ORIGINAL RESEARCH published: 01 November 2021 doi: 10.3389/fneur.2021.755432 Current Incidence and Risk Factors of Fecal Incontinence After Acute Stroke Affecting Functionally Independent People Giuseppe Lucente 1*, Javier Corral 2 , Luis Rodríguez-Esparragoza 1 , Sara Castañer 3 , Hector Ortiz 4,5 , Anna Piqueras 2 , Joaquim Broto 1 , María Hernández-Pérez 1 , Sira Domenech 3 , Alicia Martinez-Piñeiro 1 , Jordi Serra 6 , Miriam Almendrote 1 , David Parés 2 and Mònica Millán 1* 1 Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Edited by: Barcelona, Badalona, Spain, 2 General Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain, Adriana Bastos Conforto, 3 Institut de Diagnostic per Imatge (IDI), Hospital Universitari Germans Trias i Pujol, Badalona, Spain, 4 Department of Project Universidade de São Paulo, Brazil and Construction Engineering (EPC), Universitat Politècnica de Catalunya, Barcelona, Spain, 5 Department of Engineering Reviewed by: Design, Universitat Politècnica de Barcelona, Barcelona, Spain, 6 Gastroenterology Department, Hospital Universitari Rebeca Boltes Cecatto, Germans Trias i Pujol, Barcelona, Spain University of São Paulo, Brazil Michelle Hyczy Tosin, Rush University, United States Background: Previously published retrospective series show a high prevalence of fecal *Correspondence: incontinence (FI) in stroke patients. We aimed to analyze in a prospective series the Giuseppe Lucente current incidence of FI in acute stroke in functionally independent patients and its lucenteg@gmail.com Mònica Millán evolution over time and the patient characteristics associated with the appearance of mmillan.germanstrias@gencat.cat FI in acute stroke. Specialty section: Methods: We included consecutive patients with acute stroke admitted in our stroke This article was submitted to unit who fulfilled the following inclusion criteria: a first episode of stroke, aged >18 Stroke, years, with no previous functional dependency [modified Rankin Scale (mRS) ≤ 2] and a section of the journal Frontiers in Neurology without previous known FI. FI was assessed by a multidisciplinary trained team using Received: 08 August 2021 dedicated questionnaires at 72 ± 24 h (acute phase) and at 90 ± 15 days (chronic phase). Accepted: 28 September 2021 Demographic, medical history, clinical and stroke features, mortality, and mRS at 7 days Published: 01 November 2021 were collected. Citation: Lucente G, Corral J, Results: Three hundred fifty-nine (48.3%) of 749 patients (mean age 65.9 ± 10, 64% Rodríguez-Esparragoza L, Castañer S, male, 84.1% ischemic) fulfilled the inclusion criteria and were prospectively included Ortiz H, Piqueras A, Broto J, Hernández-Pérez M, Domenech S, during a 20-month period. FI was identified in 23 patients (6.4%) at 72 ± 24 h Martinez-Piñeiro A, Serra J, and in 7 (1.9%) at 90 days ± 15 days after stroke onset. FI was more frequent in Almendrote M, Parés D and Millán M hemorrhagic strokes (18 vs. 5%, p 0.007) and in more severe strokes [median National (2021) Current Incidence and Risk Factors of Fecal Incontinence After Institute of Health Stroke Scale (NIHSS) 18 (14–22) vs. 5 (3–13), p < 0.0001]. No Acute Stroke Affecting Functionally differences were found regarding age, sex, vascular risk factors, or other comorbidities, Independent People. Front. Neurol. 12:755432. or affected hemisphere. Patients with NIHSS ≥12 (AUC 0.81, 95% CI 0.71 to 0.89) had doi: 10.3389/fneur.2021.755432 a 17-fold increase for the risk of FI (OR 16.9, IC 95% 4.7–60.1) adjusted for covariates. Frontiers in Neurology | www.frontiersin.org 1 November 2021 | Volume 12 | Article 755432 Lucente et al. New-Onset Fecal Incontinence in Acute Stroke Conclusions: At present, the incidence of FI in acute stroke patients without previous functional dependency is lower than expected, with an association of a more severe and hemorrhagic stroke. Due to its impact on the quality of life, it is necessary to deepen the knowledge of the underlying mechanisms to address therapeutic strategies. Keywords: fecal incontinence, acute stroke, incidence, acute, epidemiology INTRODUCTION METHODS Fecal incontinence (FI) is defined as an involuntary loss of We conducted a prospective observational study of consecutive solid or liquid feces. It is a highly prevalent condition in the stroke patients admitted to our stroke unit from May 2018 to general population, although its incidence and prevalence are December 2019. usually underestimated due to reluctance of patients to report its symptoms (1). Large community-based studies have shown a Data Sample wide variability of rate of FI in the general population ranging Patients fulfilling the following criteria were included in the from 1 to 24% (2, 3). The maintenance of fecal continence is the study: age ≥18 years, first-ever anterior circulation stroke, result of the integration of somatic pelvic motor coordination functionally independent patients defined as a modified Rankin and visceral and sensory functions. Therefore, FI may present Scale (mRS) score ≤2, and absence of previous FI due to other as a result of an anal sphincter dysfunction, an abnormal rectal etiologies. Every included patient was prospectively screened for compliance, a decreased rectal sensation, or a combination of any the presence of new-onset fecal incontinence at 72 ± 24 h (acute of those abnormalities (4, 5). phase) after stroke onset and at 90 ± 15 days (chronic phase). FI has been reported to be a common complication after Out of 743 patients admitted to the stroke unit for a 20-month stroke. Previous studies have estimated an incidence from 10 to period, 359 (48.3%) patients (mean age 65.2 ± 10 years, 63.2% 40% (6–9) according to the time of assessment after stroke (6). male, and 86.2% ischemic stroke) fulfilled the inclusion criteria In one of the largest epidemiological studies, the prevalence of and were included in the study. Figure 1 shows the flow chart of post-stroke FI ranged from 30% within 10 days to 15% at 3 years the study and the reasons to exclude patients. after stroke (6), whereas a prevalence of 5 to 6% was detected in two more recent studies beyond the acute phase (10, 11). Fecal Incontinence Assessment Additionally, severe FI was reported in 5% of stroke survivors in a Data about fecal depositions are routinely collected by our large population-wide survey, a four-fold increase compared with trained stroke unit nurses during hospitalization, and when non-stroke patients (9). suspected, FI diagnosis was confirmed by a trained physician FI in stroke patients has been associated with age, both in the acute and chronic phase. FI was defined as diabetes mellitus, stroke severity, and other comorbidities any involuntary leakage of feces according to the Rome IV (6). Importantly, stroke patients with FI had higher risk of criteria (14), and patients were classified for the purpose of the short- and long-term mortality (6) and an increased need for study in FI and No FI subgroups accordingly. At 3 months institutionalization and nursing support in the community follow-up, a dedicated questionnaire [the Wexner score (15)] (10, 11), leading to a healthcare estimated costs of 55% higher was administered by a trained surgeon. This questionnaire investigates the presence of uncontrolled loss of gas, liquid, and compared with stroke patients without FI (12). However, the solid stools, if their presence requires the use of physical restraints available published data about FI after stroke are mostly based such as dressings or diapers and the impact on the quality and on studies conducted before the widespread use of intravenous sexual life. The score range from the minimum score = 0 which thrombolysis and especially, mechanical thrombectomy in means “perfect continence” to the maximum score = 20 points acute stroke treatment, and additionally, FI information has which means “totally incontinent.” been retrospectively collected through the use of general questionnaires or non-specific clinical scales for FI diagnosis. Studied Variables Remarkably, the general approach to stroke care has been Demographic, previous functional status, vascular risk factors, deeply changing over the last decades. The implementation of comorbidities, gastrointestinal tract diseases, history of dedicated stroke units managed by trained personnel, as well as abdominal surgeries, and stroke characteristics were recorded in the focus on rehabilitation strategies, with its facilities and the a dedicated database. Abdominal surgeries and gastrointestinal unequivocal benefit of reperfusion treatments have significantly diseases were defined as any intervention or relevant pathology reduced stroke patient dependency (13). In this new scenario, the involving the gastrointestinal tract previous to stroke. aims of this study were to identify (1) the current incidence of Stroke severity was defined using the National Institute of FI in acute stroke in previous functionally independent patients, Health Stroke Scale (NIHSS) (16). Ischemic stroke etiology was (2) the incidence of persistent FI in stroke patients beyond the determined according to the Trial of ORG 10172 in acute stroke acute phase, and, (3) the patient characteristics associated with treatment (TOAST) (17). Functional status was defined by the the appearance of FI in acute stroke. modified Rankin Scale Score (mRS) at admission and discharge Frontiers in Neurology | www.frontiersin.org 2 November 2021 | Volume 12 | Article 755432 Lucente et al. New-Onset Fecal Incontinence in Acute Stroke FIGURE 1 | FINISH study workflow. TIA, transient ischemic attack; mRS, modified Rankin Scale. (18). Favorable functional outcome was defined as a mRS ≤ 2 at (three during hospitalization, four after discharge), nine (39.1%) 3 months. patients recovered FI, and seven (30.4%) patients had persistent The study protocol was approved by the local Ethics FI. Thus, 2% of the first-ever anterior circulation strokes and 44% Committee, and written informed consent was obtained from of stroke patients with FI in the acute phase had persistent FI patients or relatives. after stroke. Statistical Analysis Patients Characteristics Associated With Descriptive analyses were obtained for all demographic and Post-stroke Fecal Incontinence clinical variables. Baseline characteristics between groups Demographic and clinical data according to the presence of FI (patients with FI and non-FI) were compared using X2 test, are shown in Table 1. Fisher’s test, t-test, or Mann–Whitney’s U-test, as appropriate. Patients with FI had higher stroke severity [NIHSS 18 (14– Logistic regression analysis was used to determine predictor 22) vs. 5 (3–13)] at admission compared with patients with fecal factors independently associated with the presence of FI in the continence. FI was more frequent in hemorrhagic stroke (12 vs. univariate analysis (p < 0.05) and variables previously related 5%) compared with ischemic stroke. No significant differences to in other published articles. Receiver-operator characteristics were found in age, sex, vascular risk factors, history of abdominal (ROC) curves were constructed by plotting basal NIHSS that surgery, or other comorbidities, affected hemisphere, vessel better predict the presence of FI, according to the best specificity occlusion, intracranial hemorrhage location, or ischemic stroke and sensitivity. Statistical significance was defined as two-sided etiology between patients with and without FI. At discharge, p-value < 0.05. All the statistical analyses were made using patients with FI had higher stroke severity, poor functional SPSS statistical package vs. 22 (IBM Deutschland GmbH, outcome, and higher mortality rate compared with those without Ehningen, Germany). FI (Table 1). RESULTS Independent Predictors of Post-stroke Fecal Incontinence Appearance FI was identified in 23 (6.4%) out of 359 included patients in the A logistic regression model adjusted for age, sex, and affected acute phase. Of those, at 3 months, seven (30.4%) patients died hemisphere showed that hemorrhagic stroke and NIHSS were Frontiers in Neurology | www.frontiersin.org 3 November 2021 | Volume 12 | Article 755432 Lucente et al. New-Onset Fecal Incontinence in Acute Stroke TABLE 1 | Baseline clinical characteristics and functional outcome of fecal TABLE 1 | Continued incontinence and continence stroke patients. Total sample Fecal Fecal P Total sample Fecal Fecal P N = 359 incontinence continence N = 359 incontinence continence N = 23 N = 336 N = 23 N = 336 Mortality at 7 days or at 11 (3.1) 3 (13) 8 (2.7) 0.029 Demographics and medical history discharge Gender, male 229 (64) 12 (52.1) 217 (64.5) 0.129 Numbers are expressed as mean ± SD, median [quartiles] and number (percentages). Age (years) 65.9 ± 10 65.7 ± 10 67.8 ± 11 0.115 COPD, chronic obstructive pulmonary disease; heart disease, coronary heart disease or Smoking habit 90 (25.1) 5 (21.7) 85 (25.3) 0.639 heart failure; TICA, terminal internal carotid artery; MCA, middle cerebral artery; ACA, anterior cerebral artery; Tpa, tissue plasminogen activator; EVT, endovascular treatment; Alcohol abuse 25 (6.9) 0 (0) 25 (7.4) 0.239 TOAST, Trial of ORG 10172 in acute stroke treatment; NIHSS, National Institute of Health Hypertension 237 (66) 16 (69.5) 221 (65.8) 0.899 Stroke Scale; mRS, modified Rankin Score. Diabetes 104 (29) 6 (26.1) 98 (29.2) 0.919 Hypercholesterolemia 194 (54) 12 (52.1) 182 (54.2) 0.766 TABLE 2 | Multivariate analysis of factors associated with fecal incontinence (FI) Atrial Fibrillation 63 (17.5) 6 (26.1) 57 (16.7) 0.413 during the acute stroke phase. Heart disease 41 (11.4) 2 (8.6) 39 (11.6) 0.753 OR 95% IC p COPD 36 (10) 3 (13) 33 (9.8) 0.729 Chronic kidney failure 9 (2.5) 0 (0) 9 (2.7) 1.000 Age 1.010 0.967–1.056 0.65 Obesity 42 (11.7) 1 (4.3) 41 (12.2) 0.271 Female gender 2.308 0.876–6.084 0.091 Urinary incontinence 0 (0) 0 (0) 0 (0) 1.000 Left side stroke 1.629 0.613–4.327 0.328 Abdominal surgery 28 (7.8) 3 (13) 25 (7.4) 0.431 Hemorrhagic stroke 4.743 1.701–13.224 0.003 Gastrointestinal disease 18 (5) 1 (4.3) 17 (4.2) 0.881 NIHSS admission >12 16.915 4.759–60.120 0.001 Clinical features Ischemic stroke 302 (84.1) 16 (69.5) 286 (85.1) 0.008 Hemorrhagic stroke 57 (15.9) 7 (20.5) 50 (14.9) independently associated with the presence of FI in the acute Affected side 0.717 phase of stroke (Table 2). A further model adjusted for vascular Left 200 (55.7) 16 (69.5) 184 (55.3) risk factors or other comorbidities as well did not modify the Right 149 (41.5) 7 (30.4) 140 (42) effect (data not shown). A cut-off point of NIHSS ≥12 in the ROC Bilateral 9 (2.5) 0 (0) 9 (2.7) curve (AUC 0.81, 95% CI 0.71 to 0.89; p < 0.001) predicted the Arterial occlusion N = 302 N = 16 N = 286 0.500 presence of FI with a sensitivity of 84% and specificity of 75%. No 86 (28.4) 3 (18.7) 83 (29) Stroke patients with NIHSS≥ 12 had a 17-fold increase in the risk TICA 18 (5.9) 1 (6.2) 17 (5.9) ACM M1 158 (44) 6 (37.5) 152 (53.1) of FI compared with those with NIHSS <12 (OR 16.9 IC 95% 4.7– ACM M2 25 (8.2) 2 (12.5) 23 (8) 60.1) adjusted for covariates. Moreover, when we classified stroke TANDEM 8 (2.6) 2 (12.5) 6 (2) patients according to stroke severity in mild stroke (NIHSS ≤ 6), ACA 7 (2.3) 2 (12.5) 5 (1.7) moderate stroke (NIHSS 7–15), and severe stroke (NIHSS>15) Reperfusion treatment N = 302 N = 16 N = 286 0.252 (19), we found that the higher the stroke severity, the higher the No 162 (53.6) 9 (56.2) 153 (53.1) rate of FI in the acute phase and in the chronic phase (Figure 2). IV tPA 52 (17.2) 0 (0) 52 (18.2) EVT 49 (16.2) 4 (25) 45 (15.8) Table 3 shows the patient and stroke characteristics associated IV tPA + EVT 41 (13.6) 3 (18.8) 38 (13.3) with persistent FI at 3 months. No differences were found in Intracranial hemorrhage N = 57 N=7 N = 50 0.102 clinical, demographic features, stroke subtype, baseline NIHSS, location and severity of FI measured by the Wexner’s score between Lobar 22 (38.6) 3 (42.8) 19 (38) patients with persistent FI or recovered FI at 3 months. Basal ganglia 33 (57.9) 4 (57.2) 29 (58) Thus, no independent predictors of persistent FI beyond acute Both 2 (3.5) 0 (0) 2 (4) stroke phase were identified in a logistic regression analysis TOAST classification N = 302 N = 16 N = 286 0.152 Atherothrombotic 103 (34.1) 5 (31.5) 98 (34.2) (data not shown). Cardioembolic 100 (33.1) 8 (50) 92 (32.1) Lacunar 45 (14.9) 0 (0) 45 (15.7) Undetermined 39 (12.9) 3 (18.5) 36 (12.5) DISCUSSION Other causes 15 (5) 0 (0) 15 (5.2) NIHSS at baseline 6 [3–6] 18 [14–22] 5 [3–13] <0.001 Stroke patients may suffer different complications both during NIHSS at 7 days 2 [0–5] 13 [5–21] 2 [0–5] <0.001 the acute (such as neurological worsening or stroke recurrence, seizure, infections) and the chronic phase (cognitive impairment, mRS ≤2 at 7 days or 182 (50.6) 2 (9) 180 (53.6) <0.001 discharge depression, and emotional lability, among others) (20). Fecal incontinence in stroke patients has been poorly investigated (Continued) during the last decade, probably due to a lack of interest of Frontiers in Neurology | www.frontiersin.org 4 November 2021 | Volume 12 | Article 755432 Lucente et al. New-Onset Fecal Incontinence in Acute Stroke TABLE 3 | Baseline clinical characteristics of patients with persistent fecal incontinence and recovered fecal incontinence at 90 days. Total sample Persistent fecal Recovered fecal N = 16 Incontinence incontinence N=7 N=9 Demographics and medical history Gender, male 6 (37.5) 2 (28.5) 4 (44.4) Age (years) 66.4 ± 12.4 69.7 ± 10.7 62.7 ± 18.2 Smoker 3 (18.7) 1 (14.3) 2 (22.2) Alcohol abuse 0 (0) 0 (0) 0 (0) Hypertension 6 (37.5) 1 (14.3) 5 (55.5) Diabetes 4 (25) 3 (42.9) 1 (11.1) Hypercholesterolemia 6 (37.5) 3 (42.9) 3 (33.3) Atrial fibrillation 1 (6.2) 0 (0) 1 (11.1) FIGURE 2 | Prevalence of fecal incontinence (FI) in acute phase (gray bar) and Heart disease 2 (12.5) 2 (28.6) 0 (0) chronic phase (black bar) according to stroke severity (NIHSS) at admission. Inside each bar % of FI patients is shown. COPD 1 (6.2) 1 (14.3) 0 (0) Chronic kidney failure 0 (0) 0 (0) 0 (0) Obesity 1 (6.2) 1 (13.3) 0 (0) Urinary incontinence 0 (0) 0 (0) 0 (0) Abdominal surgery 3 (18.7) 2 (28.6) 1 (11.1) neurologists and its main prevalence in long-term hospitalized Gastrointestinal disease 1 (6.2) 1 (14.3) 0 (0) stroke patients. However, FI has a strong impact on a person Clinical features quality of life and on its caregiver (21). Ischemic stroke 10 (62.5) 4 (57.1) 6 (66.7) The present study shows an incidence of 6% of FI in first- Hemorrhagic stroke 6 (37.5) 3 (42.9) 3 (33.3) ever functionally independent stroke patients during the acute Side phase that decreases to 2% at 3 months. This rate is significantly Left 9 (56.2) 4 (57.1) 5 (55.6) lower than expected and reported before. Brocklehurst et al. (22) Right 7 (43.7) 3 (42.94) 4 (44.4) Bilateral 0 (0) 0 (0) 0 (0) observed FI in 23% of patients immediately after stroke, which Arterial occlusion N = 10 N=4 N=6 diminished down to 16% after 2 weeks, and eventually to 8% at No 1 (10) 0 (0) 1 (16.7) 1 year. The large registry of the Copenhagen Stroke study (23) TICA 0 (0) 0 (0) 0 (0) reported FI in 40% of stroke patients at hospital admission, in ACM M1 5 (50) 3 (75) 2 (33.3) 18% at hospital discharge, and in 9% at 6 months. Of note, the ACM M2 1 (10) 1 (25) 0 (0) Harari et al. (6) study showed that the prevalence of FI was of TANDEM 1 (10) 0 (0) 1 (16.7) ACA 2 (20) 0 (0) 2 (33.3) 30% at 7 to 10 days, 11% at 3 months, 11% at 1 year and 15% at Hemorrhage localization N=6 N=3 N=3 3 years. Recently, Jacob et al. (24) showed that up to 6% of stroke Lobar 3 (50) 3 (100) 0 (0) survivors presented FI at some point during the 10-year study Basal ganglia 3 (50) 0 (0) 3 (100) period in a large retrospective cohort. It is important to highlight Both 0 (0) 0 (0) 0 (0) that these studies identified FI through the use of Barthel Index TOAST classification N = 10 N=4 N=6 scale or a customized questionnaire (9, 11), and no other specific Atherothrombotic 3 (30) 2 (50) 1 (16.7) or dedicated scales, or clinical or electrophysiological assessments Cardioembolic 5 (50) 1 (25) 4 (66.7) Lacunar 0 (0) 0 (0) 0 (0) were done to properly diagnose FI. We selected the Wexner score Undetermined 2 (20) 1 (25) 1 (16.7) (15) because it is a widely used scale in fecal incontinent patients, Incomplete 0 (0) 0 (0) 0 (0) usually employed by proctologists and gastroenterologists to NIHSS at baseline 18 [17–20] 18 [17–21] 19 [9–21] evaluate fecal incontinence and its severity. It has been widely Wexner Score 9 [8–12] 10 [8–12] 9 [8–13] validated in FI assessment and it strongly correlates with FI severity. Wexner score has been related to subjective perception Numbers are expressed as mean ± SD, median [quartiles] and number (proportion). COPD, chronic obstructive pulmonary disease; heart disease, coronary heart disease or of FI and it could be self-assessed by patients. This fact and heart failure; TICA, terminal internal carotid artery; MCA, middle cerebral artery; ACA, the retrospective evaluation of some of these previous studies anterior cerebral artery; tPA, tissue plasminogen activator; EVT, endovascular treatment; could partly explain the difference in the incidence rates with TOAST, Trial of ORG 10172 in acute stroke treatment; NIHSS, National Institute of Health respect to our series, in which the patients were prospectively Stroke Scale. The p-values are not shown due to no statistical significance. assessed with scales designed to the detection of FI. In addition and importantly, the improvement in stroke care through its management in stroke units and the advancement in reperfusion have strongly modified the incidence and the natural history of treatments, rehabilitation strategies, and patient and caregiver fecal incontinence in acute stroke. education, have played an important role on the functional Moreover, It is known that the lack of mobility, the functional outcome of stroke patients in the last decade (25), and it could dependence, and indeed, the use of multiple medications are risk Frontiers in Neurology | www.frontiersin.org 5 November 2021 | Volume 12 | Article 755432 Lucente et al. New-Onset Fecal Incontinence in Acute Stroke factors to develop fecal incontinence (6, 10, 25, 26). One of the linked to a more severe stroke, with a probable large hemispheric pillars of stroke rehabilitation is the early mobilization and the lesion, and contrarily, no association was found to stroke implementation of instrument use to improve the self-care and lateralization. Until now, there is no knowledge about the precise autonomy of the patient, so, this approach could as well have cortical area involved in the fecal continence (the “continence” reduced the incidence of FI during the last years. Nevertheless, area), so, further anatomical and radiological functional studies 30% of patients with FI detected during the acute phase in our are needed. cohort died before 90-days follow-up evaluation, so we cannot The main strengths of this study are the high-quality rule out a potential higher incidence of persistent FI after stroke data due to the systematic and prospective data collection, (up to 3.8% higher). the multidisciplinary approach, the use of FI specific clinical According to our results, the strongest independent predictor scales and stroke severity assessment. Thus, it has followed to have FI was stroke severity at admission, since patients a large sample of patients in an observational study in a with a severe stroke (NIHSS >12) have a 17-fold increase in short period of time without differences in the acute stroke the probability of developing FI in the acute phase compared care, recanalization techniques, and rehabilitation facilities for with patients with NIHSS ≤ 12 (Figure 2). Harari et al. (6) a long time between patients. However, several limitations already described the association between stroke severity and have to be stated. First, our study was carried out in a FI although using only clinical features (neglect, dysphagia, single comprehensive tertiary stroke center, so these results etc.) instead of a validated and widely used stroke scale for might not be generalizable to other settings. Second, we severity assessment such as NIHSS (16). In our cohort, patients focused on the incidence of FI in the acute phase until 3 suffering from a hemorrhagic stroke were five times more months after stroke. Consequently, we did not assess the likely to present FI during the acute phase compared with potential resolution or the new appearance of FI beyond patients with ischemic stroke, which was not previously found this period. Third, we excluded patients with previous stroke associated with FI. The limited acute treatment strategies able to and/or other gastrointestinal tract disease to select patients modify the natural course and functional outcome of intracranial in whom the acute stroke was the single cause of FI, a fact hemorrhage and, as already described, the more severe disability that could contribute to rule out patients in whom FI was that usually implies hemorrhagic stroke compared with ischemic multifactorial. Fourth, we did not specifically collect language stroke (27) [median NIHSS 20 (15–23) vs. 18 (14–22) in impairment or cognitive disturbance, which might have altered hemorrhagic/ischemic stroke in our series], might explain the the continence independently of the stroke; however, we included higher incidence of FI in these patients. Interestingly, no only functionally independent patients (mRS < 2), able to live association has been found with vascular risk factors, deliveries, alone and to carry on daily life activities by themselves. So, and previous abdominal surgeries that have been already related we think that the cognitive impairment, if present, would have to FI (6). Although it could be due to the sample size, we infer that been mild or very mild. Last, we also excluded patients with this could strengthen the role of the acute stroke as the primary vertebrobasilar stroke territory to minimize clinical heterogeneity cause of FI appearance. in the sample of patients, so a higher incidence of FI could have To the best of our knowledge, this is the first study specifically been identified. designed to prospectively investigate the appearance of FI using Sacral nerve stimulation is an established treatment for FI due a multidisciplinary approach. We implemented a comprehensive to several etiologies (34). Its neuromodulatory effect on cortical protocol that allowed us to study our patients by means of the areas would be promising for incontinent patients due to stroke stroke neurologist and the proctologist. We used the Wexner in addition with standard care based on rehabilitation. scale instead of the Barthel index to quantify fecal incontinence Therefore, prospective randomized clinical studies analyzing in the chronic phase that provides a deeper description of the FI the real effect of neuromodulation for FI in stroke patients compared with the dichotomic item within the functional clinical are warranted. assessment of the Barthel Index. Our results show a moderate severity of FI in our patients (Wexner score 9–10). Remarkably, half of the incontinent patients in the acute CONCLUSION phase of stroke were still affected 3 months after stroke, although no differences were found in clinical or demographic features At present, the incidence of persistent fecal incontinence reaches between those patients with persistent or recovered FI. Of note, 2% of the previous functionally independent patients with a first the severity of the FI diagnosed in the acute phase did not anterior circulation stroke, lower than expected and strongly correlate with its persistence at 3 months follow-up. related to stroke severity. However, due to its impact on the Interestingly, the cerebral mechanisms underlying the quality of life, it is necessary to deepen the knowledge of the appearance of FI in stroke patients are not completely underlying mechanisms to address therapeutic strategies. understood (28–31). The maintenance of fecal continence is the result of a coordination of pelvic motor, visceral and sensory functions; therefore, the loss of fecal continence may be DATA AVAILABILITY STATEMENT the result of an anal sphincter dysfunction, an abnormal rectal compliance, a decrease rectal sensation, or a combination of The raw data supporting the conclusions of this article will be any of these abnormalities (5, 32, 33). We found that FI was made available by the authors, without undue reservation. Frontiers in Neurology | www.frontiersin.org 6 November 2021 | Volume 12 | Article 755432 Lucente et al. New-Onset Fecal Incontinence in Acute Stroke ETHICS STATEMENT and included the subject. SC, MH-P, HO, and SD revised the patients included. GL, MM, and DP wrote and revised the The studies involving human participants were reviewed manuscript. All authors contributed to the article and approved and approved by the Ethic Committee of our center - the submitted version. CEIC (comité ético de Investigación Hospital Germans Trias i Pujol). The patients/participants provided FUNDING their written informed consent to participate in this study. This project was granted by Fundació/Marató TV3 (ID Number: 201718.10). MM and MH-P are part of the research group AUTHOR CONTRIBUTIONS RETICS-INVICTUS-PLUS (RD0016/0019/0020) granted from the Instituto de Salud Carlos III (Spanish Ministry of Economy GL, DP, MM, JC, JS, JB, LR-E, MA, and AM-P designed the and Competiveness). MH-P receives funding from Instituto de study. JC, JB, AP, MH-P, MA, and AM-P selected the patients Salud Carlos III with a grant for Health Research (JR17/00006). REFERENCES 17. Love BB, Bendixen BH. Classification of subtype of acute ischemic stroke definitions for use in a multicenter clinical trial. Stroke. (1993) 24:35– 1. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent 41. doi: 10.1161/01.STR.24.1.35 affliction. Am J Gastroenterol. (1996) 91:33–6. 18. Bonita R, Beaglehole R. Recovery of motor function after stroke. Stroke. (1988) 2. Andrews CN, Bharucha AE. The etiology, assessment, and treatment of 19:1497–500. doi: 10.1161/01.STR.19.12.1497 fecal incontinence. Nat Clin Pract Gastroenterol Hepatol. 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Sacral neuromodulation for fecal incontinence: a review of endorsed by the publisher. the central mechanisms of action. J Clin Gastroenterol. (2017) 51:669– 76. doi: 10.1097/MCG.0000000000000850 Copyright © 2021 Lucente, Corral, Rodríguez-Esparragoza, Castañer, Ortiz, Piqueras, Broto, Hernández-Pérez, Domenech, Martinez-Piñeiro, Serra, Conflict of Interest: The authors declare that the research was conducted in the Almendrote, Parés and Millán. This is an open-access article distributed under the absence of any commercial or financial relationships that could be construed as a terms of the Creative Commons Attribution License (CC BY). 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