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Treatment of Fecal Incontinence: State of the Science Summary for the National Institute of Diabetes and Digestive and Kidney Diseases Workshop

Whitehead, William E PhD1,2; Rao, Satish S C MD, PhD3; Lowry, Ann MD4; Nagle, Deborah MD5; Varma, Madhulika MD6; Bitar, Khalil N PhD7; Bharucha, Adil E MBBS, MD8; Hamilton, Frank A MD, MPH9

American Journal of Gastroenterology: January 2015 - Volume 110 - Issue 1 - p 138–146
doi: 10.1038/ajg.2014.303
REVIEW: CLINICAL AND SYSTEMATIC REVIEWS
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This is the second of a two-part summary of a National Institutes of Health conference on fecal incontinence (FI) that summarizes current treatments and identifies research priorities. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback, often recommended as first-line treatment after conservative management fails, produces satisfaction with treatment in up to 76% and continence in 55%; however, outcomes depend on the skill of the therapist, and some trials are less favorable. Electrical stimulation of the anal mucosa is ineffective, but continuous electrical pulsing of sacral nerves produces a ≥50% reduction in FI frequency in a median 73% of patients. Tibial nerve electrical stimulation with needle electrodes is promising but remains unproven. Sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor. Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients. Colostomy is used as a last resort because of adverse effects on quality of life. Several new devices are under investigation but not yet approved. FI researchers identify the following priorities for future research: (1) trials comparing the effectiveness, safety, and cost of current therapies; (2) studies addressing barriers to consulting for care; and (3) translational research on regenerative medicine. Unmet patient needs include FI in special populations (e.g., neurological disorders and nursing home residents) and improvements in behavioral treatments.

1Division of Gastroenterology and Hepatology, Department of Medicine, Chapel Hill, North Carolina, USA

2Division of Urogynecology and Reconstructive Pelvic Floor Surgery, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA

3Department of Gastroenterology, Georgia Regents University, Augusta, Georgia, USA

4Colon and Rectal Surgery Associates, Ltd., St. Paul, Minnesota, USA

5Department of Colon and Rectal Surgery, Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

6Section of Colorectal Surgery, University of California, San Francisco, California, USA

7Department of Regenerative Medicine, Wake Forest Institute for Regenerative Medicine, Winston Salem, North Carolina, USA

8Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA

9National Institutes of Diabetes, Digestive and Kidney Diseases, National Institute of Health, Bethesda, Maryland, USA

Correspondence: William E. Whitehead, PhD, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box 7080, Chapel Hill, North Carolina 27516-7080, USA. E-mail: William_Whitehead@med.unc.edu

Received 01 June 2014; accepted 05 August 2014

Guarantor of the article: William E. Whitehead, PhD.

Specific author contributions: Planning committee, conference presenter, and manuscript author: William E. Whitehead; planning committee, conference presenter, and manuscript revised and accepted: Satish S.C. Rao and Adil E. Bharucha; conference presenter and manuscript revised and accepted: Ann Lowry, Deborah Nagle, Madhulika Varma, and Khalil N. Bitar.

Financial support: National Institute of Diabetes and Digestive and Kidney Diseases provided financial assistance for the conference.

Potential competing interests: William Whitehead received grant support from Salix Pharmaceuticals.

© The American College of Gastroenterology 2015. All Rights Reserved.
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