MANAGEMENT

OF
FECAL
INCONTINENCE
Dr Peeyush Varshney

MODERATOR : Prof Ashok Kumar Gupta

 INTRODUCTION

 Fecal incontinence is a physically and psychologically debilitating

condition that has a negative impact on quality of life, leads to
embarrassment and social isolation, and strains personal and family
relationships
 Prevalance – 1.4% to 18%
 Increases with age, affects both sex
 Mainly American and European data
 Not much Indian data

Goode PS, Burgio KL, Halli AD, et al. Prevalence and correlates of fecal incontinence in community-dwelling older adults. J Am Geriatr Soc 2005 Apr;53(4):629-
35.
Quander CR, Morris MC, Melson J, Bienias JL, Evans DA. Prevalence of and factors associated with fecal incontinence in a large community study of older
individuals. Am J Gastroenterol 2005 Apr;100(4):905-9.
DEFINITION
 Inability to control passage of stool and flatus at a socially acceptable
place
 ICD 10- A disorder characterized by inability to control the escape of
stool from the rectum
 R 15 -Fecal incontinence
 R 15.0 Incomplete defecation
 R 15.1 Fecal smearing
 R 15.2 Fecal urgency
 R 15.9 Full incontinence for feces
 SUBTYPES
 Passive incontinence –
 The involuntary discharge of fecal matter or flatus without any awareness
 Loss of perception and/or impaired rectoanal reflexes either with or without
sphincter dysfunction.

 Urge incontinence -
 The discharge of fecal matter or flatus in spite of active attempts to retain these
contents.
 Due to sphincter dysfunction or rectal capacity to retain stool

 Fecal seepage-
 The undesired leakage of stool, often after a bowel movement, with otherwise
normal continence and evacuation.
 Due to incomplete evacuation of stool and/or impaired rectal sensation.
 Sphincter function and pudendal nerve function are mostly intact

Rao SSC. Diagnosis and management of fecal incontinence. J Am Gastro, 2004.Practice guidelines
HISTORY
TOPIC RATIONALE
Onset/risk factors May suggest etiology
Natural history May reveal reason for seeking medical
attention
Bowel habits/type of incontinence Incontinence for solid stool suggests greater
sphincter weakness than incontinence for
liquid stools only
Management is often based on the nature of
bowel disturbance.
Warning before incontinence Passive incontinence is often associated
with internal anal sphincter weakness
Urge incontinence is often associated with
external anal sphincter weakness

Nocturnal incontinence Most frequently seen in diabetes and

scleroderma
Quality of life Assesses severity and impact of
incontinence
Urinary incontinence A frequent comorbid condition that requires
separate evaluation
EXAMINATION

Wald A. Clinical practice. Fecal incontinence in adults. N Engl J Med. 2007;356(16):1648-1655

CAUSES
EVALUATION
SCORES
 Parks introduced a simple system based on the degree of leakage

A. Being normal
B. Incontinent to flatus
C. Incontinent to liquid stool
D. Incontinent to solid stool

Parks A. Anorectal incontinence. Proc R Soc Med. 1975;68:681–690.

 THE JORGE–WEXNER INCONTINENCE
SCORING SYSTEM

Now termed –
Cleveland Clinic Incontinence Score

Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993 Jan;36(1):77-97.
 THE PESCATORI SCORE

Pescatori M, Anastasio G, Bottini C, et al. New grading system and scoring for anal incontinence. Evaluation of 335 patients. Dis Colon
Rectum 1992;35:482–7
THE AMERICAN MEDICAL
SYSTEMS SCORE

American Medical Systems. Fecal incontinence scoring system. Minnetonka: American Medical Systems.
 ST MARKS FI GRADING
SYSTEM

Vaizey, C., Carapeti, E., Cahill, J. and Kamm, M. (1999) Prospective comparison of faecal incontinence grading systems. Gut 44: 77–80.
 FECAL INCONTINENCE SEVERITY
INDEX ( FISI )
 FECAL INCONTINENCE QUALITY OF LIFE
INSTRUMENT

 Questionnaire containing 29 questions relating to 4 fields-

 Lifestyle- ten items.
 Coping/Behavior- nine items.
 Depression/Self Perception -seven items.
 Embarrassment -three items

Rockwood, T., Church, J., Fleshman, J., Kane, R., Mavrantonis, C. and Thorson, A. (2000) Fecal Incontinence Quality of Life Scale: quality of
life instrument for patients with fecal incontinence. Dis Colon Rectum 43: 9–16; discussion 16–17.
MANAGEMENT STRATEGY

 Result of the Assessment

 Severity of incontinence from the history

 Intact or ruptured anal ring by inspection and confirmed by anal ultrasound
 Diffuse or localized sphincter weakness by palpation and anal ultrasound
 Presence or absence of sensory loss by clinical sensation testing, electrical
sensitivity, and balloon volumetry
TREATMENT OPTIONS
NON INVASIVE INVASIVE
Conservative Management Injectables
General Measures SECCA
Drugs Nueromodulation
 Sacral Nerve
 Posterior Tibial Nerve
 Puedendal Nerve
Excercises Tissue Repair
 Sphincteroplasty
 Post Anal repair
 Levataroplasty
Bio Feedback Muscle Flaps
 Gracilis
 Gluteus
 Free muscle
Irrigation Artificial Bowel sphincter
Anal Plug Stoma
CONSERVATIVE MEASURES
 General Measures :

 Education of the patient

 Life style modifications
 Dietary Advice
 Weight Reduction
 Smoking
 Review Drug History
DRUGS
 Octreotide -(Rasmussen et al, 1996)

 Phenylephrine - alpha-1 adrenergic antagonist

 Incontinence following ileal pouch formation (Carapeti et al, 2000)

 Amitriptyline -serotoninergic, anticholinergic and antimuscarinic

properties
 Used In urge incontinence (Santoro et al, 2000)

 Loperamide - some strengthening effect on the internal sphincter.

Success rate 20-90%

PERINEAL EXERCISES

 1950- Kegel – beneficial in both fecal and urinary incontinence

 Numerous articles - attesting to the validity of this approach.

 No increase in internal anal sphincter tone by perineal strengthening

exercises
 Muscle bulk and voluntary contractility of the external anal sphincter,
puborectalis sling, and levatores may be improved by such a regimen

 Kegel A. Active exercise of the pubococcygeus muscle. In: Meigs JV, Strugis SH, eds. Progress in Gynecology: Vol. 2.
New York, NY: Grune & Stratton; 1950.
 CONTINENCE PLUGS
 Mortensen and Humphreys 1 -1991
 The median wear time - 12 hours
 82 % continent till plug was in place
 Patients required a median of 11 plugs per week, and in 82% of cases
insertion was as easy as with a suppository
 The authors concluded that plugs may have a place in the management of
patients with anorectal incontinence.
 Electrically stimulated anal plugs 2

 Dislodgement and infection

1. Mortensen N, Humphreys SM. The anal continence plug: a disposable device for patients with anorectal incontinence. Lancet 1991; 338:295–297
2. Hopkinson BR. Electrical treatment of anal incontinence. Ann R Coll Surg Engl 1972; 50:92–111.
ANAL CONTINENCE PLUGS
COLONIC IRRIGATION
 Antegrade vs. Retrograde

 Indications :
 Children with intractable constipation
 Spinal Cord Injury
 LAR Syndrome
 Tube Appendicostomy

Levitt MA, Soffer SZ, Pe–a A. Continent appendicostomy in the bowel management of fecally incontinent children. J Pediatr Surg. 1997;32(11):1630–1633,
with permission
 Neoappendicostomy

Levitt MA, Soffer SZ, Pe–a A. Continent appendicostomy in the bowel management of fecally incontinent children. J Pediatr Surg. 1997;32(11):1630–1633,
with permission
Hughes SF, Williams NS. Continent colonic conduit for the treatment of faecal incontinence associated with disordered evacuation. Br J Surg.
1995;82(10):1318–1320
EQUIPMENT FOR PERFORMING RETROGRADE
IRRIGATION

 Easy

 Low
Morbidity
 17 studies
 1 RCT
 1229 patients
 648 , 55% - success
 In the incontinent patients, success was recorded in 47%.
BIOFEEDBACK
 The use of various devices (mechanical, electrical) that are supposedly
able to increase the awareness of a biological response, so that patients
can learn, through a process of “trial and error”

 3 components
 Exercise of the external sphincter muscle
 Training in the discrimination of rectal sensations
 Training synchrony of the internal and external sphincter responses during
rectal distention
 BIOFEEDBACK
 Several studies and RCTs to compare one method of biofeedback to another
or other method to improve fecal incontinence
 Success rates ranging from 50% to 90% 1

 Cochrane review 2 , 21 studies, 1525 patients, conclusions:

 No one method has shown superiority over the others
 The limited number of trials together with methodological weaknesses - do not
allow for a definitive assessment of the role of biofeedback in the management of
fecal incontinence
 Addition of electrical stimulation may enhance the outcome over biofeedback
alone

1. Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clin Colon Rectal Surg 2011;24(1):64–70.
2. Norton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2012;
(7):CD002111
BIOFEEDBACK
 Advantages
 Easy and safe
 Still recommended and considered as first-line therapy in the highly
motivated patient for whom traditional medical management has failed

 Disadvantages
 Time
 Lack of specialized and dedicated training centers
 Motivation of patient
INVASIVE TREATMENT
BULKING AGENT INJECTION
 Submucous and intersphincteric plane in the upper anal canal
 Shafik was the first to report this approach using Teflon (polytetrafl
uoroethylene) paste (DuPont, Texas)
 4 RCTs till date
 Anal injection of bulking agents improves passive incontinence in
the short term in more than 50% of patients
 The improvement is often short-lived and may reduce the continence
score only slightly
 Repeated injections may be necessary.
 It is not known whether intersphincteric or submucosal injection is more
effective.
 The procedure can be carried out in the office or day center.
RADIOFREQUENCY ENERGY DELIVERY
FOR THE TREATMENT OF FECAL
INCONTINENCE
(SECCA PROCEDURE)
 To deliver temperature-controlled RF energy to the muscle of the anal
canal to induce fibrosis
 Indication
 Mainly in case of passive incontinence i.e internal sphincter weakness
SECCA PROCEDURE
 Energy is delivered to all four electrodes for 1 minute to achieve a
target temperature of 85 degree C
 Vaginal mucosa can be injured in females
 Not much evidence to support this procedure, no RCT
 Efron et al
 50 patients treated in five centers who had not responded to conservative
measures.
 At 6 months, the Wexner score - from 14.8 to 11.1, with corresponding
improvements in the different domains of the SF-36 assessment

1. Efron J, Corman ML, Fleshman J, et al. Safety and effectiveness of temperature-controlled radio-frequency energy delivery to the
anal canal (Secca procedure) for the treatment of fecal incontinence. Dis Colon Rectum. 2003;46(12):1606–1616.
NEUROMODULATION
 SNS- Sacral nerve stimulation
 SNS has emerged as one of the most promising modalities for treating
severe fecal incontinence.
 Initially used to treat urinary incontinence, it was also anecdotally found
to have efficacy in improving symptoms associated with fecal
incontinence.
 The therapy involves implantation of an electrode adjacent to the S3
nerve root
RESULTS OF SNS

Wexner score 15 to 5
Success rate – 50-90%
 Diseases of the Colon & Rectum Volume 58: 2 (2015)

 16 patients
 26.8 months Follow up

 Given a ON and OFF period of 3 weeks each

 The frequency of fecal incontinence episodes and Cleveland Clinic

Incontinence Score (CCIS) were both significantly lower in the ON period
than the OFF period (p < 0.005)

 All patients decided to stay in the ON mode for the final period and have
continued in the ON mode until now.
 BJS, 2004

 They analyzed the data on 266 patients who underwent temporary screening.
 Of these, 149 (57%) progressed to permanent implantation.
 Follow up ranged from 1 to 99 months

 Complete continence was achieved in 41% to 75% of patients, whereas an

improvement in the number of incontinent episodes per unit time of more than 50%
occurred in 75% to 100%

 Conclusion: SNS results in significant improvement in faecal incontinence in patients

resistant to conservative treatment.
SNS
 Simple and well tolerated.
 Costly
 It can be carried out as a day case procedure.
 Patient selection is important
 In patients with a diffusely weak sphincter or those who have failed
sphincter repair, SNM has about a 70% chance of resulting in
satisfactory continence provided there is neuromuscular integrity.
 In presence of sphincter defect role is questionable
POSTERIOR TIBIAL NERVE
MODULATION
 In 1983, Nakamura and colleagues reported that transcutaneous stimulation
of the posterior tibial nerve reduced urinary urgency and irritable bladder
 Shafik and coworkers reported its value in the treatment of incontinence
 Direct stimulation by an electrode- percutaneous
 Indirectly through the skin by an electrode fixed over the nerve -
transcutaneous
 POSTERIOR TIBIAL NERVE
STIMULATION
 Short-term improvement in continence score and frequency of
incontinence episodes from 30% to more than 70%.
 It appears that percutaneous stimulation is more effective than
transcutaneous.
 Queralto et al.
 66% fall in the Wexner score (4–15 vs. 0–10).
 In those showing benefit, the effect lasted at least 12 weeks

 Portilla et al
 Initial improvement in 10 of 16 patients with a mean incontinence score of
13.3 +_ 4.1 before treatment to 9 +_ 5.2.
 Five patients were free of incontinence at 6 months

• Queralto M, Portier G, Cabarrot PH, et al. Preliminary results of peripheral transcutaneous neuromodulation in the treatment of
idiopathic fecal incontinence. Int J Colorectal Dis. 2006;21(7):670–677
• de la Portilla F, Rada R, Vega J, et al. Evaluation of the use of posterior tibial nerve stimulation for the treatment of fecal
incontinence: preliminary results of a prospective study. Dis Colon Rectum. 2009;52(8): 1427–1433.
 BJS 2015; 102: 349–358

 40 patiennts ; 23 SNS, 17 PTNS

 FU 6 months

 Cleveland Clinic Incontinence Score values at baseline, and 3 and 6 months

were: 16⋅2, 11⋅1 and 10⋅4 for SNS versus 15⋅1, 11⋅7 and 12⋅1 for PTNS.

 Conclusion: In the short term, both SNS and PTNS provide some clinical
benefit to patients with FI
PUDENDAL NERVE STIMULATION

 Patients who fail sacral nerve stimulation may have a more distal
neurologic lesion

STIMULATION OF THE DORSAL NERVE OF THE

CLITORIS OR PENIS

 The dorsal nerve of the clitoris or penis offers another peripheral nerve
for access to the central nervous system.
 The use of the pudendo-anal reflex was first described by Binnie and
colleagues
 OVERLAPPING
SPHINCTEROPLASTY
 Most common operation performed
 The patient must have an intact neuromuscular bundle with detectable
voluntary sphincter contraction
 If a primary repair has failed, a minimum duration of 3 months should
elapse before overlapping sphincteroplasty is attempted
 Scar tissue from the severed muscles should not be excised
 The internal and external sphincter muscles should not be separated
 A temporary colostomy is not necessary

Fang DT, Nivatvongs S, Vermeulen FD, et al. Overlapping sphincteroplasty for acquired anal incontinence. Dis Colon Rectum 1984; 27:720–722.
 A curvilinear incision
is made along the perineal body

The sphincter scar is

divided but not excised
The internal anal
sphincter is imbricated when a
layered repair is performed

The external anal

sphincter is overlapped

The edges of the

wound are approximated in a
V-Shape or longitudinally with
interrupted 3.0 absorbable mattress
sutures
RESULTS OF DELAYED SPHINCTER
REPAIR
Success Rate 9-44%
Early symptom improvement up to 90% in some series
 Deterioration of FI over time with return to base line in 10 years.
 Improvement after sphincteroplasty is noted but it is not to the level
that it was before the sphincter injury
POSTANAL REPAIR (PARKS)
 He believed that this procedure works by restoring the

anorectal angle and increasing the length of the anal canal.

 Indications
 Nuerogenic causes
 “Idiopathic”
(A) Posterior angular incision
(B) Identification of intersphincteric plane
(C) Dissection to rectosacral fascia (dotted line)
(D) Identification of levator ani muscles.
(E) Plication of ischiococcygeus muscle.
(F) Plication of pubococcygeus muscle.
(G) Plication of puborectalis muscle.
(H) Plication of external sphincter muscle.
(I) Skin closure in shape of a Y, with separate stab wound for suction drain.
 RESULTS OF PARKS
POSTANAL REPAIR

Success
Rate -
15-88%

1. Successful ––continent for solid stool

2. Significant improvement– sporadic episodes of fecal incontinence
3. Failure ––incontinent for solid stool.
 ANTERIOR LEVATORPLASTY

 Relatively poor results of postanal repair and the observation of a

rectocele during videoproctography in 70–90% of patients
 Women with postobstetric neurogenic faecal incontinence
 Miller et al-

Miller R, Orrom WJ, Cornes H, Duthie G & Bartolo DCC (1989) Anterior sphincter plication and levatorplasty in the treatment of faecal
incontinence. Br J Surg 76: 1058–1060.
 GRACILOPLASTY (GRACILIS MUSCLE
TRANSPOSITION)
 Nonstimulated Graciloplasty
 Pickrell et al -1952
 ‘‘living Thiersch procedure’’
 Corman found this to be a very effective operation for selected
patients when a supplementary sphincter was required or when
multiple attempts at direct repair had been unsuccessful

• Pickrell KL, Broadbent TR, Masters FW, et al. Construction of a rectal sphincter and restoration of anal continence by transplanting gracilis muscle: report of four
cases in children. Ann Surg. 1952;135(6): 853–862
• Corman M. Gracilis muscle transposition. Contemp Surg. 1978;13:9.
• Corman ML. Follow-up evaluation of gracilis muscle transposition for fecal incontinence. Dis Colon Rectum. 1980;23(8):552–555
 Indications
 Fecal incontinence not be controlled by nonoperative means or where
sphincteroplasty had failed.
 Contraindications
 Irritable bowel, diarrhea or constipation
 An irradiated perineum
 Radiation proctitis
 Older age
Graciloplasty
TYPES OF CONFIGURATION
 Complex and technically difficult procedure with a high failure rate
(50%)
 Corman et al
 14 patients - excellent (7), good, fair (4), and poor (3)

 Christiansen et al -
 transposed the gracilis muscle in 13 patients.
 Six had “satisfactory” continence

 Faucheron and coworkers

 Reported 22 patients operated on over a 12-year
 At 6 months, 18 were improved, but only 1 was fully continent.
 The authors concluded that GMT should be used initially, and then
electrostimulation should be considered if the results are unsatisfactory
STIMULATED
GRACILOPLASTY

Two electrodes are

tunneled from
transposed gracilis
to the stimulator in
the pocket
 STIMULATED (DYNAMIC
GRACILOPALSTY)
 One of the drawbacks of the gracilis transposition procedure is the
inability of the muscle to simulate sustained contraction, as does the
external sphincter

 Chronic low-frequency stimulation of skeletal muscle can convert a

fast twitch muscle into a slow-twitch muscle capable of sustained
activity

 In 1988, Baeten et al. were the first to report

Baeten C, Spaans F, Fluks A. An implanted neuromuscular stimulator for fecal continence following previously implanted gracilis muscle: report of a case. Dis
Colon Rectum 1988; 31:134–137
RESULTS OF STIMULATED
GRACILOPLASTY

Success Rate –
45 – 100%
GLUTEUS MUSCLE
TRANSPOSITION
 Best suited for
 young, motivated patients
 neurogenic fecal incontinence
 multiple failed sphincteroplasties
 severe sphincter defects that preclude primary repair

 Innervated by the L5 and S1 nerve roots through the inferior gluteal

nerve
 Advantage over Gracilis- large, strong muscle
 Eliminates the need for disfiguring thigh incisions.
 ARTIFICIAL BOWEL
SPHINCTER- ABS
 Successfully employed for the treatment of urinary incontinence for
many years
 Fecal incontinence - 1987 by Christiansen and Lorentzen

Christiansen J, Lorentzen M. Implantation of artificial sphincter for anal incontinence. Lancet. 1987;2(8553):244–245.
ABS
 Indications :
 Traumatic sphincter disruption
 Neurologic incontinence; neurogenic (idiopathic) incontinence
 Failure or contraindication& to sacral nerve stimulation
 Failed Graciloplasty
 Imperforate anus/anal agenesis
 Severely scarred perineum
 Thin rectovaginal septum; advanced age, diabetes, severe digital arthritis
 Anorectal reconstruction after abdominoperineal excision

 Contraindications
 Excessive perineal descent
 Severe constipation
 Irradiated perineum
 Perineal sepsis
 Crohn's disease
 Anal intercourse
CRITERIA
 Well -motivated , selected patients with fecal incontinence
 of more than a year's duration
 whose condition is regarded as an important personal, familial, and/or social
handicap
 as an alternative to definitive colostomy
 who are able to manipulate the control pump as required
 with sufficient intellectual capacity to understand the functioning of the
device and to ensure regular rectal evacuation
 A. Anal cuff closure

B. Opening of the cuff by

pumping on the control pump.

C. ABS control
pump manipulation

D. Automatic closure of the cuff after evacuation

RESULTS OF ABS
 ABS VS. DYNAMIC
GRACILOPLASTY
Comparison of 75
Studies
Including 1,510 Patients

Tan EK, Vaizey CJ, Cornish J, et al. Surgical strategies for faecal incontinence—a decision analysis between dynamic graciloplasty, artificial bowel
sphincter and end stoma. Colorectal Dis. 2008;10(6): 577–586
 RECTAL AUGMENTATION
 Fecal incontinence with severe urgency or frequency
 External sphincter defect
 Rectal hypersensitivity
 Low anterior resection - a reduction in neorectal compliance and volume

 Can be combined with Stimulated graciloplasty

 Initial results are convincing

Creation of side-to-side
ileorectal pouch

Williams NS, Ogunbiyi OA, Scott SM, Fajobi O & Lunnis PJ (2001) Rectal augmentation and stimulated gracilis anal neosphincter Dis Colon Rectum 44: 192–
198
 Annals of Surgery • Volume 247, Number 3, March 2008
 4.5 years FU
 7/11 patients had avoided stoma construction.
 Symptoms recurred leading to permanent stoma formation in 1 patient,
whereas one other developed evacuatory difficulty with overflow
incontinence.
 Median ability to defer defecation improved from seconds preoperatively to
10 minutes at 1 year (P = 0.0002), and 15 minutes at 4.5 years (P
=0.002).
 Median Wexner incontinence scores improved from 15 preoperatively to 3
at 1 year (P =0.002), and 4 at 4.5 years (P =0.02)
ANTROPYLORUS
TRANSPOSITION
 For patients in whom other techniques fail
 in patients with incapacitating disability whose only other alternative would
be a permanent stoma
 The pyloric sphincter complex is mobilized along with the vascular
arcade of the right and left gastroepiploic vessels by dividing the
branches to the stomach along its greater curvature.
 The vascularity of this mobilized sphincter is primarily based on the
left gastroepiploic artery.
 The distal end of the colon is anastomosed to the antral end of APV,
and the duodenal end is sutured to the perianal skin
 Diseases of the Colon & Rectum Volume 56: 3 (2013)

 RESULTS
 17 patients, 18 months follow up
 The transposed grafts had a definite tone on digital examination,
 Well visualized on perineal MRI, showed high-velocity vascular inflow on Doppler
ultrasound study, and good vascularity on celiac CT angiography.
 Anal manometry showed a significant (p = 0.03) rise in the postoperative resting
neosphincter pressures with good retention of barium proximal to pyloric valve on
distal loopogram.
 The postoperative St Mark incontinence score improves (pre op 24 to post op 4-
15)
 Improvement in QoL scores
DIVERSION
Indications
 Following perineal trauma or a severe infected obstetric injury
 Risk of sepsis is high, such as in patients requiring re-operations, poor
bowel preparation, the obese, diabetics, extensive sphincter deficiency
 Previous failed repair
 Associated rectovaginal fistula
 Irradiation destruction of Rectum
 Last resort
DIVERSION VS NO
DIVERSION

Hasegawa H1, Yoshioka K, Keighley MR. Randomized trial of fecal diversion for sphincter repair. Dis Colon Rectum. 2000
Jul;43(7):961-4; discussion 964-5.
 NEW DEVELOPMENTS
 Hyperbaric Oxygen
 Oxygen at pressure has been shown to aid the regeneration of nerves that have
been damaged.
 Promotion of angiogenesis and reduction of edema

 Cundall et al. -

 Pilot study in 13 patients with fecal incontinence due to chronic pudendal

neuropathy.
 30 treatments in 6weeks.
 Each treatment was at 2.4 atm breathing pure oxygen for 90 minutes.
 No major complications
 The authors found a consistent improvement of the latencies on both sides.
 Incontinence scores also improved

Cundall JD, Gardiner A, Chin K, Laden G, Grout P, Duthie GS. Hyperbaric oxygen in the treatment of fecal incontinence secondary to pudendal neuropathy. Dis
Colon Rectum 2003; 46:1549–1554.
THANK YOU