By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: Older women with fecal incontinence manage their symptoms with dietary modification.
SOURCE: 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 ≥ age 65 years and reported 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 adjust their diets. Women who resided in a care facility, and therefore could not adjust their diet, were excluded. Women with bloody diarrhea, diagnosis of colorectal/anal malignancy, or inflammatory bowel disease also were excluded.
The study authors used qualitative research methods. A trained facilitator following a moderator guide conducted the focus groups. During these sessions, they explored the relationship between diet and symptoms, the tactics women use to manage symptoms, and suggestions regarding dissemination of dietary information. The focus groups were audio-recorded and transcribed verbatim. Under the supervision of a qualitative research scientist, two authors independently coded the transcripts. 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 occurred.
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:
- Discovery of a relationship between FI and diet: Participants reported an awareness that diet contributed to FI symptoms.
- 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, eating a large volume of food, or even consuming any food at all, triggered fecal urgency and subsequent leakage.
- Modifications and tactics used: Participants described several modification tactics, including avoiding food triggers, eating less food, using supplemental fiber, modifying food preparation to avoid frying, giving preference to self-prepared meals, and consuming smaller, more frequent meals.
- 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 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 effect of FI can be devastating. The economic toll of FI also is quite significant. Despite this, women are reluctant to seek help, 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 Andy et al study expressed a strong desire for their providers to inquire about FI symptoms and discuss treatment options. An electronic study of 6,000 women revealed 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 treatments include education, dietary changes, medications, and pelvic floor muscle rehabilitation with biofeedback. Women in the Andy et al study identified many helpful dietary modifications or other techniques; however, the authors did not report whether subjects had received prior counseling from providers. Many of the tactics women reported in this study, including avoiding dietary triggers, align with those recommended by the American College of Gastroenterology.7
The efficacy of certain techniques 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; 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, some dietary modifications and medical treatment can significantly affect the post-cholecystectomy diarrhea. 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 Andy et al study highlights the need for everyone to inquire and start conversations about FI symptoms with our patients and empowers clinicians to discuss simple lifestyle modifications that may be of great benefit to 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.
- 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.
This study highlights the need for everyone to inquire and start conversations about fecal incontinence symptoms with patients and empowers clinicians to discuss simple lifestyle modifications that may be of great benefit.
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