The Effect Of A Sexual Abuse History On Symptoms And Anorectal Physiology Findings In Patients Presenting To A Colorectal Pelvic Floor Service

doi:10.21203/rs.3.rs-1430665/v1

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The Effect Of A Sexual Abuse History On Symptoms And Anorectal Physiology Findings In Patients Presenting To A Colorectal Pelvic Floor Service

https://doi.org/10.21203/rs.3.rs-1430665/v1

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Purpose: Studies report that 12-23% of patients with functional anorectal disorders have a history of sexual abuse (SA). This paper 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.

Methods: A retrospective analysis of all female patients attending a single tertiary pelvic floor unit for faecal incontinence or constipation between 2017 and 2019 was performed. Patients were divided into two groups depending on the presence or absence of a volunteered history of sexual abuse. Validated quality of life and symptom severity scores, along with anorectal physiology studies were analysed and compared between the two groups.

Results: There were 148 patients included in the study period and 17% reported a history of SA. There was no statistically significant difference in symptom severity, quality of life scores or anorectal physiology studies between those with and without a history of SA.

Conclusion: In female patients seeking management for defaecatory symptoms, those who have reported a history of SA did not demonstrate any significant difference in symptom severity, quality of life or physiological measures when compared to those without a history of SA.

Sexual abuse

Faecal incontinence

Constipation

Pelvic floor

Anorectal physiology

Dyssynergia

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 [5–8]. 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 [7, 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 paper 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.

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 2017–2019. 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. Patients who were male, transgender, or who did not complete the questionnaire, were 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 endoanal manometry for resting and squeeze pressures, endoanal ultrasound to assess for internal or external sphincter defect, rectal sensation with balloon inflation, and pudendal nerve terminal motor latency. Dyssynergia was also evaluated objectively using both manometry and electromyography.

Analysis

Variables were analysed either with chi-squared (χ²) 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).

Data was collected on 244 patients who had been assessed at the functional colorectal pelvic floor unit for defaecatory dysfunction. Patients who were male (n = 40), transgender (n = 1), or who did not complete the questionnaire (n = 55), were 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.

Table 1

Cohort Characteristics by History of SA
Characteristic	No History of SA n (%)	History of SA n (%)	P Value*
Age, mean (SD)	51.5 (17.7)	48.8 (15.0)	0.48
History of episiotomy	48 (47.5)	12 (57.1)	0.42
History of perineal tear	68 (68.7)	11 (55.0)	0.24
Hysterectomy	31 (25.2)	8 (32.0)	0.88
Anorectal operation	40 (32.5)	8 (33.3)	0.94
Vaginal prolapse operation	7 (5.8)	1 (4.2)	0.89
Rectocele or cystocele operation	33 (28.2)	6 (27.3)	0.93
Sexually active	66 (53.7)	12 (48.0)	0.61
Psychiatric diagnosis^a	14 (11.4)	4 (16.0)	0.52
Abbreviations: SA: sexual abuse
*Derived from χ² or with Mann-Whitney test
^aIncludes any diagnosis of anxiety, depression, bipolar disorder, or post-traumatic stress disorder.

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 (EMG) did not differ significantly between those with and without a history of SA (Table 3).

Table 2

Symptom Severity, Quality of Life Scores and Physiologic Testing Results by History of SA
	No History of SA Mean (SD)	History of SA Mean (SD)	P Value*
Symptom severity and quality of life scores
• WEXNER	10.1 (4.3)	10.4 (5.4)	0.83
• VAIZEY	12.3 (5.5)	12.9 (5.0)	0.73
• FIQOL Total	10.3 (3.3)	9.48 (2.9)	0.36
o Lifestyle	2.91 (0.9)	2.86 (0.9)	0.83
o Coping/Behaviour	2.19 (0.9)	1.91 (0.7)	0.27
o Depression/Self-perception	2.87 (0.9)	2.57 (0.9)	0.25
o Embarrassment	2.37 (1.0)	2.15 (0.7)	0.44
• CSS	12.9 (5.4)	15.9 (7.1)	0.10
• ODS	13.2 (6.1)	13.9 (6.7)	0.70
• PACQL - Dissatisfaction	67.6 (25.6)	77.6 (30.4)	0.22
• PACQL - Satisfaction	8.45 (4.2)	8.77 (4.6)	0.81
Anorectal physiology
• Resting tone, mm Hg	76.0 (29.3)	67.5 (26.5)	0.19
• Squeeze tone, mm Hg	149.0 (63.2)	155.2 (56.4)	0.65
• First sensation, ml	53.1 (29.6)	50.4 (27.2)	0.70
• Urge to defecate, ml	93.1 (42.0)	89.6 (40.5)	0.71
• Maximum volume tolerated, ml	71.4 (126.1)	67.1 (90.1)	0.88
• Pudendal nerve terminal motor latency Right, s	2.67 (1.5)	2.11 (0.67)	0.35
• Pudendal nerve terminal motor latency Left, s	2.09 (0.98)	2.42 (1.43)	0.45
• Internal sphincter defect, %	17.0	16.0	0.90
• External sphincter defect, %	22.2	16.7	0.55
Abbreviations: SD, standard deviation; SA, sexual abuse; WEXNER, Continence Grading Scale; VAIZEY, St Mark’s Incontinence Score; FIQOL Faecal Incontinence Quality of Life Score; CSS, Constipation Scoring System; ODS, Obstructed Defecation Score; PACQL, Patient Assessment of Constipation Quality of Life Score.
*Derived from χ² or with Mann-Whitney test

Table 3

Presence of Dyssynergia by History of SA
Presence of Dyssynergia	No History of SA %	History of SA %	P Value*
Physical examination	14.6	20.0	0.50
Manometry	16.9	20.0	0.72
EMG	15.2	11.1	0.75
Any of physical examination, manometry or EMG^a	22.8	24.0	0.89
Abbreviations: SA, sexual abuse; EMG, electromyography
*Derived from χ² test
^aDyssynergia considered present if positive in any of the three tests

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[17]. 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[18]. However, the study had a small sample size of 15 patients and so conclusions should be taken guardedly.

Our study has several limitations. The relatively small sample size of 148 patients, retrospective nature, and possible under-reporting of sexual abuse may have affected our results. Recall bias may have played a role given the history of SA was self-reported.

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.

Author Contributions:

Conceptualization: Christopher Gillespie, Andrea Warwick, Mark Hanna; Data curation and investigation: Mark Hanna, Gerard Bray, Ye Chen Ding; Formal analysis: Havish Srinath, Mark Hanna; Writing – original draft: Mark Hanna; Writing – review and editing: Christopher Gillespie, Andrea Warwick, Mark Hanna, Havish Srinath; Resources and validation: Christopher Gillespie, Andrea Warwick; Supervision: Christopher Gillespie. All authors have approved the final draft of the manuscript.

Ethics approval

Ethics approval was obtained from Metro South Human Research Ethics Committee. Reference: HREC/2020/QMS/62215.

Competing interests

The authors have no competing interests to declare that are relevant to the content of this article.

Funding

No funding was received for conducting this study.

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No competing interests reported.

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The Effect Of A Sexual Abuse History On Symptoms And Anorectal Physiology Findings In Patients Presenting To A Colorectal Pelvic Floor Service

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Abstract

Introduction

Methods

Patient Selection

Symptom And Quality Of Life Assessment

Functional Assessment

Analysis

Results

Discussion

Conclusion

Statements And Declarations

References

Additional Declarations

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