Sacral nerve stimulation for treatment of fecal incontinence

Fecal incontinence is common, distressing to the patient and socially incapacitating. Surgical treatment for fecal incontinence is often associated with disappointing results, especially when the patient presents with a functional and/or dynamic deficits without any structural defect. Thus, disappointing treatment results are often common. Sacral nerve stimulation (SNS) is an innovative, minimally invasive treatment that uses chronic low-level electrical stimulation of the sacral plexus to recruit residual physiological function. The exact mechanism of action is still unknown, but it is assumed that electric stimulation of the sacral nerves leads to neuromodulation as well as clinically beneficial effects to the pelvic floor, the sphincter complex and the distal color rectum. SNS is a multistep procedure, including acute and subchronic percutaneous nerve evaluation (PNE), followed by permanent stimulation provided by an implanted device. The predictive value of PNE is high, morbidity and surgical trauma are low. The screening phase provided by PNE makes this technique unique and offers an ideal instrument for patient selection. However, criteria for patient selection are evolving and are yet to be defined. Published data support the medium-term treatment success combined with improvement of quality of life in over 80% of patients. In patients in whom preceding therapies had failed, SNS is superior to other treatment options. Moreover, SNS seems to be more cost-effective in the short term. However, results for SNS in the treatment of fecal incontinence are promising, but need to be further validated in the long term. Heterogeneity of most study populations and varying causes of fecal incontinence makes data difficult to compare and do not allow a final statement of the impact of this technique. There is a clear need for prospective randomized trials to address these open questions.