By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
Older women with fecal incontinence manage their symptoms with dietary modification.
Andy UU, Ejike N, Khanijow KD, et al. Diet modifications in older women with fecal incontinence: A qualitative study. Female Pelvic Med Reconstr Surg 2020;26:239-243.
This was a qualitative study of older women with symptoms of fecal incontinence (FI). Women were included if they were 65 years of age or older and had current bothersome FI symptoms occurring at least monthly over the prior three months. FI symptoms were defined as any uncontrolled loss of liquid or solid fecal material.
Subjects also were required to be able to make adjustment to their diets. Women who resided in a care facility, and therefore were unable to adjust their diet, were excluded. Women with bloody diarrhea, diagnosis of colorectal/anal malignancy, or inflammatory bowel disease also were excluded.
This study employed qualitative research methods. Focus groups were conducted by a trained facilitator following a moderator guide to explore the relationship between diet and symptoms, the strategies women use to manage symptoms, and suggestions regarding dissemination of dietary information. The focus groups were audio-recorded and transcribed verbatim. Transcripts were coded independently by two authors supervised by a qualitative research scientist, and coding discrepancies were resolved by consensus. Codes were reviewed and grouped in thematic categories. Focus groups were conducted until no new concepts emerged and thematic saturation was achieved. Twenty-four women were enrolled in the study, and 21 participated in one of three focus groups. Participants were an average of 72 years of age (65-86), 38% were African American, and 62% were white. Subjects reported moderate to severe FI symptoms based on frequency of leakage, with one-quarter reporting daily leakage and more than one-third reporting leakage a couple of times per week. Researchers identified four thematic categories:
1. Discovery of a relationship between FI and diet: Participants reported an awareness that diet contributed to FI symptoms.
2. Dietary triggers for FI: Participants reported a range of foods that appeared to trigger FI, including caffeine, dairy (cheese and ice cream), meats, fruits, beans, leafy vegetables, juice, and sauces. Fried food preparation triggered FI symptoms. For some, having a large volume of food, or even eating, triggered fecal urgency and subsequent leakage.
3. Modifications and strategies used: Participants described several modification strategies, including avoiding food triggers, decreasing the quantity of food consumed, using supplemental fiber, modifying food preparation to avoid frying, giving preference to self-prepared meals, and eating smaller, more frequent meals.
4. Suggestions for dietary modifications for FI management: Participants described feelings of shame, which deterred them from seeking care, and thought they would benefit from providers directly addressing FI symptoms and diets with them. Participants preferred balancing modifications with the degree of improvement modifications achieved. Sharing successful techniques was very important to the participants, and many thought they would benefit from a support group.
COMMENTARY
FI, or accidental bowel leakage, is defined as the accidental loss of liquid and/or solid stool.1 The prevalence of FI is thought to be 7% to 15% in community-dwelling women and higher in care-seeking women.2 The risk factors for FI include diarrhea, chronic illness, neurological disorders, and sphincter trauma. Modifiable risk factors include smoking and obesity.2
The quality of life burden and emotional impact of FI can be devastating. The economic toll of FI also is quite significant. Despite this, women are reluctant to seek care, with less than one-third of affected women seeking care.3 A study of primary care providers at midwestern academic centers revealed that, although providers screen for urinary incontinence, most do not screen for FI.4 The women in the current study expressed a strong desire to have their providers inquire about FI symptoms and discuss treatment options. An electronic study of 6,000 women found that terminology used for FI screening was important, with 71% of women preferring “accidental bowel leakage” to “fecal incontinence” or “bowel incontinence.”5
The American College of Gastroenterology lists numerous treatments for FI, which can result in improvement or resolution of symptoms.6 These strategies include education, dietary changes, medications, and pelvic floor muscle rehabilitation with biofeedback. Women in the current study identified many helpful dietary modifications or strategies; however, it was not reported whether subjects had received prior counseling from providers. Many of the strategies women reported in this study, including avoiding dietary triggers, such as meats or dairy, caffeine, and fatty or greasy foods, align with those recommended by the American College of Gastroenterology.7
The efficacy of certain strategies may depend on the etiology of FI. Identifying specifics is critical when evaluating a patient with FI. For example, it is important to assess for frequency and timing of leakage as well as the presence of diarrhea and constipation. The Bristol Stool Form Scale (BSFS) is a helpful, validated tool that categorizes stools into seven types. The types range from type 1 (hard lumps) to type 7 (watery diarrhea).8 The BSFS chart can aid a provider in initiating a more detailed discussion of bowel function. Liquid stool is more difficult to control and, thus, it is essential to identify the presence of diarrhea to discriminate the presence of fecal urgency.
Post-cholecystectomy diarrhea is a frequently forgotten cause of diarrhea and severe fecal urgency. Ultimately, it contributes significantly to FI. Post-cholecystectomy diarrhea may affect more than one-third of patients who undergo cholecystectomy.9 Merely eating after a period of fasting (even a normal overnight fast) can be extremely problematic to a post-cholecystectomy patient.
Fortunately, dietary modification and medical treatment can affect post-cholecystectomy diarrhea significantly. In particular, patients benefit from eating smaller regular meals and avoiding long periods of fasting. Patients also benefit from consuming fiber regularly and avoiding greasy foods. Cholestyramine also has been associated with improvements in diarrhea and in diarrhea-related FI.
The study by Andy et al highlights the need for us all to inquire and start conversations about FI symptoms with our patients and empowers us all to discuss simple lifestyle modifications that may be of great benefit to our patients.
REFERENCES
- Sultan AH, Monga A, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. Int Urogynecol J 2017;28:5-31.
- Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: State of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol 2015;110:127-136.
- Brown HW, Wexner SD, Lukacz ES. Factors associated with care seeking among women with accidental bowel leakage. Female Pelvic Med Reconstr Surg 2013;19:66-71.
- Brown HW, Guan W, Schmuhl NB, et al. If we don’t ask, they won’t tell: Screening for urinary and fecal incontinence by primary care providers. J Am Board Fam Med 2018;31:774?782.
- Brown HW, Wexner SD, Segall MM, et al. Accidental bowel leakage in the mature women’s health study: Prevalence and predictors. Int J Clin Pract 2012;66:1101-1108.
- Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: Management of benign anorectal disorders. Am J Gastroenterol 2014;109:1141-1157.
- Bharucha AE. Fecal incontinence. American College of Gastroenterology. Updated July 2013. https://gi.org/topics/fecal-incontinence/
- Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32:920-924.
- Del Grande LM, Leme LFP, Marques FP, et al. Prevalence and predictors of changes in bowel habits after laparoscopic cholecystectomy. Arq Bras Cir Dig 2017;30:3-6.
