Sexual function and quality of life after surgical treatment for anal fistulas in Crohn’s disease
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- Riss, S., Schwameis, K., Mittlböck, M. et al. Tech Coloproctol (2013) 17: 89. doi:10.1007/s10151-012-0890-x
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The aim of this study was to assess sexual function and quality of life (QoL) in patients after surgery for perianal Crohn’s disease.
Eighty-eight consecutive patients with perianal Crohn’s disease, operated on at the Medical University of Vienna, completed a self-administered questionnaire including the International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), Short Form-12 Health Survey (SF-12), and the Inflammatory Bowel Disease Questionnaire (IBDQ). Patients with a current stoma were excluded from further analysis. The median follow-up time was 104 months (range 3–186 months). Healthy subjects served as controls for each case and were matched by age (±6 years) and gender. Forty-seven (68 %) female and 22 male patients with a median age of 46.5 years (range 18–64 years) were analyzed. Eleven (16 %) patients had simple and 58 (84 %) complex anal fistulas.
The median SF-12 physical health score of the patients was significantly lower (47.9 (range 25.5–57.2)) than that of the controls (54.3 (range 34.6–61.8); p = 0.03). Not surprisingly, the median total sore of the IBDQ of the controls was significantly better than that of the patients (controls: 188.5 (range 125–206.5), patients: 157 (range 60–199.5); p < 0.0001). Analysis with the multiple logistic regression test showed that type of operation, >1 perianal fistula opening, and active Crohn’s disease were independent risk factors for a worse IBDQ (p = 0.03, p = 0.015 and p < 0.0001). Interestingly, the median FSFI and IIEF score were not found to be significant different in any domain.
QoL but not sexual function is significantly influenced by surgery for perianal Crohn’s disease.
KeywordsPerianal Crohn’s diseaseQuality of lifeSexual function
Anal complaints like abscess and fistula are frequent disorders in Crohn’s disease patients. The incidence in a population-based cohort was found to be 33 % after 10 years and 50 % after 20 years .
Apart from medical therapies, the initial therapeutic approach is to treat symptoms by drainage in case of abscesses. Secondary, according to the type of fistula, several treatment modalities are recommended. Low fistulas can be laid open by fistulotomy, whereas complex fistulas require loose seton placement in order to prevent fecal incontinence . Additionally, other less well-investigated therapies, such as fistula plug, adipose-derived stem cell therapy, or fibrin glue injection can be considered in selected cases . Notably, in up to 20 % of patients, a proctocolectomy needs to be performed .
Due to a high surgical recurrence rate after primary fistula treatment, it is also mandatory to maintain a satisfying quality of life (QoL) . Interestingly, there are very few studies that assess QoL after surgery for perianal fistulizing Crohn’s disease. Kasparek et al. compared diverted Crohn patients with perianal fistula with undiverted patients and found a nearly similar QoL rate, measured by the Cleveland Global Quality of Life Score and the Short Inflammatory Bowel Disease Questionnaire .
Another essential aspect in anal fistula surgery refers to the sexual function of affected patients. To the authors’ knowledge, there are no studies in the literature that investigates whether sexual function is altered in patients with surgically treated perianal Crohn’s disease.
Therefore, the present study was designed to evaluate the impact of surgery for anal fistula on QoL, sexual function, and behavior in patients with Crohn’s disease, by using standardized and validated questionnaires.
Materials and methods
We reviewed the records of 147 consecutive patients with perianal Crohn’s disease who where operated on for anal abscess and fistulas at the Medical University of Vienna, Department of Surgery, between 1994 and 2010. Clinical data were extracted retrospectively from an institutional database and individual chart review.
Available patients were contacted by telephone or mail and were invited to participate in the study. They were required to fill out a standardized self-administered questionnaire. Eighty-eight (60 %) patients returned the questionnaire. After excluding patients with a current stoma, 69 patients were included in the final analysis.
The study was approved by the local ethics committee. All participants gave written informed consent.
The median follow-up time (from last fistula operation until follow-up date) was 104 months (range 3–186.48 months).
Healthy subjects from the general population with no history of inflammatory bowel disease, cancer and other chronic diseases, and without previous surgery for anal fistulas were mainly contacted outside the hospital and were asked to participate in the study. All controls filled out a self-administered questionnaire. They served as controls for each case and were matched by age (±6 years) and gender.
Initially, anal fistulas were classified according to the criteria developed by Parks et al. . As the vast majority of patients underwent multiple surgical interventions, fistulas were divided into simple (intersphincteric and superficial fistula) and complex (transsphincteric, extrasphincteric, suprasphincteric, and rectovaginal fistula). The maximum number of external perianal openings found during any perianal operation was documented and categorized into 1 and >1. In addition, the occurrence of concomitant abscesses and the total number of operations performed in each patient were recorded. The treatment modalities of perianal fistula were separated into fistulotomy, loose seton drainage, advancement flap, and creation of a temporary protecting stoma.
The surgical intervention included a primary clinical examination under general anesthesia. Superficial and low intersphincteric fistulas were usually laid open, whereas complex fistulas were initially treated by loose seton drainage. This procedure is the same as in patients with perianal fistula of cryptoglandular origin. Advancement flaps and the creation of a temporary stoma were performed when appropriate .
Main outcome measures
Quality of life
The SF-12 provides a shorter alternative to the SF-36, which is one of the most commonly used instruments for evaluating health-related QoL. The SF-12 contains a subset of 12 items from the SF-36, including one or two items from each of the eight SF-36 scales. Information in all 12 items is used to calculate physical and mental component summary measures (PCS and MCS).
In contrast, the IBDQ is a disease-specific instrument, which was already translated into German (IBDQ-D) and correlates well with the Crohn’s disease activity index (CDAI) in terms of disease activity. It consists of 32 questions, whereas each question ranges from one point (worst) to seven points (best). The overall score summarizes four subscales: bowel function, systemic function, emotional function, and social function. It is important to note that, Janke et al. recommended using the overall score only, due to high correlations of the subscales in the German validated version .
Sexual function was assessed by the “Female Sexual Function Index” (FSFI), a comprehensive 19-item instrument that measures six domains of sexual function including desire, arousal, lubrication, orgasm, satisfaction, and pain . The overall FSFI score ranges from 2 to 36 points, with a lower score indicating a lower level of sexual function.
Male sexual function was assessed by the German version of the “International Index of Erectile Function” (IIEF) . The IIEF consists of 15 items that evaluate five domains: erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction. A higher score is associated with a superior sexual function.
Additionally, factors considered to impact disease-specific QoL (IBDQ) and female and male sexual functions were analyzed.
Continuous data are shown as mean with standard deviation (±SD) if normally distributed or with median and minimum–maximum otherwise. Categorical variables are described with absolute numbers and percentages. Differences between groups were tested by t tests for normally distributed variables and with Wilcoxon rank-sum tests for skew data. An exact Wilcoxon rank-sum test was used if a group size was smaller than 10. Associations between a continuous and an ordinal variable were assessed and tested with Spearman’s correlation coefficient. A general linear regression model was used to model the FSFI of female patients and the IBDQ-D dependent on prognostic variables in a simultaneous manner.
Differences between matched pairs were tested with paired t test in case of normally distributed differences, with the Wilcoxon signed rank test for other continuous variables and with the McNemar test for binary variables.
All p values were two-sided, and p ≤ 0.05 was considered statistically significant. All calculations were performed with the statistical analysis software SAS (SAS Institute Inc., version 9.2, Cary, NC, USA).
Forty-seven (68 %) female and 22 (32 %) male patients with a median age of 46.5 years (range 18–64 years) were analyzed. The median body mass index (BMI) (kg/m²) was 24.5 (15.2–35.7). The median age of the matched control group was 48 years (21–70 years). No significant difference was found in regard to BMI (p = 0.41), diabetes mellitus (p = 0.10), neurologic disorders (p = 1.0), and previous pelvic floor operations (p = 0.52) between patients and controls.
The median duration of Crohn’s disease was 202.2 months (range 29–406.5 months). Thirty-five (50.7 %) patients reported smoking regularly. Seventeen (24 %) patients had prior surgery for anal fistula or perianal abscess in other hospitals.
Surgical characteristics of patients with Crohn’s disease
Number of perianal operations
Type of fistula
Number of perianal openings
Loose seton drainage
Creation of temporary stoma
Current immunosuppressive medication was recorded in 36 patients (exposure to infliximab: n = 15, exposure to azathioprin/6-mercaptopurin: n = 18, exposure to infliximab and azathioprin/6-mercaptopurin: n = 3).
Fecal incontinence, defined as the involuntary leakage of solid stool, liquid stool’ or gas at the time of follow-up was observed in 41 patients (incontinence of solid stool: n = 21, incontinence of liquid stool: n = 37, incontinence of gas: n = 36).
Quality of life
Comparison of the short form-12 health survey (SF-12) between patient and control group
Physical health score
Mental health score
Additionally, the median total sore of the IBDQ of the controls was significantly better than that of the patients (controls: 188.5 (range 125–206.5), patients: 157 (range 60–199.5); p < 0.0001).
Comparison of FSFI and IIEF between cases and controls
Female sexual function index (FSFI)
International index of erectile function (IIEF)
Finally, we aimed to define factors predictive of a worse disease-specific QoL, characterized by the IBDQ-D. In univariate analysis, type of operation (fistulotomy better than loose seton drainage (p = 0.03), type of fistula (simple better than complex fistula) (p = 0.004), current complaints due to Crohn’s disease (=active Crohn’s disease) (diarrhea, abdominal pain, arthritis, fever over 37.7 °C, iritis) (p < 0.0001), and current perianal complaints (itching, pain, soiling) (p < 0.0001) were found to significantly impact QoL. In the stepwise multiple logistic regression test, active Crohn’s disease and type of operation remained significant (p < 0.0001, p = 0.028). In addition, >1 perianal fistula opening was another independent risk factor for decreased disease-specific QoL (p = 0.015). Interestingly, a concomitant abscess at the time of surgery was associated with a superior total IBDQ score (0.002).
Moreover, additional pelvic floor operations and postoperative exposure to infliximab therapy were associated with a decreased total FSFI score (p < 0.0001, p = 0.018).
We observed several risk factors for impaired male sexual function in each domain of the IIEF: Erectile function was reduced in patients with a loose seton drainage in situ (p = 0.013) and an abscess at the time of operation (p = 0.003). Satisfaction with intercourse was impaired in patients with a longer duration of Crohn’s disease (p = 0.026). Furthermore, additional pelvic floor operations, smoking, and current pelvic complaints were found to impact negatively on orgasmic function (p = 0.013, p = 0.042, p = 0.003). Sexual desire in men was negatively influenced by an abscess at the time of operation, a loose seton drainage in situ, current pelvic complaints, and complex fistula (p = 0.046, p = 0.046, 0.026, p = 0.024). The last domain of the IIEF “overall satisfaction” was reduced in patients with additional pelvic floor operations (p = 0.0001).
Male patients with fecal incontinence were found to have a reduced orgasmic function (p = 0.021), whereas no alteration was observed in female patients with fecal incontinence. Notably, QoL (IBDQ) was significantly altered in both male and female patients with fecal incontinence (p = 0.0006).
The present long-term study of patients following anal surgery for fistulizing Crohn’s disease revealed, not surprisingly, a significant decreased QoL in comparison with healthy controls. Interestingly, no difference was detected with regard to sexual function and behavior between the groups. This is an important and unexpected finding, as sexual function is an essential component of life.
However, the total FSFI score was low in female patients. Wiegel et al. performed a cross-validation of the FSFI and found a clinical cutoff score of 26.5 for differentiating women with and without sexual disorders . In the present investigation, both groups showed a median score below 26.5 points, indicating sexual dysfunction in a high number of participating women. However, when the total FSFI score was calculated excluding those patients who reported no sexual activity in the last 4 weeks, the subjects of the control group scored above and the Crohn patients below the cutoff score of 26.5 (results not shown). As this difference was not found to be statistically significant, it can only be speculated that there is a tendency toward impaired sexual function after surgery for perianal Crohn’s disease. Moreover, there was a trend for a lower level of desire in female patients. In addition, sexual function can be influenced by several parameters, such as the sexual partner body image perception and other physiological factors. Timmer et al. performed a survey using the Brief Index of Sexual Function in women with inflammatory bowel disease (Crohn’s disease and ulcerative colitis) . The authors concluded that mood disturbances and social environment were more closely associated with sexual dysfunction than disease-specific factors. In addition, smoking was found to correlate with lubrication problems. In our group of patients, smoking influenced only orgasmic function in male patients.
Another study investigated patients with rectovaginal fistulas only and showed comparable results in terms of QoL and sexual function in patients with healed fistulas and those with unhealed fistulas .
Fecal incontinence can frequently occur after anal fistula surgery . Crohn’s patients are especially likely to develop symptoms of incontinence, as they often have complex types of fistula, which require recurrent perianal surgical interventions. In the present study, we observed that patients with fecal incontinence showed a reduced QoL, characterized by the IBDQ. Interestingly, only male sexual function was negatively influenced by the involuntary loss of stool, whereas no effect was found in female patients.
Notably, female sexual function was altered by additional pelvic floor operations. In our series, most patients had been operated on for hemorrhoidal disease. Thus, affected patients need to be informed about the increased risk for overall pelvic floor alterations (not only fecal incontinence) before undergoing pelvic floor operations.
However, as there are no other studies available focusing on risk factors for sexual dysfunction in this group of patients, further studies are needed.
Another crucial aspect of treating patients with a chronic disease is achieving an acceptable QoL. To date, there are several disease-specific and non-disease-specific questionnaires available to assess QoL in patients with Crohn’s disease. We aimed to measure all components by using the SF-12 and the IBDQ. Both instruments are well validated and widely used among clinicians, thus comparison between studies is possible.
A number of studies evaluated the effect of intestinal resections on QoL in Crohn’s disease patients. By using the Cleveland Global Quality of Life score, Delaney et al. found an early improvement of QoL within 30 days after surgery for Crohn’s disease . Similar results were obtained by Tillinger et al. who detected an improved QoL in 16 patients following abdominal surgery .
There are several studies available that assessed the effect of anti-TNF treatment on QoL in patients with Crohn’s disease [18–20]. Ng et al. investigated the impact of infliximab and adalimumab on the health-related QoL of 26 patients with fistulising anal Crohn’s disease. By using the IBDQ, the authors observed a significant improvement of QoL at 12 months . This improvement was associated with clinical fistula closure.
Another study aimed to determine what factors affected QoL in patients with Crohn’s disease. Patients were followed up over 1 year . The authors concluded that tobacco, hospitalization, and use of corticosteroids had a negative impact on QoL. In contrast, the intake of immunosuppressive medications correlated with a better QoL. In the present study, active Crohn’s disease, loose seton drainage, and more than one perianal fistula opening were associated with a poor QoL.
Kasparek et al.  found a similar QoL in diverted patients compared with undiverted patients suffering from perianal Crohn’s disease. In the present study, we excluded those patients with a current stoma. The impact of a stoma on sexual function and QoL in this group of patients is not well investigated and we felt that including them could potentially bias our results. However, we analyzed whether patients with a temporary stoma might have an impaired QOL and sexual function, but no negative impact could be detected.
Some limitations of the present investigation need to be addressed. As we did not assess the QoL of patients before perianal surgery, no direct influence of the operation on each patient can be evaluated. However, we tried to overcome this shortcoming by using a healthy matched control group of the general population for detailed comparison. We are well aware that this procedure has its restrictions, even though we found the results interesting and clinically important. Secondly, despite the high number of patients included in this analysis, several patients did not respond to the questionnaire. This might be due to the very long follow-up period on the one hand, and the still embarrassing, “taboo,” issue of sexuality on the other hand.
This long-term study demonstrated that the QoL of patients undergoing surgery for perianal Crohn’s disease was significantly reduced compared to that of healthy controls, whereas the sexual function of these Crohn’s patients was not different from that of the general population.
Conflict of interest