Quantitative and qualitative analysis of fecal incontinence
Review Article

Quantitative and qualitative analysis of fecal incontinence

Maria Abou Khalil1, Marylise Boutros2

1Division of General Surgery, McGill University, Montreal, QC, Canada; 2Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada

Contributions: (I) Conception and design: Both authors; (II) Administrative support: Both authors; (III) Provision of study materials or patients: Both authors; (IV) Collection and assembly of data: Both authors; (V) Data analysis and interpretation: Both authors; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors.

Correspondence to: Marylise Boutros, MDCM, FRCSC. Associate Professor of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, Quebec H3T 1E2, Canada. Email: marylise.boutros@mcgill.ca.

Abstract: Fecal incontinence (FI), a condition characterised by the involuntary passage of flatus or fecal matter, has significant impacts on individuals it afflicts. Despite the availability of a myriad of treatments, it remains a difficult condition to treat. Valid and reliable measures for this condition are important to evaluate its severity at baseline, assess treatment response, and compare various treatment options and innovations. Various tools have been described to assess FI, but few are widely adopted. These tools can assess the degree of incontinence, qualify and characterise it further, or assess its impact on quality of life—respectively categorized as grading scales, severity scores and impact measures. Grading scales use ordinal scales to describe various types of incontinence (for example incontinence to solid stool, liquid stool or flatus). While easy to use, they lack important details and cannot detect the subtle effects of treatments on incontinence. Summary scores address some of the limitations of grading scales by incorporating both quantifying and qualifying values to describe and grade the incontinence. While less straightforward to use than the available grading scales, they represent a more accurate reflection of the patient’s incontinence. In addition, summary scores are more likely to reflect the effects of treatment interventions. As such, they have emerged as the preferred way of measuring FI and of comparing different interventions. Impact measures aim to qualify the effect of FI on various spheres of life such as the emotional, social or physical spheres. However, they can be arduous to administer, and their use has largely been limited to research settings. This article will review and summarize the various tools available to measure FI.

Keywords: Fecal incontinence (FI); quality of life (QoL); measurement instruments

Received: 23 January 2022; Accepted: 29 April 2022; Published: 30 April 2022.

doi: 10.21037/ales-22-1

Introduction

Fecal incontinence (FI), the involuntary passage of fecal matter and/or flatus from the anus, is a debilitating problem that can be difficult to treat. Symptom severity and its effect on quality of life (QoL) may vary from one individual to another (1). Moreover, the magnitude of symptoms does not always correlate with an anatomic or physiologic abnormality. This contributes to the difficulties in standardizing tools that can be used to accurately measure FI. Qualifying the type of incontinence and quantifying its severity is important. It allows us to have a reproducible measure of the degree of incontinence, evaluate treatment response, compare outcomes for different interventions, and assess this condition’s impact on QoL. Clinical tests such as anal manometry, defecography and electromyography can sometimes better delineate the mechanism for the FI. However, given the subjective nature of this symptom, these tests are not enough to accurately and consistently reflect the degree of incontinence experienced by the patient and its subjective impact on their QoL, nor can these tests determine the outcome of an intervention for FI.

Thus, reliable and valid symptom assessment tools are needed to evaluate FI for clinical and research use. While various tools have been described to measure FI, few are widely used. This article will review the various instruments available to measure FI, categorized as grading scales, severity scores, and impact measures (2,3).

Thresholds, validity, and reliability

Prior to describing the available tools to measure and report FI, one must understand how these tools should be assessed for suitability of use in clinical and research settings. Certain measures are necessary to evaluate the accuracy of newly developed tools, how they compare to existing tools, and how they perform in various settings (4,5). Reliability refers to the ability of the assessment tool to capture the true phenomenon and not be the result of random error (4,6). As such, a reliable instrument has reproducible consistent result for the same patient in similar contexts. The test-retest reliability is the test of choice to assess instrument reliability (7). Internal consistency, whereby a tool is tested for its ability to be consistent with measuring similar facets of a variable is also an important indicator. Validity, in general, refers to whether the instrument accurately measures what it was intended to measure. Content validity, or the ability of the test to assess elements that are important for the instrument to capture, should be determined both by patients and healthcare providers. Criterion validity is the comparison of the new tool to the gold standard. As mentioned earlier, one of the important distinguishing factors for instruments are their ability to detect clinically important changes, as assessed by sensitivity or responsiveness studies (8).

In addition to these measures to assess the adequacy of a tool, establishing thresholds for each tool can be important. These thresholds identify the point at which patients may benefit from various interventions, and allows standardization of treatment indications.

Grading scales for FI

Grading scales are descriptive systems that assign an ordinal (categorical) value to different types of incontinence (3). One of the earliest and simplest grading scales for FI is a category scale described by Parks in 1975 (9). It consists of four categories ranging from normal continence (A) to incontinence to both liquid/solid stool and gas (D). Similarly, others have described grading scales that also qualify continence into broad categories that range from perfect to poor continence. Another example is the grading scale for FI described by Womack et al. categorizing incontinence into continence to solid/liquid stool and flatus (Grade A), continence to solid and liquid stool but not to flatus (Grade B), continence to solid stool but not to liquid or flatus (Grade C), and finally incontinence to solid/liquid stool and flatus (Grade D) (10). A summary of the most commonly reported grading scales is presented in Table 1 (9-17). The majority of these scales were used in original research papers to report on outcomes of specific treatments for FI and lack validation. These scales all attribute an ordinal description to the symptoms of FI, without significant details and lack important information. Some of these grading scales incorporate frequency, while others rely solely on the type of incontinence (to solid/liquid stool or flatus). As such, despite their ease of use, these tools are unable to detect subtle changes in outcomes and are thus not often used in colorectal pelvic health assessment and research.

Table 1

Summary of commonly used grading scales

Author(s) Year Grades
Parks (9) 1975 (A) Continent to stool and liquid stool and flatus; (B) continent to solid and liquid stool but not flatus; (C) continent to solid but not liquid stool or flatus; (D) incontinent to solid and liquid stool and to flatus
Rudd (11) 1979 Grade I: perfect continence; Grade II: minor defects like flatus incontinence; Grade III: still acceptable but presence of minor fecal leakage and patient must wear a pad; Grade IV: unsatisfactory with major incontinence; Grade V: totally unsatisfactory, necessitating a colostomy
Keighley and Fielding (12) 1983 Minor incontinence usually to diarrhea (no more than once a month); moderate incontinence to solid stool at least once a week; severe incontinence on most days
Corman (13) 1985 Excellent: continence all the time with no pad use; good: totally continent, may require suppositories/enemas or dilation, no pad use; fair: continent to solid stool but not liquid stool, may wear a pad and have difficulty regulating bowel action; poor: incontinent to formed stool, obstructed or required colostomy
Hiltunen et al. (14) 1986 Totally continent; partially incontinent: incontinence to liquid stools, daily mucous discharge, fecal soiling, inability to control flatus, urgency or both; totally incontinent: gross fecal incontinence
Broden et al. (15) 1988 1: None, no episodes of incontinence; 2: medium, episodes of incontinence to solid stool, incontinence to gas, incontinence to liquid stool only or soiling; 3: severe, incontinence to solid stool at all times
Womack et al. (10) 1988 Grade A: continence to solid/liquid stool and flatus; Grade B: continence to solid and liquid stool but not to flatus; Grade C: continence to solid stool but not to liquid or flatus; Grade D: incontinence to solid/liquid stool and flatus
Rainey et al. (16) 1990 Continence to solid ± flatus to incontinent to all
Williams et al. (17) 1991 1: Continent to solids, liquids and flatus; 2: continent to solid and liquid stool but not flatus; 3: continent to solids but occasional liquid incontinence; 4: occasional episodes of incontinence of solids and frequent episodes of incontinence to liquids; 5: frequent episodes of incontinence of solids and liquids

Summary scores for FI

Summary scores address some of the limitations of grading scales by including the type of incontinence and incorporating qualifying values like frequency of the incontinent episodes. A variety of summary scores exist, and they each differ by the use of diverse categories [summarized in Table 2 (8,18-20,23)].These questionnaires can be weighted whereby each category of the assessment tool is assigned a weight (2). The weights assigned to each category can be patient-assigned or pre-determined by the authors (4). When different weights are assigned in the summary scores, an assumption is made on the bigger/smaller importance of that category compared to another. Given the significant subjective component of FI, questionnaires that incorporate patient perspective may be more reflective of the condition. However, the increased subjectivity that patient-driven weights adds may make comparison and evaluation of treatment effects difficult across populations seeking treatment. Another way to include patient’s experience of the symptoms without weighting is to include impact or bother measures like the use of pads or medication within the score. With the inclusion of these impact measures, some scoring systems share similarities with QoL questionnaires, and the separation between the two types of tools is blurred.

Table 2

Summary of commonly used severity scores

Severity score Pescatori Incontinence score Wexner/CCFIS FISI Vaizey/SMIS RAFIS
Reference Pescatori et al., 1992 (18) Jorge and Wexner, 1993 (19) Rockwood et al., 1999 (20) Vaizey et al., 1999 (21) de la Portilla, 2021 (22)
Validity Yes Yes Yes Yes Yes
Reliability Yes Yes Yes Yes Yes
Items 3 items (degree of incontinence): A: incontinence to flatus/mucous; B: incontinence to liquid stool; C: incontinence to solid stool 5 items: incontinence to solid stool; incontinence to liquid stool; flatus incontinence; wears pad; lifestyle alteration 4 items: flatus incontinence; mucous incontinence; liquid incontinence; solid stool incontinence 7 items: incontinence to solid stool; incontinence to liquid stool; incontinence to flatus; alteration of lifestyle (yes/no); needs to wear a pad/plug; takes constipating medicines; inability to defer defecation for 15 min 3 items: severity (S); type of incontinence (T); perception (P)
Frequency category scores 1: less than once a week; 2: at least once a week; 3: every day 0: never; 1: rarely (<1/month); 2: sometimes (more than 1/week, not more than 1/month); 3: usually (more than 1/day, not more than 1/week); 4: always (at least 1/day) At least 2 times a day; once a day; at least 2 times a week; once a week; up to 3 times a month; never; separate severity weighting systems developed for patients and surgeons 0: never (no episodes in the past 4 weeks); 1: rarely (1 episode in the past 4 weeks); 2: sometimes (>1 episode in the past 4 weeks but <1 a day); 3: weekly (1 or more episodes/week but <1 a day); 4: daily (1 or more episodes a day); Pad/plug use: no [0]; yes [2]; constipating agents: no [0]; yes [2]; urgency: no [0]; yes [2] Severity: 5: at least 1 episode of incontinence daily ± without toilet proximity → always incontinent episodes; 4: several incontinent episodes each week, but not daily; 3: several leaks per month, but some weeks without incontinence; 2: occasional incontinence episodes; 1: rarely have incontinence; 0: no incontinence
Type (T): 3: would have leaks of solid/liquid stool if toilet not close; 2: incontinence of solid or liquid stool (no spotting of the underwear); 1: staining of underwear; 0: no incontinence
Perception (P): 3: patient feels terrible incontinence; 2: patient feels bad for incontinence; 1: does not feel well because of incontinence; 0: feels good despite incontinence
Weighted Yes No Yes Yes Yes
Scoring Score = FI degree (A = 1, B = 2 or C = 3) + FI frequency Score = sum of each item’s frequency score Patient-derived score = sum of each item × patient-derived weight for the item Score = sum of each item’s frequency score Score = sum of severity score+ type score + perception score
Range: 0 (perfect continence) → 6 (worst continence) Range: 0 (perfect continence) → 20 (worst continence) Range 0 (perfect continence) to 61 (worst continence) Range 0 (perfect continence) → 24 (worst continence) Range: 0 (perfect continence) → 11 (worst continence)
Surgeon derived score = sum of each item × surgeon-derived weight for the item
Range 0 (least severe) → 58 (most severe)

CCFIS, Cleveland Clinic Florida Incontinence Score; FISI, Fecal Incontinence Severity Index; SMIS, St.Mark’s Incontinence Score; RAFIS, Rapid Assessment Fecal Incontinence Score; FI, fecal incontinence.

While the increased items and increasing categories make summary scores less straightforward to use than the available grading scales, they represent a more accurate reflection of the patient’s incontinence, and are more likely to reflect the effects of treatment interventions on incontinence. For these reasons, they have emerged as the preferred way of measuring FI and comparing different treatment interventions.

Scores that are the most widely used include the Wexner/Cleveland Clinic Florida Incontinence Score (CCFIS), the Vaizey/St.Mark’s score and the FI Severity Index (FISI). The Wexner/CCFIS is the most-cited and most-translated FI score, and consists of a five item score, with each item graded on a scale from 0 to 4, with a total score of 20 (19). This score is validated and has been widely adopted because of its ease of use and reproducibility. The Wexner score can be utilized in clinical practice and for research purposes by patients throughout their treatment journey in order to assess the response to various interventions at different timepoints. The Vaizey/St. Mark’s Fecal Incontinence Score (FIS) is very similar to the Wexner score but also includes anti-diarrheal medication use and fecal urgency (21). The FISI was developed with input from colorectal surgeons and patients as an initiative from the American Society of Colon and Rectal Surgeons (24). It is a score that qualifies the type of incontinence, the quantity of incontinence with regards to number of episodes and generates a summary score in combination. Symptom severity is highly correlated with FISI scores, and correlates well with Fecal Incontinence Quality of Life (FIQL) scales (24).

Another available scoring system is the American Medical Systems score (AMS score) which was initially developed to assess outcomes of the artificial bowel sphincter (25). It comprises more than 30 questions and needs a retrospective evaluation of the 4 weeks preceding the assessment. Given its complexity and the lack of evidence of superiority to the commonly used scoring systems, its use has been largely limited to industry-sponsored research.

The Rapid Assessment Fecal Incontinence Score (RAFIS) was first published in 2015 and recently updated and validated (8,22). Compared to other tools, it allows for the inclusion of some bother indicators such as the importance of being close to a toilet , and the severity of the incontinence by reporting the frequency of stool loss. This tool has a qualitative component (type of incontinence), a quantitative component (frequency of incontinence episodes), as well as the inclusion of impact on QoL. The older version of this score included a visual analogue scale, while the new version includes Likert scales to ease understanding. A multicenter validation study showed that the RAFIS had good internal consistency, good test-retest reliability and a good correlation with the Wexner score (8). Furthermore, the RAFIS appears to be sensitive at identifying changes brought forth by FI interventions, and was better that the FIQL score in this regard. Further research is needed to assess the external validity of this novel tool as well as its uptake and use.

Assessment of the Impact of FI on QoL

QoL instruments measure the subjective effect of a given patient’s health state on different facets of their life (emotional, behavioral, physical, social and cognitive) (6). There exists FI specific QoL tools as well as generic tools that also assess QoL related to FI (26). The FIQL scale is a well-known validated and reliable tool developed by the American Society of Colon and Rectal Surgeons in 2000 (20). It includes four domains (lifestyle, behavior, depression/self-perception and embarrassment) each containing up to 10 questions. Each domain’s score is calculated by the mean of the included questions (lower score indicating a lower QoL). The FIQL score has shown good correlation with the SF-36 (a generic validated health-related QoL measurement tool) and the Wexner score. Disease specific quality-of-life scales like the FIQL score are important as they were developed with that specific problem in mind, and may be a better reflection of the impact of the condition on the patient’s QoL (27). Gastrointestinal specific QoL scales are also commonly used to measure the impact of FI within specific gastrointestinal disease states. They include amongst others the Memorial Sloan Kettering Cancer Center (MSKCC) Bowel Function Instrument, Modified Manchester Health Questionnaire, and the Gastrointestinal Quality of Life Index (GIQL) and the Low Anterior Resection Syndrome (LARS) score (6). Generic QoL questionnaires such as the SF-36 have the advantage of being a leveling ground that allows for easier comparison across different populations in different settings (27). Attention should be drawn to the variety of impact measures that are specific for certain populations and may be better suited to assess patients in specific clinical settings (such as the use of the LARS score for patients after rectal surgery or specific scales developed for patients with anorectal malformations if that is the cause of FI) (28). Thus, special care should be paid when selecting a QoL questionnaire as not all condition-specific tools provide an equal qualitative evaluation of FI (27). Lastly, despite their importance in the assessment of symptomatology, the use of these questionnaires is mostly limited to research.

Conclusions

While not straightforward, quantitative and qualitative evaluation of FI is important to stratify patients, initiate and assess treatment response, and compare interventions. The ideal tool to evaluate FI is a validated, reliable tool, with thresholds to categorize severity and guide treatment. It is also a tool that is easy to administer, incorporates the important impact of the condition on QoL and can reflect treatment response. While no one such perfect tool exists for FI, a variety of tools are available to guide physicians and patients alike. This chapter summarized the most commonly used scales, scores and questionnaires.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Lucia Oliveira, Steven D. Wexner and Sarah A. Vogler) for the series “The Pelvic Floor and Anorectal Disorders” published in Annals of Laparoscopic and Endoscopic Surgery. The article has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-22-1/coif). The series “The Pelvic Floor and Anorectal Disorders” was commissioned by the editorial office without any funding or sponsorship. MB received teaching honorarium from Minogue, Johnson & Johnson, and Stryker—none of which affect the content of this review. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. McKenna C, Bartlett L, Ho YH. Fecal Incontinence Reduces Quality of Life More Than You May Think. Dis Colon Rectum 2017;60:e597-8. [Crossref] [PubMed]
  2. Baxter NN, Rothenberger DA, Lowry AC. Measuring fecal incontinence. Dis Colon Rectum 2003;46:1591-605. [Crossref] [PubMed]
  3. van Koughnett JA, Boutros M, Wexner SD. Signs and symptoms in coloproctology: data collection and scores. Colon, Rectum and Anus: Anatomic, Physiologic and Diagnostic Bases for Disease Management. Switzerland: Springer, Cham, 2017:127-50.
  4. Hunt CW, Cavallaro PM, Bordeianou LG. Metrics Used to Quantify Fecal Incontinence and Constipation. Clin Colon Rectal Surg 2021;34:5-14. [Crossref] [PubMed]
  5. Hays RD, Anderson RT, Revicki D. Assessing reliability and validity of measurement in clinical trials. In: Staquet MJ, Hays RD, Fayers PM, et al. (eds). Quality of life assessment in clinical trials: Methods and practice. Oxford University Press, 1998:169-82.
  6. Lee JT, Madoff RD, Rockwood TH. Quality-of-life measures in fecal incontinence: is validation valid? Dis Colon Rectum 2015;58:352-7. [Crossref] [PubMed]
  7. Hussain ZI, Lim M, Stojkovic S. The test-retest reliability of fecal incontinence severity and quality-of-life assessment tools. Dis Colon Rectum 2014;57:638-44. [Crossref] [PubMed]
  8. de la Portilla F, Ramallo I, Maestre MV, et al. Validation of a Novel Fecal Incontinence Scale: The Rapid Assessment Fecal Incontinence Score (RAFIS). J Clin Gastroenterol 2021;55:141-6. [Crossref] [PubMed]
  9. Parks AG. Royal Society of Medicine, Section of Proctology; Meeting 27 November 1974. President's Address. Anorectal incontinence. Proc R Soc Med 1975;68:681-90. [Crossref] [PubMed]
  10. Womack NR, Morrison JF, Williams NS. Prospective study of the effects of postanal repair in neurogenic faecal incontinence. Br J Surg 1988;75:48-52. [Crossref] [PubMed]
  11. Rudd WW. The transanal anastomosis: a sphincter-saving operation with improved continence. Dis Colon Rectum 1979;22:102-5. [Crossref] [PubMed]
  12. Keighley MR, Fielding JW. Management of faecal incontinence and results of surgical treatment. Br J Surg 1983;70:463-8. [Crossref] [PubMed]
  13. Corman ML. Gracilis muscle transposition for anal incontinence: late results. Br J Surg 1985;72:S21-2. [Crossref] [PubMed]
  14. Hiltunen KM, Matikainen M, Auvinen O, et al. Clinical and manometric evaluation of anal sphincter function in patients with rectal prolapse. Am J Surg 1986;151:489-92. [Crossref] [PubMed]
  15. Brodén G, Dolk A, Holmström B. Recovery of the internal anal sphincter following rectopexy: a possible explanation for continence improvement. Int J Colorectal Dis 1988;3:23-8. [Crossref] [PubMed]
  16. Rainey JB, Donaldson DR, Thomson JP. Postanal repair: which patients derive most benefit? J R Coll Surg Edinb 1990;35:101-5. [PubMed]
  17. Williams NS, Patel J, George BD, et al. Development of an electrically stimulated neoanal sphincter. Lancet 1991;338:1166-9. [Crossref] [PubMed]
  18. Pescatori M, Anastasio G, Bottini C, et al. New grading and scoring for anal incontinence. Evaluation of 335 patients. Dis Colon Rectum 1992;35:482-7. [Crossref] [PubMed]
  19. Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77-97. [Crossref] [PubMed]
  20. Rockwood TH, Church JM, Fleshman JW, et al. Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2000;43:9-16; discussion 16-7. [Crossref] [PubMed]
  21. Vaizey CJ, Carapeti E, Cahill JA, et al. Prospective comparison of faecal incontinence grading systems. Gut 1999;44:77-80. [Crossref] [PubMed]
  22. de la Portilla F, Calero-Lillo A, Jiménez-Rodríguez RM, et al. Validation of a new scoring system: Rapid assessment faecal incontinence score. World J Gastrointest Surg 2015;7:203-7. [Crossref] [PubMed]
  23. Vaizey CJ, Kamm MA. Prospective assessment of the clinical value of anorectal investigations. Digestion 2000;61:207-14. [Crossref] [PubMed]
  24. Rockwood TH, Church JM, Fleshman JW, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 1999;42:1525-32. [Crossref] [PubMed]
  25. O'Brien PE, Dixon JB, Skinner S, et al. A prospective, randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence. Dis Colon Rectum 2004;47:1852-60. [Crossref] [PubMed]
  26. Rothbarth J, Bemelman WA, Meijerink WJ, et al. What is the impact of fecal incontinence on quality of life? Dis Colon Rectum 2001;44:67-71. [Crossref] [PubMed]
  27. Pang A, Koughnett JAV, Boutros M. Quantitative and Qualitative Analysis of Fecal Incontinence. In: Kobashi KC, Wexner SD (eds). Female Pelvic Medicine: Challenging Cases with Expert Commentary. New York: Springer, 2021.
  28. Meinds RJ, Timmerman MEW, van Meegdenburg MM, et al. Reproducibility, feasibility and validity of the Groningen Defecation and Fecal Continence questionnaires. Scand J Gastroenterol 2018;53:790-6. [Crossref] [PubMed]
doi: 10.21037/ales-22-1
Cite this article as: Abou Khalil M, Boutros M. Quantitative and qualitative analysis of fecal incontinence. Ann Laparosc Endosc Surg 2022;7:19.

Article Options

Download Citation

Share