What Your Bowel Urgency Symptoms Might Really Mean

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 today as always is Sarah Jenkins, the Executive Director for the National Association for Continence. Welcome, Sarah. 

Sarah Jenkins: Thanks so much, Bruce. I’m so glad to be here.

Bruce Kassover: Today our guest is Dr. Maria Roell. She is a third year internal medicine resident at the Medical University of South Carolina. She’s looking to pursue a fellowship in gastroenterology and hepatology with a particular interest in inflammatory bowel disease. And today she’s gonna be talking with us about bowel disorders and urgency. So, Dr. Roell welcome. Thank you for joining us today. 

Dr. Roell: Hi Bruce. Hi Sarah. Thank you so much for having me. 

Bruce Kassover: You know, when most people are growing up, they want to be an astronaut, they want to be a firefighter, but you are going into medicine. How did you get to where you are today and how did your interest in your particular specialty develop?

Dr. Roell: So growing up I was always interested in the sciences. I loved learning about anatomy and the human body, and I feel like that kind of. Puts itself into pursuing medicine a little bit naturally. I don’t have any family members or anything in the medical field, so it was all new to me. And then in medical school I liked a little bit of everything and I didn’t really like surgery.

So I think liking everything but not necessarily wanting to be operating all the time puts you into a category of either internal medicine or pediatrics. And I definitely prefer adults, so landed in internal medicine. I’ve been passionate about gut health and GI pathology since undergrad. I focused on nutrition as part of my studies in undergrad and that has kind of led me into the path of pursuing gastroenterology.

Over the past three years, I have been working in our IBD clinic and GI clinics and it’s definitely become a passion of mine and something I really enjoy. 

Bruce Kassover: That’s great to hear. And I sort of get the feeling that gastroenterology and gut health and things related to that are actually having a little bit of a moment in the sense that, you know, you actually see ads for medications to treat these sorts of conditions, and people seem to be getting a little more comfortable talking about it, but it’s still a topic that’s really taboo for a lot of people.

Do you find that the patients you’re dealing with that, that sometimes it’s a struggle to get them to open up to you and discuss what they’re really going through? 

Dr. Roell: Definitely. I think talking about bowel issues, whether it’s urgency, diarrhea, constipation, any of those things can be uncomfortable for a patient to bring up.

It’s personal, they don’t know how to mention it. But I do think the things that we’re seeing on social media with gut health and all of that stuff has made it a little bit easier to talk about and to ask questions about it.

Bruce Kassover: When you mentioned urgency, and I think everybody’s experienced urgency at some, you know, a few points in their lives. But this is not just regular, “Oh my God, I ate, you know, a bad shrimp!” What are we talking about when we’re talking about, clinical bowel urgency that’s really related to a medical condition. 

Dr. Roell: Definitely, yes. Like you said, I think everyone can relate to having the feeling of needing to find a bathroom right now, whether they’ve eaten a large meal or drank a strong cup of coffee or something like that.

We can all relate to that. But from a medical standpoint, bowel urgency is the sudden compelling need to have a bowel movement that’s difficult to defer. It feels like you need to go to the bathroom right now and may not make it. It’s much harder to control in patients who have true, like medical bowel urgency.

And it tends to happen more frequently or unexpectedly to the point that it can interfere with daily life. 

Bruce Kassover: So what sort of things could be causing this aside from, like I was saying, that bad shrimp? What, what, what else is actually making this happen? 

Dr. Roell: One of the common causes of bowel urgency is irritable bowel syndrome. This is urgency that tends to be related to a hypersensitivity or a functional problem with the gut. You might be more likely to experience that need to go. Now, feeling in IBS after you eat certain trigger foods or experience certain stressors that may stimulate your anxiety. A lot of the time people with IBS will say that they need to find a bathroom right away before a big presentation or before a big test as their anxiety ramps up.

Inflammatory bowel disease is another pathology that can cause bowel urgency. So this urgency is linked to true inflammation in the GI tract. Urgency can be one of the most common symptoms in patients with IBD and definitely has a significant impact on their quality of life. A couple other things include food intolerances, so lactose intolerance, gluten intolerance, those things can definitely present with bowel urgency.

And then pelvic floor dysfunction or neurological diseases can also have urgency. This tends to be more related to control and coordination issues with the muscles in the anal and pelvis region. 

Bruce Kassover: You know, I want to ask you about that intolerance thing, because there’s things like sensitivity and intolerance and allergies and, I don’t know about other people, but I think that there’s a lot of confusion about what the differences or similarities between those things are. Could you talk a little bit about that? 

Dr. Roell: Yeah. So a lot of people have food intolerances. So lactose intolerance is very common. You eat dairy, you can experience diarrhea, urgency, or on the other end of it, you may experience constipation, but you don’t have a true allergy to lactose. If you had a true allergy to lactose, we would be more concerned that you are having swelling, inflammation in other parts of the body, not just necessarily like diarrhea or an upset stomach.

Similarly, like gluten intolerance versus celiac’s disease are very different. So celiac’s disease, you’re able to see the underlying pathology on biopsies from the intestines, whereas gluten intolerance, you tend to experience abdominal pain, cramping, diarrhea, constipation, but again, it’s not true with celiac’s disease. There are tests that we have that can kind of distinguish these two things, and with intolerances, you tend to not see anything abnormal on the colonoscopy or endoscopy. 

Bruce Kassover: Okay. That’s really interesting. Now, speaking of differences, you were also talking about IBS and IBD and personally, I think it’s really unfortunate that the acronyms or the initialisms are so similar because it really is confusing and hard to keep in your mind. Maybe for the lay person, you can help give us a better sense of what the differences are and you know how to think of those two different conditions. 

Dr. Roell: Definitely the acronyms are very confusing and patients definitely can mix them up pretty easily. So inflammatory bowel disease or IBD is a chronic condition where the immune system essentially attacks the digestive tract and causes ongoing inflammation and damage.

There are two main types, which are Crohn’s disease and ulcerative colitis. IBS or Inflammatory Bowel Syndrome is more of a functional disease that affects how the gut works, but it doesn’t cause vis visible inflammation or damage to the intestines. On colonoscopy, symptoms definitely can overlap with diarrhea, constipation, abdominal pain, but with inflammatory bowel disease, they tend to, symptoms tend to include bleeding.

You can see ulcers, patients can develop fistulas on colonoscopy as well. IBD can also have systemic symptoms that we can talk about as well. But IBS is more of a functional condition that does not typically have any findings on colonoscopy. Sometimes it can be frustrating because patients feel like all of the other things have been ruled out, but irritable bowel syndrome really does kind of fall into a category of a diagnosis of exclusion.

Bruce Kassover: Well, still it’s a diagnosis nonetheless. 

Dr. Roell: Definitely. 

Bruce Kassover: Now I’m thinking about a lot of what you’re describing sounds like it’s chronic conditions. You know, if you have IBS or IBD or a food sensitivity or any of these things, you go through your life and you realize when something happens, I have, you know, certain biological you responses, but are there any sort of sudden things that might occur that, that, you know, sudden symptoms or flares or you know, anything that happens that might say, Hey, wait, this is not one of these chronic conditions. I need to go to an ER right now, or I need to go to a doctor immediately. Are there any things like that that might happen? 

Dr. Roell: Yeah, so it sounds like you’re asking about red flag symptoms when I would say you need to be evaluated right away. So some of those things would be really bloody stools associated with high fever or severe abdominal pain. Additionally, if you are having so much diarrhea or vomiting that you just can’t stay hydrated, you can’t keep any food in your system, those would be reasons that I would advise someone to present to the emergency department.

Bruce Kassover: So let’s say that we’re not talking about these red flags. We’re talking about. Somebody does seem to have a chronic condition. Maybe you could give us an idea of what the diagnostic process is you finally work up the courage to go to a physician and they sit down with you what actually happens in the office to get to the point of a diagnosis. 

Dr. Roell: So a lot of questions. To kind of start off the visit, main thing will be getting a good history from the patient. So some questions I would ask are, what are your symptoms? When did they begin? How have they changed over time? How often are you experiencing these symptoms? Are you noticing any blood or mucus in your stool? Is it in your stool every time that you have a bowel movement? Or just occasionally, do you notice the blood in your actual stool or is it just when you wipe? Have you noticed any unintentional weight loss? Do you feel like you’re more fatigued than usual? Have you been having any fevers or chills? Are you having any extraintestinal issues such as joint pain, red eyes, or any other skin changes? And then other things like family history. Does anyone in the family have a history of inflammatory bowel disease or IBS? Does anyone have a history of colon cancer? Does anyone have a history of other autoimmune conditions like rheumatoid arthritis or Sjogren’s? What medications are you on? Are you using any specific dietary supplements?

So after all asking all of those questions, we would jump to lab tests and physical exam. So for physical exam findings, I would be listening to someone’s belly pressing on their belly to see if they have any tenderness. Sometimes patients may warrant a rectal exam to see if they have any hemorrhoids, and to see how basically the tone of their anal sphincter is if they’re experiencing incontinence regularly.

After a physical exam and getting a good history, we would move on to lab tests. We’d start with basic things like looking at complete blood counts, electrolytes, kidney and liver function. When testing for inflammatory bowel disease, we send inflammatory markers such as CRP or ESR, and those give us an idea of how much inflammation is in the body.

We also tend to test for iron deficiency or other vitamin deficiencies like B12 or folate because it’s pretty common for patients with these chronic inflammatory bowel disease to have nutrient deficiencies. And then we’ll also send stool tests. If we’re working up more of an IBS type picture, we might test for parasites or celiacs disease. If we’re working up an IBD type picture, we would test for inflammation in the stool with a marker that’s called fecal calprotectin. 

Bruce Kassover: That is a bunch of tests. I would imagine, does, not every patient goes through every one of those though, right? 

Dr. Roell: So depending on the history, at some point most patients would go through all of these. Fortunately they are blood tests, so from a patient standpoint, it should be fairly easy. They go down to the lab, get their blood drawn, and we get a lot of these tests back. The stool samples, we can send people home with their own little stool collection kit and they can just bring it back to the lab so they can do it with the privacy of their own home.

Bruce Kassover: Okay. That’s a little reassuring because I know that one of the reasons why people avoid seeking professional help is that they’re afraid of these tests that feel invasive, they’re embarrassing, they’re uncomfortable. So, I guess part of your job isn’t just to diagnose and the condition and help patients, you know, develop a treatment path, but to also put their minds at ease that this is not going to be as embarrassing a situation as it might be. Is that something you encounter a lot, patients who are nervous like that? 

Dr. Roell: Yes, definitely. I think in general there’s a lot of hesitation and stigma around talking about bowel issues and bowel movements. I try to make my patients feel as most comfortable as they can be when they come into the office.

Usually we have some idea, like in the IBD clinic, we know they’re coming in for IBD evaluation, so we definitely anticipate talking about their bowel movements. But even in, when I’m in my primary care office as a resident and people come in with GI symptoms I don’t hesitate to ask about their bowel movements, what they look like, what symptoms they’re having, and sometimes I hope that by me asking it eases a little bit of the anxiety around them having to bring it up.

Bruce Kassover: I’m sure that I, I hope that it would, but I’m sure it does that and that’s excellent to hear. So now we’ve gone through the diagnostic process and you have a sense of what sort of a condition the patient may be having. What are we looking at when it comes to treatments? What are some of the first things that they might hear you recommend?

Dr. Roell: So jumping back, just to expand a little bit more on the diagnostic criteria we do advanced imaging tests when we are concerned about inflammatory bowel disease. So after we’ve gotten our routine basic labs like blood counts and all that stuff and we think someone has some inflammation in their GI tract, we would typically move on to a colonoscopy.

So with the colonoscopy, that’s our gold standard for diagnosing inflammatory bowel disease. We go in with a long camera, take a look through the colon. We’re looking for things like ulcers or lesions in the GI tract that look consistent with Crohn’s or ulcerative colitis. And during colonoscopy we’ll take small little biopsies that patients don’t feel and don’t impact the health of the GI tract.

But we’ll take biopsies and then send those to the pathologist to look at them under the microscope. So depending on what the colonoscopy shows and what the pathology shows, that’s where you would get your confirmed diagnosis of Crohn’s disease or ulcerative colitis, or it would tell you that that’s not what we’re dealing with and we need to kind of jump down a different pathway. 

Bruce Kassover: And by ‘not what we’re dealing with, jump down a different pathway or use,’ is that another way to say cancer? 

Dr. Roell: No, not necessarily. I would say if someone is coming in with symptoms that are very convincing, seems like inflammation but is not, I would be looking at things like celiac disease. I’d be seeing if there’s some or other autoimmune condition. But if the patient is of older age and maybe they’ve been having some alarming symptoms and have a family history of cancer that might be a route that we go down. But this, the colonoscopy kind of will tell us, yes, IBD, no IBD, and then the rest can be explored a little bit more from there. 

Bruce Kassover: Now for people who’ve never had one before is it as bad as I imagine it might be? 

Dr. Roell: I hope to think that it’s not as bad as people chalk it up to being. The prep is probably the most challenging part. You do have to drink a lot of bowel prep the night before. You have to drink clear liquids the day before, and the goal is to clean out your colon. So you definitely anticipate that you’ll be having a lot of bowel movements. That definitely can be uncomfortable for patients, but I try to encourage them that ideally colonoscopies are at most every one year.

For your standard screening colonoscopies for like colon cancer and stuff, those can even be up to every 10 years. And I try to encourage them that one day it will give us a lot of answers and let us fully see what we need to see during the colonoscopy. So hopefully a little bit of discomfort or unpleasurable or like not pleasurable bowel movements makes it, makes the diagnosis worth it. 

Bruce Kassover: Excellent. Well that’s good to hear. So then let’s go back to treatment, the treatment path. So what are some of the things that you’re likely to recommend initially? 

Dr. Roell: So, diet and lifestyle modification is a huge thing that we would talk to all of our patients about. We also would look at medications. So some patients may need to be started on steroids to reduce some of the inflammation in their GI tract. They might benefit from other medications called mesalamines. And then we get into our area of biologic therapies which there are lots of medicines in that category. They can be administered different ways and there’s a ton of research in that area that’s continuing to grow.

But working on lifestyle and dietary changes is something we talk to about every patient, no matter what their medication treatment will be whether that’s incorporating a lower fiber diet to help reduce some diarrhea, whether that’s helping to manage their stressors, that tend to cause their symptoms to flare with meditation, therapy, sometimes even medications for depression or anxiety.

And then also incorporating like nutritional supplements if they’ve lost a lot of weight are all things that we would talk about probably in an initial visit with someone who is newly diagnosed with IBD. 

Bruce Kassover: Okay. And down the road, are there more either advanced treatments or even maybe surgical things that might be an option for some people?

Dr. Roell: Yes, definitely. So surgery is very patient specific. It can go into areas that might not be the most favorable thing for patients. Sometimes surgery can look like resecting part of the bowel, and people may have such severe disease that they end up needing an ostomy. I wouldn’t necessarily say this is standard for most patients who are diagnosed with inflammatory bowel disease, but when we get into further complications like strictures or fistulas or blockages in the GI tract that’s when surgery might become an option or a need.

Bruce Kassover: Okay. But I would imagine that surgery today is probably much further along than many patients may remember, especially if you’re an older patient. If you think of surgery back when you were in the earlier stage in life, it’s probably a lot better today. Is is that fair to say?

Dr. Roell: Yes, I would say so, I’m not a surgeon, but it seems like the procedures that they’re doing today try to be as minimalistic as possible while still providing an optimal solution for whatever is going on in the intestines. 

Bruce Kassover: Yeah, no, you, you mentioned for example, like ostomies and we’ve spoken with patients before who’ve had them, and you know, you only get one of those if you really, really need it.

You know, it’s not like, you know, what am I gonna do today ? It’s, and the people who’ve had it have almost, to the person said that it’s been a life changing positive for them because it’s given them back the freedom that they just never had. And it’s, you know, saved them from so much emotional, so much heartache and stress that it’s really been a life changer for them.

And I’m wondering, maybe you could talk a little bit about. Urgency in some of these conditions and the emotional toll it takes and maybe the sort of benefit that you see these patients receive when they come to you and they get a proper diagnosis and treatment. 

Dr. Roell: Definitely. This kind of makes me think of one of the very first patients I met my first year of residency in the Inflammatory Bowel Disease Clinic.

She came in and she was so excited that she was finally able to come in for an in-person appointment because for the past, I think probably three years, she was doing all virtual appointments because her bowel urgency and her diarrhea was so bad that she couldn’t leave the house or she couldn’t travel for more than an hour in her car.

So she was very excited to be in person that day and that’s definitely an experience I hear many patients talk about. The symptoms of bowel urgency and diarrhea can cause a lot of anxiety and it can lead to a lot of social isolation. Patients fear leaving the house because they don’t know where the closest bathroom is. They don’t know when their symptoms are gonna start and they are nervous to be out in public and when they might have an episode of bowel urgency or incontinence and may not be able to make it to the bathroom in time. 

Bruce Kassover: It’s got to be very rewarding to work in a specialty where you could see the things that you do, the recommendations right off the bat.

You know, things like behavioral changes, you change your diet and you change your life where you could see these things have a real effect. I hope that it’s as rewarding as I imagine 

Dr. Roell: It definitely is. I would say that’s probably one of the most rewarding aspects of it. I get very excited when patients come in and we’ve finally been able to get them on a good medication regimen. They have incorporated some lifestyle changes to help manage their stress and incorporate a better diet and they’re feeling better and they’re able to get back to their day-to-day lives. 

Bruce Kassover: I love hearing that. Now, as you know, this is Life Without Leaks, and one of the things we like to do before we leave is to ask our guests if they have one little hint or tip or strategy to help them live a life without leaks.

Now we’re not really talking about leaks today, we’re talking more about bowel urgency and related conditions. So I’m still wondering if you might have, you know, one particular takeaway, a tip that you wish everyone understood about bowel urgency to help them live a better, healthier and more comfortable life.

Dr. Roell: I think my biggest tip is just to reassure patients that bowel urgency is more common than you think. More people than you would anticipate experience it and. It’s something that can be treated. So I encourage patients to reach out to their doctor, even if it’s not a gastroenterologist, if it’s their primary care doctor, whoever they’re in contact with, to reach out to them and to talk to them about it. Sometimes bowel urgency warrants further workup. And sometimes there can be simple solutions to, so I definitely just encourage patients that it’s more common than you think and that you’re not alone. 

Bruce Kassover: Well, that’s great. And I hope people take you up on it. Do visit their doctors because without doing that, you’re not doing anything. So thank you so much for sharing all this with us and we’re certainly confident that a lot of people are gonna get enormous amount of benefit out of it. So thank you for joining us today. 

Dr. Roell: Thank you so much for having me. 

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.