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Fecal incontinence in adults: Management

Fecal incontinence in adults: Management
Authors:
Kristen M Robson, MD, MBA, FACG
Anthony J Lembo, MD
Section Editor:
Nicholas J Talley, MD, PhD
Deputy Editor:
Shilpa Grover, MD, MPH, AGAF
Literature review current through: Jul 2022. | This topic last updated: Nov 02, 2021.

INTRODUCTION — Fecal incontinence has a significant social and economic impact and significantly impairs quality of life [1-4]. Fecal incontinence can contribute to the loss of the ability to live independently [5,6]. This topic will review the management of fecal incontinence in adults. Our recommendations are largely consistent with society guidelines and consensus statements [7-9]. The etiology and evaluation of fecal incontinence in adults is discussed in detail, separately. (See "Fecal incontinence in adults: Etiology and evaluation".)

TERMINOLOGY AND CLASSIFICATION

Fecal incontinence is defined as the involuntary loss of solid or liquid feces.

Anal incontinence is defined as the involuntary loss of solid or liquid feces or flatus.

Based on the mechanism of incontinence, fecal incontinence is divided into the following:

Urge incontinence is characterized by the desire to defecate, but incontinence occurs despite efforts to retain stool.

Passive incontinence is characterized by the lack of awareness of the need to defecate before the incontinent episode.

INITIAL MANAGEMENT — Initial management of fecal incontinence consists of supportive care and medical therapy.

Supportive care — Supportive measures include avoiding foods or activities known to worsen symptoms and improving perianal skin hygiene. This includes avoidance of incompletely digested sugars (eg, fructose, lactose) and caffeine. Patients should be advised to keep a food and symptom diary to identify factors that cause diarrhea and incontinence. The anoderm should be kept clean and dry, without excessive wiping or use of astringent cleaners. Alternatively, a premoistened pad or tissue can be used for wiping. We suggest application of a barrier cream (eg, zinc oxide) to the perianal skin. Incontinence pads can be used to protect both skin and clothing from fecal soiling [10]. Patients who have incontinence related to cognitive dysfunction or physical debility may benefit from assistance with a regular defecation program.

Medical therapy — Medical therapy should be aimed at reducing stool frequency and improving stool consistency. No specific medication has been proven to be of benefit for fecal incontinence, except for antidiarrheal drugs in patients with liquid stools [11-13].

We begin by supplementing the diet with a bulking agent (eg, psyllium or methylcellulose 1 to 2 tablespoons per day) to improve stool consistency, especially in patients who have low-volume, loose stools. However, fiber may exacerbate incontinence in patients with decreased rectal compliance by increasing stool volume (eg, radiation proctitis, rectal stricture).

In patients with diarrhea, it is important to treat the underlying etiology. In addition, we use the antidiarrheal agent loperamide to reduce fecal incontinence [14]. A systematic review of medical therapy for fecal incontinence identified 16 randomized studies with 558 participants [11]. In four randomized trials in which loperamide or diphenoxylate plus atropine was compared with placebo, use of these antidiarrheals resulted in a reduction in fecal urgency, episodes of incontinence, unformed stools, and use of pads. Anorectal physiological measurements showed no clear differences between treatment periods. As compared with diphenoxylate, loperamide may be more effective at reducing urgency associated with incontinence and has fewer central nervous system side effects [15].

For patients who do not respond to loperamide, other antidiarrheal agents such as bismuth subsalicylate or bile acid binders (eg, cholestyramine, particularly for patients with a history of cholecystectomy or ileocolonic resection), may be useful for alleviating symptoms [16].

Patients with fecal impaction should be disimpacted, and concomitant constipation should be treated to prevent recurrent episodes [17,18]. (See "Management of chronic constipation in adults", section on 'Other laxatives'.)

Evacuation of the rectum by using suppositories or enemas may reduce incontinence episodes [19]. This may be particularly helpful for patients with neurogenic bowel dysfunction due to spinal cord injury. Chronic gastrointestinal complications related to spinal cord injury and bowel management in patients with spina bifida are discussed separately. (See "Chronic complications of spinal cord injury and disease", section on 'Gastrointestinal complications' and "Myelomeningocele (spina bifida): Management and outcome", section on 'Bowel management'.)

Data comparing the efficacy of nonsurgical interventions for fecal incontinence are limited. In a trial including 300 women with ≥1 episode of fecal incontinence per month and normal stool consistency, loperamide (2 mg with ability to titrate the dose higher or lower) and six sessions of biofeedback (each intervention alone or in combination) resulted in no significant difference in fecal incontinence as compared with oral placebo and education after 24 weeks [13]. Clinical response was associated with higher symptom severity at baseline (adjusted odds ratio [aOR] 1.20, 95% CI 1.11-1.28) and being overweight compared with normal/underweight (aOR 2.15, 95% CI 1.07-4.34) [20].

SUBSEQUENT MANAGEMENT — If initial management fails, additional evaluation with anorectal manometry and endorectal ultrasound/magnetic resonance imaging should be performed to detect functional and structural abnormalities causing fecal incontinence. We reserve defecography for patients who have refractory symptoms, especially if surgery is being considered. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Additional studies'.)

Biofeedback — We suggest biofeedback therapy in patients with fecal incontinence if anorectal manometry demonstrates weakness of the external anal sphincter or decreased ability to perceive rectal distension because of nerve injury [4,21,22]. Biofeedback is a painless, noninvasive means of cognitively retraining the pelvic floor and the abdominal wall musculature and is particularly useful in individuals with intact anal sphincters and urge incontinence or decreased rectal sensation.

Biofeedback is not indicated in patients with the following:

Isolated internal anal sphincter weakness

Overflow incontinence associated with behavioral or psychiatric disorders

Neurological disorders associated with substantial loss of rectal sensation and/or the inability to contract the external anal sphincter

Decreased rectal storage capacity from resection, inflammation, or fibrosis

Suspected or established major structural damage to continence mechanisms

Patients are guided to improve control of these muscles by electromyographic surface electrodes on an anal plug and an abdominal wall surface electrode. Biofeedback may improve fecal incontinence by enhancement of the ability to perceive rectal distension and improved coordination of the sensory and strength components that are required for continence. An effect on anal pressures has not been consistently demonstrated [23,24]. However, there are limited data to support biofeedback [25]. Although some studies have reported success rates between 38 and 100 percent, these studies have been small, have lacked a control group, have defined endpoints differently, or have had significant other methodological limitations [21,26-30].

Injectable anal bulking agents — We use the injectable anal bulking agent, dextranomer stabilized in hyaluronic acid, in patients with passive fecal incontinence. It is hypothesized that injection of anal bulking agents may enhance resting anal pressures and thereby improve fecal continence, especially in patients with passive fecal incontinence. Studies have suggested limited efficacy in the treatment of fecal incontinence while further studies are awaited [31-34].

A randomized trial with 206 patients compared injection with dextranomer-hyaluronic acid with sham injections of no substance [32]. After six months of follow-up, 71 of 136 (52 percent) patients in the active treatment arm reported a 50 percent or greater reduction in incontinence episodes, compared with 22 of 70 patients (32 percent) in the sham arm. Complications included proctalgia, rectal hemorrhage, and an abscess (14, 7, and 1 percent, respectively). No significant improvements between active and sham patients were noted in three of the four parts of the fecal incontinence quality of life scale (lifestyle, depression and self-perception, and embarrassment scales), and only a small improvement was noted in the coping and behavior scale. Only 6 percent of treated patients were fully continent at six months. A limitation of the study was that patients were not characterized clinically as to whether they had urge or passive incontinence or manometrically. The limited efficacy of dextranomer-hyaluronic acid in this study may be due to the inclusion of patients with urge incontinence [35]. Patients with urge incontinence often have external anal sphincter weakness or decreased rectal compliance, and it is biologically plausible that they are unlikely to benefit from an injectable bulking agent.

An open-label study included 115 patients with fecal incontinence treated with dextranomer-hyaluronic acid [33]. Of the 83 individuals who completed 24-month follow-up, 63 percent experienced a ≥50 percent reduction in the total number of episodes of fecal incontinence and a significant increase in the number of incontinence-free days at 24 months, as compared with baseline (22 versus 15 days).

In a trial of 126 patients with fecal incontinence who were followed for two years, clinical improvement measured by incontinence scores was not significantly different for patients who received injection with dextranomer-hyaluronic acid compared with patients who had sphincter training with biofeedback [36].

In 2011, dextranomer-hyaluronic acid gel was approved by the United States Food and Drug Administration the treatment of fecal incontinence in adult patients who have failed conservative therapy. Four 1 mL injections into the deep submucosa are given in the proximal part of the high-pressure zone of the anal canal, approximately 5 mm above the dentate line. If the response is inadequate after a minimum of four weeks, treatment can be repeated a second time.

Other injectable materials have been used to augment the internal anal sphincter (eg, silicone biomaterial, collagen, carbon-coated microbeads), but there are limited data to support their use [37-40].

Anal sphincteroplasty — Anal sphincteroplasty is usually reserved for patients with fecal incontinence who do not respond to initial management and have evidence of anatomic sphincter injury on anorectal ultrasound/magnetic resonance imaging shortly after vaginal delivery. (See "Obstetric anal sphincter injury (OASIS)".)

Although short-term improvements in fecal incontinence have been reported in up to 85 percent of patients after anal sphincteroplasty, continence deteriorates thereafter, with an approximately 50 percent failure rate after 40 to 60 months [41-44].

Sacral nerve stimulation — We reserve sacral nerve stimulation for patients who are either not candidates for biofeedback or sphincteroplasty, or in whom they have failed [7]. Electrical stimulation of the sacral nerve roots can improve fecal continence in patients with anal sphincter defects and those with structurally intact anal sphincters [45-48]. The exact mechanism of action of sacral nerve stimulation is not known but its effects may occur at the pelvic afferent or central level rather than primarily peripheral motor neurostimulation [49]. Sacral nerve stimulation appears to be particularly effective in patients with neurologic disorders and those with fecal incontinence after lower anterior resection [50,51]. It involves placement of a temporary electrode into the sacral foramen to provide low-grade electrical stimulation. Patients who respond to a two-week trial then undergo placement of a permanent electrode connected subcutaneously to an embedded stimulator [45,46,50-58].

Sacral nerve stimulation may improve fecal continence by improving resting and squeeze pressures of the anal sphincter, rectal sensation, and increasing retrograde colonic propagating sequences [54,59,60]. The most common complications include dislocation of the electrode (12 percent) and infection (3 percent) [61]. Following stimulator implantation, a significant number of patients will require surgical revision for various indications (eg, device failure, electrode displacement or breakage, or battery depletion) [46,52,62].

In a randomized trial that included 120 patients with fecal incontinence, patients were assigned to sacral nerve stimulation or optimal medical therapy consisting of pelvic floor exercises, bulking agents, and dietary changes [46]. The permanent sacral nerve stimulator was placed into 54 of the 60 randomized patients who had demonstrated improvement during a temporary trial period. In contrast with the control group, in which there was no significant improvement in the number of episodes of fecal continence and fecal incontinence quality of life scores at 12 months follow-up, use of the sacral nerve stimulator was associated with a significant increase in both as compared with baseline. In addition, 25 patients (47 percent) who underwent sacral nerve stimulation achieved complete continence. Complications included pain at the implant site (6 percent), seroma (2 percent), and tingling in the vaginal region (9 percent). There were no septic complications requiring explantation.

In a prospective, multicenter cohort of 120 patients who received implantation of a sacral nerve stimulator, 86 percent achieved greater than 50 percent reduction in incontinent episodes per week, and 40 percent had no fecal incontinence at three-year follow-up [63,64]. The most common adverse events included implant-site pain, paresthesia, change in the sensation of stimulation, and infection (28, 15 12, and 10 percent, respectively).

In another study, during a mean follow-up of 49 months, 36 of 87 patients (41 percent) who had undergone stimulator implantation required surgical revision [62]. Reasons for revision included infection (four patients), electrode displacement (two patients), electrode breakage (two patients), dysfunction due to an increase in impedance (four patients), pain with stimulation (seven patients), battery depletion (eight patients), and partial or total loss of clinical efficacy (nine patients).

Posterior tibial nerve stimulation (PTNS) has also been associated with short-term improvements in fecal incontinence in several series [65-69]. However, in a randomized trial in which 227 patients with fecal incontinence were assigned to PTNS or sham stimulation, there was no significant reduction in the number of episodes of fecal incontinence with PTNS [68]. However, additional studies are needed to assess the long-term efficacy of PTNS and to determine if there are sub-groups of patients who may benefit from treatment.

REFRACTORY SYMPTOMS — We reserve colostomy for patients with intractable symptoms who have failed nonsurgical management and who have failed or are not candidates for minimally invasive surgical interventions [8].

Dynamic graciloplasty or an artificial anal sphincter device may be used to treat refractory fecal incontinence. However, there are insufficient data to compare these treatment options [70,71]. Both procedures are associated with significant morbidity and should therefore be performed in centers of expertise.

Colostomy — Diversion of the fecal stream with a colostomy or ileostomy is definitive therapy for patients with intractable symptoms who have failed nonsurgical management and who have failed or are not candidates for minimally invasive surgical interventions [8]. (See "Overview of surgical ostomy for fecal diversion".)

Dynamic graciloplasty — Dynamic graciloplasty may improve fecal incontinence, but the procedure is complicated by considerable morbidity [72,73]. Dynamic graciloplasty involves continuous electrical stimulation of the gracilis muscle that is surgically transposed around the anal canal to increase resting tone [74]. The implantable pulse generator that provides the electrical stimulation is not available in the United States but is available in some other countries.

In one series of 52 patients with fecal incontinence who underwent dynamic graciloplasty, 38 (73 percent) were continent after a median follow-up of two years [75]. The procedure was associated with improved bowel frequency, ability to postpone defecation, less anxiety, and improved quality of life.

In a multicenter study that included 128 patients who underwent dynamic graciloplasty for fecal incontinence, during a median follow up of 24 months, 85 (66 percent) patients had a 70 percent or more reduction in stool incontinence [72]. However, 41 (32 percent) patients experienced a major wound complication, and therapy failed in 17 (40 percent).

Artificial anal sphincter — Although implantation of an artificial sphincter device has been associated with a clinically significant improvement in fecal continence, its use is limited by complications including explantation in up to one-third of patients [76,77].

The Acticon neosphincter consists of an occlusive cuff implanted around the anal canal, a pressure-regulating balloon implanted in the prevesical space, and a control pump with a septum port implanted in the labium or scrotum. The user is able to squeeze the control pump to permit defecation.

A prospective study evaluating this device included 112 patients (86 women) who underwent implantation [78]. Repeated surgery was required to revise the implant in 51 patients (46 percent), some of whom needed more than one revision. The artificial anal sphincter had to be removed in 41 patients (37 percent); however, it was reimplanted in seven. In patients with a functioning artificial anal sphincter, there was improvement in quality of life and anal continence. A clinically significant improvement in fecal incontinence scores was observed in 53 percent of patients.

A small, randomized trial included 14 patients with fecal incontinence that were assigned to conservative management that included dietary advice, medications, and biofeedback or placement of an artificial anal sphincter [79]. As compared with baseline, placement of an artificial anal sphincter, but not conservative management, resulted in a significant improvement in continence and quality of life at six months. However, complications led to permanent explantation of the device in one patient.

Other devices include a rectally inserted balloon with a sensing device that alerts the user to an imminent bowel movement, a synthetic sphincter device with a silastic inflatable cuff, and a magnetic anal sphincter [42,80-83].

Other — Although several other therapies have been evaluated in patients with fecal incontinence, there are limited data to support their use, and they cannot be routinely recommended.

Radiofrequency ablation – Radiofrequency ablation (RFA) is a procedure that involves delivering temperature-controlled radiofrequency energy to the anorectal junction to create thermal lesions in the muscle while preserving mucosal integrity. RFA is a minimally invasive treatment for fecal incontinence that takes less than one hour to perform and is generally performed under local anesthesia and sedation. While some small, prospective studies have demonstrated efficacy, conflicting results have also been published, and randomized trials are lacking [84-88].

Anal plugs (or anal insert device) may decrease fecal incontinence, but efficacy has not been established and for some patients, the device has been poorly tolerated [89-94]. In a randomized trial including 28 pediatric and 20 adult patients with fecal incontinence, use of an anal plug resulted in no significant difference in fecal incontinence compared with placebo, while the device remained in place for most patients [91].

Phenylephrine – The role of phenylephrine in the treatment of fecal incontinence in patients with an intact internal anal sphincter but low resting pressures is unclear. In small, randomized trials, application of phenylephrine gel to the anal sphincter was associated with a significant improvement in anal sphincter tone and symptoms as compared with placebo [95-99]. However, another randomized trial did not demonstrate any improvement in fecal incontinence from baseline in patients treated with phenylephrine as compared with placebo [99]. Adverse effects of phenylephrine include localized dermatitis, stinging or burning sensation, and headaches.

Anal sling – Surgical placement of a perianal sling designed to enhance the anorectal angle may be a potential option for patients, but additional studies are needed [100].

Vaginal insert – A vaginal insert with a pressure-regulated pump to temporarily occlude the rectum has been shown to reduce incontinence episodes by 50 percent in approximately 80 percent of women at one month [101]. However, studies are needed to evaluate its efficacy in the long-term.

WHEN TO REFER — Referral to a specialist should be considered in patients who fail to respond to initial management with supportive care and medical therapy. Such patients require additional evaluation to detect functional and structural abnormalities causing fecal incontinence and to guide subsequent management. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Additional studies' and 'Subsequent management' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Fecal incontinence".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Fecal incontinence (The Basics)")

Beyond the Basics topics (see "Patient education: Fecal incontinence (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Fecal incontinence is defined as the involuntary loss of solid or liquid feces. Anal incontinence is defined as the involuntary loss of solid or liquid feces or flatus. Fecal urge incontinence is characterized by the desire to defecate, but incontinence occurs despite efforts to retain stool. Passive fecal incontinence is characterized by the lack of awareness of the need to defecate before the incontinent episode. (See 'Terminology and classification' above.)

Initial management of fecal incontinence consists of supportive care and medical therapy. Supportive care includes avoiding foods or activities known to worsen symptoms and maintenance of perianal skin hygiene. We suggest a bulking agent and antidiarrheals in patients with fecal incontinence due to diarrhea (Grade 2C). (See 'Initial management' above.)

Referral to a gastroenterologist should be considered in patients who fail to respond to initial management. Such patients should undergo additional evaluation (eg, anorectal manometry, endorectal ultrasound/magnetic resonance imaging) to detect functional and structural abnormalities causing fecal incontinence and to guide subsequent management. (See 'When to refer' above.)

For patients who fail to respond to initial management, options include biofeedback, injectable anal bulking agent, sacral nerve stimulation, and anal sphincteroplasty. Biofeedback therapy for fecal incontinence should only be considered in patients with manometric evidence of weakness of the external anal sphincter or decreased ability to perceive rectal distension because of nerve injury. We reserve anal injections of dextranomer stabilized in hyaluronic acid for patients with passive fecal incontinence and anal sphincteroplasty for patients who have a recognized anatomic sphincter injury shortly after vaginal delivery. We reserve sacral nerve stimulation for patients who are either not candidates for injectable anal bulking agents or sphincteroplasty or in whom they have failed. (See 'Subsequent management' above.)

Fecal diversion with a colostomy or ileostomy should be reserved for patients with intractable symptoms who have failed nonsurgical management and who have failed or are not candidates for minimally invasive surgical interventions. Dynamic graciloplasty and artificial anal sphincter devices are associated with significant morbidity and should therefore only be used to treat refractory fecal incontinence. (See 'Refractory symptoms' above.)

  1. Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of anal incontinence. JAMA 1995; 274:559.
  2. Sangwan YP, Coller JA. Fecal incontinence. Surg Clin North Am 1994; 74:1377.
  3. Rothbarth J, Bemelman WA, Meijerink WJ, et al. What is the impact of fecal incontinence on quality of life? Dis Colon Rectum 2001; 44:67.
  4. Landefeld CS, Bowers BJ, Feld AD, et al. National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med 2008; 148:449.
  5. Lahr CJ. Evaluation and treatment of incontinence. Pract Gastroenterol 1988; 12:27.
  6. Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol 2015; 110:127.
  7. Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum 2015; 58:623.
  8. Bharucha AE, Rao SSC, Shin AS. Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders. Clin Gastroenterol Hepatol 2017; 15:1844.
  9. Wald A, Bharucha AE, Limketkai B, et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987.
  10. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol 2014; 109:1141.
  11. Omar MI, Alexander CE. Drug treatment for faecal incontinence in adults. Cochrane Database Syst Rev 2013; :CD002116.
  12. Bharucha AE, Fletcher JG, Camilleri M, et al. Effects of clonidine in women with fecal incontinence. Clin Gastroenterol Hepatol 2014; 12:843.
  13. Jelovsek JE, Markland AD, Whitehead WE, et al. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial. Lancet Gastroenterol Hepatol 2019; 4:698.
  14. Markland AD, Burgio KL, Whitehead WE, et al. Loperamide Versus Psyllium Fiber for Treatment of Fecal Incontinence: The Fecal Incontinence Prescription (Rx) Management (FIRM) Randomized Clinical Trial. Dis Colon Rectum 2015; 58:983.
  15. Palmer KR, Corbett CL, Holdsworth CD. Double-blind cross-over study comparing loperamide, codeine and diphenoxylate in the treatment of chronic diarrhea. Gastroenterology 1980; 79:1272.
  16. Remes-Troche JM, Ozturk R, Philips C, et al. Cholestyramine--a useful adjunct for the treatment of patients with fecal incontinence. Int J Colorectal Dis 2008; 23:189.
  17. Wrenn K. Fecal impaction. N Engl J Med 1989; 321:658.
  18. Ryan D, Wilson A, Muir TS, Judge TG. The reduction of faecal incontinence by the use of "Duphalac" in geriatric patients. Curr Med Res Opin 1974; 2:329.
  19. Velde SV, Biervliet SV, Bruyne RD, Winckel MV. A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients. Spinal Cord 2013; 51:873.
  20. Richter HE, Jelovsek JE, Iyer P, et al. Characteristics Associated With Clinically Important Treatment Responses in Women Undergoing Nonsurgical Therapy for Fecal Incontinence. Am J Gastroenterol 2020; 115:115.
  21. Madoff RD, Parker SC, Varma MG, Lowry AC. Faecal incontinence in adults. Lancet 2004; 364:621.
  22. Rao SS, Bharucha AE, Chiarioni G, et al. Functional Anorectal Disorders. Gastroenterology 2016.
  23. Norton C, Chelvanayagam S, Wilson-Barnett J, et al. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology 2003; 125:1320.
  24. Heymen S, Scarlett Y, Jones K, et al. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Dis Colon Rectum 2009; 52:1730.
  25. Norton C, Hosker G, Brazzelli M. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2000; :CD002111.
  26. Ko CY, Tong J, Lehman RE, et al. Biofeedback is effective therapy for fecal incontinence and constipation. Arch Surg 1997; 132:829.
  27. Ryn AK, Morren GL, Hallböök O, Sjödahl R. Long-term results of electromyographic biofeedback training for fecal incontinence. Dis Colon Rectum 2000; 43:1262.
  28. Guillemot F, Bouche B, Gower-Rousseau C, et al. Biofeedback for the treatment of fecal incontinence. Long-term clinical results. Dis Colon Rectum 1995; 38:393.
  29. MacLeod JH. Management of anal incontinence by biofeedback. Gastroenterology 1987; 93:291.
  30. Byrne CM, Solomon MJ, Young JM, et al. Biofeedback for fecal incontinence: short-term outcomes of 513 consecutive patients and predictors of successful treatment. Dis Colon Rectum 2007; 50:417.
  31. Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev 2013; :CD007959.
  32. Graf W, Mellgren A, Matzel KE, et al. Efficacy of dextranomer in stabilised hyaluronic acid for treatment of faecal incontinence: a randomised, sham-controlled trial. Lancet 2011; 377:997.
  33. La Torre F, de la Portilla F. Long-term efficacy of dextranomer in stabilized hyaluronic acid (NASHA/Dx) for treatment of faecal incontinence. Colorectal Dis 2013; 15:569.
  34. https://www.clinicaltrials.gov/ct2/show/record/NCT01647906 (Accessed on July 06, 2020).
  35. Wald A. New treatments for fecal incontinence: update for the gastroenterologist. Clin Gastroenterol Hepatol 2014; 12:1783.
  36. Dehli T, Stordahl A, Vatten LJ, et al. Sphincter training or anal injections of dextranomer for treatment of anal incontinence: a randomized trial. Scand J Gastroenterol 2013; 48:302.
  37. Tjandra JJ, Lim JF, Hiscock R, Rajendra P. Injectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective. Dis Colon Rectum 2004; 47:2138.
  38. Stojkovic SG, Lim M, Burke D, et al. Intra-anal collagen injection for the treatment of faecal incontinence. Br J Surg 2006; 93:1514.
  39. Altomare DF, La Torre F, Rinaldi M, et al. Carbon-coated microbeads anal injection in outpatient treatment of minor fecal incontinence. Dis Colon Rectum 2008; 51:432.
  40. Sarveazad A, Newstead GL, Mirzaei R, et al. A new method for treating fecal incontinence by implanting stem cells derived from human adipose tissue: preliminary findings of a randomized double-blind clinical trial. Stem Cell Res Ther 2017; 8:40.
  41. Cheung O, Wald A. Review article: the management of pelvic floor disorders. Aliment Pharmacol Ther 2004; 19:481.
  42. Kamm MA. Faecal incontinence. BMJ 1998; 316:528.
  43. Malouf AJ, Norton CS, Engel AF, et al. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet 2000; 355:260.
  44. Grey BR, Sheldon RR, Telford KJ, Kiff ES. Anterior anal sphincter repair can be of long term benefit: a 12-year case cohort from a single surgeon. BMC Surg 2007; 7:1.
  45. Mowatt G, Glazener C, Jarrett M. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev 2007; :CD004464.
  46. Tjandra JJ, Chan MK, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon Rectum 2008; 51:494.
  47. Boyle DJ, Knowles CH, Lunniss PJ, et al. Efficacy of sacral nerve stimulation for fecal incontinence in patients with anal sphincter defects. Dis Colon Rectum 2009; 52:1234.
  48. Thaha MA, Abukar AA, Thin NN, et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev 2015; :CD004464.
  49. Carrington EV, Evers J, Grossi U, et al. A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation. Neurogastroenterol Motil 2014; 26:1222.
  50. Gourcerol G, Gallas S, Michot F, et al. Sacral nerve stimulation in fecal incontinence: are there factors associated with success? Dis Colon Rectum 2007; 50:3.
  51. Hetzer FH, Bieler A, Hahnloser D, et al. Outcome and cost analysis of sacral nerve stimulation for faecal incontinence. Br J Surg 2006; 93:1411.
  52. Leroi AM, Parc Y, Lehur PA, et al. Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study. Ann Surg 2005; 242:662.
  53. Rosen HR, Urbarz C, Holzer B, et al. Sacral nerve stimulation as a treatment for fecal incontinence. Gastroenterology 2001; 121:536.
  54. Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP. Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence. Lancet 1995; 346:1124.
  55. Jarrett ME, Matzel KE, Christiansen J, et al. Sacral nerve stimulation for faecal incontinence in patients with previous partial spinal injury including disc prolapse. Br J Surg 2005; 92:734.
  56. Uludağ O, Koch SM, van Gemert WG, et al. Sacral neuromodulation in patients with fecal incontinence: a single-center study. Dis Colon Rectum 2004; 47:1350.
  57. Matzel KE, Kamm MA, Stösser M, et al. Sacral spinal nerve stimulation for faecal incontinence: multicentre study. Lancet 2004; 363:1270.
  58. Rasmussen OO, Buntzen S, Sørensen M, et al. Sacral nerve stimulation in fecal incontinence. Dis Colon Rectum 2004; 47:1158.
  59. Kenefick NJ, Nicholls RJ, Cohen RG, Kamm MA. Permanent sacral nerve stimulation for treatment of idiopathic constipation. Br J Surg 2002; 89:882.
  60. Patton V, Wiklendt L, Arkwright JW, et al. The effect of sacral nerve stimulation on distal colonic motility in patients with faecal incontinence. Br J Surg 2013; 100:959.
  61. Duelund-Jakobsen J, Lehur PA, Lundby L, et al. Sacral nerve stimulation for faecal incontinence - efficacy confirmed from a two-centre prospectively maintained database. Int J Colorectal Dis 2016; 31:421.
  62. Faucheron JL, Voirin D, Badic B. Sacral nerve stimulation for fecal incontinence: causes of surgical revision from a series of 87 consecutive patients operated on in a single institution. Dis Colon Rectum 2010; 53:1501.
  63. Wexner SD, Coller JA, Devroede G, et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg 2010; 251:441.
  64. Mellgren A, Wexner SD, Coller JA, et al. Long-term efficacy and safety of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum 2011; 54:1065.
  65. George AT, Kalmar K, Sala S, et al. Randomized controlled trial of percutaneous versus transcutaneous posterior tibial nerve stimulation in faecal incontinence. Br J Surg 2013; 100:330.
  66. Queralto M, Portier G, Cabarrot PH, et al. Preliminary results of peripheral transcutaneous neuromodulation in the treatment of idiopathic fecal incontinence. Int J Colorectal Dis 2006; 21:670.
  67. Govaert B, Pares D, Delgado-Aros S, et al. A prospective multicentre study to investigate percutaneous tibial nerve stimulation for the treatment of faecal incontinence. Colorectal Dis 2010; 12:1236.
  68. Knowles CH, Horrocks EJ, Bremner SA, et al. Percutaneous tibial nerve stimulation versus sham electrical stimulation for the treatment of faecal incontinence in adults (CONFIDeNT): a double-blind, multicentre, pragmatic, parallel-group, randomised controlled trial. Lancet 2015; 386:1640.
  69. Peña Ros E, Parra Baños PA, Benavides Buleje JA, et al. Short-term outcome of percutaneous posterior tibial nerve stimulation (PTNS) for the treatment of faecal incontinence. Tech Coloproctol 2016; 20:19.
  70. Murphy J, Chan CL, Scott SM, et al. Rectal augmentation: short- and mid-term evaluation of a novel procedure for severe fecal urgency with associated incontinence. Ann Surg 2008; 247:421.
  71. Brown SR, Wadhawan H, Nelson RL. Surgery for faecal incontinence in adults. Cochrane Database Syst Rev 2013; :CD001757.
  72. Madoff RD, Rosen HR, Baeten CG, et al. Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial. Gastroenterology 1999; 116:549.
  73. Rongen MJ, Uludag O, El Naggar K, et al. Long-term follow-up of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2003; 46:716.
  74. Khaikin M, Wexner SD. Treatment strategies in obstructed defecation and fecal incontinence. World J Gastroenterol 2006; 12:3168.
  75. Baeten CG, Geerdes BP, Adang EM, et al. Anal dynamic graciloplasty in the treatment of intractable fecal incontinence. N Engl J Med 1995; 332:1600.
  76. Mundy L, Merlin TL, Maddern GJ, Hiller JE. Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence. Br J Surg 2004; 91:665.
  77. Wong MT, Meurette G, Wyart V, et al. The artificial bowel sphincter: a single institution experience over a decade. Ann Surg 2011; 254:951.
  78. Wong WD, Congliosi SM, Spencer MP, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum 2002; 45:1139.
  79. O'Brien PE, Dixon JB, Skinner S, et al. A prospective, randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence. Dis Colon Rectum 2004; 47:1852.
  80. Giamundo P, Welber A, Weiss EG, et al. The procon incontinence device: a new nonsurgical approach to preventing episodes of fecal incontinence. Am J Gastroenterol 2002; 97:2328.
  81. Vaizey CJ, Kamm MA, Gold DM, et al. Clinical, physiological, and radiological study of a new purpose-designed artificial bowel sphincter. Lancet 1998; 352:105.
  82. Wong MT, Meurette G, Stangherlin P, Lehur PA. The magnetic anal sphincter versus the artificial bowel sphincter: a comparison of 2 treatments for fecal incontinence. Dis Colon Rectum 2011; 54:773.
  83. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm477914.htm (Accessed on December 21, 2015).
  84. Takahashi T, Garcia-Osogobio S, Valdovinos MA, et al. Radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence. Dis Colon Rectum 2002; 45:915.
  85. Takahashi-Monroy T, Morales M, Garcia-Osogobio S, et al. SECCA procedure for the treatment of fecal incontinence: results of five-year follow-up. Dis Colon Rectum 2008; 51:355.
  86. Ruiz D, Pinto RA, Hull TL, et al. Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1-year follow-up? Dis Colon Rectum 2010; 53:1041.
  87. Efron JE, Corman ML, Fleshman J, et al. Safety and effectiveness of temperature-controlled radio-frequency energy delivery to the anal canal (Secca procedure) for the treatment of fecal incontinence. Dis Colon Rectum 2003; 46:1606.
  88. Kim DW, Yoon HM, Park JS, et al. Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence? Am J Surg 2009; 197:14.
  89. Deutekom M, Dobben AC. Plugs for containing faecal incontinence. Cochrane Database Syst Rev 2012; :CD005086.
  90. Lukacz ES, Segall MM, Wexner SD. Evaluation of an Anal Insert Device for the Conservative Management of Fecal Incontinence. Dis Colon Rectum 2015; 58:892.
  91. Bond C, Youngson G, MacPherson I, et al. Anal plugs for the management of fecal incontinence in children and adults: a randomized control trial. J Clin Gastroenterol 2007; 41:45.
  92. Van Winckel M, Van Biervliet S, Van Laecke E, Hoebeke P. Is an anal plug useful in the treatment of fecal incontinence in children with spina bifida or anal atresia? J Urol 2006; 176:342.
  93. Norton C, Kamm MA. Anal plug for faecal incontinence. Colorectal Dis 2001; 3:323.
  94. Pfrommer W, Holschneider AM, Löffler N, et al. A new polyurethane anal plug in the treatment of incontinence after anal atresia repair. Eur J Pediatr Surg 2000; 10:186.
  95. Cheetham MJ, Kamm MA, Phillips RK. Topical phenylephrine increases anal canal resting pressure in patients with faecal incontinence. Gut 2001; 48:356.
  96. Carapeti EA, Kamm MA, Phillips RK. Randomized controlled trial of topical phenylephrine in the treatment of faecal incontinence. Br J Surg 2000; 87:38.
  97. Carapeti EA, Kamm MA, Nicholls RJ, Phillips RK. Randomized, controlled trial of topical phenylephrine for fecal incontinence in patients after ileoanal pouch construction. Dis Colon Rectum 2000; 43:1059.
  98. Chassagne P, Jego A, Gloc P, et al. Does treatment of constipation improve faecal incontinence in institutionalized elderly patients? Age Ageing 2000; 29:159.
  99. Park JS, Kang SB, Kim DW, et al. The efficacy and adverse effects of topical phenylephrine for anal incontinence after low anterior resection in patients with rectal cancer. Int J Colorectal Dis 2007; 22:1319.
  100. Devesa JM, Vicente R. The use of a simple anal sling in the management of anal incontinence. Gastroenterol Rep (Oxf) 2014; 2:136.
  101. Richter HE, Matthews CA, Muir T, et al. A vaginal bowel-control system for the treatment of fecal incontinence. Obstet Gynecol 2015; 125:540.
Topic 96913 Version 17.0

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