Spinal stenosis and incontinence are often connected as the nerves involved with bladder control (and bowel control) can be impacted by narrowing of the spinal canal. The spinal nerves innervating the bladder and bowel may then become dysfunctional or permanently damaged, leading to bladder leakage, accidents, or incontinence. Loss of bladder control is considered a red-flag symptom for patients with spinal stenosis as it often means that the spinal nerve compression has become severe and chronic, necessitating more aggressive treatment than that given for occasional back pain or discomfort.
Diagnosing Incontinence Causes
Spinal stenosis may be apparent on X-Rays for many patients and yet remain asymptomatic for months or even years. When symptoms do begin, they are usually only noticeable with certain movements that further narrow the spine, such as forward or back bends in the cervical or lumbar spinal segments. These symptoms may progress to chronic constant pain regardless of posture, or even radicular pain down the legs or arms, or up into the head or chest as more nerves become pinched or trapped. Numbness and weakness can also develop as the nerves providing both sensory information and transmitting movement signals are affected. Clumsiness and progressive muscle wasting can be signs of spinal stenosis.
Symptoms of Spinal Stenosis and Incontinence
Just as muscles in the arms, hands, and legs can begin to atrophy as spinal nerves can no longer innervate them correctly, the muscles controlling the bowel and bladder may also begin to weaken or become unresponsive. Lower back pain or sciatic nerve pain may be worsened by infection, other injury, or any cause of inflammation in the body as the nerves become further compressed. Occasional incontinence at times of other injury or illness could signify spinal stenosis that, under better conditions, does not affect the nerves in the lower spine. This is why those patients experiencing loss of bladder control or bowel control are advised to seek medical attention immediately as it is often easier to treat spinal stenosis in its early stages than when already progressed to a severe level.
What is Incontinence?
Bowel incontinence or faecal incontinence is where a person loses voluntary control of their bowel movements to varying degrees. Some patients experience the occasional accident involving the loss of a small quantity of liquid waste and others may suffer from the loss of control of a complete bowel movement. More than five and a half million Americans suffer from bowel incontinence and yet it is rarely discussed. Most of the sufferers are women who have delivered one or more baby through the birth canal as this can cause injury to the muscles and nerves in the anal region. It is not uncommon for men and women with bowel incontinence to change their social and professional activities rather than seek medical attention, especially when they are unaware that their incontinence is caused by spinal stenosis and may be treatable. While understandable, embarrassment about bowel incontinence may prevent patients receiving help for their condition and oftentimes patients assume that there is no treatment for incontinence and spinal stenosis.
Causes of Incontinence
Spinal stenosis is just one cause of bowel and bladder incontinence as normal function in both relies on muscle and nerve health, which can be affected by a wide variety of medications, diseases, infections, and other issues. Normal bowel movements depend on the control of the colon and rectum, as well as the anal sphincter muscles, the nerves innervating the area, and also the diet and lifestyle of patients.
Damage to the anal sphincter muscles or nerves can occur through trauma to the area, whether acute or chronic, muscle-wasting diseases, demyelinating nervous system conditions such as amyotrophic lateral sclerosis or multiple sclerosis, and other things such as infections which create inflammatory damage. Anal surgery for another condition can also lead to dysfunction of the muscles, with prostate surgery or surgery for severe haemorrhoids or gastrointestinal diseases sometimes leading to such damage. Radiotherapy used in the pelvic area, for prostate cancer, ovarian cancer or other condition can also lead to damage of the muscles controlling bowel and bladder function.
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Medication, Lifestyle, and Diet
Certain medications, such as neurontin (an anti-seizure drug), can have side-effects including damage to the muscles and nerves controlling bowel function. Chemotherapy may also leave lingering adverse effects on bowel control. Patients consistently eating a diet lacking in fiber or who suffer from chronic constipation or diarrhoea are also at risk of developing bowel incontinence through muscle straining and damage.
Spinal Stenosis, Incontinence, and Other Causes
Other patients at risk of incontinence include those who have suffered nerve or muscle damage from a stroke or severe infection. Systemic diseases such as diabetes and scleroderma are also associated with an increased risk of bowel incontinence and inflammatory damage. Acute trauma to the spinal cord, resulting in bruised or even severed nerves can be the cause of both bladder and bowel incontinence or dysfunction and, for some patients, this may become a permanent disability where nerve damage is irreversible. Mild spinal stenosis does not normally lead to incontinence but the symptoms can arise after many years of managing stenosis conservatively. It can also occur as a result of failed back surgery syndrome to treat other spinal stenosis symptoms and is, therefore, a consideration for anyone scheduling back surgery. Acute disc herniation or spinal slippage may be the cause of spinal stenosis and incontinence and diagnostic imaging is normally used to locate the problem with spinal surgery often the only way to resolve the issue.
Diagnosing Spinal Stenosis and Incontinence
A variety of methods are used to diagnose spinal stenosis incontinence and other causes of bladder or bowel dysfunction, with the results then affecting the type of treatment recommended. Patients with bowel and bladder incontinence may not always be able to be treated and restored to full function, especially where the damage to the muscles or nerves is severe or longstanding. This is why it is extremely important to discuss such symptoms, however embarrassing, with the physician as soon as they occur. Catching spinal stenosis early means that it is easier to treat in most cases and can help prevent it ever leading to incontinence.
Endosonography and Sigmoidoscopy
Endonosonography is a rectal ultrasound which allows the physician to check the status of the anal sphincter muscles and find such things as muscle tears or other abnormalities. Flexible sigmoidoscopy may also be used to assess the lining of the lower third of the gastrointestinal tract. This technique uses a thin and flexible illuminated tube (the endoscope) to explore any possible areas of damage leading to bowel incontinence.
Manometry and Nerves Studies
Manometry may be used in cases of bowel incontinence to detect abnormalities in the strength of the anal muscles. If the muscles show signs of weakness then there are a number of further studies that can help determine the cause of such weakness, whether this is due to nerve damage, a muscle-wasting disease, trauma, or another condition. Nerve studies are used when bowel or bladder incontinence is suspected as connected to pinched or damaged nerves in the spine. Such studies are usually a last resort unless nervous system injury appears extremely likely and patients often find such tests unpleasant as they check that the anal sphincter muscles remain responsive.
Magnetic resonance imaging (MRI) may also be used to check for areas of dysfunction and weakness in the anal muscles. X-Rays are usually insufficient to identify the causes of bowel or bladder incontinence, although severe spinal stenosis may show up as putting pressure on the nerves controlling bowel and bladder function. In some cases however, the signs of spinal stenosis on imaging studies do not necessarily tally with symptoms in the patient and many people have some degree of spinal canal narrowing whilst remaining asymptomatic. This highlights the need for a variety of tests to isolate the exact cause of the incontinence; simply assuming spinal stenosis and incontinence are related could lead to unnecessary back surgery when the real cause lies elsewhere.
Severe lumbar spinal stenosis is also referred to as cauda equina and may also leave patients with abnormal sexual function and significant weakness in the legs. Early signs of such spinal stenosis include postural pain in the legs and feet from neurogenic claudication, sciatic nerve pain, radiating numbness, weakness, and tingling in the leg(s), and possible gait (walking) disturbances through spinal stenosis and foot-drop. Balance issues from disturbed proprioception and muscle function are also often observed prior to full-blown cauda equina occurring which is a medical and surgical emergency.
Treating incontinence from spinal stenosis involves isolating the cause of the stenosis and tailoring therapy accordingly. Some cases of spinal stenosis are due to significant inflammation in the body due to acute injury, chronic stress, or another condition such as diabetes or Crohn�s Disease. In other cases, it may be that degenerative disc disease has led to spinal slippage or curvature, osteophyte growth and foraminal narrowing, or other contributing factor to pinched nerves in the lower spine. Where a mechanical stressor is the culprit it is often the case that back surgery will be the only way to restore proper bowel and bladder function.
Medications for Incontinence
Mechanical causes of incontinence are unlikely to be helped through medication alone, although some medications can help reduce the severity of symptoms. In some cases it may be that switching or ceasing medications for another health condition actually resolves the incontinence as bowel and bladder dysfunction may be a side-effect of some drugs. Medications for incontinence include those that help with the consistency of the stool as firmer stools are usually more easy to control for patients with bowel incontinence compared to loose stools. Imodium and Lomotil are two prescription medications that may be able to help control diarrhoea. Patients may also find that anti-inflammatory medications help in some cases where nerve irritation from herniated disc material is thought responsible for the loss of voluntary bladder or bowel control and spinal stenosis.
Biofeedback for Bowel Incontinence
It is often difficult for patients who have lost voluntary control of the bowel or bladder to pinpoint the muscles involved in such control. Biofeedback is a method of helping patients isolate the specific muscles that need to be strengthened and controlled for continence to be reinstated. A pressure probe can be inserted into the anus, or patients can use a sensor comprising of electrodes on the skin in the pelvic region in order to help provide such biofeedback. A visual or sound display is then able to relay the information to the patient so that they can start to establish which anal muscles are being used and work on strengthening those muscles. Such feedback also allows patients to develop a better idea of when a bowel movement is needed as the nerves related to the accumulation of stool in the rectum also become more sensitive and can alert the patient earlier.
Pelvic-floor exercises (Kegel exercises) are excellent for helping patients recover bowel and bladder control lost through muscle wasting, trauma, or nerve injury. Such exercises may be used in conjunction with biofeedback or can be performed at home. To carry out Kegel exercises contract the muscles of the anus, buttocks, and pelvis and hold fast for five seconds before relaxing. Repetitions, in sets of ten or so, can be performed three times a day to help build up bowel control and bladder control. To find out if Kegel exercises are being performed correctly it can help to have a physician examination as the exercises are performed. There are also devices suitable for home-use that can measure the strength of muscle contraction in the pelvis and these may be available on prescription for some patients. Muscle strengthening exercises for bowel and bladder control should be performed in such a fashion as the patient feels that they are trying to stop the flow of urine and/or trying to not pass gas or stool. Patients with spinal stenosis-related incontinence caused by disrupted nerve innervation may also find these exercises helpful in re-educating the muscles and nerves in the anus and bladder to reduce the risk of incontinence.
Surgery for Bowel Dysfunction
Persistent bowel and bladder incontinence may mean that surgery becomes necessary to give back some control to patients. Conservative therapies are normally tried first, such as medication, biofeedback, and exercises, but where acute nerve damage has occurred through back trauma or disc herniation, for example, patients may need immediate surgery to prevent permanent nerve damage. Surgery may be limited to the anal muscles themselves if these have been injured (through childbirth, for example), and spinal surgery is not always necessary, depending on the cause of incontinence.
Surgery and Incontinence
Common surgeries for incontinence include sphincteroplasty (to repair the rectal sphincter), and muscle transposition (to reconstruct and strengthen the anal passage). Muscles may be moved from the buttock or inner thigh during the latter procedure and electrodes similar to those in a pacemaker are implanted so as to train the muscle to contract unless told otherwise. Colostomy is a last resort for patients unable to have other types of surgery. This procedure involves creation of an abdominal wall opening through which the colon is passed and a bag connected to collect stool. Artificial bowel sphincters are now also available, using an inflation/deflation pressure technique to control the opening and closing of the bowel and to pass stool.
Back Surgery and Incontinence
Where a patient’s bowel and/or bladder incontinence is connected to spinal stenosis, it is possible that back surgery is needed to resolve the issue. Such surgery is rarely necessary unless patients are also experiencing leg weakness or changes in sensation of the lower limbs also connected to spinal stenosis. Problems in the sacral region of the spine (below the lumbar spine) which are causing compression on nerves in the region may be the sole cause of bowel and bladder incontinence and so surgery is often indicated in such cases. Lumbar laminectomy, laminotomy, or laminoplasty may help reduce nerve compression in the region and resolve incontinence from spinal stenosis as the nerves heal. Endoscopic spine surgery may also help remove disc fragments and decompress the lumbar spine to allow the nerves more space. In cases of osteophyte growth in the lumbar or sacral spine, a foraminotomy to widen the spaces through which the nerves travel could also help restore sensation and innervation to the pelvic region and resolve incontinence and spinal stenosis.