title: Subtypes of anal incontinence associated with bowel dysfunction: clinical, physiologic, and psychosocial characterization.
abstract: BACKGROUND
  We hypothesized that functional anal incontinence with no structural explanation comprises distinct pathophysiologic subgroups that could be identified on the basis of the predominant presenting bowel pattern.
  
  
  METHODS
  Consecutive patients (n = 80) were prospectively grouped by bowel symptoms as 1) incontinence only, 2) incontinence + constipation, 3) incontinence + diarrhea, and 4) incontinence + alternating bowel symptoms. The Hopkins Bowel Symptom Questionnaire, the Symptom Checklist 90-R, and anorectal manometry were completed.
  
  
  RESULTS
  Significant group differences were found between subcategories of incontinent patients on the basis of symptoms. Abdominal pain was more frequent in patients with altered bowel patterns. Patients with alternating symptoms reported the highest prevalence of abdominal pain, rectal pain, and bloating. Basal anal pressures were significantly higher in alternating patients (P = 0.03). Contractile pressures in the distal anal canal were diminished in the incontinent-only and diarrhea groups (P = 0.004). Constipated patients with incontinence exhibited elevated thresholds for the urge to defecate (P = 0.027). Dyssynergia was significantly more frequent in patients with incontinence and constipation or alternating bowel patterns.
  
  
  CONCLUSIONS
  Distinct patterns of pelvic floor dysfunction were identified in patient subgroups with anal incontinence, based on the presence or absence of altered bowel patterns. Physiologic assessments suggested different pathophysiologic mechanisms among the subgroups. The evaluation of patients with fecal incontinence should consider altered bowel function.
authors.affiliation: Clinical Enteric Neuroscience Translational and Epidemiologic Research (CENTER) Program, Mayo Foundation and Mayo Clinic, Rochester, Minnesota, USA. crowell.michael@mayo.edu
authors.forename: M D
authors.initials: MD
authors.lastname: Crowell
authors.forename: B E
authors.initials: BE
authors.lastname: Lacy
authors.forename: V A
authors.initials: VA
authors.lastname: Schettler
authors.forename: T N
authors.initials: TN
authors.lastname: Dineen
authors.forename: K W
authors.initials: KW
authors.lastname: Olden
authors.forename: N J
authors.initials: NJ
authors.lastname: Talley
mesh_terms: D015746:Abdominal Pain / Q000209:etiology; D000328:Adult; D000368:Aged; D003106:Colon / Q000473:pathology / Q000502:physiology; D003967:Diarrhea; D005242:Fecal Incontinence / Q000145:classification* / Q000473:pathology* / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D017773:Pelvic Floor / Q000473:pathology*; D011446:Prospective Studies; D011788:Quality of Life; D012007:Rectum / Q000473:pathology / Q000502:physiology; D012720:Severity of Illness Index