Diseases of the Volume Number

CozoN RecrvM 42 12 DECEMBER 1999

ORIGINAL CONTRIBUTIONS

Patient and Surgeon Ranking of the Severity of Symptoms Associated with Fecal Incontinence The Fecal Incontinence Severity Index

Todd H. Rockwood, Ph.D.,* James M. Church, M.D.,-~ James W. Fleshman, M.D.,:} Robert L. Kane, M.D.,* Constantinos Mavrantonis, M.D.,$ Alan G. Thorson, M.D.,[] Steven D. Wexner, M.D.,q] Donna Bliss, R.N., Ph.D.,# Ann C. Lowry, M.D.,**

From the * Clinical Outcomes Research Center, University of Minnesota, Minneapolis, Minnesota, tDepartment of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, }Division of Colon and Rectal Surgery, Barnes Jewish Hospital, St. Louis, Missouri, §Department of Colon and Rectal Surgery, Cleveland Clinic .Florida, Ft. Lauderdale, Florida, ]]Division of Colon and Rectal Surgery, Creighton University, Omaha, Nebraska, q[Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota, #School of Nursing, University of Minnesota, Minneapolis, Minnesota, and **Department of Surgery, University of Minnesota, Minneapolis, Minnesota

PURPOSE: The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index. METHODS: The Fecal Incontinence Severity Index is based on a type × frequency matrix. The matrix includes four types of leakage com- monly found in the fecal incontinent population: gas, mu- cus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores. RESULTS: Surgeons and patients had very similar weightings for each of the type × frequency com- binations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale. CONCLUSIONS: Evaluation of the Fecal Incontinence Sever-

Supported by a contract between the University of Minnesota Clin- ical Outcomes Research Center and The American Society of Colon and Rectal Surge W and the Minnesota Coton and Rectal Founda- tion. No reprints are available.

ity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differ- ences associated with the accidental loss of solid stool. [Key words: Fecal incontinence; Health surveys; Outcome assess- ment (health care); Severity of illness index]

Rockwood TH, Church JM, Fleshman J~', Kane RL, Mavran- tonis C, Thorson AG, Wexner SD, Bliss D, LowI T AC. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 1999;42:1525-1532.

A fundamenta l issue related to the successful study of ou tcomes is the identif icat ion of the severity

of a condit ion. Severity measures are impor tant in

establ ishing the comparabi l i ty of pat ients in order to

assess the effectiveness of alternative methods of

treatment. 1 The goal of this research was to deve lop

and evaluate a severity index for fecal i ncon t inence

(FD. The fundamen ta l s trength of such a tool is to

al low for assessment of severity i n d e p e n d e n t of direct

clinical observations; thus, assessment can be d o n e at

1525

1526 ROCKWOOD ETAL Dis Colon Rectum, December 1999

any time and provide a cost-effective means of mon-

itoring the severity of a patient's status w-ithout direct

clinician contact.

For many conditions, objective data may be used to

assess severity. The DeMeester Score relies on data

from 24-hour patient monitoring. 2 Although there are

numerous physiologic measurements used for incon-

tinence, none have been shown to reflect severity or

response to therapy accurately. 3 As a group patients

with FI have lower manometric pressures than con-

trols~ but there is significant overlap. In addition, a

worsening clinical status is not always associated with

decreasing pressures. 4, 5 Pudendal nerve terminal mo-

tor latency has not been shown to correlate with

manometric pressures or clinical status. 6 There is con-

troversy over whether pudendal nerve terminal motor

latency status is predictive of outcome after sphincter repair. 7 Anal ultrasound reliably detects sphincter de-

fects. The presence of a defect correlates with mano- metric pressures but not clinical function. 8

Patient history is thus the best way to estimate severity of fecal incontinence. One approach would

be to record each patient's experience descriptively,

but that information is difficult to use for comparison.

Numerous scoring or grading systems are present in the literature. 9-2° A number of systems include only

the consistency of the leakage, ignoring the frequency

of occurrence. Those scales sacrifice discriminatory

power for simplicity. Other scales mix historical data with data from physical examination or testing. 14, 15

The numerical values assigned each data point seem

to have been chosen arbitrarily.

Other scales mix lifestyle issues with type and fre-

quency.~7, ~9 Although quality of life (QOL) instru-

ments are related to severity, they are designed to

measure the impact of a given condition on a patient's life. Intuitively, the more severe the condition is, the

more impact it will have on QOL. Therefore, the two

measures should be correlated. However, QOL instru- ments measure different aspects of a patient's condi-

tion and should not be considered a direct indicator of severity, because they do not assess the same thing

(i.e., the same level of severity can affect different patients in dissimilar ways).

To our knowledge none of the scales have been

tested or compared with other measures (convergent validity analysis). The lack of a standard, validated, severity measure makes comparison of patients and the outcomes of treatment modalities difficult. The goal of this research was to develop a severity mea- sure for fecal incontinence, the Fecal Incontinence

Severity Index (FISI). The initial step was to explore

surgeon and patient severity ~ rankings of various com-

ponents of FI and to provide a logical basis for the

assigned severity score. The basic components of the

FISI include the type of incontinence (gas, mucus,

liquid, or solid) and the frequency of occurrence. Information on these topics is invariably obtained

through a self-report, whether during a clinical assess-

ment or a patient self-report done outside of the

clinical setting.

P A T I E N T S A N D M E T H O D S

Study Design

A type × frequency matrix was developed based

on the components of fecal incontinence. The focus

was on four types of incontinence: gas, mucus, and

liquid and solid stool. The frequency dimension used

five time frames: two or more times per day, once per

day, two or more times per week, once per week, and

one to three times per month. Figure 1 A illustrates the

matrix that was presented to the participants.

Participants in the research were given the 20-cell

table shown in Figure 1 A and instructed to rank the

severity of the items relative to each other, assigning

a "1" to the most severe cell in the table and a "20" to

the least severe. The participants were instructed not

to use tie scores The type × frequency- matrix was

administered to both surgeons and patients. A total of

26 colon and rectal surgeons completed the form. All

of these were conducted in person, in a focus-group

type of setting. A total of 34 patients completed the

form. Twelve of these were conducted through the

mail and the additional 22 were completed by pa-

tients in a colon and rectal surgery clinic (Minneapo-

lis, MN). Analysis of the two separate patient groups

demonstrated no significant differences be tween their

rankings; these data have been pooled for the analy- sis.

Using patient and surgeon ratings, separate severity

weighting systems were developed. One was based on patient ratings and one on surgeon ratings. The

mean value for each of the 20 ceils shown in Figure 1

was calculated. This mean value provides the weight- ing of each type × frequency toward the overall severity score. (Table 1 gives the resultant cell-by-cell

weighting scores for both patients and surgeons. Note that for calculation of the FISI scores, the original responses have been reverse coded so that a higher score indicates greater severity, e.g., 1 = least severe condition and 20 = most severe condition.)

Vol. 42, No. 12

A

Gas

Mucus

Liquid

Solid

FECAL INCONTINENCE SEVERITY INDEX

2 or More Once a 2 or More Once a 1 to 3 Times Times a Day Day Times a Week Week A Month

1527

B

2 or More Once a 2 or More Once a 1 to 3 Times Times a Day Day Times a Week Week A Month Never

a. Gas [] [ ] [] [] [] [ ] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Mucus [] [] [] [] [] []

c. Liquid Stool [] [] [] [] [] []

d Solid Stool [] [] [] [] [] []

Figure 1. Fecal Incontinence Severity Index. A, Event × frequency matrix presented to surgeons and patients to develop weightings and overall severity score. Participants were instructed to rank the importance of each cell by placing a "1" in the most severe cell and a "20" in the least severe cell. B. Fecal Incontinence Severity Index Question. Presented to the fecal incontinence study population, the question asked, "For each of the following, please indicate on average how often in the past month you experienced any amount of accidental bowel leakage: (Check only one box per row.)"

Table 1. Surgeon and Patient Ratings of Fecal Incontinence

Two or More Times per Day

Once per Day Two or More

Times per Week Once per Week

One to Three Times per Month

Patient Surgeon Patient Surgeon Patient Surgeon Patient Surgeon Patient Surgeon

Gas 12/5.7 9/4.7 11/4.6 8/4.5 8/3.9 6/4.6 6/3.2 4/4.9 4/3.3 2/3.9 Mucus 12/5.6 11/3.8 10/4.6 9/3.2 7/3.8 7/2.1 5/3.1 7/3.7 3/3.0 5/4.6 Liquid 19/1.9 18/3.6 17/2.4 16/2.8 13/3.3 14/2.7 10/3.7 13/3.0 8/4.1 10/4.1 Solid 18/2.7 19/3.8 16/2.4 17/3.4 13/2.1" 16/3.2 10/2.7" 14/2.9 8/3.1" 11/3.7

Figures are mean/standard deviation. Note for calculation of the Fecal Incontinence Severity Index scores that the original responses have been reverse coded so that a higher score indicates greater severity, e.g., 1 = least severe condition and 20 = most severe condition.

* Indicates significant difference at the .01 level (Bonferroni adjusted t-test of means).

The following is an example illustrating how the

FISI is calculated:

Patient A reported the following: gas once per day,

mucus leakage never, liquid stool loss once per week,

and solid stool loss one to three times per month.

Taking the surgeon weighting scores from Table 1,

their FISI score would be determined in the following

manner: gas once per day, +8; mucus leakage never,

+0; liquid stool loss once per week, +13; solid stool

loss 1-3 times per month, +11; for a total FISI score of

32. Using the patient ratings from Table 1, the FISI score

would be: gas once a day, +11; mucus leakage never,

÷0; liquid stool loss once a week, +10; solid stool loss

1-3 times a month, +8; for a total FISI score of 29.

1528 ROCKWOOD ETAL Dis Colon Rectum, December 1999

To evaluate the FISI, data from another study on an FI patient population was also used. In that study 118 people with FI were surveyed and patients reported the frequency of incontinence they were experienc- ing. 21 This survey included the question presented in Figure 1 B. The data on the frequency of occurrence for each of the types of leakage given in this self-report were used to calculate each patient's severity score.

Another data source from this study that will be used is the quality-of-life scales in the Fecal Inconti- nence Quality of Life scale (FIQL). is These scales were used to test how well the FISI scores correlated with measures of fecal incontinence--specific quality- of-life measures.

Analysis

Evaluation of the severity rankings used two sepa- rate analyses. The first directly compared the weight- ings of the surgeons and patients to determine whether there were differences between them in their ranking of the severity of Ft. Two approaches were used for this analysis. First, a Pearson correlation examined the extent of agreement in the rankings between patients and surgeons. Second, the mean ranking of each cell in the table presented in Figure 1 A was compared using a t-test of means.

The second analysis sought to evaluate whether or not the rankings of one group (patient or surgeons) better predicts patient QOL by comparing the Pearson correlation of both the patient and surgeon rankings with each of the four FIQL scale scores. Finally, the sensitivity of using one or the other ranking was tested by comparing the scores generated for hypo- thetical patients.

RESULTS

The rankings for the surgeons and patients corre- late very highly (r = 0.97; Fig. 2). Nonetheless, the surgeons and patients differ in the relative importance they place on some elements used to calculate the FISI score. Table 1 presents the results of the analysis that compares the mean rankings assigned to each of the cells by the surgeons and patients. Overall, pa- tients and surgeons demonstrated consistency- in their severity rankings. As shown in Table 1, the weighting given by patients and surgeons were significantly dif- ferent in only three of the twenty cells (Bonferroni adjusted 1-test of means). Surgeons assigned more weight (severity) to infrequent episodes of solid stool incontinence than patients.

Because the rankings by each group for liquid and solid stools and for gas and mucus were essentially

70 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

t - O

GO

60

50

40

30

20

10

R 2 = 0 , 9 6 6 3

0

0 10

i i

20 30 40 Patient

50

Figure 2. Comparison of patient and surgeon severity ratings.

i

6O 70

Vol. 42, No. 12 FECAL INCONTINENCE SEVERITY INDEX 1529

the same, in seemed reasonable to collapse these into

two types of discharge: liquid or solid stool and gas or mucus. Figure 3 compares the rankings for the col-

lapsed event types. There are no significant differ- ences for the Gas/Mucus combinations, but as ex- pected three of the Liquid/Stool combinations

demonstrate significant differences: one to three times per month, once per week, and twice per week (Bon-

ferroni adjusted t-test of means).

Correlation of Severity and Quality of Life

The correlation between each of the four FIQL scale scores and the severity weights generated from each of the two sources (patient and surgeons) for the weightings is shown in Table 2. The correlations be- tween the severity weights and the scales from the FIQL are similar for patients and surgeons for each of the four scales. Three of the scales demonstrate sig- nificant correlations with both the surgeon and pa-

tient severity scores: Lifestyle, Coping/Behavior, and Embarrassment (P < 0.05). The Depression/Self-Per- ception scale, although correlated in the expected

direction, did not demonstrate significant correlations

with the severity scores.

D I S C U S S I O N

The goal of this research was to evaluate a scheme to assess the severity of FI. The findings from this preliminary research reveal a general pattern of sim- ilarities with a few differences in how patients and

surgeons rank the severity. The primary difference occurs in the ranking of infrequent leakage of solid stool, which the surgeons rank as being more severe. Although these differences do exist, there is no sig- nificant gain from using one set of rankings over the other in the prediction of a patient's self-reported QOL.

The fact that the two respondent groups agreed in

the majority of cases is encouraging. The discrepan- cies reflect the interpretation each group places on

the different types of incontinence. A real difference in perception is shown by the surgeons putting

greater importance on incontinence of solid stool than patients did. The surgeons are more likely to

Gas/Mucus 1-3x Month

Gas/Mucus lx Week ~ l , , t~ , t / I? ~ ' ~ : t ~,,,: ~ ~ B i ~

Gas/Mucus 2x Week ~ [:J ~,tmH~;~ ~{~Btttt~@g@t ~1!,~

Gas/Mucus lx Day t~IFII~I/@

*Liquid/Solid 1-3x Month ~I~'~,~:~@~ ~#~@~t~ ~

*Liquid/Solid 2x Week

Liquid/Solid lx Day ~ ~ ~ ~ ' ~ . . . . . . . ~'~ . . . . ~!~'~ l" ~

Liquid/Solid 2x Day t~M'~!tt t~ t~t~t ~ . ~ ,, @ ~ % q ~ I I I I I I I

0 2 4 6 8 10 12 14 16 18 20 ] [] Patient • Surgeon I Less More

Severity

Figure 3. Comparison of surgeon and patient ratings of fecal incontinence. Combining Gas/Mucus and Liquid/Solid categories, higher score indicates greater severity. * = significant difference, Bonferroni adjusted t-test of means.

1530 ROCKWOOD E T A L Dis Colon Rectum, December 1999

Table 2. Surgeon and Patient Severity Ratings Correlation with Fecal Incontinence Quality of Life (FiQL) Scales

Coping/ Depression/ Embarrassment Rating Lifestyle Behavior Self-Perception

Patient - . 45~ - .29" - . 2 0 -.381" Surgeon - .44~ - .32* - . 23 -.391"

Figures are Pearson correlation coefficients. Note that severity score and FIQL scale scoring run in opposite directions; a higher rating indicates more severe fecal incontinence, whereas for the FiQL scales a higher score indicates a higher functional status or quality of life.

* Significant at P < .05. 1 Significant at P < .01.

emphasize a physiological interpretation of events,

whereas patients are more conscious of leakage that can affect personal hygiene and provoke social em- barrassment. Surgeons view solid stool loss as reflec-

tions of sphincter integrity and the adequacy of sur- gical repairs.

The question then becomes how- important the differences are between the two groups in producing different levels of overall severity. As noted earlier, either weighting source produces scores that are sig-

nificantly correlated with three of the four QOL mea- suresY The score for an individual patient might vary depending on whether surgeon or patient rankings were used. The extent of the effect of using different weighting sources at a patient level can be appreci- ated from the following example: Patient 1 reported the following: gas two or more times per day (patient

weight, 12; surgeon weight, 9), mucus two or more times per week (patient weight, 7; surgeon weight, 7),

solid stools once per day (patient weight, 16; surgeon weight, 17); thus, Patient l 's severity score based on the patient rankings is 35 and based on the surgeon rankings is 33. Patient 2 had gas one to three times per month (patient weight, 4; surgeon weight, 2), mucus once per week (patient weight, 5; surgeon weight, 7), liquid stools once per week (patient weight, 10; sur- geon weight, 12), and no solid stool loss; the severity score based on patient weightings would be 19 and based on surgeon weightings would be 22.

Although the differences between the two groups (patients and surgeons) are not great, they can pro- duce slightly different results. The magnitude of the difference will depend on the underlying frequency of the type of FI problem in a given sample of pa- tients. Patients able to control stool but not flatus or mucus will receive higher scores when the patient ratings are used. It is unclear how important these differences are clinically.

This pattern of modest differences in the impor-

tance assigned by professionals and consumers has been seen in other contexts. In a study examining the relative importance ratings of activities of daily living, professionals tended to assign higher value to more

severe elements, whereas consumers placed higher importance on the more common events. 22

In the end, the choice of which rating group to use as the criterion standard may depend on what out- come is being emphasized. In the context of an eval- uation of surgical success, the surgeon weightings make more sense, because they reflect sphincter com- petence. Gas and mucus production are less likely to be sensitive to surgical intervention. However, from the perspective of patient satisfaction with the result,

these elements have high salience. Further research is necessary to confirm these find-

ings and test both the surgeon and patient weightings in clinical settings. If the significant differences be- tween patients and surgeons persist, ultimately a choice of which perspective to use as a standard will need to be made or both scores will need to be

reported. Further work is also necessary to unde> stand whether combining the categories of gas and mucus and of liquid and solid stool is useful. Finally, the details of assigning specific weighting scores need further resolution.

REFERENCES

1. Smith M. Severity. In: Kane RL, ed, Understanding health care outcomes research. Gaithersburg: Aspen Publishers, 1997:129-52.

2. Jamieson JR, Stein HJ, DeMeester TR, et al. Ambulatory 24-h esophageal pH monitoring: normal values, optima/ thresholds, specificity, sensitivity, and reproducibility [see comments]. Am J Gastroenterol 1992;87:1102-11.

3. Shelton A, Madoff R. Defining anal incontinence: estab- lishing a uniform continence scale. Semin Colon Rectal Surg 1997;8:54-60.

4. Felt-Bersma RJ, Klinkenberg-Knol EC, Meuwissen SG.

Vol. 42, No. 12 FECAL INCONTINENCE SEVERITY INDEX 1531

Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value. Dis Colon Rectum 1990;33:479-85; discussion 485-6.

5. Rogers, J, Henry MM, Misiewicz JJ. Combined sensory and motor deficit in primary neuropathic faecal incon- tinence. Gut 1988;29:5-9.

6. Tjandra J, Sharma B, McKirdy H, et al. Anorectal phys- iolo M testing in defecatory disorders: a prospective study. Aust N Z J Surg 1994;64:322-6.

7. Gilliland R, Altomare DF, tvioreira H Jr, et al. Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty. Dis Colon Rectum 1998; 41:1516-22.

8. Bartram C, Law P. Anal endosonography: technique and application. Adv Gastrointest Radiol 1991; 1:101-15.

9. Broddn G, Dolk A, HolmstrOm B. Recovery of the in- ternal anal sphincter following rectopexy: a possible explanation for continence improvement. IntJ Colorec- tal Dis 1988;3:23-8.

10. Corman ML. Gracilis muscle transposition for anal in- continence: late results. BrJ Surg 1985;72(Suppl):S21-2.

11. Rainey, JB, Donaldson DR, Thomson JP. Postanal re- pair: which patients derive most benefit? J R Coil Surg Edinb 1990;35:101-5.

12. Rudd ~GV. The transanal anastomosis: a sphincter- saving operation with improved continence. Dis Colon Rectum 1979;22:102-5.

13. Womack NR, Morrison JF, Williams NS. Prospective study of the effects of postanal repair in neurogenic faecal incontinence. Br J Surg 1988;75:48-52.

14. Kelly JH. Cine radiography in anorectal malformations. J Pediatr Surg 1969;4:538-46.

15. Holschneider AM. Treatment and functional results of anorectal continence in children with imperforate anus. Acta Chit Belg 1983;82:191-204.

16. Lunniss PJ, Kamm ~vL&, Phillips RK. Factors affecting continence after surgery for anal fistula. Br J Surg 1382; 81:1382-5.

17. Rothenberger D. Anal incontinence. In: CameronJL, ed. Current surgical therapy. Philadelphia: Decker Mosby, 1984:185-94.

18. Miller R, Bartolo DC, Locke-Edmunds JC, Mortensen NJ. Prospective study of conservative and operative treat- ment for faecal incontinence. Br J Surg 1988;75:101-5.

19. Jorge JM, Wexner SD. Etiology and management of" fecal incontinence. Dis Colon Rectum 1993;36:77-97.

20. Pescatori M, Anastasio G, Bottini C, Mentasti A. New t grading and scoring for anal incontinence: evaluation of 335 patients. Dis Colon Rectum 1992;35:482-7.

21. Rockwood TH, ChurchJM, Fleshman JW, et al. FIQL: a quality of life instrument for patients with fecal incon- tinence. Dis Colon Rectum (in press).

22. Kane R, Rockwood T, Finch M, Philp I. Consumer and professional ratings of the importance of functional

status components. Health Care Financing Rev 1997;19: 11-22.

Invited Editorial

To the Editor--The study by Rockwood and co-

workers is a welcome addition to the literature on the

quantitative assessment of fecal incontinence using a

scoring system. There is no doubting the need for an

internationally agreed scoring system for fecal incon-

tinence to allow- comparisons be tween patient popu-

lations and outcomes of medical and surgical treat-

ment. Such a goal has been achieved for urinary

incontinence through the International Continence

Society, but this body is mainly the preserve of urol-

ogists and urogynecologists. A similar grouping with

representatives from colorectal surgery, gastroenter-

ology and associated specialists would be helpful.

Agreeing a universal scoring system should be possi-

ble, but from whose perspective should the system be

created, the patients' or the surgeons'?

Rockwood and colleagues first of all constructed a

chart with four types of incontinence and five fre-

quencies, from twice per day up to one to three times per month. The 20 cells could then be weighted 1 to

20 by a group of patients and colorectal surgeons.

Slightly confusingly, they adopted the convention of

the lowest score "1" for the most severe symptoms

and the highest "20" for the least severe. Although this

score has been inverted to make the highest value the

worst incontinence in the final calculation of severity,

the patients participating in the original ranking exer-

cise might have found this off-putting. The mean

score for each cell was then calo.llated for patients

and surgeons, and on the whole there was a good

correlation. Interestingly, patients were more con-

cerned about frequent episodes of gas incontinence,

whereas surgeons ranked less frequent episodes of

solid stool more severely. It is a pity that the authors

did not look at urgency in a similar way. Patients

report urgency and the uncertainty that accompanies

it an important and troublesome symptom in ulcer-

ative colitis and incontinence. They then went on to compare their new Fecal

Incontinence Severity Index with an as yet unpub- lished but validated Fecal Incontinence Quality of Life

scale, and there was a similarly good correlation. In discussion they did not r ecommend which rankings

should be used, because it is dea r that much depends on what is being assessed--surgeons look with the

results of surgery in mind, are less able to achieve