Anal incontinence and quality of life following operative treatment of simple cryptoglandular fistula-in-ano: a prospective study
Jayarajah et al. BMC Res Notes
Anal incontinence and quality of life following operative treatment of simple cryptoglandular fistula-in-ano: a prospective study
Umesh Jayarajah 0
Dakshitha Praneeth Wickramasinghe 0
Dharmabandhu Nandadeva Samarasekera 0
0 Department of Surgery, Faculty of Medicine, University of Colombo , Kynsey Road, P. O. Box 271, Colombo 8 , Sri Lanka
Background: Anal incontinence is a known complication following operative treatment of fistula-in-ano which can significantly impact the quality of life. This study was aimed to objectively assess the impact of operative treatment of simple fistula-in-ano on quality of life related to anal incontinence. Therefore, a prospective study was conducted in 34 patients who underwent surgery for fistula-in-ano over a period of 24 months. Quality of life and incontinence were assessed using fecal incontinence quality of life (FIQL) scale and Cleveland clinic incontinence score (CCIS) preoperatively and after a minimum of 12 months follow up (mean-27 months, range 12-40 months). The difference in FIQL and CCIS was analysed using Wilcoxon Rank test and Mann-Whitney U test. Results: The median age of the participants was 42.5 years (range 22-63, males = 30). The majority had a transsphincteric tract (n = 22, 65%). Superficial tracts and inter-sphincteric tracts were found in 8 (24%) and 4 patients (12%). The overall preoperative and postoperative rates of incontinence were 18 and 38% respectively, but the severity was low. The mean overall FIQL was 16.0 (SD ± 0.4) preoperatively and 16.1 (SD ± 0.4) postoperatively. Considerable difference was seen in the scale measuring “depression/self-perception” (p = 0.012). Only 1 patient (3%) had reduction in scale “lifestyle” which measures the impact of incontinence on day-to-day activities. Conclusions: Analysis of a cohort of simple cryptoglandular fistula-in-ano with low pre-operative incontinence showed no worsening in the FIQL following successful treatment despite minor worsening of incontinence. Since greater improvement was noted in scale measuring depression/self-perception, psychological interventions may be helpful before surgery to improve quality of life.
Fistula-in-ano; Quality of life; Anal incontinence
The operative treatment of fistula-in-ano remains a
challenge as it is essential to achieve a cure while
minimizing postoperative complications. The most important
factors that determine outcome are recurrence and anal
incontinence following surgery [
]. Anal incontinence
is a complication that can significantly affect the
quality of life of the patients [
]. The reported overall rates of
incontinence vary up to 40% depending on the type of
fistula and the operative treatment modality used. However,
the majority of patients had minor incontinence
following surgery [
]. Studies have shown that simple fistulae
also carry a risk of incontinence though not as high as
following surgery for complex fistulae [
studies have also shown that quality of life and patient
satisfaction may be low because of anal incontinence
despite a complete cure [
There has been a few previous studies examining
QOL in anal fistula using the gastrointestinal quality of
life index (GIQLI) [
]. The GIQLI was developed from
patients with pathologies in the upper gastrointestinal
tract, such as peptic ulceration and biliary disease, and
it assesses symptoms such as chronic abdominal pain,
reflux symptoms, eating habits and bowel habits which
are usually not affected in peri-anal fistulae unless it is
associated with a known aetiology such as
inflammatory bowel disease or TB. Therefore, it is not an accurate
assessment for cryptoglandular anal fistula [
Studies on quality of life related to anal incontinence
following surgery are limited and the authors could not
find any prospective studies which had compared
preoperative and postoperative quality of life related to anal
incontinence. Therefore, this study was aimed to
objectively assess the impact of operative treatment on anal
incontinence quality of life in simple cryptoglandular
A prospective analysis was done. All patients who
underwent successful operative treatment for fistula-in-ano
from 2012 January to 2013 December at the Professorial
Surgical Unit at the National Hospital of Sri Lanka were
included in this study. Patients with other comorbidities
or psychological conditions that may affect quality of life
were excluded. Sample size was determined using the
results of 2 previous studies which assessed incontinence
following fistula surgery [
], targeting a 95% confidence
interval and 80% power to detect worsening of
incontinence. This yielded a minimum sample size of 33.
All surgeries were done by a single consultant
colorectal surgeon. Those who had fistulae with multiple
external openings, high trans-sphincteric fistulae,
suprasphincteric fistulae, extra-sphincteric fistulae, or had high
blind extensions or horseshoe tracts or were anterior in a
female patient were excluded as they were complex
]. A biopsy was done in all patients to exclude any
The instrument used to assess the quality of life related
to anal incontinence was fecal incontinence quality of life
(FIQL) scale which is a validated and a widely accepted
]. It consists of a total of 29 items which form
four sub scales. They are lifestyle (10 items), coping
behavior (9 items), depression/self-perception (7 items)
and embarrassment (3 items). Psychometric evaluation
of these scales demonstrated that they are both reliable
and valid. The sub scales have satisfactory test/retest
reliability and acceptable internal reliability (Cronbach’s
alpha > 0.70) [
The degree of incontinence was measured objectively
using the Cleveland clinic incontinence score (CCIS)
which is a widely accepted validated score to measure
anal incontinence [
]. It consists of five questions to
assess the degree of incontinence (solid, liquid, gas, wears
pad, lifestyle alteration). The frequency of each type of
incontinence is rated on a scale ranging from 0 (never) to
4 (always or to once a day) so that the sum of the
frequencies add up to a total score that may range from 0 to 20.
Higher scores indicate higher levels of incontinence.
These tools were administered as an interviewer
administered questionnaire to minimize discrepancies. All
patients gave informed written consent to be included in
the study. Ethical clearance was obtained from the Ethical
Review Committee of the National Hospital of Sri Lanka.
Each person’s FIQL and CCIS were assessed at two
points, preoperatively and after a minimum follow up
period of 12 months after the last surgery. A follow up
period of 12 months was chosen to allow adequate time
for complete healing and to a certain extent, exclude
recurrence. After the follow up period of 12 months,
patients were assessed by a clinical examination to
confirm the absence of recurrence.
Data were analysed using SPSS 17.0 statistical software
(SPSS Inc., USA). Continuous variables were expressed
using means ± standard deviations. Wilcoxon Rank test
was used to analyse whether there is a statistical
difference between preoperative and postoperative scores and
Mann–Whitney U test was used to determine
associations. All statistical testing was performed at the 0.05
Thirty-four patients participated in this study. The
median age of the study participants was 42.5 years
(range 22–63). The majority of patients were males
(n = 30, 88%). The median number of surgeries that the
patients had undergone was 2 (range 1–6). The patients
were followed up for a mean duration of 27.47 months
(range 12–40). The Parks classification [
] was used to
classify all fistulae at the time of surgery. The majority
had a trans-sphincteric tract (n = 22, 65%). Superficial
tracts were found in 8 patients (24%) and
inter-sphincteric tracts were found in 4 patients (12%).
The mean preoperative CCIS was 0.4 ± 1.1 and after
follow up the CCIS was 0.9 ± 1.3 out of a maximum
score of 20. The difference seen was statistically
significant (p = 0.039). The greatest significance was in
incontinence to flatus (p = 0.013). However, no patients had
significant soiling for solid faeces (Table 1). Plot showing
pre and post-operative CCIS scores of individual patients
is shown in Fig. 1.
Of the participants, 18% had some degree of
incontinence (CCIS range 1–5) preoperatively, and 38% had some
degree of incontinence after follow up (CCIS range 1–4). In
the majority, there was no change in the degree of
incontinence (n = 22, 65%) while 9 patients (27%) had worsening
of incontinence and 3 patients (9%) had an improvement.
Pre-op CCIS ± SD
Post-op CCIS ± SD
The mean overall FIQL calculated by adding the scores
of 4 scales was 16.0 (SD ± 0.4) (95% confidence interval
15.9–16.2) preoperatively and 16.1 (SD ± 0.4) (95%
confidence interval 16.0–16.2) postoperatively. There was no
worsening of overall FIQL after surgery (Table 2). Plot
showing pre and post-operative FIQL scores of individual
patients is shown in Fig. 2.
There was no considerable difference in the pre and
post-operative FIQL scores (15.9 vs 16.1 and 16.0 vs 16.2
respectively) in those with worsening incontinence
compared to those without.
Greater difference was seen in scale measuring
“depression/self-perception”. There was no difference
in the mean score on “lifestyle” which measures the
impact of incontinence on day to day activities and
Considering individual scores, the majority (n = 20,
59%) had an improvement in FIQL and 6 patients (18%)
had no change and 8 patients (24%) had reduced FIQL.
However, only 1 patient (3%) had reduction in scale
“lifestyle” which measures the impact of incontinence on
This study has shown a significant increase in the mean FIQL
scores following surgery for simple fistula-in-ano. Studies
have been done to compare rates of incontinence and FIQL
between simple and complex fistulae [
studies that prospectively assessed the degree of incontinence in
simple fistulae before and after treatment are scant [
The quality of life was mainly affected due to
depression and self-perception. Furthermore, the difference
seen in the scores measuring lifestyle was small. This was
consistent with a similar study which showed that scores
measuring psychological and social outcomes
significantly improved following successful operative treatment
of fistula-in-ano [
]. Therefore, it may be ideal to
incorporate the intervention of a psychologist to improve the
quality of life.
There was a statistically significant increase in the mean
score measuring incontinence. However, the majority
had no change in the degree of incontinence while 27%
had mild worsening and 9% had an improvement. This
is consistent with findings in a similar study which has
reported worsening of incontinence in patients following
surgery for simple fistulae [
] however, in the present
study the degree of incontinence following surgery was
low. This study also confirms that simple fistulae are also
at risk of incontinence following surgery.
A cross-sectional study by Owen et al. [
the quality of life with anal incontinence, using St. Marks
incontinence score, showed a very low median score of 0
and there was no difference in the degree of incontinence in
relation to recurrence of fistulae. Furthermore, in that study
there was a significant reduction in the quality of life score
compared to the normal population scores [
]. Thus in that
study, although the scoring of degree of incontinence is low,
there was a reduction in the quality of life of patients.
It was interesting to note that despite the increase in
degree of incontinence, there was no worsening of
quality of life related to anal incontinence. The reason may be
that the statistically significant increase in the degree of
incontinence was not clinically significant and did not
have a significant impact on their day to day activities. That
is probably due to the fact that, all the patients had only
minor incontinence and had low mean incontinence scores
both preoperatively and after follow up. The fact that there
was no reduction in the faecal incontinence quality of life
after surgery is important in terms of the outcome of the
surgery. This indicates that those with low pre-operative
incontinence scores in our cohort had not experienced
worsening of faecal incontinence related quality of life,
which is a major concern and a challenge for the surgeon.
Certain limitations in this study should be taken into
consideration when interpreting the results. The observed
increase in the quality of life may be influenced by the
low degree of pre-operative and post-operative
incontinence. Therefore the patient characteristics in our
sample should be considered when interpreting the findings
which were low pre-operative incontinence score and the
presence of simple cryptoglandular fistula-in-ano.
Therefore, operative treatment could be offered despite
the risk of worsening of anal incontinence in patients
diagnosed to have simple cryptoglandular fistula-in-ano
with low pre-operative incontinence scores as there was
no worsening of quality of life in terms of anal
incontinence after surgery.
In this study, analysis of a cohort of simple
cryptoglandular fistula-in-ano with low pre-operative incontinence
showed no worsening in the FIQL following successful
treatment despite minor worsening of incontinence.
Since greater improvement was noted in scale measuring
depression/self-perception, psychological interventions
may be helpful before surgery to improve quality of life.
We recommend large scale prospective studies to gain
further insight on the impact of operative treatment on
quality of life related to anal incontinence and to identify
the contributory factors.
FIQL: faecal incontinence quality of life; CCIS: Cleveland clinic incontinence
score; SD: standard deviation; TB: tuberculosis; QOL: quality of life; GIQLI:
gastrointestinal quality of life index; SPSS: Statistical Package for the Social
UJ and DPW participated in study concept, study design, data collection
and analysis, manuscript preparation. DNS contributed to study concept,
manuscript preparation and final approval. All authors read and approved the
The authors declare that they have no competing interests.
Availability of data and materials
Data supporting above findings are not made available for readers as consent
for publication was not obtained.
Ethics approval and consent to participate
Ethical approval was obtained from Ethical Review Committee of National of
Sri Lanka to conduct the study. All patients gave informed written consent to
participate in this study.
Consent to publish
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