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The functional and psychosocial impact of fecal incontinence on women with urinary incontinence
The functional and psychosocial impact of fecal incontinence on women with urinary incontinence M. F. Fialkow, MD,a J. L. Melville, MD, MPH,a G. M. Lentz, MD,a E. A. Miller, MD,a J. Miller, MD,a and D. E. Fenner, MDb Seattle, Wash, and Ann Arbor, Mich OBJECTIVES: The study was undertaken to determine the impact of fecal incontinence (FI) on functional status and quality of life in women with urinary incontinence (UI). STUDY DESIGN: In 24 months 732 women completed a standardized assessment and questionnaire, including the Short Form (SF)-12 and Incontinence Quality of Life (I-QOL) scores. Analysis of variance was used to compare SF-12 scores between groups defined as having UI, FI, or both UI and FI. I-QOL scores in patients with UI or UI and FI were compared by using the Student t test. RESULTS: Of the 732 patients enrolled, 425 patients had either UI (n = 342, 80%), FI (n = 18, 4%), or both (n = 65, 15%). Greater impairment in physical functioning was seen in the group with UI and FI (38.6; P = .027) compared with the group with UI (42.4). Significant decreases in I-QOL scores were seen for the group with UI and FI compared with those with UI (P < .005). CONCLUSION: Fecal incontinence further reduces the functional status and quality of life of women with urinary incontinence. (Am J Obstet Gynecol 2003;189:127-9.)
Key words: Fecal incontinence, urinary incontinence, quality of life
Urinary incontinence (UI) is estimated to affect 20% to 50% of women during their lifetimes.1 Several studies have documented the impact of urinary incontinence on an individual’s quality of life (QOL).2-5 QOL in women with UI is affected by a number of factors, including volume of urine loss, frequency of UI episodes, and frequency of voids.6 UI type has also been shown to differentially effect QOL, with urge UI having a greater impact on QOL than stress UI.2,4,5,7 Many assessment tools, such as the Short Form (SF)-12 are available to measure global symptoms, functional status, and QOL. The development of incontinence-specific descriptive measures, such as the Incontinence Quality of Life Instrument (I-QOL), has resulted in illness-specific instruments that are more responsive to change with treatment.8-10 Fecal incontinence (FI) is estimated to affect 2% to 25% of women in their lifetimes.11,12 Accidental loss of stool or flatus can be embarrassing and socially isolating for the patient and has been shown to have a significant impact on QOL measures.13,14 As with UI, the QOL in
From the Departments of Obstetrics and Gynecology and Urology, University of Washington,a and the University of Michigan.b Presented at the Twenty-Third Annual Meeting of the American UroGynecologic Society, San Francisco, Calif, October 6-18, 2002. Reprints not available from the authors. © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 + 0 doi:10.1067/mob.2003.548
women with FL is affected by type (ie, loss of flatus, liquid, or solid stool) and frequency of FL.13,15 Several QOL measures specific to fecal incontinence have also been developed to monitor a patient’s progress after conservative or surgical therapy.13,15,16 Dual incontinence (UI + FI) is estimated to be present in approximately 20% of women presenting with UI.17 How the combination of these two conditions affect a woman’s QOL is not known. The aim of this study was therefore to determine the impact of fecal incontinence on QOL measures in a population of women with urinary incontinence. Material and methods Study setting. The study was conducted at the University of Washington Medical Center–Roosevelt Urology and Urogynecology Clinic, a specialty clinic staffed by two urogynecologists and two urologists. The four clinic physicians evaluate 400 new female patients annually, approximately 60% of whom have a diagnosis of UI, and 12% of whom have a diagnosis of FI. Patients. From June 13, 2000, to July 1, 2002, all new patients presenting to the Urology and Urogynecology Clinic were recruited into a database registry used for clinical care and research; before their first appointment patients were sent information by mail regarding the database registry, a consent form, and a clinical questionnaire. At the time of the first visit, those wishing to participate in the research portion of the database registry were 127
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Table I. Demographic and clinical characteristics by incontinence type
Age (mean y ± SD) Postmenopausal (%) White (%) Parity (mean ± SD) Hysterectomy (%) Wexner score (mean ± SD) Patient Incontinence Severity Assessment (mean score ± SD) Chronic medical illnesses (mean No. ± SD)
F, t, or χ2 statistic*
Fecal (n = 18)
Urinary (n = 342)
Dual (n = 65)
P value†
57.3 ± 16.0 67 (n = 12) 99 (n = 15) 2.5 ± 1.2 65 (n = 11) 12.33 ± 4.7 NA
55.3 ± 14.2 74 (n = 247) 87 (n = 290) 2.6 ± 1.5 48 (n = 166) NA 3.1 ± 1.3
58.7 ± 14.0 83 (n = 53) 89 (n = 57) 3.0 ± 1.7 61.5 (n = 40) 9.5 ± 4.2 3.6 ± 1.3
F = 1.6 χ2 = 3.0 χ2 = 0.9 F = 1.4 χ2 = 21.0 t = 1.7 t = 2.2
.19 .22 .62 .25 .00 .12 .02
1.8 ± 1.3
1.8 ± 1.8
2.7 ± 2.0
F = 5.8
.00
P value
NA, Not available.
Table II. Quality of life and functional status vary by incontinence type
SF-12:PCS12 (physical) SF-12:MCS12 (mental) I-QOL total I-QOL: avoid/limit I-QOL: psychosocial I-QOL: embarrassment
US population (mean)
Fecal
Urinary
Dual
F or t statistic*
49.1 ± 9.9 49.4 ± 9.8 62.3 ± 22.4 57.8 ± 22.5 73.2 ± 23.7 49.8 ± 28.0
45.5 46.9 NA NA NA NA
42.4 50.4 62.9 58.9 71.6 50.4
38.6 46.8 46.4 43.8 53.2 37.9
F = 3.63 F = 3.47 t = –3.5 t = –3.8 t = –3.8 t = –3.0
.027† .032† <.001† <.001† <.001† .004†
NA, Not available. *Degrees of freedom for F is 433; degrees of freedom range for t is 309 to 355. †Significant at P < .05.
asked to sign the consent form. Institutional Review Board approval was obtained from our Human Subjects Division. For this study, we included all communitydwelling women age 18 to 90 years who complained of accidental loss of stool or urine. We excluded women with current urinary tract infection, genitourinary or rectovaginal fistula, or inability to read and complete the questionnaire because of cognitive impairment or language difficulty. Study design. Self-report information from the clinical questionnaire and physician diagnoses were collected on all patients. The clinical questionnaire contained information about current medical complaints, medical and surgical history, gynecologic history, urologic history, obstetrical history, menopausal status, current medications, and demographic characteristics. The questionnaire contained specific questions regarding UI symptoms, duration of UI in years and months, number of medical visits in the last year to treat UI, the amount of urine lost per episode, the number of UI episodes in the last month, and a patient incontinence severity assessment (PISA) question that rated UI severity on a 5-point Likert scale (range: l [mild] to 5 [severe]). It included two diseasespecific QOL measures, the I-QOL,8 the SF-12 functional status measure with the mental and physical component subscales.18 The questionnaire also included the Depression Port Medical Comorbidity Scale, a validated scale for assessing the number of comorbid medical disorders of a possible total of 18 common chronic illnesses.19 The Wexner scale, a commonly used measure of FI frequency,
type, and QOL impact, was used to estimate the severity of fecal incontinence.14,15 Physicians performed a history, physical examination, urinalysis and urine culture, and reviewed a 3-day voiding diary. Multichannel urodynamic testing, defecography, or anal manometry was performed as indicated by history of prior surgery, nonresponse to conservative treatment, or as a preoperative evaluation. Results Subject characteristics. A total of 732 patients were enrolled into the clinical registry database during the recruitment period. Of these, 425 patients met the inclusion criteria of reporting urine or fecal loss and receiving a physician diagnosis of UI, FI, or both. The mean (±SD) age of the patients was 55.9 ± 14.3 years. Eightyseven percent were white and 75% were postmenopausal. The mean (±SD) gravity and parity were 3.4 ± 1.9 and 2.7 ± 1.5, respectively. Fifty-one percent of the subjects had previously had a hysterectomy. The mean (±SD) number of chronic medical illnesses was 1.9 ± 1.8. As shown in Table I the study population was divided into the groups diagnosed with UI, FI, or both UI and FI (dual incontinence) for further analysis. Excluding the rate of hysterectomy, there were no significant differences in the essential demographics of the subgroups. The patients with dual incontinence, however, did have a significantly higher number of comorbid medical illnesses compared with those with fecal or urinary incontinence alone. In addition, the dual group also considered
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their urinary incontinence more severe on the self-report scale than those patients with only UI. When analyzed by number of urinary incontinent episodes in the last month, amount of urine lost per episode, and duration of urinary incontinence, however, there were no significant differences between the groups. QOL and functional status. When functional status and QOL were examined by urinary, fecal, or dual incontinence (Table II), significant differences were observed. The SF-12 physical component measures for the patients with UI or FI alone were not significantly different; however, those with dual incontinence had significantly lower scores. For the SF-12 mental component scores, all the patients with fecal incontinence had significantly lower scores than those with urinary incontinence alone. The dual incontinence patients also had significantly lower IQOL scores than those patients with urinary incontinence alone. Comment In a sample of women presenting to a urogynecology and urology specialty clinic with the complaint of UI and/or FI, we found that those women with dual incontinence consistently had significantly decreased functional status and QOL. They also had a higher mean number of chronic medical illnesses and perceived their urinary incontinence as more severe than those women with only UI, despite similar clinical characteristics of incontinence. This perception of increased severity by the women with dual incontinence may result from the additive impact of their fecal incontinence or may be related to the impact of other comorbid conditions as has been seen with UI and major depression.7 There are limitations to the interpretation of this study. The design is cross-sectional and therefore causal relationships cannot be established. Our patients are primarily white, so our findings may not apply to other populations and our group of women with FI only is relatively small. Despite these limitations, we believe that our study supports the hypothesis that women with both fecal and urinary incontinence have a lower QOL and functional status than those women with only one type of incontinence. Several prior studies have documented the reduction in QOL and functional status in women with urinary or fecal incontinence; however, the authors believe this is the first study to consider the combined impact of urinary and fecal incontinence. This is important because it has been documented that these conditions commonly occur together.17,20 In our study population as well, approximately 20% of women presenting with UI also had FI. When successful treatments of women who have these conditions are assessed, QOL measures are equally or perhaps more important than objective outcome mea-
sures. Successful treatment will require addressing both conditions. REFERENCES
1. Fantyl J, Newman D, Coiling J, et al. Urinary incontinence in adults: acute and chronic management. Rockville (MD): US Department of Health and Human Services, Agency for Health Care Policy and Research; 1996. Clinical practice guideline No.: 2. 2. Wyman J, Harkins S, Choi S, Taylor J, Fantyl J. Psychosocial impact of urinary incontinence in women. Obstet Gynecol 1987;70:378-90. 3. Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff L. Definition of overactive bladder and epidemiology of urinary incontinence. Urology 1997;50(6A Suppl):4-14. 4. Grimby A, Milsom I, Molander U, Wiklund I, Ekelund P. The influence of urinary incontinence on the QOL of older women. Ageing 1993;22:82-9. 5. Hunskaar S, Visnens A. The quality of life in women with urinary incontinence as measured by the sickness impact profile. J Am Geriatric Soc 1991:378-82. 6. Robinson D, Pearce K, Preiser J, Dugan E, Suggs P, Cohen D. Relationship between patient reports of urinary incontinence symptoms and quality of life measures. Obstet Gynecol 1998;91:224-8. 7. Melville J, Walker E, Katon W, Lentz G, Miller J, Fenner D. Prevalence of comorbid psychiatric illness and its impact on symptom perception, quality of life, and functional status in women with urinary incontinence. Am J Obstet Gynecol 2002;187:80-7. 8. Patrick D, Martin M, Bushnell D, Yalcin I, Wagner T, Buesching D. Quality of life for women with urinary incontinence: further development of the Incontinence Quality of Life Instrument (IQOL). Urology 1999;53:71-6. 9. Shumaker S, Wyman J, Uebersax J, McClish D, Fantyl J. Healthrelated quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group. Qual Life Res 1994;3:291-306. 10. Uebersax J, Wyman J, Shumaker S, McClish D, Fantyl J. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontience Impact Questionnaire and the Urogenital Distress Inventory. Neurourol Urodyn 1995;14:131-9. 11. Leigh R, Turnberg L. Faecal incontinence: the unvoiced symptom. Lancet 1982;1:1349-51. 12. Nelson R, Norton N, Cautley E, Fumer S. Community based prevalence of anal incontinence. JAMA 1995;274:559-61. 13. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, 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. 14. Rothbarth J, Bemelman W, Meijerink WJ, Stiggelbout AM, Zwinderman AH, Buyze-Westerweel ME, et al. What is the impact of fecal incontinence on quality of life? Dis Colon Rectum 2001;44:67-71. 15. Olivera L, Pfeifer J, Wexner SD. Physiological and clinical outcome of anterior sphincteroplasty. Br J Surg 1996;83:502-5. 16. Pescaton M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence: evaluation of 335 patients. Dis Colon Rectum 1992;35. 17. Jackson S, Weber A, Hull T, Mitchinson A, Walters M. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 1997;89:423-7. 18. Ware J, Kosinski M, Keller S. SF-12: how to score the SF-12 physical and mental health summary scales. Boston (MA): Health Institute, New England Medical Center; 1995. 19. Wells K, Stewart A, Hays R, Burnam MA, Rogers W, Daniels M, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1999;262:914-9. 20. Khullar V, Damiano R, Toozs-Hobson P, Cardozo L. Prevalence of faecal incontinence among women with urinary incontinence. BJOG 1998;105:1211-3.
Key words: Fecal incontinence, urinary incontinence, quality of life
Urinary incontinence (UI) is estimated to affect 20% to 50% of women during their lifetimes.1 Several studies have documented the impact of urinary incontinence on an individual’s quality of life (QOL).2-5 QOL in women with UI is affected by a number of factors, including volume of urine loss, frequency of UI episodes, and frequency of voids.6 UI type has also been shown to differentially effect QOL, with urge UI having a greater impact on QOL than stress UI.2,4,5,7 Many assessment tools, such as the Short Form (SF)-12 are available to measure global symptoms, functional status, and QOL. The development of incontinence-specific descriptive measures, such as the Incontinence Quality of Life Instrument (I-QOL), has resulted in illness-specific instruments that are more responsive to change with treatment.8-10 Fecal incontinence (FI) is estimated to affect 2% to 25% of women in their lifetimes.11,12 Accidental loss of stool or flatus can be embarrassing and socially isolating for the patient and has been shown to have a significant impact on QOL measures.13,14 As with UI, the QOL in
From the Departments of Obstetrics and Gynecology and Urology, University of Washington,a and the University of Michigan.b Presented at the Twenty-Third Annual Meeting of the American UroGynecologic Society, San Francisco, Calif, October 6-18, 2002. Reprints not available from the authors. © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 + 0 doi:10.1067/mob.2003.548
women with FL is affected by type (ie, loss of flatus, liquid, or solid stool) and frequency of FL.13,15 Several QOL measures specific to fecal incontinence have also been developed to monitor a patient’s progress after conservative or surgical therapy.13,15,16 Dual incontinence (UI + FI) is estimated to be present in approximately 20% of women presenting with UI.17 How the combination of these two conditions affect a woman’s QOL is not known. The aim of this study was therefore to determine the impact of fecal incontinence on QOL measures in a population of women with urinary incontinence. Material and methods Study setting. The study was conducted at the University of Washington Medical Center–Roosevelt Urology and Urogynecology Clinic, a specialty clinic staffed by two urogynecologists and two urologists. The four clinic physicians evaluate 400 new female patients annually, approximately 60% of whom have a diagnosis of UI, and 12% of whom have a diagnosis of FI. Patients. From June 13, 2000, to July 1, 2002, all new patients presenting to the Urology and Urogynecology Clinic were recruited into a database registry used for clinical care and research; before their first appointment patients were sent information by mail regarding the database registry, a consent form, and a clinical questionnaire. At the time of the first visit, those wishing to participate in the research portion of the database registry were 127
128 Fialkow et al
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Table I. Demographic and clinical characteristics by incontinence type
Age (mean y ± SD) Postmenopausal (%) White (%) Parity (mean ± SD) Hysterectomy (%) Wexner score (mean ± SD) Patient Incontinence Severity Assessment (mean score ± SD) Chronic medical illnesses (mean No. ± SD)
F, t, or χ2 statistic*
Fecal (n = 18)
Urinary (n = 342)
Dual (n = 65)
P value†
57.3 ± 16.0 67 (n = 12) 99 (n = 15) 2.5 ± 1.2 65 (n = 11) 12.33 ± 4.7 NA
55.3 ± 14.2 74 (n = 247) 87 (n = 290) 2.6 ± 1.5 48 (n = 166) NA 3.1 ± 1.3
58.7 ± 14.0 83 (n = 53) 89 (n = 57) 3.0 ± 1.7 61.5 (n = 40) 9.5 ± 4.2 3.6 ± 1.3
F = 1.6 χ2 = 3.0 χ2 = 0.9 F = 1.4 χ2 = 21.0 t = 1.7 t = 2.2
.19 .22 .62 .25 .00 .12 .02
1.8 ± 1.3
1.8 ± 1.8
2.7 ± 2.0
F = 5.8
.00
P value
NA, Not available.
Table II. Quality of life and functional status vary by incontinence type
SF-12:PCS12 (physical) SF-12:MCS12 (mental) I-QOL total I-QOL: avoid/limit I-QOL: psychosocial I-QOL: embarrassment
US population (mean)
Fecal
Urinary
Dual
F or t statistic*
49.1 ± 9.9 49.4 ± 9.8 62.3 ± 22.4 57.8 ± 22.5 73.2 ± 23.7 49.8 ± 28.0
45.5 46.9 NA NA NA NA
42.4 50.4 62.9 58.9 71.6 50.4
38.6 46.8 46.4 43.8 53.2 37.9
F = 3.63 F = 3.47 t = –3.5 t = –3.8 t = –3.8 t = –3.0
.027† .032† <.001† <.001† <.001† .004†
NA, Not available. *Degrees of freedom for F is 433; degrees of freedom range for t is 309 to 355. †Significant at P < .05.
asked to sign the consent form. Institutional Review Board approval was obtained from our Human Subjects Division. For this study, we included all communitydwelling women age 18 to 90 years who complained of accidental loss of stool or urine. We excluded women with current urinary tract infection, genitourinary or rectovaginal fistula, or inability to read and complete the questionnaire because of cognitive impairment or language difficulty. Study design. Self-report information from the clinical questionnaire and physician diagnoses were collected on all patients. The clinical questionnaire contained information about current medical complaints, medical and surgical history, gynecologic history, urologic history, obstetrical history, menopausal status, current medications, and demographic characteristics. The questionnaire contained specific questions regarding UI symptoms, duration of UI in years and months, number of medical visits in the last year to treat UI, the amount of urine lost per episode, the number of UI episodes in the last month, and a patient incontinence severity assessment (PISA) question that rated UI severity on a 5-point Likert scale (range: l [mild] to 5 [severe]). It included two diseasespecific QOL measures, the I-QOL,8 the SF-12 functional status measure with the mental and physical component subscales.18 The questionnaire also included the Depression Port Medical Comorbidity Scale, a validated scale for assessing the number of comorbid medical disorders of a possible total of 18 common chronic illnesses.19 The Wexner scale, a commonly used measure of FI frequency,
type, and QOL impact, was used to estimate the severity of fecal incontinence.14,15 Physicians performed a history, physical examination, urinalysis and urine culture, and reviewed a 3-day voiding diary. Multichannel urodynamic testing, defecography, or anal manometry was performed as indicated by history of prior surgery, nonresponse to conservative treatment, or as a preoperative evaluation. Results Subject characteristics. A total of 732 patients were enrolled into the clinical registry database during the recruitment period. Of these, 425 patients met the inclusion criteria of reporting urine or fecal loss and receiving a physician diagnosis of UI, FI, or both. The mean (±SD) age of the patients was 55.9 ± 14.3 years. Eightyseven percent were white and 75% were postmenopausal. The mean (±SD) gravity and parity were 3.4 ± 1.9 and 2.7 ± 1.5, respectively. Fifty-one percent of the subjects had previously had a hysterectomy. The mean (±SD) number of chronic medical illnesses was 1.9 ± 1.8. As shown in Table I the study population was divided into the groups diagnosed with UI, FI, or both UI and FI (dual incontinence) for further analysis. Excluding the rate of hysterectomy, there were no significant differences in the essential demographics of the subgroups. The patients with dual incontinence, however, did have a significantly higher number of comorbid medical illnesses compared with those with fecal or urinary incontinence alone. In addition, the dual group also considered
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their urinary incontinence more severe on the self-report scale than those patients with only UI. When analyzed by number of urinary incontinent episodes in the last month, amount of urine lost per episode, and duration of urinary incontinence, however, there were no significant differences between the groups. QOL and functional status. When functional status and QOL were examined by urinary, fecal, or dual incontinence (Table II), significant differences were observed. The SF-12 physical component measures for the patients with UI or FI alone were not significantly different; however, those with dual incontinence had significantly lower scores. For the SF-12 mental component scores, all the patients with fecal incontinence had significantly lower scores than those with urinary incontinence alone. The dual incontinence patients also had significantly lower IQOL scores than those patients with urinary incontinence alone. Comment In a sample of women presenting to a urogynecology and urology specialty clinic with the complaint of UI and/or FI, we found that those women with dual incontinence consistently had significantly decreased functional status and QOL. They also had a higher mean number of chronic medical illnesses and perceived their urinary incontinence as more severe than those women with only UI, despite similar clinical characteristics of incontinence. This perception of increased severity by the women with dual incontinence may result from the additive impact of their fecal incontinence or may be related to the impact of other comorbid conditions as has been seen with UI and major depression.7 There are limitations to the interpretation of this study. The design is cross-sectional and therefore causal relationships cannot be established. Our patients are primarily white, so our findings may not apply to other populations and our group of women with FI only is relatively small. Despite these limitations, we believe that our study supports the hypothesis that women with both fecal and urinary incontinence have a lower QOL and functional status than those women with only one type of incontinence. Several prior studies have documented the reduction in QOL and functional status in women with urinary or fecal incontinence; however, the authors believe this is the first study to consider the combined impact of urinary and fecal incontinence. This is important because it has been documented that these conditions commonly occur together.17,20 In our study population as well, approximately 20% of women presenting with UI also had FI. When successful treatments of women who have these conditions are assessed, QOL measures are equally or perhaps more important than objective outcome mea-
sures. Successful treatment will require addressing both conditions. REFERENCES
1. Fantyl J, Newman D, Coiling J, et al. Urinary incontinence in adults: acute and chronic management. Rockville (MD): US Department of Health and Human Services, Agency for Health Care Policy and Research; 1996. Clinical practice guideline No.: 2. 2. Wyman J, Harkins S, Choi S, Taylor J, Fantyl J. Psychosocial impact of urinary incontinence in women. Obstet Gynecol 1987;70:378-90. 3. Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff L. Definition of overactive bladder and epidemiology of urinary incontinence. Urology 1997;50(6A Suppl):4-14. 4. Grimby A, Milsom I, Molander U, Wiklund I, Ekelund P. The influence of urinary incontinence on the QOL of older women. Ageing 1993;22:82-9. 5. Hunskaar S, Visnens A. The quality of life in women with urinary incontinence as measured by the sickness impact profile. J Am Geriatric Soc 1991:378-82. 6. Robinson D, Pearce K, Preiser J, Dugan E, Suggs P, Cohen D. Relationship between patient reports of urinary incontinence symptoms and quality of life measures. Obstet Gynecol 1998;91:224-8. 7. Melville J, Walker E, Katon W, Lentz G, Miller J, Fenner D. Prevalence of comorbid psychiatric illness and its impact on symptom perception, quality of life, and functional status in women with urinary incontinence. Am J Obstet Gynecol 2002;187:80-7. 8. Patrick D, Martin M, Bushnell D, Yalcin I, Wagner T, Buesching D. Quality of life for women with urinary incontinence: further development of the Incontinence Quality of Life Instrument (IQOL). Urology 1999;53:71-6. 9. Shumaker S, Wyman J, Uebersax J, McClish D, Fantyl J. Healthrelated quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group. Qual Life Res 1994;3:291-306. 10. Uebersax J, Wyman J, Shumaker S, McClish D, Fantyl J. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontience Impact Questionnaire and the Urogenital Distress Inventory. Neurourol Urodyn 1995;14:131-9. 11. Leigh R, Turnberg L. Faecal incontinence: the unvoiced symptom. Lancet 1982;1:1349-51. 12. Nelson R, Norton N, Cautley E, Fumer S. Community based prevalence of anal incontinence. JAMA 1995;274:559-61. 13. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, 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. 14. Rothbarth J, Bemelman W, Meijerink WJ, Stiggelbout AM, Zwinderman AH, Buyze-Westerweel ME, et al. What is the impact of fecal incontinence on quality of life? Dis Colon Rectum 2001;44:67-71. 15. Olivera L, Pfeifer J, Wexner SD. Physiological and clinical outcome of anterior sphincteroplasty. Br J Surg 1996;83:502-5. 16. Pescaton M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence: evaluation of 335 patients. Dis Colon Rectum 1992;35. 17. Jackson S, Weber A, Hull T, Mitchinson A, Walters M. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 1997;89:423-7. 18. Ware J, Kosinski M, Keller S. SF-12: how to score the SF-12 physical and mental health summary scales. Boston (MA): Health Institute, New England Medical Center; 1995. 19. Wells K, Stewart A, Hays R, Burnam MA, Rogers W, Daniels M, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1999;262:914-9. 20. Khullar V, Damiano R, Toozs-Hobson P, Cardozo L. Prevalence of faecal incontinence among women with urinary incontinence. BJOG 1998;105:1211-3.