https://orcid.org/0000-0003-1066-4671
Inflammatory bowel disease (IBD) is a chronic inflammation of the gastrointestinal tract and represents a heavy burden that typically impairs health-related quality of life (QoL) of suffering patients leading to hospitalization or a temporary inability to work. In fact, both anxiety and depression are common in IBD and patients tend to reduce their activities with feeling of social isolation [Citation1].
This impairment is more pronounced in Crohn’s disease (CD) than in Ulcerative Colitis (UC) due to the higher probability of having a perianal involvement that can occur in up to 50% of patients and can be the first manifestation of the disease in 5% of patients [Citation2].
Functional defecation disorders in IBD have been assessed with contradictory results that may reflect differences in anorectal physiopathology of fecal incontinence (FI) between IBD and the general population. In particular, FI is one of the main actors of this reduced QoL.
Apart from the perianal involvement as well as the aggressive surgical treatment that may disrupt the integrity of the anal sphincter complex, several other factors such as with clinical disease activity, older age, female sex, ileoanal pouch surgery, and anal fibrosis have been correlated with IBD-related FI [Citation3,Citation4].
Unfortunately, even if the occurrence of FI in IBD patients is reported in up to 25% of patients [Citation5], it continues to be underestimated.
In their observational study, Litta et al. [Citation6] tried to underline the effect of perianal disease on anorectal function and QoL in IBD patients.
The authors analyzed a series of 37 consecutive patients with active or inactive IBD with an anorectal complaint (31 patients with CD and 7 patients with UC). All patients underwent a complete clinical examination, anorectal manometry (ARM), three-dimensional endoanal ultrasound (3D-EAUS) and endoscopy. Patients’ QoL was evaluated using an Italian Version of the Inflammatory Bowel Disease Questionnaire (IBDQ) meanwhile the Harvey Bradshaw Index and the Clinical Mayo Score were used to assess disease activity.
Nine out of thirty-seven (20%) of patients experienced on a certain degree of FI [mean CCFIS (Cleveland Clinic Fecal Incontinence Score) 7.2]. These results were consistent with several previous studies [Citation7] and are closely correlated with the several previous surgical attempts to solve the disease.
In this context, a direct consequence of the impaired FI-related QoL has been demonstrated by the low value of the IBDQ (mean score 167.6). Indeed, this latter is a disease specific instrument with four main items (bowel function, systemic function, emotional function and social function) and 32 questions that correlate with the disease activity index.
Twenty healthy volunteers were included as a control group in order to determine any differences in anorectal function between groups but 3D-EAUS findings were normal in all volunteers and no significant differences were found in the ARM between patients and controls.
However, in 5 (13.5%) patients belonging to the control group the recto-anal inhibitory reflex (RAIR) was absent. RAIR plays a major role in anorectal continence and is dependent on intrinsic nerves [Citation8]. In fact, according to Mueller et al. [Citation9] the dysfunctions of the RAIR in patients without alteration in external sphincter function suggest an alteration of the enteric nervous system.
Finally, the authors found that about two-thirds of IBD patients had a dyssynergic defecation pattern in the ARM. These results were common among IBD patients even if the real prevalence is unknown [Citation10].
The study by Litta et al [Citation6] is one of the first reports concerning the complete evaluation of anorectal function in IBD patients. Moreover, since sexual health is one of the main determinants of QoL in these patients [Citation11], we think that a specific evaluation of the sexual function, using proper scoring systems such as the Female Sexual Function Index [Citation12] for women and the International Index of Erectile Function [Citation13] for men, would have increased the strength of this paper.
Currently, the evaluation of anorectal function in IBD patients is definitely “a must” but the use of the correct scores for the evaluation of continence and sexual function is mandatory.
Declaration of interest
The authors declare that no conflicts of interest exist. The author declares that he has no competing interests.
The authors alone are responsible for the content and writing of the paper.
The authors declare that this commentary has not been published elsewhere and that it has not been submitted previously for publication elsewhere.
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