What to Know About Fecal Incontinence

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Dr. Scott Steele: So, hi again, everyone. Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And I'm very pleased to have one of our own within the department of colorectal surgery, Dr. Rebecca Gunter, who is a colorectal surgeon in Cleveland Clinic's Digestive Disease and Surgery Institute, practicing primarily at Main Campus, as well as Hillcrest Hospital. And we're going to talk a little bit today about something that we don't talk a whole lot about, and that's what to know about fecal incontinence. So Becca, thanks for joining us and welcome to Butts & Guts.

Dr. Rebecca Gunter: Thank you so much for having me.

Dr. Scott Steele: So we always like to start off first by telling a little bit about yourself, where you're from, where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Rebecca Gunter: So I'm mostly from the outside of the Chicago land area. I went to college at Miami University in Ohio and did my medical school training at Emory University in Atlanta. I did my general surgery training at the University of Wisconsin, and really became interested in colorectal surgery there. I enjoyed the variety of diseases, the diversity of the patient population and just found out that'd it be really interesting and very rewarding. And so I was very fortunate to have the opportunity to train at the premier place, to do colorectal surgery at the Cleveland Clinic and decided to stay on as faculty, after my training here.

Dr. Scott Steele: And we were so lucky to coerce you into staying. So we're going to talk a little bit about fecal incontinence. And again, this is something that we recognize that it's not like people walk around and say, "Hey, I have fecal incontinence." But it is probably much more prevalent than we care to take notice of. So on a very high level overview, what is fecal incontinence and what are some of the factors that contribute to it occurring?

Dr. Rebecca Gunter: So as you alluded to, fecal incontinence is a lot more common than I think people realize, especially because it isn't something that we talk about, but it does affect a large number of people. Up to 20% of adults have some component of fecal incontinence. And we define that as having new onset leakage of either gas or stool for over a month in someone who previously has had control of their bowels. So that's generally how we define that.

And a lot of factors can contribute to that. Classically, we see that in a middle-aged or older woman, who's had multiple children and develop some laxity or weakness in their pelvic floor. That's the classic picture of a patient, but we can also see it in patients who've had anal rectal procedures in the past with fissure or fistula surgery or after hemorrhoid surgery.

And then we can also see it in patients who've had surgery for rectal cancer and have had changes in their bowel habits and continence after they've been treated for their cancer. And so we've treated one problem, but then they're left with some symptoms following that treatment that we can address, including incontinence and urgency.

Dr. Scott Steele: Kind of a straightforward question, but how does one diagnose fecal incontinence?

Dr. Rebecca Gunter: Yeah. So part of it is a clinical diagnosis. A patient comes in and says, "This is what I'm experiencing, and this is how often I'm having incontinence." So a lot of it is about a patient history. But once someone comes in, and describing those symptoms and there's some workup that's involved after that to figure out what is causing it and what kinds of, sort of, just leading us down various treatment pathways.

Dr. Scott Steele: Truth or myth. If I have diarrhea, it means that I have fecal incontinence.

Dr. Rebecca Gunter: That is a myth. They can go together. But just the fact of having loose stool doesn't mean that you are in incontinent, if you're able to control it. If you have leakage of stool, then that's when we start to think about incontinence, but often if it's the case that it's leakage of loose stool, our first move is to see if we can treat the diarrhea and bulk up the stool. And if you're still having incontinence of formed stool, that's when we get you down more of the treatment pathway for fecal incontinence.

Dr. Scott Steele: Becca, just for, there's a lot of people that listen to this, and these are topics they have these questions and they're too scared almost to ask them. So couple of scenarios. So I got to go to the bathroom right now, does that mean I have fecal incontinence? I wake up and I have stains in my underwear and I don't really want to tell anybody, does that mean I have fecal incontinence? Or I get up and I wipe my bottom and then I got to wipe again a little bit later, do those things mean that you have fecal incontinence?

Dr. Rebecca Gunter: They certainly can. If you're having uncontrolled leakage of stool, or if you have some urgency where you really have almost no time to get to the bathroom, and if you're not sitting right next to the bathroom and you leak stool, then that can fall in the category fecal incontinence and is something to potentially talk to your doctor about.

Dr. Scott Steele: So truth or myth, changing your diet can improve incontinence.

Dr. Rebecca Gunter: For some people, it certainly can. And one of the first things we'll ask patients to do if they come in with incontinence is to keep a diary of the foods that they eat. And if there are things that set them off. Some of the common offenders being things like dairy, caffeine, spicy foods, sometimes even chocolate, some of the really enjoyable things in life can certainly stimulate fecal incontinence.

So everybody's a little bit different, the things that will trigger those episodes. So keeping track of what are the things that seem to cause the fecal incontinence and seeing if cutting those things out of your diet help. And conversely things like adding more fiber to your diet or eating things like, you know, healthy fruits and vegetables and whole grains can sometimes help provide more bulk to your stool and improve your continence.

Dr. Scott Steele: So are there any other methods that we can use, non-surgical treatment options? Or what is bowel training and how can that help?

Dr. Rebecca Gunter: Yeah. So if it's really just a matter of your pelvic floor being a little weak, things that we could do are have you see one of our pelvic floor physical therapists. And that's very similar if you have a sports injury, where you have weakness in your hip or your shoulder or something like that, we can also do training of your pelvic floor and sphincter muscles, to help get you a little better coordinated and improve your strength and control.

And then sometimes just changing your diet or adding some medications to bulk your stool and then getting you stronger with physical therapy that sometimes is all that some patients need to get improved continence.

Dr. Scott Steele: So let's talk a little bit about surgical treatment. What are some of the options that are out there and, kind of, can you categorize them in terms of when they're recommended?

Dr. Rebecca Gunter: Sure. I think before we even talk about what surgical treatments are on the table, we would want to do a workup to determine what the incontinence is from. That will send people down various treatment pathways. Some people have incontinence because they have prolapse of their rectum and those patients would benefit from a surgery to fix their prolapse. And there are a variety of surgeries that we would do to fix the prolapse, but that sends people down one pathway of having prolapse repair.

But then patients who don't have prolapse, but just have some weakness of their sphincters or their pelvic floor, there are a number of different procedures that have been described. Some surgery would involve repairing their sphincters directly with an operation to bring their sphincters back together. That would be typically for women who have a sphincter defect related to having had traumatic vaginal delivery.

That's not done quite so often anymore because it doesn't seem to have very durable results. There are some nonsurgical devices that are used to either plug up the anus itself or to provide some bulk through the vagina to keep the rectum closed. Those can be kind of tricky and can be difficult to get fitted or approved by insurance. So those are also not used as often.

But the thing that has become the most standard surgery out there is something called sacral nerve stimulation or sacral nerve modulation. And that is a permanent device that gets implanted, that provides stimulation to the pelvic floor and also to the brain to improve coordination and strength on the pelvic floor and improve continence.

There's a test phase that's done initially to see if patients will respond to that kind of stimulation and if they do, we move on to putting in a permanent device. And patients who respond to that do really well. We have over 80% of patients who get at least a 50% improvement in their symptoms. And then about a 30 to 40% of patients who have full control of their bowel movements after implantation. So patients do quite well with that procedure, once they've gone down the pathway, like I described, and we think that they're a good candidate for it.

Dr. Scott Steele: So you mentioned this earlier, so, you know, if I'm a listener out there and I worry that I have a little bit of fecal incontinence, sometimes it's a little embarrassing to kind of go forward. But what can a patient expect in a visit with you or a member of your team in the department of colorectal surgery?

Dr. Rebecca Gunter: Yeah, I think one of the first things that you can expect is that we understand and are not embarrassed by it. And it's something that we see quite a bit and we're happy to have you come and talk with us about it. And it is quite a lot more common than people expect. So you shouldn't be embarrassed or feel like you're the first person to walk in the door saying you're having the symptoms.

So our first step should be to reassure you that this is normal and it's something that we can take care of. But then we would ask you for a full history of what your symptoms are like, how often you have episodes of incontinence? Is it just the stool or is it also to gas? And does it matter if your stools are liquid or formed? All of that, what are your symptoms like? What kinds of surgeries have you had in the past, particularly any colorectal surgery or any surgery on your anus?

And then we would talk about the various testing that we would need to do to put you into one of those buckets like I'd said. Is it because you have prolapse? Is it because you just have weakness? And there are a couple different tests we would do to sort that out. And we could talk about that more in the clinic, but those would be things like manometry to look at your sphincter strength and coordination, a test like defecography that's done in radiology to look at what is happening in your pelvic floor when you have a bowel movement, to see is that prolapse or is it just weakness?

So after those testing, we would do ourselves a really good physical exam to test to see what your sphincter muscles and coordination are like. Get a good history of any medications that you're on. Any dietary changes, things like that. And we'd send you home with a bowel diary so you keep track of what your bowel movements are like, how often are you having leakage of stool?

If you can come to that first appointment with that information, that's really helpful to say, having it about this many times in a week with this consistency. I've already made these dietary changes, but if you haven't done that already, that's fine too. And then we would get you down a treatment pathway to see if we can help you out with your symptoms.

Dr. Scott Steele: Well, that's great stuff. And so now it's time for some quick hitters to get to know our guest a little bit better. So what's your favorite food?

Dr. Rebecca Gunter: Oh, gosh, my favorite food. I really like a scrambled eggs hash in the morning with vegetables and some hot sauce.

Dr. Scott Steele: Sounds delicious. I like that. So what is your favorite sport, either to play or to watch?

Dr. Rebecca Gunter: Oh man, my favorite sport to play or watch is soccer. Not really good at it, but that's what I played growing up and I really like to watch it.

Dr. Scott Steele: And what's a favorite place that you visited or grown on a trip?

Dr. Rebecca Gunter: I went to Cambodia several years ago, went to Angkor Wat. I liked seeing the temples and the history there.

Dr. Scott Steele: Yeah, I've only seen pictures, but it looks awesome. And so finally you've been in a lot of different places. What is something that you like about here in Northeast Ohio?

Dr. Rebecca Gunter: I think in Northeast Ohio, the people are really great. Really friendly, very welcoming, and Cleveland has a good variety of things to do with advantages of a big city, but a small town feel. And then lots of opportunities to get outside in the Metropark system.

Dr. Scott Steele: So what is a final take-home message for our listeners regarding fecal incontinence?

Dr. Rebecca Gunter: Yeah, I'd say that the people that I see who come with this complaint are often really bothered by it with their quality of life. And also obviously are a little embarrassed about it. And I would just say, don't let that stop you from getting help because there are options out there to give you your life back and we're happy to have you come in and see us.

Dr. Scott Steele: That's fantastic. And I echo that tremendously. And so to learn more about fecal incontinence, colorectal surgery,ema and the various treatment options at Cleveland Clinic, please visit clevelandclinic.org/colorectalsurgery. That's clevelandclinic.org/colorectalsurgery. And to speak with a specialist in the Digestive Disease and Surgery Institute, please call 216-444-7000. That's 216-444-7000.

And remember it's important for you and your family to continue to receive medical care, receive regular checkups and screenings. Rest assured here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and to protect our patients and caregivers. Becca, thanks for joining us on Butts & Guts.

Dr. Rebecca Gunter: Thank you so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.