Brian Lacy, MD, and Stacy Menees, MD on Fecal Incontinence: Part 2

In the second of 2 podcasts, Drs Lacy and Menees discuss testing and treatment, including surgical interventions, for fecal incontinence.

Brian Lacy, MD, is a professor of medicine at the Mayo Clinic in Jacksonville, Florida. Stacy Menees, MD, is associate professor of medicine at the University of Michigan and the GI Clinic director at the VA Ann Arbor Healthcare System in Ann Arbor, Michigan.

TRANSCRIPT:

Brian Lacy:  Welcome to this Gastroenterology Learning Network podcast. My name is Brian Lacy. I'm a Professor of Medicine at the Mayo Clinic in Jacksonville, Florida. Thank you for joining us today, as Dr. Stacy Menees and I continue our discussion on fecal incontinence with more on treatments, especially that of surgical options.

Thinking about testing, we have a couple of options available. This discussion doesn't necessarily mean that every patient needs every test, but let's go through them kind of quickly. What do you think about anorectal manometry? Is that necessary for everybody?

Stacy Menees:  It depends on your resources that are around you. Certainly, anorectal manometry will be available at tertiary care centers and some bigger practices, even some smaller practices. It's going to help if there are rectal sensitivity or compliance issues, but it's not by a rectal exam, you can know what's going on with the sphincter.

It's not an end all be all. There are also issues with insurance. That's always something to investigate before because you don't want the patients to get saddled with the bill. I've encountered that also. This is not necessarily 100% needed.

Brian:  What about endoanal or transrectal ultrasound? Does this have clinical value?

Stacy:  It did in the past. It is important and it depends on how the patients get filtered in. It does help with discerning the extent of a sphincter defect, but it may not change the management.

We used it along, when I first started practice somewhere in the 2000s, more frequently, and that was because we were using overlapping sphincteroplasty as a primary treatment, because the initial data looked good. But after years of follow-up, when zero people are continent, you've got to wonder about the efficacy of a surgery.

An endoanal ultrasound is usually going to be used if they're having like uterine prolapse surgery performed. If there's something else going on, then that's really a low-risk thing to see if it'll help. It won't necessarily harm. That's where I think the surgeons would use it if they're doing something else.

Brian:  What about defecography, whether video or MR? We do that all the time for patients with persistent symptoms of constipation thought secondary to pelvic floor dysfunction. What about patients with fecal incontinence? Is there a role there?

Stacy:  For MR defecography, that may not be widely available at different centers. It's good for looking at muscles. It's going to be good and important if they're doing a surgery, but a lot of the MR defecographies are performed laying supine, so you really don't get that physiologic sense of prolapse, what's going on as far as the relationship as well, as I think the traditional radiographic defecography.

And it costs a lot of money. There will be some, but there are a few that are with the patient in upright position. I think the surgeons would order it more so further investigation, not as from a gastroenterologist standpoint.

Brian:  Sounds like it's low on your list and low on my list as well. Any other tests we should consider for the diagnosis of FI?

Stacy:  We used to do a lot of pudendal nerve latency testing, but that's fallen out of favor, because it doesn't change management. Besides, you can check for anal wink. If the anal wink's there, you know the pudendal nerve is intact. It doesn't guide management so that has fallen by the wayside.

Brian:  Agreed. I don't think we've done one in 15 years now. Stacy, let's shift gears and think about treatment. What about dietary interventions for the treatment of FI? Any role for that?

Stacy:  Yeah, so, this is my favorite area, Brian, for fecal incontinence. It's an area that I'm really passionate about. It's because there are a lot of dietary triggers that are available that people ingest, that put them at risk for fecal incontinence. I am always doing an incredibly careful diet history, specifically looking for triggers.

It's amazing what I've got, and not just food — beverage. I've got people drinking 2 liters of iced tea. I have people drinking 8 liters of diet soda. Those are things that I can get out of their lives that are stimulants. There are a lot of stimulants and nonabsorbable poorly digested carbohydrates. We know about caffeine, and then also dairy. A quarter of the population has lactose intolerance. I try and find dairy triggers for milk.

Then, the thing that I've been researching is about FODMAPs. FODMAPs, these are fermentable carbohydrates that can cause an osmotic diarrhea, and put people at risk for fecal incontinence. We are using that in our irritable bowel syndrome patients. I've been researching that. Certainly, in a retrospective chart review, for patients that didn't get enrolled into my randomized control trial, of those 64% of patients who had FI and loose stool had responded to a low FODMAP diet, and a third of those became continent.

I think this is an area for study. Now, not everyone's really excited about getting rid of their garlic, and getting rid of their onions. But it's certainly an area that I definitely talk about because I find a lot of different things. People come in chewing gum with me. They're chewing Orbit, and I'm like, "We have to get rid of your gum." I've changed people's lives that way.

Brian:  Great point. Ask about sugar-free candies, gums, and mints. The teaching point that I use is anything that ends in OL—lactitol, mannitol, erythritol, sorbitol—get those out of your diet.

So, probiotics — huge market in the United States, billions of dollars spent each year. Any role for fecal incontinence?

Stacy:  I think more of an indirect role. You did the 2018 study, the meta-analysis, which said globally, in IBS patients, it's helped. If you can help diarrhea, or you can help constipation, I think it can't hurt. Which one? I don't know, to be honest. I say get the cheapest one. There's never been a study yet in fecal incontinence. I think low-cost, maybe benefit, can't hurt.

Brian:  Right, but no data as you pointed out.

Stacy:  No data.

Brian:  Kind of a data-free zone.

Stacy:  It is a data-free zone.

Brian:  Loperamide used to be a prescription, as we all know, over-the-counter now. It stood the test of time for diarrhea. Is this still something you recommend for patients with fecal incontinence?

Stacy:  Yeah, I definitely use it. It is for certainly not solid stool incontinence. They'd have to have fecal incontinence associated with loose stool or diarrhea. We have evidence for this. There's the firm trial that was done by Markman and colleagues, where it helped reduce fecal incontinent episodes by close to 50%, but the big issue was, this was just FI. It wasn't FI with loose stool or diarrhea. It was all comers FI, so 30% had constipation. You know how much people love constipation.

I'm always trying to find the best way for these people, because we see a lot of people with concomitant IBS. Those people seem to be especially sensitive to loperamide. This is the time where I will use liquid loperamide, where you can use microdoses, so they're not going back and forth on the pendulum from diarrhea to constipation. I've actually used more liquid Imodium in my FI patients more successfully.

Brian:  That's good to hear. I think a lot of providers don't think about that. Thank you, that's very helpful. Many colorectal surgeons recommend fiber products, and then if that fails, more fiber and more fiber. Is there data to support this? Does this make physiologic sense?

Stacy:  There is. The use of fiber is definitely a good thing in fecal incontinence. We know that patients with a high-fiber diet are less likely to have fecal incontinence. But it is important to note that not all fiber products are the same. We have the best data for psyllium. That's not equal to Benefiber, which is inulin, it's less fermentable.

This is psyllium. It should only be psyllium because now we have 3 randomized controlled trials that show anywhere from a third to 50% reduction in fecal incontinence with the use of psyllium, and that's the only one I recommend. For physiologic sense for psyllium itself, it's 70% soluble and 30% insoluble. It's going to dissolve in water. It's going to form a viscous gel and it's not fermented.

Because it's not fermented, it's going to remain gel throughout the entire large bowel and it gives that stool-normalizing effect where for someone who's got hard stool, it's going to soften it, where someone's got loose or liquid stool, it's going to firm it up. I like psyllium a lot. That is, besides diet — which I go crazy about people's caffeine. They drink a crap, stop drinking a crap. Then, I add in psyllium, I definitely do.

Brian:  Stacy, that's great. A great teaching point. Another great teaching point is all fibers are not created equal and you want a soluble fiber like psyllium. It's easy to remember.

Let's say you've got somebody, they're adhering to your vigorous diet. They've listened to you, they've stopped all those artificial sugars. They've used some liquid or even solid regular pills Imodium. They're adding some fiber and nothing is working. Do we move on to something else? Do we use a 5HT3 antagonist? Do we use a mu-opioid antagonist? Shall we be using neuromodulators in these patients?

Stacy:  At that point, I'm definitely referring people to physical therapy. I think they need biofeedback training for sure. Now, granted, in these studies where we've looked at physical therapy, they are very heterogeneous.

If you look at all studies for biofeedback, people can reduce their fecal incontinence, and they have to buy into this. They have to buy in that we're trying to work on their pelvic floor. We can reduce fecal incontinence by 50% to 80%. That's important. The other important point is that not all physical therapists are created equal. You don't want someone who is a back-arm specialist doing your pelvic floor. You need a dedicated pelvic floor therapist.

There are resources on the Internet where you say, "Do you do pelvic floor?" That's much more common now. You need that resource, for sure. Now, other things that I think about at this point, and I go back to my physical exam, because would the patient be a candidate for Celesta?

That's an injectable that we use to help bolt up the internal anal sphincter. This is this hyaluronic acid mixture that we put in into the anal canal right above the dentate line. Sometimes, it takes up to 3 injections for it to have a good result. In the studies about this, 52% of patients or subjects who had this had a 50% reduction in fecal incontinence episodes as compared to 31% with the sham injection.

One more thing to talk about, and then we'll talk about those meds that you listed, is a vaginal bowel control system, and this is obviously for women only. This is a device that is used intravaginally. When it's inflated, it pushes on the rectal vault to prevent stool passage.

In protocol analysis— because they only had one size, not everyone was able to get into this study—but of those who it fitted correctly in 84% of women had 50% or more reduction in episodes of fecal incontinence and 44% had complete continence at 3 months. Now, this one you couldn't get, because it was so expensive. It was like $7,000. But now we have expanded access because there are CMS codes for it. That's exciting, I have to tell you.

Things to think about there is you need a urogynecologist. You need someone who has been dealing with pessaries because they have to be fitted for this. The other thing is that it's not uncommon is that women, because they're postmenopausal, they're going to need estrogen suppositories because there can be some abrasions. The vagina gets atrophic so you want that to be healthier.

Brian:  That's great, because I think a lot of providers don't think about that. I'm sorry, Stacy, please go ahead.

Stacy:  No, all those different meds that you talked about. The 5HT3 antagonist, certainly there's no specific data in fecal incontinence for this. We see a lot of people who have IBS, who have FI, and so we know that ondansetron has worked in those patients with IBS. If you reduce the diarrhea and firm up the stool as a byproduct, you can reduce fecal incontinence.

For the mu-opioid antagonist, certainly as constipation is associated with fecal incontinence, you've got the fecal overload with those people on chronic opioids. This certainly can be considered.

Then, neuromodulators, we don't have any specific data except with amitriptyline where there was, you can kind of use their anticholinergic profile, which may not be as harsh as Imodium. There was one small study with amitriptyline, which reduced fecal incontinence episodes, and there was a physiologic increase in sphincter tone. That's definitely a possibility.

Brian:  Wonderful. Stacy, as we wind down, let's lastly discuss surgery. When do you refer to surgery for an ileostomy? Do you think we wait too long for this? Should we explore it earlier?

Stacy:  Yeah, for an ileostomy or a diverting colostomy, I haven't had to, which is good. It's going to be the extreme situation for that. The surgery that I use more frequently would be sacral stimulation. That certainly was proved in 2011.

What's interesting, sacral stimulation was initially for urinary incontinence. It's very common with people with urinary incontinence to have fecal incontinence. About 30% have concurrent disorders. They noticed by that there was a byproduct improvement in fecal incontinence. Now, we can use that for our people. When people aren't responding, I do bring it up. I often bring it up even in the first visit because I'm like, you need to know what's available. I do talk about it, at least maybe even first visit, depending on how things are sounding and how severe their symptoms are.

As far as numbers, how people improve, in the pivotal trial for sacral simulation, they follow them for 36 months, 86% had a reduction of at least 50% reduction in fecal incontinence episodes, and 40% had complete continence. That's a big deal. There was a really interesting real-world study in the Netherlands where they followed 197 subjects for 5 years. They showed that, with sacral stimulation, that there was a mean frequency decrease in episodes of fecal incontinence from 5.3 times per week to 1 episode per week.

The subjects were able to postpone defecation from 1.5 minutes of screening to 7.5 minutes of screening, but the big kicker is that 25% had to be explanted. That's just good to know. Then, other surgeries, everything like the different replacements, like surgeons were trying to help augment this feature that they implanted, all those have gone by the wayside at this moment.

There is some exciting stuff about biosphincters in the future, injectables, and all those kind of things. At this point, it's pretty much sacral stimulation that I start talking to my patients early about that. Very rarely, just it could only be that severe, severe, where ileostomy or a diverting colostomy, for sure.

Brian:  Stacy, this has been an amazing discussion. Thank you so much for lending your expertise today. Any last comments for our listeners?

Stacy:  Just reverse the reversible. They had diarrhea. You've got a lot of hope with like two-thirds of fecal incontinence, so that's the big one.

Brian:  Wonderful. Once again, Stacy, thank you so much. For our listeners, this has been an amazing educational podcast today about fecal incontinence from a national and international expert. We're delighted to have Stacy Menees here today, associate professor of medicine in the University of Michigan and also at the VA Hospital. Stacy, once again, thank you so much for this great discussion.

Stacy:  You're very kind. Thanks for inviting me. It was wonderful.