Crohnʼs perianal fistulas and the incidence of fecal incontinence

Abstract

Fistulizing perianal Crohn's disease (CD) can cause significant morbidity including fecal incontinence. The rate of fecal incontinence in these patients (pts) varies in the literature. The purpose of this study was to assess the rate of fecal incontinence in pts with Crohn's perianal fistulas and to determine if there is a difference in outcomes between those pts who have undergone primarily medical or surgical treatment for their perianal disease. The medical records of pts who presented to the GI Clinic at a single academic medical center between 1/01 and 6/05 with perianal CD were reviewed. Demographic data and information regarding treatment was recorded. Mailed questionnaires and telephone interviews were conducted to determine the Fecal Incontinence Severity Index (FISI) score and patient satisfaction with medical and surgical outcomes. Of 118 pts identified with Crohn's perianal fistulas, a total of 65 (55%) completed the questionnaire. 43 (66%) pts had surgical treatment while 22 (34%) had medical treatment only. The overall rate of fecal incontinence was high with 48% of all pts having ≥ 1 episode a week of solid stool incontinence. There was no difference between the medical and surgical cohorts (55% vs. 44%; p=.45) The median FISI for the medical group was 34, (range 0 - 59) while the median FISI for the surgical cohort was 29 (range 0-56; p=.37). The type of surgical treatment did not affect outcome. Surgical pts who had less invasive operations (incision and drainage or seton placement) had a median FISI of 29, and pts who underwent more aggressive surgical treatment (fistulotomy, fistulectomy, or advancement flap) had a median FISI of 43 (range 5-54; p=.11). All pts were asked to rate their degree of satisfaction (1 = poor and 5 = excellent). Pearson's product moment analysis revealed that there did not appear to be a strong relationship between level of satisfaction and FISI score (correlation = -0.18, p=.17). The rate of fecal incontinence in pts with perianal CD is high. There is not a significant difference in the degree of fecal incontinence between pts treated medically or surgically for perianal CD, nor is there a significant difference in fecal incontinence with the different surgical procedures. Patients with higher FISI scores are not necessarily less satisfied with their results.