The combination of fecal and urinary incontinence is the most extreme manifestation of pelvic floor dysfunction and is associated with a negative effect on quality of life.
Both urinary and fecal incontinence have detrimental effects on patients’ general health, including sexual, social, and working life. It is also a frequent reason for referrals to nursing homes in elderly patients.
The aim of this study is to assess the prevalence of fecal incontinence in women and men diagnosed with urinary incontinence, to determine possible associated risk factors and to describe the impact of this diagnosis on patients’ quality of life based on validated questionnaires.
The results of this study may help identify modifiable risk factors that can aid in disease prevention and treatment.

We present a multicentric, population-based, cross-sectional study that prospectively analyses basal characteristics, comorbidities and scoring on fecal and urinary incontinence as well as Quality-of-Life questionnaires in patients of all age groups and genders presenting with urinary incontinence on urology consultations in an outpatient setting. 
Urinary incontinence was assessed with the International Consultation on Incontinence Questionnaire – Short Form (ICIQ-SF), considering as urinary incontinent all patients with an ICIQ-SF ≥ 1.
Fecal incontinence was measured with Wexner Score for fecal incontinence, diagnosing severe fecal incontinence with a Wexner score ≥ 9.
Impact on quality of life was evaluated with the 36-Item Short Form Survey Instrument (SF-36) and the Barthel Index for Activities of Daily Living.
An univariant and multivariant analysis was conducted to determine which variables behaved as risk factors for severe fecal incontinence in patients diagnosed with urinary incontinence.

A total of 430 patients have been included in the study to date, all of whom had urinary incontinence with an ICIQ-SF ≥ 1. The prevalence of severe fecal incontinence (Wexner ≥ 9) was 45.1% (194/430). 
Demographic and clinical variables are described in Figure #1. 
Mean age was 62.6 (SD 13.3) years, with a predominance of women (79.5%, 342/430).
In regards to medical history, patients with severe fecal incontinence presented with significantly more type 2 Diabetes mellitus (7.6% vs. 14.4%, p=0.032), grade IV rectocele (p<0.001), grade IV hysterocele (p<0.001) and grade IV apical prolapse (p<0.001).
Questionnaire results are described in Figure #2.
Patients with severe fecal incontinence had a higher score in ICIQ-SF (11.9 vs. 14.8, p<0.001), therefore being associated with more severe urinary incontinence. 
In relation to Quality-of-Life questionnaires, patients with severe fecal incontinence had a lower score on all items of SF-36 (118 vs. 106, p<0.001) and a lower global score on the Barthel Index for Activities of Daily Living (85.4 vs 79.6, p<0.001). A breakdown of the Barthel Index reveals a lower score in both Bladder Control (4.3 vs 2.9, p<0.001) and Bowel Control (8.6 vs. 5.4, p<0.001) items. 
The univariant and multivariant analysis of demographic and clinical variables presented apical prolapse as the sole statistically significant multiplying factor for severe fecal incontinence, with an univariant Odds Ratio of 4.9 (95%CI 1.3 – 18.8, p=0.019) and a multivariant Odds Ratio of 16.5 (95%CI 1.4 – 191.7, p=0.025).

The overall high prevalence of severe fecal incontinence found in this study (45.1%) contrasts with previous reports and show how underestimated this condition is nowadays. Predominance of women in the study populations is concordant with previous data, probably due to anatomical configuration and obstetric history.
As previously stated, patients with history of prolapse (grade IV rectocele, hysterocele and apical prolapse) appear to suffer with higher rates of combined incontinence. These results support the possible pathophysiology of pelvic floor dysfunction caused by aging and obstetric trauma, frequently seen in multiparous women. 
Nevertheless, the number of non-instrumental vaginal births does not look to be associated with major dual incontinence (1.4 (SD 1.2) vs. 1.5 (SD 1.5), p 0.761), nor other classical risk factors like age (61.3 (SD 14.2) vs. 64.1 (SD 12.1), p 0.066), Body Mass Index (27.6 (SD 4.5) vs. 28.1 (SD 6.9), p 0.643) or neurologic diseases (47 (19.9%) vs. 51 (26.3%), p 0.129). These results may be influenced by the fact that the sample population only includes patients with urinary incontinence assessed in Urology consultations. 
When analysing the quality of life of our patients, statistical differences have been found in patients with severe fecal incontinence, including every item of the SF-36 questionnaire (Physical role, Bodily pain, General health, Vitality, Social functioning, Emotional role, Mental health and reported health transition), revealing how critical this condition is for patients’ self-idea of health. Based on the Barthel Scale results, severe combined incontinence is also enormously disabling, given the differences shown in their global score, as seen in Figure #2 (85.4 (SD 16.7) vs. 79.6 (SD 19.0), p <0.001).

It is of paramount importance to assess fecal incontinence in patients suffering from urinary incontinence given the high prevalence of severe fecal incontinence in this population as well as its detrimental effects on the quality of life.

Continence 7S1 (2023) 100891
DOI: 10.1016/j.cont.2023.100891