Current status and strategies for the treatment of fecal incontinence
Wang Xiaofeng, Li Huashan
Wang Xiaofeng, Department of Anorectology, Guang’anmen Hospital, Chinese Academy of Traditional Chinese Medicine
[Abstract] Fecal incontinence is relatively common and seriously affects patients’ quality of life. In the past two decades, new therapies aimed at treating and reducing complications have been developed to some extent. Currently, the commonly used non-surgical therapies include dietary modification, pharmacotherapy, biofeedback therapy, and surgical therapies include repair (sphincteroplasty), neurostimulation (presacral nerve stimulation, etc.), artificial anal sphincter replacement or autologous muscle transfer, and fecal diversion stoma. Still in its infancy, controversial treatments include radiofrequency energy therapy and injection therapy, which are less invasive and may be non-surgical treatment options for some patients with mild fecal incontinence. Physicians should develop individualized treatment plans that take into account anal function, quality of life, and potential complications. For patients with severe fecal incontinence, more invasive surgical treatments should be chosen with caution. This article focuses on a systematic review and summary of the current strategies and efficacy of various treatment options for fecal incontinence.
【Key words】Fecal incontinence; presacral nerve stimulation; sphincteroplasty; artificial anal sphincter; biofeedback
Current treatments and managing strategy of fecal incontinence
Wang Xiaofeng, Li Huashan
Guang’anmen hospital, China academy of Chines medical sciences
Abstract】Fecal incontinence is common. Key words】fecal incontinence; sacral nerve stimulation; sphincteroplasty; artificial bowel sphincter; biofeedback In the past two decades, new treatmentmen have defined fecal incontinence as the inability to control feces and gas voluntarily, and it is classified as complete incontinence (inability to control dry and loose feces and gas) and incomplete incontinence (inability to control loose feces and gas) [1]. 1999 American Consensus Conference on the Treatment of Fecal Incontinence reported that fecal incontinence is defined as age at least four years and recurrent inability to control feces for at least one month; gas spillage without fecal matter is not considered to constitute incontinence. However, frequent gas spills that affect quality of life should be treated [2]. The prevalence of fecal incontinence ranges from approximately 1.4% to 18% in the population and can be as high as 50% in the nursing home population [3-5]. One study investigated 5800 American women and found that the rate of involuntary anal discharge was as high as nearly 20%, and nearly 40% of them had severe symptoms that affected their quality of life [6]. Therefore, the treatment of fecal incontinence should not be neglected. Currently, the treatment of fecal incontinence includes dietary modification, medical therapy and a range of surgical treatments including enterostomies. In recent decades, in addition to traditional therapies such as anal sphincteroplasty and ostomy, many new treatments have achieved better results, including biofeedback, radiofrequency energy transfer, injection therapy, and some surgical interventions such as presacral nerve stimulation, muscle transposition, and artificial anal sphincter implants. A recent Cochrane systematic review showed that there is insufficient evidence to compare the efficacy of various procedures for the treatment of fecal incontinence [8]. Therefore, physicians must take a thorough history and use physical examinations such as pelvic floor ultrasound, anal manometry, fecography, MRI, and latent EMG of the pubic motor nerve endings to understand the likely cause and degree of incontinence and to develop an individualized and optimal treatment plan that takes into account the patient’s wishes. This article focuses on a systematic review and summary of the current strategies and efficacy of various treatment options for fecal incontinence. I. Lifestyle, dietary modifications, and medications Lifestyle and dietary modifications are often considered a simple and effective intervention to improve fecal incontinence symptoms. Some studies have shown that smoking and physical inactivity are associated with fecal incontinence [9] and that weight loss can improve fecal incontinence symptoms in obese women [10]. low-fiber, high-fat diet may result in the passing of loose stools, which in turn or diarrhea often exacerbates the symptoms of fecal incontinence; whereas increased fiber intake may promote the formation of solid stools, thereby improving symptoms. In addition to fiber supplementation, some antidiarrheal drugs may be effective in some patients with fecal incontinence who have unformed stools, including loperamide, diphenoxylate, atropine, and codeine, of which loperamide is most commonly used to increase resting anal sphincter pressure while antidiarrheal [11]. It has been shown that koleleneamine helps to relieve postoperative diarrhea and flatulence in patients with cholecystectomy, thus relieving incontinence symptoms, suggesting that some anatomical and functional alterations may be risk factors for exacerbating incontinence symptoms and should be taken into account in clinical work [12]. In addition, certain medications may aggravate incontinence symptoms, and care should be taken in the selection of medications for patients. There is still a lack of comparative studies between the efficacy of different drugs and of trial studies related to the treatment of different etiologies of incontinence, so there is insufficient evidence to guide the choice of drugs for the treatment of fecal incontinence; however, it is certain that drugs are ineffective in patients with severe fecal incontinence. Biofeedback Currently, biofeedback is usually recommended to be tried in patients who have failed to respond to pharmacological treatment, as a muscle training therapy that is safe, inexpensive, effective in the long term, and without adverse effects, and includes a variety of methods such as pelvic floor training, digital feedback, electrical stimulation, balloon and anal manometry, or ultrasound response monitoring. There have been some relevant studies exploring the most effective modalities and the most appropriate population, but none of them were of high overall quality; further anorectal physiological examinations such as manometry, defecography, pelvic floor MRI or latent electromyography of motor nerve endings do not seem to be helpful in screening for more appropriate cases [13]. Pelvic floor training has been shown to improve fecal incontinence scores and quality of life, with similar efficacy of different approaches, all improving patient symptoms [14]. Biofeedback combined with anal manometry can be more effective in improving fecal incontinence scores and promoting physiological defecation than pelvic floor training [15]. A randomized controlled study showed that biofeedback combined with digital feedback was similar to anal manometry and ultrasound-guided repetitive training methods, both providing more feedback information [16]. Some studies have concluded that electrical stimulation is more effective than biofeedback alone, and that extending electrical stimulation beyond 3 months has the best efficacy; while others have concluded that biofeedback alone is sufficient [17]. However, biofeedback therapy often requires the participation of both the patient and an experienced therapist and requires adherence for several weeks or even months. One study found that only 44% of patients with fecal incontinence recommended for biofeedback completed the treatment, but it was effective in 80% of patients [19], while improving some physiological indicators, such as anal canal systolic pressure and maximum rectal volume [20]. Improvement in fecal incontinence scores can be maintained for at least 1 year of treatment, but some patients need to be combined with other means to increase the efficacy [21], such as pelvic floor training combined with biofeedback may benefit patients with fecal incontinence in the long term, but the patient needs to cooperate with the therapist to complete the treatment plan. If biofeedback is completed consistently, patients’ symptoms can often improve, thus avoiding invasive surgery. III, radiofrequency energy transfer It is currently believed that there is a gap between conservative and surgical treatment of fecal incontinence. Although controversial, there is a growing belief that radiofrequency energy delivery and injection therapy can fill this gap. The transmission of radiofrequency energy to the internal sphincter is called SECCA® procedure, which aims to induce local collagen remodeling, thereby increasing the strength of the internal sphincter for better stool control. This method can be used in patients with mild to moderate fecal incontinence who are unwilling or unsuitable for surgical treatment after failure of conservative treatment, or in patients with sphincter defects or congenital fecal incontinence. Radiofrequency energy transfer therapy is relatively simple to perform and can be administered in an outpatient endoscopy room or operating room under local anesthesia, with an operating time of approximately 30 minutes. The surgical device resembles a clear plastic anoscope with four retractable needle-like electrodes for piercing the mucosa to transmit radiofrequency energy to the internal sphincter. The device automatically monitors energy transfer time, tissue temperature and impedance to avoid burns when transmitting RF energy. One study reported that after radiofrequency energy transfer treatment, patients had a durable decrease in Wexner fecal incontinence scores from 14 to 8 on average, with >50% symptom improvement, long-term improvement in fecal incontinence scores, and improved satisfaction and quality of life after 5 years [22-23]; however, another study with a mean follow-up of 40 months in patients with high basal fecal incontinence scores found that only 22% of patients benefited [ 24]. Although the results of radiofrequency energy delivery therapy were generally good, anal manometry revealed no significant changes in physiological parameters [25]. Common complications include infection, hematoma, mild bleeding, and anal pain, but no serious adverse events have been reported [23, 25]. Based on the current overall results of radiofrequency energy transfer therapy, its therapeutic effectiveness remains controversial. IV. Injection therapy Injectable therapy is another treatment for fecal incontinence and can be performed with materials such as collagen, silicone, autologous fat, glutaraldehyde, charcoal-coated particles, polyglycolic hyaluronic acid gel, and other materials, of which polyglycolic hyaluronic acid gel (NASA/Dx) has been a recent focus of attention and research in the literature [16]. This method is simple to perform, can be done on an outpatient basis, is free of discomfort and has few complications. It can be used in patients with mild to moderate fecal incontinence who have failed conservative treatment. its filling effect is not necessarily effective in the long term and may require repeat injections at postoperative outpatient review depending on the condition. During the operation, the patient is placed in a prone folding knife position or bladder stone position, and the needle is inserted under the anoscope 5-10 mm above the dentate line at an angle of 30. into the submucosa, and NASA/Dx 1 ml is injected, and the needle is held in place for 30 s and then withdrawn to avoid leakage of the injected colloid, for a total of four quadrants [27]. Comparative studies of efficacy between different injection materials are scarce, and no studies have been seen comparing NASHA/Dx with A randomized controlled study comparing NASHA/Dx and biofeedback therapy found no statistically significant difference in functional efficacy [28], but it is clear that biofeedback therapy requires more time and effort on the part of the patient. Injection therapy affects anal manometry parameters by increasing the length of the high pressure area and the asymmetry index [29], and the effect of this method on resting pressure has been reported to be controversial in the literature [29-30]. The most commonly used NASHA/Dx has not been reported for long-term efficacy, with the longest follow-up being 2 years [31].A systematic review published in 2013 concluded that there are no long-term follow-up studies to confirm the efficacy of the injection method [32]. Some studies have reported a 50% or greater reduction in the incidence of fecal incontinence in more than 50% of patients treated with this method [27, 30], improving the quality of life [27, 31]. Injection therapy is associated with fewer complications, of which fever and anal pain are relatively common, as well as bleeding and abscesses [27]. Although injection therapy can be considered for many patients, it is ideal for patients with anal leakage, mild to moderate fecal incontinence who have failed pharmacologic therapy or who are not temporarily considering surgical treatment; even if treatment fails, it does not prevent subsequent surgical treatment. V. Anterior sacral nerve stimulation Initially used to treat urinary incontinence, presacral nerve stimulation has been modified and found to be effective in the treatment of fecal incontinence, while having no direct effect on the anal sphincter, and can be used in the treatment of moderate to severe fecal incontinence. One study found that stool consistency and low stimulation intensity during the detection phase of the procedure were associated with the success of anterior sacral nerve stimulation treatment; whereas age, gender, etiology and physiological findings did not affect the effectiveness of anterior sacral nerve stimulation [34]. Although there is no evidence directly comparing anterior sacral nerve stimulation with sphincteroplasty, numerous studies suggest that anterior sacral nerve stimulation is more effective for treating patients with pubic nerve injury, sphincter defects, or a history of sphincteroplasty [36], and is independent of the degree of sphincter injury [37]. There are three possible routes of action of presacral nerve stimulation:(1) stimulation of the somato-visceral reflex, which directly affects the anal sphincter and modulates the afferent nerves [38].
There is also a hypothesis that it may promote the conversion of the anal sphincter from fast to slow muscle, thus reducing muscle fatigue, but it has not been confirmed in people receiving presacral nerve stimulation [39]. (2) Sensory alterations, including altered sensation of rectal fullness and urge to defecate at higher rectal volumes [40]. (3) Induces retrograde colonic transport and slows down colonic transport in patients with fecal incontinence [41]. There are two methods of implanting an anterior sacral nerve stimulation stimulator, one is to implant a peripheral nerve stimulation lead under outpatient conditions according to anatomical landmarks, and after a 1-2 week response testing period, if the patient responds well, a long-term stimulation device is implanted in the operating room. In the first stage, a wire is implanted in the 3rd sacral foramen under X-ray and direct patient sensory guidance in the operating room, and light sedation combined with local anesthesia is used during electrical stimulation so that feedback to the operator can be given when the patient feels perianal, perineal, or saddle stimulation, during which time the ipsilateral plantar flexion of the great toe of the wire is also considered as a response to stimulation of the presacral nerve, and if there is a good response, the patient is stimulated via the Wires were placed in subcutaneous tunnels; then after a 2-week trial period, if the response was good, a second stage procedure was performed with a long-term stimulation device implanted and wires attached. Although the likelihood of wire displacement during the trial of this method was minimal, a second procedure was still required. The trial period for both methods is important, as it allows for timely adjustment of areas where stimulation is not effective [42]. In addition, each stimulation device should be programmed according to individual response patterns, while optimized use strategies can result in a battery life greater than 6 years, including cyclic stimulation and subcritical stimulation (stimulation intensity below the critical stimulation intensity for sensory production) [43-44]. Long-term results have been derived for anterior sacral nerve stimulation for fecal incontinence, which is significantly more effective than pharmacological treatment [45]. A recent study found significant and sustained improvement in fecal incontinence in 89% of patients with at least 5 years of follow-up, and 36% had a complete response to presacral nerve stimulation [46]. long-term quality of life scores have also improved with the use of anterior sacral nerve stimulation [47]. There are a number of potential complications of presacral nerve stimulation, with surgical site pain and foreign body sensation being the most common, subcutaneous lead displacement during approximately 5% of trials, and a 10% incidence of long-term stimulation device implantation or surgical site infection, with half of infections requiring surgical management [47, 49]. Taking into account the effectiveness of the treatment, the economics and the complications, anterior sacral nerve stimulation is a very valuable treatment, especially for the treatment of patients with severe fecal incontinence. VI. Anal sphincteroplasty Anal sphincterplasty has long been the standard treatment for fecal incontinence due to anal sphincter injury [50]. The vast majority of cases treated with sphincteroplasty have a history of vaginal delivery, but only about one third of women with sphincter injury from vaginal delivery subsequently develop fecal incontinence [50]. Pubic nerve injury, multiple vaginal deliveries, history of third- and fourth-degree tears, and device-assisted vaginal delivery can cause sphincter injury and affect the success of sphincteroplasty [51]. Notably, pubic nerve injury, manifested as prolonged latency of the pubic motor nerve endings, is not an independent influencer in predicting sphincteroplasty success [52]. Many women treated with sphincteroplasty have pelvic floor injuries, but this does not seem to affect the success rate [53]. In addition, combined internal sphincter combined with external sphincter defect repair has better efficacy than external sphincter repair alone [54]. Several sphincteroplasty techniques have been reported in the literature, with the most commonly used procedure being anterior sphincter folding and plication. Using a curved perineal incision, the external sphincter margin is separated and identified to free it; care is taken not to free it too much to the side to avoid damaging the nerve. Folding and suturing the severed end to form a new sphincter complex. Folding the internal sphincter does not seem to increase the durability of sphincter folding if the internal sphincter is not damaged [55]. Early sphincteroplasty for third- and fourth-degree lacerations due to vaginal delivery does not necessarily require a diversionary stoma, as the second stage also increases the total medical costs, but does not significantly improve clinical outcomes [56]. Since the etiology of most sphincter injuries is a birth injury caused by transvaginal delivery, posterior sphincter repair is less commonly used. Posterior repair is sometimes used to treat neurogenic fecal incontinence, but also in patients with multiple sphincter injuries or failed anterior repairs. The procedure is similar to the anterior repair technique, with a posterior curved incision to expose the external sphincter. In rare cases, some surgeons may use both anterior and retroanal dual access. The success rate of the posterior anal approach is roughly comparable to or slightly worse than that of anterior sphincteroplasty [57]. The long-term functional outcome of anal sphincteroplasty is not satisfactory. the Wexner fecal incontinence score showed that fecal incontinence control was effective in 70% of patients in the short term, and half of the patients had a significant outcome [58]. However, many retrospective studies have consistently suggested decreased long-term efficacy, ranging from 15% to 60% of patients with good long-term anal autonomic function [52, 59-60]. However, long-term quality of life scores differ from fecal incontinence scores, with a median follow-up of 7 years suggesting that 95% of patients were satisfied with their long-term quality of life after sphincteroplasty [59]. Several studies have shown poorer long-term outcomes in older patients than younger patients, and age is considered a risk factor for sphincteroplasty outcomes [52, 59-60]. However, there was also a large retrospective study that included 321 female patients with sphincteroplasty that showed that age was not a predictor of long-term fecal incontinence scores [61]. Although several new techniques have emerged, we believe that anal sphincteroplasty remains one of the options for fecal incontinence due to sphincter injury and that proper preoperative evaluation and selection must be performed to achieve the desired outcome. VII. Muscle transfer muscle transfer is a technique that replaces the anal sphincter with a physiologically active muscle bundle to treat anal sphincter lacerations or medically induced injuries by reconstructing the perianal muscle ring. For patients with congenital or traumatic anal sphincter deficits. Femoral thin muscle plication followed by artificial anal sphincter implantation is perhaps the best combined treatment option for adult fecal incontinence patients with congenital anal atresia [62]. Muscle transfers reported in the literature mostly use two muscles: gluteus maximus and femoris profundus, for the reason that these two muscles are close to the anus and provide sufficient muscle tissue, while their innervated nerves are conveniently located for protection. In addition, it is believed that the gluteus maximus is suitable for muscle transfer surgery because the gluteus maximus muscle contracts unconsciously, satisfying the patient’s strong desire to avoid unconscious defecation [63]. The surgical technique of muscle transfer is complex and requires a great deal of experience. There are usually three surgical options: gluteus maximus plication, thin femoral plication, and dynamic (stimulator) thin femoral plication. In gluteus maximus plication the patient is placed in the prone position, 1 incision is made above each gluteus maximus bilaterally, the muscle flap below 10% of the gluteus maximus is separated, attention is paid to protecting the neurovascular bundle [63], then the free muscle flap is transferred through a tunnel to the curved incision on both sides of the anus, and the free muscle flaps on both sides are sutured to form a muscle ring. Patients undergoing sphincteroplasty are placed in a modified cystotomy position, and two to three incisions are made along the long axis of the proposed transferred thin femoral muscle to protect the neurovascular bundle by identifying the anatomical features of the thin femoral muscle. the distal femoral thin muscle is freed and transferred through a tunnel to the perineal incision and around the anus. Dynamic sphincteroplasty is an implantable stimulation device in which electrodes are placed into the sphincter and attached to the abdominal wall similar to anterior sacral nerve stimulation. Modified dynamic trochanteroplasty can also be performed with an external stimulation device to produce temporary stimulation similar to biofeedback therapy to exercise the transferred trochanteric function [62]. Similar to artificial anal sphincter replacement, patients have good functional improvement after muscle transfer, but complication rates and reoperation rates are higher; a large-scale gluteoplasty study showed good functional improvement in 59% of patients after surgery [63]. dynamic and stimulatorless devices have a high success rate of 60%-75% for thin femoral muscle plication, and even higher success rates for early type stimulatorless thin femoral muscle plication treatment [62-64]. The presence or absence of a stoma does not affect patient outcomes [64]. Common surgical complications include surgical site infection, pain, rectal injury, and tissue necrosis at the site of dynamic femoroplasty stimulation device implantation, as well as constipation in some patients due to bowel obstruction [65-66]. VIII. artificial anal sphincter Only patients with severe fecal incontinence and basic intellectual and operative skills should be considered for artificial anal sphincter replacement surgery. Because of the high incidence of adverse events, artificial anal sphincter replacement therapy should be considered when other treatments have been tried and failed. Indications for surgery include anal fissures, severe birth injuries, and congenital anal atresia; contraindications include Crohn’s disease, history of local infection, history of radiation therapy, poor perineal tissue quality, severe constipation, and irritable bowel syndrome with incontinence [67]. Because the improvement in fecal function and quality of life scores in patients after anterior sacral nerve stimulation and artificial anal sphincter replacement is significant compared to muscle transfer surgery and dynamic femoral sphincteroplasty, it is suitable for the treatment of patients with severe fecal incontinence. Strict asepsis and adequate bowel preparation are essential to reduce the risk of infection after artificial anal sphincter replacement. The artificial anal sphincter replacement is a fluid-filled system consisting of an artificial sphincter ring, a reservoir balloon, and a control valve connected by a tube. These components need to be implanted through the perineum, transverse lower abdominal incision and labia majora or scrotal incision, respectively. The type of artificial sphincter ring needs to be selected according to the circumference and width of the anal canal, and care should be taken to preserve enough terminal tissue after implantation to avoid infection and necrosis. At the end of the procedure, the control valve was tested normal and approximately 40 ml of fluid was injected. artificial anal sphincter is withheld for 4 to 6 weeks after surgery to allow for adequate recovery of the surgical wound. Patients who have successfully completed treatment with artificial anal sphincter replacement have shown good functional and quality-of-life improvement. anal manometry results showed that patients had normal anal resting pressure when the artificial sphincter ring was filled [68]. More than 3/4 of patients have improved anal autonomic function and 2/3 of patients have achieved normal anal autonomic function [69-70]. The results of fecal incontinence scores showed that patients who were successfully implanted responded well to the artificial anal sphincter, although adverse events were significant [68-73], and quality of life scores improved significantly [72]. Fecal function and quality of life in patients with surgical failure have not been reported in the literature. Complications after artificial anal sphincter replacement remain high, with infection and device failure being the most common causes and requiring surgical intervention in up to 50% of patients, reducing the overall benefit for the fecal incontinence population [73]. Approximately 25-40% of patients with artificial anal sphincter replacement gradually develop infection [73-74]. Artificial sphincter rings or control valve area necrosis and postoperative constipation have also occurred. In conclusion, it is important to consider the potential risks and benefits together, and artificial anal sphincter replacement may still be the ideal treatment option for some patients with severe fecal incontinence. ix. cascading knotty enema cascade knotty enemas [75] were first reported in 1990 by Malone et al. for the control of fecal incontinence in adults or children, predominantly children. Indications for surgery include: neurological disorders such as spina bifida in children, overflow incontinence due to constipation and colonic motility disorders, neurogenic urinary incontinence and fecal incontinence requiring concomitant urological surgery [76]. The cis-articulated thrombolytic enema does not adjust anorectal physiology and anatomy, but only provides a controlled way to empty the colon so that the patient can engage in daily life without fear of fecal incontinence. Currently there are several alternative enema entrances for this method, such as appendix, ileum, cecum and left hemicolectomy. The most commonly used method is to turn and fix the appendix to the umbilicus or to the skin of the right lower abdominal wall, leave a catheter in place for about 3 weeks to avoid entrance closure, and thereafter the patient himself or his family will irrigate the colon with tap water, saline or enema solution daily or every few days, and adjust the time interval and the amount of enema solution as appropriate. Overall, patients treated with cis-controlled enemas showed good functional improvement, with approximately 75% of adult patients treated effectively. Although not all patients continue to use cis-ablative enemas on a long-term basis, those who adhere to them have improved quality of life [77]. complete abstinence function was reported in 77%% of patients, and although the duration of fecal care was not significantly reduced, satisfaction and quality of life scores improved in most patients [79]. Persistent fluid leakage, stoma stricture and surgical site infection are common complications, with 13% of patients requiring reoperation for stoma complications [79, 81]. The cathartic enema is not usually used in adults, and adult patients still require long-term follow-up and monitoring for these complications. X. Fecal diversion stoma A colostomy or ileostomy can completely improve fecal incontinence symptoms. Colostomy is the standard stoma for the treatment of fecal incontinence, but ileostomy may also be considered in patients with colonic transmission dysfunction. Many patients can apply a laparoscopic stoma to shorten the recovery time. Although colostomy risks, such as bleeding, anesthesia-related cardiopulmonary complications, and stoma herniation, remain safe and effective treatments for severe fecal incontinence. for patients in whom other treatments have failed. Many patients refuse long-term colostomy use due to concerns about the difficulty of care and the severe impact on their personal image and social activities. Investigations showed that patients with fecal incontinence treated by colostomy had higher overall quality of life scores and quality of life scores than patients with fecal incontinence treated by other treatment modalities [82]. Another study reported a high level of satisfaction with the stoma in patients with fecal incontinence, with more than 80% of patients indicating that they would probably or definitely choose the stoma again if given the opportunity to choose treatment again [83]. Although most patients with fecal incontinence do not require a fecal diversion ostomy, it remains a viable, well-tolerated, and quality-of-life ultimate treatment option. In conclusion, fecal incontinence has a serious impact on patients’ quality of life and is receiving increasing attention. However, due to the large number of patients who are avoiding treatment and the complex etiology and pathological changes, research progresses slowly and few studies of good quality have been reported in China, while some progress in treatment has been made in the last 20 years abroad. Treatment of fecal incontinence should be based on comprehensive history taking, sound physical examination and evaluation. The choice of treatment should take into account the severity and treatment needs of the patient, and the transition from inexpensive pharmacological and physical treatments to complex surgical treatments such as muscle transfer and artificial anal sphincter replacement should be made gradually. Minimally invasive treatment modalities include biofeedback, radiofrequency energy and injection therapy, all of which have some long-term efficacy. Sphincteroplasty remains an acceptable option for patients with a clear history of sphincter injury, but is not effective in the long term. Anterior sacral nerve stimulation for moderate to severe fecal incontinence has been widely accepted; after a considerable period of time patients may need another procedure to replace the battery of the anterior sacral nerve stimulation device, but this procedure does not decrease patient satisfaction or quality of life and is repeated effectively. Although there are more serious complications with artificial anal sphincter replacement, the outcome is satisfactory in those patients with successful implantation. The fecal diversion procedure provides a satisfactory quality of life and is economical, and remains a treatment option for patients with severe fecal incontinence. Given the complexity and intractability of fecal incontinence, especially severe fecal incontinence, there is no perfect solution; it is crucial to give an objective and detailed account of the advantages and disadvantages of the various treatment options and to work with the patient to select the appropriate treatment. Ref. [1] Huang Naijian, ed. Chinese anorectal pathology. Shandong: Shandong Science and Technology Press, 1996,831. [Whitehead WE, Wald A, Norton NJ. Treatment options for fecal incontinence. Dis Colon Rectum, 2001,44:131-144. [3] Kuehn BM. Silence masks prevanlence of fecal incontinence. JAMA, 2006,295:1362-1363. [4] Nelson RL. 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