Can hemorrhoids cause fecal incontinence?

Can Hemorrhoids Cause Fecal Incontinence?

Hemorrhoids themselves do not directly cause fecal incontinence, but prolapsing hemorrhoids can contribute to minor incontinence through mechanical obstruction and soilage rather than true sphincter dysfunction. 1

Understanding the Relationship

Hemorrhoids and Continence Mechanism

The relationship between hemorrhoids and incontinence is nuanced and often misunderstood:

• Anal cushions contribute 15-20% of resting anal pressure and play a role in maintaining continence, but symptomatic hemorrhoids represent pathologic enlargement of these normal structures 2
• Prolapsing hemorrhoids may cause "relative anal incontinence" through mechanical effects rather than true sphincter failure 3
• The American Gastroenterological Association notes that anal itching from prolapsing hemorrhoids is just as likely due to inadequate hygiene or minor incontinence as it is to the hemorrhoids themselves 1

Mechanisms of Soilage (Not True Incontinence)

Prolapsing hemorrhoids cause soilage through three distinct mechanisms:

• Partial obstruction of defecation leading to incomplete evacuation and subsequent leakage 4
• Passage of mucus or blood from the hemorrhoidal tissue itself, which patients may perceive as incontinence 4
• Interference with complete anal closure, allowing seepage of fecal material around the prolapsed tissue 4

Clinical Pitfall: Attribution Error

The most critical clinical error is attributing incontinence symptoms to hemorrhoids when other pathology is actually responsible:

• The American Gastroenterological Association emphasizes that "when hemorrhoids are simply assumed to be the cause, other pathology is too often overlooked" 1
• A careful anorectal evaluation is warranted for any patient reporting both hemorrhoids and incontinence symptoms, as 20% of patients with hemorrhoids have concomitant anal fissures 1
• True fecal incontinence requires investigation for sphincter injury (obstetric trauma, prior surgery), neurologic disease, or inflammatory bowel disease 5

Hemorrhoidectomy and Incontinence Risk

Surgical treatment of hemorrhoids carries a small but real risk of causing incontinence:

• Standard hemorrhoidectomy with proper indication is safe, with approximately 10% experiencing complications including soiling or incontinence 5
• Risk increases dramatically (30-80%) when concomitant disease is present, such as perianal cryptoglandular infection causing complex fistula/abscess 5
• Older procedures like sphincterotomy or anal stretch have been associated with incontinence rates of 30-50% and should be avoided 5
• Incontinence after hemorrhoidectomy is typically multifactorial, often involving prior obstetric injury, perianal infection, or other comorbidity rather than the surgery alone 5

Treatment Approach When Both Conditions Coexist

When patients present with both hemorrhoids and incontinence symptoms:

• First, determine if symptoms represent true incontinence or soilage through detailed history about stool consistency, urgency, and passive versus active leakage 4
• For soilage from prolapsing hemorrhoids, endoscopic banding can eliminate the mechanical obstruction and mucus production 4
• For true incontinence with concurrent hemorrhoids, treat the incontinence first with antidiarrheal agents (loperamide, diphenoxylate) if diarrhea-associated, or fiber supplementation and biofeedback 4, 6
• Avoid aggressive hemorrhoid surgery in patients with baseline sphincter weakness or prior obstetric injury, as this increases incontinence risk 5

Key Takeaway

Hemorrhoids cause soilage and minor seepage, not true fecal incontinence. When a patient reports both conditions, perform thorough evaluation to identify the actual cause of incontinence rather than assuming the hemorrhoids are responsible. 1, 5