Fecal incontinence

What is fecal incontinence?

Fecal incontinence is the involuntary leakage of liquid or solid stool. Gas leakage may also occur; the term “anal incontinence” encompasses both stool and gas leakage. A sudden urge to have a bowel movement that is difficult to delay is called fecal urgency.

What are the causes of fecal incontinence?

Fecal incontinence can result from several issues: weakened muscles, a reduced sense of the urge to have a bowel movement, or difficulty holding in stool. The pelvic floor is a group of muscles at the base of the pelvis that helps support the organs and control the passage of urine and stool.

The anal sphincters are the muscles that close the anus. The internal sphincter maintains tension at rest, without conscious effort. This tension stems primarily from the muscle’s inherent properties; nerves also regulate its intensity. The external sphincter and the pelvic floor also help retain stool.^{1, 2}

Several factors may contribute to leaks or be associated with them:

• Pregnancy and vaginal delivery, especially when a tear affects the muscles that close the anus, such as in third- or fourth-degree tears³;
• Diet and Physical Activity. In older adults, low fiber intake and reduced physical activity are associated with fecal incontinence⁴;
• Organ prolapse (pelvic organ prolapse), which occurs when a pelvic organ descends into the vagina; prolapse of the rectum—the part of the intestine that stores stool—can interfere with bowel movements;
• Constipation, with stools that are difficult to pass, and persistent diarrhea⁵;
• Hormonal changes surrounding menopause, the period when menstruation permanently ceases;
• Surgery or an injury involving the anus, rectum, or colon—the largest part of the large intestine;
• Certain diseases that affect the nerves, such as Parkinson's disease and multiple sclerosis. Diabetes can also damage the nerves involved in bowel control⁶;
• Certain medications, particularly hormone therapies after menopause⁴;
• Aging and difficulties moving around or getting to the bathroom in time.

Radiation therapy to the pelvis—a form of cancer treatment—can irritate the bowel and contribute to urgent urges or leakage. The International Continence Society describes these factors⁷. Be sure to inform your healthcare team about your treatments; do not change your medications without medical advice.

Chronic lung diseases are also worth mentioning during the evaluation. A U.S. study found a higher prevalence of lung diseases among people with fecal incontinence. However, the link was no longer clearly established after taking into account urinary incontinence, depressive symptoms, and activity limitations. This finding does not prove that lung disease causes incontinence.⁸

What are the symptoms of fecal incontinence?

• Leakage of solid or liquid stool;
• Difficulty or inability to hold gas;
• Difficulty completely emptying bowels;
• Constipation with leakage: hard stools become stuck in the rectum, and liquid stool leaks around them—a condition known as overflow incontinence⁵
• Minor leaks or traces of stool in underwear after having a bowel movement;
• Prolonged wiping after a bowel movement.

When coughing, the pelvic floor muscles may contract to help hold in stool. A study of 16 women found that the contraction around the anus was stronger when the cough was more intense.^{2, 9}

How is fecal incontinence diagnosed?

The evaluation includes questions about incontinence, bowel habits, medications, and how incontinence affects your life. An examination of your abdomen and, with your consent, the muscles around the anus may be part of this evaluation. A doctor may order additional tests based on your symptoms to determine the cause of the incontinence.

How does physical therapy help reduce fecal incontinence?

Physical therapy can improve bowel control by strengthening the pelvic floor muscles and teaching you how to contract and relax them at the right time. A physical therapist who specializes in perineal and pelvic rehabilitation and pelvic floor care will assess your habits, posture, breathing, and how you contract and relax these muscles. This assessment helps determine which exercises are appropriate and identifies whether a medical evaluation is needed.

This assessment of the pelvic floor also helps identify spasmodic anal pain, a condition related to tension in these same muscles. The pelvic floor also helps the body remain stable during movement and plays a role in breathing. One study measured changes in its activity during arm movements and breathing¹⁰. The physical therapist takes your breathing and movements into account when tailoring the exercises.

What types of treatment can your physical therapist offer?

• Personalized advice on your lifestyle habits;
• Tips on toilet positioning and ways to make bowel movements easier;
• Home exercises, selected based on the evaluation to improve muscle control and bowel control;
• Gentle manual techniques on the abdominal muscles or pelvic floor, if the examination indicates a need, with your consent.

If the leakage persists despite treatment, the physical therapist will refer you to a doctor to evaluate other options. This referral may be made right from the start if your symptoms warrant it.

During and after pregnancy, pelvic floor exercises are used to treat fecal incontinence and urinary incontinence.¹¹ A 2020 Cochrane review, which synthesizes clinical studies, primarily supports the prevention of urinary leakage in women who did not experience it at the start of pregnancy. For fecal leakage after childbirth, the evidence remains too uncertain to quantify a benefit compared to standard care.¹² The program therefore takes your situation and the type of leakage into account.

In adults with fecal incontinence, a trial randomly assigned 98 participants to two programs. At 16 weeks, supervised exercises with feedback on muscle contractions—added to usual care—improved symptoms more than a massage designed to provide comparable attention, which was also added to usual care. Feedback, sometimes called biofeedback, helps participants recognize muscle contractions through measurable indicators. There was no clear difference in quality of life between the groups.¹³

When should you see a physiotherapist for fecal incontinence?

You can see a physical therapist if you experience fecal or gas incontinence or have difficulty controlling these muscles. Medical advice is also recommended for new episodes of incontinence or persistent changes in your bowel movements, even if you are already receiving physical therapy.

You can schedule a physical therapy appointment without a doctor's prescription. The physical therapist will refer you to a doctor if your symptoms or the results of your examination warrant it.

What symptoms require immediate medical attention?

Black or dark red stools, or bloody diarrhea, require urgent medical attention. Unexplained weight loss or bleeding from the anus should also be discussed with a doctor. The British National Health Service (NHS) describes these as urgent signs¹⁴.

A recent loss of bowel control accompanied by back or leg pain requires immediate evaluation in the emergency room. Do not wait if you experience a loss of sensation around the genitals or anus, or new difficulty urinating. These signs may indicate a nerve problem that requires prompt care. The NHS describes these neurological signs¹⁵.

What can you do at home?

• Maintain a balanced diet and drink according to your needs and medical advice. Adequate fluid intake helps prevent hard stools;
• Engage regularly in physical activities that are appropriate for your abilities;
• Try finding a comfortable position on the toilet.
  
  • While sitting on the toilet, rest your feet on a small stool, with your knees slightly higher than your hips, and then lean forward slightly. Avoid pushing too hard.

Keep track of your leaks, meals, and stool consistency for a few days. Adjust one food or drink at a time, rather than eliminating several foods all at once. The amount of fiber should be adjusted based on your symptoms: adding a lot of fiber doesn’t help everyone.

To learn more

• Canada's Food Guide
• Physical Activity Guidelines for Adults Aged 18 to 64

References

1. Bharucha AE. Pelvic floor: anatomy and function. Neurogastroenterol Motil. 2006;18(7):507-19. ↩ Back to text
2. Raizada V, Mittal RK. Pelvic floor anatomy and applied physiology. Gastroenterol Clin North Am. 2008;37(3):493-509, vii. ↩ Back to text: 1st, 2nd citations
3. Perrin S, Billecocq S. [Impact of obstetric injuries to the levator ani on anal continence]. Prog Urol. 2022;32(17):1519-1530. ↩ Back to text
4. Deb B, Prichard DO, Bharucha AE. Constipation and Fecal Incontinence in the Elderly. Curr Gastroenterol Rep. 2020;22(11):54. ↩ Back to text: 1st, 2nd citations
5. Scarlett Y. Medical management of fecal incontinence. Gastroenterology. 2004;126(1 Suppl 1):S55-63. ↩ Back to text: 1st, 2nd citations
6. Camilleri, M. Gastrointestinal motility disorders in neurological disease. J Clin Invest. 2021;131(4). ↩ Back to text
7. International Continence Society (ICS). Fecal Incontinence. Fact Sheet. ↩ Back to text
8. Ogbu C, Momodu I, Umerah C, Bhatt PR. Fecal Incontinence as a Marker of Multisystem Cardiopulmonary-Renal Disease and Mortality in U.S. Adults: A Nationally Representative Cohort Study. Dela J Public Health. 2026;12(3):101-107. ↩ Back to text
9. Amarenco G, Ismael SS, Lagauche D, Raibaut P, Rene-Corail P, Wolff N, et al. Cough-anal reflex: a close relationship between intravesical pressure and pelvic floor muscle electromyographic activity during coughing. A urodynamic and electrophysiological study. J Urol. 2005;173(1):149-52. ↩ Back to text
10. Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-71. ↩ Back to text
11. Boyle R, Hay-Smith EJ, Cody JD, Mørkved S. Pelvic floor muscle training for the prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women: a short-form Cochrane review. Neurourol Urodyn. 2014;33(3):269-76. ↩ Back to text
12. Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A, et al. Pelvic floor muscle training for preventing and treating urinary and fecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2020;5(5):CD007471. ↩ Back to text
13. Ussing A, Dahn I, Due U, Sørensen M, Petersen J, Bandholm T. Efficacy of Supervised Pelvic Floor Muscle Training and Biofeedback vs. Attention-Control Treatment in Adults With Fecal Incontinence. Clin Gastroenterol Hepatol. 2019;17(11):2253-2261.e4. ↩ Back to text
14. National Health Service (NHS), United Kingdom. Bowel incontinence. ↩ Back to text
15. National Health Service (NHS), United Kingdom. Sciatica. ↩ Back to text

Our physical therapists defined the research strategy, plan, and clinical content of this article. An AI tool assisted with the literature review and text editing to ensure consistency in content and writing style.