Male faecal incontinence presents as two separate entities with implications for management

Comparison of etiological and physiological characteristics of fecal incontinence in men and women

Fecal incontinence (FI) is often underreported and underestimated in men. Our aims were to clarify the causes and the physiological characteristics of FI in men and to underline the differences between etiological and physiological factors in men and women diagnosed with FI. The study cohort encompassed 200 men and 200 women who underwent anatomical and physiological evaluation for FI in a tertiary referral center specializing in pelvic floor disorders. All patients underwent endoanal ultrasound and anorectal manometry. Evacuation proctography was performed in some patients. Demographic, medical, anatomical, and physiological parameters were compared between the two study groups. Urge incontinence was the most frequent type of FI in both genders. In men, anal fistula, history of anal surgeries, rectal tumors, and pelvic radiotherapy were common etiologic factors, whereas history of pelvic surgeries was more common in women. Associated urinary incontinence was reported more frequently by women. External anal sphincter defects, usually anterior, were more common in women (M: 1.5%, F: 24%, P < 0.0001), whereas internal anal sphincter defect prevalence was similar in men and women (M: 6%, F: 12%, P = 0.19). Decreased resting and squeeze pressures were less common in men (M: 29%, F: 46%, P < 0.0001: M: 44%, F: 66%, P < 0.0001). The incidence of rectal hyposensitivity was higher in men (M: 11.1%, F: 2.8%, P < 0.0001), whereas rectal hypersensitivity was higher in women (M: 5.8%, F: 10.8%, P < 0.0001). Anorectal dyssynergia was more common in men (M: 66%, F: 37%, P < 0.0001). Significantly different etiological factors and physiological characteristics for FI were found in men. Acknowledging these differences is significant and may yield better treatment options.NEW & NOTEWORTHY Fecal incontinence (FI) in men has different etiological factors when compared with women. The prevalence of internal anal sphincter defect among men with FI was similar to women. Different manometric measurements were found among men with FI: decreased anal pressures were less common among men, whereas rectal hyposensitivity and anorectal dyssynergia were more common among men.

Is Sacral Nerve Modulation a Good Option for Fecal Incontinence in Men?

OBJECTIVE

The objective was to assess the efficacy and the safety of sacral nerve modulation (SNM) in men with fecal incontinence (FI) compared with those of SNM in women.

METHOD

Prospectively collected data from patients from seven tertiary colorectal units who underwent an implant procedure between January 2010 and December 2015 were reviewed retrospectively. Outcomes and surgical revision and definitive explantation rates were compared between men and women.

RESULTS

A total of 469 patients (60 men [12.8%]; mean age = 61.4 ± 12.0 years) were included in the study, 352 (78.1%) (31 men [8.8%]) of whom received a permanent implant. The ratio of implanted/tested men was significantly lower than the ratio of implanted/tested women (p = 0.0004). After a mean follow-up of 3.4 ± 1.9 years, the cumulative successful treatment rates tended to be less favorable in men than in women (p = 0.0514): 88.6% (75.6-95.1), 75.9% (60.9-86.4), 63.9% (48.0-77.3), and 43.9% (26.7-62.7) at one, two, three, and five years, respectively, in men; 92.0% (89.1-94.2), 84.2% (80.3-87.4), 76.8% (72.3-80.7), and 63.6% (57.5-69.3) at one, two, three, and five years, respectively, in women. The revision rate for infection and the definitive explantation rate for infection were higher in men than in women (p = 0.0001 and p = 0.0024, respectively).

CONCLUSION

Both short- and long-term success rates of SNM for FI were lower in men than in women. The revision and definitive explantation for long-term infection rates were significantly higher in men.

Use of Anal Acoustic Reflectometry in the Evaluation of Men With Passive Fecal Leakage

BACKGROUND

Men with passive fecal leakage represent a distinct clinical entity in which the pathophysiology remains unclear. Standard anorectal investigations fail to demonstrate consistent abnormalities in this group. Anal acoustic reflectometry is a new test of anal sphincter function with greater sensitivity and discriminatory ability than conventional anal manometry.

OBJECTIVE

The aim of this study was to determine whether men with fecal leakage have an abnormality in anal sphincter function that is detectable by anal acoustic reflectometry.

DESIGN

This was an age-matched study of continent and incontinent men.

SETTINGS

The study was conducted at a university teaching hospital.

PATIENTS

Male patients with isolated symptoms of fecal leakage were recruited. Anal acoustic reflectometry, followed by conventional anal manometry, was performed. Results were then compared with those from an age-matched group of men with no symptoms of anal incontinence or anorectal pathology.

MAIN OUTCOME MEASURES

Variables measured with anal acoustic reflectometry and anal manometry in the incontinent and continent men were compared.

RESULTS

Thirty subjects were recruited, of whom 15 were men with fecal leakage and 15 were continent men. There was a significantly higher incidence of previous anorectal surgery in the men with leakage. The anal acoustic reflectometry variables of opening and closing pressure were significantly lower in leakers compared with continent subjects (p = 0.003 and p = 0.001). Hysteresis was significantly greater in the male leaker group (p = 0.026). No difference was seen in anal manometry.

LIMITATIONS

With a larger sample size, the effect of previous anorectal surgery and the presence of an anal sphincter defect could be clarified.

CONCLUSIONS

Anal acoustic reflectometry is a sensitive test of anal sphincter function and, unlike anal manometry, can discriminate male leakers from continent subjects. An identifiable abnormality has been detected using anal acoustic reflectometry, which may further our understanding of the pathogenesis in this group.

Novel insights into fecal incontinence in men

Fecal incontinence (FI) in men is common, yet data on sex differences in clinical features, physiology, and treatment are scarce. Our aim was to provide insights into FI in males compared with females. Prospectively collected data from 73 men and 596 women with FI in a tertiary referral center were analyzed. Anorectal physiology, clinical characteristics, and outcome of instrumented biofeedback (BF) were recorded. Thirty-one men with FI proceeded to BF and were matched with 62 age-matched women with FI who underwent BF. Men with FI had higher resting, squeeze, and cough anal sphincter pressures (P < 0.001) and were more able to hold a sustained squeeze compared with women (P = 0.04). Men with FI had higher rectal pressure and less inadequate rectal pressure on strain and higher sensory thresholds (P < 0.05). Men, but not women, with isolated soiling had higher anal resting and squeeze pressures compared with those with overt FI (P < 0.05). Men were less likely to undergo BF when offered compared with women. Baseline symptom severity did not differ between the groups. In men, the absence of an organic cause for the FI and the presence of overt FI, but not isolated soiling, were correlated with improvement in patient satisfaction following BF. The outcomes of 50% reduction in FI episodes, physician assessment, symptoms, and quality of life scores after BF all significantly improved in men similarly to women. We conclude that men, compared with women, with FI have unique clinical features and physiology and are less likely to have investigations and treatment despite successful outcome with BF. Future studies to customize treatment in males and determine barriers to therapy are warranted.

NEW & NOTEWORTHY

Fecal incontinence in men is common, yet data on sex differences in clinical features, physiology, and treatment are scarce. We provide evidence that men, compared with women, with fecal incontinence have unique clinical features and physiology and are less likely to have investigations and treatment despite successful outcome with anorectal biofeedback therapy.

Pathophysiology of fecal incontinence differs between men and women: a case-matched study in 200 patients

BACKGROUND

Fecal incontinence (FI) is a common and socially disabling condition with obstetric trauma considered the principal etiological factor. This study aimed to systematically evaluate symptom presentation and anorectal function in both females and males with FI.

METHODS

One hundred males (M) and 100 age-matched females (F) with FI presenting between 2012 and 2014 were identified from a prospectively collected database. Comparison of clinical (history, symptom profile, and severity using validated questionnaires) and anorectal physiological (manometry, rectal sensory testing, endoanal ultrasonography, and evacuation proctography) data between M and F was performed.

KEY RESULTS

Incidence of prior anal surgery (M: 28% vs F: 18%, p = 0.13) and abdominal surgery (M: 25% vs F: 26%, p = 0.90) was similar between sexes, but females had a higher incidence of previous pelvic surgery (M: 4% vs F: 47%, p < 0.001). Eighty-five females were parous and 75% reported history of traumatic vaginal delivery. There was a trend toward higher St Mark's incontinence scores in females (mean ± SD; M: 13 ± 4 vs F: 14 ± 5, p = 0.06). In men, structural sphincter abnormalities were uncommon (M: 37% vs F: 77%, p < 0.001), while impaired rectal sensation (M: 24% vs F: 7%, p = 0.001) and functional disturbances of evacuation (M: 36% vs F: 13%, p = 0.001) were more common than in women. No abnormality on all tests performed was observed in twice as many males (M: 18% vs F: 9%, p = 0.10).

CONCLUSIONS & INFERENCES

Pathophysiological mechanisms of FI differ between sexes. Anal sphincter dysfunction was an uncommon finding in males, with impaired rectal sensation and functional disturbances of evacuation much more prominent than in the female cohort. These findings are likely to impact options for symptom management.

Quality of Life Differences in Female and Male Patients with Fecal Incontinence

Background/Aims

To explore and compare quality of life (QoL) differences in female and male patients with fecal incontinence.

Methods

Ninety-one patients with fecal incontinence (60 women, mean (SD) age 64.13 (9.72) years; 31 men, mean (SD) age 63.61 (13.33) years) were assessed for pathophysiology (anorectal manometry and ultrasound), clinical severity (Wexner and Vaizey scales), QoL (Fecal Incontinence Quality of Life Score [FIQL]) and health status (EQ-5D).

Results

External and internal anal sphincter impairment rates were 96.5% and 70.2%, respectively, in women, compared to 30% and 43.3% respectively in men (P < 0.05). Clinical severity was similar in both sexes, with mean (SD) Wexner scores of 10.95 (4.35) for women and 9.81 (4.30) for men, and mean (SD) Vaizey scores of 13.27 (4.66) for women and 11.90 (5.22) for men. Scores for women were significantly lower for all FIQL depression and coping subscales (P < 0.001) and the EQ-5D depression subscale (P < 0.01). EQ-5D index was 0.687 (0.20) for women and 0.835 (0.15) for men (P < 0.001). QoL was negatively affected by female gender (−1.336), anxiety/depression (−1.324) and clinical severity (−0.302), whereas age had a positive impact (0.055 per year) (P < 0.01).

Conclusions

The pathophysiology of fecal incontinence differed between the sexes. For similar severity scores, impact on QoL was higher in women. Gender had the highest impact on QoL compared to other factors. QoL measurements should be part of assessment and treatment protocols.

Loperamide Versus Psyllium Fiber for Treatment of Fecal Incontinence: The Fecal Incontinence Prescription (Rx) Management (FIRM) Randomized Clinical Trial

BACKGROUND

Fecal incontinence is a devastating condition with few US Food and Drug Administration-approved pharmacologic treatment options. Loperamide and psyllium, both first-line treatments, have different mechanisms of action without any comparative data.

OBJECTIVE

The purpose of this study was to examine the effectiveness and tolerability of loperamide compared with psyllium for reducing fecal incontinence. We hypothesized that psyllium fiber supplementation would be more effective than loperamide for reducing fecal incontinence episodes and have fewer adverse effects.

DESIGN

We conducted a randomized, double-blind, placebo-controlled crossover trial comparing loperamide (followed by psyllium) with psyllium (followed by loperamide).

SETTINGS

Our sites included outpatient clinics within a Veterans Affairs medical center and university affiliate.

PATIENTS

Participants included community-dwelling adults (n = 80) with at least 1 fecal incontinent episode on a 7-day bowel diary.

INTERVENTION

Participants received either daily loperamide (plus placebo psyllium powder) or psyllium powder (plus loperamide placebo) for 4 weeks. After a 2-week washout, participants crossed over to 4 weeks of alternate treatment.

MAIN OUTCOME MEASURES

The primary outcome was the number of fecal incontinence episodes from 7-day bowel diaries. Secondary outcomes included symptom severity, quality of life, and tolerability.

RESULTS

Mean age was 60.7 ± 10.1 years; 68% were men. After determining nonsignificant carryover effects, combined analyses showed no differences between the loperamide and psyllium groups for reducing fecal incontinent episodes, symptom severity, or quality of life. Within each group, both loperamide and psyllium reduced fecal incontinent episodes and improved symptom severity and quality of life. Constipation occurred in 29% of participants for loperamide vs 10% for psyllium.

LIMITATIONS

Limitations include the washout period length and dropout rate after crossing over to the second intervention.

CONCLUSIONS

Both loperamide and psyllium improve fecal incontinence. Loperamide was associated with more adverse effects, especially constipation.

Faecal incontinence in men referred for specialty care: a cross-sectional study

AIM

Little is known about men with faecal incontinence. We compared clinical findings and quality of life in a large cohort of men and women with faecal incontinence to guide its evaluation and treatment in men.

METHOD

We analysed men and women presenting to a tertiary referral centre with faecal incontinence between 2005 and 2013. Demographics, physical examination, anorectal physiology testing, symptom severity (Fecal Incontinence Severity Index) and quality of life (Fecal Incontinence Quality of Life Scale) were recorded. We determined differences between men and women and analysed the association between gender and quality of life.

RESULTS

Data were obtained from 144 men and 897 women. Men with faecal incontinence were slightly younger than women (55.3 vs 57.6 years, P = 0.001), more likely to report coexisting constipation (P = 0.004) and more likely to have normal internal and external sphincter function on physical examination (both P < 0.001). Anorectal physiology testing revealed fewer sphincter defects (P < 0.05) and less pudendal neuropathy (P < 0.05) in men compared with women. Although symptom severity and overall quality of life were similar, men had improved coping and less embarrassment compared with women after we adjusted for important clinical factors.

CONCLUSION

Men with faecal incontinence presenting to a tertiary referral centre are more likely than women to have a mixed presentation characterized by constipation and less sphincter dysfunction. They exhibited better coping and less embarrassment than women. These findings should be taken into consideration when evaluating and treating men with faecal incontinence.

Fecal incontinence in men: Causes and clinical and manometric features

AIM: To determine the causes and characteristics of fecal incontinence in men and to compare these features with those presented by a group of women with the same problem.

METHODS: We analyzed the medical history, clinical and manometric data from 119 men with fecal incontinence studied in our unit and compared these data with those obtained from 645 women studied for the same problem. Response to treatment was evaluated after 6 mo of follow-up.

RESULTS: Fifteen percent of patients studied in our unit for fecal incontinence were male. Men took longer than women before asking for medical help. Ano-rectal surgery was the most common risk factor for men related to fecal incontinence. Chronic diarrhea was present in more than 40% of patients in both groups. Decreased resting and external anal sphincter pressures were more frequent in women. No significant differences existed between the sexes regarding rectal sensitivity and recto-anal inhibitory reflex. In 17.8% of men, all presenting soiling, manometric findings did not justify fecal incontinence. Response to treatment was good in both groups, as 80.4% of patients improved and fecal incontinence disappeared in 13.2% of them.

CONCLUSION: In our series, it was common that men waited longer in seeking medical help for fecal incontinence. Ano-rectal surgery was the major cause of this problem. Chronic diarrhea was a predisposing factor in both sexes. Manometric differences between groups were limited to an increased frequency of hypotony of the external anal sphincter in women. Fecal incontinence was controllable in most patients.

Clinical parameters and symptom severity in males with fecal leakage and incontinence

BACKGROUND

Despite the commonality of fecal incontinence (FI) in men, few studies have been carried out in this patient group. The aim of the study was to determine the contributions of clinical and physiological factors to symptom severity in males with fecal leakage (FL) and FI.

METHODS

The records of all male patients referred for evaluation of FI and FL over a 6-year period were analyzed. For each male case, the records of three age-matched female controls with FI or FL were retrieved. All patients completed symptom assessment questionnaires (Vaizey score) and standard anorectal manometry testing.

KEY RESULTS

A total of 100 males and 300 age-matched female controls were included. Vaizey scores were similar between sexes. For all Vaizey strata, males had normal maximal resting pressures (MRP) as well as normal maximal squeeze pressure (MSP). Females had a significantly reduced MRP and MSP across all Vaizey strata. In the FL subgroup, males had higher MRP and MSP than females. A multivariable linear regression analysis in males did not identify any clinical factors predictive of symptoms severity. For females, increased symptom duration, abnormal Bristol score, and reduced MSP were associated with worsening in Vaizey score.

CONCLUSIONS & INFERENCES

For females, FL represents one end of the severity spectrum of FI while in males FL has a distinct pathophysiology. Contributing factors to symptoms in males with FL are not identified by routine clinical tests; however, anorectal manometry may identify a subgroup of FL males with low anal sphincter pressures that may respond to targeted interventions.