Despite fecal incontinence (FI) having a major impact on quality of life, a paucity of data exists comparing characteristics of individual FI phenotypes: urge FI, passive FI and combined urge/passive FI. The primary aim of this study is to characterize symptom specific distress and quality of life among women with these FI phenotypes. The secondary aim is to characterize FI symptom specific distress and quality of life in women with a fourth phenotype, stress FI.

Women presenting to a single academic institution for the evaluation of anal incontinence symptoms from 2003-2017 were included in this retrospective study. IRB approval was obtained. All participants completed the Modified Manchester Health Questionnaire (MMHQ) which consists of the validated Manchester Health Questionnaire (MHQ) measuring symptom specific impact and the Fecal Incontinence Severity Index (FISI) measuring symptom distress. General health-related quality of life was assessed with the Short Form-12 (SF-12). Patients were included in this study if they had at least monthly FI as reported by their responses on the MMHQ. Patients were divided into 4 groups: urge FI, passive FI, combined urge/passive FI and stress FI based on responding “most of the time” or “all of the time” to the urge, passive and stress symptom specific questions of the MMHQ. The urge question asks, “Can you hold solid/liquid stool long enough to get to the bathroom.” The passive question asks, “Do you lose any solid/liquid stool when walking?” The stress question asks, “Do you lose any solid /liquid stool when coughing or sneezing?” Anorectal physiology was assessed using anorectal manometry and endoanal ultrasound. Demographic data and clinical medical history were collected.  Patient characteristics and symptoms were compared across FI subtypes using one-way ANOVA (and Kruskal-Wallis tests as appropriate) for quantitative measures and chi-squared tests (and Fisher’s exact test as appropriate) for categorical measures.  Analysis of covariance (ANCOVA) was performed to evaluate associations between patient symptoms and FI subtypes while controlling for pertinent baseline characteristics. Level of significance was assessed at 0.05.

In the total cohort of 404 subjects, the majority of patients were Caucasian (88%) with a mean age of 58 ± 12 years. Baseline demographics and medical history were similar in all 3 groups except for age (p=0.02), diabetes, presence of inflammatory bowel disease and urinary incontinence (all p<0.01). Total MMHQ scores were significantly different among the 3 main subtypes with combined urge/passive FI having the most impact and urge FI alone having the least impact (p<0.01) (Table 1). FISI scores were also significantly different among the 3 main subtypes with combined urge/passive FI having the greatest distress and urge FI having the least (p<0.01). SF-12 subscales were similar across the 3 main subtypes. No differences were observed in anorectal manometric measurements or anal sphincter integrity among the 3 groups (Table1). The differences in total MMHQ and FISI scores remained statistically significant (both p<0.01) when controlling for relevant patient characteristics in multivariable models.  FI symptom distress and condition specific impact among women with stress FI compared to urge and passive FI were then explored (Table 2). Baseline demographics and medical history were similar in all 3 groups except for smoking status and urinary incontinence (both p<0.01). No differences among the 3 groups were observed for total MMHQ scores. FISI scores were greater in the stress FI group compared to the urge FI and passive FI groups (p<0.01). No differences were observed in the SF-12 subscales. Rectal capacity was greater in the in the passive FI group followed by stress FI and urge FI (p=0.01). No differences were observed in the remaining anorectal manometric measurements or anal sphincter integrity among the 3 groups (Table 2). In multivariable analyses, there continued to be no statistically significant difference in MMHQ (p=0.31) and the observed differences in FISI were nullified (p=0.26).

Among the 3 main subtypes studied, combined urge/passive FI has a greater symptom distress and impact on quality of life than urge FI and passive FI alone.. There were no differences in anorectal manometric measurements or anal sphincter integrity among these 3 main subtypes. Symptom distress and impact for stress FI did not differ from urge or passive FI, but this may be due to the relatively small sample size in this study.

In conclusion, combined urge/passive FI has a higher symptoms distress and impact on quality of life than either urge or passive fecal incontinence alone despite similar anorectal testing results. Further research is needed to determine the significance of stress FI as a potential subtype and its response to treatment.