Fecal incontinence: just ask!

Martha Spencer MD FRCPC, Providence Health Care, Clinical Instructor, UBC (biography and disclosures)

Disclosures: Speaking honorarium (unrestricted), fellowship bursary, clinic grant, unrestricted research grant (Pfizer); Speaking honorarium (unrestricted), national geriatric consultant meeting, conference symposium (Astellas). Mitigating bias: Treatments or recommendations in this article are unrelated to products involved in disclosure statements. Recommendations are consistent with current practice patterns.

What frequently asked question I have noticed

Fecal incontinence (FI), defined as the involuntary passage of stool or the inability to control the expulsion of stool (1), is a common but under-reported condition that can affect people of all ages but has increased prevalence in older adults.

Data that answers this question

A recent population-based survey in the US found that 1 in 7 people in this population were affected by FI (2). Despite this high prevalence, FI remains an under-recognized, under-diagnosed and under-treated condition. FI is a treatable and potentially even curable condition. FI, just like urinary incontinence, is NOT a normal consequence of aging! FI and diarrhea are NOT synonymous. Diarrhea, the frequent passage of loose stools, may lead to new or worsening FI but does not have to be present for FI to exist. As such, it should be considered as a separate entity and should prompt additional investigations, including testing for infectious and inflammatory causes.

What I recommend (practice tips)

Here are a few tips that will get you started in building individualized treatment plans for your patients:

1. To start, determine the type of FI- The types of FI to consider are urge (desire to defecate is present, loss of fecal matter occurs despite active steps to avoid), passive (no awareness, and therefore no attempt to avoid loss), and seepage (normal evacuation followed by leakage of stool).
2. Active case finding is key- All older adults should be screened for FI, especially those with identified risk factors such as advanced age, chronic kidney disease, depression and concomitant urinary incontinence (3). Since patients are often reluctant to discuss FI with their care providers, simply inquiring about the presence of FI (“Do you leak stool or have difficulty controlling your bowel movements”) is recommended (4).  If patients endorse FI, bowel diaries (handout 1) along with the Bristol Stool Chart should be used to assess severity and consistency of stools in FI (4).
3. Beware the red flag symptoms- These include persistent unexplained change in bowel habits for 3 months, rectal bleeding or mucus, unexplained weight loss, anemia and family history of bowel cancer which should prompt a referral for a colonoscopy. New onset FI associated with back pain and neurological abnormalities in the lower extremities necessitates an urgent MRI.
4. Think outside the GI system- The nervous system plays a key role in normal defecation. Disorders of the central nervous system (ex. stroke, dementia) and peripheral nervous system (ex. diabetes, toxins such as chemotherapy and alcohol) are often contributing causes in older adults.
5. Blame medications- Common culprits are magnesium supplements, ranitidine, proton pump inhibitors, metformin and cholinesterase inhibitors. These loosen stool and make passage more difficult to control.
6. Do a complete rectal exam- This should include an external exam to look for skin breakdown, hemorrhoids, anal fissures and prolapse, an internal exam to determine presence of stool and strength of contraction, and a neurological screen with anal wink and saddle sensation (S2-S4).
7. Investigations can often be kept to a minimum- Bloodwork including hemoglobin, calcium, TSH, HbA1C and albumin can be considered in select patients depending on symptom duration and stool quality. Stool studies and hydrogen breath tests (for lactose intolerance and bacterial overgrowth) may be ordered in those with FI associated with loose stools, flatulence and bloating.  Imaging, including rectal ultrasound or MRI, can be ordered in rare cases where a structural cause of FI is suspected.

Treatment  

1. Education on lifestyle interventions is a good starting point- Relevant lifestyle factors include avoiding fatty foods, caffeine and artificial sugars, as well as encouraging regular exercise. Recognizing and avoiding constipation with the use of regular osmotic laxatives is also key as overflow FI (impaction in the colon and rectum leading to loose, difficult to control stool passage) is common.  Use of zinc oxide-based creams is important in preventing skin breakdown and irritation.
2. Contract those muscles!- Kegel exercises, a cornerstone of treatment for urinary incontinence, are important for FI too. Kegels strengthen the external anal sphincter and puborectalis muscles, which is important in elderly patients who may be deconditioned and have reduced muscle strength.  Pelvic floor physiotherapists can play an important role for all patients, especially those who have lost awareness of how to properly contract their pelvic floor. The addition of biofeedback (use of a probe within the rectum) can have additional benefit when added to pelvic floor physiotherapy, as it allows patients to obtain sensory and visual feedback to guide anal contraction (5).
3. Medical therapy is a reasonable next step- Over-the-counter products are first-line in terms of medication management for FI. For those with normal storage capacity, bulking agents containing psyllium (ex. Metamucil, starting at 1tbsp/day, and gradually increasing to 4 tbsp/day) is the first-line option.  Caution should be taken in elderly patients with reduced mobility who are unable to drink adequate amounts of fluid as psyllium products may lead to constipation in this population.  Similarly, those with reduced storage capacity (rectal surgery, radiation, inflammatory bowel disease) may need to reduce dietary fibre in order to decrease the amount of stool for their reduced holding capacity.   Anti-diarrheal agents can be considered in FI, as they slow transit time and may increase internal anal sphincter tone (6).  Loperamide, which is preferred over others as it does not cross the blood-brain barrier, should be taken only on as as-needed basis before outings when patients may be concerned about washroom access.  For patients with irritable bowel disease with loose stools and associated FI, 5HT3 antagonists (ex. Ondansetron) can improve stool consistency and lessen urgency (7).  It is postulated that such patients may also have bile acid malabsorption (8) and therefore bile acid sequestrants such as cholestyramine may also be effective (9).
4. Invasive approaches are second line- Anal plugs may be trialed in those with passive incontinence and weak anal tone, although are generally used only for short periods of time (ex. when going out or for a social gathering) as they are difficult to tolerate. Fecal irrigation systems, which use water to assist with bowel evacuation, may be especially useful in those with neurogenic bowel incontinence and can be trialed in those with post-operative functional FI (10).  Continuous sacral nerve stimulation has shown promise in those with refractory fecal incontinence and may be particularly attractive for those with both urinary and fecal incontinence due to its efficacy for both conditions (11).

Patient Handouts: handouts are ineffective without concurrent patient education from a health practitioner.

1. Bowel Diary. Accessed August 19, 2018. (View pelvicfloorcenter.org)
2. Food chart. Improving Bowel Function after Bowel Surgery. Retrieved June 20, 2017. Accessed August 27, 2018.  (View Food Chart) from bladderbowel.gov.au
3. Dealing with Diarrhea and/or Bowel Incontinence. St. Paul’s Hospital and Mount St. Joseph’s Hospital Continence Clinic. Accessed August 27, 2018. (View Handout Dealing with Bowel Incontinence)
4. Find a Pelvic Floor Physiotherapist in BC: (View Handout Find Pelvic Floor PT)

Algorithm for the initial treatment of FI (12):

Fig. 13. Initial management of Faecal Incontinence. Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourology and Urodynamics. 2010;29(1):213-240. DOI: 10.1002/nau.20870.

Referrals:

1. Elder Care: Geriatric Outpatient Clinic (View providencehealthcare.org)
2. Centre for Pelvic Competence for Women (View centreforpelvicfloor.ca)
3. BC Women’s: Self-referral and doctor referral accepted: (View bcwomens.ca)

References:

1. Shah BJ, Chokhavatia S, Rose S. Fecal incontinence in the elderly: FAQ. The American Journal of Gastroenterology. 2012;107(11):1635-1646. DOI: 10.1038/ajg.2012.284. (View with CPSBC or UBC)
2. Menees SB, Almario CV, Spiegel BM, Chey WD. Prevalence of and factors associated with fecal incontinence: results from a population-based survey. Gastroenterology. 2018;154(6):1672-1681. DOI: 10.1053/j.gastro.2018.01.062. (Request with CPSBC or view with UBC)
3. Markland AD, Goode PS, Burgio KL, et al. Incidence and risk factors for fecal incontinence in black and white older adults: a population‐based study. Journal of the American Geriatrics Society. 2010;58(7):1341-1346. DOI: 10.1111/j.1532-5415.2010.02908.x. (View)
4. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. The American Journal of Gastroenterology. 2014;109(8):1141. DOI: 10.1038/ajg.2014.190. (View with CPSBC or UBC).
5. Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead WE. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Diseases of the Colon and Rectum. 2009;52(10):1730-1737. DOI: 10.1007/DCR.0b013e3181b55455. (View)
6. Sun WM, Read NW, Verlinden M. Effects of loperamide oxide on gastrointestinal transit time and anorectal function in patients with chronic diarrhoea and faecal incontinence. Scandinavian Journal of Gastroenterology. 1997;32(1):34-38. DOI: 10.3109/00365529709025060. (Request with CPSBC or view with UBC)
7. Garsed K, Chernova J, Hastings M, et al. A randomised trial of ondansetron for the treatment of irritable bowel syndrome with diarrhoea. Gut. 2017;63:1917-1925. DOI: 10.1136/gutjnl-2013-305989. (View)
8. Wedlake L, A’hern R, Russell D, Thomas K, Walters JRF, Andreyev HJN. Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea‐predominant irritable bowel syndrome. Alimentary Pharmacology & Therapeutics. 2009;30(7):707-717. DOI: 10.1111/j.1365-2036.2009.04081.x. (View with CPSBC or UBC)
9. Remes-Troche JM, Ozturk R, Philips C, Stessman M, Rao SS. Cholestyramine—a useful adjunct for the treatment of patients with fecal incontinence. International Journal of Colorectal Disease. 2008;23(2):189-194. DOI: 10.1007/s00384-007-0391-y. (View with CPSBC or UBC)
10. Wilson M. A review of transanal irrigation in adults. British Journal of Nursing. 2017;26(15):846-856. DOI: 10.12968/bjon.2017.26.15.846. (View with CPSBC or UBC)
11. Leroi AM, Michot F, Grise P, Denis P. Effect of sacral nerve stimulation in patients with fecal and urinary incontinence. Diseases of the Colon & Rectum. 2001;44(6):779-789. (Request with CPSBC or view with UBC).
12. Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourology and Urodynamics: Official Journal of the International Continence Society. 2011;29(1):213-240. DOI: 10.1002/nau.20870. (Request with CPSBC or view with UBC)

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