If We Don't Ask, They Won't Tell

Screening for Urinary and Fecal Incontinence by Primary Care Providers

Heidi W. Brown, MD, MAS; Wen Guan, BA; Nicholas B. Schmuhl, PhD; Paul D. Smith, MD; William E. Whitehead, PhD; Rebecca G. Rogers, MD


J Am Board Fam Med. 2018;31(5):774-782. 

In This Article


Among 724 clinicians emailed and 696 verified valid emails, 27% (185/696) responded, of whom 83% (154/185) provided primary care to adult patients at the time and were thus eligible for inclusion (Figure 1). Table 1 describes the sample overall and stratified by screening status. Family medicine providers and attending physicians were more likely to screen for UI. Attending physicians and advanced practice providers were more likely to screen for FI. Information about age and gender were not collected.

Figure 1.

Study sample flow diagram. Describes responses to a 2015 email survey of primary care providers at a Midwest academic medical center.

Table 2 displays differences in opinions and practices regarding screening practices, perceived importance of screening, and confidence to treat UI versus FI among PCPs. Clinicians were twice as likely to screen for UI as they were to screen for FI (P < .001), with 75% screening at least some patients for UI, but only 35% screening at least some patients for FI. Only 10 providers (6%) were aware of online information sources about FI such as the National Institutes of Health Bowel Control Awareness Campaign (https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/).

When asked about their preferred method of screening for FI, 49% of PCPs (n = 74) would screen via verbal review of systems, 22% (n = 34) via written review of systems, and 12% (n = 18) via verbal discussion if patient disclosed symptoms on a written review of systems; 17% (n = 25) preferred that the patient bring it up. The most commonly used terms to discuss FI with patients were "bowel control issues" (60%, n = 91), "bowel incontinence" (36%, n = 55), "fecal incontinence" (25%, n = 38), and "accidental bowel leakage" (18%, n = 27). Thirty participants also mentioned other terms, such as "losing stool," "having a bowel movement when you do not mean to," "having your stool come out unexpectedly," "trouble holding in your stool/poop," and "fecal incontinence, like pooping your pants." Four participants bundled bladder and bowel symptoms together and asked about changes/problems/issues with urine or stool.

Participants were asked how important they considered various potential risk factors for FI to be. Older age (86%, n = 130), prior surgery or radiation for prostate cancer (83%, n = 125), childbirth (81%, n = 123), diarrhea (83%, n = 125), and constipation (78%, n = 119) were widely perceived to be very or extremely important risk factors. Fewer PCPs recognized diabetes mellitus as a very or extremely important risk factor (38%, n = 58). Female sex was identified as an important risk factor by 46% (n = 69) and hypertension by 11% (n = 16).

On univariate logistic regression, screening for FI was associated with screening for UI (OR, 11.27; 95% CI, 4.9–26.0; P < .001); feeling somewhat or very informed to treat FI (OR, 10.21; 95% CI, 1.2–90.0; P = .01); preferring to screen for FI verbally (OR, 3.9; 95% CI, 1.9–8.0; P < .001); perceiving screening for FI as important (OR, 3.7; 95% CI, 1.8–7.4; P < .001); using the term, "accidental bowel leakage" (OR, 2.9; 95% CI, 1.2–6.7; P = .02) or "bowel control issues" (OR, 2.2; 95% CI, 1.1–4.5; P = .03); and being a resident physician (OR, 0.37; 95% CI, 0.16–0.82; P = .02). Given that only 53 providers screened for FI, multivariate logistic regression was infeasible. PCPs reported similar top barriers in clinical practice to screening for UI and FI (Figure 2). The most commonly cited barrier to screening for both UI and FI was having too many other issues to address during the office visit. However, PCPs were more likely to report that the condition was not common among their patients as a barrier to screening for FI than for UI (P < .001), and were also more likely to endorse the statement that they had no good treatments to offer for FI as compared with UI (P < .001). Of note, 27% (38/139) of providers who did not screen for FI stated their belief that patients would initiate the conversation if they were bothered. Only 5/110 (5%) of providers cited patients' lack of desire to talk about the condition as a barrier to screening for UI, versus 13/139 (9%) for FI (P = .23). Few reported a lack of specialists or other providers to whom they could refer patients for treatment of UI (4%, n = 4) or FI (10%, n = 14) (P = .07).

Figure 2.

Barriers to screening for urinary (UI) (N = 110) and fecal incontinence (FI) (N = 139). Compares responses from primary care providers (PCPs) who screen sometimes, rarely, or never for UI (N = 110) with those who screen sometimes, rarely, or never for FI (N = 139) about barriers to or reasons for not screening in a 2015 email survey of PCPs at a Midwest academic medical center.

When informed that the prevalence of monthly FI is 8% in independent US adults, 75% (n = 114) of PCPs characterized that prevalence as higher than they expected, and 66% (n = 100) reported that they felt screening for FI was more important as a result of learning that prevalence rate. Those who do not screen for FI were more likely to characterize that prevalence as higher than they expected (79%, n = 78/99) than those who do screen for FI (68%, n = 36/53), P = .02.

Clinicians reported interest in patient education materials and online or printed algorithms to follow for diagnosis and treatment for both UI and FI (Figure 3). There was significantly higher demand for provider education materials regarding FI (44%) versus UI (34%) (P < .01) and higher demand for screening and treatment education modules for FI (25%) versus UI (17%) (P = .03).

Figure 3.

Recommendations to better inform providers about urinary (UI) and fecal incontinence (FI) (N = 154). Compares responses from primary care providers (PCPs) about preferences for resources relate to UI and FI screening and treatment in a 2015 email survey of PCPs at a Midwest academic medical center.