Clinical Anatomical and Physiological Evaluation

**6**

*Current Topics in Faecal Incontinence*

[1] Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems.

[2] Jorge JMN, Wexner SD. Etiology and management of faecal incontinence. Diseases of the Colon and Rectum.

Fleshman JW, et al. Fecal incontinence quality of life scale: Quality of life instrument for patients with fecal incontinence. Diseases of the Colon and

[4] Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care.

[5] National Institute for Clinical

Guideline 49 NICE 2007

Excellence (NICE). The Management of Faecal Incontinence in Adults. Clinical

[3] Rockwood TH, Church JM,

Rectum. 2000;**43**(1):9-17

1992;**30**:473-483

Gut. 1999;**44**:77-80

1993;**36**:77-97

**References**

**9**

**Chapter 2**

**Abstract**

**1. Introduction**

Comprehensive Clinical Approach

Fecal incontinence is a disturbing condition, which reduces the quality of life of patients. Prevalence of this apprehensive problem is usually underestimated. However, it is more common in female, elderly, and institutionalized subjects. Factors that may be associated are urinary incontinence, diabetes mellitus, depression, diarrhea, history of anorectal surgery, anorectal trauma, pelvic organ surgery, and pelvic irradiation. To improve this condition, physicians should have insight into the individual's pathophysiology through the process of careful history taking, severity, and quality of life assessment, thorough physical examination and comprehensive anatomic and neurophysiologic evaluation. These tests include imaging, anorectal manometry, and neural conduction tests. Finally, by these gathered information, individualized treatment for the patient is designed. Patient's educa-

**Keywords:** fecal incontinence, digital rectal examination, endoanal ultrasound,

Fecal incontinence (FI) is defined as recurrent uncontrolled passage of solid or liquid stool at least 3 months in an at least 4-year-old individual [1]. For research, onset should be at least 6 months with the episodes of two times in 4 week-period [1]. Severity of FI has a direct deteriorating effect on the quality of life of the patients, especially on life style and depression [2, 3]. The higher severity was also significantly associated with more direct annual medical (i.e. medical resources used for diagnosis, treatment, and management of related conditions) and nonmedical costs (i.e. nonmedical care such as transportation and use of protective products) [4]. Other indirect cost is associated with loss of productivity [4] and work load of caregivers [5]. Prevalence of FI in general population was 7.7% (range, 2.0–20.7%) [6, 7]. It equally affected both gender in most studies; male 8.1% (range 2.3–16.1%) and female 8.9% (range 2.0–20.7%) [7, 8]. The prevalence increased with age, that is, 5.7% at 15–34 year, 9.9% at 60–90 year, and 15.9% at >90 years [7, 9]. Associated risk factors of FI included increasing age, watery stool, functional diarrhea, urinary incontinence, and polypharmacy (use of five or more medications) [5, 7, 9, 10, 11]. In instituted population, the prevalence of FI was up to 46–57.1% [11, 12]. Significant associated factors of FI were poor general health status (≥4 comorbidities), urinary incontinence, cognitive-function impairment (dementia), decreased mobility, and length of nursing home residency [12]. In elderly female, marriage was another predictive factor of FI [9]. This may be explained by the difference in pathophysiology

to Fecal Incontinence

tion and judicious follow-up are also parts of the plan.

anorectal manometry, neurophysiologic test

*Kasaya Tantiphlachiva*

#### **Chapter 2**

## Comprehensive Clinical Approach to Fecal Incontinence

*Kasaya Tantiphlachiva*

#### **Abstract**

Fecal incontinence is a disturbing condition, which reduces the quality of life of patients. Prevalence of this apprehensive problem is usually underestimated. However, it is more common in female, elderly, and institutionalized subjects. Factors that may be associated are urinary incontinence, diabetes mellitus, depression, diarrhea, history of anorectal surgery, anorectal trauma, pelvic organ surgery, and pelvic irradiation. To improve this condition, physicians should have insight into the individual's pathophysiology through the process of careful history taking, severity, and quality of life assessment, thorough physical examination and comprehensive anatomic and neurophysiologic evaluation. These tests include imaging, anorectal manometry, and neural conduction tests. Finally, by these gathered information, individualized treatment for the patient is designed. Patient's education and judicious follow-up are also parts of the plan.

**Keywords:** fecal incontinence, digital rectal examination, endoanal ultrasound, anorectal manometry, neurophysiologic test

#### **1. Introduction**

Fecal incontinence (FI) is defined as recurrent uncontrolled passage of solid or liquid stool at least 3 months in an at least 4-year-old individual [1]. For research, onset should be at least 6 months with the episodes of two times in 4 week-period [1]. Severity of FI has a direct deteriorating effect on the quality of life of the patients, especially on life style and depression [2, 3]. The higher severity was also significantly associated with more direct annual medical (i.e. medical resources used for diagnosis, treatment, and management of related conditions) and nonmedical costs (i.e. nonmedical care such as transportation and use of protective products) [4]. Other indirect cost is associated with loss of productivity [4] and work load of caregivers [5]. Prevalence of FI in general population was 7.7% (range, 2.0–20.7%) [6, 7]. It equally affected both gender in most studies; male 8.1% (range 2.3–16.1%) and female 8.9% (range 2.0–20.7%) [7, 8]. The prevalence increased with age, that is, 5.7% at 15–34 year, 9.9% at 60–90 year, and 15.9% at >90 years [7, 9]. Associated risk factors of FI included increasing age, watery stool, functional diarrhea, urinary incontinence, and polypharmacy (use of five or more medications) [5, 7, 9, 10, 11]. In instituted population, the prevalence of FI was up to 46–57.1% [11, 12]. Significant associated factors of FI were poor general health status (≥4 comorbidities), urinary incontinence, cognitive-function impairment (dementia), decreased mobility, and length of nursing home residency [12]. In elderly female, marriage was another predictive factor of FI [9]. This may be explained by the difference in pathophysiology

of FI in female where parity, traumatic vaginal delivery, and previous pelvic surgery played roles [13]. In parous female, the incidence of FI was as high as 46% from postal survey [14]. In male with FI, impaired rectal sensation and evacuation disorder are more prominent than female [13]. Thus, pathophysiology of FI is likely to be different between genders and individuals. Careful systematic evaluation should be performed to assess these underlying mechanisms in order to guide a successful management.

#### **2. Pathophysiology of fecal incontinence**

Normal control of defecation requires intact neuromuscular structures, including rectum, anal canal, pelvic floor, and neural network. Rectum, as a reservoir; anal canal, with intact sensation and vascular cushion as a checkpoint; pelvic floor and anal sphincter, as controlling gate; and neural network, as a communication system, all play roles in bowel control. For perfect action, colorectal motility, stool volume, and stool consistency should also be normal. Disruption of one or more compositions of the system leads to FI. In clinical practice, most patients with FI were found to have multiple contributing factors [15].

*Rectum* is the distal part of colon, which extends from the rectosigmoid junction, dilates to form a reservoir, and ends at the tight circular anal canal [16]. It is distensible and acts as a temporary storage of residue of ingested food [17]. Surgical removal of rectum or physical injury to rectum such as radiation predisposes the subject to FI.

*Anal canal* is the terminal part of the gastrointestinal tract. It is a close tube surrounded by anal sphincter muscle (surgical anal canal). Anal sphincter and pelvic floor muscle act together to close the bowel. Anal sphincter muscles comprise internal anal sphincter (IAS) and external anal sphincter (EAS). *IAS* is the inner circular smooth muscle layer, which contributes to most of the anal sphincter pressure at rest [17, 18]. It is a continuation of inner circular muscle of the rectum and ends just proximal to the subcutaneous part of EAS [18]. Its length is 2.5 cm and thickness is 2–5 mm in normal population [18]. IAS is innervated by the autonomic nervous system. Parasympathetic supply is from the first, second, and third sacral nerves via pelvic plexus and sympathetic supply from both thoracolumbar outflow and hypogastric nerves [18]. The enteric nervous system connecting between neurons and glial cells situates in the myenteric (Auerbach's) plexus and the submucosal (Meissner's) plexus is a part of reflex pathways that control bowel [18]. *EAS* is the outer striated muscle layer, which voluntarily functions during squeeze. In the literature, it had been described as three parts: subcutaneous, superficial, and deep [19, 20]. However, the findings during surgery and from advance imaging, the current concept accepts that the deep portion of EAS it on continuous circumferential mass with the puborectalis muscle [19]. The upper part of superficial EAS is attached anteriorly with transverse perinei muscle at the perineal body [19]. The subcutaneous portion of EAS is just underneath the skin and is traversed by the conjoined longitudinal muscle, which is the continuation of the outer longitudinal layer of the rectum. EAS is innervated by the perineal branch of pudendal nerve (S2–4), inferior rectal nerve, and perineal branch of the forth sacral nerve [19, 21]. These nerves contribute in various patterns [21]. Mucosa of the upper anal canal is lined by columnar epithelium and the lower anal canal is lined by squamous epithelium [19]. Submucosal tissue and subepithelial tissue contain internal hemorrhoidal plexus and external hemorrhoidal plexus, respectively [19]. This distensible hemorrhoidal cushion plays a protecting role for anus and helps in complete closure of the anal canal. It contributes to 15–20% of resting anal canal pressure in addition to the major 85% contributed by IAS [22].

**11**

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

nerves (S3–5) proximal to sacral plexus [19, 24].

bowel or pass it out at an appropriate time.

and neural pathways of fecal continence control.

approximately 90o

*Pelvic floor muscle*, or the levator ani muscle, continues with the uppermost part of the external anal sphincter. It comprises of (1) *puborectalis muscle*, a U-shaped muscular sling from each side of pubic symphysis that joins behind the rectum at the anorectal junction [17]. It is a major muscle that maintains anorectal angle

back of the pubic bone, lateral to the puborectalis muscles, and from the anterior half of the obturator fascia [19, 22]. It runs backward, downward, and medially to decussate with the fibers from the opposite side forming a tendinous center called anococcygeal raphe [19, 22]. (3) Iliococcygeus muscle arises from the ischial spine and posterior part of the obturator fascia and passes downward, backward, and medially to insert on the lower part of sacrum, coccyx, and anococcygeal raphe [19]. In the middle of the anterior part of the levator ani, there is the levator hiatus, which pelvic organs pass through [19]. Pubococcygeus and iliococcygeus contribute to lateral pressure to narrow the levator hiatus, and puborectalis muscle has a role in maintaining continence [22]. Impaired levator ani contraction is strongly correlated with severity of FI [23]. Levator ani is innervated by direct branches from sacral

*Sensory innervation* of the anorectal area is responsible for correct afferent information of the luminal content. Anal canal is sensitive to pain, temperature, and touch, and afferent conduction is via pudendal nerve back to S2, S3, and S4 nerve roots [16, 25]. For rectum, parasympathetic fiber transmits the sensation of rectal distension via the nervi erigentes which are derived from the S2, S3, and S4 spinal segment [22]. These fibers join the sympathetic nerve fiber which is derived from L1,

L2, and L3 spinal segment [16, 18, 22, 24] to form hypogastric plexus [18, 24].

*Sacral reflexes*, including rectoanal inhibitory reflex (RAIR), sampling reflex, and cough reflex, are additional mechanisms of sensing and controlling stool [26]. These involve anorectum sensing area, peripheral nerve, spinal cord sensory and motor nuclei, and anorectal musculature, acting in a coordinated circle. *RAIR*, mediated by intramural myenteric neurons, is an immediate IAS relaxation following rectal distension [26]. Sensation of rectal distention and stretch by nerve fibers in rectal mucosa, submucosa, and myenteric plexus then go along the parasympathetic system to S2, S3, and S4 [27]. When the intrarectal pressure becomes higher than intra-anal canal pressure, bowel content is allowed to reach the anodermal area in the upper anal canal where sensory receptors are abundant [26, 27]. This anorectal sampling reflex provides information for discrimination between solid, liquid, and gas contents [27]. Thus, the person can choose to retain those contents in the

*Cough reflex* prevents leakage during a sudden rise in intra-abdominal pressure by immediate contraction of EAS [26]. It is triggered by receptors on the pelvic floor and transferred through a spinal reflex arc [28]. Connection between the central nervous system and the anorectal area contributes to a higher function of bowel control. Intact CNS to percept, process, and produce the efferent action is required for perfect control. Specific sensory areas in the brain are responsible for sensing the rectal distension [29]. Specific motor area in the parasagittal cortex is responsible for controlling anal sphincter [30, 31]. **Figure 1** shows the anatomical

FI occurs when one or more of the controlling mechanisms were damaged. Obvious etiology of FI is anal sphincter damage. In females, obstetric anal sphincter injury can occur after vaginal delivery. Postpartum fecal incontinence had been reported in 3–4% of women [32]. Sphincter weakness after delivery may be caused by injury to internal and external sphincter and injury to pudendal nerve or combination [32]. Risk factors include forcep delivery, prolonged second stage of labor (>5 h), shoulder dystocia, ano-vulvar distance <2 cm, perineal scar and third or

at rest [19, 22]. (2) *Pubococcygeus muscle*: originates from the

*Current Topics in Faecal Incontinence*

subject to FI.

**2. Pathophysiology of fecal incontinence**

were found to have multiple contributing factors [15].

of FI in female where parity, traumatic vaginal delivery, and previous pelvic surgery played roles [13]. In parous female, the incidence of FI was as high as 46% from postal survey [14]. In male with FI, impaired rectal sensation and evacuation disorder are more prominent than female [13]. Thus, pathophysiology of FI is likely to be different between genders and individuals. Careful systematic evaluation should be performed to assess these underlying mechanisms in order to guide a successful management.

Normal control of defecation requires intact neuromuscular structures, including rectum, anal canal, pelvic floor, and neural network. Rectum, as a reservoir; anal canal, with intact sensation and vascular cushion as a checkpoint; pelvic floor and anal sphincter, as controlling gate; and neural network, as a communication system, all play roles in bowel control. For perfect action, colorectal motility, stool volume, and stool consistency should also be normal. Disruption of one or more compositions of the system leads to FI. In clinical practice, most patients with FI

*Rectum* is the distal part of colon, which extends from the rectosigmoid junction, dilates to form a reservoir, and ends at the tight circular anal canal [16]. It is distensible and acts as a temporary storage of residue of ingested food [17]. Surgical removal of rectum or physical injury to rectum such as radiation predisposes the

*Anal canal* is the terminal part of the gastrointestinal tract. It is a close tube surrounded by anal sphincter muscle (surgical anal canal). Anal sphincter and pelvic floor muscle act together to close the bowel. Anal sphincter muscles comprise internal anal sphincter (IAS) and external anal sphincter (EAS). *IAS* is the inner circular smooth muscle layer, which contributes to most of the anal sphincter pressure at rest [17, 18]. It is a continuation of inner circular muscle of the rectum and ends just proximal to the subcutaneous part of EAS [18]. Its length is 2.5 cm and thickness is 2–5 mm in normal population [18]. IAS is innervated by the autonomic nervous system. Parasympathetic supply is from the first, second, and third sacral nerves via pelvic plexus and sympathetic supply from both thoracolumbar outflow and hypogastric nerves [18]. The enteric nervous system connecting between neurons and glial cells situates in the myenteric (Auerbach's) plexus and the submucosal (Meissner's) plexus is a part of reflex pathways that control bowel [18]. *EAS* is the outer striated muscle layer, which voluntarily functions during squeeze. In the literature, it had been described as three parts: subcutaneous, superficial, and deep [19, 20]. However, the findings during surgery and from advance imaging, the current concept accepts that the deep portion of EAS it on continuous circumferential mass with the puborectalis muscle [19]. The upper part of superficial EAS is attached anteriorly with transverse perinei muscle at the perineal body [19]. The subcutaneous portion of EAS is just underneath the skin and is traversed by the conjoined longitudinal muscle, which is the continuation of the outer longitudinal layer of the rectum. EAS is innervated by the perineal branch of pudendal nerve (S2–4), inferior rectal nerve, and perineal branch of the forth sacral nerve [19, 21]. These nerves contribute in various patterns [21]. Mucosa of the upper anal canal is lined by columnar epithelium and the lower anal canal is lined by squamous epithelium [19]. Submucosal tissue and subepithelial tissue contain internal hemorrhoidal plexus and external hemorrhoidal plexus, respectively [19]. This distensible hemorrhoidal cushion plays a protecting role for anus and helps in complete closure of the anal canal. It contributes to 15–20% of resting anal canal pressure in addition

**10**

to the major 85% contributed by IAS [22].

*Pelvic floor muscle*, or the levator ani muscle, continues with the uppermost part of the external anal sphincter. It comprises of (1) *puborectalis muscle*, a U-shaped muscular sling from each side of pubic symphysis that joins behind the rectum at the anorectal junction [17]. It is a major muscle that maintains anorectal angle approximately 90o at rest [19, 22]. (2) *Pubococcygeus muscle*: originates from the back of the pubic bone, lateral to the puborectalis muscles, and from the anterior half of the obturator fascia [19, 22]. It runs backward, downward, and medially to decussate with the fibers from the opposite side forming a tendinous center called anococcygeal raphe [19, 22]. (3) Iliococcygeus muscle arises from the ischial spine and posterior part of the obturator fascia and passes downward, backward, and medially to insert on the lower part of sacrum, coccyx, and anococcygeal raphe [19]. In the middle of the anterior part of the levator ani, there is the levator hiatus, which pelvic organs pass through [19]. Pubococcygeus and iliococcygeus contribute to lateral pressure to narrow the levator hiatus, and puborectalis muscle has a role in maintaining continence [22]. Impaired levator ani contraction is strongly correlated with severity of FI [23]. Levator ani is innervated by direct branches from sacral nerves (S3–5) proximal to sacral plexus [19, 24].

*Sensory innervation* of the anorectal area is responsible for correct afferent information of the luminal content. Anal canal is sensitive to pain, temperature, and touch, and afferent conduction is via pudendal nerve back to S2, S3, and S4 nerve roots [16, 25]. For rectum, parasympathetic fiber transmits the sensation of rectal distension via the nervi erigentes which are derived from the S2, S3, and S4 spinal segment [22]. These fibers join the sympathetic nerve fiber which is derived from L1, L2, and L3 spinal segment [16, 18, 22, 24] to form hypogastric plexus [18, 24].

*Sacral reflexes*, including rectoanal inhibitory reflex (RAIR), sampling reflex, and cough reflex, are additional mechanisms of sensing and controlling stool [26]. These involve anorectum sensing area, peripheral nerve, spinal cord sensory and motor nuclei, and anorectal musculature, acting in a coordinated circle. *RAIR*, mediated by intramural myenteric neurons, is an immediate IAS relaxation following rectal distension [26]. Sensation of rectal distention and stretch by nerve fibers in rectal mucosa, submucosa, and myenteric plexus then go along the parasympathetic system to S2, S3, and S4 [27]. When the intrarectal pressure becomes higher than intra-anal canal pressure, bowel content is allowed to reach the anodermal area in the upper anal canal where sensory receptors are abundant [26, 27]. This anorectal sampling reflex provides information for discrimination between solid, liquid, and gas contents [27]. Thus, the person can choose to retain those contents in the bowel or pass it out at an appropriate time.

*Cough reflex* prevents leakage during a sudden rise in intra-abdominal pressure by immediate contraction of EAS [26]. It is triggered by receptors on the pelvic floor and transferred through a spinal reflex arc [28]. Connection between the central nervous system and the anorectal area contributes to a higher function of bowel control. Intact CNS to percept, process, and produce the efferent action is required for perfect control. Specific sensory areas in the brain are responsible for sensing the rectal distension [29]. Specific motor area in the parasagittal cortex is responsible for controlling anal sphincter [30, 31]. **Figure 1** shows the anatomical and neural pathways of fecal continence control.

FI occurs when one or more of the controlling mechanisms were damaged. Obvious etiology of FI is anal sphincter damage. In females, obstetric anal sphincter injury can occur after vaginal delivery. Postpartum fecal incontinence had been reported in 3–4% of women [32]. Sphincter weakness after delivery may be caused by injury to internal and external sphincter and injury to pudendal nerve or combination [32]. Risk factors include forcep delivery, prolonged second stage of labor (>5 h), shoulder dystocia, ano-vulvar distance <2 cm, perineal scar and third or

**Figure 1.** *Fecal continence system.*

fourth-degree perineal injury, and infant birth weight >3500 g [32, 33]. Symptoms of continence may occur later in life as there are other compensatory mechanisms to compensate [32]. Symptomatic group was older, had less body mass index, and had more forceps delivery than the asymptomatic group [33]. FI in men was more associated with constipation and previous colon and anorectal surgery compared to women [34]. Anorectal surgery, including hemorrhoidectomy, lateral internal sphincterotomy, and fistulectomy, may affect the anal sphincter and vascular cushion, thus leading to FI [15, 35].

Normal rectum is a low-pressure space acting as a reservoir of fecal material until a coordinated and effective evacuation is appropriate [36]. Decreased rectal compliance, accommodation, or sensation may be found in inflammatory bowel disease and radiation proctitis [15, 36]. Neurological interruption of the central, peripheral, or autonomic nervous system is another cause of FI. These include cerebrovascular accident, spinal cord injury, and pudendal neuropathy. The latter had been reported after radiotherapy for prostatic cancer [37]. FI after multimodality treatment of pelvic malignancy, including prostate, cervical cancer, and rectal cancer, had been reported between 3 and 53% [38].

Other contributing risk factors of FI are stool consistency and transit function of the colon. In the presence of diarrhea and history of previous cholecystectomy, the control of stool becomes more difficult. In obesity, increased body mass index predisposed the subjects to FI due to weakening of pelvic floor musculature and increased intra-abdominal pressure [15, 39]. Shorter anal canal length, lower resting pressure, and higher rectal perception threshold were seen compared to nonobese patients [39]. **Table 1** summarizes the risk factors of fecal incontinence.

**13**

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

Diarrheal status

Irritable bowel syndrome Inflammatory bowel disease Post cholecystectomy

Hypersecretory tumors

Rectal resection

Radiation proctitis Ulcerative proctitis -Overflow Fecal impaction (overflow incontinence/paradoxical diarrhea) Dyssynergic defecation Rectal hyposensitivity

and meningocele)

Trauma brain injury

Cerebral infection Multiple sclerosis Spinal surgery Spina bifida Dementia Tabes dorsalis

Rectal intussusception/rectal prolapse

Trauma/anorectal impalement



Neoplasm of brain and spinal cord


Previous pelvic surgery/radiation

Medication *Causing loose stool:* laxatives/metformin/magnesium-containing antacids/ serotonin reuptake inhibitors, and orlistat

bolulinum toxin injection

*Alter gut flora:* cephalosporins, penicillins, and erythromycin *Alter sphincter tone:* nitrate, calcium channel blocker, sildenafil, and

Parkinson's disease

Endocrine Diabetic gastroenteropathy and hyperthyroidism

Electrolyte disturbance Hypercalcemia and hypermagnesemia

Malabsorption/food intolerance/enteral tube feeding

**Category Risk factors**

**Anal sphincter and pelvic floor factors**



**Metabolic and systemic factors**

**Neurological factors**

**Intestinal factors**

**Rectal factors** -Acquired structural abnormalities

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

*Current Topics in Faecal Incontinence*

cushion, thus leading to FI [15, 35].

cancer, had been reported between 3 and 53% [38].

fourth-degree perineal injury, and infant birth weight >3500 g [32, 33]. Symptoms of continence may occur later in life as there are other compensatory mechanisms to compensate [32]. Symptomatic group was older, had less body mass index, and had more forceps delivery than the asymptomatic group [33]. FI in men was more associated with constipation and previous colon and anorectal surgery compared to women [34]. Anorectal surgery, including hemorrhoidectomy, lateral internal sphincterotomy, and fistulectomy, may affect the anal sphincter and vascular

Normal rectum is a low-pressure space acting as a reservoir of fecal material until a coordinated and effective evacuation is appropriate [36]. Decreased rectal compliance, accommodation, or sensation may be found in inflammatory bowel disease and radiation proctitis [15, 36]. Neurological interruption of the central, peripheral, or autonomic nervous system is another cause of FI. These include cerebrovascular accident, spinal cord injury, and pudendal neuropathy. The latter had been reported after radiotherapy for prostatic cancer [37]. FI after multimodality treatment of pelvic malignancy, including prostate, cervical cancer, and rectal

Other contributing risk factors of FI are stool consistency and transit function of the colon. In the presence of diarrhea and history of previous cholecystectomy, the control of stool becomes more difficult. In obesity, increased body mass index predisposed the subjects to FI due to weakening of pelvic floor musculature and increased intra-abdominal pressure [15, 39]. Shorter anal canal length, lower resting pressure, and higher rectal perception threshold were seen compared to nonobese patients [39]. **Table 1** summarizes the risk factors of fecal incontinence.

**12**

**Figure 1.**

*Fecal continence system.*



#### **Table 1.**

*Risk factors of fecal incontinence.*

#### **3. Assessment of fecal incontinence**

To define the underlying etiology of FI in each patient, the clinician should have stepwise systematic assessment. There are three important steps in evaluation of patients with FI: clinical assessment, anatomical assessment, and neurophysiologic assessment.

#### **3.1 Clinical assessment**

Manifestation of FI may be classified into three subtypes: urge incontinence, total incontinence, and seepage [27].


Careful history taking should detect patients with FI who may not admit this embarrassing condition [40]. By using different terms, such as diarrhea, fecal urgency, accident, etc., and privacy of the clinic environment should allow more patients to discuss about their symptoms. Information retrieved from history taking should include severity, onset duration, clinical subtypes, and associated symptoms, for example, rectal prolapse, pelvic organ prolapse, and urinary incontinence [41]. Stool diary and stool form charts such as the Bristol stool form scale can be used for better communication [15]. Aggravating factors should be elicited. These include detailed obstetric history and abdominal-colon-anorectal surgical history, and coexisting medical condition should be noted [41]. Previous and current treatments and results should be recorded [41]. Severity score should be documented by using one of the available established scores: St. Mark's Fecal Incontinence Severity Score (Vaizey's score), Cleveland Clinic Fecal Incontinence Score (Wexner's score), the American Medical System score, and Pescatori score [42]. From the international survey, the Wexner score is the most commonly used scoring system even though the score does not include fecal urgency [43]. These scores do not have a cut-off point, may not be used to guide treatment, and cannot predict the treatment outcome [44, 45]. However, it reveals the patient's current

**15**

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

Onset, duration, and precipitating event(s)

Clinical subtypes: passive, urge, and fecal seepage

Underlying medical problem and current medication

Coexisting problem: urinary incontinence and pelvic organ prolapses Previous surgery: anorectal surgery, abdominal surgery, and pelvic surgery

Central nervous system problem: cerebrovascular disease and spinal cord injury

Severity and timing of symptoms

constipation, and fecal impaction

Current medication/caffeine/diet

Clinical grading of severity

Previous pelvic irradiation

**Table 2.**

burden which can be used to compare during follow-up after treatment. **Table 2** shows the information that should be obtained during history taking [27]. Change in bowel habit, stool character, advanced age, bleeding per rectum, anemia, mucous bloody stool, and family history of cancer should alert the physician to further endoluminal investigation. Multi-compartment involvement of pelvic organ prolapse should be approached by the multidisciplinary team. Quality of life assessment using standardized scores—fecal incontinence quality of life scale (FIQL) [46], SF-36 (short Medical Outcomes Questionnaire), and Gastrointestinal Quality of Life Index—may be used

Obstetric history: previous delivery, instrumentation, baby birth weight, perineal tear, and repair

*Information that should be obtained during history taking from patient with fecal incontinence.*

Previous and current bowel movement activity; frequency, stool consistency, urgency, change in bowel habit,

for clinical assessment and should be used routinely in research [44, 45].

*Physical examination,* especially perineal and anorectal examination, is an important part of assessment. Information of baseline anatomy and function of the subject are obtained [41]. Patients are usually placed on a left lateral position with hip and knee flexion. *Inspection* of the perineum, at rest and strain, may be positive for scar from previous surgery or obstetric injury, skin inflammation, thinning or loss of perineal body, anal gaping, soiling fistula, hemorrhoid, mucosal prolapse, rectal prolapse, and perineal descent [41, 47–49]. Following inspection, *testing for perineal sensation* and anocutaneous reflex is performed by stroking the perianal skin in a centripetal fashion with a stick with cotton bud, in all four quadrants [47]. The absence of anocutaneous reflex suggests pudendal neuropathy or a cauda equina lesion [48]. *Digital palpation* should then be performed gently using a gloved index finger [47]. Anal epithelium and rectal mucosa should be felt for tumor, smoothness, bulging, protruding, and impacted stool. Resting anal sphincter tone and length of anal canal should be noted before asking the patient to squeeze to note voluntary squeeze tone [41, 47]. Then the patient is asked to push and bear down while the examiner places her left hand over the patient's abdomen. The defecation pattern is noted by observing abdominal push effort, anal relaxation, and perineal descent [47]. Patients with suspected pelvic organ prolapse are further examined in a lithotomy position, by asking them to bear down to reveal prolapse of rectum, vaginal, uterus, and/or bladder [41]. By inspection, patients with gaping anus showed lower resting anal sphincter pressure than those without and patients with anal scar had lower incremental squeeze pressure than those without these signs [49]. When comparing squeeze pressure measure by DRE and by high-resolution manometry, there was moderate agreement in the diagnosis of fecal incontinence (ƙ-coefficient = 0.418, *p* = 0.006).


**Table 2.**

*Current Topics in Faecal Incontinence*

**Psychological factors**

**Individual characteristics**

**Category Risk factors**

**3. Assessment of fecal incontinence**

total incontinence, and seepage [27].

assessment.

**Table 1.**

**3.1 Clinical assessment**

*Risk factors of fecal incontinence.*

retain them.

To define the underlying etiology of FI in each patient, the clinician should have stepwise systematic assessment. There are three important steps in evaluation of patients with FI: clinical assessment, anatomical assessment, and neurophysiologic

Institutionalization/physical disabilities

Psychiatric disorder Medication

Aging Female gender Smoking Obesity

Manifestation of FI may be classified into three subtypes: urge incontinence,

1.*Passive incontinence*: involuntary leakage of fecal material or gas without awareness.

2.*Urge incontinence:* leakage of fecal material or gas in spite of active attempts to

3.*Fecal seepage*: undesired leakage of fecal material after normal bowel move-

Careful history taking should detect patients with FI who may not admit this embarrassing condition [40]. By using different terms, such as diarrhea, fecal urgency, accident, etc., and privacy of the clinic environment should allow more patients to discuss about their symptoms. Information retrieved from history taking should include severity, onset duration, clinical subtypes, and associated symptoms, for example, rectal prolapse, pelvic organ prolapse, and urinary incontinence [41]. Stool diary and stool form charts such as the Bristol stool form scale can be used for better communication [15]. Aggravating factors should be elicited. These include detailed obstetric history and abdominal-colon-anorectal surgical history, and coexisting medical condition should be noted [41]. Previous and current treatments and results should be recorded [41]. Severity score should be documented by using one of the available established scores: St. Mark's Fecal Incontinence Severity Score (Vaizey's score), Cleveland Clinic Fecal Incontinence Score (Wexner's score), the American Medical System score, and Pescatori score [42]. From the international survey, the Wexner score is the most commonly used scoring system even though the score does not include fecal urgency [43]. These scores do not have a cut-off point, may not be used to guide treatment, and cannot predict the treatment outcome [44, 45]. However, it reveals the patient's current

ment without abnormal continence or evacuation.

**14**

*Information that should be obtained during history taking from patient with fecal incontinence.*

burden which can be used to compare during follow-up after treatment. **Table 2** shows the information that should be obtained during history taking [27]. Change in bowel habit, stool character, advanced age, bleeding per rectum, anemia, mucous bloody stool, and family history of cancer should alert the physician to further endoluminal investigation. Multi-compartment involvement of pelvic organ prolapse should be approached by the multidisciplinary team. Quality of life assessment using standardized scores—fecal incontinence quality of life scale (FIQL) [46], SF-36 (short Medical Outcomes Questionnaire), and Gastrointestinal Quality of Life Index—may be used for clinical assessment and should be used routinely in research [44, 45].

*Physical examination,* especially perineal and anorectal examination, is an important part of assessment. Information of baseline anatomy and function of the subject are obtained [41]. Patients are usually placed on a left lateral position with hip and knee flexion. *Inspection* of the perineum, at rest and strain, may be positive for scar from previous surgery or obstetric injury, skin inflammation, thinning or loss of perineal body, anal gaping, soiling fistula, hemorrhoid, mucosal prolapse, rectal prolapse, and perineal descent [41, 47–49]. Following inspection, *testing for perineal sensation* and anocutaneous reflex is performed by stroking the perianal skin in a centripetal fashion with a stick with cotton bud, in all four quadrants [47]. The absence of anocutaneous reflex suggests pudendal neuropathy or a cauda equina lesion [48]. *Digital palpation* should then be performed gently using a gloved index finger [47]. Anal epithelium and rectal mucosa should be felt for tumor, smoothness, bulging, protruding, and impacted stool. Resting anal sphincter tone and length of anal canal should be noted before asking the patient to squeeze to note voluntary squeeze tone [41, 47]. Then the patient is asked to push and bear down while the examiner places her left hand over the patient's abdomen. The defecation pattern is noted by observing abdominal push effort, anal relaxation, and perineal descent [47]. Patients with suspected pelvic organ prolapse are further examined in a lithotomy position, by asking them to bear down to reveal prolapse of rectum, vaginal, uterus, and/or bladder [41].

By inspection, patients with gaping anus showed lower resting anal sphincter pressure than those without and patients with anal scar had lower incremental squeeze pressure than those without these signs [49]. When comparing squeeze pressure measure by DRE and by high-resolution manometry, there was moderate agreement in the diagnosis of fecal incontinence (ƙ-coefficient = 0.418, *p* = 0.006). Sensitivity, specificity, PPV, and NPV were 77.4, 70.0, 88.9, and 50.0%, respectively [50]. Even the agreement is poor if anal resting pressure was used; DRE can be a useful beside test to diagnose FI [50]. Mechanical abnormalities detected during physical examination including palpable mass, mucous bloody stool, and anemia warrant additional investigation such as endoscopy, stool examination, and breath tests [51].

#### **3.2 Anatomical assessment**

After secondary FI has been ruled out, investigation to define the underlying mechanism of FI in that patient should be performed. These include endoanal ultrasound or MRI to evaluate anal sphincter and pelvic floor anatomy integrity. For the assessment of anal sphincter defects, DRE is inaccurate for determining external anal sphincter defect <90° (accuracy 36%) [49]. Sensitivity is 90% and specificity is only 27.8% in distinguishing small from extensive anal sphincter defect [52]. Thus, DRE may be able to identify anal sphincter defect but is not sensitive enough to quantify its degree. *Endoanal ultrasound (EAUS)* has been recommended as a useful and sensitive tool to detect and define anal sphincter anatomy [44, 45]. It has a firm role in diagnostic work-up of FI [53]. EAUS is the gold standard for morphologic assessment of anal canal [54]. Various kinds of probes are available. Traditional 2D, 360o rotating endoprobe had been used to examine anal canal at multiple levels: (1) uppermost level, U-shaped puborectalis muscle is seen; (2) middle level, complete rings of IAS and EAS were seen and transverse perinei muscle is visualized; and (3) lower level, complete ring of subcutaneous part of EAS was seen without IAS [54, 55]. Normative data using 3D-EAUS had been described in both western and Asian population, and in both genders [56, 57]. Male had longer anal canal length than female by 3D-EAUS [56, 57]; M *vs.* F, 3.9 ± 0.7 *vs.* 3.4 ± 0.43 cm, *p* = 0.007 [57]. Importantly, anterior anal canal length, where puborectalis muscle mass is devoid, is significantly shorter in female [56, 57]; M *vs.* F, 3.6 ± 0.8 vs. 2.8 ± 0.5 cm, *p* < 0.001 [57]. Information which can be obtained included thickness, length, defect, and scar of IAS, EAS components (subcutaneous and superficial parts), and puborectalis muscle. The information of defect and residual anal sphincter remnant can guide anal sphincter repair. **Figure 2** is an example of anal sphincter defect detected by 3D-EAUS. Alternative to EAUS may be transperineal ultrasound (TPUS), which can also detect anal sphincter defect [44]. There was no difference between MRI and EAUS

**17**

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

**3.3 Functional and neurophysiologic assessment**

patients with cauda equina or sacral nerve plexus lesion [28].

subjects [58]. However, further studies are required.

Clinical utility of ARM in FI is to assess the weakness of sphincter muscle and abnormal anorectal sensation. For discrimination between normal and incontinent individuals, ARM had reported a sensitivity of 91.4%, an accuracy of 85.8%, and a specificity of 62.5% only [73]. By meta-analysis, ARM is accurate for diagnosis of FI with a sensitivity of 0.80 (95% confidence interval (CI) 0.69–0.88) and a specificity of 0.80 (95%CI 0.65–0.90). The diagnostic likelihood ratio was 16.61 (95%CI 5.52–50.03) [74]. The common parameter used to determine FI was maximal resting pressure [74]. Recent technology of high-definition manometry (HDM) may be able to predict the possibility and to distinguish subjects with FI from healthy

vs. 90% and the positive predictive value was 89% vs. 85% [58].

in depiction of external anal sphincter defect [58]. Sensitivity of MRI vs. EAUS was 81%

In detecting external anal sphincter atrophy, EAUS was also comparable to MRI [59]. External phase-array MRI is comparable to endoanal MRI in detecting EAS atrophy [60]. However, MRI is more expensive and time-consuming than EAUS [45] and is recommended only in the institute with sufficient experience available [60]. Dynamic MRI may be useful in subjects with suspected concomitant pelvic floor disorder, such as rectal prolapse, pelvic organ prolapses, rectocele, enterocele, and perineal descent.

*Anorectal manometry* (ARM) has been used to assess global anorectal function. It is used to quantify IAS and EAS function, rectal sensation, rectoanal reflexes, and rectal compliance [51, 61]. Traditional techniques used water-perfused and solidstate probe (6–8 channels). The newer technique uses high-resolution (HRM, 12 channels) and high definition probes (3D-HRM, 256 channels) [51, 61]. From recent international survey, most institutions use a conventional water-perfused system [62]. Solid-state and high-resolution systems are used mostly by specialist center [62]. Techniques and minimum standards of ARM had been described by Rao et al. [63]. These steps can be applied to the new probes. HRM and HDM results were comparable to measurement by water-perfused systems [64, 65]. Important information obtained includes resting anal sphincter pressure which primarily reflects internal anal sphincter function [64, 67]. Resting anal sphincter pressures are varied by gender, age, and testing methodology [28]. Pressure is usually higher in men and younger age [28, 53, 67]. Normal value using classic catheter had been described using solid-state catheter [68]. In our institute, water-perfusion catheter, normative value is shown in **Table 3**. Males had longer high-pressure zone, higher squeeze pressure, and longer squeeze duration than females [68]. **Figure 3** shows manometric findings of a patient with fecal incontinence, in whom, the anal squeeze pressure did not increase as high as normal. Rectal sensory testing and rectal compliance evaluation can be performed as a part of anorectal manometry or can be performed separately using the barostat technique or electrical stimulus [28]. Incontinent patients may have rectal hyposensitivity or hypersensitivity [51]. Rectal hypersensitivity is commonly found in patients with FI which may be explained by the cognitive precaution of the patients. However, this finding should be studied in detail. Rectal hyposensitivity, found in 10% of subjects with FI, had been reported as a cause of idiopathic FI which may reflect the afferent nerve dysfunction [69, 70]. It may also be due to megarectum and may be associated to fecal retention with overflow FI. Reduced rectal compliance is seen in patients with colitis, low spinal cord lesion, and diabetes mellitus. Increased rectal compliance is seen in high spinal cord lesion [51]. RAIR and cough reflex may be impaired and contribute to FI in some individuals. For example, RAIR may be impaired after low rectal surgery [71] and spinal cord injury below L2 level [72]. Cough reflex is impaired in

**Figure 2.** *Anal sphincter defect detected by 3D-endoanal ultrasound.*

#### *Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

*Current Topics in Faecal Incontinence*

**3.2 Anatomical assessment**

Sensitivity, specificity, PPV, and NPV were 77.4, 70.0, 88.9, and 50.0%, respectively [50]. Even the agreement is poor if anal resting pressure was used; DRE can be a useful beside test to diagnose FI [50]. Mechanical abnormalities detected during physical examination including palpable mass, mucous bloody stool, and anemia warrant additional investigation such as endoscopy, stool examination, and breath tests [51].

After secondary FI has been ruled out, investigation to define the underlying mechanism of FI in that patient should be performed. These include endoanal ultrasound or MRI to evaluate anal sphincter and pelvic floor anatomy integrity. For the assessment of anal sphincter defects, DRE is inaccurate for determining external anal sphincter defect <90° (accuracy 36%) [49]. Sensitivity is 90% and specificity is only 27.8% in distinguishing small from extensive anal sphincter defect [52]. Thus, DRE may be able to identify anal sphincter defect but is not sensitive enough to quantify its degree. *Endoanal ultrasound (EAUS)* has been recommended as a useful and sensitive tool to detect and define anal sphincter anatomy [44, 45]. It has a firm role in diagnostic work-up of FI [53]. EAUS is the gold standard for morphologic assessment of anal canal

had been used to examine anal canal at multiple levels: (1) uppermost level, U-shaped puborectalis muscle is seen; (2) middle level, complete rings of IAS and EAS were seen and transverse perinei muscle is visualized; and (3) lower level, complete ring of subcutaneous part of EAS was seen without IAS [54, 55]. Normative data using 3D-EAUS had been described in both western and Asian population, and in both genders [56, 57]. Male had longer anal canal length than female by 3D-EAUS [56, 57]; M *vs.* F, 3.9 ± 0.7 *vs.* 3.4 ± 0.43 cm, *p* = 0.007 [57]. Importantly, anterior anal canal length, where puborectalis muscle mass is devoid, is significantly shorter in female [56, 57]; M *vs.* F, 3.6 ± 0.8 vs. 2.8 ± 0.5 cm, *p* < 0.001 [57]. Information which can be obtained included thickness, length, defect, and scar of IAS, EAS components (subcutaneous and superficial parts), and puborectalis muscle. The information of defect and residual anal sphincter remnant can guide anal sphincter repair. **Figure 2** is an example of anal sphincter defect detected by 3D-EAUS. Alternative to EAUS may be transperineal ultrasound (TPUS), which can also detect anal sphincter defect [44]. There was no difference between MRI and EAUS

rotating endoprobe

[54]. Various kinds of probes are available. Traditional 2D, 360o

**16**

**Figure 2.**

*Anal sphincter defect detected by 3D-endoanal ultrasound.*

in depiction of external anal sphincter defect [58]. Sensitivity of MRI vs. EAUS was 81% vs. 90% and the positive predictive value was 89% vs. 85% [58].

In detecting external anal sphincter atrophy, EAUS was also comparable to MRI [59]. External phase-array MRI is comparable to endoanal MRI in detecting EAS atrophy [60]. However, MRI is more expensive and time-consuming than EAUS [45] and is recommended only in the institute with sufficient experience available [60]. Dynamic MRI may be useful in subjects with suspected concomitant pelvic floor disorder, such as rectal prolapse, pelvic organ prolapses, rectocele, enterocele, and perineal descent.

#### **3.3 Functional and neurophysiologic assessment**

*Anorectal manometry* (ARM) has been used to assess global anorectal function. It is used to quantify IAS and EAS function, rectal sensation, rectoanal reflexes, and rectal compliance [51, 61]. Traditional techniques used water-perfused and solidstate probe (6–8 channels). The newer technique uses high-resolution (HRM, 12 channels) and high definition probes (3D-HRM, 256 channels) [51, 61]. From recent international survey, most institutions use a conventional water-perfused system [62]. Solid-state and high-resolution systems are used mostly by specialist center [62]. Techniques and minimum standards of ARM had been described by Rao et al. [63]. These steps can be applied to the new probes. HRM and HDM results were comparable to measurement by water-perfused systems [64, 65]. Important information obtained includes resting anal sphincter pressure which primarily reflects internal anal sphincter function [64, 67]. Resting anal sphincter pressures are varied by gender, age, and testing methodology [28]. Pressure is usually higher in men and younger age [28, 53, 67]. Normal value using classic catheter had been described using solid-state catheter [68]. In our institute, water-perfusion catheter, normative value is shown in **Table 3**. Males had longer high-pressure zone, higher squeeze pressure, and longer squeeze duration than females [68]. **Figure 3** shows manometric findings of a patient with fecal incontinence, in whom, the anal squeeze pressure did not increase as high as normal.

Rectal sensory testing and rectal compliance evaluation can be performed as a part of anorectal manometry or can be performed separately using the barostat technique or electrical stimulus [28]. Incontinent patients may have rectal hyposensitivity or hypersensitivity [51]. Rectal hypersensitivity is commonly found in patients with FI which may be explained by the cognitive precaution of the patients. However, this finding should be studied in detail. Rectal hyposensitivity, found in 10% of subjects with FI, had been reported as a cause of idiopathic FI which may reflect the afferent nerve dysfunction [69, 70]. It may also be due to megarectum and may be associated to fecal retention with overflow FI. Reduced rectal compliance is seen in patients with colitis, low spinal cord lesion, and diabetes mellitus. Increased rectal compliance is seen in high spinal cord lesion [51]. RAIR and cough reflex may be impaired and contribute to FI in some individuals. For example, RAIR may be impaired after low rectal surgery [71] and spinal cord injury below L2 level [72]. Cough reflex is impaired in patients with cauda equina or sacral nerve plexus lesion [28].

Clinical utility of ARM in FI is to assess the weakness of sphincter muscle and abnormal anorectal sensation. For discrimination between normal and incontinent individuals, ARM had reported a sensitivity of 91.4%, an accuracy of 85.8%, and a specificity of 62.5% only [73]. By meta-analysis, ARM is accurate for diagnosis of FI with a sensitivity of 0.80 (95% confidence interval (CI) 0.69–0.88) and a specificity of 0.80 (95%CI 0.65–0.90). The diagnostic likelihood ratio was 16.61 (95%CI 5.52–50.03) [74]. The common parameter used to determine FI was maximal resting pressure [74]. Recent technology of high-definition manometry (HDM) may be able to predict the possibility and to distinguish subjects with FI from healthy subjects [58]. However, further studies are required.


#### **Table 3.**

*Normative anorectal manometric data.\**

**19**

**Figure 4.**

*Pudendal nerve terminal motor latency testing.*

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

770 (735–805) ml in male and 530 ml in female (410–650) [68]. The total volume that a male could retain was about 790 (770–810) ml and for a female was 670 (620–750) ml [68]. Subjects with FI had significantly lower volume infused at first

*Electromyography* (EMG) performed by inserting a needle electrode in the external anal sphincter muscle and levator ani muscle had been used to assess integrity of neuromuscular connection of the muscle [76]. Due to invasiveness, surface EMG had also been used [77]. However, the detection of the EAS defect has been replaced by other imaging techniques such as EAUS and MRI [78], and EMG

*Pudendal nerve terminal motor latency test* (PNTML) assesses the neuromuscular circuit between the terminal branch of the pudendal nerve and the external anal sphincter by measuring the conduction time between the initial stimulation and the EAS contraction (seen by motor evoked potential curve). Prolonged latency time suggests pudendal neuropathy [76]. However, the test is not sensitive enough to be related with clinical symptoms, manometric findings, and histologic findings [76, 80]. This is because a single intact nerve fiber in a FI patient can give the normal latency time. Thus, it is not routinely recommended [45]. However, in clinical practice, it can be used in conjunction with anorectal manometry and endoanal ultrasound to provide the "missing link" [81] or the possible explanation of underlying pathophysiology of FI in the patient. **Figure 4** demonstrates the abnormal

Novel neurophysiological investigations can be used to assess the spino-anorectal

neuropathy with higher sensitivity. These include *translumbar and trassacral magnetic neurostimulation* **(***TLMS, TSMS***)**, which induce motor evoked potential in the anal and rectal areas by using magnetic stimulation at the lumbar and sacral levels [82]. The magnetic stimulation induces the electrical current in the lumbosacral motor nerve roots and then the conduct along the peripheral nerves. The test could detect more anorectal neuropathy than PNTML, is well-tolerated, and can be used to assess the lumbosacral neuropathy in spinal cord injury subjects with anorectal problems [83]. Underlying pathophysiology of fecal incontinence which involves brain-gut axis connection can be tested bi-directionally [84]. For testing efferent pathways, cortical stimulation using transcranial magnetic stimulation over the paramedian motor cortex can be performed [84] and motor-evoked potentials are registered intraluminal at the rectum and anal canal levels. The test has been validated for reproducibility and good interobserver agreement [84]. In one study where both cortico-anorectal and spino-anorectal magnetic stimulations were performed, the peripheral spino-anal and spino-rectal neuropathy was identified to

leak and total volume retained compared to healthy volunteers [75].

could not predict the response to biofeedback therapy in FI [79].

PNTML in a FI patient compared to a normal subject.

#### **Figure 3.**

*Anorectal manometric findings in subjects with fecal incontinence during squeeze captured by different techniques; water-perfusion system on the left and high-resolution manometry on the right.*

Adjunctive test in FI is the *saline continence test***,** which is performed by infusing 800 ml of 0.9% sodium chloride into the patient's rectum while sitting on a commode at a rate of 60 ml/min [55]. Volume infused at the onset of first leak was about

#### *Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

*Current Topics in Faecal Incontinence*

**Rectal sensory testing**

**Saline continence test**

*\*Author's unpublished data.*

*Normative anorectal manometric data.\**

**Table 3.**

**Parameters (mean ± 95%CI) Male Female Total** HPZ rest (cm) 2.4 ± 0.4 2.2 ± 0.2 2.3 ± 0.2 HPZ squeeze (cm) 2.9 ± 0.4 2.8 ± 0.3 2.9 ± 0.3 Resting sphincter pressure (mmHg) 65.3 ± 15.2 58.5 ± 8.3 64.3 ± 8.3 Sustained squeeze pressure (mmHg) 126.9 ± 25.9 102.8 ± 10.3 121.3 ± 14.0 Maximal squeeze pressure (mmHg) 205.8 ± 43.2 169.1 ± 19.1 203.5 ± 23.1 Duration of squeeze (s) 31.8 ± 3.6 29.4 ± 3.1 31.1 ± 2.3

Mean first sensation (ml) 15.0 ± 4.3 13.9 ± 3.1 15.1 ± 2.7 Volume at desire to defecate (ml) 35.8 ± 9.5 36.5 ± 6.0 38.7 ± 5.7 Volume at urge to defecate (ml) 61.7 ± 13.8 60.0 ± 8.0 63.8 ± 8.0 Volume at maximal toleration (ml) 120.0 ± 34.1 103.2 ± 16.4 119.1 ± 18.7

Saline volume retained (ml) 655.8 ± 72.6 633.2 ± 56.7 638.0 ± 46.0 Mean %volume retained (ml) 90.8 ± 9.3 88.3 ± 7.4 90.0 ± 5.9 Volume at first leak (ml) 313.0 ± 76.4 263.6 ± 52.3 283.1 ± 43.5 Median volume at first leak (ml) 325 280 280 Median retained volume (ml) 750 750 750 Mean % retained volume 100 100 100

**18**

**Figure 3.**

Adjunctive test in FI is the *saline continence test***,** which is performed by infusing 800 ml of 0.9% sodium chloride into the patient's rectum while sitting on a commode at a rate of 60 ml/min [55]. Volume infused at the onset of first leak was about

*Anorectal manometric findings in subjects with fecal incontinence during squeeze captured by different* 

*techniques; water-perfusion system on the left and high-resolution manometry on the right.*

770 (735–805) ml in male and 530 ml in female (410–650) [68]. The total volume that a male could retain was about 790 (770–810) ml and for a female was 670 (620–750) ml [68]. Subjects with FI had significantly lower volume infused at first leak and total volume retained compared to healthy volunteers [75].

*Electromyography* (EMG) performed by inserting a needle electrode in the external anal sphincter muscle and levator ani muscle had been used to assess integrity of neuromuscular connection of the muscle [76]. Due to invasiveness, surface EMG had also been used [77]. However, the detection of the EAS defect has been replaced by other imaging techniques such as EAUS and MRI [78], and EMG could not predict the response to biofeedback therapy in FI [79].

*Pudendal nerve terminal motor latency test* (PNTML) assesses the neuromuscular circuit between the terminal branch of the pudendal nerve and the external anal sphincter by measuring the conduction time between the initial stimulation and the EAS contraction (seen by motor evoked potential curve). Prolonged latency time suggests pudendal neuropathy [76]. However, the test is not sensitive enough to be related with clinical symptoms, manometric findings, and histologic findings [76, 80]. This is because a single intact nerve fiber in a FI patient can give the normal latency time. Thus, it is not routinely recommended [45]. However, in clinical practice, it can be used in conjunction with anorectal manometry and endoanal ultrasound to provide the "missing link" [81] or the possible explanation of underlying pathophysiology of FI in the patient. **Figure 4** demonstrates the abnormal PNTML in a FI patient compared to a normal subject.

Novel neurophysiological investigations can be used to assess the spino-anorectal neuropathy with higher sensitivity. These include *translumbar and trassacral magnetic neurostimulation* **(***TLMS, TSMS***)**, which induce motor evoked potential in the anal and rectal areas by using magnetic stimulation at the lumbar and sacral levels [82]. The magnetic stimulation induces the electrical current in the lumbosacral motor nerve roots and then the conduct along the peripheral nerves. The test could detect more anorectal neuropathy than PNTML, is well-tolerated, and can be used to assess the lumbosacral neuropathy in spinal cord injury subjects with anorectal problems [83]. Underlying pathophysiology of fecal incontinence which involves brain-gut axis connection can be tested bi-directionally [84]. For testing efferent pathways, cortical stimulation using transcranial magnetic stimulation over the paramedian motor cortex can be performed [84] and motor-evoked potentials are registered intraluminal at the rectum and anal canal levels. The test has been validated for reproducibility and good interobserver agreement [84]. In one study where both cortico-anorectal and spino-anorectal magnetic stimulations were performed, the peripheral spino-anal and spino-rectal neuropathy was identified to

### **Figure 4.**

*Pudendal nerve terminal motor latency testing.*

have a possible role in the pathogenesis of FI [85]. For afferent pathways, the cortical sensory perception of anal and rectal stimulation can be detected for cortical evoked potentials (CEPs) using the scalp electrodes [84]. After rectal balloon distension, the prolonged CEP latency was seen in subjects with idiopathic FI [86] suggesting afferent dysfunctions [86]. Brain response to rectal distension can also be detected by functional MRI [28]. Preliminary findings suggested that central cerebral processing of rectal and anal stimuli plays a role in the pathogenesis of FI [29, 86].

#### **3.4 Clinical utility of anorectal anatomical and neurophysiologic tests**

FI usually has multiple etiologies including structural and functional defects. Endoanal ultrasound is strongly recommended to detect anal sphincter defects in patients with FI [44, 45]. Three-dimensional ultrasonography is useful to document anal sphincter defects, levator ani muscle avulsion, and tears [44]. Anorectal physiologic tests are used to confirm the diagnosis of FI, to grade the severity, and to determine the underlying pathophysiology. Thus, appropriate management can be planned accordingly. Anorectal manometry provides the baseline resting function of anal sphincter and squeeze function during voluntary contraction. Subjects with FI had shorter high-pressure zone, lower resting, and lower squeeze pressure than normal healthy subjects [75]. In subjects with dyssynergic defecation with overflow continence, the dyssynergic defecation pattern can also be demonstrated [66]. Abnormal anorectal reflex can be demonstrated together with rectal sensation. This information can guide in the biofeedback treatment and planning additional investigation or treatment.

The EMG technique is used to define an underlying neuromuscular dysfunction in selected cases. It is recommended for specialist use in the research study but not in routine clinical practice [28]. PNTML may be useful for assessment of FI especially when considering surgical intervention [28]. The test should be carefully performed and interpreted with caution in conjunction with other investigation results. Other neurophysiologic tests including motor evoked potential after lumbosacral (TLMS, TSMS) and cortical stimulation (TMS) are used to study the efferent brain-gut axis pathways, whereas cortical evoked potential after anorectal stimulation is used to study afferent brain-gut pathways. Functional MRI is a research tool to examine the brain-gut interaction and has not been tested for clinical use [28].

#### **4. Conclusion**

Fecal incontinence is a distressing condition of multifactorial etiologies. Detailed clinical evaluation together with selective use of anatomical and neurophysiologic testing is useful for clarification of the underlying pathophysiology. Recent change in bowel habit or stool characters should prompt the attention to rule out secondary FI from organic causes, such as colorectal cancer and inflammatory bowel disease. Severity and quality of life should be assessed. Clinical examination can detect gross, but not minor, defects. 3D-EAUS is recommended to objectively verify anal sphincter integrity. However, anal sphincter scar is better detected with MRI. Dynamic MRI can demonstrate concomitant pelvic floor disorders. TPUS is an alternative to EAUS and dynamic MRI but the accuracy is dependent on the operator's experience. ARM-quantified anal sphincter function measures rectal sensation and compliance. The saline continence test quantifies the severity of FI. EMG has limited clinical utilities and had been replaced by EAUS in detecting the anal sphincter defect. PNTML is insensitive to detect minor neuropathy. TLMS and TSMS are more sensitive to assess the spino-anorectal efferent pathways and TMS assesses the cortico-anorectal efferent pathway. CEP and functional MRI are used

**21**

provided the original work is properly cited.

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

of this group of patients.

**Conflict of interest**

**Abbreviations**

The author has no conflict of interest.

FI fecal incontinence IAS internal anal sphincter EAS external anal sphincter RAIR rectoanal inhibitory reflex CNS central nervous system DRE digital rectal examination PPV positive predictive value NPV negative predictive value EAUS endoanal ultrasound TPUS transperineal ultrasound MRI magnetic resonance imaging ARM anorectal manometry HRM high-resolution manometry

CI confidence interval

EMG electromyography

**Author details**

Thailand

Kasaya Tantiphlachiva

HDM high-definition manometry

PNTML pudendal nerve terminal motor latency TLMS translumbar magnetic stimulation TSMS transsacral magnetic stimulation CEP cortical evoked potentials

TMS transcranial magnetic stimulation

\*Address all correspondence to: kasaya.tan@gmail.com

to assess the anorectal-cortical afferent pathways. The latter tests for brain-gut-axis are mostly performed in the tertiary specialized institutes. By integration of the patient's all information, management can be planned accordingly. Further study regarding brain-gut-microbiota interaction is continuing for a better understanding

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok,

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

to assess the anorectal-cortical afferent pathways. The latter tests for brain-gut-axis are mostly performed in the tertiary specialized institutes. By integration of the patient's all information, management can be planned accordingly. Further study regarding brain-gut-microbiota interaction is continuing for a better understanding of this group of patients.

### **Conflict of interest**

*Current Topics in Faecal Incontinence*

have a possible role in the pathogenesis of FI [85]. For afferent pathways, the cortical sensory perception of anal and rectal stimulation can be detected for cortical evoked potentials (CEPs) using the scalp electrodes [84]. After rectal balloon distension, the prolonged CEP latency was seen in subjects with idiopathic FI [86] suggesting afferent dysfunctions [86]. Brain response to rectal distension can also be detected by functional MRI [28]. Preliminary findings suggested that central cerebral processing

of rectal and anal stimuli plays a role in the pathogenesis of FI [29, 86].

**3.4 Clinical utility of anorectal anatomical and neurophysiologic tests**

FI usually has multiple etiologies including structural and functional defects. Endoanal ultrasound is strongly recommended to detect anal sphincter defects in patients with FI [44, 45]. Three-dimensional ultrasonography is useful to document anal sphincter defects, levator ani muscle avulsion, and tears [44]. Anorectal physiologic tests are used to confirm the diagnosis of FI, to grade the severity, and to determine the underlying pathophysiology. Thus, appropriate management can be planned accordingly. Anorectal manometry provides the baseline resting function of anal sphincter and squeeze function during voluntary contraction. Subjects with FI had shorter high-pressure zone, lower resting, and lower squeeze pressure than normal healthy subjects [75]. In subjects with dyssynergic defecation with overflow continence, the dyssynergic defecation pattern can also be demonstrated [66]. Abnormal anorectal reflex can be demonstrated together with rectal sensation. This information can guide in the biofeedback treatment and planning additional investigation or treatment. The EMG technique is used to define an underlying neuromuscular dysfunction in selected cases. It is recommended for specialist use in the research study but not in routine clinical practice [28]. PNTML may be useful for assessment of FI especially when considering surgical intervention [28]. The test should be carefully performed and interpreted with caution in conjunction with other investigation results. Other neurophysiologic tests including motor evoked potential after lumbosacral (TLMS, TSMS) and cortical stimulation (TMS) are used to study the efferent brain-gut axis pathways, whereas cortical evoked potential after anorectal stimulation is used to study afferent brain-gut pathways. Functional MRI is a research tool to examine the brain-gut interaction and has not been tested for clinical use [28].

Fecal incontinence is a distressing condition of multifactorial etiologies. Detailed clinical evaluation together with selective use of anatomical and neurophysiologic testing is useful for clarification of the underlying pathophysiology. Recent change in bowel habit or stool characters should prompt the attention to rule out secondary FI from organic causes, such as colorectal cancer and inflammatory bowel disease. Severity and quality of life should be assessed. Clinical examination can detect gross, but not minor, defects. 3D-EAUS is recommended to objectively verify anal sphincter integrity. However, anal sphincter scar is better detected with MRI. Dynamic MRI can demonstrate concomitant pelvic floor disorders. TPUS is an alternative to EAUS and dynamic MRI but the accuracy is dependent on the operator's experience. ARM-quantified anal sphincter function measures rectal sensation and compliance. The saline continence test quantifies the severity of FI. EMG has limited clinical utilities and had been replaced by EAUS in detecting the anal sphincter defect. PNTML is insensitive to detect minor neuropathy. TLMS and TSMS are more sensitive to assess the spino-anorectal efferent pathways and TMS assesses the cortico-anorectal efferent pathway. CEP and functional MRI are used

**20**

**4. Conclusion**

The author has no conflict of interest.

#### **Abbreviations**


#### **Author details**

Kasaya Tantiphlachiva Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

\*Address all correspondence to: kasaya.tan@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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*Current Topics in Faecal Incontinence*

specialty care: A cross-sectional study. Colorectal Disease. 2015;**17**:802-809

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2014;**126**:146-150

Disease. 2015;**47**:628-645

2015;**58**:623-636

Rectum. 2000;**43**:9-17

[46] Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavran- tonis C, Thorson AG, et al. Fecal incontinence quality of life scale: Quality of life instrument for patients with fecal incontinence. Diseases of the Colon and

[47] Tantiphlachiva K, Rao P, Attaluri A, Rao SSC. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clinical Gastroenterology and Hepatology. 2010;**8**:955-960

[48] Andromanakos NP, Filippou DK, Pinis SI, Kostakis AI. Anorectal

incontinence: A challenge in diagnostic and therapeutic approach. European Journal of Gastroenterology & Hepatology. 2013;**25**:1247-1256

[49] Dobben AC, Terra MP, Deutekom M, Gerhards MF, Bijnen AB, Felt-Bersma RJ, et al. Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence. International Journal of Colorectal Disease. 2007;**22**:783-790

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[38] Schiano di Visconte M, Santoro GA, Cracco N, Sarzo G, Bellio G, Brunner M, et al. Effective of sacral nerve stimulation in fecal incontinence after multimodal oncologic treatment for pelvic malignancies: A multicenter study with 2-year follow-up. Techniques in Coloproctology. 2018;**22**:97-105

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[41] Alavi K, Chan S, Wise P, Kaiser AM,

incontinence: Etiology, diagnosis and management. Journal of Gastrointestinal

[42] Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems.

Sudan R, Bordeianou L. Fecal

Surgery. 2015;**19**:1910-1921

Gut. 1999;**44**:77-80

2018;**70**:477-484

2015;**54**:882-888

2017;**29**:313051

pp. 89-93

**24**

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[55] Stone DE, Quiroz LH. Ultrasound imaging of the pelvic floor. Obstetrics and Gynecology Clinics of North America. 2016;**43**:141-153

[56] Knowles AM, Knowles CH, Scott SM, Lunniss PJ. Effects of age and gender on three-dimensional endoanal ultrasonography measurements: Development of normal ranges. Techniques in Coloproctology. 2008;**12**:323-329

[57] Tantiphlachiva K, Sahakitrungruang C, Pattanaarun J, Rojanasakul A. Normative anatomy of the anal sphincter detected with 3D-endoanal ultrasonography. Asian Biomedicine. 2013;**7**:865-871

[58] Zifan A, Ledgerwooe-Lee M, Mittal RK. A predictive model to identify patients with fecal incontinence based

on high-definition manometry. Clinical Gastroenterology and Hepatology. 2016;**14**:178-196

[59] Cazemier M, Terra MP, Stoker J, de Lange-de Klerk ES, Boeckxstaens GE, Mulder CJ, et al. Atrophy and defects detection of the external anal sphincter: Comparison between threedimensional anal endosonography and endoanal magnetic resonance imaging. Diseases of the Colon and Rectum. 2006;**49**:20-27

[60] Terra MP, Beets-Tan RG, van der Hulst VP, Deutekom M, Dijkgraaf MG, Bossuyt PM, et al. MRI in evaluating atrophy of the external anal sphincter in patients with fecal incontinence. American Journal of Roentgenology. 2006;**187**:99109

[61] Bharucha AE, Rao SS. An update on anorectal disorders for gastroenterologists. Gastroenterology. 2014;**146**:37-45

[62] Carrington EV, Heinrich H, Knowles CH, Rao SS, Fox M, Scott SM. Methods of anorectal manometry vary widely in clinical practice: Results from an international survey. Neurogastroenterology and Motility. 2017;**29**:e13016. DOI: 10.1111/nmo.13016

[63] Rao SSC, Azpiroz F, Diamant N, Enck P, Tougass G, Wald A. Minimum standards of anorectal manometry. Neurogastroenterology and Motility. 2002;**14**:553-559

[64] Kang HR, Lee JE, Lee JS, Lee TH, Hong SJ, Kim JO, et al. Comparison of high-resolution anorectal manometry with water-perfused anorectal manometry. Journal of Neurogastroenterology and Motility. 2015;**21**:126-132

[65] Vitton V, Ben Hadj Amor W, Baumstarch K Grimaud JC, Bouvier M. Water-perfused manometry vs. three-dimensional high-resolution

manometry: A comparative study on a large patient population with anorectal disorders. Colorectal Disease. 2013;**15**:e726-e731. DOI: 10.1111/ codi.12397

[66] Staller K. Role of anorectal manometry in clinical practice. Current Treatment Options in Gastroenterology. 2015;**13**:418-431

[67] Lee HR, Lim SB, Park JY. Anorectal manometric parameters are influenced by gender and age in subjects with normal bowel function. International Journal of Colorectal Disease. 2014;**29**:1393-1399

[68] Rao SS, Hatfield R, Soffer E, Rao S, Beaty J, Conklin JL. Manometric tests of anorectal function in healthy adults. The American Journal of Gastroenterology. 1999;**94**:773-783

[69] Burgell RE. Hyposensitivity SSMR. Journal of Neurogastroenterology and Motility. 2012;**18**:373-384

[70] Madbouly KM, Hussein AM. Temporary sacral nerve stimulation in patients with fecal incontinence owing to rectal hyposensitivity: A prospective, double-blind study. Surgery. 2015;**157**:56-63

[71] Kakodkar R, Gupta S, Nundy S. Low anterior resection with total mesorectal excision for rectal cancer: Functional assessment and factors affecting outcome. Colorectal Disease. 2006;**8**:650-656

[72] Thiruppathy K, Mason J, Akbari K, Raeburn A, Emmanuel A. Physiological study of the anorectal reflex in patients with functional anorectal and defecation disorders. Journal of Digestive Diseases. 2017;**18**:222-228

[73] Pehl C, Seidl H, Scalecio N, Gundling F, Schmidt T, Schepp W, et al. Accuracy of anorectal manometry in patients with fecal incontinence. Digestion. 2012;**86**:78-85

[74] Yeap ZH, SImillis C, Qiu S, Ramage L, Kontovounisios C, Tekkis P. Diagnostic accuracy of anorectal manometry for fecal incontinence: A meta-analysis. Acta Chirurgica Belgica. 2017;**117**:347-355

[75] Tantiphlachiva K, Pattana-arun J, Sahakitrungrueng C, Rojanasakul A. Comprehensive evaluation of fecal incontinence: A preliminary report of anatomical neurophysiology study. Journal of the Medical Association of Thailand. 2018;**101**(Suppl 4):S29-S37

[76] Kumar A, Rao SS. Diagnostic testing in fecal incontinence. Current Gastroenterology Reports. 2003;**5**:406-413

[77] Nowakowski M, Tomaszewski KA, Herman RM, Salowka J, Romaniszyn M, Rubinkiewicz M, et al. Developing a new electromyography-based algorithm to diagnose the etiology of fecal incontinence. International Journal of Colorectal Disease. 2014;**29**:747-754

[78] Dobben AC, Terra MP, Deutekom M, Bossuyt PM, Felt-Bersma RJ, Stoker J. Diagnostic Work-up for Faecal Incontinence in Daily Clinical Practice in the Netherlands

[79] Lacima G, Pera M, Gonzalez-Argente X, Torrents A, Valls-Sole J, Espuna-Pons M. Is electromyography a predictive test of patient response to biofeedback in the treatment of fecal incontinence? Neurourology and Urodynamics. 2016;**35**:390-394

[80] Osterberg A, Graf W, Eeg-Olofsson K, Hynninen P, Pahlman L. Results of neurophysiologic evaluation in fecal incontinence. Diseases of the Colon and Rectum. 2000;**43**:1256-1261

[81] Remes-Troche JM, Rao SSC. Neurophysiological testing in anorectal

**27**

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

disorders. Expert Rev Gasroenterol

Tantiphlachiva K, Attaluri A, Remes-Troche J. Translumbar and transsacral magnetic neuro-stimulation for the assessment of neuropathy in fecal incontinence. Diseases of the Colon and

Hepatol. 2008;**2**:323-335

Rectum. 2014;**57**:645-652

[83] Tantiphlachiva K, Attaluri A, Valestin J, Yamada T, Rao SSC. Translumabar and transsacral motorevoked potentials: A novel test for spino-anorectal neuropathy in spinal cord injury. The American Journal of Gastroenterology. 2011;**106**:907-914

[84] Remes-Troche JM, Tantiphlachiva K, Attaluri A, Valestin J, Yamada T, Hamdy S, et al. A bi-directional assessment of the human brainanorectal axis. Neurogastroenterology and Motility. 2011;**23**:240-e118. DOI: 10.1111/j.1365-2982.2010.01619.x

[85] Xiang X, Patcharatrakul T, Sharma A, Parr R, Hamdy S, Rao SSO. Cortico-anorecatl, spinoanorectal, and cortico-spinal nerve conduction and locus of neuronal injury in patients with fecal incontinence. Clinical Gastroenterology and Hepatology. 2018. DOI: 10.1016/j.

[86] Haas S, Brock C, Krogh K, Gram M, Lundby L, Drewes AM, et al. Abnormal neuronal response to rectal and anal stimuli in patients with idiopathic fecal incontinence. Neurogastroenterology

and Motility. 2015;**27**:954-962

cgh.2018.09.007

[82] Rao SSC, Coss-Adame E,

*Comprehensive Clinical Approach to Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.86346*

disorders. Expert Rev Gasroenterol Hepatol. 2008;**2**:323-335

*Current Topics in Faecal Incontinence*

manometry: A comparative study on a large patient population with anorectal disorders. Colorectal Disease. 2013;**15**:e726-e731. DOI: 10.1111/

in patients with fecal incontinence.

Ramage L, Kontovounisios C, Tekkis P. Diagnostic accuracy of anorectal manometry for fecal incontinence: A meta-analysis. Acta Chirurgica Belgica.

[75] Tantiphlachiva K, Pattana-arun J, Sahakitrungrueng C, Rojanasakul A. Comprehensive evaluation of fecal incontinence: A preliminary report of anatomical neurophysiology study. Journal of the Medical Association of Thailand. 2018;**101**(Suppl 4):S29-S37

[76] Kumar A, Rao SS. Diagnostic testing in fecal incontinence. Current Gastroenterology Reports.

to diagnose the etiology of fecal incontinence. International Journal of Colorectal Disease. 2014;**29**:747-754

[77] Nowakowski M, Tomaszewski KA, Herman RM, Salowka J, Romaniszyn M, Rubinkiewicz M, et al. Developing a new electromyography-based algorithm

[78] Dobben AC, Terra MP, Deutekom M, Bossuyt PM, Felt-Bersma RJ, Stoker J. Diagnostic Work-up for Faecal

Incontinence in Daily Clinical Practice

[79] Lacima G, Pera M, Gonzalez-Argente X, Torrents A, Valls-Sole J, Espuna-Pons M. Is electromyography a predictive test of patient response to biofeedback in the treatment of fecal incontinence? Neurourology and

Urodynamics. 2016;**35**:390-394

Rectum. 2000;**43**:1256-1261

[81] Remes-Troche JM, Rao SSC.

[80] Osterberg A, Graf W, Eeg-Olofsson K, Hynninen P, Pahlman L. Results of neurophysiologic evaluation in fecal incontinence. Diseases of the Colon and

Neurophysiological testing in anorectal

[74] Yeap ZH, SImillis C, Qiu S,

Digestion. 2012;**86**:78-85

2017;**117**:347-355

2003;**5**:406-413

in the Netherlands

[66] Staller K. Role of anorectal

Journal of Colorectal Disease.

[69] Burgell RE. Hyposensitivity

[70] Madbouly KM, Hussein AM. Temporary sacral nerve stimulation in patients with fecal incontinence owing to rectal hyposensitivity: A prospective,

double-blind study. Surgery.

[71] Kakodkar R, Gupta S, Nundy S. Low anterior resection with total mesorectal excision for rectal cancer: Functional assessment and factors affecting outcome. Colorectal Disease.

[72] Thiruppathy K, Mason J, Akbari K, Raeburn A, Emmanuel A. Physiological

study of the anorectal reflex in patients with functional anorectal and defecation disorders. Journal of Digestive Diseases. 2017;**18**:222-228

[73] Pehl C, Seidl H, Scalecio N, Gundling F, Schmidt T, Schepp W, et al. Accuracy of anorectal manometry

Neurogastroenterology and Motility.

manometry in clinical practice. Current Treatment Options in Gastroenterology.

[67] Lee HR, Lim SB, Park JY. Anorectal manometric parameters are influenced by gender and age in subjects with normal bowel function. International

[68] Rao SS, Hatfield R, Soffer E, Rao S, Beaty J, Conklin JL. Manometric tests of anorectal function in healthy adults. The American Journal of Gastroenterology.

codi.12397

2015;**13**:418-431

2014;**29**:1393-1399

1999;**94**:773-783

SSMR. Journal of

2012;**18**:373-384

2015;**157**:56-63

2006;**8**:650-656

**26**

[82] Rao SSC, Coss-Adame E, Tantiphlachiva K, Attaluri A, Remes-Troche J. Translumbar and transsacral magnetic neuro-stimulation for the assessment of neuropathy in fecal incontinence. Diseases of the Colon and Rectum. 2014;**57**:645-652

[83] Tantiphlachiva K, Attaluri A, Valestin J, Yamada T, Rao SSC. Translumabar and transsacral motorevoked potentials: A novel test for spino-anorectal neuropathy in spinal cord injury. The American Journal of Gastroenterology. 2011;**106**:907-914

[84] Remes-Troche JM, Tantiphlachiva K, Attaluri A, Valestin J, Yamada T, Hamdy S, et al. A bi-directional assessment of the human brainanorectal axis. Neurogastroenterology and Motility. 2011;**23**:240-e118. DOI: 10.1111/j.1365-2982.2010.01619.x

[85] Xiang X, Patcharatrakul T, Sharma A, Parr R, Hamdy S, Rao SSO. Cortico-anorecatl, spinoanorectal, and cortico-spinal nerve conduction and locus of neuronal injury in patients with fecal incontinence. Clinical Gastroenterology and Hepatology. 2018. DOI: 10.1016/j. cgh.2018.09.007

[86] Haas S, Brock C, Krogh K, Gram M, Lundby L, Drewes AM, et al. Abnormal neuronal response to rectal and anal stimuli in patients with idiopathic fecal incontinence. Neurogastroenterology and Motility. 2015;**27**:954-962

**29**

**Chapter 3**

**Abstract**

used QOL scales.

**1. Introduction**

a disease, disability or disorder.

satisfaction

Quality of Life Considerations on

Traditionally, it has been assumed that tests like anorectal manometry and endoanal ultrasound are essential in the evaluation of fecal incontinence (FI). However, in daily practice, this testing rarely helps in the decision-making, as are mainly based on the patient's symptoms. Moreover, indications and outcome evaluation should not be decided by only considering the symptom severity but the impact on QoL and patient satisfaction. Nowadays, patients tend to be active consumers of health care, so they may participate on the medical decision-making. On the other hand, monitoring treatment results are mandatory in current practice. Finally, considering the cost of some of the current treatments for FI, changes in QoL should be demonstrated before implementing some procedures. For all these reasons, the QoL scales should be used, and readers encouraged to become familiar with QoL instruments and their limitations. The following chapter will cover almost all areas on existing knowledge about QoL in patients with FI: from how many types of QOL scales have been described, to the different ways to measure our patients' satisfaction, passing through the difference between severity and QOL, going deep on if the improvement of patients treated for FI is reflected enough in the current

**Keywords:** Quality of Life, Fecal Incontinence, Evaluation, Severity, Patients'

Quality of life (QoL) is the general well-being of an individual including all the emotional, social and physical aspects. A half century ago, the WHO defined QoL as an "individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" [1]. Therefore, the concept was already multidimensional including physical, mental and social domains. Health-Related Quality of Life (HRQoL) has been defined as the "physical, psychological, and social domains of health, seen as distinct areas that are influenced by a person's experiences, beliefs, expectations and perceptions" [2]. In other words, it would be an assessment of how the individual's well-being may be affected over time by

Patients should be actively involved in the treatment decisions, and therefore, the assessment of health perception is essential. Therapeutic outcomes are not meaningful if they are not balanced with the patient's perception of QoL, thus

Fecal Incontinence

*Arantxa Muñoz Duyos and Yolanda Ribas*

#### **Chapter 3**

## Quality of Life Considerations on Fecal Incontinence

*Arantxa Muñoz Duyos and Yolanda Ribas*

#### **Abstract**

Traditionally, it has been assumed that tests like anorectal manometry and endoanal ultrasound are essential in the evaluation of fecal incontinence (FI). However, in daily practice, this testing rarely helps in the decision-making, as are mainly based on the patient's symptoms. Moreover, indications and outcome evaluation should not be decided by only considering the symptom severity but the impact on QoL and patient satisfaction. Nowadays, patients tend to be active consumers of health care, so they may participate on the medical decision-making. On the other hand, monitoring treatment results are mandatory in current practice. Finally, considering the cost of some of the current treatments for FI, changes in QoL should be demonstrated before implementing some procedures. For all these reasons, the QoL scales should be used, and readers encouraged to become familiar with QoL instruments and their limitations. The following chapter will cover almost all areas on existing knowledge about QoL in patients with FI: from how many types of QOL scales have been described, to the different ways to measure our patients' satisfaction, passing through the difference between severity and QOL, going deep on if the improvement of patients treated for FI is reflected enough in the current used QOL scales.

**Keywords:** Quality of Life, Fecal Incontinence, Evaluation, Severity, Patients' satisfaction

#### **1. Introduction**

Quality of life (QoL) is the general well-being of an individual including all the emotional, social and physical aspects. A half century ago, the WHO defined QoL as an "individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" [1]. Therefore, the concept was already multidimensional including physical, mental and social domains. Health-Related Quality of Life (HRQoL) has been defined as the "physical, psychological, and social domains of health, seen as distinct areas that are influenced by a person's experiences, beliefs, expectations and perceptions" [2]. In other words, it would be an assessment of how the individual's well-being may be affected over time by a disease, disability or disorder.

Patients should be actively involved in the treatment decisions, and therefore, the assessment of health perception is essential. Therapeutic outcomes are not meaningful if they are not balanced with the patient's perception of QoL, thus

asking patients about their health and QoL before and after a procedure is crucial to improve the quality of care. Patient-reported outcomes are reports coming directly from patients about how they feel or function in relation to a health condition and its treatment without any interpretation by healthcare professionals or anyone else [3].

In the last 30 years, different instruments assessing HRQoL and the broader concept of patient-reported outcomes have been developed. These instruments do not substitute the physical, physiological or biochemical evaluations, as they are complementary and represent the patient's general perception of the effect of illness and treatment in different aspects of life such as physical, psychological and social [4].

Fecal incontinence (FI) is a social and emotionally devastating condition that significantly affects the QoL of patients and their families, and the ultimate goal of treatment should be to improve it, being essential to obtain direct data from the patient. Considering that it is a symptom, the subjective perception is essential in assessing the impact of incontinence on QoL. Patients commonly experience embarrassment, and some people limit their social life to assure an easy access to a toilet. Unfortunately, given the social stigma associated with the condition, many patients do not seek treatment. It has been suggested that the prevalence in the general population has been systematically underestimated, to the point that it has been proposed that healthcare professionals should improve detection by actively enquiring about symptoms of FI in high-risk groups [5]. The fact that only 5–27% of people report their symptoms to their physicians may justify the low number of published studies assessing the QoL in patients with FI [6].

This chapter will cover almost all areas on the existing knowledge about FI patients' QoL.

#### **2. Types of QoL scales**

There are two ways of administering questionnaires: by a face-to-face interview or in a self-administered way. Traditionally, face-to face surveys have been considered the gold standard because of their ability to obtain high response rates and valid data. However, in QoL questions, it seems that less bias in responses is produced by self-administered questionnaires due to the embarrassing situation of confessing such sensitive questions to an interviewer [7]. Furthermore, face-to-face surveys are more expensive.

Having an alternative viewpoint on a patient's QOL provided by family caregivers or other proxies is important to avoid excluding patients who cannot respond for themselves due to some cognitive impairment, of in case of very young children. Furthermore, proxy assessment of health utility may also supplement critical information for clinical decision-making on economic evaluations of patients care and health of cost-effectiveness and cost-utility analyses [8]. Proxy-patient agreement is lower for more subjective measures (e.g., expectations and satisfaction with social activities) compared with more objective ones (e.g., the frequency of social participation) [9].

In case of children, parent-proxy rapport can often be a limitation in the assessment of QOL [10], with only a few studies evaluating the level of agreement between parents and children on a child's QOL over time. A large study [11] showed low to moderate levels of parent-child agreement at baseline and lower agreement at follow-up; child's age and parent's self-perceived health were the primary factors associated with parent-child disagreements over time. Based on these findings,

**31**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

to measure (criterion validity).

Health Status Questionnaire (SF-36) [15].

scales is that the global sense of QoL is not reflected [18].

cents as much as possible.

dimensions, the domains.

tency as well.

condition.

authors recommended direct self-assessment of QOL among children and adoles-

the physical and the emotional aspects, which are usually divided in different

Most QoL questionnaires are self-administered and they take into account both

For the development of a questionnaire, several questions have to be considered:

1.*Validity*: it is the degree to which evidence and theory support the interpretations of test scores entailed by the proposed uses of tests [12]. Validity refers to whether the questionnaire actually measures what it is intended to measure and not something else, so it has to be established whether the questions and the responses are phrased appropriately. Thus, it has to be determined how representative the questions are (content validity), an association between the test scores and the prediction of a theoretical trait has to be demonstrated (construct validity), and if the questionnaire is measuring what it is intended

2.*Reliability*: it is the ability of the questionnaire to yield reproducible and consistent estimates of true treatment effect [12]. Reliability means that the responses to the questionnaire are reproducible and that it has internal consis-

3.*Responsiveness*: the instrument should be able to detect the changes in the

naires: generic QoL scales, specialized scales and condition-specific scales.

Generic QoL Scales try to cover all aspects of life and are summarized in an overall score. They are commonly used to measure QoL in patients with more than one disease, and they permit comparison of QoL across groups of patients with different medical conditions. Generic scales enable researchers to look at the target population relative to other populations. They are usually adequate for detecting gross changes in a specific population, but they often lack the specific questions to detect subtle changes and, in the case of FI, many remarkable aspects may not be reflected. For FI, the most widely used generic questionnaire is the Short Form 36

Specialized scales have been developed for a specific condition or symptom, not a specific population. These scales focus on the measurement of a particular aspect of QoL, such as the assessment of sleeping disorders in patients with irritable bowel syndrome [16] or depression in patients with FI [17]. Specialized scales provide two advantages. First, there is a lower probability that other dimensions of life will emerge, and the instrument will therefore probably be more responsive to change. Second, as with general QoL measures, specialized scales allow for comparison across different populations (for instance, comparing the presence of depression in FI versus depression in multiple sclerosis). The main disadvantage of specialized

expected outcomes. For instance, if a questionnaire is determining the QoL of certain condition, then it should be able to predict the QoL after treating that

Furthermore, in order to avoid erroneous research conclusions, the translation of questionnaires should undergo an appropriate and rigorous validation process, as it was done by the International Quality of Life Assessment (IQOLA) project to translate the S-36 Health Survey [13]. Questionnaires must adapt in a culturally relevant and comprehensible form while keeping the original meaning and intention [13, 14]. Studies assessing the QoL in patients with FI have used three types of question*Current Topics in Faecal Incontinence*

als or anyone else [3].

and social [4].

with FI [6].

patients' QoL.

**2. Types of QoL scales**

surveys are more expensive.

participation) [9].

asking patients about their health and QoL before and after a procedure is crucial to improve the quality of care. Patient-reported outcomes are reports coming directly from patients about how they feel or function in relation to a health condition and its treatment without any interpretation by healthcare profession-

In the last 30 years, different instruments assessing HRQoL and the broader concept of patient-reported outcomes have been developed. These instruments do not substitute the physical, physiological or biochemical evaluations, as they are complementary and represent the patient's general perception of the effect of illness and treatment in different aspects of life such as physical, psychological

Fecal incontinence (FI) is a social and emotionally devastating condition that significantly affects the QoL of patients and their families, and the ultimate goal of treatment should be to improve it, being essential to obtain direct data from the patient. Considering that it is a symptom, the subjective perception is essential in assessing the impact of incontinence on QoL. Patients commonly experience embarrassment, and some people limit their social life to assure an easy access to a toilet. Unfortunately, given the social stigma associated with the condition, many patients do not seek treatment. It has been suggested that the prevalence in the general population has been systematically underestimated, to the point that it has been proposed that healthcare professionals should improve detection by actively enquiring about symptoms of FI in high-risk groups [5]. The fact that only 5–27% of people report their symptoms to their physicians may justify the low number of published studies assessing the QoL in patients

This chapter will cover almost all areas on the existing knowledge about FI

There are two ways of administering questionnaires: by a face-to-face interview or in a self-administered way. Traditionally, face-to face surveys have been considered the gold standard because of their ability to obtain high response rates and valid data. However, in QoL questions, it seems that less bias in responses is produced by self-administered questionnaires due to the embarrassing situation of confessing such sensitive questions to an interviewer [7]. Furthermore, face-to-face

Having an alternative viewpoint on a patient's QOL provided by family caregivers or other proxies is important to avoid excluding patients who cannot respond for themselves due to some cognitive impairment, of in case of very young children. Furthermore, proxy assessment of health utility may also supplement critical information for clinical decision-making on economic evaluations of patients care and health of cost-effectiveness and cost-utility analyses [8]. Proxy-patient agreement is lower for more subjective measures (e.g., expectations and satisfaction with social activities) compared with more objective ones (e.g., the frequency of social

In case of children, parent-proxy rapport can often be a limitation in the assessment of QOL [10], with only a few studies evaluating the level of agreement between parents and children on a child's QOL over time. A large study [11] showed low to moderate levels of parent-child agreement at baseline and lower agreement at follow-up; child's age and parent's self-perceived health were the primary factors associated with parent-child disagreements over time. Based on these findings,

**30**

authors recommended direct self-assessment of QOL among children and adolescents as much as possible.

Most QoL questionnaires are self-administered and they take into account both the physical and the emotional aspects, which are usually divided in different dimensions, the domains.

For the development of a questionnaire, several questions have to be considered:


Furthermore, in order to avoid erroneous research conclusions, the translation of questionnaires should undergo an appropriate and rigorous validation process, as it was done by the International Quality of Life Assessment (IQOLA) project to translate the S-36 Health Survey [13]. Questionnaires must adapt in a culturally relevant and comprehensible form while keeping the original meaning and intention [13, 14].

Studies assessing the QoL in patients with FI have used three types of questionnaires: generic QoL scales, specialized scales and condition-specific scales.

Generic QoL Scales try to cover all aspects of life and are summarized in an overall score. They are commonly used to measure QoL in patients with more than one disease, and they permit comparison of QoL across groups of patients with different medical conditions. Generic scales enable researchers to look at the target population relative to other populations. They are usually adequate for detecting gross changes in a specific population, but they often lack the specific questions to detect subtle changes and, in the case of FI, many remarkable aspects may not be reflected. For FI, the most widely used generic questionnaire is the Short Form 36 Health Status Questionnaire (SF-36) [15].

Specialized scales have been developed for a specific condition or symptom, not a specific population. These scales focus on the measurement of a particular aspect of QoL, such as the assessment of sleeping disorders in patients with irritable bowel syndrome [16] or depression in patients with FI [17]. Specialized scales provide two advantages. First, there is a lower probability that other dimensions of life will emerge, and the instrument will therefore probably be more responsive to change. Second, as with general QoL measures, specialized scales allow for comparison across different populations (for instance, comparing the presence of depression in FI versus depression in multiple sclerosis). The main disadvantage of specialized scales is that the global sense of QoL is not reflected [18].

Condition-specific scales are specially designed to go deep into QoL aspects in each group of patients and its main advantage is that they can be used to detect changes in the treated population. However, as expected, these instruments cannot be used to compare QoL between different diseases. Four different types of condition-specific scales have been used to assess QoL in FI, each of them with strengths and weaknesses that will be further explained. The first one, the Fecal Incontinence Quality of Life Scale (FIQL), has been used as an evaluation tool for patients with FI and it has been widely translated [19]. The second one, the Gastrointestinal Quality of Life Index (GIQLI) [20], is an instrument for measuring QoL specifically in patients with gastrointestinal disorders, which has the additional advantage of looking at FI relative to other gastrointestinal diseases. Finally, the third type would be condition-specific quality instruments, which are designed to assess QoL in specific populations. The Manchester Health Questionnaire (MHQ ) [21] was adapted to measure the condition-specific QoL related to FI from a validated measure of urinary incontinence (the King's Health Questionnaire [22]). Subsequently, the Modified Manchester Health Questionnaire (MMHQ ) [23] was developed by combining the Fecal Incontinence Severity Scale (FISI) and the MHQ.

#### **3. Measuring the impact of FI: the difference between severity and QoL**

Initial scores to assess FI did not include questions about QoL [24, 25]. The most frequently used questionnaires, the Cleveland Clinic Continence Score (CCCS) [26] and the St Mark's score [27], have demonstrated and excellent intra and interobserver reliability [28] and they added a question about lifestyle alterations, with answers ranking in time frequency. However, ranking limitations in daily activities on the basis of time frequency may be difficult for patients. Furthermore, a person who has adapted oneself to deal with episodes of FI over a long period of time may not realize the magnitude of the impact that these episodes have been having on the activities of daily living.

Moreover, severity scores in FI were developed to be as objective as possible but introducing variables such as coping mechanisms and lifestyle changes tends to add subjective aspects, thus they should be interpreted with caution [29].

Additionally, some limitations in applying some scores should be mentioned. Both the CCCS and the St Mark's score characterize the frequency of each type of incontinence separately (i.e. solid, liquid or gas). However, other authors consider that it is difficult for patients to specify and, consequently, their scale has been developed using a different grading system, as in the Fecal Incontinence and Constipation Assessment (FICA) scale [30].

Moreover, health professionals have an additional difficulty scoring the frequency of liquid stool incontinence. In patients never experiencing liquid stools, score could be considered both in the CCCS and the St Mark's score, but if the question is what patient think that it would happen in case that they had liquid stools, score could be 4.

Other significant limitations when assessing FI are: (a) most scores do not include urgency, with the exception of the FICA and the St Mark's score and (b) the FICA score is the only one that quantifies the amount of leakage, thus in other questionnaires the severity of FI would be identical for a minor staining or a large bowel leakage once a week [31].

For all the reasons mentioned above, we need to be aware that severity alone may not be sufficient to establish a therapeutic decision.

As a result, some authors have tried to correlate the QoL assessments with the severity scores. Eypasch et al. [20] determined that patients with a CCCS over 9 had

**33**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

as important for other people.

solid stool incontinence.

surveys.

a severe alteration in their QoL measured by the Gastrointestinal Quality of Life Índex (GIQLI), and that they rested home with very poor social activities.

of FI (i.e. symptom severity) but also the impact on QOL [31].

Bharucha et al. correlated the FICA symptom severity score and a modification of the FIQL scale, and concluded that the FICA score is a simple instrument to use in the office, and that it demonstrates reasonably both the physical manifestations

However, the correlation between severity and QoL questionnaires is still a controversial issue. Impact on QoL varies between patients depending on daily activity, work, personality and many other dimensions. While one episode of solid FI might represent a significant trauma leading to changes in personal and working life for one patient, another one might consider it significant just in the case that it happened frequently. Consequently, gas incontinence may be a significant problem for a young person with an active social and working life, but it may not be considered

Rockwood et al. reported that patients acknowledged gas incontinence being more severe than what their doctors considered, being the opposite regarding solid FI [19]. This difference is due to the fact that severity scores are constructed under a pathophysiologic point of view mainly reflecting the doctor's perspective. Thus, gas incontinence is considered less severe by doctors, as they don't expect to find a significant structural or functional disorder when compared with a patient with

Furthermore, FI assessment of the outcome of treatments for FI measurement should take into account the impact on lifestyle. For instance, improving gas incontinence in a young person with an active working life, could decrease the severity

The Short Form-36 (SF-36) is a multidimensional questionnaire constructed to survey health status in the Medical Outcomes Study [15]. It is used in clinical practice and research, as well as health policy evaluations and general population

The questionnaire includes 36 items grouped in 8 dimensions: limitations in physical activities, limitations in social activities, limitations in usual role activities because of physical health problems, bodily pain, general mental health, limitations in usual role activities because of emotional problems, vitality (energy and fatigue) and general health perceptions. The SF-36 is scaled from 0 to 100, where higher scores represent a better health status. The questionnaire was designed for self-administration as well as for administration by a trained interviewer either by telephone or in person. The questionnaire has been sufficiently validated and its main advantage is that it is easy and relatively fast to fill in, taking 10–20 minutes as an average. It is the most used instrument to validate other questionnaires subse-

The SF-36 allows us to compare FI populations with urinary incontinence patients or to compare FI populations with altogether different populations, such as

As other generic scales, the main disadvantage of the SF-36 is that while the "role physical" measurement might be sufficient to detect changes among persons with FI, the "role social" measurement is probably not sensitive enough to detect such

The Gastrointestinal Quality of Life Index (GIQLI) [15] is a "systemic", but not generic, QoL instrument designed to be administered across all populations with

score less than 20%, but, however, have a significant impact on QoL.

**4. Measuring QoL in fecal incontinence**

quently designed and to assess the specific questionnaires.

healthy persons or persons with other chronic diseases [13].

changes (i.e. going to a movie or travelling) [32].

#### *Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

*Current Topics in Faecal Incontinence*

activities of daily living.

score could be 4.

bowel leakage once a week [31].

Constipation Assessment (FICA) scale [30].

may not be sufficient to establish a therapeutic decision.

Condition-specific scales are specially designed to go deep into QoL aspects in each group of patients and its main advantage is that they can be used to detect changes in the treated population. However, as expected, these instruments cannot be used to compare QoL between different diseases. Four different types of condition-specific scales have been used to assess QoL in FI, each of them with strengths and weaknesses that will be further explained. The first one, the Fecal Incontinence Quality of Life Scale (FIQL), has been used as an evaluation tool for patients with FI and it has been widely translated [19]. The second one, the Gastrointestinal Quality of Life Index (GIQLI) [20], is an instrument for measuring QoL specifically in patients with gastrointestinal disorders, which has the additional advantage of looking at FI relative to other gastrointestinal diseases. Finally, the third type would be condition-specific quality instruments, which are designed to assess QoL in specific populations. The Manchester Health Questionnaire (MHQ ) [21] was adapted to measure the condition-specific QoL related to FI from a validated measure of urinary incontinence (the King's Health Questionnaire [22]). Subsequently, the Modified Manchester Health Questionnaire (MMHQ ) [23] was developed by

combining the Fecal Incontinence Severity Scale (FISI) and the MHQ.

subjective aspects, thus they should be interpreted with caution [29].

**3. Measuring the impact of FI: the difference between severity and QoL**

Initial scores to assess FI did not include questions about QoL [24, 25]. The most frequently used questionnaires, the Cleveland Clinic Continence Score (CCCS) [26] and the St Mark's score [27], have demonstrated and excellent intra and interobserver reliability [28] and they added a question about lifestyle alterations, with answers ranking in time frequency. However, ranking limitations in daily activities on the basis of time frequency may be difficult for patients. Furthermore, a person who has adapted oneself to deal with episodes of FI over a long period of time may not realize the magnitude of the impact that these episodes have been having on the

Moreover, severity scores in FI were developed to be as objective as possible but introducing variables such as coping mechanisms and lifestyle changes tends to add

Additionally, some limitations in applying some scores should be mentioned. Both the CCCS and the St Mark's score characterize the frequency of each type of incontinence separately (i.e. solid, liquid or gas). However, other authors consider that it is difficult for patients to specify and, consequently, their scale has been developed using a different grading system, as in the Fecal Incontinence and

Moreover, health professionals have an additional difficulty scoring the frequency of liquid stool incontinence. In patients never experiencing liquid stools, score could be considered both in the CCCS and the St Mark's score, but if the question is what patient think that it would happen in case that they had liquid stools,

Other significant limitations when assessing FI are: (a) most scores do not include urgency, with the exception of the FICA and the St Mark's score and (b) the FICA score is the only one that quantifies the amount of leakage, thus in other questionnaires the severity of FI would be identical for a minor staining or a large

For all the reasons mentioned above, we need to be aware that severity alone

As a result, some authors have tried to correlate the QoL assessments with the severity scores. Eypasch et al. [20] determined that patients with a CCCS over 9 had

**32**

a severe alteration in their QoL measured by the Gastrointestinal Quality of Life Índex (GIQLI), and that they rested home with very poor social activities.

Bharucha et al. correlated the FICA symptom severity score and a modification of the FIQL scale, and concluded that the FICA score is a simple instrument to use in the office, and that it demonstrates reasonably both the physical manifestations of FI (i.e. symptom severity) but also the impact on QOL [31].

However, the correlation between severity and QoL questionnaires is still a controversial issue. Impact on QoL varies between patients depending on daily activity, work, personality and many other dimensions. While one episode of solid FI might represent a significant trauma leading to changes in personal and working life for one patient, another one might consider it significant just in the case that it happened frequently. Consequently, gas incontinence may be a significant problem for a young person with an active social and working life, but it may not be considered as important for other people.

Rockwood et al. reported that patients acknowledged gas incontinence being more severe than what their doctors considered, being the opposite regarding solid FI [19]. This difference is due to the fact that severity scores are constructed under a pathophysiologic point of view mainly reflecting the doctor's perspective. Thus, gas incontinence is considered less severe by doctors, as they don't expect to find a significant structural or functional disorder when compared with a patient with solid stool incontinence.

Furthermore, FI assessment of the outcome of treatments for FI measurement should take into account the impact on lifestyle. For instance, improving gas incontinence in a young person with an active working life, could decrease the severity score less than 20%, but, however, have a significant impact on QoL.

#### **4. Measuring QoL in fecal incontinence**

The Short Form-36 (SF-36) is a multidimensional questionnaire constructed to survey health status in the Medical Outcomes Study [15]. It is used in clinical practice and research, as well as health policy evaluations and general population surveys.

The questionnaire includes 36 items grouped in 8 dimensions: limitations in physical activities, limitations in social activities, limitations in usual role activities because of physical health problems, bodily pain, general mental health, limitations in usual role activities because of emotional problems, vitality (energy and fatigue) and general health perceptions. The SF-36 is scaled from 0 to 100, where higher scores represent a better health status. The questionnaire was designed for self-administration as well as for administration by a trained interviewer either by telephone or in person. The questionnaire has been sufficiently validated and its main advantage is that it is easy and relatively fast to fill in, taking 10–20 minutes as an average. It is the most used instrument to validate other questionnaires subsequently designed and to assess the specific questionnaires.

The SF-36 allows us to compare FI populations with urinary incontinence patients or to compare FI populations with altogether different populations, such as healthy persons or persons with other chronic diseases [13].

As other generic scales, the main disadvantage of the SF-36 is that while the "role physical" measurement might be sufficient to detect changes among persons with FI, the "role social" measurement is probably not sensitive enough to detect such changes (i.e. going to a movie or travelling) [32].

The Gastrointestinal Quality of Life Index (GIQLI) [15] is a "systemic", but not generic, QoL instrument designed to be administered across all populations with

#### *Current Topics in Faecal Incontinence*

gastrointestinal conditions, which has also been used to assess FI. The questionnaire was designed in three phases and it was also validated against other generic measures of QoL. The GIQLI contains 36 questions, each with 5 response categories, in 5 areas: a symptom list, physical issues (function and perception of functional ability), psychological issues (primarily affect), social issues and disease-specific items (items tied directly to a specific condition, such as bowel urgency for FI). The significant advantage of this type of instrument over condition-specific QoL measures is its ability to look at FI relative to other gastrointestinal conditions [18].

The FIQL scale is the most widely used condition specific QoL instrument in FI. It was developed by a panel of experts, including colorectal surgeons and health service researchers, that selected aspects (or domains) of QoL likely to be affected by FI [19, 33]. The study included 190 participants (118 patients with FI and 72 controls) from 5 different clinics. The psychometric evaluation showed that the questionnaire produced a reliable and valid measurement of QoL in patients with FI. The questionnaire is self-administered, and it includes questions regarding the limitations in their activities caused by FI during the last month.

The FIQL scale includes 29 items that are grouped into 4 scales or domains:


Possible answers range from 1 to 4, where 1 indicates a low functional status. The score of each domain is obtained from the mean of all items. The scale includes a "not applicable" category that is coded as a null value in the final sum, although the author recommends not to use it as a response option [33]. Thus, the four domains are scored from 1 to 4, and the higher score better QoL.

The main advantages of the FIQL scale are that it can be used in all adult populations with FI regardless their particular characteristics, and that it is sensitive to the dynamic relationship between the condition, the treatment, and QoL. A recent study re-evaluated the FIQL and confirmed several strengths but also has pointed out some limitations warranting a revision [34].

The Manchester Health Questionnaire (MHQ ) [21] was made up of items adapted from the King's Health Questionnaire [22], a condition-specific HRQOL to evaluate urinary incontinence. The MHQ contains 31 items that are grouped into 9 subscales: general health, physical limitations, social function, role limitations, emotional problems, sexual function, sleep/energy, incontinence impact and incontinence severity. Scores range between 0 and 100, a higher score indicating impairment of HRQOL. The questionnaire was evaluated for content validity by 15 females with known FI, and pre-tested for ambiguity and ease of comprehension in a group of 15 females without known FI and in 20 midwives. Interestingly, during pre-testing, it was found that women had difficulty understanding words such as "fecal" and "stool" and thus, wording was replaced with the term "bowel leakage." The final questionnaire showed excellent internal consistency, test-retest reliability, criterion validity and construct validity.

**35**

ful tools in the future.

tion on reliability is not available.

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

Scores on the MHQ were compared with scores on the SF-36 reaching modest to strong correlations depending on the domain, but the pattern of correlation

As the instrument appeared promising, it has been suggested that further research is required to validate the measure and test sensitivity to change, before it could be used as a primary end point for studies. Moreover, research comparing the MHQ and the FIQL scale would be also useful as the sampled content is similar [32]. The Modified Manchester Health Questionnaire (MMHQ ) [23] is a telephoneadministered version of the Fecal Incontinence Severity Scale (FISI) [29] and the Manchester Health Questionnaire [21]. Questions from the FISI were combined with similar questions from the MHQ, and some of the MHQ questions, which had been validated in the UK, were rephrased to make them more consistent with American English. Although the authors planned to collect data from 50 female patients, they achieved a relatively small sample as only 30 patients provided data, being incomplete in 4 of them. The MMHQ includes 8 subscales: overall impact, role limitations, physical/social limitations, personal relationships, emotions, sleep/ energy, sexual activity and lifestyle adaptation. The MMHQ is scaled from 0 to 100, for total and subscale scores, where higher scores represent a negative impact on HRQOL. In an invited commentary in the same article, Rockwood considered that whether the MMHQ is a viable instrument for a telephone assessment of QoL in FI

between the individual scales of the measures was not specified.

remains to be established due to the risk of measurement error [23].

naire also queries the patient to rank issues that are most bothersome.

There are other types of impact measures less frequently used that need to be mentioned. Although further investigation is required, they might prove to be use-

The TyPE specification designed by Wexner and colleagues [36] was developed to measure the fear of incontinence and how activities were affected by using a single question: "During the past 4 weeks, did fear of bowel accidents or leakage limit your participation in the following activities?". Listed activities are: walking, vigorous exercise, household chores, visiting friends, driving, sexual relations, employment, traveling, church or temple attendance and shopping. There are no summary scores for the measure, and thus, each item is evaluated individually. Very little information is available about the development of the measure and informa-

The Direct Questionning of Objectives (DQO) measure consists of a highly personal assessment, constructed on the basis of each patient's feelings. To calculate the DQO, patients list different objectives that are important for them, such as travelling or working, rate the importance of each objective on a scale and also rate their ability to perform that objective in another scale, both from 0 to 10. The product of ability and performance for each objective is calculated and divided by 10. This number is added for all objectives and divided by the importance scores for all objectives, resulting in a score from 0 to 1.0. The main disadvantages of this system of ranking the impact are: (a) the initial generation of objectives and importance

The International Consultation on Incontinence Questionnaire–Bowel Symptoms (ICIQ-B) [35] was developed by a multidisciplinary team of clinical experts in order to evaluate symptoms of FI and impact on HRQOL in a general adult population. The goal was to design an instrument including the patient's input that could be used globally in clinical practice or research. The ICIQ-B has 21 items evaluating bowel pattern, bowel control and HRQOL. Scores are generated for each section; the higher the score, the greater the symptom severity and bother to the patient. The instrument has undergone psychometric evaluation and deemed to be valid, reliable and responsive, and it is well suited to clinical practice. The question*Current Topics in Faecal Incontinence*

gastrointestinal conditions, which has also been used to assess FI. The questionnaire was designed in three phases and it was also validated against other generic measures of QoL. The GIQLI contains 36 questions, each with 5 response categories, in 5 areas: a symptom list, physical issues (function and perception of functional ability), psychological issues (primarily affect), social issues and disease-specific items (items tied directly to a specific condition, such as bowel urgency for FI). The significant advantage of this type of instrument over condition-specific QoL measures is its ability to look at FI relative to other gastrointestinal conditions [18]. The FIQL scale is the most widely used condition specific QoL instrument in FI. It was developed by a panel of experts, including colorectal surgeons and health service researchers, that selected aspects (or domains) of QoL likely to be affected by FI [19, 33]. The study included 190 participants (118 patients with FI and 72 controls) from 5 different clinics. The psychometric evaluation showed that the questionnaire produced a reliable and valid measurement of QoL in patients with FI. The questionnaire is self-administered, and it includes questions regarding the

limitations in their activities caused by FI during the last month.

The FIQL scale includes 29 items that are grouped into 4 scales or domains:

as dining out, travelling, or even basic activities such as shopping.

their feelings, and how they see themselves in their environment.

• Embarrassment and feeling of social rejection, including 3 questions.

domains are scored from 1 to 4, and the higher score better QoL.

out some limitations warranting a revision [34].

criterion validity and construct validity.

• Lifestyle: comprising 10 questions about the limitation in social activities such

• Coping/behaviour: including 9 questions relating to the level of concern of FI in daily thoughts, and the limitation that represents on sexual relations, work, etc.

• Depression/self-perception: comprising 7 questions about the impact of FI on

Possible answers range from 1 to 4, where 1 indicates a low functional status. The score of each domain is obtained from the mean of all items. The scale includes a "not applicable" category that is coded as a null value in the final sum, although the author recommends not to use it as a response option [33]. Thus, the four

The main advantages of the FIQL scale are that it can be used in all adult populations with FI regardless their particular characteristics, and that it is sensitive to the dynamic relationship between the condition, the treatment, and QoL. A recent study re-evaluated the FIQL and confirmed several strengths but also has pointed

The Manchester Health Questionnaire (MHQ ) [21] was made up of items adapted from the King's Health Questionnaire [22], a condition-specific HRQOL to evaluate urinary incontinence. The MHQ contains 31 items that are grouped into 9 subscales: general health, physical limitations, social function, role limitations, emotional problems, sexual function, sleep/energy, incontinence impact and incontinence severity. Scores range between 0 and 100, a higher score indicating impairment of HRQOL. The questionnaire was evaluated for content validity by 15 females with known FI, and pre-tested for ambiguity and ease of comprehension in a group of 15 females without known FI and in 20 midwives. Interestingly, during pre-testing, it was found that women had difficulty understanding words such as "fecal" and "stool" and thus, wording was replaced with the term "bowel leakage." The final questionnaire showed excellent internal consistency, test-retest reliability,

**34**

Scores on the MHQ were compared with scores on the SF-36 reaching modest to strong correlations depending on the domain, but the pattern of correlation between the individual scales of the measures was not specified.

As the instrument appeared promising, it has been suggested that further research is required to validate the measure and test sensitivity to change, before it could be used as a primary end point for studies. Moreover, research comparing the MHQ and the FIQL scale would be also useful as the sampled content is similar [32].

The Modified Manchester Health Questionnaire (MMHQ ) [23] is a telephoneadministered version of the Fecal Incontinence Severity Scale (FISI) [29] and the Manchester Health Questionnaire [21]. Questions from the FISI were combined with similar questions from the MHQ, and some of the MHQ questions, which had been validated in the UK, were rephrased to make them more consistent with American English. Although the authors planned to collect data from 50 female patients, they achieved a relatively small sample as only 30 patients provided data, being incomplete in 4 of them. The MMHQ includes 8 subscales: overall impact, role limitations, physical/social limitations, personal relationships, emotions, sleep/ energy, sexual activity and lifestyle adaptation. The MMHQ is scaled from 0 to 100, for total and subscale scores, where higher scores represent a negative impact on HRQOL. In an invited commentary in the same article, Rockwood considered that whether the MMHQ is a viable instrument for a telephone assessment of QoL in FI remains to be established due to the risk of measurement error [23].

The International Consultation on Incontinence Questionnaire–Bowel Symptoms (ICIQ-B) [35] was developed by a multidisciplinary team of clinical experts in order to evaluate symptoms of FI and impact on HRQOL in a general adult population. The goal was to design an instrument including the patient's input that could be used globally in clinical practice or research. The ICIQ-B has 21 items evaluating bowel pattern, bowel control and HRQOL. Scores are generated for each section; the higher the score, the greater the symptom severity and bother to the patient. The instrument has undergone psychometric evaluation and deemed to be valid, reliable and responsive, and it is well suited to clinical practice. The questionnaire also queries the patient to rank issues that are most bothersome.

There are other types of impact measures less frequently used that need to be mentioned. Although further investigation is required, they might prove to be useful tools in the future.

The TyPE specification designed by Wexner and colleagues [36] was developed to measure the fear of incontinence and how activities were affected by using a single question: "During the past 4 weeks, did fear of bowel accidents or leakage limit your participation in the following activities?". Listed activities are: walking, vigorous exercise, household chores, visiting friends, driving, sexual relations, employment, traveling, church or temple attendance and shopping. There are no summary scores for the measure, and thus, each item is evaluated individually. Very little information is available about the development of the measure and information on reliability is not available.

The Direct Questionning of Objectives (DQO) measure consists of a highly personal assessment, constructed on the basis of each patient's feelings. To calculate the DQO, patients list different objectives that are important for them, such as travelling or working, rate the importance of each objective on a scale and also rate their ability to perform that objective in another scale, both from 0 to 10. The product of ability and performance for each objective is calculated and divided by 10. This number is added for all objectives and divided by the importance scores for all objectives, resulting in a score from 0 to 1.0. The main disadvantages of this system of ranking the impact are: (a) the initial generation of objectives and importance

ratings require assistance by trained personnel; (b) it is a cognitively more complex task than completing a questionnaire and (c) measuring only certain individualized objectives may decrease the validity of the measure when groups of patients are to be compared. However, on the other side, the result is directly relevant to a specific person, so it would be more useful when deciding the treatment of an individual patient. This measure has been used to assess the QoL in patients on home parenteral nutrition after surgery for inflammatory bowel disease and also to assess the impact of neuropathic FI on QoL [37].

A study [38] analyzing the validation of QoL measures in FI concluded that the scales with the strongest degree of validity are the GIQLI, FIQL and the ICIQ-B although all of them have some deficiency. The FIQL is the most widely used by far, the main reason for this probably being that it was constructed on a strong methodological basis, being useful and sensitive to change. However, there may be other factors such as habit and the easiness to use it, as it has fewer domains than other questionnaires. Furthermore, the FIQL scale has been translated into many languages (French, Portuguese, Italian, Spanish, Turkish, German, Norwegian and Japanese).

#### **5. What do we know about QoL in patients with FI?**

Over the last 25 years, there have been improvements in the understanding, diagnosis and treatment of FI. Although FI has a major impact on QoL, it was not discussed in the literature until 15 years ago.

Few studies in elderly patients showed alterations in specific domains of the SF-36 questionnaire, such as the emotional role, mental health and physical role [39, 40]. However, in younger populations, the assessment of the impact of FI on QoL including specific questions such as change in eating patterns, work, social and sexual activities, only began when disease-specific measures were designed (**Table 1**).

Initially, aspects concerning QoL came from epidemiological studies performed in the general population. Perry and colleagues [41] designed a population-based study using a postal questionnaire that was mailed to almost 16,000 subjects aged 40 years or more. Although it was published in 2002, the study was designed before the development of the FIQL scale, and QoL was measured using general questions: Do your bowel symptoms: bother you?; cause you any physical discomfort?; interfere with your daily activities?, interfere with your social life?; affect your relationships with other people?, upset or distress you?, affect your sleep? and affect your overall QoL? Overall, the prevalence of at least a monthly leakage was 3.3% and the prevalence of soiling was 2.7%. Half of the patients with major FI and, interestingly, 16% of patients with minor FI reported that their bowel symptoms had a significant impact on their life. Nearly two thirds of this group reported to need help for their symptoms.

A panel of experts including colorectal surgeons and health service researchers, was invited to identify QOL-related domains adversely affected by FI, leading to the development of the FIQL scale [19]. An extensive research in two distinct populations demonstrated that patients with FI had a significantly lower QoL than the control population (patients with other gastrointestinal problems). The study demonstrated that these patients reduce activities that other people take for granted such as shopping, going to the cinema, dining out or having sexual intercourse. They suffer from embarrassment, shame and sometimes depression. This was the first evidence that specific daily activities are affected in patients with FI.

**37**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

> 1995 2001

O'Keefe et al. [39], Edwards and Jones [40]

Rockwood et al.

Bordeianou et al. [42]

Bharucha et al. [30]

[29]

**Author Year N Population** 

Perry et al. [41] 2002 16.000 Population-

704 2818

2000 190 FI vs. other

2008 502 Patients

2006 2800 Population-

based study Postal questionnaire

**studied**

based study, >40 years old Postal questionnaire

gastrointestinal disorders

referred to a Pelvic Floor Centre because of FI

**Questionnaires QoL alterations**

FIQL -FI patients reduced

mental health, and physical role

−50% with major FI and 16% with minor FI reported that bowel symptoms had a negative impact on their life -Nearly two thirds of this group said they wanted help with symptoms

shopping, going to the cinema, dining out or having sexual intercourse -FI patients suffer from embarrassment, shame and sometimes depression




altered

Elderly patients SF-36 -Emotional role,

Specific questions "Do your bowel symptoms:….?"

FIQL + SF-36

FIQL adaptation FICA score


#### *Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

*Current Topics in Faecal Incontinence*

impact of neuropathic FI on QoL [37].

**5. What do we know about QoL in patients with FI?**

discussed in the literature until 15 years ago.

Japanese).

designed (**Table 1**).

ratings require assistance by trained personnel; (b) it is a cognitively more complex task than completing a questionnaire and (c) measuring only certain individualized objectives may decrease the validity of the measure when groups of patients are to be compared. However, on the other side, the result is directly relevant to a specific person, so it would be more useful when deciding the treatment of an individual patient. This measure has been used to assess the QoL in patients on home parenteral nutrition after surgery for inflammatory bowel disease and also to assess the

A study [38] analyzing the validation of QoL measures in FI concluded that the scales with the strongest degree of validity are the GIQLI, FIQL and the ICIQ-B although all of them have some deficiency. The FIQL is the most widely used by far, the main reason for this probably being that it was constructed on a strong methodological basis, being useful and sensitive to change. However, there may be other factors such as habit and the easiness to use it, as it has fewer domains than other questionnaires. Furthermore, the FIQL scale has been translated into many languages (French, Portuguese, Italian, Spanish, Turkish, German, Norwegian and

Over the last 25 years, there have been improvements in the understanding, diagnosis and treatment of FI. Although FI has a major impact on QoL, it was not

Few studies in elderly patients showed alterations in specific domains of the SF-36 questionnaire, such as the emotional role, mental health and physical role [39, 40]. However, in younger populations, the assessment of the impact of FI on QoL including specific questions such as change in eating patterns, work, social and sexual activities, only began when disease-specific measures were

Initially, aspects concerning QoL came from epidemiological studies performed in the general population. Perry and colleagues [41] designed a population-based study using a postal questionnaire that was mailed to almost 16,000 subjects aged 40 years or more. Although it was published in 2002, the study was designed before the development of the FIQL scale, and QoL was measured using general questions: Do your bowel symptoms: bother you?; cause you any physical discomfort?; interfere with your daily activities?, interfere with your social life?; affect your relationships with other people?, upset or distress you?, affect your sleep? and affect your overall QoL? Overall, the prevalence of at least a monthly leakage was 3.3% and the prevalence of soiling was 2.7%. Half of the patients with major FI and, interestingly, 16% of patients with minor FI reported that their bowel symptoms had a significant impact on their life. Nearly two thirds of this group reported to need help for their

A panel of experts including colorectal surgeons and health service research-

ers, was invited to identify QOL-related domains adversely affected by FI, leading to the development of the FIQL scale [19]. An extensive research in two distinct populations demonstrated that patients with FI had a significantly lower QoL than the control population (patients with other gastrointestinal problems). The study demonstrated that these patients reduce activities that other people take for granted such as shopping, going to the cinema, dining out or having sexual intercourse. They suffer from embarrassment, shame and sometimes depression. This was the first evidence that specific daily activities are affected in

**36**

symptoms.

patients with FI.


#### **Table 1.** *What do we know about QoL in patients with FI?*

Some years after the development of the FIQL scale, Bordeianou and Rockwood published a prospective analysis of the correlation between severity and QoL, using two tools designed for the same group, the FISI for severity and the FIQL scale, and also the SF-36 [42]. All the domains of the FIQL were significantly altered, being coping-behaviour and embarrassment the two most affected subscales. Furthermore, SF-36 scores decreased as the severity of FI increased, with the exception of the scales on pain, physical role and physical functioning, which was expectable as usually alterations in the QoL of patients with FI are social and emotional. Moreover, the authors reviewed the SF-36 alterations in other chronic diseases managed in an outpatient setting and reported that patients with FI were worse than those with rheumatoid arthritis or diabetes, and as severely affected as patients with inflammatory bowel disease.

**39**

professionals [49].

regular consultations.

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

Since the publication of the FIQL scale, most studies have used this tool to measure the QoL in FI. Bharucha et al. [31] mailed a questionnaire to an age-stratified random sample of 5300 women treated at two primary care centres covering 80% of a population of 100.000 inhabitants. Subjects with FI during the previous year were assessed by a symptom severity validated scale (Fecal Incontinence and Constipation Assessment, FICA) [30] and a QoL scale consisting in 15 domains adapted from the FIQL scale. The survey was answered by 2800 women and the prevalence of FI was 18.5%. FI had a moderate or severe impact on one or more of the 15 QoL domains in 23% of the women with FI. The study demonstrated that urgency affects more QoL than passive FI alone, being worse if both types of FI are associated, probably due to the anxiety generated by the urgency. Interestingly, women with less than one episode of leakage per month had more impact on their QoL than those patients with the lowest QoL. Furthermore, they found that scores for activities in which toilet access was unpredictable (i.e. going to the cinema, shopping, recreational activities or sports, leaving home, travelling by car, plane or train) and for activities that involved eating (i.e. eating before leaving home, going out to eat) were higher (indicating worse QoL) than scores for activities associated with predictable toilet access (i.e. employment, working home, sex life, visiting friends or relatives, staying overnight away from home and family relationships). Boreham [43] studied FI in 457 women presenting for gynaecologic care on benign conditions, and reported that prevalence of FI was 28.4%. Moreover, even when the authors considered FI that had an impact on the QoL (answering anything except "never" on the FIQL scale), the prevalence of FI reached 21.7%. Of the 130 women with FI, 76.2% scored very low in the FIQL scales, being also embarrassment the most affected domain. Women with liquid stool leakages reported the largest impact on QoL. Another important aspect that impacts the QoL of patients with FI is the feeling that they are compelled to adapt to their poor situation for the rest of their lives. This study showed several interesting facts: (a) almost three quarters of women reported that FI symptoms were present for 3 years or less; (b) only 11.4% of them had previously sought care; (c) predictors of health care seeking included loss of solid stool and lower scores on the FIQL embarrassment scale

and (d) 44.7% of women thought that there was no treatment available.

The findings of this study explain why this condition has been referred to as "the silent affliction" or "the unvoiced symptom" [46, 47] because of the associated stigma. Moreover, we must consider that the overall prevalence of FI is also underestimated because health professionals do not ask about this problem. Aitola et al. reported that only 27% of patients had discussed FI with their physician [48]. Dunivan et al. found that 36% of primary care patients reported FI but only 2.7% carried FI as a medical diagnosis, thus suggesting a lack of knowledge by health

Bartlett and colleagues [50] studied the major reasons for non-disclosure of FI symptoms in patients attending a urogynaecology and colorectal clinic for other conditions. They identified that main reasons were: FI historical but not current; problem not considered as FI by the patient; administrated questionnaires too long; embarrassing condition; doctor considered too busy; patient wanted to focus on the primary reason for consultation and the doctor explained that a one-off bout of uncontrollable diarrhoea was not FI. Nevertheless, interviewees reported that patients would respond to FI questions initiated by their general practitioner during

Later on, the same group [44] reported that more than 22% of patients that attended urogynaecology and colorectal clinic for other conditions than FI, had

#### *Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

*Current Topics in Faecal Incontinence*

Boreham et al. [43]

Bartlett et al. [44]

Markland et al.

[45]

**Table 1.**

**Author Year N Population** 

2005 457 Women

2009 154 Patients

2010 155 Women

**studied**

presenting for gynecologic care

attending a urogynecology and colorrectal clinic for other conditions

presenting with FI in a specialty clinic FIQL FISI

MMHQ FISI

**Questionnaires QoL alterations**

care

FIQL -QoL severely


affected by FI in all four scales -Increased bowel frequency, quantity of fecal loss, type of incontinence and fecal urgency -No difference in QOL when comparing weekly and monthly incontinent episodes


**38**

patients with inflammatory bowel disease.

*What do we know about QoL in patients with FI?*

Some years after the development of the FIQL scale, Bordeianou and Rockwood

published a prospective analysis of the correlation between severity and QoL, using two tools designed for the same group, the FISI for severity and the FIQL scale, and also the SF-36 [42]. All the domains of the FIQL were significantly altered, being coping-behaviour and embarrassment the two most affected subscales. Furthermore, SF-36 scores decreased as the severity of FI increased, with the exception of the scales on pain, physical role and physical functioning, which was expectable as usually alterations in the QoL of patients with FI are social and emotional. Moreover, the authors reviewed the SF-36 alterations in other chronic diseases managed in an outpatient setting and reported that patients with FI were worse than those with rheumatoid arthritis or diabetes, and as severely affected as

Since the publication of the FIQL scale, most studies have used this tool to measure the QoL in FI. Bharucha et al. [31] mailed a questionnaire to an age-stratified random sample of 5300 women treated at two primary care centres covering 80% of a population of 100.000 inhabitants. Subjects with FI during the previous year were assessed by a symptom severity validated scale (Fecal Incontinence and Constipation Assessment, FICA) [30] and a QoL scale consisting in 15 domains adapted from the FIQL scale. The survey was answered by 2800 women and the prevalence of FI was 18.5%. FI had a moderate or severe impact on one or more of the 15 QoL domains in 23% of the women with FI. The study demonstrated that urgency affects more QoL than passive FI alone, being worse if both types of FI are associated, probably due to the anxiety generated by the urgency. Interestingly, women with less than one episode of leakage per month had more impact on their QoL than those patients with the lowest QoL. Furthermore, they found that scores for activities in which toilet access was unpredictable (i.e. going to the cinema, shopping, recreational activities or sports, leaving home, travelling by car, plane or train) and for activities that involved eating (i.e. eating before leaving home, going out to eat) were higher (indicating worse QoL) than scores for activities associated with predictable toilet access (i.e. employment, working home, sex life, visiting friends or relatives, staying overnight away from home and family relationships).

Boreham [43] studied FI in 457 women presenting for gynaecologic care on benign conditions, and reported that prevalence of FI was 28.4%. Moreover, even when the authors considered FI that had an impact on the QoL (answering anything except "never" on the FIQL scale), the prevalence of FI reached 21.7%. Of the 130 women with FI, 76.2% scored very low in the FIQL scales, being also embarrassment the most affected domain. Women with liquid stool leakages reported the largest impact on QoL. Another important aspect that impacts the QoL of patients with FI is the feeling that they are compelled to adapt to their poor situation for the rest of their lives. This study showed several interesting facts: (a) almost three quarters of women reported that FI symptoms were present for 3 years or less; (b) only 11.4% of them had previously sought care; (c) predictors of health care seeking included loss of solid stool and lower scores on the FIQL embarrassment scale and (d) 44.7% of women thought that there was no treatment available.

The findings of this study explain why this condition has been referred to as "the silent affliction" or "the unvoiced symptom" [46, 47] because of the associated stigma. Moreover, we must consider that the overall prevalence of FI is also underestimated because health professionals do not ask about this problem. Aitola et al. reported that only 27% of patients had discussed FI with their physician [48]. Dunivan et al. found that 36% of primary care patients reported FI but only 2.7% carried FI as a medical diagnosis, thus suggesting a lack of knowledge by health professionals [49].

Bartlett and colleagues [50] studied the major reasons for non-disclosure of FI symptoms in patients attending a urogynaecology and colorectal clinic for other conditions. They identified that main reasons were: FI historical but not current; problem not considered as FI by the patient; administrated questionnaires too long; embarrassing condition; doctor considered too busy; patient wanted to focus on the primary reason for consultation and the doctor explained that a one-off bout of uncontrollable diarrhoea was not FI. Nevertheless, interviewees reported that patients would respond to FI questions initiated by their general practitioner during regular consultations.

Later on, the same group [44] reported that more than 22% of patients that attended urogynaecology and colorectal clinic for other conditions than FI, had a QoL severely affected by FI in all four scales. Factors affecting the QoL were increased bowel frequency, quantity of fecal loss, type of incontinence and fecal urgency. Patients with both solid and liquid incontinence reported a poorer QoL than those with either only solid or liquid incontinent episodes. Given the relationship between the FIQL scales and the quantity of fecal leakage, the authors suggested that the quantity of fecal loss as well as frequency, type, urgency and pad wearing should be included in the definition of FI severity [44]. Another interesting aspect of this study was the small difference found in the FIQL scales when comparing weekly and monthly incontinence episodes, as other authors have previously reported [29], probably because infrequent incontinence episode are always unexpected, and hence, similarly distressing.

Several studies have assessed a potential difference between genders concerning the impact on QoL, with women experiencing a greater impact when compared with men [51, 52]. However, this has not been supported by other reports which failed to find significant differences [44, 53].

Studies using other scales such as MMHQ have been also reached interesting conclusions. Markland [45] studied women presenting with FI and reported a weak correlation between the FISI severity score and the MMHQ. Younger women (<65 years) had higher MMHQ scores, representing a negative impact on HRQoL and the authors suggested that young patients were more likely to report their limitations and seek treatment. However, other studies found that older women had worse QoL than younger women, and justified that a delay in treatment resulted in poorer QoL [50]. Thus, further studies are needed to address the impact on QOL depending on the age. In the same study [45], increased bowel movements and urgency were associated with significantly higher MMHQ scores. After controlling for age and comorbid disease, women reporting more bowel urgency had increased MMHQ score. Urinary incontinence, prior cholecystectomy and prior hysterectomy were also associated with increased QoL scores. Interestingly, loose stool or diarrhea was not a significant factor for increased MMHQ scores in the multivariate analysis.

A prospective study including women with FI investigated the relationship with depression and abdominal pain [54]. Depression was assessed by the Patient Health Questionnaire (PHQ ) [55]. Diabetes, prior hysterectomy, abdominal pain, history of previous health care for FI and higher FISI scores were associated with more severe QoL scores. Furthermore, higher PHQ scores predicted worse QoL scores overall and in all four of the FIQL subscales. Other studies have reported a relation between FI and depression [56]. This is an important fact to take into account, because patients with FI are required to cooperate in the management plan, and those suffering from major depression will be less likely to follow a rigorous program. Obviously, FI itself may be the main factor for a depression status; therefore, being aware of it and helping patients is likely to improve the overall treatment.

A study [57] with a cross-sectional design including 2269 ethnically diverse women aged 40–80 years, investigated the impact of FI on sexual QoL. The majority (60%) was sexually active despite having FI, but their sexual function was impaired. The multivariate analysis showed that women with FI experienced significantly lower sexual desire, lower sexual satisfaction, and limitation of sexual activity. Women with isolated gas incontinence reported sexual functioning similar to women without FI. The authors concluded that sexual life should be evaluated and prioritized during therapeutic management, as it is important to women with FI.

In conclusion, key points could be summarized as follows:

1.FI is a frequent condition with a higher prevalence of that reported in previous studies.

**41**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

embarrassment scales.

health care.

**in the QOL scales?**

scores, less than half used them.

into the details of the meaning of these changes.

2.FI has been a neglected problem worldwide. Reasons for non-disclosure and non-detected FI are multifactorial and related to the fear of embarrassment,

4.The FIQL scale seems to be a useful and essential tool to assess QoL. Alterations in almost all domains have been demonstrated, especially in coping and

5.The relationship between severity and QoL in FI is a complex matter, but it has been suggested that the quantity of loss, bowel urgency and increased bowel

introduced in the evaluation of these patients in order to improve the quality of

6.More specific aspects, such as depression or sexual activity, should also be

For the last 10 years, most studies regarding FI treatments have analyzed its impact on QOL. The FIQL scale has been the most used score to evidence such improvement, thus responsiveness of this score has been widely demonstrated. A systematic review [58] about outcomes after anal sphincter repair showed that, although continence deteriorates in the long-term, QoL and satisfaction remained relatively high. The scales used in the studies were heterogeneous and, despite most studies were published after the development of the specific QoL

Since the first multicentre European study about the feasibility of sacral neuromodulation [59], most centres regularly use the FIQL scale and some of them also add the SF-36. Consequently, most articles on this treatment mention the improvement in the four domains of the FIQL scale correlating with the FI improvement, as well as some changes in the generic questionnaire. However, few studies go deeper

A report about the long-term outcome and QoL in patients treated by sacral neuromodulation showed a significant and stable improvement in all four categories of the FIQL scale, in contrast to the SF-36 score, which only showed a significant improvement in the social functioning, emotional and mental health subscales, probably due to its generic profile [60]. On the other hand, other studies have demonstrated the quick onset on this QoL improvement, which is already present at 3 months follow-up [61–63]. The Sacral Nerve Stimulation Study Group in the USA [64] reported in-depth details about changes in QoL from baseline through 4 years of follow-up. They reported that not only the four FIQL scales were significantly improved but there was also an improvement in each of the component questions. Before the treatment, patients tended to stay close to a toilet, thought about the impact of food on their bowel function, disliked their body image, and were very limited in their personal intimate life. After sacral neuromodulation, less patients were worried about the proximity to a toilet, were fearful to sleep elsewhere than at home, avoided travelling by plane or train, disliked their body image. Patients also reported an improvement in their sexual life. Moreover, patient-reported overall health was significantly

improved, demonstrating a general perception of improvement in wellbeing

**6. Is the improvement of patients treated for FI reflected enough** 

but also to the lack of professionals dealing with the problem.

frequency should be measured and taken into account.

3.QoL of patients with FI is severely affected in almost all life domains.

*Current Topics in Faecal Incontinence*

unexpected, and hence, similarly distressing.

failed to find significant differences [44, 53].

a QoL severely affected by FI in all four scales. Factors affecting the QoL were increased bowel frequency, quantity of fecal loss, type of incontinence and fecal urgency. Patients with both solid and liquid incontinence reported a poorer QoL than those with either only solid or liquid incontinent episodes. Given the relationship between the FIQL scales and the quantity of fecal leakage, the authors suggested that the quantity of fecal loss as well as frequency, type, urgency and pad wearing should be included in the definition of FI severity [44]. Another interesting aspect of this study was the small difference found in the FIQL scales when comparing weekly and monthly incontinence episodes, as other authors have previously reported [29], probably because infrequent incontinence episode are always

Several studies have assessed a potential difference between genders concerning the impact on QoL, with women experiencing a greater impact when compared with men [51, 52]. However, this has not been supported by other reports which

Studies using other scales such as MMHQ have been also reached interesting conclusions. Markland [45] studied women presenting with FI and reported a weak correlation between the FISI severity score and the MMHQ. Younger women (<65 years) had higher MMHQ scores, representing a negative impact on HRQoL and the authors suggested that young patients were more likely to report their limitations and seek treatment. However, other studies found that older women had worse QoL than younger women, and justified that a delay in treatment resulted in poorer QoL [50]. Thus, further studies are needed to address the impact on QOL depending on the age. In the same study [45], increased bowel movements and urgency were associated with significantly higher MMHQ scores. After controlling for age and comorbid disease, women reporting more bowel urgency had increased MMHQ score. Urinary incontinence, prior cholecystectomy and prior hysterectomy were also associated with increased QoL scores. Interestingly, loose stool or diarrhea was not a significant factor for increased MMHQ scores in the multivariate analysis. A prospective study including women with FI investigated the relationship with depression and abdominal pain [54]. Depression was assessed by the Patient Health Questionnaire (PHQ ) [55]. Diabetes, prior hysterectomy, abdominal pain, history of previous health care for FI and higher FISI scores were associated with more severe QoL scores. Furthermore, higher PHQ scores predicted worse QoL scores overall and in all four of the FIQL subscales. Other studies have reported a relation between FI and depression [56]. This is an important fact to take into account, because patients with FI are required to cooperate in the management plan, and those suffering from major depression will be less likely to follow a rigorous program. Obviously, FI itself may be the main factor for a depression status; therefore, being aware of it and helping patients is likely to improve the overall treatment. A study [57] with a cross-sectional design including 2269 ethnically diverse women aged 40–80 years, investigated the impact of FI on sexual QoL. The majority (60%) was sexually active despite having FI, but their sexual function was impaired. The multivariate analysis showed that women with FI experienced significantly lower sexual desire, lower sexual satisfaction, and limitation of sexual activity. Women with isolated gas incontinence reported sexual functioning similar to women without FI. The authors concluded that sexual life should be evaluated and prioritized during therapeutic management, as it is important to

**40**

women with FI.

studies.

In conclusion, key points could be summarized as follows:

1.FI is a frequent condition with a higher prevalence of that reported in previous


#### **6. Is the improvement of patients treated for FI reflected enough in the QOL scales?**

For the last 10 years, most studies regarding FI treatments have analyzed its impact on QOL. The FIQL scale has been the most used score to evidence such improvement, thus responsiveness of this score has been widely demonstrated.

A systematic review [58] about outcomes after anal sphincter repair showed that, although continence deteriorates in the long-term, QoL and satisfaction remained relatively high. The scales used in the studies were heterogeneous and, despite most studies were published after the development of the specific QoL scores, less than half used them.

Since the first multicentre European study about the feasibility of sacral neuromodulation [59], most centres regularly use the FIQL scale and some of them also add the SF-36. Consequently, most articles on this treatment mention the improvement in the four domains of the FIQL scale correlating with the FI improvement, as well as some changes in the generic questionnaire. However, few studies go deeper into the details of the meaning of these changes.

A report about the long-term outcome and QoL in patients treated by sacral neuromodulation showed a significant and stable improvement in all four categories of the FIQL scale, in contrast to the SF-36 score, which only showed a significant improvement in the social functioning, emotional and mental health subscales, probably due to its generic profile [60]. On the other hand, other studies have demonstrated the quick onset on this QoL improvement, which is already present at 3 months follow-up [61–63].

The Sacral Nerve Stimulation Study Group in the USA [64] reported in-depth details about changes in QoL from baseline through 4 years of follow-up. They reported that not only the four FIQL scales were significantly improved but there was also an improvement in each of the component questions. Before the treatment, patients tended to stay close to a toilet, thought about the impact of food on their bowel function, disliked their body image, and were very limited in their personal intimate life. After sacral neuromodulation, less patients were worried about the proximity to a toilet, were fearful to sleep elsewhere than at home, avoided travelling by plane or train, disliked their body image. Patients also reported an improvement in their sexual life. Moreover, patient-reported overall health was significantly improved, demonstrating a general perception of improvement in wellbeing

beyond the mere restoration of continence. Furthermore, they demonstrated that Embarrassment and Copying-Behaviour were the most affected dimensions, and that correlated better with clinical improvement than Depression and Lifestyle subscales. This fact could be explained because even if patients are not fully continent, their QoL is better secondary to less episodes of FI, but they still remain affected by all the changes that altered their lives during the time that they suffered FI.

Other reports have highlighted the impact of different surgical treatments, such as injectable bulking agents, artificial bowel sphincter or dynamic graciloplasty, on the QOL of patients with FI [44].

#### **7. Measuring patient satisfaction**

The current role of clinicians has changed from helping patients through their illness, to have higher expectations that include both cure and alleviate chronic symptoms. Moreover, patients tend to be active consumers of health care, so they may participate on the medical decision-making. On the other hand, monitoring treatment results is mandatory in current practice. For all these reasons, the QoL scales should be used, at least when treatment outcomes are measured.

Nevertheless, the question is whether they are practical and whether its use in the clinical practice is realistic. On certain occasions, decisions based on clinical improvement and patient satisfaction need to be made, and sometimes is impossible to score a QOL scale, in the outpatients' clinic context.

Some studies have reported simple ways to measure patient satisfaction, which are complementary to the application of QOL scores. This implies the addition of study-specific customized questions, typically focusing on subjective measures of satisfaction or QOL (i.e. "Would you recommend a sphincteroplasty to a friend?" or "Are you pleased with the results of your surgery?"). Other authors have used a Likert Scale or Visual Analogue Scales (VAS) to measure patient's satisfaction with the outcome [58].

A study [28] measuring the efficacy of different tools used in FI patient's evaluation, demonstrated and excellent intra and interobserver reliability of both CCCS and St Mark's score. Moreover, all domains of the FIQL demonstrate excellent intraobserver reliability, although a simple quality of life assessment tool such as VAS still maintains a better intraobserver agreement.

The relationship between patient's satisfaction and clinical outcome, assessed by bowel diaries and symptom scores, was evaluated in a study on sacral neuromodulation [65]. Patients were asked to indicate if they were satisfied with their current treatment results, with a simple question (yes/no) that simplified the analysis of predictive factors of outcome. It was evident that this relationship is complex and does not match the traditional used success criteria.

In another study [64], patients were asked to rate his/her own bowel health on a scale from 0 to 10, 0 indicating the worst imaginable situation and a 10 indicating the best one.

There is no consensus on what is the best way to measure patient satisfaction easily, but it is clear that the way to evaluate patients must improve and its validation must be a future line of research.

#### **8. Final comments**

Traditionally, it has been assumed that testing is essential in the evaluation of FI. Anorectal manometry and anal ultrasound have been considered the most

**43**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

procedures.

instruments and their limitations.

funds have been used to this chapter.

FI fecal incontinence QoL quality of life

HRQoL health-related quality of life

IQOLA international quality of life assessment SF-36 short form 36 health status questionnaire FIQL fecal incontinence quality of life scale GIQLI gastrointestinal quality of life index MHQ Manchester health questionnaire

MMHQ modified Manchester health questionnaire

FICA fecal incontinence and constipation assessment

ICIQ-B international consultation on incontinence questionnaire–bowel

FISI fecal incontinence severity scale CCCS Cleveland Clinic continence score

symptoms DQO direct questionning of objectives PHQ patient health questionnaire VAS visual analogue scales

The authors declare no conflicts of interest.

**Acknowledgements**

**Conflict of interest**

**Nomenclature**

useful and available tests to assess FI. Investigations would be clearly useful for patients with a sphincter injury that could benefit from surgical repair. However, in daily practice, the reality for the majority of patients is that testing rarely helps in the decision-making, as decisions are mainly based on the patient's symptoms. It is commonly known that some patients with mild clinical symptoms may have a severe dysfunction when tested, and on the contrary, there are patients experiencing severe FI but showing minor structural and functional alterations. Moreover, treatment decisions and outcome evaluation after treatment should not be decided only considering the symptom severity but the impact on QOL and the patient satisfaction. Finally, considering the economic cost of some of the current treatments for FI, changes in QoL should be demonstrated before implementing certain

Society is evolving, which implies changes in lifestyle and the possibility of new treatments in the future. Therefore, it might be necessary to rethink the way of assessing QoL, and that questionnaires will need to evolve as well, to adapt to the new circumstances. Readers must be encouraged to become familiar with QoL

Laura Lagares-Tena has contributed extensively in the edition of this chapter. No

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

*Current Topics in Faecal Incontinence*

the QOL of patients with FI [44].

the outcome [58].

the best one.

**8. Final comments**

**7. Measuring patient satisfaction**

beyond the mere restoration of continence. Furthermore, they demonstrated that Embarrassment and Copying-Behaviour were the most affected dimensions, and that correlated better with clinical improvement than Depression and Lifestyle subscales. This fact could be explained because even if patients are not fully continent, their QoL is better secondary to less episodes of FI, but they still remain affected by

Other reports have highlighted the impact of different surgical treatments, such as injectable bulking agents, artificial bowel sphincter or dynamic graciloplasty, on

The current role of clinicians has changed from helping patients through their illness, to have higher expectations that include both cure and alleviate chronic symptoms. Moreover, patients tend to be active consumers of health care, so they may participate on the medical decision-making. On the other hand, monitoring treatment results is mandatory in current practice. For all these reasons, the QoL

Nevertheless, the question is whether they are practical and whether its use in the clinical practice is realistic. On certain occasions, decisions based on clinical improvement and patient satisfaction need to be made, and sometimes is impossible

Some studies have reported simple ways to measure patient satisfaction, which are complementary to the application of QOL scores. This implies the addition of study-specific customized questions, typically focusing on subjective measures of satisfaction or QOL (i.e. "Would you recommend a sphincteroplasty to a friend?" or "Are you pleased with the results of your surgery?"). Other authors have used a Likert Scale or Visual Analogue Scales (VAS) to measure patient's satisfaction with

A study [28] measuring the efficacy of different tools used in FI patient's evaluation, demonstrated and excellent intra and interobserver reliability of both CCCS and St Mark's score. Moreover, all domains of the FIQL demonstrate excellent intraobserver reliability, although a simple quality of life assessment tool such as

The relationship between patient's satisfaction and clinical outcome, assessed by bowel diaries and symptom scores, was evaluated in a study on sacral neuromodulation [65]. Patients were asked to indicate if they were satisfied with their current treatment results, with a simple question (yes/no) that simplified the analysis of predictive factors of outcome. It was evident that this relationship is complex and

In another study [64], patients were asked to rate his/her own bowel health on a scale from 0 to 10, 0 indicating the worst imaginable situation and a 10 indicating

There is no consensus on what is the best way to measure patient satisfaction easily, but it is clear that the way to evaluate patients must improve and its valida-

Traditionally, it has been assumed that testing is essential in the evaluation of FI. Anorectal manometry and anal ultrasound have been considered the most

all the changes that altered their lives during the time that they suffered FI.

scales should be used, at least when treatment outcomes are measured.

to score a QOL scale, in the outpatients' clinic context.

VAS still maintains a better intraobserver agreement.

does not match the traditional used success criteria.

tion must be a future line of research.

**42**

useful and available tests to assess FI. Investigations would be clearly useful for patients with a sphincter injury that could benefit from surgical repair. However, in daily practice, the reality for the majority of patients is that testing rarely helps in the decision-making, as decisions are mainly based on the patient's symptoms. It is commonly known that some patients with mild clinical symptoms may have a severe dysfunction when tested, and on the contrary, there are patients experiencing severe FI but showing minor structural and functional alterations. Moreover, treatment decisions and outcome evaluation after treatment should not be decided only considering the symptom severity but the impact on QOL and the patient satisfaction. Finally, considering the economic cost of some of the current treatments for FI, changes in QoL should be demonstrated before implementing certain procedures.

Society is evolving, which implies changes in lifestyle and the possibility of new treatments in the future. Therefore, it might be necessary to rethink the way of assessing QoL, and that questionnaires will need to evolve as well, to adapt to the new circumstances. Readers must be encouraged to become familiar with QoL instruments and their limitations.

#### **Acknowledgements**

Laura Lagares-Tena has contributed extensively in the edition of this chapter. No funds have been used to this chapter.

#### **Conflict of interest**

The authors declare no conflicts of interest.

#### **Nomenclature**


*Current Topics in Faecal Incontinence*

### **Author details**

Arantxa Muñoz Duyos1 \* and Yolanda Ribas2

1 University Hospital Mútua Terrassa, Barcelona University, Terrassa, Barcelona, Spain

2 Consorci Sanitari de Terrassa, Terrassa, Spain

\*Address all correspondence to: amduyos@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**45**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

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[8] Bandayrel K, Johnston BC. Recent advances in patient and proxy-reported quality of life research. Health and Quality of Life Outcomes. 2014;**12**:110

[9] Hwang HF, Chen CY, Lin MR. Patient-proxy agreement on the healthrelated quality of life one year after traumatic brain injury. Archives of Physical Medicine and Rehabilitation.

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[10] Eiser C, Varni JW. Healthrelated quality of life and symptom reporting: similarities and differences between children and their parents. European Journal of Pediatrics.

[11] Ravens-Sieberer U, Erhart M, Rajmil L, Herdman M, Auquier P, Bruil J, et al. European KIDSCREEN Group. Reliability, construct and criterion validity of the KIDSCREEN-10 score: a short measure for children and adolescents' well-being and healthrelated quality of life. Quality of Life Research. 2010;**19**(10):1487-1500

[12] American Educational Research Association. American Psychological Association, National Council on Measurement in Education. Standards for Educational and Psychological Testing. Washington, DC: American Educational Research Association; 1999

[13] Bullinger M, Alonso J, Apolone G,

Dauphinee S, et al. Translating health status questionnaires and evaluating their quality: the IQOLA Project approach. International Quality of Life Assessment. Journal of Clinical Epidemiology. 1998;**51**(11):913-923

Leplège A, Sullivan M, Wood-

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[2] Testa MA, Simonson DC. Assesment

Information/Guidances/UCM193282.pdf

[4] Acquadro C, Berzon R, Dubois D, Leidy NK, Marquis P, Revicki D, et al. Incorporating the patient's perspective

communication: an ad hoc task force report of the patient-reported outcomes (PRO) Harmonization Group meeting at the Food and Drug Administration, February 16, 2001. Value in Health.

[5] Faecal incontinence in adults: management. NICE Clinical guideline [CG49] Publisheddate. 2007. Available

from: https://www.nice.org.uk/ guidance/cg49/chapter/1-Guidance

[6] Whitehead WE. Diagnosing and managing fecal incontinence: if you don"t ask, they won"t tell. Gastroenterology. 2005;**129**(1):6

[7] Christensen AI, Ekholm O, Glümer C, Juel K. Effect of survey mode on response patterns: comparison of face-to-face and self-administered modes in health surveys. European

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into drug development and

2003;**6**(5):522-531

of quality-of-life outcomes. The New England Journal of Medicine.

[3] U.S Department of Health and Human Services Food and Drug Administration Guidance for Industry: Patient-Reported Outcome Measures: Use in Medical Product Development to Support Labeling Claims. U.S. FDA, Clinical/Medical. 2009. Available form: http://www.fda.gov/downloads/Drugs/ GuidanceComplianceRegulatory

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1996;**334**(13):835-840

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

#### **References**

*Current Topics in Faecal Incontinence*

**44**

**Author details**

Spain

Arantxa Muñoz Duyos1

\* and Yolanda Ribas2

2 Consorci Sanitari de Terrassa, Terrassa, Spain

provided the original work is properly cited.

\*Address all correspondence to: amduyos@gmail.com

1 University Hospital Mútua Terrassa, Barcelona University, Terrassa, Barcelona,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

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[4] Acquadro C, Berzon R, Dubois D, Leidy NK, Marquis P, Revicki D, et al. Incorporating the patient's perspective into drug development and communication: an ad hoc task force report of the patient-reported outcomes (PRO) Harmonization Group meeting at the Food and Drug Administration, February 16, 2001. Value in Health. 2003;**6**(5):522-531

[5] Faecal incontinence in adults: management. NICE Clinical guideline [CG49] Publisheddate. 2007. Available from: https://www.nice.org.uk/ guidance/cg49/chapter/1-Guidance

[6] Whitehead WE. Diagnosing and managing fecal incontinence: if you don"t ask, they won"t tell. Gastroenterology. 2005;**129**(1):6

[7] Christensen AI, Ekholm O, Glümer C, Juel K. Effect of survey mode on response patterns: comparison of face-to-face and self-administered modes in health surveys. European Journal of Public Health. 2014;**24**(2):327-332

[8] Bandayrel K, Johnston BC. Recent advances in patient and proxy-reported quality of life research. Health and Quality of Life Outcomes. 2014;**12**:110

[9] Hwang HF, Chen CY, Lin MR. Patient-proxy agreement on the healthrelated quality of life one year after traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 2017;**98**(12):2540-2547

[10] Eiser C, Varni JW. Healthrelated quality of life and symptom reporting: similarities and differences between children and their parents. European Journal of Pediatrics. 2013;**172**(10):1299-1304

[11] Ravens-Sieberer U, Erhart M, Rajmil L, Herdman M, Auquier P, Bruil J, et al. European KIDSCREEN Group. Reliability, construct and criterion validity of the KIDSCREEN-10 score: a short measure for children and adolescents' well-being and healthrelated quality of life. Quality of Life Research. 2010;**19**(10):1487-1500

[12] American Educational Research Association. American Psychological Association, National Council on Measurement in Education. Standards for Educational and Psychological Testing. Washington, DC: American Educational Research Association; 1999

[13] Bullinger M, Alonso J, Apolone G, Leplège A, Sullivan M, Wood-Dauphinee S, et al. Translating health status questionnaires and evaluating their quality: the IQOLA Project approach. International Quality of Life Assessment. Journal of Clinical Epidemiology. 1998;**51**(11):913-923

[14] Sperber AD. Translation and validation of study instruments for cross-cultural research. Gastroenterology. 2004;**126**(Suppl 1): S124-S128

[15] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care. 1992;**30**(6):473-483

[16] Elsenbruch S, Harnish MJ, Orr WC. Subjective and objective sleep quality in irritable bowel syndrome. The American Journal of Gastroenterology. 1999;**94**(9):2447-2452

[17] Vrijens D, Berghmans B, Nieman F, van Os J, van Koeveringe G, Leue C. Prevalence of anxiety and depressive symptoms and their association with pelvic floor dysfunctions–A cross sectional cohort study at a Pelvic Care Centre. Neurourology and Urodynamics. 2017;**36**(7):1816-1823

[18] Rockwood TH. Incontinence severity and QOL scales for fecal incontinence. Gastroenterology. 2004;**126**(Suppl 1):S106-S113

[19] Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Fecal incontinence quality of life scale: Quality of life instrument for patients with fecal incontinence. Diseases of the Colon & Rectum. 2000;**43**(1):9-16; discussion 16-7

[20] Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmülling C, Neugebauer E, et al. Gastrointestinal quality of life index: development, validation and application of a new instrument. The British Journal of Surgery. 1995;**82**(2):216-222

[21] Bugg G, Kiff E, Hosker G. A new condition-specific health-related quality of life questionnaire for the assessment of women with anal incontinence. British Journal of Obstetrics and Gynaecology;**108**:1057-1067

[22] Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary

incontinent women. British Journal of Obstetrics and Gynaecology. 1997;**104**(12):1374-1379

[23] Kwon S, Visco AG, Fitzgerald MP, Ye W, Whitehead WE. Validity and reliability of the modified manchester health questionnaire in assessing patients with fecal incontinence. Diseases of the Colon and Rectum. 2005;**48**(2):323-334

[24] Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence. Evaluation of 335 patients. Diseases of the Colon & Rectum. 1992;**35**(5):482-487

[25] Parks AG. Royal society of medicine, section of proctology; meeting 27 November 1974. President's address. Anorectal incontinence. Proceedings of the Royal Society of Medicine. 1975;**68**(11):681-690

[26] Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Diseases of the Colon and Rectum. 1993;**36**(1):77-97

[27] Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut. 1999;**44**(1):77-80

[28] Hussain ZI, Lim M, Stojkovic S. The test-retest reliability of fecal incontinence severity and quality-of-life assessment tools. Diseases of the Colon and Rectum. 2014;**57**(5):638-644

[29] Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Diseases of the Colon and Rectum. 1999;**42**(12):1525-1532

[30] Bharucha AE, Locke GR, Seide BM, Zinsmeister AR. A new questionnaire for constipation and faecal

**47**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

Diseases of the Colon and Rectum.

Zinsmeister AR, Jacobsen SJ. Bowel disorders impair functional status and quality of life in the elderly: A population-based study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 1995;**50A**(4):M184-M189

[39] O'Keefe EA, Talley NJ,

[40] Edwards NI, Jones D. The prevalence of faecal incontinence in older people living at home. Age and

Ageing. 2001;**30**(6):503-507

[41] Perry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H, et al. Prevalence of faecal incontinence

in adults aged 40 years or more living in the community. Gut.

[42] Bordeianou L, Rockwood T, Baxter N, Lowry A, Mellgren A, Parker S. Does incontinence severity

correlate with quality of life?

patients. Colorectal Disease.

[43] Boreham MK, Richter HE, Kenton KS, Nager CW, Gregory WT, Aronson MP, et al. Anal incontinence in women presenting for gynecologic care: Prevalence, risk factors, and impact upon quality of life. American Journal of Obstetrics and Gynecology.

Prospective analysis of 502 consecutive

2002;**50**(4):480-484

2008;**10**(3):273-279

2005;**192**(5):1637-1642

2009;**15**(26):3276-3282

2010;**53**(8):1148-1154

[44] Bartlett L. Impact of fecal incontinence on quality of life. World Journal of Gastroenterology.

[45] Markland AD, Greer WJ, Vogt A, Redden DT, Goode PS, Burgio KL, et al. Factors impacting quality of life in women with fecal incontinence. Diseases of the Colon and Rectum.

2015;**58**:352-357

incontinence. Alimentary Pharmacology & Therapeutics. 2004;**20**(3):355-364

[31] Bharucha AE, Zinsmeister AR, Locke GR, Schleck C, McKeon K, Melton LJ. Symptoms and quality of life in community women with fecal incontinence. Clinical Gastroenterology and Hepatology. 2006;**4**(8):1004-1009

[32] Baxter NN, Rothenberger DA, Lowry AC. Measuring fecal

Rectum. 2003;**46**(12):1591-1605

Rectum. 2008;**51**(9):1434

2018;**27**(6):1613-1623

2008;**51**(1):82-87

2002;**45**(6):809-818

incontinence. Diseases of the Colon and

[33] Rockwood T. Are you worried about bowel accidents? Quality of life in fecal incontinence. Diseases of the Colon and

[34] Peterson AC, Sutherland JM, Liu G, Crump RT, Karimuddin AA. Evaluation of the fecal incontinence quality of life scale (FIQL) using item response theory reveals limitations and suggests revisions. Quality of Life Research.

[35] Cotterill N, Norton C, Avery KNL, Abrams P, Donovan JL. A patientcentered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Diseases of the Colon and Rectum.

[36] Wexner SD, Baeten C, Bailey R, Bakka A, Belin B, Belliveau P, et al. Long-term efficacy of dynamic graciloplasty for fecal incontinence. Diseases of the Colon and Rectum.

[37] Byrne CM, Pager CK, Rex J, Roberts R, Solomon MJ. Assessment of quality of life in the treatment of patients with neuropathic fecal incontinence. Diseases of the Colon and

Rectum. 2002;**45**(11):1431-1436

[38] Lee JT, Madoff RD, Rockwood TH. Quality-of-life measures in fecal incontinence: is validation valid?

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

incontinence. Alimentary Pharmacology & Therapeutics. 2004;**20**(3):355-364

*Current Topics in Faecal Incontinence*

[15] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care.

incontinent women. British Journal of Obstetrics and Gynaecology.

[23] Kwon S, Visco AG, Fitzgerald MP, Ye W, Whitehead WE. Validity and reliability of the modified manchester health questionnaire in assessing patients with fecal incontinence. Diseases of the Colon and Rectum.

[24] Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence. Evaluation of 335 patients. Diseases of the Colon &

[26] Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Diseases of the Colon and Rectum.

[27] Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems.

[28] Hussain ZI, Lim M, Stojkovic S. The test-retest reliability of fecal

[29] Rockwood TH, Church JM,

incontinence severity and quality-of-life assessment tools. Diseases of the Colon and Rectum. 2014;**57**(5):638-644

Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Diseases of the Colon and Rectum.

[30] Bharucha AE, Locke GR, Seide BM, Zinsmeister AR. A new questionnaire

1997;**104**(12):1374-1379

2005;**48**(2):323-334

1993;**36**(1):77-97

Gut. 1999;**44**(1):77-80

1999;**42**(12):1525-1532

for constipation and faecal

Rectum. 1992;**35**(5):482-487

[25] Parks AG. Royal society of medicine, section of proctology; meeting 27 November 1974. President's address. Anorectal incontinence. Proceedings of the Royal Society of Medicine. 1975;**68**(11):681-690

[16] Elsenbruch S, Harnish MJ, Orr WC. Subjective and objective sleep quality in irritable bowel syndrome. The American Journal of Gastroenterology.

[17] Vrijens D, Berghmans B, Nieman F, van Os J, van Koeveringe G, Leue C. Prevalence of anxiety and depressive symptoms and their association with pelvic floor dysfunctions–A cross sectional cohort study at a Pelvic Care Centre. Neurourology and Urodynamics. 2017;**36**(7):1816-1823

[18] Rockwood TH. Incontinence severity and QOL scales for fecal incontinence. Gastroenterology. 2004;**126**(Suppl 1):S106-S113

[19] Rockwood TH, Church JM,

[20] Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmülling C, Neugebauer E, et al. Gastrointestinal quality of life index: development, validation and application of a new instrument. The British Journal

of Surgery. 1995;**82**(2):216-222

[21] Bugg G, Kiff E, Hosker G. A new condition-specific health-related quality of life questionnaire for the assessment of women with anal incontinence. British Journal of Obstetrics and Gynaecology;**108**:1057-1067

[22] Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary

Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Fecal incontinence quality of life scale: Quality of life instrument for patients with fecal incontinence. Diseases of the Colon & Rectum. 2000;**43**(1):9-16; discussion

1992;**30**(6):473-483

1999;**94**(9):2447-2452

**46**

16-7

[31] Bharucha AE, Zinsmeister AR, Locke GR, Schleck C, McKeon K, Melton LJ. Symptoms and quality of life in community women with fecal incontinence. Clinical Gastroenterology and Hepatology. 2006;**4**(8):1004-1009

[32] Baxter NN, Rothenberger DA, Lowry AC. Measuring fecal incontinence. Diseases of the Colon and Rectum. 2003;**46**(12):1591-1605

[33] Rockwood T. Are you worried about bowel accidents? Quality of life in fecal incontinence. Diseases of the Colon and Rectum. 2008;**51**(9):1434

[34] Peterson AC, Sutherland JM, Liu G, Crump RT, Karimuddin AA. Evaluation of the fecal incontinence quality of life scale (FIQL) using item response theory reveals limitations and suggests revisions. Quality of Life Research. 2018;**27**(6):1613-1623

[35] Cotterill N, Norton C, Avery KNL, Abrams P, Donovan JL. A patientcentered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Diseases of the Colon and Rectum. 2008;**51**(1):82-87

[36] Wexner SD, Baeten C, Bailey R, Bakka A, Belin B, Belliveau P, et al. Long-term efficacy of dynamic graciloplasty for fecal incontinence. Diseases of the Colon and Rectum. 2002;**45**(6):809-818

[37] Byrne CM, Pager CK, Rex J, Roberts R, Solomon MJ. Assessment of quality of life in the treatment of patients with neuropathic fecal incontinence. Diseases of the Colon and Rectum. 2002;**45**(11):1431-1436

[38] Lee JT, Madoff RD, Rockwood TH. Quality-of-life measures in fecal incontinence: is validation valid?

Diseases of the Colon and Rectum. 2015;**58**:352-357

[39] O'Keefe EA, Talley NJ, Zinsmeister AR, Jacobsen SJ. Bowel disorders impair functional status and quality of life in the elderly: A population-based study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 1995;**50A**(4):M184-M189

[40] Edwards NI, Jones D. The prevalence of faecal incontinence in older people living at home. Age and Ageing. 2001;**30**(6):503-507

[41] Perry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H, et al. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut. 2002;**50**(4):480-484

[42] Bordeianou L, Rockwood T, Baxter N, Lowry A, Mellgren A, Parker S. Does incontinence severity correlate with quality of life? Prospective analysis of 502 consecutive patients. Colorectal Disease. 2008;**10**(3):273-279

[43] Boreham MK, Richter HE, Kenton KS, Nager CW, Gregory WT, Aronson MP, et al. Anal incontinence in women presenting for gynecologic care: Prevalence, risk factors, and impact upon quality of life. American Journal of Obstetrics and Gynecology. 2005;**192**(5):1637-1642

[44] Bartlett L. Impact of fecal incontinence on quality of life. World Journal of Gastroenterology. 2009;**15**(26):3276-3282

[45] Markland AD, Greer WJ, Vogt A, Redden DT, Goode PS, Burgio KL, et al. Factors impacting quality of life in women with fecal incontinence. Diseases of the Colon and Rectum. 2010;**53**(8):1148-1154

[46] Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. The American Journal of Gastroenterology. 1996;**91**(1):33-36

[47] Leigh RJ, Turnberg LA. Faecal incontinence: the unvoiced symptom. Lancet. 1982;**1**(8285):1349-1351

[48] Aitola P, Lehto K, Fonsell R, Huhtala H. Prevalence of faecal incontinence in adults aged 30 years or more in general population. Colorect Disease. 2010;**12**(7):687-691

[49] Dunivan GC, Heymen S, Palsson OS, Korff M, Turner MJ, Melville JL, et al. Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization. American Journal of Obstetrics and Gynecology. 2010;**202**(5):493.e1-493.e6

[50] Bartlett L, Nowak M, Ho YH. Reasons for non-disclosure of faecal incontinence: a comparison between two survey methods. Techniques in Coloproctology. 2007;**11**(3):251-257

[51] Alsheik EH, Coyne T, Hawes SK, et al. Fecal incontinence: prevalence, severity, and quality of life data from an outpatient gastroenterology practice. Gastroenterology Research and Practice. 2012;**2012**:947694

[52] Cohan JN, Chou AB, Varma MG. Fecal incontinence in men referred for specialty care: a cross-sectional study. Colorectal Disease. 2015;**17**:802-809

[53] Christoforidis D, Bordeianou L, Rockwood TH, Lowry AC, Parker S, Mellgren AF. Fecal incontinence in men. Colorectal Disease. 2011;**13**:906-913

[54] Smith TM, Menees SB, Xu X, Saad RJ, Chey WD, Fenner DE. Factors associated with quality of life among women with fecal incontinence. International Urogynecology Journal. 2012;**24**(3):493-499

[55] Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;**16**(9):606-613

[56] Crowell MD, Schettler VA, Lacy BE, Lunsford TN, Harris LA, DiBaise JK, et al. Impact of anal incontinence on psychosocial function and healthrelated quality of life. Digestive Diseases and Sciences. 2007;**52**(7):1627-1631

[57] Imhoff LR, Brown JS, Creasman JM, Subak LL, Van Den Eeden SK, Thom DH, et al. Fecal incontinence decreases sexual quality of life, but does not prevent sexual activity in women. Diseases of the Colon and Rectum. 2012;**55**(10):1059-1065

[58] Glasgow SC, Lowry AC. Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review. Diseases of the Colon and Rectum. 2012;**55**(4):482-490

[59] Matzel KE, Kamm MA, Stösser M, Baeten CGMI, Christiansen J, Madoff R, et al. Sacral spinal nerve stimulation for faecal incontinence: multicentre study. Lancet. 2004;**363**(9417):1270-1276

[60] Uludağ O, Melenhorst J, Koch SM, Gemert WG, Dejong CHC, Baeten CG. Sacral neuromodulation: Long-term outcome and quality of life in patients with faecal incontinence. Colorect Disease. 2011;**13**(10):1162-1166

[61] Ripetti V, Caputo D, Ausania F, Esposito E, Bruni R, Arullani A. Sacral nerve neuromodulation improves physical, psychological and social quality of life in patients with fecal incontinence. Techniques in Coloproctology. 2002;**6**(3):147-152

[62] Uludağ O, Koch SMP, van Gemert WG, Dejong CHC, Baeten CGMI. Sacral neuromodulation: Long-term outcome and quality of life in patients with faecal

**49**

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

incontinence. Colorectal Disease.

[63] Leroi A-M, Parc Y, Lehur P-A, Mion F, Barth X, Rullier E, et al. Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study. Annals of Surgery.

[64] Devroede G, Giese C, Wexner SD, Mellgren A, Coller JA, Madoff RD, et al. Quality of life is markedly improved in patients with fecal incontinence after sacral nerve stimulation. Female Pelvic Medicine & Reconstructive Surgery.

[65] Duelund-Jakobsen J, van Wunnik B, Buntzen S, Lundby L, Laurberg S, Baeten C. Baseline factors predictive of patient satisfaction with sacral neuromodulation for idiopathic fecal incontinence. International Journal of Colorectal Disease. 2014;**29**(7):793-798

2011;**13**(10):1162-1166

2005;**242**(5):662-669

2012;**18**(2):103-112

*Quality of Life Considerations on Fecal Incontinence DOI: http://dx.doi.org/10.5772/intechopen.90101*

incontinence. Colorectal Disease. 2011;**13**(10):1162-1166

*Current Topics in Faecal Incontinence*

Epidemiology of fecal incontinence: the silent affliction. The American Journal of Gastroenterology. 1996;**91**(1):33-36

[55] Kroenke K, Spitzer RL, Williams JB.

[56] Crowell MD, Schettler VA, Lacy BE, Lunsford TN, Harris LA, DiBaise JK, et al. Impact of anal incontinence on psychosocial function and healthrelated quality of life. Digestive Diseases and Sciences. 2007;**52**(7):1627-1631

The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.

2001;**16**(9):606-613

[57] Imhoff LR, Brown JS,

2012;**55**(4):482-490

Creasman JM, Subak LL, Van Den Eeden SK, Thom DH, et al. Fecal incontinence decreases sexual quality of life, but does not prevent sexual activity in women. Diseases of the Colon and Rectum. 2012;**55**(10):1059-1065

[58] Glasgow SC, Lowry AC. Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review. Diseases of the Colon and Rectum.

[59] Matzel KE, Kamm MA, Stösser M, Baeten CGMI, Christiansen J, Madoff R, et al. Sacral spinal nerve stimulation for faecal incontinence: multicentre study. Lancet. 2004;**363**(9417):1270-1276

Koch SM, Gemert WG, Dejong CHC, Baeten CG. Sacral neuromodulation: Long-term outcome and quality of life in patients with faecal incontinence. Colorect Disease. 2011;**13**(10):1162-1166

[61] Ripetti V, Caputo D, Ausania F, Esposito E, Bruni R, Arullani A. Sacral nerve neuromodulation improves physical, psychological and social quality of life in patients with fecal incontinence. Techniques in Coloproctology. 2002;**6**(3):147-152

[62] Uludağ O, Koch SMP, van Gemert WG, Dejong CHC,

Long-term outcome and quality of life in patients with faecal

Baeten CGMI. Sacral neuromodulation:

[60] Uludağ O, Melenhorst J,

[47] Leigh RJ, Turnberg LA. Faecal incontinence: the unvoiced symptom. Lancet. 1982;**1**(8285):1349-1351

[48] Aitola P, Lehto K, Fonsell R, Huhtala H. Prevalence of faecal incontinence in adults aged 30 years or more in general population. Colorect

Disease. 2010;**12**(7):687-691

[49] Dunivan GC, Heymen S, Palsson OS, Korff M, Turner MJ, Melville JL, et al. Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization. American Journal of Obstetrics and Gynecology.

2010;**202**(5):493.e1-493.e6

2012;**2012**:947694

[50] Bartlett L, Nowak M, Ho YH. Reasons for non-disclosure of faecal incontinence: a comparison between two survey methods. Techniques in Coloproctology. 2007;**11**(3):251-257

[51] Alsheik EH, Coyne T, Hawes SK, et al. Fecal incontinence: prevalence, severity, and quality of life data from an outpatient gastroenterology practice. Gastroenterology Research and Practice.

[52] Cohan JN, Chou AB, Varma MG. Fecal incontinence in men referred for specialty care: a cross-sectional study. Colorectal Disease. 2015;**17**:802-809

[53] Christoforidis D, Bordeianou L, Rockwood TH, Lowry AC, Parker S, Mellgren AF. Fecal incontinence in men. Colorectal Disease. 2011;**13**:906-913

[54] Smith TM, Menees SB, Xu X, Saad RJ, Chey WD, Fenner DE. Factors associated with quality of life among women with fecal incontinence. International Urogynecology Journal.

2012;**24**(3):493-499

[46] Johanson JF, Lafferty J.

**48**

[63] Leroi A-M, Parc Y, Lehur P-A, Mion F, Barth X, Rullier E, et al. Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study. Annals of Surgery. 2005;**242**(5):662-669

[64] Devroede G, Giese C, Wexner SD, Mellgren A, Coller JA, Madoff RD, et al. Quality of life is markedly improved in patients with fecal incontinence after sacral nerve stimulation. Female Pelvic Medicine & Reconstructive Surgery. 2012;**18**(2):103-112

[65] Duelund-Jakobsen J, van Wunnik B, Buntzen S, Lundby L, Laurberg S, Baeten C. Baseline factors predictive of patient satisfaction with sacral neuromodulation for idiopathic fecal incontinence. International Journal of Colorectal Disease. 2014;**29**(7):793-798

**51**

Section 3

Faecal Incontinence and

Disorders of Evacuation

## Section 3
