My Approach to Fecal Incontinence: It s all about Consistency (Stool, that is)

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1 THE RED SECTION 977 see related editorial on page x My Approach to Fecal Incontinence: It s all about Consistency (Stool, that is) Stacy B. Menees, MD, MS 1, 2 Am J Gastroenterol 2017; 112: ; doi: /ajg ; published online 20 June 2017 DEFINITION AND SCOPE OF FECAL INCONTINENCE Fecal incontinence (FI) is defined as the recurrent uncontrolled passage of fecal material at least for 3 months in an individual older than 4 years of age ( 1 ). Flatal incontinence is included in the definition of anal incontinence, but not in the current diagnosis of FI. FI is a troublesome disorder that affects up to 4.8% of Americans weekly ( 2 ), and up to 8.39% monthly ( 3 ). The incidence of FI is expected to increase with the aging of our population. Data for these projections have only been attained in women, however there should be a similar increase in men. Wu et al. (4 ) estimated the future prevalence of FI in women alone using the U.S. Census Bureau population projections from 2010 to FI is expected to have the largest increase, at 59%, of all pelvic floor disorders with a projected increase from 10.6 million to 16.8 million affected women. ASK THE PATIENT Patients are embarrassed to discuss this problem and are unlikely to volunteer this complaint freely. Dunivan et al. ( 5 ) found 36.2% of patients reported FI on a cross-sectional survey, but only 2.7% had a medical diagnosis of FI. I can t stress enough the importance of asking the patient. One must actively seek out this disorder. Ask both your male and female patients, as FI occurs equally in both ( 3,6 ). You must inquire in your older patients, as age is an established risk factor along with any gastrointestinal (GI) disease associated with diarrhea ( 2,3,6 ). Diarrhea alone is a significant risk factor as two-thirds of FI episodes are due to watery stool ( 6 8 ). As gastroenterologists, we see a large amount of disorders/diseases associated with diarrhea. We should ask patients with celiac disease, irritable bowel syndrome and inflammatory bowel disease if they have FI ( 2 ). However, the etiology of FI is often multifactorial. Table 1 has a list of associated factors with FI. Patients prefer the term accidental bowel leakage vs. fecal incontinence or bowel incontinence ( 9 ). One simple way of starting the conversation with your patients is by ensuring that the term accidental bowel leakage (ABL) is on the GI review of systems for new patients and return-visit paperwork. It is then crucial to follow-up on what the patient has marked, as again, patients may not openly discuss this. Brown et al. ( 10 ) discovered that two-thirds of women with FI did not seek care for their symptoms even though 40% of them had symptoms severe enough to impact their quality of life. In addition, Hosmer et al. ( 11 ) found that in a cross-sectional survey of veterans in gastroenterology clinic, no patients with FI had this as their presenting complaint. EVALUATION AND TREATMENT Once you have established the presence of ABL with your patient, you should differentiate between fecal soiling and FI. Fecal soiling defined as staining or streaking of underwear has a different spectrum of causes (i.e., pelvic floor dyssynergia, rectocele, radiation therapy, prolapsing hemorrhoids,and iatrogenic anal injury) and responds to different treatments as compared to FI. For women with rectoceles, I instruct them on how to properly splint with the consideration of sending them for surgical evaluation. Post bowel movement, I recommend restraining from excess wiping, and using an alcohol-free flushable wipe. To help with hygiene, I ask the patient to place a cotton ball at the anus to act as a wick. Patients with pelvic floor dyssynergia can benefit from physical therapy retraining. Fiber can also be used as a first-line agent to help bulk up the stool. However, some patients may require the use of a rectal suppository or rectal irrigation to clear the anal canal and rectum if they fail to respond. For FI, it is also important to subtype the disorder. Is it active (i.e., associated with urge) or passive, (i.e., insensate), and also the consistency of stool when it does occur? I often show my patients the Bristol Stool Form scale, (I admit, I have a laminated copy in my coat) to help them describe their stool consistency. Since approximately two-thirds of patients who have FI, have it associated with loose stool, a reason for their loose stool should be sought. I ask the key question, when you have a formed/solid stool, do you have ABL? If they do not have FI with a formed 1 Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA ; 2 Division of Gastroenterology, Department of Internal Medicine, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA. Correspondence: Stacy B. Menees, MD, MS, University of Michigan, Gastroenterology, 3912 Taubman Center, SPC 5362, Ann Arbor, Michigan , USA. sbartnik@med.umich.edu 2017 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

2 978 THE RED SECTION Table 1. Risk factors for FI Patient level factors Increasing age Female gender (controversial) Non-Hispanic African American (protective) Asian (protective) Latino Active tobacco use Obesity Nursing home Gastrointestinal factors Loose/watery stools Frequent bowel movements (>21 per week) Rectal urgency Irritable bowel syndrome Infl ammatory bowel disease Celiac disease Constipation/fecal impaction Rectal sensation disorders Rectal hyposensitivity Rectal hypersensitivity Medical co-morbidities Urinary incontinence Multiple chronic illnesses Debility Dementia Enteral tube feeding Diabetes Neurologic disease/prior stroke History of pelvic radiation Scleroderma Spinal cord injury Multiple sclerosis Radiation Prior Surgery Hysterectomy Menopause Obstetric History Multi-parity Sphincter laceration/episiotomy Prolonged second stage of labor Vacuum extraction Vaginal delivery with forceps Birth weight >8.8 lbs Pelvic floor disorder Rectocele Descending perineum syndrome Rectal prolapse Drugs i.e., Metformin, colchicine, laxatives stool, then we must find the reason for the diarrhea and help prevent FI. Having a formed bowel movement will eliminate their episodes of FI. There are numerous reasons for patients to have diarrhea which are important to identify ( Figure 1 ). With a careful history, and eliciting red flag signs, such as nocturnal liquid bowel movements and FI, I have ordered colonoscopies that aid in the diagnosis of disorders that favor FI (i.e., microscopic colitis, IBD). I also do a careful diet history specifically looking for triggers that could be causing their loose stool, thus FI. There are a lot of stimulants and nonabsorbable/poorly digested carbohydrates in the diet that could be causing their symptoms. Caffeine is a known stimulant of the gut ( 12,13 ) and I have encountered patients who drink an abundance of caffeine-laden drinks daily. I also ask about the episode of FI and how it relates to a bowel movement. If the episode occurs only after a bowel movement, then one must consider a rectocele in the differential. In addition, it s important to consider constipation and fecal impaction as a reason for FI. It is not uncommon for elderly patients to have fecal overload and overflow FI ( 14 ). A digital rectal exam to assess for sphincter defects, rectal tone, and fecal impaction will aid in differentiation and help guide treatment. If we also look back at the continence physiology to aid/guide treatment, we must consider the muscles involved, rectal sensation, and rectal compliance. The internal anal sphincter (IAS), responsible for keeping the anal canal closed at rest, allows sampling of stool continence and enhances continence of liquid stool and flatus. Therefore, a deficit in the IAS from direct injury or damage to the afferent nerves can lead to passive incontinence. Patients with these symptoms may respond best to augmentation of the sphincter with injectable bulking agents, use of the Eclipse system, or scheduled toileting to make sure the rectum is clear. Small volume incontinence may be prevented with the use of Renew inserts. The external anal sphincter provides emergency control of liquid stool and flatus, and a symptom of this deficit is fecal urgency and urge-related loss of liquid stool. In addition, the puborectalis muscle maintains continence of solid stool. Both deficits can be associated with injuries to the muscles or nerves to cause pelvic floor muscle weakness. For the urge-related loss of liquid stool, I first concentrate on changing the patient s stool consistency. This includes dietary measures, including fiber usage and use of loperamide. Both of these deficits can respond to physical therapy with biofeedback and if there is still no improvement after the above has been tried, consider sacral nerve stimulation as this treatment is associated with a 40% continence rate. For issues with rectal sensation and compliance, use of rectal balloon training may prove beneficial (15 ). Cholecystectomy Anorectal surgery Internal sphincterotomy Hemorrhoidectomy Fistulectomy Anterior resection of the rectum Colectomy with ileoanal pouch anastomosis CONCLUSION Needless to say, FI needs to be sought out as patients often suffer in silence. We must address this for our patients as fecal incontinence is not a one size fit all disorder. We can give hope to our patients about future therapies and also concentrate on what we can accomplish with the goal of improving quality of life with the therapies available. The American Journal of GASTROENTEROLOGY VOLUME 112 JULY

3 THE RED SECTION 979 Fecal incontinence Solid stool No Clinical evaluation (DRE) Fecal impaction Liquid stool Yes Treat for chronic constipation ARM Assess reasons for diarrhea EAS weakness EAS/IAS weakness PT referral for bowel feedback IAS weakness - Diet - Drugs -Carbohydrate intolerance -IBS -IBD Microscopic colitis Improves Does not improve Consider colonoscopy for red flags -Optimize medical theraphy Radiologic evaluation: deefocography, dynamic MRI, anal USN per exam Solid stool Prolapse /rectocele -consider surgical repair -If sphincter defect then add overlapping sphincteroplasty No additional anatomic abnormalities -Sacral stimulation Yes, FI unresolved No, FI resolved -Solesta Improves Does not improve -Eclipse system FI unresolved Fecal diversion stoma Figure 1. Algorithm for evaluation and treatment of FI by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

4 980 THE RED SECTION CONFLICT OF INTEREST Guarantor of the article: Stacy B. Menees, MD, MS. Specific author contributions: Stacy B. Menees wrote the manuscript. Financial support: None. Potential competing interests: None. REFERENCES 1. Rao SS, Bharucha AE, Chiarioni G et al. Functional anorectal disorders. Gastroenterology 2016 ;150 : Menees SB, Almario CV, Spiegel BMR et al. Prevalence and predictors of bowel incontinence: results from a US population-based study. Am J Gastroenterol 2016 ;111 :S D it a h I, D e v a k i P, Lu ma H N et al. Prevalence, trends, and risk factors for fecal incontinence in United States adults, Clin Gastroenterol Hepatol 2014 ; 12 : e Wu JM, Hundley AF, Fulton RG et al. Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to Obstet Gynecol 2009 ;114 : Dunivan GC, Heymen S, Palsson OS et al. Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization. Am J Obstet Gynecol 2010 ;202 :493 e1 493 e6. 6. Whitehead WE, Borrud L, Goode PS et al. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 2009 ;137 :512 7 e Bh ar u ch a A E, Z i ns m e i ste r A R, S ch l e ck C D et al. Bowel disturbances are the most important risk factors for late onset fecal incontinence: a population-based case-control study in women. Gastroenterology 2010 ; 139 : Goode PS, Burgio KL, Halli AD et al. Prevalence and correlates of fecal incontinence in community-dwelling older adults. J Am Geriatr Soc 2005 ;53 : Brow n H W, We x ne r SD, S e g a l l M M et al. Accidental bowel leakage in the mature women's health study: prevalence and predictors. Int J Clin Pract 2012 ;66 : Brown HW, Wexner SD, Lukacz ES. Factors associated with care seeking among women with accidental bowel leakage. Female Pelvic Med Reconstr Surg 2013 ;19 : Hosmer AE MS. Prevalence and severity of accidental bowel leakage in a U.S.Veteran Gastroenterology Clinic. Am J Gastroenterol 2015 ;110 :S Brown SR, Cann PA, Read NW. Effect of coffee on distal colon function. Gut 1990 ;31 : Wald A, Back C, Bayless TM. Effect of caffeine on the human small intestine. Gastroenterology 1976 ;71 : Yu SW, Rao SS. Anorectal physiology and pathophysiology in the elderly. Clin Geriatr Med 2014 ; 30 : Bols E, Berghmans B, de Bie R et al. Rectal balloon training as add-on therapy to pelvic floor muscle training in adults with fecal incontinence: a randomized controlled trial. Neurourol Urodyn 2012 ; 31 : The American Journal of GASTROENTEROLOGY VOLUME 112 JULY

5 GASTROENTEROLOGY ARTICLE OF THE WEEK October 5, 2017 Menees SB. My approach to fecal incontinence: It s all about consistency (Stool, that is). Am J Gastroenterol 2017;112; Which of the following are risk factors for fecal incontinence? a. Asian ethnicity b. Use of metformin c. Cholecystectomy d. History of prolonged straining during bowel movements 2. The purpose of a rectal exam in the evaluation of fecal incontinence is to: a. Assess for the presence of diarrhea b. Exclude fecal impaction c. Feel for a rectocele d. Assess for sphincter tone and sphincter defects True or False 3. Incontinence that occurs in association with the urge to defecate often responds to interventions that change stool consistency 4. The majority of incontinence episodes occur with formed stool 5. Fecal staining or streaking in the underwear is usually the prelude to developing fecal incontinence 6. Fecal incontinence episodes that occur only soon after a bowel movement raise the possibility of a rectocele 7. A defective internal anal sphincter will result in active incontinence (associated with urge) 8. Anorectal manometry testing is more helpful in the evaluation of patients with solid stool incontinence compared to those that present with liquid stool incontinence