Critical analysis of fecal incontinence scores

Objectively evaluating the lack of bowel control (fecal incontinence) continues to be a challenge. Many have attempted to measure the severity of fecal incontinence and to evaluate its impact on the quality of life by developing standardized scoring systems. Some of these systems have been validated but none have achieved widespread use and all have limitations in evaluating pediatric patients.

A review of the literature was performed looking for validated scoring systems of fecal incontinence that are currently used for either adult or pediatric patients. The identified scoring systems were then critically analyzed and their applicability for managing fecally incontinent children considered.

Thirteen of the most frequently used fecal incontinence scoring systems were selected (6 for adults and 7 for children). Quality of life questionnaires were excluded not only because of their length and complexity, but mostly because they do not accurately reflect a measurement of bowel control. Our analysis revealed that all pediatric scoring systems require some degree of interpretation as they included at least one subjective parameter. These unverifiable subjective parameters were: "sensation of rectal fullness", "sphincter squeeze", and "anal shape". Equally problematic, the pediatric systems frequently focused on factors unrelated to fecal continence such as "frequency of bowel movements", "rectal prolapse", "abdominal pain", "blood in the stool", "leakage of urine", "diarrhea", and "constipation". The most objective system found from our review is the Krickenbeck system, which focuses upon two objective factors. Those two factors are the absence of voluntary bowel movements and the presence of soiling in the underwear. The major weakness of the Krickenbeck system is that it does not allow for reassessment after medical or surgical interventions. In this paper, we propose a modification of the Krickenbeck system that allows for such an assessment to be applied to those patients who are able to achieve voluntary bowel movements with the aid of laxatives or constipating agents.

Most scoring systems are flawed because they invite bias and interpretation due to their subjective nature, while systems focused on measuring quality of life do not address the fundamental issue of bowel control. The Krickenbeck score seems to be the most applicable and objective method of evaluating bowel control in pediatric patients that may be more useful when modified to assess patients after medical intervention.