Ask the Doctor: ‘Since having kids, I’ve struggled with bowel issues and urgency — What can I do?’

“I am a woman of average build and have four children in their 20s, all of whom I gave birth to naturally. Since the last child (quite a traumatic birth and a large baby), I had had some issues with needing the bathroom in very much of a hurry (number two). It’s something I have not spoken to anyone about as it causes me huge embarrassment. As the years have gone by it has become worse. Everything I do, I have to plan and research where the nearest toilet is located to try to quell my anxiety. My husband wants me to take up golf but I can’t due to this problem, which I haven’t even told him about. I’m tired of letting this rule my life. Is there anything that can be done? Please help!”

Answer from Professor R. Kalbassi, Consultant Colorectal Surgeon, Beacon Hospital

The question asked is related to faecal urgency and incontinence which is common. The patient should visit their GP, openly discuss their symptoms and arrange for a referral to a Specialist Consultant Colorectal Surgeon with specialty in pelvic floor conditions.

Faecal incontinence is a debilitating condition affecting almost 1 in 10 females and males at some stage of their lives with significant impact on quality of life. It is defined as involuntary loss of solid or liquid stool. Patients often present late or hide symptoms. The main risk factors are advancing age, Diabetes Mellitus, change of bowel habit, obstetric reasons such as multiple vaginal deliveries, instrumental delivery, potential third- and fourth-degree tears.

Occasionally previous anal or back surgery can be associated with development of faecal incontinence.

Faecal incontinence can be divided into: ‘urge’, occurring despite attempts to retain stool, ‘passive’, occurring with lack of awareness to defecate, and ‘soiling’, secondary to faecal impaction.

Thorough history and examination are necessary. The investigations of choice include sigmoidoscopy or colonoscopy, to exclude serious conditions such as colorectal malignancy and anorectal physiology, assess anorectal function and endorectal ultrasound check integrity of the anal sphincter, defecating proctogram or MRI pelvic floor check for prolapse.

The treatment starts conservative. Agents such as Loperamide are used in patients with loose motion, bulking agents improve stool quality, biofeedback and pelvic floor physiotherapy improve function.

If these fail, surgical treatment may be possible in some. In sphincter defects ‘sphincteroplasty’ is a valid option. Injectable anal bulking agents have been used with variable results. Artificial sphincter and prosthetic intersphincteric implants are under development showing reduction in soiling and better quality of life. Neuromodulation is another treatment modality either by sacral nerve (SNS) or posterior tibial nerve stimulation (PTNS). With this, an implant is placed by surgery and may need replacement due to battery depletion after a period of time.

Rectal prolapse can also lead to faecal incontinence. Ventral rectopexy by minimally invasive laparoscopic or robotic approach is the surgical treatment option.

It is most important to involve the patient in their treatment with careful consideration of expectations and realistic goals agreed before commencing treatment.

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