Ileoanal pouch (IAP) construction is arguably the procedure of choice to follow proctocolectomy for ulcerative colitis (UC) or familial adenomatous polyposis (FAP). Patients with UC or FAP at our institution choose their operation after counseling with the surgeon, with an enterostomal therapist, and with patients who have undergone IAP and proctocolectomy with ileostomy (IL). We studied these patients who chose IAP and IL, to determine differences in outcome and quality of life (QOL) between those two groups. We assessed outcomes by evaluating clinic and hospital records and surveyed patients' QOL via a standardized questionnaire. During a retrospective 10-year study period, 86 patients underwent evaluation for IAP construction for UC (64) and FAP (22). Fifty-five patients underwent IAP construction, and 31 underwent IL. There were no operative deaths. Thirty-four patients sustained 69 early and late complications (40%). The IAP group experienced a higher complication rate, 53 per cent, compared with the IL group, 16 per cent. Forty-five patients (56%) have completed questionnaires. Eighty-seven per cent of IAP patients and 93 per cent of IL patients responded that their overall QOL is "always" better since their operation (P = not significant). Both groups reported very favorable responses to questions regarding work, social life, family life, sleep, and relationships without statistically significant differences between the two groups. Despite a high complication rate, IAP is an excellent operation for many patients with UC or FAP, but patients who choose IL after preoperative counseling can be expected to have similar improvement in quality of life.