A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation

Abstract

BACKGROUND: Many patients with fecal incontinence report coexisting constipation. This subset of patients has not been well characterized or understood. OBJECTIVE: The purpose of this study was to report the frequency of fecal incontinence with concurrent constipation and to compare quality-of-life outcomes of patients with fecal incontinence with and without constipation. DESIGN: This was a prospective cohort study. Survey data, including Fecal Incontinence Severity Index, Constipation Severity Instrument, Fecal Incontinence Quality of Life survey (categorized as lifestyle, coping, depression, and embarrassment), Pelvic Organ Prolapse Inventory and Urinary Distress Inventory surveys, and anorectal physiology testing were obtained. SETTINGS: The study was conducted as a single-institution study from January 2007 to January 2017. PATIENTS: Study patients had fecal incontinence presented to a tertiary pelvic floor center. MAIN OUTCOME MEASURES: Quality-of-life survey findings were measured. RESULTS: A total of 946 patients with fecal incontinence were identified, and 656 (69.3%) had coexisting constipation. Patients with fecal incontinence with constipation were less likely to report a history of pregnancy (89.2% vs 91.4%; p = 0.001) or complicated delivery, such as requiring instrumentation (9.1% vs 18.1%; p = 0.005), when compared with patients with isolated fecal incontinence. Patients with fecal incontinence with constipation had higher rates of coexisting pelvic organ prolapse (Pelvic Organ Prolapse Inventory: 18.4 vs 8.2; p < 0.01), higher rates of urinary incontinence (Urinary Distress Inventory: 30.2 vs 23.4; p = 0.01), and higher pressure findings on manometry; intussusception on defecography was common. Patients with fecal incontinence with concurrent constipation had less severe incontinence scores at presentation (21.0 vs 23.8; p < 0.001) and yet lower overall health satisfaction (28.9% vs 42.5%; p < 0.001). Quality-of-life scores declined as constipation severity increased for lifestyle, coping, depression, and embarrassment. LIMITATIONS: This was a single-institution study, and surgeon preference could bias population and anorectal physiology testing. CONCLUSIONS: Patients with fecal incontinence with concurrent constipation represent a different disease phenotype and have different clinical and anorectal physiology test findings and worse overall quality of life. Treatment of these patients requires careful consideration of prolapse pathology with coordinated treatment of coexisting disorders. See Video Abstract at http://links.lww.com/DCR/A783.

Coexistent faecal incontinence and constipation: A cross-sectional study of 4027 adults undergoing specialist assessment

“…Notably, a recent study in 946 patients referred for investigation of faecal incontinence showed that the majority also reported constipation symptoms (69¢3% c.f. 61¢4% in current study) [21]. The absence of awareness of this coexistence amongst referring clinicians was not evaluated in previous studies.…”

Coexistent faecal incontinence and constipation: Common but frequently overlooked

“…Another recent study from the United States mirrors our findings, with 69.3% of 946 patients referred for investigation of faecal incontinence having underlying symptoms of constipation. 3 These results demonstrate that coexistent symptoms are very common though often missed.…”

Coexistence of Fecal Incontinence and Constipation

“…The impact of FI and CS on normal daily activity is considerable and involves all aspects of quality of life (QoL). The coexistence of FI and CS has been shown to affect both the psychological and physical domains as well as normal social activity; sexual activity is also affected by the presence of FI and CS [12][13][14]. The need to organize one's daily activities based on effective intestinal emptying or the risk of FI episodes and the psychological impact of embarrassing symptoms have a significant impact on QoL.…”

“…In addition, Cauley et al demonstrated that patients with coexisting FI and CS have different clinical and anorectal physiology test findings and worse overall QoL [13]. These patients have a different clinical presentation characterized mainly by difficult bowel emptying and milder symptoms of FI.…”

“…In these cases, manometric studies show normal or increased sphincter tone while defecography often reveals intra-anal or recto-rectal intussusception and rectocele. Cauley et al conclude by stating that the coexistence of FI and CS must be treated as a single nosological entity [13].…”