- Treatments for Fecal Incontinence [entered retrospectively]
- Objective. To assess the efficacy and comparative effectiveness of surgical and nonsurgical treatments for fecal incontinence (FI) in adults.
Data sources. Ovid MEDLINE®, Embase®, PEDro®, CINAHL, AMED, and the Cochrane Central Register of Controlled Trials (CENTRAL), hand searches of systematic reviews.
Methods. Two investigators screened abstracts of identified references for eligibility (examined treatments in adults with FI, published from 1980 to present, had a control/comparator group; case series were included for surgical interventions). Full-text articles were reviewed to identify patient-reported outcomes (FI episodes, FI severity, quality of life, urgency, pain, other). We extracted data, assessed risk of bias of individual studies, and evaluated strength of evidence for each comparison and outcome.
Results. Sixty-three unique studies met inclusion criteria; an additional 53 surgical case series were examined for surgical adverse effects. Enrolled adults were mostly female with mixed FI etiologies. Most RCTs were nonsurgical (n=38); 13 examined pelvic floor muscle training (PFMT) and PFMT with biofeedback (PFMT-BF). Meta-analysis was not possible because numerous outcomes were used. Low strength evidence suggests that dietary fiber (psyllium) decreases FI episodes (-2.5 per week) at 1 month; clonidine has no effect; and PFMT-BF with electrostimulation is no more effective than PFMT-BF for FI severity and quality of life over 2 to 3 months. Low-strength evidence at 6 months suggests that dextranomer anal bulking injections are more effective than sham injections on FI quality of life, the number of FI-free days, and the percent of adults with at least 50 percent reduction from baseline in FI episodes; but no more effective than PFMT-BF with or without electrostimulation on FI severity (PFMT-BF -5.4 vs. dextranomer -4.6 point Vaizey score improvements) and quality of life; and no more effective than sham injection on FI severity (-2.5 versus -1.7 point sham improvement in Cleveland Clinic FI score [CCFIS]) or FI episode frequency. Moderate-strength evidence suggests that Durasphere® (off-label) bulking injections reduce FI severity up to 6 months (-4 to -5 points CCFIS) but gains diminish thereafter. Evidence was insufficient for all other surgical and nonsurgical comparisons. Surgical improvements varied. Noninvasive nonsurgical treatments had few minor adverse effects (AEs). Surgical treatments were associated with more frequent and more severe complications than nonsurgical interventions. AEs were most frequent for the artificial bowel sphincter (22-100 percent of adults). Surgical AEs ranged from minor to major (infection, bowel obstruction, perforation, fistula). Major surgical complications often required reoperation; fewer required permanent colostomy. Only 12 percent of randomized controlled trials (RCTs) were high quality.
Conclusion. There is limited evidence to support any FI treatments beyond 3 to 6 months. It is difficult to compare the effectiveness of surgical to nonsurgical FI treatments because nonsurgical approaches generally precede surgery, and adults who undergo surgery have typically failed more nonsurgical treatment. Most current interventions show modest improvements in FI outcomes that meet minimal important differences (MID) in the short term, where MID is known. More invasive surgical procedures have substantial complications. Numerous outcome measures and lack of compliance with study reporting standards are modifiable impediments in the field. Future studies should focus on longer-term effects and attempt to identify subgroups of adults by FI etiology that might benefit from specific interventions.
- Authors of Report
- Methodology description
- Funding Source