Patients with defecatory disorders (DD) present with symptoms such as anal incontinence (AI), constipation, evacuatory disorders, and functional anal pain (1). According to the pelvic floor report in 2021, 6.5 million people suffered from bowel problems in the UK, and 57,000 required hospital admissions in England due to constipation in 2010/2011(2). Around 40% of the patients with constipation suffer from anxiety disorders while 38% experience depression (3). Similarly, anal incontinence is associated with depression (4), and living with it is highly distressing.

This study aimed to determine the association between presenting complaints and sociodemographic and clinical characteristics in patients with DD. The prevalence of the type of presenting complaint was also examined.

This is a single-institution study of patients with DD referred to a tertiary colorectal pelvic floor unit (PFU). PFU receives a mixture of rural and urban referrals. Patients are assessed via a multidisciplinary approach starting with an initial evaluation using a structured interview followed by standardized questionnaires in a nurse-led telephone triage assessment clinic (TTAC)(5). Following TTAC assessment, patients are reviewed in a face-to-face bowel function clinic (BFC) for examination and undergo conservative management. If patients fail to have satisfactory improvement in symptoms after 3-4 BFC appointments, then investigations such as integrated total pelvic floor ultrasound, defaecating proctogram and anorectal manometry are organised as considered appropriate. Patients are then discussed in the PFU multi-disciplinary meeting (6) which is attended by consultant surgeons, nurses, physiotherapists, radiologists and clinical scientists to review patients’ symptoms, treatment offered up until that point, and investigations to plan further management.

Symptoms of defecatory disorders
Anal incontinence is the involuntary loss of flatus or feces (7).
Constipation is infrequent and/or incomplete bowel movements, with or without the need for frequent straining or manual assistance to defecate (7–10).
Obstructed defaecation syndrome (ODS) is reported as difficulty in evacuating stools, requiring straining at defaecation associated with lumpy or hard stools, having the sensation of incomplete evacuation, a feeling of anorectal blockage/obstruction or the need to manually assist defaecation (8).
Due to overlap in symptoms constipation and ODS were considered as constipation for this study.
Mixed (constipation, ODS and anal incontinence)
Functional anorectal pain: levator ani syndrome and proctalgia fugax or both.
Rectal prolapse: Protrusion of the rectum through the anus. Prolapse is either mucosal or full thickness.

Data Sources and Study Variables
Patients with symptoms of DD were identified from a prospectively maintained departmental database. Data for socio-demographics such as gender, age, ethnicity, socio-economic status was collected between March 2013 and May 2019 from the prospectively collated database. Clinical characteristics such as main presenting complaint, parity, history of episiotomy, hysterectomy, and other pelvic floor surgery were collected retrospectively from electronic patient notes. 

A total of eight ethnicities were recorded: White British, White other, Black British, Black Caribbean, Black other, Asian, Mixed and Others. Socioeconomic status was proxied by the English Indices of Deprivation Measure 2019 (IMD)(11) which is an official measure of relative deprivation in England. The IMD scale is from 1 to 10 where the IMD score was divided into quintiles (1-5), by combining adjacent decile groups. The lowest quintile represented the most deprived while the highest quintile represented the least deprived.  

Main presenting complaints recorded were constipation, anal incontinence, mixed symptoms, rectal prolapse, vaginal prolapse symptoms with incomplete rectal emptying, and other symptoms of anal pain or rectal bleeding. 

Parity was recorded as nulliparous (no live birth), primiparous (one live birth), multiparous (more than one but less than five live births) and grand multiparous (five or more live births) (12). However, due to very few patients in the grand multiparous group, patients from multiparous and grand multiparous were combined for analysis.

Of the 2001 patients referred to PFU, 1956 attended TTAC appointments with a female predominance (1673, 85.5%) and mean age of 52.9 +/- 15 years.

Prevalence of presenting complaints in patients with defecatory disorders
The main presenting complaints reported by patients were constipation (819, 42.2%), anal incontinence (503, 25.9%), mixed symptoms  (411, 21.2%), rectal prolapse (84, 4.3%), other complaints such as anal pain or rectal bleeding (84, 4.3%) and symptoms of vaginal prolapse with difficulty emptying rectum (38,2.1%).

Socio-demographic risk factors for defecatory disorders
Table 1 shows the association between socio-demographic characteristics and presenting complaints in patients with DD.

Age
Age < 50 years was associated with symptoms of constipation, rectal bleeding and anal pain, and symptoms of vaginal prolapse with difficulty emptying the rectum, p-value <0.001. Age age >50 years was associated with symptoms of anal incontinence and mixed symptoms, p-value= <0.001.

Gender
Female gender was associated with symptoms of constipation, rectal prolapse, and vaginal prolapse symptoms with difficulty emptying the rectum, p-value = 0.004. Male gender was associated with anal incontinence, mixed symptoms, and other symptoms of anal pain, or rectal bleeding, with p-value < 0.001. 

Socio-economic status and ethnicity
We did not find any variability in socioeconomic status and ethnicity when compared to presenting complaints in patients with DD.

Clinical risk factors for defecatory disorders
Table 2 shows the association of clinical risk factors with presenting complaints in patients with DD.

Parity
Nulliparity was associated with symptoms of constipation and rectal bleeding or anal pain. Parity was associated with anal incontinence, mixed symptoms, and symptoms of vaginal prolapse with difficulty emptying the rectum. An increase in parity was associated with constipation and mixed symptoms, p-value <0.001. 

Episiotomy
Episiotomy was associated with constipation, rectal prolapse, rectal bleeding, and anal pain, and symptoms of vaginal prolapse with difficulty emptying the rectum, p-value = <0.001.

Hysterectomy
Hysterectomy was associated with anal incontinence, rectal prolapse, and vaginal prolapse with difficulty emptying the rectum, p-value = <0.001

Previous pelvic floor surgery
Previous pelvic floor surgery was associated with anal incontinence, mixed symptoms, rectal prolapse, rectal bleeding, and anal pain, and symptoms of vaginal prolapse with difficulty emptying the rectum, p-value = <0.001.

•	Ageing is associated with physiological changes contributing to anal incontinence.

•	Younger patients are more likely to suffer from constipation leading to straining which makes them susceptible to rectal bleeding due to developing haemorrhoids or anal fissures. 

•	Females are more likely to be constipated and at risk of developing rectal prolapse due to straining secondary to constipation and injury to pelvic floor muscles and nerves caused during childbirth.

•	Severity of symptoms or bother is perceived differently between men and women leading to differences in reporting co-existing symptoms of constipation and AI.

•	There may exist variability in socioeconomic status and ethnicity for different presenting complaints. This needs to be explored through prospective research.

•	Pelvic floor surgery including hysterectomy is associated with anal incontinence due to disruption of pelvic floor muscles and nerves during dissection during surgery.

The most common presenting complaint recorded in patients with DD is constipation. Socio-demographic and clinical characteristics variability exists in patients with DD presenting with different symptoms. Early identification and intervention will lead to improvement in patients’ care and quality of life and preservation of already constrained healthcare resources which are being utilized currently to treat patients mostly presenting with advanced symptoms of posterior pelvic floor compartment.

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Continence 12S (2024) 101681
DOI: 10.1016/j.cont.2024.101681