Fecal incontinence: major problem or incidental finding?

It has been widely demonstrated that any degree of fecal incontinence (FI), even isolated and occasional leakage of gas, can seriously impair quality of life (QOL). The prevalence of FI ranges from 2.2 % up to more than 50 % in women with urinary incontinence or pelvic organ prolapse [1], increasing with advancing age in both sexes. According to these figures, in a Western population of 500,000 inhabitants, one would expect to find a minimum of 11,000 persons and a maximum of many thousands suffering from FI. Therefore, FI is a big problem. However, if one considers the number of those people who seek specialized care, and the number of patients finally treated, FI is an anecdote. For instance, in the Ramon y Cajal Hospital, Madrid, a national reference center for FI currently serving a population of around 600,000 inhabitants, only about 75 patients, 0.6 % of a minimum of 13,200 patients with this condition, are treated annually and, of those, less than half will achieve satisfactory long-term results. These numbers are very frustrating from both the social and medical aspects. But why does this happen? There are some well-known reasons. As Paka et al. [2] state in their article, this symptom is underreported by patients, and patients are not routinely questioned about FI by general practitioners (GP) or geriatricians, who may be unaware of current treatments, which, in turn, are usually disappointing or very expensive. It is beyond the scope of this editorial to delve into the technical aspects of treatment; this would be a topic for another editorial. Instead, I want to focus on the need to find a simple, not time-consuming, scoring system for assessing this disabling condition. This is the first essential step for recruiting patients from health centers and nursing homes. Currently, three validated methods are more frequently used to score FI: the Jorge–Wexner (Cleveland Clinic) score: five items rated on a five-point scale; the Vaizey (St. Mark’s Hospital) score: seven items, four rated on a fivepoint scale and three rated on a twopoint scale; and the Fecal Incontinence Severity Index (FISI): four items rated on a six-point scale. The validity of these methods is beyond doubt and, up to now, they have been essential for determining the severity of FI, assessing periodically the response to treatment, and comparing the results of different therapeutic options. However, although one of them (Vaizey) also reports lifestyle alterations and qualitative aspects of FI, the final score is given by a single number that does not represent either the same degree of dysfunction or the different degree to which a given symptom affects a person’s life. To overcome this, it would be necessary to measure each of the different qualitative aspects of FI quantitatively with independent scores, which is too complicated for routine use in clinical practice. Moreover, although none of these methods is difficult to use, the patient often has doubts or does not have episodes of diarrhea in the limited time, or uses the pad only for fear of leakage rather than for actual leakage, or even for urinary incontinence, which results in an imprecise score. In any case, it is highly unlikely that GPs or geriatricians routinely use any of these methods as an initial tool to assess FI. For patients with FI, the true importance of incontinence lies in the way it affects their life; therefore, it is also necessary to know its impact on QOL, with the artificial number of any scoring system reflecting the qualitative & J. M. Devesa colonrecto@ruberinternacional.es