Objective To investigate the association between fecal incontinence and the risk of postoperative recurrence in patients with complete rectal prolapse (CRP).

Methods A retrospective cohort study design was employed, CRP patients who underwent surgical treatment in the Guang'anmen Hospital of China Academy of Chinese Medical Sciences from January 2013 to June 2024 were selected as the study subjects. Two sequential survival analysis models were used to explore the relationship between fecal incontinence and postoperative recurrence of rectal prolapse; restricted cubic spline regression was utilized to examine the linear relationship between the two indexes; survival curves were generated to illustrate the postoperative recurrence-free survival probabilities among patients with varying degrees of incontinence.

Results A total of 180 CRP patients were included in this study, among whom 44 patients had severe fecal incontinence. The results of the multivariate survival analysis model revealed a significant correlation between fecal incontinence and the risk of postoperative recurrence after controlling for covariates (P < 0.05). Considering a Wexner fecal incontinence score ≤ 5 as reference group, the recurrence risk in the group with a score ≥ 16 was 4.26 times than that of the reference group unadjusted model: HR=4.3(1.62 to 11.41); model 1: HR= 3.37(1.27 to 8.94); model 2: HR=4.26(1.48 to 12.24); P < 0.05, indicating a significantly elevated recurrence risk in patients with high scores. A linear positive correlation was observed between fecal incontinence and recurrence risk (P_{non-linearity}>0.05). The survival curves demonstrated significant differences in recurrence-free survival rates among different fecal incontinence groups. The survival probability in the group with a score ≥ 16 declined sharply (with only 3 cases remaining recurrence-free at 9 years), indicating the highest recurrence risk in this group.

Conclusion Fecal incontinence is an important predictor of postoperative recurrence in rectal prolapse, with severe fecal incontinence serving as an independent high-risk factor. The severity of fecal incontinence should be incorporated into the preoperative risk assessment system in clinical practice to provide evidence-based support for optimizing surgical plans, stratified postoperative management, and preventing postoperative recurrence.