Fecal incontinence in men: coexistent constipation and impact of rectal hyposensitivity

Abstract

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.