Fecal incontinence after prostate cancer irradiation: a systematic literature review.

goalFecal incontinence (FI) is an underrecognized but clinically significant late gastrointestinal toxicity following radiotherapy (RT) for prostate cancer. This systematic review aimed to synthesize current knowledge on the definition and pathophysiology of post-radiation anal continence, as well as prevention strategies, technical considerations, and therapeutic approaches.

methodA systematic literature search was conducted according to PRISMA guidelines using the keywords: "Fecal incontinence," "Radiation therapy," and "Prostatic neoplasms." Eligible studies included randomized phase III trials and prospective or retrospective series reporting on FI after definitive or adjuvant/salvage prostate RT. Fifty-four articles were included in the final analysis.

resultsFI after prostate RT results from functional, morphological, and neurogenic alterations of the anorectal system. Reported incidence ranges from 1 to 12%, most often presenting as flatulence or liquid stool leakage, while severe forms requiring pads are uncommon. Variability is largely explained by heterogeneity in definitions and assessment tools, as no standardized scoring system is universally applied. Risk factors include advanced age, prior abdominal surgery, vascular comorbidities, chronic inflammatory bowel disease, hemorrhoids, and rectal urgency during RT. Dosimetric analyses indicate that low-to-intermediate doses to the anal canal and high doses to the rectum contribute differentially to FI. Based on current evidence, the mean dose to the anal canal should be kept below 37 Gy, though further studies are needed to define precise constraints for both structures. Preventive strategies such as MRI-based contouring and endorectal balloon placement, perirectal hydrogel spacers placement show promise. Management is multidisciplinary, including dietary measures, medications, pelvic floor therapy, neuromodulation, and, in severe cases, diversion procedures.

conclusionFI after prostate RT is likely underestimated due to the absence of a standardized assessment. Developing a validated, universally applicable scoring system is a priority to improve evaluation, enable cross-study comparisons, refine preventive measures, and guide therapeutic strategies.