Recent work has shown that patients undergoing proctocolectomy and ileal pouch-anal anastomosis experience a better quality of life than those undergoing proctocolectomy and Brooke ileostomy. To assess whether the improvement with the pouch is due to the absence of a stoma or the preservation of fecal continence, functional and performance activities were assessed in 406 patients with Brooke ileostomies (stoma present, incontinent), 313 with Kock pouches (stoma present, continent), and 298 with ileal pouch-anal anastomoses (stoma absent, continent). All patients underwent proctocolectomy for ulcerative colitis or familial adenomatous polyposis. After adjusting for age, sex, diagnosis, attitude towards the operation, dietary satisfaction, and ability to work, the likelihood of an impact on performance was estimated for the three types of operation using logistic regression analysis. Patients with ileal pouch-anal anastomoses had fewer restrictions in sports and sexual activities than those with Kock pouches (P less than 0.05), whereas those with Kock pouches in turn had fewer restrictions in these activities but more restrictions in travel than those with Brooke ileostomies (P less than 0.05). In contrast, performance in the categories of social life, recreation, work, and family was similar between groups. It is concluded that both the presence of a stoma and fecal incontinence impair the quality of life after proctocolectomy. Ileal pouch-anal anastomosis, which avoids both stoma and incontinence, offers the best quality of life between the three operations studied.