chapter 44 for interventions to decrease
diarrhea caused by enteral feedings. Food allergies and intolerances increase peristalsis and cause
diarrhea. Surgeries or diagnostic testing of the lower GI tract also cause diarrhea. The aim of treatment
is to remove precipitating conditions and slow peristalsis.

Another common causative agent of diarrhea is Clostridium difficile (C. difficile), in which symptoms
range from mild diarrhea to severe colitis. C. difficile infection is acquired in one of two ways: by factors
that cause an overgrowth of C. difficile, and by contact with the C. difficile organism. A new strain of C.
difficile has been identified that is more virulent with more toxic effects (Grossman, 2010). Antibiotics
(cephalosporins, ampicillin, amoxicillin, and clindamycin (Calfee, 2008), chemotherapy, and invasive
bowel procedures such as surgery or colonoscopy disrupt normal bowel flora and may cause an
overgrowth of C. difficile. Some patients acquire the organism from a health care worker’s hands or
direct contact with the environmental surfaces contaminated with it. Only hand hygiene with soap and
water is effective to physically remove C. difficile spores from the hands. In addition, evidence supports
the use of diluted bleach (1 : 10) as an environmental disinfectant to decrease the incidence of C.
difficile (Calfee, 2008; Vonberg, 2008). The most common diagnostic test for the bacteria is the enzyme-
linked immunosorbent assay (ELISA) test, which detects C. difficile A and B in the stool.

Communicable foodborne pathogens also cause diarrhea. Hand hygiene following the use of the
bathroom, before and after preparing foods, and when cleaning and storing fresh produce and meats
greatly reduces the risk of foodborne illnesses. When diarrhea is the result of a foodborne virus, the goal
usually is to rid the GI system of the pathogen rather than slow peristalsis.

Incontinence

Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms
a patient’s body image (see Chapter 33). In many situations the patient is mentally alert but physically
unable to avoid defecation. The embarrassment of soiling clothes often leads to social isolation. Physical
conditions that impair anal sphincter function or control cause incontinence. It occurs in a variety of
settings. Conditions that create frequent, loose, large-volume, watery stools also predispose to
incontinence. Using an anal bag or a bowel management system helps to prevent perineal skin
breakdown (Fig. 46-5).
Fecal incontinence

SECTIONSFOR FECAL INCONTINENCE

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Overview

Fecal incontinence is the inability to control bowel movements, causing stool (feces) to leak
unexpectedly from the rectum. Also called bowel incontinence, fecal incontinence ranges from an
occasional leakage of stool while passing gas to a complete loss of bowel control.

Common causes of fecal incontinence include diarrhea, constipation, and muscle or nerve damage. The
muscle or nerve damage may be associated with aging or with giving birth.

Whatever the cause, fecal incontinence can be embarrassing. But don't shy away from talking to your
doctor about this common problem. Treatments can improve fecal incontinence and your quality of life.

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Symptoms

Fecal incontinence may occur temporarily during an occasional bout of diarrhea, but for some people,
fecal incontinence is chronic or recurring. People with this condition may be unable to stop the urge to
defecate, which comes on so suddenly that they don't make it to the toilet in time. This is called urge
incontinence.

Another type of fecal incontinence occurs in people who are not aware of the need to pass stool. This is
called passive incontinence.

Fecal incontinence may be accompanied by other bowel problems, such as:

Diarrhea

Constipation

Gas and bloating

When to see a doctor

See your doctor if you or your child develops fecal incontinence, especially if it's frequent or severe, or if
it causes emotional distress. Often, people are reluctant to tell their doctors about fecal incontinence.
But treatments are available, and the sooner you're evaluated, the sooner you may find some relief
from your symptoms.

Request an Appointment at Mayo Clinic

Causes

For many people, there is more than one cause of fecal incontinence.

Causes can include:

Muscle damage. Injury to the rings of muscle at the end of the rectum (anal sphincter) may make it
difficult to hold stool back properly. This kind of damage can occur during childbirth, especially if you
have an episiotomy or forceps are used during delivery.

Nerve damage. Injury to the nerves that sense stool in the rectum or those that control the anal
sphincter can lead to fecal incontinence. The nerve damage can be caused by childbirth, constant
straining during bowel movements, spinal cord injury or a stroke. Some diseases, such as diabetes and
multiple sclerosis, also can affect these nerves and cause damage that leads to fecal incontinence.

Constipation. Chronic constipation may cause a dry, hard mass of stool (impacted stool) to form in the
rectum and become too large to pass. The muscles of the rectum and intestines stretch and eventually
weaken, allowing watery stool from farther up the digestive tract to move around the impacted stool
and leak out. Chronic constipation may also cause nerve damage that leads to fecal incontinence.

Diarrhea. Solid stool is easier to retain in the rectum than is loose stool, so the loose stools of diarrhea
can cause or worsen fecal incontinence.

Hemorrhoids. When the veins in your rectum swell, causing hemorrhoids, this keeps your anus from
closing completely, which can allow stool to leak out.
Loss of storage capacity in the rectum. Normally, the rectum stretches to accommodate stool. If your
rectum is scarred or stiff due to surgery, radiation treatment or inflammatory bowel disease, the rectum
can't stretch as much as it needs to, and excess stool can leak out.

Surgery. Surgery to treat enlarged veins in the rectum or anus (hemorrhoids), as well as more-complex
operations involving the rectum and anus, can cause muscle and nerve damage that leads to fecal
incontinence.

Rectal prolapse. Fecal incontinence can be a result of this condition, in which the rectum drops down
into the anus. The stretching of the rectal sphincter by prolapse damages the nerves that control the
rectal sphincter. The longer this persists, the less likely the nerves and muscles will recover.

Rectocele. In women, fecal incontinence can occur if the rectum protrudes through the vagina.

Risk factors

A number of factors may increase your risk of developing fecal incontinence, including:

Age. Although fecal incontinence can occur at any age, it's more common in adults over 65.

Being female. Fecal incontinence can be a complication of childbirth. Recent research has also found
that women who take menopausal hormone replacement therapy have a modest increased risk of fecal
incontinence.

Nerve damage. People who have long-standing diabetes, multiple sclerosis, or back trauma from injury
or surgery may be at risk of fecal incontinence, as these conditions can damage nerves that help control
defecation.

Dementia. Fecal incontinence is often present in late-stage Alzheimer's disease and dementia.

Physical disability. Being physically disabled may make it difficult to reach a toilet in time. An injury that
caused a physical disability also may cause rectal nerve damage, leading to fecal incontinence.

Complications

Complications of fecal incontinence may include:

Emotional distress. The loss of dignity associated with losing control over one's bodily functions can lead
to embarrassment, shame, frustration and depression. It's common for people with fecal incontinence
to try to hide the problem or to avoid social engagements.

Skin irritation. The skin around the anus is delicate and sensitive. Repeated contact with stool can lead
to pain and itching, and potentially to sores (ulcers) that require medical treatment.
Prevention

Depending on the cause, it may be possible to improve or prevent fecal incontinence. These actions may
help:

Reduce constipation. Increase your exercise, eat more high-fiber foods and drink plenty of fluids.

Control diarrhea. Treating or eliminating the cause of the diarrhea, such as an intestinal infection, may
help you avoid fecal incontinence.

Avoid straining. Straining during bowel movements can eventually weaken anal sphincter muscles or
damage nerves, possibly leading to fecal incontinence.