CLINICS 2011;66(12):2007-2012 The pre- and postoperative mean CCIS were, respectively: total scores of 0.9 and 0.7 (p = 0.774), incontinence to gas values of 0.17 and 0.4 (p = 0.257), incontinence to liquid stool scores of 0.57 and 0.26 (p = 0.083), incontinence to solid stool scores of 0 and 0 (p = 1.0), wearing of a pad scores of 0.04 and 0 (p = 0.317) and lifestyle alteration scores of 0.09 and 0 (p = 0.317) (Figure 1). The prevalence of anal incontinence before and after surgery was 48% and 35%, respectively, using the index of anal incontinence (CCIS). These values were not significantly different based on the McNemar test (p = 0.508). The pre- and postoperative values of the FIQLS domains, respectively, were,as follows: depression values of 3.8 and 3.5 (p = 0.737), lifestyle scores of 3.9 and 4 (p = 0.256), behavior scores of 3.7 and 3.6 (p = 0.8) and constraint scores of 3.9 and 3.8 (p = 0.671) (Figure 2). The pre- and postoperative values of manometric para- meters were, respectively: resting pressures of 64¡23 mmHg and 65¡17 mmHg (p = 0.763) (Figure 3), maximum squeezing pressures of 130¡41 mmHg and 117¡40 mmHg (p = 0.259), high pressure zones of 3.0¡0.9 cm and 2.7¡0.8 cm (p = 0.398), fatigue rate (p = 0.754) and fatigue rate index (p = 0.438), anorectal reflexes present in 78% (18 patients) and 82% (19 patients) (p = 0.398), rectal sensitivity thresholds of 76¡25 ml and 71¡35 ml (p = 0.539) and maximum tolerated rectal volumes of 157¡48 ml and 156¡56 ml (p = 0.836) (Table 1). However, the sphincter asymmetry index was signifi- cantly decreased after surgery. The pre- and postoperative index values were 22.4¡9.1% and 14.4¡4.5% (p = 0.003), respectively (Figure 4). DISCUSSION We found that perineal prostatectomy did not affect anal continence or quality of life in this subset of patients. This disease is socially stigmatized and an active investigation of patients who are at risk of this complication is crucial to its diagnosis.23,24 Bishoff et al.5 were the first to note the potential association between perineal prostatectomy and anal incon- tinence. According to these authors, the prevalence of anal incontinence after perineal prostatectomy ranged from 8% Perineal prostatectomy and anal incontinence Guilger NR et al. to 16%. However, an important limitation of this study was that there were no records of clinical complaints regarding anal incontinence before surgery.5 This bias may lead to the conclusion that perineal prostatectomy promoted anal incontinence. These earlier studies also detected that even patients who had severe symptoms and impaired quality of life only revealed their symptoms when actively asked by the physician.5,6 It was emphasized that urologists must be aware of anal incontinence symptoms during anamnesis and should appropriately inform patients about the poten- tial risks of these complications.9,16,25 Dahm et al.6 have demonstrated that there is a significant correlation between perineal surgery and anal incontinence symptoms; however, most of these symptoms were transi- tory. In 2004, Korman et al.7 published the results of a validated bowel function domain questionnaire (University of Michigan) that was expanded to the Prostate Cancer Index Composite (EPIC) and applied to patients who underwent perineal and retropubic prostatectomy. The authors used patients who underwent prostate biopsy as a control group. There was no clinical difference between groups in terms of bowel control, fecal incontinence, rectal urgency, and global bowel function, which varied from 4.8% to 6.4%.6 Kirschner et al.26 found that 6% of the studied patients presented with anal incontinence and a decreased quality of life before perineal prostatectomy. The real prevalence of anal incontinence in the general population remains unknown. The results that are available are only estimated values because no standardized scores or specific scales for incontinence have been used. In the present study, most patients presented with mild symptoms, these results demonstrate the sensitivity of the applied instru- ments, which permits the detection of early forms of anal incontinence before its clinical features or the need for treatment of symptoms manifest. The present study validated the use of the Anal Incontinence Score (CCIS) not only in the quantification of clinical symptoms but also as a tool for the early detection of symptoms of anal incontinence. This instrument can be helpful as an aid to improve a patient’s knowledge of the symptoms of anal incontinence before the disease has a greater impact on their quality of life. Figure 1 - Comparative analyses of Cleveland Clinic Anal Incontinence Index scores before and after perineal prostatectomy. 2009