Incontinence, urinary and fecal, is a common health issue among elderly people. Double incontinence (DI) can be defined as the concomitant presence of urinary and fecal incontinence. To date, very few studies have investigated DI in Japan [1], and the detailed information on this condition still remains limited. There is some evidence to suggest a possible shared mechanism between urinary and anorectal symptoms [2]. Therefore, the aim of this study was to investigate the prevalence of DI through the assessment of lower urinary tract symptoms (LUTS) among patients with fecal incontinence, particularly in elderly people.

We conducted a cross-sectional questionnaire survey regarding LUTS among 140 patients aged 20 years and older with a chief complaint of fecal incontinence, who visited our hospital between September 2012 to February 2014. The patients were further divided into two groups according to their age: younger group in which 46 patients were under 70 years old, and older group in which 94 patients were over 70 years old and over. The questionnaire utilized the well validated tools of International Prostate Symptom Score (IPSS), IPSS Quality of Life Score (IPSS-QOL), and Overactive Bladder Symptom Score (OABSS) to evaluate LUTS. The severity of fecal incontinence was assessed by Wexner score.

The overall mean age was 71.8 years (standard deviation; 12.0, range; 34-95). The younger group comprised of 10 males and 36 females, and the older group of 34 males and 60 females. There was no significant age-dependent difference in the average scores of IPSS and IPSS-QOL in both sexes. However, the average score of OABSS was significantly higher in both sexes of older group compared to younger group (p<0.0001). The frequency of moderately severe LUTS (IPSS>8, OABSS>6) in males had no significant age-dependent difference, whereas females in older group had significantly higher proportion of cases with OABSS of at least 6 when compared with females in younger group (35% vs. 9%; p<0.001). The presence of urinary incontinence (urge, stress, or both types) was observed in 20% of males in younger group, 44% of males in older group, 58% of females in younger group, and 67% of females in older group. In total, 78 out of 140 patients (56%) were cases with DI. With respect to stress urinary incontinence, there was no significant age- and sex-dependent difference. In female, the frequency of urge urinary incontinence were significantly higher in older group than in younger group (females 13% vs. 3%; p=0.013; males 15% vs. 0%; p=0.523). As shown in the figure, there was a significant positive correlation between IPSS total score and Wexner score in females (p=0.012), but not in males.

Nearly 60% of all fecal incontinence patients seen at our hospital had DI. The older patients with fecal incontinence were more likely to have concomitant urge urinary incontinence and were more likely to have lower QOL. These suggest that the diagnosis and treatment of LUTS, especially urinary incontinence, should be considered in conjunction with fecal incontinence. The strength of the study lies in the prospective recruitment of patients, while limitations include self-reported nature of the questionnaire and a small sample size.

The present study revealed that more than half of the fecal incontinence cases were accompanied with urinary incontinence. The presence of fecal incontinence alone has a negative impact on patients. The concomitant condition of urinary incontinence can further reduce QOL. Our findings necessitate that practicing physicians be alert to clinical signs of LUTS when seeing patients with fecal incontinence. Early detection of DI is essential to maximize treatment for both urinary and anorectal symptoms at a manageable stage. The precise mechanism that triggers DI should also be explored in future research.

Nakanishi N, et al. Urinary and fecal incontinence in a community-residing older population in Japan. J Am Geriatr Soc. 1997;45:215-9.
Matsumoto S, et al. Relationship between overactive bladder and irritable bowel syndrome: a large-scale internet survey in Japan using the overactive bladder symptom score and Rome III criteria. BJU Int. 2013;111:647-52.