Prevalence and correlates of fecal incontinence in community-dwelling older adults

Objectives: To determine prevalence and correlates of fecal incontinence in older community‐dwelling adults. Design: A cross‐sectional, population‐based survey. Setting: Participants interviewed at home in three rural and two urban counties in Alabama from 1999 to 2001. Participants: The University of Alabama at Birmingham Study of Aging enlisted 1,000 participants from the state Medicare beneficiary lists. The sample was selected to include 25% black men, 25% white men, 25% black women, and 25% white women. Measurements: The survey included sociodemographic information, medical conditions, health behaviors, life‐space assessment (mobility), and self‐reported health status. Fecal incontinence was defined as an affirmative response to the question “In the past year, have you had any loss of control of your bowels, even a small amount that stained the underwear?” Severity was classified as mild if reported less than once a month and moderate to severe if reported once a month or greater. Results: The prevalence of fecal incontinence in the sample was 12.0% (12.4% in men, 11.6% in women; P=.33). Mean age±standard deviation was 75.3±6.7 and ranged from 65 to 106. In a forward stepwise logistic regression analysis, the following factors were significantly associated with the presence of fecal incontinence in women: chronic diarrhea (odds ratio (OR)=4.55, 95% confidence interval (CI)=2.03–10.20), urinary incontinence (OR=2.65, 95% CI=1.34–5.25), hysterectomy with ovary removal (OR=1.93, 95% CI=1.06–3.54), poor self‐perceived health status (OR=1.88, 95% CI=1.01–3.50), and higher Charlson comorbidity score (OR=1.29, 95% CI=1.07–1.55). The following factors were significantly associated with fecal incontinence in men: chronic diarrhea (OR=6.08, 95% CI=2.29–16.16), swelling in the feet and legs (OR=3.49, 95% CI=1.80–6.76), transient ischemic attack/ministroke (OR=3.11, 95% CI=1.30–7.41), Geriatric Depression Scale score greater than 5 (OR=2.83, 95% CI=1.27–6.28), living alone (OR=2.38, 95% CI=1.23–4.62), prostate disease (OR=2.29, 95% CI=1.04–5.02), and poor self‐perceived health (OR=2.18, 95% CI=1.13–4.20). The following were found to be associated with increased frequency of fecal incontinence in women: chronic diarrhea (OR=6.39, 95% CI=2.25–18.14), poor self‐perceived health (OR=5.37, 95% CI=1.75–16.55), and urinary incontinence (OR=4.96, 95% CI=1.41–17.43). In men, chronic diarrhea (OR=5.38, 95% CI=1.77–16.30), poor self‐perceived health (OR=3.91, 95% CI=1.39–11.02), lower extremity swelling (OR=2.86, 95% CI=1.20–6.81), and decreased assisted life‐space mobility (OR=0.73, 95% CI=0.49–0.80) were associated with more frequent fecal incontinence. Conclusion: In community‐dwelling older adults, fecal incontinence is a common condition associated with chronic diarrhea, multiple health problems, and poor self‐perceived health. Fecal incontinence should be included in the review of systems for older patients.     

Urinary and Fecal Incontinence and Quality of Life in African Americans

OBJECTIVES: To investigate associations between quality of life (QoL) and incontinence in a population‐based African‐American sample. DESIGN: Cross‐sectional survey. SETTING: Metropolitan St. Louis, Missouri. PARTICIPANTS: Eight hundred fifty‐three non‐institutionalized African Americans aged 52 to 68 in the African American Health study. MEASUREMENTS: Respondents who reported having involuntarily lost urine over the previous month were classified as having urinary incontinence (UI), and respondents who reported having lost control of their bowels or stool over the past year were classified as having fecal incontinence (FI). QoL was measured using the Medical Outcomes Study 36‐Item Short‐Form Health Survey (SF‐36) and the 11‐item Center for Epidemiologic Studies Depression Scale (CES‐D). RESULTS: Prevalences of UI and FI were 12.1% (weighted n=102/841) and 5.0% (weighted n=42/841). Participants with UI and those with FI had worse SF‐36 scores than their referent groups (physical function ?15.5 and ?38.1 points, respectively; role physical ?13.2 and ?26.5 points; bodily pain ?15.7 and ?24.5 points; general health perceptions ?15.5 and ?27.6 points; vitality ?15.0 and ?16.5 points; social functioning ?18.4 and ?25.6 points; role emotional ?13.2 and ?22.1 points; mental health ?12.2 and ?17.5 points; all Ps<.001), adjusting for age, sex, body mass index, and chronic conditions. Proportions with clinically relevant levels of depressive symptoms were also higher in both groups (UI+17.9%; P<.001) and FI (+37.2%; P<.001) than in their referent groups. CONCLUSION: UI and FI were strongly associated with worse health‐related QoL as well as symptoms of depression in this population‐based sample of African Americans.     

A Controlled Trial of an Intervention to Improve Urinary and Fecal Incontinence and Constipation

OBJECTIVES: To evaluate effects of a multicomponent intervention on fecal incontinence (FI) and urinary incontinence (UI) outcomes. DESIGN: Randomized controlled trial. SETTING: Six nursing homes (NHs). PARTICIPANTS: One hundred twelve NH residents. INTERVENTION: Intervention subjects were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months. MEASUREMENTS: Frequency of UI and FI and rate of appropriate toileting as determined by direct checks from research staff. Anorectal assessments were completed on a subset of 29 residents. RESULTS: The intervention significantly increased physical activity, frequency of toileting, and food and fluid intake. UI improved (P=.049), as did frequency of bowel movements (P<.001) and percentage of bowel movements (P<.001) in the toilet. The frequency of FI did not change. Eighty‐nine percent of subjects who underwent anorectal testing showed a dyssynergic voiding pattern, which could explain the lack of efficacy of this intervention program alone on FI. CONCLUSION: This multicomponent intervention significantly changed multiple risk factors associated with FI and increased bowel movements without decreasing FI. The dyssynergic voiding pattern and rectal hyposensitivity suggest that future interventions may have to be supplemented with bulking agents (fiber), biofeedback therapy, or both to improve bowel function.     

Design and Validation of a Comprehensive Fecal Incontinence Questionnaire

Purpose  Fecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise. Methods  Patients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion. Results  The questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (P < 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35–1). Conclusions  This questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.     

Carbon-Coated Microbeads Anal Injection in Outpatient Treatment of Minor Fecal Incontinence

Purpose

Anal bulking agents are injected to pose a stronger obstacle to the involuntary passage of feces and gas. This prospective, multicenter study was designed to evaluate the safety and efficacy of Durasphere® anal injection for the treatment of fecal incontinence.

Patients and Methods

Thirty-three unselected patients with incontinence (24 females; mean age, 61.5?±?14 (range, 22–83) years) underwent anal bulking agent submucosal injection with carbon-coated microbeads (Durasphere®) in the outpatient regimen. The causes of incontinence were obstetric lesions in 18.2 percent, iatrogenic in 36.4 percent, rectal surgery in 12.1 percent, and idiopathic in 33.3 percent. Previous unsuccessful treatments for fecal incontinence included diet and drugs in 16 patients, biofeedback training in 7 patients, sacral nerve modulation in 6 patients, sphincteroplasty in 2 patients, artificial bowel sphincter in 1 patient, and PTQ macroplastique bulking agent in 1 patient. Under local anesthesia and antibiotic prophylaxis, a mean of 8.8 (range, 2–19) ml of Durasphere® were injected into the submucosa by using a 1.5-inch, angled, 18-gauge needle.

Results

After a median follow-up of 20.8 (range, 10–22) months, the median Cleveland Clinic continence score decreased significantly from 12 to 8 (P?P?=?0.0074), but the Fecal Incontinence Quality of Life did not change significantly (74 to 76, P = not significant). Anal manometry significantly improved (resting pressure increasing from 34 to 42 mmHg; P?=?0.008) and squeezing pressure from 66 to 79 mmHg (P?=?0.04). Two patients complained of moderate anal pain for a few days after the implant, one patient had asymptomatic leakage of the injected material through a mucosa perforation, and two had distal migration of the Durasphere® along the dentate line.

Conclusions

Anal bulking agent injection is a safe treatment and can mitigate the severity of fecal incontinence by increasing anal pressure but does not significantly improve the quality of life.     

Survey of Geriatricians on the Effect of Fecal Incontinence on Nursing Home Referral

OBJECTIVES: Determine the effect of fecal incontinence (FI) on healthcare providers' decisions to refer patients for nursing home (NH) placement. DESIGN: Survey. SETTING: Questionnaires were e‐mailed to participants' homes or offices. Participants could also volunteer at the 2008 American Geriatric Society annual meeting in Washington, DC. PARTICIPANTS: Two thousand randomly selected physician members and all 181 nurse practitioner members of the American Geriatrics Society were surveyed. MEASUREMENTS: The survey presented a clinical scenario of a 70‐year‐old woman ready for discharge from a hospital and asked about the likelihood of making a NH referral if the patient had no incontinence, urinary incontinence (UI) alone, or FI. Subsequent questions modified the clinical situation to include other conditions that might affect the decision to refer. A second survey of respondents to Survey 1 addressed possible moderators of the decision to refer (e.g., family caregiver presence, diarrhea or constipation, other physical or psychiatric limitations). Significance of differences in the relative risk (RR) for NH referral was tested using the chi‐square test. RESULTS: Seven hundred sixteen members (24.7% response rate) completed the first survey, and 686 of the 716 (96%) completed the second. FI increased the likelihood of NH referral (RR=4.71, P<.001) more than UI did (RR=1.90, P<.001). Mobility restrictions, cognitive decline, and multiple chronic illnesses increased the likelihood of NH referral more than FI alone (P<.001 for each), but in all scenarios, adding FI further increased the likelihood of referral (P<.001). Having family caregivers willing to help with toileting attenuated the likelihood of referral. CONCLUSION: FI increases the probability that geriatricians will refer to a NH. More‐aggressive outpatient treatment of FI might delay or prevent NH referral, improve quality of life, and reduce healthcare costs.     

Injectable Silicone Biomaterial for Fecal Incontinence Caused by Internal Anal Sphincter Dysfunction Is Effective

PURPOSE Fecal incontinence caused by a weak or disrupted internal anal sphincter is common but there has been no effective treatment. This prospective study evaluates the medium-term clinical effects of an injectable silicone biomaterial, PTP^TM (Bioplastique), used to augment the internal anal sphincter.METHOD Eighty-two patients (64 females; median age, 66 years) with severe fecal incontinence and a low anal resting pressure caused by internal anal sphincter dysfunction (defect, n = 11; intact, n = 71) were randomized to PTP^TM injection into intersphincteric space and internal anal sphincter with (Group A, n = 42) or without (Group B, n = 40) guidance by endoanal ultrasound. Both groups were similar in terms of age, gender, past anorectal surgery, duration of follow-up (median, 6 months; range, 1–12 months), and baseline continence score. Sixty-two percent of Group A and 55 percent of Group B had prolonged pudendal nerve terminal motor latency.RESULTS There was no significant complication. Two patients in Group A and four patients in Group B noted minor discomfort at injection sites. At one month postprocedure, endoanal ultrasound confirmed retention of silicone biomaterial without migration. In both groups, fecal continence was significantly improved by PTP^TM implants 1 month after injection, but continued to improve significantly for up to 12 months in Group A and 6 months in Group B (P < 0.001). Improvement in fecal continence and maximum anal resting pressure was significantly greater in Group A, in whom injection was guided by endoanal ultrasound, than in Group B. At three months after injection, significantly more Group A patients than Group B patients achieved >50 percent improvement in Wexners continence score (69 percent vs. 40 percent; P = 0.014). Ninety-three percent of Group A and 92 percent of Group B had >50 percent improvement in global quality of life scores (visual analog scale). At a median follow-up of 6 months, all domains of the fecal incontinence quality of life scale improved significantly in both groups; however, the physical function and mental health scores of Short Form-12 only improved in Group A. A prolonged pudendal nerve terminal motor latency had no effect on functional outcome in either group.CONCLUSION Injection of silicone biomaterial provided a marked improvement in fecal continence and quality of life in patients with internal sphincter dysfunction, despite the presence of pudendal neuropathy.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Incidence and Risk Factors for Fecal Incontinence in Black and White Older Adults: A Population‐Based Study

OBJECTIVES: To determine the incidence of fecal incontinence (FI) in community‐dwelling older adults and identify risk factors associated with incident FI. DESIGN: Planned secondary analysis of a longitudinal, population‐based cohort study. SETTING: Three rural and two urban Alabama counties (in‐home assessments 2000–2005). PARTICIPANTS: Stratified random sample of 1,000 Medicare beneficiaries: 25% African‐American men, 25% white men, 25% African‐American women, 25% white women, aged 65 and older. Eligible participants for this analysis were continent at baseline and community‐dwelling 4 years later (n=557). MEASUREMENTS: FI was defined as any loss of control of bowels occurring during the previous year. Independent variables were sociodemographics, Charlson comorbidity counts, self‐reported bowel symptoms (chronic diarrhea and constipation), depression, and body mass index (BMI). Multivariable logistic regression models were constructed using incident FI as the dependent variable. RESULTS: The incidence rate of FI at 4 years was 17% (95% confidence interval (CI)=13.7–20.1), with 6% developing FI at least monthly (95% CI=4.0–8.3). White women were more likely to have incident FI (22%) than African‐American women (13%, P=.04); no racial differences were observed in men. Controlling for age, comorbidity count, and BMI, significant independent risk factors for incident FI in women were white race, depression, chronic diarrhea, and urinary incontinence (UI). UI was the only significant risk factor for incident FI in men. CONCLUSION: The occurrence of new FI is common in men and women aged 65 and older, with a 17% incidence rate over 4 years. FI and UI may share common pathophysiologic mechanisms and need regular assessment in older adults.     

Impaired Rectoanal Inhibitory Response in Scleroderma (Systemic Sclerosis): An Association with Fecal Incontinence

Gastrointestinal abnormalities in systemic sclerosis (SSc) involve both myogenic and neural mechanisms. The aims of this study were to evaluate the rectoanal inhibitory response (RAIR) in SSc patients and to correlate RAIR with duration and subtype of disease, antibody status, and lower gastrointestinal symptoms. Thirty-five patients with SSc completed a questionnaire and underwent anorectal manometry (ARM). Forty-five patients without SSc served as controls. In the 35 SSc patients, 62.3% reported diarrhea, 57.1% reported constipation, and 37.1% reported fecal incontinence. Twenty-five of the 35 scleroderma patients (71.4%) demonstrated an impaired or absent RAIR, compared with none of the 45 controls (P < 0.001). Eleven of 13 incontinent SSc patients (84%) had an impaired RAIR. No correlation was found between RAIR and duration or subtype of SSc, antibody status, or presence of diarrhea or constipation. Impaired RAIR was closely correlated with fecal incontinence, suggesting a possible neural mechanism for maintenance of continence.     

Sacral Nerve Stimulation in Fecal Incontinence

PURPOSE: The effect of sacral nerve stimulation was studied in 45 patients with fecal incontinence.METHODS: All patients were initially tested in general anesthesia. Sacral nerves 2, 3, and 4 were tested on both sides. If a perineal/perianal muscular response to sacral nerve stimulation could be obtained, electrodes were implanted for a three-week test-stimulation period. If sacral nerve stimulation resulted in at least a 50 percent reduction in incontinence episodes during the test period, a system for permanent sacral nerve stimulation was implanted.RESULTS: When tested in general anesthesia, 43 of 45 patients had a muscular response to sacral nerve stimulation and had electrodes implanted for the three-week test period. Percutaneous electrodes were used in 34 patients, and 23 of these had at least a 50 percent reduction in incontinence episodes, whereas the electrodes dislocated in 7 patients and 4 had a poor response. Permanent electrodes with percutaneous extension electrodes were used primarily in 9 patients and after dislocation of percutaneous electrodes in an additional 6 patients; 14 of these had a good result. In the last patient, no clinical response to stimulation with the permanent electrode could be obtained. A permanent stimulation system was implanted in 37 patients. After a median of six (range, 0–36) months follow-up, five patients had the system explanted: three because the clinical response faded out, and two because of infection. Incontinence score (Wexner, 0–20) for the 37 patients with a permanent system for sacral nerve stimulation was reduced from median 16 (range, 9–20) before sacral nerve stimulation to median 6 (range, 0–20) at latest follow-up (P < 0.0001). There was no differences in effect of sacral nerve stimulation in patients with idiopathic incontinence (n = 19) compared with spinal etiology (n = 8) or obstetric cause of incontinence (n = 5). Sacral nerve stimulation did not influence anal pressures or rectal volume tolerability.CONCLUSIONS: Sacral nerve stimulation in fecal incontinence shows promising results. Patients with idiopathic, spinal etiology, or persisting incontinence after sphincter repair may benefit from this minimally invasive treatment.Presented at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.Reprints are not available.     

Evolving Therapy for Fecal Incontinence

Background Fecal incontinence is common and can be socially debilitating. Nonoperative management of fecal incontinence includes dietary modification, antidiarrheal medication, and biofeedback. The traditional surgical approach is sphincteroplasty if there is a defect of the external sphincter. Innovative treatment modalities have included sacral nerve stimulation, injectable implants, dynamic graciloplasty, and artificial bowel sphincter. Discussion This review was designed to assess the various surgical options available for fecal incontinence and critically evaluate the evidence behind these procedures. The algorithm in the surgical treatment of fecal incontinence is shifting. Injectable therapy and sacral nerve stimulation are likely to be the mainstay in future treatment of moderate and severe fecal incontinence, respectively. Sphincteroplasty is limited to a small group of patients with isolated defect of the external sphincter. A stoma, although effective, can be avoided in most cases. ^aDeceased.     

Validity and Reliability of the Modified Manchester Health Questionnaire in Assessing Patients With Fecal Incontinence

PURPOSE To date, no measures of fecal incontinence severity or its impact on quality of life have been validated for telephone interview. This study was designed to 1) compare responses of a self-administered and a telephone-administered Fecal Incontinence Severity Index; 2) compare a self-administered Fecal Incontinence Quality of Life Scale to the Manchester Health Questionnaire after modifying the latter for telephone administration and American English (Modified Manchester Health Questionnaire); 3) assess test-retest reliability of the telephone-administered Modified Manchester Health Questionnaire; and 4) assess the internal consistency of the Modified Manchester Health Questionnaire subscales.METHODS Consecutive, English-speaking, nonpregnant females known to have fecal incontinence were invited to participate. Two validated paper questionnaires accompanied the letter informing them of the study: Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale. Consenting patients were contacted for the initial telephone administration of the Modified Manchester Health Questionnaire, and patients who agreed to continue the study were contacted for a repeat telephone administration of the Modified Manchester Health Questionnaire two to four weeks after completing the first interview.RESULTS Fifty-one females were invited to participate in the study; however, 13 declined or were ineligible. Thirty females, aged 49.3 ± 10.3 years, returned self-administered questionnaires and completed the first telephone interview, and 21 completed a second telephone interview after an average interval of 23 days. The telephone-administered Fecal Incontinence Severity Index scores were significantly lower than those yielded by the self-administered Fecal Incontinence Severity Index, (6.19 vs. 9.85; P < 0.001), but the telephone and written administrations were significantly correlated (r = 0.5; P < 0.02). Correlations between the Modified Manchester Health Questionnaire quality of life subscales and the paper Fecal Incontinence Quality of Life subscales ranged from 0.6 to 0.9 (median, r = 0.81). The correlation between the total score for the Fecal Incontinence Quality of Life and the total score for the Modified Manchester Health Questionnaire quality of life scales was 0.93 (P < 0.001). Test-retest reliability for the eight Modified Manchester Health Questionnaire subscales ranged from 0.55 to 0.98 (median, r = 0.83), and test-retest reliability for the two telephone administrations of the Fecal Incontinence Severity Index was r = 0.75. Cronbachs alpha for the eight Modified Manchester Health Questionnaire subscales ranged from 0.79 to 0.92 (median, alpha = 0.85).CONCLUSIONS Telephone-administered versions of the Modified Manchester Health Questionnaire showed good-to-excellent validity, internal consistency, and test-retest reliability. The telephone-administered Fecal Incontinence Severity Index yielded lower severity scores than the written Fecal Incontinence Severity Index; however, the difference (3.66 units) was not clinically significant.Supported by Pelvic Floor Disorders Network.Supported by NICHD grants U10 HD41249, U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269, U10 HD41267.Presented at the American Urogynecologic Society, Hollywood, Florida, September 11 to 13, 2003.Reprints are not available.     

Endoanal Ultrasound Compared to Anorectal Manometry for the Evaluation of Fecal Incontinence: A Study of the Effect These Tests Have on Clinical Outcome

Tests for evaluating incontinence include endoanal ultrasound (EUS) and anorectal manometry. We hypothesized that EUS would be superior to anorectal manometry in identifying the subset of patients with surgically correctable sphincter defects leading to an improvement in clinical outcome in these patients. The purpose of this study was to compare these 2 techniques to determine which is more predictive of outcome for fecal incontinence. Thirty-five unselected patients with fecal incontinence were prospectively studied with EUS and anorectal manometry to evaluate the internal anal sphincter (IAS) and external anal sphincter (EAS). EUS was performed with Olympus GFUM20 echoendoscope and a hypoechoic defect in the EAS or IAS was considered a positive test. Anorectal manometry was performed with a standard water-perfused catheter system. A peak voluntary squeeze pressure of < 60 mm Hg in women and 120 mm Hg in men was considered a positive test. All patients were administered the Cleveland Clinic Continence Grading Scale at baseline and at follow-up. Improvement in fecal control was defined as a 25% or greater decrease in continence score. EUS versus manometry were compared with subsequent surgical treatment and outcome. P-values were calculated using Fisher's exact test. Patients (n = 32; 31 females) were followed for a mean 25 months (range 13–46). Sixteen patients had improved symptoms (50%). There was no correlation between EUS or anorectal manometry sphincter findings and outcome. Seven of 14 (50%) patients who subsequently underwent surgery versus 9 of 18 (50%) without surgery improved (P = .578). In long-term follow-up, approximately half of patients improve regardless of the results of EUS or anorectal manometry, or whether surgery is performed. Supported in part by a Glaxo-Wellcome Institute for Digestive Health Award.     

Sacral Neuromodulation in Treatment of Fecal Incontinence Following Anterior Resection and Chemoradiation for Rectal Cancer

PURPOSE Fecal incontinence may occur in patients who have undergone anterior resection for rectal cancer without presenting sphincter lesions. Chemoradiation may contribute to disrupting continence mechanisms. Treatment is controversial. Assessment of fecal incontinence in patients who agreed to integrate treatment for rectal cancer and treatment with sacral neuromodulation are reported.METHODS Fecal incontinence following preoperative chemoradiation and anterior resection for rectal cancer was evaluated in four patients. A good response was observed during the percutaneous sacral nerve evaluation test, and so permanent implant of sacral neuromodulation system was performed. Reevaluation was performed at least two months after implant.RESULTS After device implantation, the mean fecal incontinence scores decreased, and the mean number of incontinence episodes dropped from 12.0 to 2.5 per week (P < 0.05). Permanent implant resulted in a significant improvement in fecal continence in three patients, and incontinence was slightly reduced in the fourth. Manometric parameters agreed with clinical results: maximum and mean resting tone and the squeeze pressure were normal in three patients and reduced in one. In these same three patients, neorectal sensation parameters increased when the preoperative value was normal or below normal and decreased when the preoperative value was higher than normal, whereas in one patient in whom extremely low values were recorded all of the parameters decreased significantly.CONCLUSIONS Fecal incontinence following anterior resection and neoadjuvant therapy should be carefully evaluated. If a suspected neurogenic pathogenesis is confirmed, sacral neuromodulation may be proposed. If the test results are positive, permanent implant is advisable. Failure of this approach does not exclude the use of other, more aggressive treatment.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.