New objective scoring system to clinically assess fecal incontinence

Table 1 Wexner scoring

	Never	Rarely	Sometimes	Usually	Always
Solid	0	1	2	3	4
Liquid	0	1	2	3	4
Gas	0	1	2	3	4
Wears a pad	0	1	2	3	4
Lifestyle alteration	0	1	2	3	4

Rarely: < 1/mo; sometimes: < 1/wk to ≥ 1/mo; usually: < 1/d to ≥ l/wk; always: ≥ l/d.

Table 2 Vaizey’s scoring

	Never	Rarely	Sometimes	Weekly	Daily
Solid stool incontinence	0	1	2	3	4
Liquid stool incontinence	0	1	2	3	4
Gas incontinence	0	1	2	3	4
Alteration in lifestyle	0	1	2	3	4
	No	Yes
Need to wear a pad or plug	0	2
Constipating medication	0	2
Lack of ability to defer defecation for 15 min	0	4

Never: No episodes in last 4 wk; rarely: 1 episode in last 4 wk; sometimes: ≥ 1 in last 4 wk but < 1/wk; weekly: ≥ 1/wk to < 1/d; always: ≥ 1/d.

Table 3 Fecal incontinence Severity Index scoring

	≥ 2 times/day (patient/surgeon scores)	Once/day (patient/surgeon scores)	≥ 2 times/week (patient/surgeon scores)	Once/week (patient/surgeon)	1-3 times/month (patient/surgeon scores)
Gas	12/9	11/8	8/6	6/4	4/2
Mucous	12/11	10/9	7/7	5/7	3/5
Liquid	19/18	17/16	13/14	10/13	8/10
Solid	18/19	16/17	13/16	10/14	8/11

Table 4 Detailed description of different types of incontinence [it was also translated into the local language (Hindi)]

Incontinence	Description
Urge	Whenever there is an urge to pass motion, normally, a person can hold the motion for a few minutes. In urge IC, the person faces difficulty holding the motions whenever there is an urge of passing motions. Although the motion does not come out, the feeling and fear that it will come out force the patient to rush to the toilet
Stress	Whenever there is an increase in pressure inside the tummy like in coughing or lifting weights, a person with normal anal sphincters can tighten his sphincters and hold the motions. A person can hold the motion for a few minutes. In stress IC, on increasing the pressure inside the tummy like in coughing or lifting weights, a little bit of motion or flatus leak from the anus
Mucus	A person with normal anal sphincters has a good anal tone due to which no leakage of mucus (normally present in the rectum as there is saliva in the mouth) occurs. However, in a person with weak sphincters, some mucus may leak out into the area around the anus spontaneously
Flatus	A person with normal anal sphincters has a good anal tone due to which he/she has control over the passage of gas/flatus. The person can hold the gas/flatus for some time. However, in a person with weak sphincters, gas/flatus may leak out of the anus with the person having no control over it
Liquid	A person with normal anal sphincters has a good anal tone due to which no leakage of liquid stool occurs. However, in a person with weak sphincters, some amount of liquid stool may leak out into the area around the anus spontaneously
Solid	A person with normal anal sphincters has a good anal tone due to which no leakage of solid stool occurs. However, in a person with weak sphincters, some amount of solid stool may leak out into the area around the anus spontaneously

Table 5 Four dimensions, 3 levels [modified EQ-5D+ (EuroQol)] description system utilized in the study and assignment of disability score for each fecal incontinence

Dimension	Dimension description	Perception of severity level
Usual routine activity	Performance of usual role activities such as working at a job, housework, child care, volunteer work, etc. Need to wear a pad, take a constipating medicine	Minimal problems with performing usual activities (0–5)
		Some problems with performing usual activities and moderate alteration in lifestyle (6–15)
		Unable to perform usual activities and severe alteration in lifestyle (16–25)
Anxiety/depression	Negative psychological states include anxiety, depression, behavioral, emotional control, loneliness, etc.	Minimal anxiety or depression (0–5)
		Moderate anxiety or depression (social isolation and loss of appetite) (6–15)
		Extremely anxious or depressed (suicidal ideation) (16–25)
Self-esteem	Perception about self	Minimal loss of self-esteem (0–5)
		Some loss of self-esteem (6–15)
		Marked loss of self-esteem (16–25)
Social life	How frequently the person goes out for socializing, like going to the cinema to watch a movie, going to a party, going out of the station for vacation	Minimal impact on social life (0–5)
		Some loss of social life (6–15)
		Marked curtailment of social life (16–25)

For example, an interviewee assessing liquid fecal incontinence assigns 18 points to Usual routine activity (out of 25), 20 points to anxiety/depression (out of 25), 15 points to self-esteem (out of 25), and 22 points to social life dimension (out of 25), then the total disability score assigned to liquid FI would be 75 (out of 100).

Table 6 Weight assignment to different types of incontinence by study group

	Solid	Liquid	Flatus	Mucous	Stress	Urge
Patients’ (n = 50) average disability score	82.5 ± 19.1	84.8 ± 15.4	58.1 ± 23.6	55.3 ± 21.2	52.0 ± 23.9	68.5 ± 23.5
Laypersons’ (n = 50) average disability score	83.0 ± 22.4	81.4 ± 19.2	54.6 ± 21.1	55.2 ± 19.3	48.8 ± 22.0	68.3 ± 22.8
Total average disability score	82.7 ± 20.7	83.1 ± 17.4	56.3 ± 22.3	55.2 ± 20.1	50.4 ± 22.9	68.4 ± 23.0
Division by 10	8.27	8.31	5.63	5.52	5.04	6.84
Final weight (after rounding-off)	8	8	6	6	5	7

Table 7 Comparison of ranking of six types of fecal incontinence as per severity perceived by patients, laypersons and surgeons

Ranking	Patients (n = 50)		Laypersons (n = 50)		Surgeons (n = 33)
Most severe to least severe	Type of FI	Ranking mean ± SD	Type of FI	Ranking mean ± SD	Type of FI	Ranking mean ± SD
6	Liquid	4.73 ± 1.25	Solid	4.80 ± 1.50	Solid	6.0 ± 0.0
5	Solid	4.51 ± 1.50	Liquid	4.64 ± 1.35	Liquid	5.0 ± 0.0
4	Urge	3.65 ± 1.52	Urge	3.70 ± 1.44	Stress	2.90 ± 1.07
3	Flatus	2.87 ± 1.50	Flatus	2.72 ± 1.45	Mucous	2.81 ± 0.91
2	Mucous	2.57 ± 1.38	Mucous	2.70 ± 1.44	Flatus	2.57 ± 1.06
1	Stress	2.53 ± 1.53	Stress	2.46 ± 1.38	Urge	1.69 ± 1.07

The persons in each group (patients, laypersons and surgeons) were asked to rank the six types of fecal incontinence (FI) in decreasing order of severity. The most severe was given 6 points, and the least severe FI was given 1 point. The average of each FI type in each group was calculated, and the final ranking of FI in that group was calculated.

Table 8 New scoring system

Incontinence type	Weight	Frequency			Maximum score
		Never (points)	Occasional (points) (≤ 1 episode/ wk)	Common (points) (> 1 episode/ wk)
Solid	8	0	1	2	16
Liquid	8	0	1	2	16
Urge	7	0	1	2	14
Flatus	6	0	1	2	12
Mucus	6	0	1	2	12
Stress	5	0	1	2	10
Total					80

Score in a cell = Weight for that incontinence type × frequency points. For example, a person with occasional liquid incontinence would have an 8 × 1 = 8 score. Maximum possible score = 80 (total incontinence), minimum score possible = 0 (no incontinence).

Table 9 Difference in mean ranking six types of fecal incontinence as per severity perceived by patients, laypersons and surgeons

Type of FI	Ranking mean ± SD			Significance
	Patients (n = 50)	Laypersons (n = 50)	Surgeons (n = 33)	(ANOVA)
Solid	4.51 ± 1.50	4.80 ± 1.50	6.00 ± 0.00	P < 0.00001
Liquid	4.73 ± 1.25	4.64 ± 1.35	5.00 ± 0.00	P = 0.35
Urge	3.65 ± 1.52	3.70 ± 1.44	1.69 ± 1.07	P < 0.00001
Flatus	2.87 ± 1.50	2.72 ± 1.45	2.57 ± 1.06	P = 0.88
Mucous	2.57 ± 1.38	2.70 ± 1.44	2.81 ± 0.91	P = 0.90
Stress	2.53 ± 1.53	2.46 ± 1.38	2.90 ± 1.07	P = 0.29

The persons in each group (patients, laypersons, and surgeons) were asked to rank the six fecal incontinence (FI) in decreasing order of severity. The most severe was given 6, and the least severe FI was given 1 point. The average of each FI type in each group was calculated and compared.

Table 10 Comparison of existing scoring systems with new scoring system

	Wexner	Vaizey	FISI	NSS
Comprehensive	No	No	No	Yes
FI type included: urge FI	No	Yes	No	Yes
FI type included: mucous FI	No	No	Yes	Yes
Presence of confounding parameters like “Need to wear a pad”, “Need to take constipating medicine”, and “Alteration of lifestyle”	Yes	Yes	No	No
Assigning weights to each FI by an objective method	No	No	No	Yes
Inclusion of patient perceptions (n)	0	0	34	50
Inclusion of laypersons’ perceptions (n)	0	0	0	50
Simple and easy to use	+++++	+++++	+	+++++
Detailed structured definitions	No	No	No	Yes
In-depth disability scores based on an objective description system	No	No	No	4D3L [modified EQ-5D+ (EuroQol)] used

FI: Fecal incontinence.