Bowel Urgency Explained: What It Means And What To Do About It

The following transcript was generated electronically. Please let us know if you see any transcribing errors and we’ll get them corrected immediately. 

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America’s leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers. All available at nafc.org. 

Welcome back to another episode of Life Without Leaks. I’m your host, Bruce Kassover, and joining us is Sarah Jenkins, the Executive Director for the National Association for Continence. Welcome Sarah. 

Sarah Jenkins: Thanks, Bruce. I’m happy to be here. 

Bruce Kassover: Yeah. Today we are going to be joined by Dr. Ryan O’Leary. He grew up in South Carolina and studied economics at the University of Notre Dame before returning to South Carolina to pursue a career in medicine. He’s completed his medical school and internal medicine residency at the Medical University of South Carolina prior to starting as the advanced fellow in inflammatory bowel disease for the most recent academic year.

And he’s committed to delivering compassionate personal care and helping patients navigate, you know, what it’s like to live with Crohn’s and colitis. And that’s really what we’re going to be talking about today is about inflammatory bowel disease. So welcome Dr. O’Leary. Thank you for joining us today.

Dr. O’Leary: Of course. Thank you so much, Bruce. I’m excited to, to talk to you guys today. 

Bruce Kassover: Yeah. So before we get going and start to talk about IBD, maybe you could share a little bit more about your background, you know, how you got to be talking with us today. 

Dr. O’Leary: I think that was a great intro, Bruce, and thank you so much for having me again.

So yeah, I’m, I’m from South Carolina originally and I’ve done all my medical training here in Charleston, South Carolina at the Medical University of South Carolina. So I, I finished to do, to pursue a career in gastroenterology. You have. To first do a residency in internal medicine.

So I finished a residency in internal medicine about two months ago, and now I’m now board certified in internal medicine. And I’m currently doing a, a year focusing on inflammatory bowel disease at MUSC, which includes Crohn’s disease and ulcerative colitis. 

Bruce Kassover: Okay, so IBD we, we hear a lot about bowel disorders. There’s IBS, there’s IBD, there’s all sorts of acronyms, and it’s, it’s really confusing what distinguishes IBD as its own particular disorder? 

Dr. O’Leary: Sure, sure. So the, so yeah, IBS and IBD are commonly kind of misconstrued and they’re completely different diseases. There’s some patients that have both too, so it’s, it’s important to distinguish between the two. So, inflammatory bowel disease includes Crohn’s disease and ulcerative colitis. And that is a chronic disease that involves inflammation of the, of part of the GI tract. Now Crohn’s disease and ulcerative colitis, they have overlap.

Lots of overlap in symptoms. And this can be anything from diarrhea and loose stools, abdominal pain, sometimes upper GI symptoms like nausea and vomiting, sometimes blood in the stools. And so there’s a lot of overlapping symptoms, but they have distinct disease patterns and there’s different ways to distinguish them.

Colonoscopy can be very helpful as well as imaging, blood work, certain genetic testing that we do. So it’s in, it’s important to distinguish these two because there’s. There’s, there’s different treatments for the two diseases. And then, so that’s inflammatory bowel disease. And then irritable bowel syndrome is a, it’s a non-inflammatory bowel condition that is very common in the, in the general population.

And it, it can have overlapping symptoms to inflammatory bowel disease. So our, our patients with IBS or, or irritable bowel syndrome can have diarrhea, they can have urgent fecal urgency, they can have abdominal pain. And there’s subtypes of irritable bowel syndrome.

So you have IBSD, which refers to irritable bowel syndrome with diarrhea and IBSC, which refers to irritable bowel syndrome with constipation. And then you have some patients with IBS that have mixed bowel, bowel habits, that kind, that varies between diarrhea and constipation. Now, so these are, these are different conditions.

IBD and IBS, but a lot of our IBD patients have comorbid IBS. And that’s a important thing to distinguish is the treatments are quite different. 

Bruce Kassover: Well, so you could have both at the same time. 

Dr. O’Leary: You can have both at the same time. And many, many of our patients do. 

Bruce Kassover: Wow. I mean, having any one sounds like it’s, it’s, you know, difficult enough.

That’s really awful sounding. 

Dr. O’Leary: Yes, yes. Certainly. These are, these are patients that are very symptomatic, but the great thing is once you, once you diagnose these conditions, there’s excellent treatments for them. So that’s the kind of the most important first step is, is like diagnosing these treatments.

Bruce Kassover: I like hearing that. You know, one of the things I was really hoping we could talk with about today is what I think you were saying can be a symptom of both IBS and IBD, and that’s bowel urgency. Is that really a common symptom? Is the way that it affects somebody with IBD versus IBS the same? 

Dr. O’Leary: So bowel urgency is a, is a extremely important symptom that we, we ask all of our GI patients and certainly our patients with IBD. So bowel urgency, it’s interesting. It used to be something that was not on our radar as much as it as it is now in the GI world.

So, you know, we separate, you know, there’s a term called Patient Reported Outcomes or PROs. And what it means is, you know, as a doctor, one of the most important things is identifying what symptoms are most important to patients. And something that has kind of emerged as a very important Patient Reported Outcome is fecal urgency.

So urgency, fecal urgency is the kind of sudden desire to go to the bathroom. And it can impact patients, in a variety of different ways. And I think first off, it’s not pathognomonic, which means it does not apply to just one condition.

So there’s many different conditions that can lead to fecal urgency, be it IBD, IBS there’s certain me medications that can cause fecal urgency, a variety of different conditions, anatomic conditions, but, I think the first thing to say is that there’s not one disease in particular that causes fecal urgency.

And it has a huge impact on patients’ lives. So it’s something that has really come out on our radar as a important thing to ask. And once you ask it, patients are really forthcoming about how it impacts their life. So, you know, I’ve heard from patients that they are like scared to leave their house if they’re having significant fecal urgency that they’re waking up at night.

It’s like disturbing their sleep. Some are some, you know, have a significant impact on their work and like personal life. So it’s a very important symptom and it’s one of those, one of those markers like in, in the IBD world that can be a marker of like disease activity. So it’s very important that we ask these patients about fecal urgency.

Bruce Kassover: You know, I even wanna ask you just about what the definition of urgency really is, because, you know, I mean, look, you’re from South Carolina, so maybe you go out and you have shrimp and grits, and there’s a, there’s a bad shrimp, and you know, later that night you have a problem, right? We’ve all experienced that, but I think that this is, that we’re talking about something that’s sort of different than the occasional, you know, food poisoning type of thing. What, when we say bowel urgency, what are we even talking about in the first place? 

Dr. O’Leary: Sure. Yeah, I think that’s a great, that’s a great important place to start. So the way I define fecal urgency is the sudden intense feeling of needing to have a bowel movement. So this can, this can come on suddenly and and it’s something yeah, where you suddenly feel like you have to go and.

When you have to be near a bathroom. And so this can be associated with other symptoms too. Some patients will have cramping, abdominal pain, some will have, difficulty with incontinence or like leak leaking, being unable to find a bathroom in time. So that’s generally how I would define fecal urgency. And like I said previously, there’s a variety of different causes that can lead to the symptom. 

Bruce Kassover: So, and you also mentioned this is something that could happen anytime of the day. It could happen at night, it could happen while you’re sleeping. Can it also be the sort of thing where you don’t even almost realize it’s happening and you just sort of go and with, without that real sense of urgency also, is that that something that happens?

Dr. O’Leary: Yeah, definitely, definitely. Particularly in our patients that have like underlying neurological conditions. So we have patients with dementia, Parkinson’s disease, certain spinal abnormalities that they lose sensation of having a bowel movement. So certainly something that can happen without the patient even knowing it.

Bruce Kassover: Okay, so what is actually going on, aside from those patients who have, you know, like you said, like nerve issues. When somebody has a bout of bowel urgency that rises to the level of, you know, the not just sort of like, “Oh, I think I have to go soon.” What’s actually happening in the body that’s causing such a problem for them.

Dr. O’Leary: Yeah, I think that’s a great question. I think to understand what’s happening during a bout of fecal urgency, you have to first understand like the mechanics and the anatomy behind bowel movement and how we maintain continence in the human body. So it’s a very complex, like coordination, like symphony between certain anatomic structures in the pelvis, our neuromuscular system, so our neurological system and the gut itself and like the stool’s, like consistency.

So to kind of provide a brief overview of a very complex topic, let’s first talk about anatomy. So for maintaining continence, we have a internal and an external anal sphincter. And these are kind of barriers to stool leakage. And so it’s how people maintain continence at baseline.

So the, the internal sphincter is under involuntary autonomic control, meaning that we can’t control it with our mind. And then the external sphincter is under our own voluntary control, meaning that we can control it with our own mind and with our own feedback from our brain.

And so I think, you know, first understanding that there’s two sphincters and that’s how we maintain continence. And then there’s a lot of complex interplay between muscles when you have a bowel movement. So certain muscles have to relax and certain muscles have to have to contract.

And you can imagine the rectum is like a reservoir for stool. And when the rectum is very compliant, meaning that can hold a lot of stool, and when it distends and there’s a lot of stool in it, we have neurological feedback that we have to have a bowel movement . And so that, that neurological feedback can lead to the sensation of urgency.

And then kind of comes the complex interplay of actually having a bowel movement, which like, which takes a lot of coordination between muscles and neurological feedback. So it’s quite complex and it involves muscles, kind of local nerves in the pelvic area as well as kind of feedback from our own brain.

Bruce Kassover: Okay, so now, it sounds like there’s a lot, that the body is a lot more complicated than I ever thought. When you think, well, you have to go to the bathroom, you know, you just, you’re going to go poop. It’s like there’s a lot that’s happening that you have no idea about. It’s a little surprising, or maybe it’s not surprising. Maybe I just never really thought about it like that. 

Dr. O’Leary: Yeah. It really is complex and there’s a lot, there’s a lot going on. It’s such a beautiful, beautiful system. Yeah. 

Bruce Kassover: Well, I Don’t know If, if I’m the one who would call it beautiful. 

Dr. O’Leary: Maybe, a aspiring gastroenterologist, I think it’s beautiful, but… 

Bruce Kassover: I want my gastroenterologist to think it’s beautiful. I think that’s a, definitely a quality to, to look for. Yeah. So if I’m somebody who’s experiencing this, I would imagine that for it to rise to the point where it’s a real medical issue that you want to see a doctor about, it’s something that would have to be happening chronically. Is that fair to say? 

Dr. O’Leary: Yeah, I would say so. I mean, we have some patients that present to us with, with acute symptoms, meaning that they’ve only been going on for, for a short amount of time. But really where we want somebody to see a doctor is like, certainly with, if this has been a chronic problem that you haven’t brought to your doctor’s attention, I certainly encourage you to talk to your doctor about this.

Bruce Kassover: Well, the thing I wanna ask you then, I, this may be the hardest question of all, because it may be just too wide ranging, but so you do, you go and ask your doctor about this? You mentioned before that treatments today are excellent. When you say excellent, what does that really mean from a, “what’ll it do for me” perspective? 

Dr. O’Leary: Sure, sure. So I think, you know, I think first is kind of going back to the fact that the, that urgency is really a symptom. It’s not a, it’s not a disease and it could be caused by many different, many different types of GI conditions. And so this could be as simple as you, you know, taking a medicine that has caused diarrhea and less urgency. So this could be as, as simple as, you know, talking to your doctor about what medicines you take for your other conditions. And it might be as simple as stopping one of those medicines. So it really, you know, there’s so many underlying causes of urgency that I think the first step is coming to your doctor, the doctor, taking a very detailed history, including what your other medical problems are, medicines, past surgical history and then doing a workup.

So this can include a variety of things, but blood work, stool studies. Certainly on the GI side, we do a lot of colonoscopies, which is a procedure that many people know for the purpose of colon cancer screening, but it can really help us identify causes of diarrhea, urgency in chronic bowel conditions. So there’s great treatments for many underlying causes of urgency. 

Bruce Kassover: Okay, so I guess you go in and you get a diagnosis and you have an idea that there’s, you know, X or Y or Z that’s going wrong and that can be addressed… depending on what that is, what sort of treatments might my physician recommend to me?

Dr. O’Leary: Sure, sure. So we can start for like, talking about IBD or inflammatory bowel disease. So certainly there’s a, there’s a variety of treatments for inflammatory bowel disease now. So this, this, you know, typically in the acute setting, or sometimes when people are initially diagnosed, we give them steroids like prednisone or budesonide that are anti-inflammatory medicines that can help tremendously with symptoms.

And then on longer term, we get patients on medicines that can control their disease over the longer period of time. So now there’s a variety of medicines. It kind of, the first biologic type medicine, which is a medicine that can control these medicines chronically, was Infliximab or Remicade.

But now there’s many, many different medicines that we use for Crohn’s disease and ulcerative colitis. And if you turn on a television, it seems to be half of the commercials on TV these days. 

Bruce Kassover: It, it’s true. I see them all over the place. And so, I mean, is it true that if you take these medicines, there’s a good chance that you can then again, be canoeing and skydiving and bowling and all the things that they show people happily doing now that they’re taking these meds?

Dr. O’Leary: Yeah, certainly, certainly when we have patients that we have patients that do amazing things. Yeah, there’s, I mean there’s examples in the media of, you know, there’s many famous, there’s a, there’s actually a couple of famous people that re I recently found out, had IBD, so the kicker for Auburn’s football team has ulcerative colitis, and had a surgery for it called a colectomy where they remove your colon, and then there was a, there’s a carolina Panthers player, Hunter Renfrow, who’s a former Clemson tiger that was also diagnosed with ulcerative colitis and is now back in the NFL, like, he got onto medicines. The medicines work. And so certainly you can be skydiving, playing in the NFL, I mean, our patients live great lives. 

Bruce Kassover: I love hearing that and 

You know, there’s another reason why I love hearing that also, is that, you know, for so long, this is, these have been conditions that, that people have been afraid to talk about and there’s, you know, an ick factor for some people, there’s there the fear that people are going to make fun of them, it’s just embarrassing. And to hear people who have a large public profile, you know, come, come out and say that, yeah, this is something that I’ve been dealing with. I’ve been dealing with it well, has got to make a real difference to help motivate those people who, you know, might, might be a little reticent about seeking help.

In fact, I wanted to talk about that a little bit, about the mental health challenges that go along with having this sort of condition and what it takes to sort of overcome that hesitancy and see a physician. In your experience, what can you say to help motivate somebody that there really is light at the end of the tunnel if they just take an active role in their healthcare.

Dr. O’Leary: Yeah. So I would say, you know, I would say first step is coming to your doctor and being honest that, you know, this is, we have these conversations every day with patients and I know they feel, it feels very sensitive to the patient, but we’re, we’re here to help you. And in the realm of, of inflammatory bowel disease we know that the brain-gut connection is extremely strong. There’s a, there’s, there’s, you know, millions of nerve endings that lead from the brain to the gut, and there’s crosstalk between those two. So patients that have inflammatory bowel disease, which is an inflammatory condition, a lot of them have comorbid depression, anxiety, sleep dysregulation. And that’s such an important part of, of taking care of them, you know, in addition to making sure that their guts are healthy, like making sure that they’re, that we, that we address that as well. So in our clinic at MUSC, for example, we have a, we have a social worker that is trained in counseling, cognitive behavioral therapy, and she’s also trained in something called gut-directed hypnotherapy.

All our, you know, there’s many different tools in the toolbox for addressing stress, depression, anxiety in these patients. And I think the most important thing is just making the first step and coming to the doctor, ’cause we, we have great resources for you and we’re here to help you. 

Sarah Jenkins: I have a quick question. Yeah, so I, you know, those are all great for the patient once they’re, they’re treated. Do you have any tips for how they can bring this up to, to a doctor? You know, a lot of patients probably are seeing their primary care doctor maybe for the first time, so they’re not at a specialist yet.

You know, what tips do you have for just kind of broaching this subject and then, how to get that referral to someone like you? 

Dr. O’Leary: Sure. Yeah. I, I definitely think it starts with coming to your primary care doctor. They tend to be, you know, a, a primary care doctor. Taking a good detailed history is, is typically what leads to a referral to gastroenterology.

So I think that’s the first step for patients is bringing their concerns to their primary care doctor. So things that can be helpful is having a detailed, like writing down what your symptoms are, and certainly they can vary day to day. We have some patients that are very proactive and they can identify certain triggers through their symptoms, be it dietary, lifestyle, you know, patients have the best insight to their own body. So I think coming to your primary care doctor with a detailed list of your symptoms. Other things that can be helpful is like knowing your, like having a good understanding of your past medical history about if you have any family history of inflammatory bowel disease, you can be at higher risk for having inflammatory bowel disease, for example.

So like understanding your family history. So I would say those are some general tips I have for the patient that’s just starting trying to get to the bottom of their symptoms and how, how we can help them. 

Sarah Jenkins: Yeah. Yeah, that’s great. And we, we actually have a bowel health diary to kind of track some of those symptoms for patients who are looking for that. So we can link to that in the show notes. 

Dr. O’Leary: That’s fantastic.

Bruce Kassover: In fact, I’ll make sure to put that link in the show notes so anybody who is looking can can find it and download it for free. And speaking of tips, as you know, this is Life Without Leaks. And one the things we always like to do before we’re done is leave our listeners with one little hint, tip strategy, bit of advice for living a life without leaks. So I’m wondering if maybe you might have some sense of what in, in your opinion, the single most important thing you wish everyone understood about bowel urgency. 

Dr. O’Leary: Sure. I would say the, so my take home point about bowel urgency is that it is, it is a symptom and it’s a very important symptom, but it doesn’t tell you what disease you have.

So it can be caused by a variety of different diseases. And we covered a couple today. So inflammatory bowel disease, which are the patients that I treat predominantly, so Crohn’s and ulcerative colitis. Irritable bowel syndrome we talked about, which is a non-inflammatory bowel disease that can encompass, both diarrhea, mixed stool habits, constipation.

And then we also talked about a variety of other causes of bowel urgency. So medications. There’s underlying medical conditions like diabetes, thyroid dysfunction. And so I think urgency is a very important symptom to bring to your doctor. And best step there is to, to get to the bottom of what is causing the urgency, which could be a variety of things.

Bruce Kassover: Those are very wise words and we appreciate you sharing them with us. So thank you for joining us today. 

Dr. O’Leary: Of course. Thank you so much, Bruce. Thank you, Sarah. 

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin McLeod. More information about NAFC is available online at nafc.org.