Brian Lacy, MD, and Stacy Menees, MD, on Fecal Incontinence: Part 1

Dr Brian Lacy and Dr Stacy Menees discuss the challenges of managing fecal incontinence.

Brian Lacy, MD, is a professor of medicine at the Mayo Clinic in Jacksonville, Florida. Stacy Menees, MD, is an associate professor of medicine at Michigan Medicine and the GI Clinic director at the VA Ann Arbor Healthcare System in Ann Arbor, Michigan.

TRANSCRIPT

Brian Lacy:  Welcome to this Gastroenterology Learning Network podcast. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, Florida. I am absolutely delighted to be speaking today to Dr Stacy Menees, associate professor of medicine at Michigan Medicine and the GI Clinic director at the VA Ann Arbor Healthcare System in Ann Arbor, Michigan.

Our topic today is one that is important for every provider regardless of specialty, and that's of fecal incontinence. Stacy, thank you again for joining this podcast today. Let's begin simply and set the stage for our listeners. How common is fecal incontinence?

Dr. Stacy Menees:  Hi, Brian. Thanks again for the opportunity to discuss this important topic. This is something that I'm excited to talk about because it is a silent affliction. It's important for other providers, and to emphasize the point of how important it is to ask our patients about this.

Fecal incontinence is common. It happens to a lot of people. It does depend on the criteria or questionnaire as far as the prevalence of fecal incontinence when you peruse the literature.

If we look at the Rome criteria for fecal incontinence, the Rome III criteria defines fecal incontinence as one episode per month for 3 months, whereas the newest Rome IV criteria define the frequency of FI that it has to occur at least twice per month for 6 months. If we look at the first US population-based study that was done using the NHANES by Will Whitehead. That was in 2009.

That was using the Rome III criteria. The prevalence was 8.3% in the US population. This is a noninstitutionalized, so this is not a nursing home population. If you looked at gender, there was no statistical difference by that. It was 8.9% in women and 7.7% in men.

Then, we look at a more recent study which Bill Whitehead compared Rome III and Rome IV criteria, the authors demonstrated a 6.9% prevalence in the Rome III criteria compared to 3.3% using the Rome IV criteria.

Lastly, I do want to discuss my own study that I performed with Bill Chey, and Chris Almario, and Brennan Spiegel, where we used the NIH GI promise questionnaire, and that employed a 7-day recall period. We found that in surveying over 71,000 individuals that 1 in 7 had an episode of fecal incontinence, and that 1 in 20 had reported fecal incontinence within the past week.

There's one more thing I want to point out is that the incidence of fecal incontinence is going to increase with aging as our population ages. There was an interesting study by Wu and colleagues where they estimated the future prevalence of fecal incontinence in women alone. They used the US Census Bureau population for comparing 2010 to 2050.

Fecal incontinence was expected to have the largest increase at 59% for all pelvic floor disorders. That went from 10.6 million people affected to 16.8 million affected women. So even though women comprise a higher percentage of the population among all older age groups, this estimation leaves out a significant number of the projected cases as men were not included. I want to emphasize how important it is to ask our patients about this.

Dr Lacy:  Stacy, thank you. Some amazing teaching points there. One is, it's not just women, it's men as well. Number 2, this problem is going to increase as we all continue with our careers. And number 3, although studies have measured this differently based on different definitions, certainly, anywhere between 3 to 14% and maybe a good 5 to 6% of our patients have this problem, which is really impressive and highlights the need to attack this.

For some of our listeners who may not routinely see these patients in clinic, we recognize, you and I recognize, how truly debilitating this can be. Can you explain how this can affect their quality of life?

Dr. Menees:  Definitely. Patients who have fecal incontinence, their quality of life is significantly impacted. These patients suffer from embarrassment and psychological distress. These patients know where the bathrooms are at all time, and fecal incontinence is unpredictable. It's because of this unpredictability and the prior episodes that these people have faced—they're in Home Depot, and their stool running down their pants. I've had many patients tell me about all these different episodes.

That leads to social isolation. They can't leave their house because they don't know what's going to happen. Obviously, even though now we're in a virtual world, but before when people had to be in person, it could lead to loss of jobs for some people.

Actually, barring all the things, glass-half-full with a pandemic here, virtual world has helped people with fecal incontinence in that respect. The other thing that is very sobering is that it is the second leading cause for nursing home placement, fecal incontinence, so it's a big deal.

Dr Lacy:  It is a big deal, and I've heard my patients say they can't go out, they don't go to church, they don't go to the grocery store. That concept of social isolation is so important. Thank you.

Stacy, this could be a sensitive topic for many patients for some of the reasons you've just alluded to. How do you broach this topic? What are some of the tips for our listeners on how we can make patients feel more comfortable discussing FI or fecal incontinence?

Dr. Menees:  I agree. This is incredibly sensitive area for patients. I want to highlight again how they don't talk about it. Research has demonstrated that people with fecal incontinence don't seek care. There is a study by Brown where two-thirds of women who had severe impact on quality of life, 40% of those did not seek care.

Then, even in our own study at the VA, where 36% of people had at least an episode of fecal incontinence once per month, and none of those people had that as a presenting complaint because nobody wants to talk about it. One simple way is to make sure that you have fecal incontinence—or what patients like better is accidental bowel leakage—as the term. That has less stigma with it. I would put that in your review systems, however you're collecting review systems, if it's by the computer, if it's by paper. I would make sure that that is listed under your review systems in your gastrointestinal area. I would also put it in your RV review systems for people.

And you have to double-check that you look at the review system so that if the patient has marked it you bring it up to them, because again, they are just not going to volunteer this to us. We have to actively seek out this disorder.

Dr Lacy:  Great teaching points, and 1 trick too, is sometimes people, once they have an accident or incontinence, but they have diarrhea, when somebody tells me they have diarrhea, "Do you mean that sometimes you might have," or I try to lead the field that way.

Dr. Menees:  I agree. Absolutely.

Dr Lacy:  Stacy, what are some of the most common causes of fecal incontinence? What should we be asking in clinic to try to help tease out why this may have happened? Do you have a list of questions about standard risk factors for fecal incontinence?

Dr. Menees:  Usually, the etiology for fecal incontinence is actually multifactorial. About in 80% of patients, there's at least more than 1 pathophysiologic factor that causes fecal incontinence. I usually put these into the following categories. One is physical status. I look at age, obesity, limited physical activity like mobility. People are not able to race to the bathroom are going to be affected if they have a loose stool, if they have urge.

I look at other neuropsychiatric conditions, so multiple sclerosis, back pain, spinal cord injury, and then trauma, of course. It's not just women. Hemorrhoidectomy, prostatectomy, radiation. Lastly I look at associated causalities, and the biggest one is diarrhea, like you said. Usually, it's that loose stool or diarrhea. It's the straw that breaks the camel's back.

Consistently across all population-based studies, diarrhea and fecal urgency are the biggest risk factors associated with fecal incontinence. I always think about, as a gastroenterologist, this is our patient population, our IBS, our IBD, our celiac. Anyone who is at risk for diarrhea, who comes in for diarrhea, I agree. I always ask if they have accidents. Do you ever lose control?

An important one is age. Age is an established risk factor. You have to inquire in your older patients because this is the largest group of patients with fecal incontinence. We already talked about gender is not a risk factor, and you have to enquire in male and female patients.

Then, we often commonly think of women with the risk of pelvic floor due to the burden of childbearing. Some highlights I want to point out here about the episiotomy is a risk factor, and so important to prevent this, that the American College of Obstetrics and Gynecology put out a position statement in 2002 saying to avoid routine episiotomy.

Some other things when you're asking your patients about second stage of labor, they may not remember this but they'll know if they had vacuum-assisted or forceps delivery and then obviously if they had a perineal laceration.

But I don't want to forget about men, because men have insults to their pelvic floor that we already talked about, which is prostate cancer, surgery, hemorrhoidectomy, radiation.

Then lastly, a big group of people that sometimes we forget about are people with diabetes mellitus, and that's 10% of the population. They have multiple mechanisms that can increase their risk for fecal incontinence. This is definitely an important group to consider.

Dr Lacy:  Nice list of things we should all be thinking about and asking about. Stacy, I want to tease something out because we've mentioned it now twice about aging. Is fecal incontinence just a natural part of aging? Will everybody become incontinent when they're 90 or 100, or does there have to be some other insult and then aging layers on top of that?

Dr. Menees:  It is the latter. We always want to age gracefully. Incontinence is an incredibly complex process that involves the internal and external sphincter, a compliant rectum, a functioning puborectalis muscle, a neurologically intact anal sphincter complex, and functional pelvic floor.

As we talked about age as a risk factor, there's a reason for that. There are multiple physiologic factors with that. Both sphincters are affected by aging. The internal anal sphincter will get fibrotic and thicken. That can lead to decreased resting tone. For the external anal sphincter, it can thin. That can cause a weak squeeze pressure.

Additionally, we've seen in manometric studies that older age is associated with decreased rectal sensation, rectal compliance, and rectal capacity. However, that said, there are many seniors that are continent until they die. It is another insult that is on top of that. It's not the only thing.

Dr Lacy:  Wonderful. Stacy, let's shift gears for a second, and let's talk about diagnosis. Is the history enough if somebody says they're having accidents and leaking and maybe losing full control of their bowel, is that enough? Or do you need to do an exam? Do you need to do a rectal exam? Will that tease out the cause, or help identify the severity of fecal incontinence?

Dr. Menees:  Definitely, history is the first step, and that's enough for the diagnosis of fecal incontinence. On history, it's important to subtype the disorder. Is it active? Do they have the episodes with an urgency? Or is it happening while at night, or while they're sitting there, they don't have a clue? They go to the bathroom and they check their underwear, and there's an accident.

I also want to know about the consistency of the stool when it occurs. I actually do show all patients the Bristol stool form scale. I admit it. I have it with me in my pocket. If somehow I don't, you bet, I am pulling up the computer and I'm showing him an image on Google of the Bristol stool form scale because I want to know when it happens, with what stool form did it occur?

Because we talked about that fecal incontinence occurs with two-thirds of people with diarrhea that I ask the key question, "When you have a formed solid stool, do you have an accidental bowel leakage?" Then I've got some good hope there that if I reverse the reversible, I can make them continent again.

There's obviously numerous reasons for patients to have diarrhea that we need to identify. Certainly, in certain populations, if they're having nocturnal watery diarrhea, if there's inflammation that I see with fecal calprotectin, I have ordered colonoscopies in these patients.

I also want to know about when it happens. If it only occurs after a bowel movement, like a post-defecation episode of fecal incontinence. I'm thinking about either a rectocele, weakness of the rectal wall. Also, pelvic floor dyssynergia. People are not getting everything out, so then they have soiling afterwards. Just trying to help.

The other thing I do want to highlight, or I'll talk about this a little bit more, maybe, is about constipation. It's not uncommon for elderly patients have fecal overload and overflow FI. That's why it's important to do a physical exam. A rectal exam can tease out the cause. By your rectal exam, you're going to know what's going on with the internal and external anal sphincter. If you see a patulous anus or there's decreased resting tone, you know the internal anal sphincter is not working. When you're doing your digital rectal exam, you always ask patients to squeeze your finger. If it's weak, you know that they're going to have urge incontinence, and that's a contributor.

Lastly, you're doing the rectal exam. You want to make sure there's not a big bolus of stool there. That's the other thing because that, people easily can seep around. You've got to do the opposite. Definitely, rectal exams are really important.

Dr Lacy:  A wealth of information there, Stacy, and a great teaching point as you finish there was patients with constipation, and sometimes fecal impaction can be incontinent as well, so that rectal exam is critical.

Thank you for joining us today. We're looking forward to have you join us on our next discussion as Dr. Menees and I discuss fecal incontinence, including treatment options.