The effect of a sexual abuse history on symptoms and anorectal physiology findings in patients presenting to a colorectal pelvic floor service

Studies report that 12%–23% of patients with functional anorectal disorders have a history of sexual abuse (SA). This article aims to assess whether there is a difference in symptom severity, quality of life or anorectal physiology findings in female patients presenting to a colorectal pelvic floor service with and without a history of sexual abuse.


Introduction
Functional anorectal disease, manifesting as faecal incontinence, constipation or a combination of the two, is significantly associated with an impaired quality of life. 1 Faecal incontinence is the accidental leakage of liquid or solid stool, with a reported prevalence in Australia and New Zealand of 12%-13%. 2,3 Constipation, most commonly reported as straining, hard stools and a feeling of incomplete evacuation of stools, has a prevalence of 24% in the Australian community. 4 Amongst patients with functional anorectal disease, 12%-23% report a prior history of sexual abuse. [5][6][7][8] This is similar to the lifetime prevalence of SA in the general Australian population, which is 23% according to the Australian Bureau of Statistics. 9 Some studies have suggested that patients with a history of sexual abuse have exacerbated symptom perception related to their pelvic floor dysfunction. 5,10 Currently, there is little published data on whether this perception correlates with objective clinical or physiological disease and the impact it has on quality of life. We hypothesize that SA may cause a change to defaecatory dynamics and lead to dyssynergia, which is the incoordination of muscles involved in defaecation. This article aims to assess for a difference in symptom severity, quality of life or anorectal physiology findings in female patients presenting to a colorectal pelvic floor service with and without a history of sexual abuse.

Methods
A cross-sectional study was conducted of a prospectively maintained database of patients seeking assessment at the Colorectal Pelvic Floor Service at the Queen Elizabeth II Jubilee Hospital, Queensland, Australia. This study was approved by the Metro South Human Research Ethics Committee reference: HREC/2020/ QMS/62215.

Patient selection
Data was collected on all patients who had been assessed at the functional colorectal pelvic floor unit for defaecatory dysfunction from 2017 to 2019. All patients were routinely asked to complete validated questionnaires, including being asked about a history of previous sexual abuse. We included all female patients who completed the questionnaire with regards to their symptoms, quality of life, and history of sexual abuse. Male and transgender patients were excluded. Similar studies that sought to evaluate the effect of SA on pelvic floor dysfunction included female patients only. Patients who did not complete the questionnaire were also excluded. A retrospective review of patient charts was conducted to capture demographic data, medical, surgical, obstetric and social histories. Sexual abuse (SA) is defined as responses to the following questions: (1) Have you ever had sex without agreeing to it? (2) If yes, was this vaginal sex, anal sex, or both?

Symptom and quality of life assessment
All patient questionnaires were completed at the initial visit to the Colorectal Pelvic Floor unit. Symptom severity and quality of life were assessed on symptoms of faecal incontinence and constipation using validated scoring systems. Patients completed those surveys that correspond to their presenting complaint of either faecal incontinence, constipation, or both. The Wexner Incontinence Scale 11 and Vaizey Incontinence Score 12 quantify the severity of incontinence based on different types of bowel contents (gas, mucus, liquid and/or solid stool). Higher values reflect increase in symptom severity. The Faecal Incontinence Quality of Life Score (FIQOL) has demonstrated high reliability in measuring the effect of faecal incontinence on quality of life. 13 It assesses four domains: lifestyle, coping and behaviour, depression and self-perception, and embarrassment, which have been added together for a total score. Lower values indicate a reduced quality of life. The Constipation Scoring System 14 and Obstructed Defecation Score 15 are validated systems that assess severity of disease with higher scores reflecting increased severity. The Patient Assessment of Constipation Quality of Life Sore (PACQL) is a validated questionnaire that assesses the burden of constipation on everyday function and well-being. 16 Four categories are evaluated: worries/concerns, physical discomfort, psychosocial discomfort, and satisfaction. The first three categories are summed up to give a dissatisfaction score and the fourth category a satisfaction score.

Functional assessment
Clinical examination and anorectal physiology studies were performed on all patients. Relevant clinical examination pertaining to this study evaluated dyssynergia by the presence or absence of paradoxical puborectalis contraction when asked to strain. Anorectal physiology assessments included high resolution endoanal manometry for resting and squeeze pressures, endoanal ultrasound to assess for internal or external sphincter defects, rectal sensation testing with balloon inflation, and anorectal electromyography (EMG). Dyssynergia was defined by endoanal manometry as a lack of adequate anal relaxation during strain, with patients whose anal pressure did not drop by 25% during strain being defined as dyssynergic, along with appropriate findings on clinical examination by a colorectal surgeon, and anorectal EMG with or without imaging, as per the Rome IV criteria. 17 Surface electrode EMG was used as an adjunct to assess for dyssynergia, which was defined as an increase in electrical activity during strain, rather than the normal reduction in activity. All patients had this diagnostic procedure done.

Analysis
Variables were analysed either with chi-squared (χ 2 ) test for categorical variables, or with Mann-Whitney test for continuous variables comparing the two cohorts of patients with and without a history of SA. A multivariate linear regression model was used to determine the effect of sexual abuse on the results of the different survey scores evaluating symptom severity, quality of life, and anorectal physiology study results. A P-value of 0.05 or less was considered statistically significant. All analysis was performed using SPSS Statistics for Windows, version 25 (SPSS Inc., Chicago, Ill., USA).

Results
Data was collected on 244 patients who had been assessed at the functional colorectal pelvic floor unit for defaecatory dysfunction. None of the male (n = 40) or transgender (n = 1) patients have reported a history of sexual abuse and so were excluded. Patients who did not complete the questionnaire were also excluded. A total of 148 female patients were included in this study, and of these 17% (n = 25) reported a history of penetrative SA. Abuse was reported as vaginal in 52%, anal in 16% and both in 32%. Patients with and without a history of SA were similar in age with a mean of 48.8 and 51.5, respectively (Table 1). They had a similar obstetric history with regards to episiotomy, perineal tear, and hysterectomy. A similar proportion in both groups had undergone anorectal operations, vaginal prolapse operations, and rectocele or cystocele operations. Approximately half of both groups were sexually active, 48.0% with a history of SA and 53.7% with no history of SA. The rate of psychiatric diagnoses was also similar. None of the baseline characteristics differentiated the two groups by a significant degree.
Symptom severity and quality of life survey scores for faecal incontinence (WEXNER, VAIZEY and FIQOL), and constipation (CSS, ODS, and PACQL) showed no significant difference between the two groups with and without a history of SA ( Table 2). The four FIQOL domains: lifestyle, coping and behaviour, depression and self-perception, and embarrassment, were similar between the two groups. Anorectal physiology testing (resting tone, squeeze tone, first sensation, urge to defecate, maximum volume tolerated, pudendal nerve terminal motor latency, and percentage of internal/ external sphincter defect) showed no significant difference between the two groups. The percentage of women with evidence of dyssynergia determined by physical examination, manometry, or electromyography did not differ significantly between those with and without a history of SA (Table 3).

Discussion
A history of sexual abuse is an important element in functional anorectal disorders, and this history is often uncovered during a functional anorectal consultation. The association between psychological distress and functional GI disorders is well established and the psychological impact of sexual abuse may play a part in the genesis or perception of functional anorectal disorders in this cohort.
In this study, we evaluated symptom severity, quality of life, and anorectal physiology findings in female patients with faecal incontinence or constipation who may or may not have had a prior history of SA, and we found no significant differences between the two groups. There were no clinical, manometric, or electromyographic differences in the assessment of dyssynergia between the two groups.
Our findings were different to those from a systematic review and meta-analysis of 23 studies describing 4640 patients that reported an association between SA and functional gastrointestinal disorders, non-specific chronic pain, and chronic pelvic pain. 18 Out of five studies that assessed for functional gastrointestinal disorders, only three demonstrated a significant odds ratio (OR) to indicate a correlation with SA, with an overall significant OR. However, these studies defined functional gastrointestinal disorders as irritable bowel syndrome and did not specifically assess for faecal incontinence or constipation.
A cross-sectional study of 1781 women in a tertiary referral centre for pelvic floor disorders at the University of California reported altered disease perception with increased symptom severity and diminished quality of life scores for both faecal incontinence and constipation in those with a history of SA compared to those without. 10 This contrasts with our study in which we found no correlation between reported perceived disease and a history of SA. In addition, the study from California reported no significant difference in anorectal physiologic variables. Similarly in our study there was no demonstrable difference between the two groups in anorectal physiology or dyssynergia measured both clinically and functionally. In fact, no studies have been identified by our literature review that showed a significant difference in anatomy or physiology in patients with a history of SA. These findings are pertinent to clinicians who evaluate and manage patients with pelvic floor dysfunction that volunteer a history of SA. The lack of objective anorectal pathology findings to differentiate patients with and  without a history of SA suggests a management algorithm should not differ between the two groups. History of anorectal operations, vaginal prolapse operations, rectocele or cystocele operations, hysterectomy or obstetric injuries did not correlate with a prior history of SA. Interestingly, a study on the impact of SA on patients with slow-transit constipation undergoing subtotal colectomy and ileorectal anastomosis found that those with a history of SA had more previous operations, more post-colectomy abdominal pain complaints, and more functional diagnoses. 19 However, the study had a small sample size of 15 patients and so conclusions should be taken guardedly.
It is interesting to note that those with a history of SA had no significant physical damage compared to those without history of SA as evident by the percentage of internal and external sphincter defects in both groups: 16.0% and 16.7% in those with history of SA versus 17.0% and 22.2% in those without history of SA. Several studies that evaluated anogenital trauma in children and adolescents who were victims of penetrative sexual abuse reported that only about 2%-13% of abused patients were found to have signs of anal injuries on examination following the incident. [20][21][22] This suggests that the majority of penetrative sexual abuse victims do not have signs of anal physical damage.
Our study has several limitations. The relatively small sample size of 148 patients, retrospective nature, and possible underreporting of sexual abuse may have affected our results. Recall bias may have played a role given the history of SA was self-reported. SA is defined in our questionnaire as non-consensual penetrative sex, either vaginal, anal or both. This narrow definition of SA is a limitation of our retrospective study. A broader definition of SA would also include forced sexual touching, and sexual attempts. 7,23 Although this is a limitation, the questions used to elicit a history of SA would arguably select out those who are most affected. There is currently no standard for defining sexual abuse. 7,24 However, abusive experiences have been rated in various studies by their degree of invasiveness with intercourse being the most serious resulting in worse health outcomes in all variables including pain, non-gastrointestinal symptoms, psychological distress, and functional disability. 5,23 Patients' reluctance to disclose sensitive information, such as their history of SA, in a questionnaire followed by a meeting with a non-psychology-trained clinician is another limitation of this study that may have impacted the observed prevalence of SA. Multiple studies assessing the prevalence of SA report variable figures which have been found to be the result of divergent techniques used and lack of standardization in obtaining SA histories, including face-toface interviews, telephone interviews, and questionnaires. 24 The complexity of such disclosures is also partly due to the patients' feelings and beliefs. In addition, it is recognized that building a therapeutic relationship over a long period of time allows for this type of disclosure to unfold more readily compared to a short initial meeting. 25 This limitation may have played a role in underrating those with a history of SA in our study to be 17% compared to the lifetime prevalence of SA in the general Australian population of 23% according to the Australian Bureau of Statistics. 9 There is a limitation in our assessment of dyssynergia. We used clinical examination, high resolution manometry, and surface EMG; however, we did not routinely use balloon expulsion test and defecography.

Conclusion
The rate of SA in female patients with defaecatory dysfunction presenting to our pelvic floor unit is similar to that reported in the general population of Australia. We found no significant difference in symptom severity or quality of life in patients attending the clinic who had a self-reported history of penetrative SA. Moreover, SA had no objective consequence on anorectal anatomy or physiology, and specifically there was no difference in the rates of dyssynergia. Although a history of SA may have other consequences not assessed in this study, the lack of evidence to support symptom-related or physiologic differences with regards to faecal incontinence or constipation should empower clinicians to employ standard management principles of the disease to patients with a history of SA.