When Urgency Takes Over: Breaking the Cycle of Bowel Symptoms and Anxiety

What happens when you’re constantly scanning for the nearest bathroom? When social plans, work schedules and even sleep revolve around the fear of not making it in time?

In this episode of Life Without Leaks, we welcome Dr. Ehsan Navabi, the director of the IBD Center and the GI Motility Disorders Lab at United Medical Doctors in California, to take a closer look at one of the most disruptive digestive symptoms patients face: bowel urgency.

 Dr. Navabi explains how persistent urgency is more than an inconvenience - it can reshape daily life and significantly affect mental health.

We explore why urgency develops, how the brain-gut axis amplifies symptoms and why anxiety and bowel disorders often feed into each other. Dr. Navabi also discusses common but overlooked causes as well as inflammatory conditions like Crohn’s disease and ulcerative colitis.

Most importantly, he emphasizes that urgency is treatable. With proper diagnosis, multidisciplinary care and early intervention, many patients can regain predictability, confidence and freedom.

If urgency is quietly controlling your schedule, this episode offers reassurance: you don’t have to plan your life around a bathroom — and help is available.

For more information about the National Association for Continence, click here, and be sure to follow us on Facebook, Instagram and Pinterest.

Music:
Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

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Transcript

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, Bruce. I'm so glad to be here. 

Bruce Kassover: Yeah, me too. Today our guest is Dr. Ehsan Navabi. He's a board-certified gastroenterologist, a hepatologist, and an obesity medicine specialist as well. He currently serves as the director of the IBD Center and the GI Motility Disorders Lab at United Medical Doctors in California where he works with patients who have inflammatory bowel disease, complex motility disorders, and a whole range of digestive health conditions. So, Dr. Navabi, thank you for joining us today. 

Dr. Navabi: Oh, thank you. Thank you so much Bruce, and thank you Sarah for inviting me here. And it is an honor actually to be talking to you guys and all hope that basically we have a very good conversation about something that basically is very dear to my heart about basically helping our patients with the struggles that they have. So no, thank you so, so much for your invitation. 

Bruce Kassover: Yeah. You know, this is not a comfortable subject for a lot of people and I'm wondering, you know, you are on the other side of things. How did you get to be where you are today, where, where this is sort of the focus of your, your career and your life's work?

Dr. Navabi: Oh, thanks for asking that. So, I mean, as you basically mentioned, medicine has been my passion. So I did my training actually in Iran, but I was practicing for a few years in Iran and in 2012 basically I came to the United States and gastroenterology basically something that I was always looking to.

It came from earlier stages of my training. And I got lucky enough to get to Penn State, which, I had a very good chance and opportunity to basically get to work with very giants of basically, gastroenterology. They, they're folks that, they helped me a lot. So I did my training basically in general GI, but I had a very good exposure to inflammatory bowel disease because of basically.

And also it was one of the initial centers that basically United States started to focus on . So I was blessed. And after that, I got an opportunity to go to New Jersey. I was attending and basically teaching at Rodgers University. At the time I was director of both motility disorders and also inflammatory bowel disease disorders.

And then life brought me to California. And I am basically being blessed to have a very great team and working with the greatest patients in California. And hopefully I can help them. 

Bruce Kassover: Well, that's quite a journey that you've taken, so, so you really have been all over the place. It's pretty cool to hear.

So tell me this, when a patient, speaking of journeys, winds up in front of you, you know, if somebody has, well, let me put it this way. People are very good oftentimes at either ignoring or downplaying whatever's going wrong with them. And they, they will, will put off seeing, many people will put off seeing a doctor until they really have no other choice.

At the point that people are seeing you, what stage are they usually at? Or do you get people who really sort of do head things off early or are most people sort of pretty deep into their issues before they even get in front of you? 

Dr. Navabi: Oh, that's a very great question. And the best way that you can basically to bring it up.

So I would say that it all depends basically on acuity of their symptoms. All right. So, most of us, especially for basically, some delicate subject matters that we don't feel comfortable to basically to open up the conversation. We try to put it in a, basically back of our minds. We try to basically try to say that it's going to resolve.

And one of the things that happens after few years, few months it just becomes new normal. And we get so much used to those symptoms that they're not actually normal. But because we used to them we think it is our new normal and till the time that unfortunately may progress to the time that affects our quality of life, it becomes so disruptive and it come by basically, seek medical health.

And it is interesting part that when you hopefully can basically help your patient and they start to feel better, say, "oh, I forgot how, was basically the normal life mean to me. I mean, when I didn't have any of these disruptive symptoms." But I want to put it this way, if they have very acute symptoms, all right, especially if they have some alarm signs.

Let's say you have the patient that comes bleeding. So these are the ones that they worry about too much and basically they try to seek medical attention sooner. But sometimes these symptoms are more chronic and basically as I said, people may not feel more comfortable to talk about them. So sometimes we have years, I mean, that the patient will come to our clinic for the first time to have the discussion and conversation.

And I think that's, that's the most important factor that we start to dig in and figure out when was the first time that essentially patient has started to feel these symptoms? And more importantly, it is not just the gastrointestinal presentation of that, the way that it affects their quality of life.

I think that's, that's something that's very important because it affects their work, their life balance. Many, many factors that I'm hoping that we can discuss today about. 

Bruce Kassover: Yeah, absolutely. You know, we're talking about symptoms and I'm wondering if there's a common family of symptoms that tend to get people to come and see the doctor or is it really a mixed bag?

Are there certain symptoms that people can more easily ignore and other things that, that really do sort of send them running to the doctor? What, what do you see? 

Dr. Navabi: Yeah, I mean I think it's both ways, right? So some of them especially in gastroenterology, the symptoms sometimes they are not always specific , right?

So, let's put it that way. Bloating, it's something that we get used to. Changes in bowel habits is something that we get used to. Sometimes it's normal to have them. Alright, so you have it for a day or two. And there are basically pretty minimal, but at some point it become chronic. And you're dealing with that on a daily basis and without us knowing they're affecting our life.

And these are the things that basically we don't pay much attention to. But sometimes the symptoms are basically more abrupt. They're basically, um, more concerning, as I mentioned, bleeding, very significant changes in bowel habits, including very significant diarrhea, progressive unexplained weight loss that we have, or, severe abdominal pain. So these are the ones that may be the patient is seek attention sooner than later. But more than often, I would say still many of these symptoms are chronic. And by the time that the patient comes and usually the opening sentence that the patient has, "You know, doc, as long as I remember, was dealing with these digestive symptoms."

And it is very interesting that it becomes so normal for them that they already come up with some sort of diagnosis that, and when you dig into that, you see that is either something simpler or even more basically significance. But I would say that in gastroenterology clinic it is very, very common that we get to see patient that they're already dealing with symptoms for longer term, except if you have some of those alarming basic symptoms as I mentioned, that they were more acute and more concerning to the patient.

Bruce Kassover: It reminds me of, you know, the story of, you know, the frog in boiling water. You know, you turn up the heat, the frog doesn't even realize that it's boiling until it reaches a point where it's in real mortal danger. And one of the things that I wanted to ask you about in particular, because we really get a lot of questions about is urgency among the, the family of symptoms.

And like you mentioned that there's, you know, sometimes things just happen, you know, you ate a bad fish and for the weekend you have terrible symptoms, but it goes away. But urgency that's persistent. What should I be looking for as sort of a warning sign? Both in the symptom itself and the length of time that I've had it before I go to a doctor?

Dr. Navabi: I think that's that's a very great question. So I want to make it very, very simple. If you, if you have a bowel urgency that I think that basically effects our daily life. That we have it in our basically, the back of our mind as a concern all the time. I think that's, regardless of how simple we think it is, there is always a solution for that .

So I want to make it very, very simple . If you want to go out with your friends and your concern is, you know what, maybe I should check to the bathroom, should do, I know where are the bathrooms are at, or I'm avoiding going out with my friends because I'm worried about the symptoms that I have , it's not normal.

So it is something that we probably can look into that and hopefully we can help the patient. So I think that seeking medical attention and basically medical care can help if you are seeing that you are avoiding the jobs that you like, simply because you have a fear of basically the job situation that may not allow you to have ease of access to the bathroom. That is something that basically I think is very basic that we have to help our patients and basically get them back to normal life.

I want to go a little bit further in. I mean, we do see this in younger patient even, it affects sometimes the intimacy, right? So that's something that basically is out there.

And if you are worrying about this, there is always a chance that we can have a solution for this problem . Or if you have the simplest thing, I mean, going to the mall for shopping. I mean, if you have to make the shopping so short that you are worried about this bowel urgency, that it cannot make it to bathroom that easy, alright?

That's the time that you have to basically try to think that there may be some answers for these that we can get treatment . So that's the very basic one. Anything that affects your quality of life probably needs a medical attention. On top of that, there are some basically more, more, more concerning factors, right?

So if you start to feel that, "Oh, I'm looking at my weight for the last six months, all of a sudden I lost about 10% of my body weight." That is something that definitely you need to ask your doctors basically to see what's the reason for that. If you are. Not sleeping at nighttime because of the urge that you have and affects your quality of life, that's a time that basically you may need to seek that attention sooner. If you're seeing the changes in bowel habits and all of a sudden you have frequency in the bowel movement beside the bowel urgency, that is something that probably need to seek attention. Or if you see bleeding with the bowel movements , that is something that basically will trigger those alarm signs if, if there is severe abdominal pain beside the bowel urgency.

So it is not just the concern that I may have incontinence and basically I have this space to find a bathroom. No, but I have severe abdominal pain . I mean, literally it affects my daily life with these pain. I'm cramping all the time. These are the times that probably should seek the medical attention sooner than later.

And hopefully we can catch up and basically treat the patient sooner so we can get them back to normal life. 

Bruce Kassover: Now I, I think all that makes perfect sense and these are obviously signs of things that are not going right in your body. But it seems to me that the hard part is admitting it, speaking up because even though you know something is going wrong, I mean, this is tough to talk about to anybody.

What do you say to a patient who is concerned? They're embarrassed. They're afraid, they're ashamed. How do you, what do you say to get that patient to actually make the phone call, talk to the receptionist and get into your office? 

Dr. Navabi: I think that it has two points, right? It is, one comes from us as physicians and I think that's the most important part.

And I think that, I hope, I'm very lucky that to have very great colleagues all across the world. But I think that one of the beauty of the medicine, and I remember when we were in medical school, there was a basically course that you start to learn about the signs and symptoms of the disease.

And in a textbook there was a famous quote in saying that the beauty of the medicine and being a medical doctor is you get so close to your patient in a few minutes that they will share the information with you that they will not share it to their closest friends, closest family members or relatives.

So that's a trust that you build and basically that safe environment that you build for your patient, that they can trust you and they share the information, they feel welcome. So I think that the most important part, I still think that basically comes to provider is just to make that environment so safe that the patients, and that can be the primary care physician, can be gastroenterologist, can be the gynecologist.

So any p physician that you see, and again, we are lucky that we across the world have the greatest basically doctors in the world or basically, healthcare providers in the world that they can provide that situation. But knowing the fact that basically that environment is available to us, then the next question is, what would be the next step to hesitate about this?

Alright, and I think that one, nothing is more important in our life, the one time that we are living to have the best quality of life that we can have, alright? And there is no reason that basically delayed this care that we can receive as much as possible. So while we think that these are the matters that we, we feel shy because this is socially, these are not the things that we discuss as much basically these are the things that we try to basically avoid mentioning them because of the stigmas that unfortunately has been presented basically around us before. But one thing that is important is, our health is important. When I'm healthy, I can do better. When I'm healthy, I function better in society. When I'm healthy, I can enjoy the time that I have with the family, and also I can enjoy the time that I have with the friends. So then we try to avoid any obstacles that can prevent that . And I think when these things happen, the first thing that comes to mind, I would say the first place to start is your primary care physician that you basically build up the trust. You know them, you see them frequently. They know all about you, about your kids, the grandkids, everybody basically was your life. So maybe it's a good start to keep up the, pick up the phone, call and it just say, "Hey, I need to be in touch base with my primary care. Right? So I just have an issue that I want to discuss." And then when you go to the clinic, I think that's going to be the best time that you start to express, and I'll get to the point that it's an art, how we ask questions from the patients and how patients can bring that up. And I think that's very important.

But I think that the first thing is a reluctancy to consider to basically ask for care from the doctors or healthcare providers. Um, it just basically affects the quality of life and any seconds, any minutes, and any basically years that we're missing at this point, it just affects basically our life, the precious life that we have.

So I think that, basically, if you feel that today this is something that you have a subtle concern or you think is a major concern, pick up the phone, make that appointment, get into one-to-one with your healthcare provider. Hopefully there is a way that we can help.

Sarah Jenkins: You know, one thing that we hear a lot on our end is patients go in and talk to their primary care. And the primary care might not know exactly what's going on yet and is trying to figure out, but it sometimes takes a really long time for those patients to even get to someone like you. Do you have any advice for them to move that along a bit more quickly?

Dr. Navabi: No, absolutely. Part of that, as you know, it depends what type of access that we have to healthcare, right? So sometimes, regardless of basically having every year so many great graduates join into medicine, we still basically a struggle to have enough providers, even at the areas that you think that basically you should have access to the providers very easily.

It's very challenging. And hopefully, as time goes by, we can have more providers available to the patient with easier access.

But I would start with this: when we go and see our primary care physician, the big thing is, we share the importance of the matter. Alright? So I think that's going to be the first conversation .

The first thing that happens is for many of us. We may not have that much of a great awareness about the bowel urgency itself, you know, because that wasn't a matter that was brought up by the patients directly very easily. And I may not have basically, that awareness about the bowel urgency.

And it may not be a routine question that comes up with a primary care physician or a gastroenterologist, alright. Hopefully that will change. And I think that basically there is a very, especially in gastroenterology, there is very significant campaign for bringing up this awareness.

But I think that also can help from the patient that if they don't feel shy to bring up the question, I mean, know, just simple, simple question from a doctor. As simple as, "You know, doctor, I think that I'm worried about basically my bowel habits now. I think I'm struggling that basically at some point that I'm always concerned about if I can make it to the bathroom on time and it affects my life. I cannot enjoy my time with a family. I had missing time from work. And is there anything that we need to do about this? Or is there anything concerning?" And I'm pretty sure that triggers that basically question mark for the doctors to start to ask further questions, to figure out basically what are the causes of these differentials for basically etiology.

And honestly, many of these parts can be easily handled even by primary care physician. And of course there is always some complexity and more complex forms that you may need to seek subspecialties like gastroenterology or motility disorders. But there are still certain workups, and I would say still maybe 80, 90% of the workups that can be done at the level of primary care , very easily, at least to reassure that there is no alarming signs. The patient doesn't come with anemia, the patient doesn't have any bleeding, and assessing those and then doing some basic therapies in treatment. If that doesn't work, then for sure, I mean that, I think that patients and physicians should have the conversation that is this important to have another level of care, attention to help them to basically resolve the symptoms .

Sarah Jenkins: Thank you. That's great. 

Bruce Kassover: I'm wondering with what you're talking about is, do you also see a difference between the way men and women come to see you in terms of, not just what they're presenting physically, but in terms of, you know, what it actually takes to get them through the door?

Dr. Navabi: I think that's that's very important. And in both sides basically there is limitations , right? So number one, um, women basically may tend to be more comfortable with the female providers to share this information. And again, it's my role as a physician just to make this very comfortable, environment for having that conversation.

So that is something that's being missed, alright? And especially if those are the quick visits that you don't really go into the detail. I mean, the patient comes really having this question in the back of the mind, but the physician's attention is just something else. And you do not build up that environment to have the conversation.

So that is something that basically happens. And, um, for men also, it is something that basically they are somewhat more reluctant to talk about, these two. And again, this goes back to basically in many unfortunate social norms that has been existed for many, many years.

But I can, I can say this and I'm going to give you basically story. So I do inflammatory bowel disease, right? And that is something that's very routine with that I do. And as a physician, it was like 2018, 2019 that we had very major study that started to talk about bowel urgency and inflammatory bowel disease that's how disruptive it is. 50% of people basically are wearing diaper for once a week.

And that was basically a shock for me. I had no clue about it. And up until that point I probably did not ask this question much from patients. So now basically when this awareness comes, then the physicians feel more comfortable to ask this question, Hey, have you ever had any trouble that basically going out with your friends that, without basically having concern of an accident or is bowel habits is something that is of your concern on daily basis for you? Is this something that you think about it too much? Right? These are the good opening. I mean, we don't have to all of a sudden start with the details that people feel a little bit shy about it to open that up. I think that when you start asking that, then the next question, what about diarrhea? Do you have any diarrhea or as simple as that? I mean, has it ever happened that you feel that, um, you may not be able to make it to the bathroom and it may have an accident? And with that started, then you can basically make it to the next question that I think that almost everybody tried to avoid having that conversation that actually, if you ever had accident, because this is an experience that basically, I cannot make it basically any simpler.

It is considered to be embarrassing for all of us, right? So we don't feel comfortable to share this, if you are not asked and I think that basically that is something that we have to delicately open up and basically discuss about this. At some point, again, if it is a disruptive matter, and even if you feel that your healthcare provider did not get to that point because they were basically targeting the other parts of the medical problem, I think it's very, very important that we proactively bringing that up to, "Hey doctor, there is another important issue that I want to discuss."

And I know it is not a comfortable subject to discuss. It's never comfortable and nobody wants to open up about it, but I always say, let's step back a little bit and see that if I can fix this problem, how much I can have better quality of life. I mean, we think about that. I think that it will helps us to be basically more proactive to seek the help.

Bruce Kassover: You know, you talk about fixing the problem and I suppose that really is the ultimate goal. I mean, if some of these things can actually be treated to the point where they either go away or are minimized so much that it's not really a bother anymore. Is that sort of degree of relief achievable with modern medicine and therapies and treatments? 

Dr. Navabi: That's, that's a very great question and I, my answer is for most of these agencies, the answer is yes. Alright. But it all depends on what's the, what's the cause. But I can tell you, I mean, if it is an inflammatory process because of basically infection. Yes, you treat the infection and this will resolve. Alright? If it is basically inflammatory process because of an autoimmune disorder like Crohn's and ulcerative colitis , that's a target. And we still have very great medicines that we can achieve basically with almost complete resolution of bowel urgency.

And that's the area of the study, if there is basically treatable bowel syndrome as a cause, all right? So we can still basically modify the lifestyle, modify the medicines, and we achieve the targets and goals. And sure, there are some other ones that be more challenging if somebody had very bad neurologic damage to the spine that essentially do not have the control, mostly they do not feel the pain or urge, but if they have the urge and they do not have control, then it's more challenging. But it doesn't mean that if we cannot stop basically the, the bowel, we cannot basically give them a solution to have a better quality of life. Right? We, we cannot, we can basically handle the way that the bowel habits are happening.

We can handle the way that transit time happening. So, or we do have some sophisticated treatments and therapies, including special physical therapies, pelvic floor therapies that the target is just to make it go away. And that's, that's a hope for all of our patients, but at least we can basically make it to be better.

We can make it the way that it is predictable so we can get back to our routine life as much as possible. 

Bruce Kassover: I would imagine that for a lot of patients, even predictability would be a tremendous success. Because you know what, living with this is has got to be very, very challenging. And I'm wondering if maybe you could talk a little bit about sort of everyday life support, you know, what strategies might, patients who either they haven't yet started their treatment journey or they've just begun it and they haven't sort of reached that point of predictability, what strategies might they use to help them manage the unpredictability of day-to-day urgency? 

Dr. Navabi: That's a great question. And again, it goes back to the etiology of the disease because it's not always basically as simple as basically the one strategy to do that. But, the end, the end thing that we see a lot in our patients basically routinely being happening is the one that basically we try to avoid as much.

And that's basically the, they're wearing the protection, right? So that's something because they want to be out and they're worrying about it. And there is a basically Hallmark study and basically IBD that was showing about , as I said, 50% of people with Crohn's and ulcerative colitis, 47 and 50% basically they're wearing is some sort of protection once a week while the doctors are feeling that they're in remission. so that is something that basically, it's something that quite often happens, but I can tell you that how much it can affect brings up anxiety, depression. You have a 22-year-old that basically walks in your office and when you examine, all of a sudden you see that they're wearing the protection, right?

So that's nothing that you would expect to see routinely. Even if you have older patient, that is something that basically you don't expect to see routinely. So then it goes back to the etiology. I would say that there are some certain points that basically, you adjust basic, the timing of the bowel habits, you try to basically try to schedule your bowel movements on certain times so you know that you are going out. You wouldn't have basic the problem there. You adjust the type of food or the timing of the food that you have, but have to be very, very clear about this. Sometimes with some diseases it's not doable, So that requires the medical attention. And sometimes with the lifestyle is not basically doable. I mean, you have a person that has to be at work at six in the morning. And their concern is they have to have at least three or four times bowel movement before they get out of house. So I have patient that really will wake up at four in the morning just to be sure that they can make it.

So it is not that easy to have a routine strategy. So that is why I think that seeking the medical attention and looking for etiology can help to come up with a better strategy than having a broader strategy to prevent that. 

Bruce Kassover: I certainly will take what you said as really encouraging the fact that in many or most cases, the treatments really can be effective.

And we hope that people who are listening to this today, take away a lot of different lessons. But among everything, that's sort of the one that they take home more than anything else is that yes, treatment works if you go out and seek it. So I really appreciate that.

But as you know, this podcast is Life Without Leaks, and one of the things we always like to do before we leave is give our listeners one little hint, tip, strategy, bit of advice to live a life without leaks. Now, usually when we're talking about things is in reference to bladder leaks, but the bowel is the subject today, so I'm wondering if you might have a single bit of advice that we could share to help people live more comfortably and more healthily as well. 

Dr. Navabi: Absolutely. So, I want to touch on a little bit for the reasons and the common ones for the bowel urgency. So one of the things that quite often happens and they forget about it, basically, surprisingly constipation is one of the reasons for bowel urgency. So we think that, basically, having constipation would be exactly the opposite of bowel urgency. But the matter of fact is exactly the other way around. I mean, when you're severely constipated, I use this analogy of, basically, a clogged tube, right? So the only thing that just passes basically is just the liquid and the urge around.

If this is Something that is happening for us and you're dealing with constipation, I think that basically, taking fibers, being sure we are adequately managed with constipation, having adequate hydration, exercise and all those things basically. Can help very significantly to have more regular normal bowel movements and mean you have prevent prevented the constipation, then you prevented basically the bowel leaks that can happen for you because if there is an empty reservoir there, then you don't have much of a bowel leak that you would be concerned about. So that's one of the common ones.

The other ones that we see basically quite often is, basically, irritable bowel syndrome. If I want to make it very simple, nowhere else in the body has that much connection to your brain as much as your gut has. We call it gut-brain axis. We still do not know what's the reason that the gut become hypervigilant.

There is a terminology they called basically microbiota that basically their bacteria that work, these are living in our gut and probably there is this fight within the bacteria that make this imbalanced. But whatever reasons that can happen could be basically medicines, could be basically food, could be environmental effects or even a stressor.

So one of the things that happened that we start to get basically this urgency through run the bathroom and usually we really do not have much of bowel movement as well too. So one of the techniques to help with this irritable bowel syndrome is basically special dietary changes , but more than that, relaxation techniques, routine exercises, meditation. These are the ones that are helping to prevent these impulses that goes from gut to the brain. So they're very, very effective. And of course, I mean, there's always a medical attention and if there is, basically, more serious cases like, basically, if you see bleeding, if you have persistent diarrhea, then for sure seeking medical attention because there are treatable causes like autoimmune disorders or, basically, infection.

But the more common ones, I think that if, basically, work in constipation management, if you work on ery bowel syndrome, these are the important ones. And again, if there is alarms that if you're feeling a mass in the bottom area, if we see bleeding, if we see, basically, weight loss, then I would definitely recommend that's while we try to handle this at home, but it's much important that we see the medical providers. 

Bruce Kassover: That is outstanding advice and I certainly hope that people take you up on it and certainly hope people don't ignore things that are, you know, genuinely, you know, threaten their health and their wellbeing and their sense of self also.

So thank you so much for sharing all of this with us today. We really appreciate it and I'm sure that our listeners do as well. 

Dr. Navabi: Thank you so, so much. I'm happy that, basically, we had this opportunity and I'm hoping that, basically, we really don't have anyone that, basically, have to struggle with this because we do have good modalities, good diagnostic techniques, very good treatments available that we can help majority of our patients to overcome this very important obstacle.

Bruce Kassover: That's really encouraging to hear. I appreciate it. Thank you. 

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

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

Bruce Kassover: Today's guest is a friend of the podcast. It's Dr. Ehsan Navabi. He's a board certified gastroenterologist, a hepatologist and, basically, medicine specialist.

And he's also currently serving as the director of the IBD Center and the GI Motility Disorders Lab at United Medical Doctors in California. He's been on with us before to talk about bowel incontinence and treatment methods for it and how to cope with it. And we're going to be talking a little bit more in detail about some of that today. So, Dr. Navabi, thank you for joining us. 

Dr. Navabi: I really appreciate your opportunity, and thank you so much for having me today. 

Bruce Kassover: You know, when we had you on before, one of the things we were talking about right before we had finished was the remarkable connection between the brain and the bowel. And I was wondering if you could explore this a little more, because it sort of seems like, well, I mean, I guess everybody knows your brain is sort of connected to everything, you know, without the brain, nothing is working.

But there is a, a much deeper sort of connection than a lot of people would realize or expect between the two. And maybe you could talk a little bit about that and why it's important for people to understand. 

Dr. Navabi: Oh, absolutely. So that is something that, basically, it's now a part of gastroenterology. So we have a terminology that we call "neuro gastroenterology." So, um, many of the things that for many years we did not have a great understanding about, now we started to know more and more that basically that's that neuro connection that we have from the gut to the brain. As I mentioned, we do think that the most connection that you have to your brain is from the gut.

And we call it gut-brain-axis . Still very difficult to study that. So we think that's part of the role is the significant amounts of bacteria that are living with us. They're helping us. We cannot live without them. All. Right? We cannot digest without them. And basically these bacterial environments are very important to have a healthy guts for whatever reasons; it can be our food. I mean, our life is changing. I mean, we are dealing with more of a processed food. We're dealing with, basically, more of, basically, more changes in our food on daily basis, or even the timing, right? The medicines exposure, the environmental exposures that we have, right? They may change, basically, this gut microbiota.

They alter, basically, the sensation of the nerves that we have. And I can tell you basically 40% of our patients, 50% of our patients in general GI clinic, actually, they have one sort of dysfunctional GI disorder. And I wanted, wanted to make a sense for it. So I want to give you a very simple example that I think that makes, very, makes sense about it.

It is not just in human. So there was a study in Canada that's, one of the things that they start to assess that how the neurologic function or more of anxiety or depression function in mouses are they start to do a test that they see how much they tried to swim in the water, without letting go, basically, without, basically, getting drowned.

So they removed them from the water. So they started to knock out all of the bacteria from the guts, from the mouse. And it was just a clean gut . They put them in the water and they tried to basically time that how much effort they have without obviously living a drought. So it was just six minute after six minute, they were tired.

They let go. So they take them out of the water to be sure that basically would be okay. Then they tried another mouse with the same healthy gut bacteria, put them on water. It was interesting. They never let go. They continued to swim. So that is something that shows that that bacteria in the gut also plays a role.

In mental health as well too, and it's other way around. So we do see this a lot. Part of that, we do not really have great understanding about how the process and how things would happen, and that's the subject of further investigation and the studies that happens every day.

But we have no doubts that the brain-gut health are basically playing hand in hand together. Her, and we have no doubt that, basically, the guts, these issues can affect the brain and other way around . So that's basically a known fact that we know, and that's a, that's a question that you were having. Yeah, this neuro guts basically axis, it's something that's very important that we get to know more, and I think plays an important role in taking care of our patients these days as well. 

Bruce Kassover: That is really fascinating. It sounds a little, a little spooky, also a little strange. And, um, I guess that makes it even more interesting.

Um, but you know, you, you mentioned one thing at the end that I think is, you know, when we're talking about the, the brain and bowel connection, um, not just literally, you know, neurons and synapses and things, but also the sort of broader mental health picture when we're talking about our brains and our minds and our, our sense of who we are and, you know, no, I, I would imagine that as a doctor who treats patients who are going through one of the most sort of, you know, emotionally challenging sorts of things that they can, they can deal with, um, you probably have to be a little bit of a therapist as well as a physician.

And I'm wondering if you could talk a little bit about that, about what sort of mental health challenges people present with, along with their physical symptoms and how you help them address them and overcome them. 

Dr. Navabi: Absolutely. I mean, one thing that is very, very important, is to note that any time that you have a chronic medical condition based on different studies, it will increase the risk of effective spectrum disorders such as anxiety, depression, somewhere between two to four times.

So we did a study in Penn State looking at inflammatory bowel disease is a chronic disease and, um, the risk of anxiety and depression in our patient was almost about three times more than the people that they did not have anxiety and depression. So that is something that basically can be as significant and some of them is very understandable.

Is that right? So you are having constant, basically, medical problem that you have to deal with that includes, basically, missing time from family, missing time from, basically, social life, the financial burden that it will have, right? So all of these things can affect, basically, anxiety and disorder. And more important, if you have something that's very disruptive that you are even shy to talk about.

So we're talking about bowel urgency. That's something that we're constantly worried that, basically, they have this social stigma that you want to avoid, that you cannot go out with your friend, or if you go out with your friend, you're constantly worried if something is going to happen to me. So all of these in the back burner will start and increase their risk of anxiety and depression.

So it is very, very, very important to discuss this. On the other hand, it is a known fact that if we do not adverse anxiety and depression in gastroenterology, you cannot get these functional GI disorders fixed. So part of a treatment is treatment of anxiety and depression. Part of a treatment is PCD, many of these effective spectrum disorders that we have, we have to address those and it's a delicate matter.

So I always start with that. I tell my patients I'm not an expert in, basically, psychiatric treatments and I don't think that I'm the best qualified person, but I can ask you questions that I can help to see if you need to basically get some further help or not. I'll start to do the questioners. That basically is very informal.

It's not a paper that we read, just very simple conversations that we have to help me to figure out if there is any background, basically depression going on, background anxiety going on. Then we'll try to discuss and see if I can start a medicine for the patient or if they need to basically seek out a therapies because sometimes where these gastrointestinal disorders, seeking that psychiatric help has much more better.

Effects and basically outcome than just doing a medical therapy and try to focus on the GI disorder. So it is always hand in hand. 

Bruce Kassover: Makes perfect sense. I would, I would imagine that especially, you know, living with a chronic condition that is life limiting. I mean, that, that's sort of, you know, a recipe for depression and anxiety.

Um, you know, one thing I'm wondering about from a doctor's perspective is that, um, treatments are rarely, you know, just all in one direction. Just you, you start taking it and everything gets better. Um, you know, you may find that a medication doesn't work for you or a therapy only has some results. So there are ups and downs along the process.

How do you work with patients who are going through those ups and downs to sort of help them manage expectations and, you know, and, and maintain the best outlook possible? 

Dr. Navabi: I think one of the things that is very important for me as a physician is to set their right timing and expectation to my. So I have to be very cautious to tell my patient this is, I usually say the first visit that we have with each other, I just get to know you.

I don't have the answers. And many times after we have the conversation, I just tell the patient, you know, I have to think about it. I may already have a diagnosis in my mind, but I think that it is more to it because it's been years of a struggle. So that's very important that we set the expectation because the most frustration comes if the patient basically were told, okay, you just do this and it's a miracle, you'll be good.

And I always say it's a work in progress. In medicine these days, it is very important to note, especially for such basically more chronic, complex issues. It is always a multidisciplinary approach, right? So for many of the bowel disease issues, I rely on my colleague from both gynecology and also basically the psychiatry and also radiology as well too.

So this is a multidisciplinary approach. I can't say, okay, I'm going to treat you today. I exactly know what's going on. But I think if I'm basically, front forward with my patient and I basically tell them the expectation that it's a work in progress, I know it is basically very, very, very busy.

Frustrating for you, but just gimme time. It may take few weeks, even if it takes basically a month or two, but we start to do the progress. You will still see, you will see these small steps, but the target eventual goal is you don't even need to come back and see me anymore. Alright? So you're just doing well.

I think when you do that, you set the expectations right for the patient. Then they are always willing to work with you. I mean, I, I can say that, well, I never, ever had any encounter that basically we set this expectation and the patient comes in the second visit and their first, or they understand it's a work in progress and if they see the small steps that are working, excluding finding a diagnosis, narrowing it down, and then they basically have the patients that they're willing and basically about working with you to get better center as well too.

Bruce Kassover: Suppose what, what may also contribute to that is that you, you were talking about how you have patients who often come after a long period of time dealing with their condition. So waiting a little bit longer to try and find a solution is probably not that, um, you know, that much of a hardship if they've been waiting so long before they even seek treatment in the first place.

And I'm wondering for those patients who are still not quite there yet, either they're, they're still, you know, struggling with the idea of seeking a physician, um, or they're, you know, they're just sort of realizing, Hey, this is a problem that, that, that maybe I need to go get treated. Do you have any thoughts to help them manage their own mental health along with their physical health while they sort of, you know, get themselves into the mindset that, yeah, I really don't need, need to do something about this.

Dr. Navabi: For sure. As you just basically mentioned, even I, I understand it, even few weeks of continuation of basically, having this trouble is still too much. Right. But as you mentioned, it is something that basically we can work and the idea of I can get better always helps. But to get back to your basically question that you just asked, I'm a big believer that basically mental health care is a very, very important science.

And it's very, very delicate. I mean, all of us as physicians, we learn how to basically diagnose through the screening. But I always say that giving a wrong message, helping basically a patient in a wrong way while you're trying to help right. Can have very significant consequence. So. I think the mental is the most important thing of basically dealing with now.

Right? So it's something basically, we see that the epidemic, basically, having mental health disorders is basically under rise for many, many reasons. Alright? And maybe that those are the triggers of our gastrointestinal symptoms. I would think that the first thing first is we, we, when we identify this, alright, I get back to the point, try to seek the medical attention.

The first person is going to be a primary care physician. Sure. I mean, getting information from basically about social media from journals can be effective and helpful. Alright. Those are the good ways that you brings awareness. But to handle that and also management, I think that's very important.

Basically, we try to seek the opinion from the basically experts here. And one thing that is very important is difficult is basically insight. Many of us, it's difficult for us to have that insight that there may be a mental basically disorder, that basically we're dealing with or something basically needs to be addressed.

So I think that the awareness that we get from the environment is very important, but at some point we have to basically take that time as much as we basically take important time of other medical health, the body health and the mental health basic situation and assessment is important. And any point that we feel that we are not comfortable as if we see the blood pressure that is not basically normal and we go to the doctor, if you're not feeling comfortable, maybe it is time that we do not wait and basically seek the medical attention from the doctors or respiratory healthcare providers or therapies that it can guide us and lead us to basically get to the better, basically, situation.

And one thing that is medicine is important, I think it is same in the med, basically mental health as well too. In medicine, we always say let's get things basically treated sooner than later because when it becomes chronic. It's become a little bit more challenging to treat it. The same thing goes with the mental health too, right?

It is always better if you basically seek the attention in the earliest stages. And it doesn't have to be medicine, it doesn't have to be even therapies, right? Sometimes that have conversation and basically the doctor tell you, you, it's completely normal, right? So you don't have to worry about it. That gives us the ease of mind, or if they tell you, okay, let's just do this meditation technique.

Let's just do this exercise. That may be the solution for that. Or at some point it may require, basically, medical therapy, or basically, other sort of basically, non-medical therapies. But I think that's identified that for ourself, having the insight and seeking the attention for basically care early on is very important.

Bruce Kassover: You know, I think you may have it doubly hard because in your specialty you have patients who are reluctant to talk about their physical symptoms, and I think that we know that people are often very reluctant to talk about. The mental health issues that they're facing as well. Um, what do you do to try and help get people to open up not only about, you know, the stuff that's actually happening to their bowels, but the stuff that's happening inside their head?

Dr. Navabi: That's, that's a very great question. So I think that one thing that I, I found it, um, very, very helping and helpful is sometimes in our clinic, that extra five minutes that we spend listening to our patient worth the hours of CT scans, ultrasounds, endoscopies, colonoscopies, because in that five minutes, the patient will open up and share some information that you already got all of your answers for treatment.

So I think that's being a good listener for a healthcare provider is very, very important. St. Basically, we, we let the patient b, c to open up with the open B, c, D questions. And then when we get the leads, we start to basically a target and narrowing. If you just basically get that something's bothering the patient, it's important to focus and basically start to narrow it down.

Let it be in a more pleasant environment for the patient to open up and share that information with you. And somewhat you see that basically a bowel urgency that the patient has not discussed and caused significant trouble. You discuss with the patient, say, you know what? I think that it was just a simple constipation.

Why don't you treat, basically try this for two weeks and come back to me and the patient comes back, everything is done. The same thing goes basically with a mental health as well too. So especially anytime that I have a chronic patient, I, I, this is my basically key question and I always say, I'm going to ask you a question today and I'm going to ask this question every time from you.

And you may not like me for this, but bear with me because I think it is the most important question of the day. How is your mood? How's the life? Are you feeling happy? I'll start with that. And let me tell you this, many times the patient may not open up and share, but at the second session, third session, when they see that I keep asking this question, I say, you know what?

A week ago I had this basically down moment that I was tearful because of this. And I think that's a good opening. Then you start to basically make that bond and basically have the conversation. Again, most of the times I may not be the person who is able to treat that basically, mental condition or disorder, but at least I can guide them where to go or should they seek attention or not.

And I think that opening that up and letting them basically to open up that basically the concern that they had would help them to have that significant relief. I think that's very, very important. And again, my colleagues have been great, but I think that's something that basically needs time and attention more and more from our end as well too.

Bruce Kassover: I love that answer. Now, before I go on this, um, a, another question I wanted to turn to Sarah, see if she wanted to have anything to hop in with, um, as well. 

Sarah Jenkins: Yeah. Um, you know, just kind of piggy piggybacking on that a little bit. Do, how often do you refer out to a, a mental health specialist or someone that they can talk to in more depth about this?

And then I guess a follow up to that would be, do you find that when patients have a, a full care team that's kind of communicating, do they tend to fare a little bit better emotionally than those who are kind of struggling, you know, more with just one person? 

Dr. Navabi: I mean, it happens very frequently for me in my practice, although as I brought up basically earlier one of the.

Problems that we have is, unfortunately, the accessibility is not that easy, and that brings up the frustration for all of us. I mean, seeing basically specialist for basically, mental health can be very, very challenging at the same time because you're waiting for basically to seeing a provider. But I'm a big believer in multidisciplinary, basically, approach to your patient.

I'm a big believer that I should have basically, direct line of communication to my basically referring provider and other way around, all right, I have to pick up the phone and have a conversation. And that's my routine, all right? I work with surgeons, I work basically with the, the, the psychiatrist. And we pick up the phone with chat.

We chat because I think that that two seconds of chats works basic 10,000 times more than basically reading the notes. And I'm a big believer in that, but I have to say that it is not always feasible. I tend to basically, um, come up with a diagnosis and I think if I basically think that the patient will benefit from attention from mental health care.

I always provide two approach. I always think that we are lucky to have primary care physicians because they know patients basic for many, many years, and they're very well capable of basically, handling this not complex basically, mental health disorders very easily. So I always circle back and basically just discuss with them.

Yeah, maybe we need to basic c cendra. Sometimes I may proactively treat for some certain conditions in gi. Then I basically have some medicines that basically are very well known to be connected. So I may proactively treat, but it's very often and it is not basically just that, basically the therapies or basically psychiatrists.

It is the same thing with other multidisciplinary approach. As I said, I mean, for the bowel urgency, you have to have connection with your surgeons. You have to have connection with your gynecologist, right? So, and you have to pick up the phone and you say, you know what? That's the reason that I send the patient to you.

Because many times you make the referral, the patient goes for the bowel urgency, and we're seen basically for fibroid uterus. And the bowel agency was never discussed because these phone calls has not happened or a clear request has not happened. So I tend to basically ask frequently. I don't think that we, I asked for medicine for treatment, but I think having a screening I maybe 70% of the time I wasn't quite right.

All right. So there was everything healthy. But I think having assessment by an expert, it's very, very important for the patient as well too, that they know that it has been assessed and everything was okay. 

Sarah Jenkins: Right? Yeah. Thank you. 

Dr. Navabi: Absolutely. 

Bruce Kassover: You know, I'm wondering when you talk about having that, that that team approach and you're reaching out to, um, people who can help, professionals who can help with mental health, there is still a lot of patients who are resistant to that.

You know, they think therapy is bunk or I don't want to go see a shrink, or, you know, there's nothing wrong with me. Do you encounter patients who are resistant to that, and if so, what sort of strategies do you use to try and get them to open up to it? 

Dr. Navabi: It's very common and I can put it actually both ways.

One of the struggles that we have, especially for the therapies, is basically, um, lack of coverage by the insurance and the financial burdens that we have. Because not always, basically it is accessible. What we have greatest therapies, b, c, the greatest access available, but. The thing that would happen. And when I'm talking about therapy is not just basically the only mental therapy.

I mean, I send patients for music therapy. All right? So I send patients for different kinds of therapy for treatment. But one thing that is important is I think keep asking questions. If I think that I'm going to solve all these problems in first session, I'm always wrong. It's not going to happen.

Alright? And that's why I said that I have that strategy to keep asking this question. So when you keep asking the question, then at some point the patient will open up, right? He said, I mean you have patient that culturally thinking that basically seeing a therapy is, is basically the stigma. It can happen, right?

And that's something that basically we have to be aware as well too, because we always look, oh, okay, why don't you see a therapy? So there is a problem with no, you have to go back to the cultural background. You have a family social support seeing it basically outsider has been always a stigma. So just.

When you, they open up, then you start to guide them and say, you know, as I am helping with your body, you have a specialist that will help you with the mental health, right? And they can basically have dramatic symptom improvement in your, basically, outcome. So I think that after visit a couple of sessions of this conversation that you have, I want to say that we are a hundred percent basically successful, but it can happen.

One thing that is important, and I want to bring that up, many times, we may think that if something ha didn't happen and the patient did not pursue it's impatient, but I didn't think that at the same time we as providers can play a role to become more convincing to the patient. Not all of us studied medicine.

Not all of us studied psychiatry. Not all of us studied math. All right? So that's why we go to experts. So that is why me having anticipation that why the patient doesn't have that insight. It's not fair to the patient. So that comes with the education, which requires multiple position to get them to that point.

Bruce Kassover: You know, you have me thinking that, that there is one very interesting distinction with what you do and with your role in this whole sort of team approach is that, you know, if somebody is going to a therapist or you know, some sort of a, is seeing somebody who, who can help, you know, from a mental health perspective because they just have depression or anxiety or you know, some other issue that they want to be addressed.

And you know, they, they, they hope that whatever treatment path they follow does the job, however. The patients who are going because they have anxiety or depression that really is driven by their bowel disorder. If you can solve the bowel disorder, you could probably do a pretty good job solving the anxiety and depression as well.

So I would imagine that you really get to see a lot of patients improve, not just physically, but also really improve their whole outlook on life with what, with, with some of the treatments that you're able to provide. 

Dr. Navabi: No, that's exactly true. And I've got to tell you something that's basically, um, it's my habit and practice.

So in medicine, we are always basically taught that you have to have the background history in medical history. What was the medicines, what was basically, past medical history, and then basically start to go with the basically. Current situation, I'll usually try to go backward. So I try to avoid looking at the notes from the past for the first time when I've seen the patient.

I mean, for the past medical, because sometimes I just don't want to have that prejudgments, right? So something that happens. You see depression or anxiety as a medic medical history and all of a sudden you have these pre-judgment that basically will stigmatize basically the whole condition and I'll just have this premature closure.

So I usually have the conversation with my patient because more than not, as you mentioned, their problem is the bowel urgency as the initial triggering factor for the anxiety and depression. So if I basically address that, I may be successful to solve that problem significantly, and that is why that medical role basically plays a very, very important factor for the treatment.

But as a part of the treatment, it is important to address that basically concerns, right? Anxiety concern, depression concerns, right? The mood concerns, everything that they had. It is very, very important. But I agree. I mean, it is very important they are in my clinic to address that medical problem, which probably plays a very significant role for the mental basically distress that they have at that point as well too.

Bruce Kassover: Well, I think that if the promise of, you know, being able to, to treat and if not cure at least you know, reduce a lot of the physical symptoms is not enough, then knowing that that treatment can also really help in many cases, reduce a lot of the mental health strain that you're under also has got to really be a big motivator to, to, to go out and get the help that you deserve.

So, I love hearing that. Now, of course, you know, oh, go on. 

Dr. Navabi: I just want to tell you this. I mean, just imagine that you are not going out with your friends for the whole year. You're sitting at home, you're on disability from work, alright? Because you cannot do it right. And then I can help you getting back to work, helping you basically being back with your friends, go and watch the sports.

So that can significantly help lots of those distress that we had before with the basically anxiety and depression and mental distress that we had. So. I don't think it's, I don't say it's going to solve all of it because there may be more into that, but I think it can be definitely very significantly helpful.

Bruce Kassover: It sounds like it. Yeah. And, and you're right. You know, you're not just giving them, you know, freedom, you're giving them the freedom to go and do other things that themselves can also be, um, can help improve their, their, their mental health. You know, going out and socializing, um, isn't just good because you're no longer a prisoner, but you know that this benefit, look, we know after COVID that lack of socialization can, can have, you know, terribly dramatic negative effects on people.

And, and really this is sort of the same sort of isolation that, that, that people have to live with. So, yeah, I love hearing that, that is really encouraging. 

Dr. Navabi: Absolutely. 

Bruce Kassover: As you know, this is Life Without Leaks, and we always like to end on positive notes like that. But one of the things we also like to end with is one little hint, tip strategy, bit of advice for our listeners to help them live a life free of the issues that have been plaguing them.

So I'm wondering if maybe you might have one more little bit of advice that you could share with us today. 

Dr. Navabi: Absolutely. So, I think that something that's very important is, I understand that dealing with these issues like bowel urgency, all right, and having the problem basically with managing and even accidents that we have is basically very, very, very challenging.

And it is something that is difficult for us to discuss. But we discussed that how we can have a strategist to open that up. At the same time, it basically causes some challenges in basically our routine life and our mental health. So I think it is very, very encouraging that we know that there are so many ways that we can treat and handle this medically.

And by not only managing the bowel urgency aspect of that, we can also helping addressing the distress that we basically encounter in life that can affect our mental health, that can be guiding the patient's to get to that point. So I think that from today, if we are dealing with any of these issues with bowel urgency, maybe this time that we get ourselves as a pause and basically say maybe the bowel urgency is something bothersome, but the more urgent thing is I feel better.

And we consider this as more urgent matter just to seek help, try to basically call our primary care physicians, get some more awareness about the bowel urgency because the end product here and the end game is overall we will have better body health and mental health. So I think that can be a very, very important factor to make this decision that we pick up the phone and call and seek the attention for help.

Bruce Kassover: Love hearing that. And I hope that people take that to heart and do pick up the phone. Because, you know, like you have stressed a number of times, help is really available. This is not just sort of a treatment that's going to take your time but not deliver results.

There are real results to be had. So thank you so much for sharing all your insight today. We really appreciate it. 

Dr. Navabi: No, I really appreciate this opportunity. It is exciting just to have these conversations with our patients because awareness is the key. There is much more to know and getting this to our patients that they may get a chance and watch this or listening to this and making a little bit of decision changes to call their doctors and seek the attention.

Hopefully the next year they will enjoy basically their holidays without any problem and they're enjoying their time with the family. 

Bruce Kassover: That would be fantastic. So thank you so much. 

Dr. Navabi: Thank you. 

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.