Systematic review Faecal incontinence following radiotherapy for prostate cancer: A systematic review Yasuko Maeda a,⇑ , Morten Høyer b , Lilli Lundby c , Christine Norton a,d a Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK; b Department of Oncology; and c Surgical Research Unit, Aarhus University Hospital, Denmark; d Bucks New University & Imperial College Healthcare NHS Trust, London, UK article info Article history: Received 15 September 2010 Received in revised form 6 December 2010 Accepted 8 December 2010 Available online 21 January 2011 Keywords: Faecal incontinence Radiotherapy Prostate cancer abstract Background: Faecal incontinence (FI) after radiotherapy is a known phenomenon, but has received little attention to date. This article aimed to review current knowledge on faecal incontinence related to radio- therapy for prostate cancer. Methods: PubMed was searched for English-language articles published from January 1966 to December 2009 using the primary keywords ‘faecal incontinence’, ‘prostate cancer’ and ‘radiotherapy’. Prospective, retrospective and controlled trials reporting FI as a complication of radiotherapy for prostate cancer were included. The retrieved titles and abstracts were screened permissively and evaluated as to whether they satisfied the predefined inclusion and exclusion criteria. Results: Nine hundred and ninety four articles were identified from the search. After step-wise review, 213 papers were selected for full article review of which 40 were selected for this review. The incidence of faecal incontinence following radiotherapy for prostate cancer varied from 1.6% to 58%. The mecha- nism of faecal incontinence was not entirely clear but it is most likely due to injury to the nerve plexus of the rectal muscular layer. Correlation between rectal dose–volume parameters and incidence is equiv- ocal, although some studies suggest parameters confined to the lower rectum and/or anal canal may be of value to predict the extent of the injury and could be used as constraints in the dose planning process. Conclusions: Interpretation of data is limited due to lack of large cohort studies with data on pre-treat- ment continence status and because variable instruments have been used to assess the severity of the condition. Well-designed prospective studies are needed to investigate dosimetric parameters focusing on the anal canal and sphincter apparatus. Considering the spatial distribution of radiation to the rectum may identify a more direct linkage between radiation damage and faecal incontinence. Ó 2010 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 98 (2011) 145–153 Background Radiotherapy is an established curative treatment for prostate cancer with a significant survival benefit [64]. The technique of administering radiation has evolved and improved, particularly in the last 15 years, which has contributed to a reduction in adverse effects whilst preserving therapeutic effect. Intensity modulated (IMRT) and image guided radiotherapy (IGRT) are the latest advancement of techniques that allow precise and conformal deliv- ery of the radiation to the target whilst minimising the dose to nor- mal tissues. However, some normal tissues surrounding a tumour still receive inadvertent radiation, which may result in irreversible and chronic complications. Faecal incontinence (FI) is a known sequela of radiotherapy but has received little attention to date in comparison to other toxici- ties and complications. The maintenance of faecal continence is a product of stool consistency, colorectal activity and the harmoni- ous functioning of external and internal anal sphincters [18] and interruption of any of these factors alone or in combination may result in symptoms of incontinence, which can vary from loss of controlling flatus, a small seepage of faecal material on underwear, loss of stool due to failure to resist the urge for timely defaecation, or loss of stool without any advance urge and sensation. FI is thought to be caused by radiation exposure of the ano-rectum and result in complex constellation of changes in bowel frequency, stool consistency, urgency, bleeding, pain and mucous loss. How- ever, the precise mechanism is not known and the relationship be- tween dose–volume parameters and the severity of FI symptoms has not been fully established. This article presents a systematic literature review on current knowledge of incidence, mechanism, assessment and the treat- ment of FI following radiotherapy for prostate cancer. Methods Search strategy We searched the PubMed database, using the primary keywords ‘faecal incontinence’, ‘prostate cancer’ and ‘radiotherapy’ for 0167-8140/$ - see front matter Ó 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.radonc.2010.12.004 ⇑ Corresponding author. Address: Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Northwick Park, Watford Road, Harrow HA1 3UJ, UK. E-mail address: yazmaeda@gmail.com (Y. Maeda). Radiotherapy and Oncology 98 (2011) 145–153 Contents lists available at ScienceDirect Radiotherapy and Oncology journal homepage: www.thegreenjournal.com