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Fecal incontinence, the inability to deliberately control the anal sphincter, is a common disease and may affect up to 20% of the age group above 65 years []. Fecal incontinence has a substantial impact on quality of life. It is a socially disabling problem that prevents up to one third of patients from seeking medical advice for it. The most common causes include traumatic (obstetric, surgical) sphincter defects, neurogenic dysfunction of the musculature of the pelvic floor, and rectal prolapse. The prevalence of fecal incontinence in women is eight times higher than in men []. The most common cause in women is child-birth, during which the sphincter muscles are commonly damaged []. Traumatic rupture of the anal sphincters may result in immediate-onset fecal incontinence. Pudendal neuropathy, caused by stretching the branches of the pudendal nerve to the sphincter and levator ani as the fetal head pushes down on the pelvic floor to dilate the introitus, leads to delayed-onset incontinence. Following vaginal delivery, the pudendal nerve terminal motor latencies (PNTML) are increased for about 6 months, and there is a fall in squeeze pressure regardless of sphincter damage [].

Anal continence is assured by the activity of complex anatomical and physiological structures (anal sphincters, pelvic floor musculature, rectal curvatures, transverse rectal folds, rectal reservoir, rectal sensation). It is dependent also on numerous other factors, such as stool consistency, patient’s mental faculties and mobility, and social convenience. Only if there is an effective, coordinated integration between these elements can defecation proceed normally. On the other hand, fecal incontinence (FI) is the result of disruption of one or several of these different entities: frequently, it can be due to a multifactorial pathogenesis, and in many cases, it is not secondary to sphincter tears. The disruption could lie in alterations intrinsic to the anorectal neuromuscular structures of continence control or be extrinsic to them, involving extrapelvic control mechanisms. The primary aim of an effective therapeutic approach must be the improvement-better, the resolution-of this distressing condition. Different forms of therapy are now available so that physicians must select the best option for each patient.

Criteria for patient selection to a certain treatment are of central importance in the management of fecal incontinence (FI). Even though the understanding of continence physiology has improved, there persists a lack of comprehensive knowledge regarding the very complex mechanisms by which various structures contribute to the regulation of continence control. It is now assumed that a continuous modulation of different stimuli is necessary to effectively maintain the various functions involved with continence. On the other hand, the instruments available to measure or analyze parameters associated with continence, albeit numerous and sometimes sophisticated, are not used in a standardized manner, so that data obtained at one center are not comparable with those obtained in another. Also, the entire diagnostic workup is still debatable, being routinely limited to clinical examination in the opinion of some, whereas others recommend extensive evaluation. However, other aspects must be considered in the decision-making process surrounding treatment choice.

Management of fecal incontinence (FI) should be based on a meticulous assessment of pathophysiology through both clinical and physiological diagnostic workup. There are cases with prevalently altered diet and hygiene. Very frequently, diarrhea and constipation can be found involved in the development and maintenance of FI [1-3], both in the presence or absence of other traumatic or nontraumatic causes. Consequently, in those cases, treatment must be directed toward cure of these dysfunctions, either as single-line or combined treatment. Little evidence exists in the available literature about medical therapy for FI; recently, a Cochrane Database Review high-lighted that “there is little evidence with which to assess the use of drug therapies for the management of fecal incontinence” []. Therefore, medical treatment in FI is debatable and often pragmatic.

Fecal continence depends on the interaction of many factors. Anal sphincters, pelvic floor muscles, anal sensation, rectal sensory-motor activity, and neural integrity all have determinant roles, which together provide a coordinated mechanism of gas and stool continence. The pathophysiology of fecal incontinence is, therefore, often multifactorial, and each patient has his or her own specific pathogenetic profile as a result of a mix of etiological factors. It is clear that any treatment for fecal incontinence must allow for this fundamental aspect, and each patient thus requires a clinical approach that has been modulated on his or her specific incontinence etiology. This basic fact must be considered when planning therapy for a patient with fecal incontinence.

Fecal incontinence, as a result of trauma to the muscular sphincter complex, has long been surgically treated by approximation of healthy muscular edges on either side of the defect. In his 1923 textbook, Lockhart-Mummery described the operative procedure of mobilizing muscle lateral to the defect and sewing the “ends firmly in contact” []. Operative success was “usually most satisfactory,” yet contingent on “proper antiseptic precautions” and “carefully performed” technique. In 1940, however, Blaisdell reported general dissatisfaction among American proctologists with this classic “plastic repair” due to infectious complications, technical challenges, and poor outcomes []. Blaisdell went on to describe two techniques that involved overlapping muscle edges while leaving the scarred portion of the sphincter intact. The “reefing operation” brought together muscle opposite the site of damage to narrow the circumference of the anal outlet and thus avoid manipulation of the damaged portion of the sphincter [].

Postanal repair was developed by Sir Allan Parks in the 1970s [] and popularised in the early 1980s for patients with neuromyopathic faecal incontinence. The original objective of this operation was to restore the anorectal angle, which was thought to be an important factor in continence. In 1975, Parks suggested the flap-valve theory that stressed the importance of the acute anorectal angle. According to this theory, a rise in intra-abdominal pressure caused the upper end of the anal canal to be occluded by anterior rectal mucosa, preventing rectal contents from entering the anal canal. Neuromyopathic faecal incontinence was associated with perineal descent and an obtuse anorectal angle, which rendered the flap-valve-like mechanism ineffective. Further investigations, however, failed to show changes of the anorectal angle, and currently, it is thought that an improvement of muscular contractility is responsible for any improvement in continence [].

Fecal incontinence is a terrible burden for patients. In severe forms of incontinence, patients feel excluded from any social interaction. They prefer to stay at home close to the toilet and try to avoid shopping, attending parties, or visiting friends. If they do go into public places, they know the location of every public toilet. Even in their own homes, most of them have rules with partner and children that the moment the patient feels any urge, the toilet must be free immediately. People who are not familiar with this phenomenon can hardly understand how terrible this can be for patients. Fecal continence is so normal and taken for granted that those who have never experienced it cannot imagine how life would be if the moment arrived when he or she became incontinent. The world shrinks to a size no bigger than the patient’s home. These patients have the choice of either accepting such a life or accepting a colostomy.

Fecal incontinence is a severe disability that deeply affects the quality of life of the afflicted patient. The estimated prevalence in the general population ranges from 1% to 17%. In France, it is estimated that 350,000 persons over the age of 45 years have a severe form of fecal incontinence. In the event of ineffective medical treatment and the inability or failure of conventional surgery, the only choice for these patients until recently was to accept their condition or opt for end colostomy. However, technological progress has opened up the prospect of effective therapy for severe fecal incontinence both in terms of performance and long-term reliability. Replacement of sphincter function by an artificial bowel sphincter is one available option that has shown promising results.

Fecal incontinence is a devastating condition in which patients have extremely poor quality of life, with limitations in social interaction, physical activity, and employability. Defined as incomplete control of the fecal stream, fecal incontinence may be due to a number of factors, such as increased stool production, decreased rectal vault capacitance, diminished rectal distension sensibility, and anal sphincter disruption. Despite such medical therapies as motility inhibitors, stool-bulking agents, biofeedback, and Kegel exercises, these interventions may only provide limited relief from this disabling condition [].