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Fecal Incontinence in Men: Coexistent Constipation and Impact of Rectal Hyposensitivity

Burgell, Rebecca E. F.R.A.C.P.; Bhan, Chetan M.R.C.S.; Lunniss, Peter J. F.R.C.S.; Scott, S. Mark Ph.D.

Diseases of the Colon & Rectum: January 2012 - Volume 55 - Issue 1 - p 18–25
doi: 10.1097/DCR.0b013e318237f37d
Original Contributions

BACKGROUND: The pathophysiology of fecal incontinence in men is poorly established.

OBJECTIVE: The aim of this study was to assess the coexistence of constipation and determine the impact of rectal sensorimotor dysfunction in males with fecal incontinence.

SETTING: This study was conducted at a tertiary referral center.

PATIENTS: Included were adult male patients referred for the investigation of fecal incontinence over a 5-year period who underwent full anorectal physiology testing and completed a standardized symptom questionnaire.

INTERVENTION: Standardized symptom questionnaires were fully completed, and anorectal physiologic test results (including evacuation proctography) were evaluated.

MAIN OUTCOME MEASURES: The primary outcomes measured were the frequency of symptoms of associated constipation, the association of blunted rectal sensation (rectal hyposensitivity) with symptoms, and other physiologic measures.

RESULTS: One hundred sixty patients met the inclusion criteria, and 47% of these patients described concurrent constipation. Fifty-four patients (34%) had sphincter dysfunction on manometry, only 19 of whom had structural abnormalities on ultrasound. Overall, 28 patients (18%) had rectal sensory dysfunction, 26 (93%) of whom had rectal hyposensitivity. Patients with rectal hyposensitivity were more likely to subjectively report constipation (77%) in comparison with patients with normal rectal sensation (44%; p = 0.001), allied with decreased bowel frequency (19% vs 2%; p = 0.003) and a sense of difficulty evacuating stool (27% vs 8%; p = 0.008). Cleveland Clinic constipation scores were higher in patients with rectal hyposensitivity (median score, 13 (interquartile range: 8–17) vs normosensate, 9 (5–13); p = 0.004). On proctography, a higher proportion of patients with rectal hyposensitivity had protracted defecation (>180 s; 35% vs 10%; p = 0.024) and incomplete rectal evacuation (<55% of barium neostool expelled, 50% vs 20%; p = 0.02).

LIMITATIONS: This study was limited by the retrospective analysis of prospectively collected data.

CONCLUSIONS: Only one-third of incontinent men had sphincteric dysfunction. Other pathophysiologies must therefore be considered. Nearly half of patients reported concurrent constipation, and one-sixth had rectal hyposensitivity, which was associated with higher frequencies of both symptomatic and objective measures of rectal evacuatory dysfunction. In the majority of adult males, fecal incontinence may represent a secondary phenomenon.

Academic Surgical Unit (GI Physiology Unit), Queen Mary, University of London, Barts and the London School of Medicine and Dentistry, London, United Kingdom

Financial Disclosures: None reported.

Presented at The Joint International Meeting, Neurogastroenterology and Motility, Chicago, IL, August 27 to 30, 2009; at Digestive Disease Week, New Orleans, LA, May 1 to 5, 2010; published in abstract form in Neurogastroenterology & Motility 2009;21(suppl 1):33, and in Gastroenterology 2010;138:S542.

Correspondence: S. Mark Scott, Ph.D., Academic Surgical Unit (GI Physiology Unit), 3rd Floor Alexandra Wing, The Royal London Hospital, Whitechapel, London E1 1BB, UK. E-mail:

© The ASCRS 2012