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=> array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Antonio" "apellidos" => "Codina Cazador" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Fernando" "apellidos" => "de la Portilla de Juan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Mario" "apellidos" => "de Miguel Velasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "Alberto" "apellidos" => "de San Ildefonso Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "Fernando" "apellidos" => "Jiménez Escovar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 7 => array:3 [ "nombre" => "Franco" "apellidos" => "Marinello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 8 => array:3 [ "nombre" => "Mónica" "apellidos" => "Millán Scheiding" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] 9 => array:3 [ "nombre" => "Arantxa" "apellidos" => "Muñoz Duyos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 10 => array:3 [ "nombre" => "Mario" "apellidos" => "Ortega López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] ] ] 11 => array:3 [ "nombre" => "José Vicente" "apellidos" => "Roig Vila" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">l</span>" "identificador" => "aff0060" ] ] ] 12 => array:3 [ "nombre" => "Gervasio" "apellidos" => "Salgado Mijaiel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">m</span>" "identificador" => "aff0065" ] ] ] ] "afiliaciones" => array:13 [ 0 => array:3 [ "entidad" => "Unidad de Coloproctología, Hospital Viamed Santa Elena, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General y Aparato Digestivo, Unidad de Coloproctología, Hospital General Universitario de Elche, Elche, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Universitario de Girona, Girona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cirugía General, Unidad de Coloproctología, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Coloproctología, Hospital Virgen del Camino, Pamplona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Unidad de Coloproctología, Servicio de Cirugía General, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Unidad de Coloproctología, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Unidad de Cirugía Colorrectal, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Unidad de Coloproctología, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Unidad de Coloproctología, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Unidad de Coloproctología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Unidad de Coloproctología, Hospital Vithas 9 de Octubre, Valencia, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Unidad de Coloproctología, Hospital Santa Elena, Marbella, Málaga, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Consenso Baiona sobre Incontinencia Fecal: Asociación Española de Coloproctología" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 754 "Ancho" => 1333 "Tamanyo" => 141875 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fecal incontinence (FI) is the loss of the ability to retain or to voluntarily eliminate and discriminate rectal effluents. Factors involved in defecation are neurological, myogenic, sensory, hormonal and anatomical. In addition to these factors are a large number of variables that participate in the complex interaction of continence, such as: stool consistency, reservoir capacity, rectal compliance, rectal sensation, and effective sphincter pressures at rest and during contraction.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The most common etiology (at least in a surgical consultation) is obstetric trauma, although other factors may be involved. The most important include anal surgery, anal and perineal trauma, radiation therapy, chronic straining during defecation, neurological problems, psychosis, side effects of medication, and food intolerance.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Apart from the FI itself, 3 transcendental concepts should be differentiated:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Passive incontinence: incontinence accident of a complete or near-complete abundant stool, which occurs with no prior warning or desire to defecate, typical of neurological disorders and severe pelvic organ prolapse.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Soiling: emission of a small amount of feces or mucus through the anus that is continuous, occasional, or post-defecatory, which can cause anal and perianal margin irritation.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Fecal urgency: sudden desire to defecate which the patient is unable to defer.</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">The exact incidence and prevalence of FI is difficult to determine, ranging from 2% to 20.7%. This incidence increases in patients admitted to nursing homes and is very frequently associated with urinary incontinence.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It not only has a transcendental psychosocial impact, but it also entails a high financial cost for healthcare systems and individuals.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis and treatment of FI are complicated by its multifactorial etiology and multiple conditions involved. Currently, there is no unanimity when it comes to recommending the most effective diagnostic methods or applying the most appropriate therapeutic measures for each case, which is why discrepancies are frequently found in the literature and even among different clinical guidelines.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">Under the auspices of the Spanish Association of Coloproctology and during the 27th International Coloproctology Conference held in Baiona (Spain) in 2019, a decision was made to develop a consensus document on fecal incontinence, with the purpose to aid in the diagnosis and treatment of this problematic pathology, directed at all surgeons and healthcare workers concerned about the issue.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Among the different modalities used to develop a consensus document in medicine, the “Nominal Group Technique” was chosen.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The consensus group was comprised of 12 experts, all with extensive experience and interest in FI, and one General Coordinator. A roundtable discussion was held to assess all the problems and discrepancies regarding the diagnosis and treatment of FI.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Six working groups were created with 4 participants each; thus, each expert participated in 2 different groups that analyzed differing topics. A coordinator was nominated for each group, who distributed the topics among the participants. The experts made their evaluations based on their experience as well as an analysis of the literature by means of a structured qualitative review of sources identified by the search engines usually used in biomedical research: PubMed, MEDLINE, EMBASE and Cochrane Library, both in Spanish and English, until March 2022. The search terms were: “anal incontinence”, “fecal incontinence”, “sphincteroplasty”, “sacral nerve stimulation”, “posterior tibial nerve stimulation”, “bulking agents”, “dietary treatment”, and “artificial anal sphincter”.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical experimental articles in Spanish and English were included in order to evaluate and present possible future alternatives. The Levels of Evidence and Grades of Recommendation were established following the criteria of the Oxford Center for Evidence-Based Medicine<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Once the corresponding items were prepared by each expert, they were assessed by the Group Coordinator and the General Coordinator, who included comments that they considered appropriate. After this second proposal, the topics were sent to all the members of the group for another assessment. After the final analysis in each Group, the study and proposals were sent electronically to the entire group of experts who again made the recommendations they deemed pertinent.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Lastly, the manuscript and its main recommendations were presented at the 28th International Coloproctology Conference, held in Baiona in 2022.</p><p id="par0080" class="elsevierStylePara elsevierViewall">After this rigorous preparation, the Baiona Consensus Statement on Fecal Incontinence document was drawn up, under the auspices of the AECP.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical history — physical examination</span><p id="par0085" class="elsevierStylePara elsevierViewall">Considering the possible multifactorial etiology, all antecedents that could alter one or more should be analyzed in the clinical history. The medical history must include the following factors:</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Symptoms of incontinence</span><p id="par1225" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Time of evolution</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Correlation with changes in intestinal habit</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Characteristics of incontinence (soiling, passive, defecatory urgency, mixed)</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Intensity of symptoms (severity of incontinence)</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Accompanying symptoms (mucorrhea, bleeding)</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Finally, questions aimed at clarifying the type of involvement, defining the following factors:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">o</span><p id="par0120" class="elsevierStylePara elsevierViewall">QUALITY: lack of control refers to gases, liquid stools or solid stools?</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">o</span><p id="par0125" class="elsevierStylePara elsevierViewall">FREQUENCY: leaks are daily, weekly, monthly, or sporadic?</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">o</span><p id="par0130" class="elsevierStylePara elsevierViewall">DEGREE OF SOCIAL IMPACT: exact impact for each person?</p></li></ul></p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">All of these parameters are quantified using a calendar or evacuation diary that patients complete for three weeks, where all events related to incontinence are recorded in detail.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Background — identification of risk factors</span><p id="par1230" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">Age</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0145" class="elsevierStylePara elsevierViewall">Hygienic-dietary habits (tobacco, amount of fiber in the diet, body mass index, limited physical activity)</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">Medical history (neurodegenerative, metabolic, digestive pathology)</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Previous medication, or changes</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">Associated urinary incontinence</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0165" class="elsevierStylePara elsevierViewall">Surgical history (previous anorectal surgery)</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">Obstetric–gynecological history (childbirth, laborious births, traumatic births, hysterectomy, genital prolapse)</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Trauma history (pelvic–perineal trauma)<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,11–13</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Physical examination</span><p id="par0180" class="elsevierStylePara elsevierViewall">A detailed physical examination is essential for the correct evaluation of patients with FI, which will include:</p><p id="par0185" class="elsevierStylePara elsevierViewall">Inspection of the perineal area (rest and contraction) to evaluate scars, asymmetries, suppurative pathology, prolapses, perineal descent and dermatitis or excoriations in the perianal skin, as well as sensitivity in the perineal skin.</p><p id="par0190" class="elsevierStylePara elsevierViewall">The digital rectal examination provides subjective, but very reliable, evaluation of rest and effort pressures as well as muscle coordination, with expulsion or retention maneuvers. Furthermore, it rules out pathologies, such as rectal tumors or stenosis and sometimes the presence of fecal impaction.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Basic instrumentation (anoscopy, proctoscopy) can be useful as a complement to rectal examination to identify other anal pathologies.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,15</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">To study fecal incontinence, a detailed and directed anamnesis is essential, as well as a physical examination that includes inspection and examination, both digital and instrumental</span>.</p><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 1c; grade of recommendation A.</span></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Scoring instruments that evaluate the severity of fecal incontinence</span><p id="par0215" class="elsevierStylePara elsevierViewall">Measuring FI is challenging. To evaluate the severity of this symptom, several scoring systems have been developed to define the subjective perception of the patient, evaluate the treatments for their scientific dissemination in a homogeneous manner.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Scoring instruments can be either simple scales or grading scales. On simple scales, patients define their degree of fecal continence ranging from 0 to 10.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Grading scales include measuring fecal loss in type and frequency, the use of coping mechanisms, and the impact on lifestyle.</p><p id="par0230" class="elsevierStylePara elsevierViewall">In our setting, the most used scales are the Cleveland Clinic or Jorge–Wexner scores<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and the St Mark’s or Vaizey incontinence scales,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> which are easy to conduct and interpret.</p><p id="par0235" class="elsevierStylePara elsevierViewall">None of these scales have been validated, nor do they assess soiling. This has led certain studies to analyze the limited correlation between the assessment of the scores and the subjective perception reflected by the visual analogue scale.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">In the literature, there is no consensus on which is the best instrument to assess the severity of fecal incontinence, but these should be used to identify more severe symptoms that may initially require more aggressive treatment. By homogenizing the treatments established, results could be compared between studies, populations and institutions.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Scoring instruments to evaluate the quality of life in fecal incontinence</span><p id="par0245" class="elsevierStylePara elsevierViewall">The impact of fecal incontinence on quality of life is a vital point in the management of these patients. Quality-of-life assessment scales are divided into generic and specific types. The most widely used generic scale is the SF-36 (Medical Outcomes Survey Short-Form),<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and the most widespread specific instrument (validated in Spanish) is the FIQL scale (Fecal Incontinence Quality-of-Life Scale).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendation</span></p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In the medical assessment of fecal incontinence and for scientific research purposes, specific severity and quality-of-life scales should be used in these patients, even though there are no studies that support their routine use.</span></p><p id="par0260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 5; grade of recommendation D.</span></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnostic tests in fecal incontinence</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Endoanal ultrasound</span><p id="par0265" class="elsevierStylePara elsevierViewall">This is the main test used to study fecal incontinence, since objective, higher-quality images of the anal sphincters can be obtained compared to other methods. In most studies, its sensitivity and specificity for the detection of sphincter defects are in the range of 83%–100%.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">3D ultrasound does not provide much more information than 2D.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The Starck score can be useful in the evaluation of these patients, especially in the presence of obstetric damage.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Transvaginal and transperineal ultrasound</span><p id="par0275" class="elsevierStylePara elsevierViewall">These can be useful in the event that the endoanal probe cannot be used.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Magnetic resonance imaging</span><p id="par0280" class="elsevierStylePara elsevierViewall">Especially useful to detect external anal sphincter (EAS) atrophy<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26,27</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Defecography and MRI defecography</span><p id="par0285" class="elsevierStylePara elsevierViewall">Its use must be individualized and used on an exceptional basis.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Anal manometry and sensitivity tests</span><p id="par0290" class="elsevierStylePara elsevierViewall">Conventional anal manometry, with electronic or pneumatic perfusion, is used to measure anal canal pressures and rectal sensitivity. As a minimum, the following parameters must be collected: maximum resting pressure, maximum contraction pressure, length of the anal canal (at rest and contraction), point of maximum pressure, minimum and maximum tolerated sensitivity, and finally the rectoanal inhibitory reflex.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,30</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Neurophysiological tests</span><p id="par0295" class="elsevierStylePara elsevierViewall">These are not frequently recommended.</p><p id="par0300" class="elsevierStylePara elsevierViewall">In the future, we must consider the role that the determination of evoked potentials will play in testing the cerebral cortex. Likewise, the determination of the conduction of peripheral nerves, especially the posterior tibial nerve (in its sural sensory and motor branches) should be considered to assess therapy with peripheral neurostimulation.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31,32</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Anoscopy and rectoscopy</span><p id="par0305" class="elsevierStylePara elsevierViewall">These are used in order to rule out other coexisting processes, especially in patients with tenesmus.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> In select cases, colonoscopy is used.</p><p id="par0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">1) Anal ultrasound is mandatory in the diagnosis of patients with fecal incontinence, especially to detect structural anomalies of the sphincter complex.</span></p><p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation B.</span></p><p id="par0325" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2) MRI can be useful in certain circumstances, especially to determine sphincter atrophy.</span></p><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation C.</span></p><p id="par0335" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">3) Both defecography and MRI defecography have limited value in the diagnosis of FI, as they only have a certain role in patients presenting prolapses of other pelvic organs.</span></p><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation C.</span></p><p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">4) Colonoscopy can be useful for diseases that may exacerbate FI (diarrhea, etc.), but the related data available are very limited.</span></p><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 5; grade of recommendation D.</span></p><p id="par0355" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">5) Anorectal manometry can be useful in the diagnosis of FI, but never alone.</span></p><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation C.</span></p><p id="par0365" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">6) Although manometry can be useful to guide treatment alternatives, it is currently difficult to know its true impact.</span></p><p id="par0370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation B.</span></p><p id="par0375" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">7) High-resolution manometry is a new and promising technique; however, there are currently not enough studies to support its recommendation.</span></p><p id="par0380" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p><p id="par0385" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">8) Latency of the Motor Nerve should not be used in the diagnosis of fecal incontinence as a predictor of a successful sphincteroplasty.</span></p><p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p><p id="par0395" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">9) Needle electromyography (EMG) is the only technique to identify neurological damage.</span></p><p id="par0400" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2a; grade of recommendation B.</span></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conservative treatment</span><p id="par0405" class="elsevierStylePara elsevierViewall">Different conservative measures can provide satisfactory results that avoid surgical treatment. These include:</p><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Diet</span><p id="par0410" class="elsevierStylePara elsevierViewall">Dietary modifications can provide satisfactory results, with the aim of improving the frequency and consistency of bowel movements.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34,35</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0420" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In patients with fecal incontinence, it is advisable to record daily eating habits in a diary in order to personalize dietary recommendations.</span></p><p id="par0425" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b. Grade of recommendation C.</span></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Fiber</span><p id="par0430" class="elsevierStylePara elsevierViewall">Fiber improves stool consistency by absorbing excess intraluminal water. It is indicated in cases of fecal incontinence associated with diarrhea and liquid stools or stools of reduced consistency.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36,37</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0440" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Psyllium may be indicated in patients with fecal incontinence associated with stools of a soft or liquid consistency. Said fiber must be administered with a small amount of water so that the astringent effect is achieved.</span></p><p id="par0445" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation C</span></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Transanal irrigation</span><p id="par0450" class="elsevierStylePara elsevierViewall">This is based on emptying the colon of the maximum amount of fecal matter, used regularly. The published results are variable, the dropout rate is high, and adverse effects are not negligible.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38,39</span></a> However, it can be recommended in select cases.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0460" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Transanal irrigation may be recommended as a second line of treatment in patients with defecatory dysfunction of neurological causes or with low anterior resection syndrome.</span></p><p id="par0465" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Pharmacological treatment</span><p id="par0470" class="elsevierStylePara elsevierViewall">Different drugs have been used with the aim of achieving pseudo-constipation to avoid soft or liquid stools, or with the purpose of increasing the resting pressure of the internal sphincter.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41–44</span></a> The evidence is very limited, with multiple biases, which has led to its use being exceptional.</p><p id="par0475" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0480" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Antidiarrheal drugs like loperamide may be indicated in patients with fecal incontinence associated with stools of a soft or liquid consistency.</span></p><p id="par0485" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2a; grade of recommendation B.</span></p><p id="par0490" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Experience is limited with the use of topical drugs that increase anal pressure or with the administration of antidepressants.</span></p><p id="par0495" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation D.</span></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Biofeedback</span><p id="par0500" class="elsevierStylePara elsevierViewall">The objective of biofeedback is to strengthen the pelvic muscles, re-educate rectal sensitivity and coordinate the pelvic muscles with defecation.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45–47</span></a> In addition, it can be a satisfactory complementary treatment after sphincteroplasty.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48,49</span></a></p><p id="par0505" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0510" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Biofeedback may be useful in the treatment of FI in combination with other conservative treatment modalities.</span></p><p id="par0515" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2a; grade of recommendation B.</span></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Pelvic floor rehabilitation</span><p id="par0520" class="elsevierStylePara elsevierViewall">This entails performing short or long repeated contractions of the external anal sphincter and the puborectalis, while keeping the abdominal muscles relaxed. Better results have been reported when it is used in combination with biofeedback.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a></p><p id="par0525" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0530" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pelvic floor rehabilitation is a treatment option for fecal incontinence as part of conservative treatment, which is recommended based on its low cost, low morbidity and some evidence of effectiveness. Patients with little or no sphincter contractility capacity should be excluded. Its use is recommended in association with biofeedback.</span></p><p id="par0535" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b, grade of recommendation B.</span></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Electrostimulation</span><p id="par0540" class="elsevierStylePara elsevierViewall">Electrostimulation consists of the utilization of anal probes or electrodes placed in the perineum. There is no evidence on possible benefits.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52–54</span></a></p><p id="par0545" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0550" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Although there is little evidence, it seems that electrostimulation at high frequencies can improve the effectiveness of biofeedback.</span></p><p id="par0555" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation D.</span></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Palliative measures</span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Anovaginal mechanical devices</span><p id="par0560" class="elsevierStylePara elsevierViewall">These are passive obstruction barriers that block the flow of feces in the rectum to help prevent fecal incontinence. Data on their effectiveness are limited.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55–59</span></a></p><p id="par0565" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0570" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">There is no evidence to indicate the use of anal plugs in fecal incontinence, although they may be recommended in select patients, with warnings about possible intolerance.</span></p><p id="par0575" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation D.</span></p><p id="par0580" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The evidence for the use of mechanical vaginal devices for the treatment of fecal incontinence is limited, but they may be a good alternative within conservative treatments.</span></p><p id="par0585" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4. Degree of recommendation D.</span></p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Surgical treatment</span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Sphincteroplasty. Other surgical options</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Indications</span><p id="par0590" class="elsevierStylePara elsevierViewall">External anal sphincter (EAS) repair is indicated in patients with symptoms of fecal incontinence, with a limited defect and sufficient residual muscle mass. Its objective is to restore the anatomical barrier necessary for continence. It can be indicated for any type of EAS lesion, but the patient selection criteria and results obtained are extremely variable.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42,60–70</span></a></p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Surgical technique</span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Sphincteroplasty or suture of the external anal sphincter (EAS)</span><p id="par0595" class="elsevierStylePara elsevierViewall">Sphincteroplasty is the most commonly performed technique to treat EAS defects secondary to obstetric, postoperative or accidental trauma.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63,71–75</span></a></p><p id="par0600" class="elsevierStylePara elsevierViewall">There is a growing tendency to use overlapping, even in primary repairs, although there are several technical variations depending on the habits and experience of each surgeon, with variable results.<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75–77</span></a></p><p id="par0605" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0610" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sphincteroplasty is indicated in patients with severe fecal incontinence and observed sphincter injury of EAS or both sphincters between</span> 30º <span class="elsevierStyleItalic">and</span> 180º <span class="elsevierStyleItalic">of separation and that does not respond to conservative measures</span>.</p><p id="par0615" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p><p id="par0620" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Overlapping the sphincter ends is superior to direct repair</span>.</p><p id="par0625" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation B.</span></p><p id="par0630" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">There are no differences between the use of resorbable suture material in the medium or long term.</span></p><p id="par0635" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 1b; grade of recommendation A.</span></p></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Repair of both sphincters</span><p id="par0640" class="elsevierStylePara elsevierViewall">There is enormous technical variability in relation to <span class="elsevierStyleItalic">en bloc</span> suturing of both sphincters or with individualized repair, and different series have reported non-homogeneous results.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63,72,76–80</span></a> However, other authors have published satisfactory results with selective IAS suture, separated from the EAS.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">64,74,75</span></a> Given the variability of lesions in each case, rigorous randomization seems extremely difficult.</p><p id="par0645" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0650" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Individualized repair of both sphincters improves results, so it should be performed whenever possible</span>.</p></li></ul></p><p id="par0655" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Isolated internal anal sphincter (IAS) repair</span><p id="par0660" class="elsevierStylePara elsevierViewall">This has been attempted for defects with very symptomatic passive leaks secondary to fistulotomy or internal sphincterotomy. Although the results are usually not satisfactory, they can provide significant improvement to well-selected patients.<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">81–83</span></a></p><p id="par0665" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0670" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Repair of isolated IAS lesions can be performed, although with a low level of evidence</span>.</p></li></ul></p><p id="par0675" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Association with levator plication</span><p id="par0680" class="elsevierStylePara elsevierViewall">This has been used in association with sphincteroplasty, not only to treat sphincter defects,<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75,84</span></a> but also when there are none.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> However, there is no clear evidence of its use in cases of obstetric injuries, and it can lead to dyspareunia if the suture is tense.</p><p id="par0685" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">-</span><p id="par0690" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Levatorplasty should not be systematically associated with sphincteroplasty in obstetric injuries.</span></p></li></ul></p><p id="par0695" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 5; grade of recommendation D.</span></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Association with plastic surgery</span><p id="par0700" class="elsevierStylePara elsevierViewall">In patients with a thin or absent perineal body, or even with a common anovaginal cloaca, plastic surgery procedures have been performed with good results, both in terms of improving continence and sexual function.<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">86–88</span></a></p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Re-sphincteroplasty</span><p id="par0705" class="elsevierStylePara elsevierViewall">When an anterior muscle defect persists or occurs over time, most series have obtained good results with re-sphincteroplasty. The failure of an initial repair does not exclude a new one.<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">89–91</span></a></p><p id="par0710" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">-</span><p id="par0715" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">It is feasible to perform a new sphincteroplasty when persistence or recurrence of the sphincter defect is proven</span>.</p></li></ul></p><p id="par0720" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p></span></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Complications and prevention</span><p id="par0725" class="elsevierStylePara elsevierViewall">Complications associated with sphincter repair occur in 15% of cases; they are usually mild and include infection and dehiscence of the surgical wound, abscess, bleeding, urinary retention, fecal impaction, dehiscence of the sphincter suture, pain and dyspareunia.<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">92,93</span></a> Preventive measures are based on empirical treatments and general recommendations, such as the use of prophylactic antibiotics, partial or non-closure of the surgical wound, the use of antegrade colon preparation or preoperative cleansing enemas, and bladder catheterization, with no evidence of any benefits.</p><p id="par0730" class="elsevierStylePara elsevierViewall">Protective stomas have been described in situations of risk of perianal sepsis and in extensive or complex sphincter defects, but they do not provide any benefit over a regular sphincteroplasty,<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> nor does “chemical colostomy” seem to offer significant advantages.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a></p><p id="par0735" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">-</span><p id="par0740" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A protective stoma is unnecessary to prevent complications after performing a sphincteroplasty</span>.</p></li></ul></p><p id="par0745" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 1b; grade of recommendation A.</span></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Results</span><p id="par0750" class="elsevierStylePara elsevierViewall">Sphincteroplasty improves fecal incontinence in 70%–90% of cases in the short term, but the assessment of success differs according to the studies,<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72,73,95</span></a> and they generally deteriorate over time.</p><p id="par0755" class="elsevierStylePara elsevierViewall">However, other studies with long-term follow-up and rigorous controls demonstrate sustained improvement, confirming the prolonged effectiveness of the technique.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">61,66,75,96</span></a> Even so, patients should be informed about the possibility of progressive deterioration of sphincter function over time. No significant factors have been described for a poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a></p><p id="par0760" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0765" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Despite possible deterioration over time, sphincteroplasty provides functional results and improvement in quality of life that are satisfactory enough to be recommended.</span></p></li></ul></p><p id="par0770" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation C.</span></p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Pelvic floor repair</span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Indications</span><p id="par0775" class="elsevierStylePara elsevierViewall">Indications include idiopathic (neuropathic) fecal incontinence and complex trauma to the external anal sphincter and puborectalis muscle.<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">98,99</span></a> It has also been used in patients with descending perineum syndrome associated with decreased anal canal pressure and altered anorectal angle.<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a> Currently, it is an uncommon procedure.<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">101,102</span></a></p><p id="par0780" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendation</span></p><p id="par0785" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pelvic floor repair can be performed in selected patients with idiopathic fecal incontinence and descending perineum syndrome, in whom significant weakness of the sphincter complex is observed, when other therapeutic options are not possible.</span></p><p id="par0790" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p></span></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Use of other muscles: muscle transposition</span><p id="par0795" class="elsevierStylePara elsevierViewall">The objective is to create a neo-anal sphincter when direct repair of the sphincter complex is considered inappropriate, with the aim of passively increasing output resistance in patients with severe symptoms.</p><p id="par0800" class="elsevierStylePara elsevierViewall">The most commonly used procedure is dynamic graciloplasty. The results are very heterogeneous, and the complication rate is high.<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">103–107</span></a> The use of gluteoplasty is currently unusual.<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">108,109</span></a></p><p id="par0805" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0810" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Graciloplasty and gluteoplasty, performed at medical centers with experience, can be considered in motivated patients as a final alternative prior to a colostomy.</span></p><p id="par0815" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation D.</span></p></span></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Sacral neuromodulation</span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">What is it?</span><p id="par0820" class="elsevierStylePara elsevierViewall">Sacral neuromodulation (SNM) involves electrically stimulating a root of the sacral spinal nerve to modulate a neural pathway with the aim of treating defecatory dysfunction. After a test phase, if satisfactory, we move on to chronic or definitive stimulation. The surgical technique is highly reproducible and should be performed according to standards described by several expert committees.<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">110–115</span></a></p><p id="par0825" class="elsevierStylePara elsevierViewall">The mechanism of action of SNM is not yet completely known, but it is believed to act at the somatic motor, somatosensory, and autonomic levels, while mediating somatovisceral reflexes. It is seemingly not limited to the effector organ, as central and cortical effects have been demonstrated.<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">116,117</span></a></p><p id="par0830" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0835" class="elsevierStylePara elsevierViewall">A thorough and multangular evaluation of patients is necessary (defecation diary, subjective evaluation, scores, etc.), both at baseline and during the test phase, to avoid false positives or false negatives. The recommended cut-off point is 50% improvement in the evaluated parameters, although individualization is important.</p><p id="par0840" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Indications</span><p id="par0845" class="elsevierStylePara elsevierViewall">In general terms, SNM is considered the second line of treatment for patients with moderate or severe FI who have not found improvement through conservative treatment.<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">118–122</span></a> The short-term results in the literature demonstrate a reduction of more than 50% in incontinence episodes in 79% of patients implanted, maintaining an effectiveness of 83% after 3 years of follow-up.<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">121,123–126</span></a></p><p id="par0850" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0855" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sacral neuromodulation can be indicated as a second line of therapy in patients with fecal incontinence in whom conservative treatment fails. Multifactorial FI best responds to SNM.</span></p><p id="par0860" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Morbidity</span><p id="par0865" class="elsevierStylePara elsevierViewall">The morbidity of SNM is low and mild, including pain related to stimulation or the implanted device and infection of the system. Patient followed-up should be lifelong because the incidence of minor events or transient relapses is considerable.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">127</span></a></p><p id="par0870" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0875" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">It is recommended to closely monitor immune status and coagulation prior to performing SNM.</span></p><p id="par0880" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b. Grade of recommendation C.</span></p><p id="par0885" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">There is no consistent evidence on how to act on the stimulation parameters when confronted with different incidents during follow-up, so it is recommended to rely on clinical experience.</span></p><p id="par0890" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation D.</span></p></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Efficacy by etiopathogenic subgroups</span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Fecal incontinence in patients with injury to the external anal sphincter</span><p id="par0895" class="elsevierStylePara elsevierViewall">The presence of a sphincter injury does not seem to influence the result of SNM.<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">118,128,129</span></a></p><p id="par0900" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0905" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Neuromodulation may be indicated in selected patients with sphincter injury, preferably of long duration.</span></p><p id="par0910" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Neurological fecal incontinence</span><p id="par0915" class="elsevierStylePara elsevierViewall">There is little evidence on its effects on neurological fecal incontinence.<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">130,131</span></a></p><p id="par0920" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0925" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">SNM offers a promising therapeutic option for patients with neurogenic incontinence refractory to other therapies.</span></p><p id="par0930" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Incontinence in low anterior resection syndrome (LARS)</span><p id="par0935" class="elsevierStylePara elsevierViewall">Although applied in small, heterogeneous samples, the results are encouraging.<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">132–134</span></a></p><p id="par0940" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0945" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Although it is necessary to agree on a correct algorithm that considers the different variables related to LARS, SNM is indicated in these patients when conservative treatment has failed.</span></p><p id="par0950" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p></span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Fecal incontinence in the context of chronic diarrhea</span><p id="par0955" class="elsevierStylePara elsevierViewall">Various studies have shown improvement in the number of bowel movements after neuromodulation applied in different diarrheal conditions, although the evidence is scarce.<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">135</span></a></p><p id="par0960" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0965" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Given the persistence of incontinence associated with diarrhea despite the application of conservative treatments, and after assessment by a digestive specialist, a neuromodulation trial phase may be indicated.</span></p><p id="par0970" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Congenital fecal incontinence</span><p id="par0975" class="elsevierStylePara elsevierViewall">There is little experience, and complex cases require thorough study and strict individualized technique.<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">136–138</span></a></p><p id="par0980" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par0985" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">After meticulous study to confirm the existence of residual sphincter apparatus, SNM can be attempted in this type of patient.</span></p><p id="par0990" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 4; grade of recommendation C.</span></p></span></span></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Posterior tibial nerve stimulation (PTNS)</span><p id="par0995" class="elsevierStylePara elsevierViewall">The posterior tibial nerve contains sensory, motor, and autonomic fibers that originate from the roots of the S2–S4 sacral plexus. Its stimulation affects the sacral roots in retrograde related to visceral and muscular control of the pelvic floor, but the exact mechanism of action is unknown.<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">139</span></a></p><p id="par1000" class="elsevierStylePara elsevierViewall">Treatment can be percutaneous, with needle electrodes, or transcutaneous, with surface electrodes.<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">140–142</span></a> Bilateral stimulation has been tested in limited studies.<a class="elsevierStyleCrossRefs" href="#bib0715"><span class="elsevierStyleSup">143,144</span></a></p><p id="par1005" class="elsevierStylePara elsevierViewall">There are still numerous unknowns regarding indications, differences with SNM, need to maintain treatment, stimulation regimens and long-term results.<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">145–151</span></a></p><p id="par1010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">1) PTNS offers an alternative to patients with less severe fecal incontinence, although its results are sometimes discreet.</span></p><p id="par1020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p><p id="par1025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2) The short- and medium-term results and its high acceptance by patients mean that PTNS can be used as a bridge therapy before offering SNS.</span></p><p id="par1030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p><p id="par1035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">3) It can be performed both percutaneously and transcutaneously.</span></p><p id="par1040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p><p id="par1045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">4) A standardized administration schedule cannot be recommended, although it seems that the most frequently used is 1–2 sessions per week for 3 months, followed by “booster” treatments with no clear schedule.</span></p><p id="par1050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p><p id="par1055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">5) Offering PTNS when conservative treatment and/or biofeedback fail can reduce the need for SNS, or at least delay it.</span></p><p id="par1060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 2b; grade of recommendation B.</span></p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Less common procedures</span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">Artificial anal sphincter (AAS)</span><p id="par1065" class="elsevierStylePara elsevierViewall">The high number of complications, with no viable solutions, has led to the disappearance of AAS.<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">152–154</span></a></p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">Magnetic anal sphincter (MAS)</span><p id="par1070" class="elsevierStylePara elsevierViewall">The complication rate is high, and it has been taken of the market.</p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">Bulking agents</span><p id="par1075" class="elsevierStylePara elsevierViewall">The use of these products presents low complexity and morbidity rates.<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78,155,156</span></a> They are indicated in cases of internal sphincter injuries that cause soiling.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> There are no long-term results available.<a class="elsevierStyleCrossRefs" href="#bib0775"><span class="elsevierStyleSup">155–158</span></a></p><p id="par1080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The use of bulking agents is a valid option for patients with soiling or other effects derived from an injury to the internal sphincter.</span></p><p id="par1090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation C.</span></p></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0310">Injection of mesenchymal cells</span><p id="par1095" class="elsevierStylePara elsevierViewall">This application is used in experimental research.<a class="elsevierStyleCrossRefs" href="#bib0795"><span class="elsevierStyleSup">159–161</span></a></p><p id="par1100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cell therapy presents promising results, but it is currently in the experimental field, so there is no evidence for its recommendation.</span></p></span><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0315">Radio frequency (SECCA)</span><p id="par1110" class="elsevierStylePara elsevierViewall">Favorable results are limited, so its use is currently very limited.<a class="elsevierStyleCrossRefs" href="#bib0810"><span class="elsevierStyleSup">162–164</span></a></p><p id="par1115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Although there is evidence of clinical improvement, poor long-term results mean that its use is currently very limited.</span></p><p id="par1125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation C.</span></p></span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">TOPAS (Trans Obturator Posterior Anal Sling)</span><p id="par1130" class="elsevierStylePara elsevierViewall">Preliminary results are favorable,<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">165–167</span></a> but its use is not approved.</p><p id="par1135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Product not approved despite good preliminary results.</span></p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0325">Malone anterograde continence enema (MACE)</span><p id="par1145" class="elsevierStylePara elsevierViewall">Possible option in very select cases, but not free of complications.<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">168–170</span></a></p><p id="par1150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Malone anterograde continence enema is a valid therapeutic option in patients with incontinence and constipation, or with neurogenic bowel dysfunction, prior to the indication of a colostomy.</span></p><p id="par1160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Level of evidence 3b; grade of recommendation C.</span></p></span><span id="sec0305" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0330">Acupuncture</span><p id="par1165" class="elsevierStylePara elsevierViewall">Few studies, but good results<a class="elsevierStyleCrossRefs" href="#bib0855"><span class="elsevierStyleSup">171,172</span></a></p><p id="par1170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In the absence of evidence, it cannot be recommended as a treatment.</span></p></span><span id="sec0310" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0335">Pyloric valve transposition</span><p id="par1180" class="elsevierStylePara elsevierViewall">Anastomosis between the distal colon and the perianal skin, and the pylorus acts as a valve or “sphincter” mechanism.<a class="elsevierStyleCrossRefs" href="#bib0865"><span class="elsevierStyleSup">173–175</span></a></p><p id="par1185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In the absence of clinical evidence, this alternative is in the experimental phase.</span></p></span><span id="sec0315" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0340">Colostomy</span><p id="par1195" class="elsevierStylePara elsevierViewall">Although it is an aggressive option, it can radically improve the quality of life of patients when all therapeutic options have failed.<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">176</span></a></p><p id="par1200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Expert recommendations</span></p><p id="par1205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">No comparative studies have been published. Its use is recommended in consensus with the patient as the last therapeutic option.</span></p><p id="par1210" class="elsevierStylePara elsevierViewall">In conclusion, FI is an important problem that significantly affects the quality of life of patients. There are numerous therapeutic options, which must be established only after thorough, meticulous assessment on an individualized basis.</p></span></span><span id="sec0320" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0345">Funding</span><p id="par1215" class="elsevierStylePara elsevierViewall">The authors declare that they have received no funding.</p></span><span id="sec0325" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0350">Conflict of interests</span><p id="par1220" class="elsevierStylePara elsevierViewall">The authors of the article do not have any commercial association that might pose a conflict of interest in relation to this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:24 [ 0 => array:3 [ "identificador" => "xres2162339" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres2162338" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1834458" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres2162340" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0015" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1834457" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 7 => array:3 [ "identificador" => "sec0015" "titulo" => "Clinical history — physical examination" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Symptoms of incontinence" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Background — identification of risk factors" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Physical examination" ] ] ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Scoring instruments that evaluate the severity of fecal incontinence" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Scoring instruments to evaluate the quality of life in fecal incontinence" ] 10 => array:3 [ "identificador" => "sec0045" "titulo" => "Diagnostic tests in fecal incontinence" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Endoanal ultrasound" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Transvaginal and transperineal ultrasound" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Magnetic resonance imaging" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Defecography and MRI defecography" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Anal manometry and sensitivity tests" ] 5 => array:2 [ "identificador" => "sec0075" "titulo" => "Neurophysiological tests" ] 6 => array:2 [ "identificador" => "sec0080" "titulo" => "Anoscopy and rectoscopy" ] ] ] 11 => array:3 [ "identificador" => "sec0085" "titulo" => "Conservative treatment" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Diet" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Fiber" ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Transanal irrigation" ] ] ] 12 => array:2 [ "identificador" => "sec0105" "titulo" => "Pharmacological treatment" ] 13 => array:2 [ "identificador" => "sec0110" "titulo" => "Biofeedback" ] 14 => array:2 [ "identificador" => "sec0115" "titulo" => "Pelvic floor rehabilitation" ] 15 => array:2 [ "identificador" => "sec0120" "titulo" => "Electrostimulation" ] 16 => array:3 [ "identificador" => "sec0125" "titulo" => "Palliative measures" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0130" "titulo" => "Anovaginal mechanical devices" ] ] ] 17 => array:3 [ "identificador" => "sec0135" "titulo" => "Surgical treatment" "secciones" => array:5 [ 0 => array:3 [ "identificador" => "sec0140" "titulo" => "Sphincteroplasty. Other surgical options" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0145" "titulo" => "Indications" ] 1 => array:3 [ "identificador" => "sec0150" "titulo" => "Surgical technique" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0155" "titulo" => "Sphincteroplasty or suture of the external anal sphincter (EAS)" ] ] ] 2 => array:2 [ "identificador" => "sec0160" "titulo" => "Repair of both sphincters" ] 3 => array:2 [ "identificador" => "sec0165" "titulo" => "Isolated internal anal sphincter (IAS) repair" ] 4 => array:2 [ "identificador" => "sec0170" "titulo" => "Association with levator plication" ] 5 => array:2 [ "identificador" => "sec0175" "titulo" => "Association with plastic surgery" ] 6 => array:2 [ "identificador" => "sec0180" "titulo" => "Re-sphincteroplasty" ] ] ] 1 => array:2 [ "identificador" => "sec0185" "titulo" => "Complications and prevention" ] 2 => array:2 [ "identificador" => "sec0190" "titulo" => "Results" ] 3 => array:3 [ "identificador" => "sec0195" "titulo" => "Pelvic floor repair" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0200" "titulo" => "Indications" ] ] ] 4 => array:2 [ "identificador" => "sec0205" "titulo" => "Use of other muscles: muscle transposition" ] ] ] 18 => array:3 [ "identificador" => "sec0210" "titulo" => "Sacral neuromodulation" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0215" "titulo" => "What is it?" ] 1 => array:2 [ "identificador" => "sec0220" "titulo" => "Indications" ] 2 => array:2 [ "identificador" => "sec0225" "titulo" => "Morbidity" ] 3 => array:3 [ "identificador" => "sec0230" "titulo" => "Efficacy by etiopathogenic subgroups" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0235" "titulo" => "Fecal incontinence in patients with injury to the external anal sphincter" ] 1 => array:2 [ "identificador" => "sec0240" "titulo" => "Neurological fecal incontinence" ] 2 => array:2 [ "identificador" => "sec0245" "titulo" => "Incontinence in low anterior resection syndrome (LARS)" ] 3 => array:2 [ "identificador" => "sec0250" "titulo" => "Fecal incontinence in the context of chronic diarrhea" ] 4 => array:2 [ "identificador" => "sec0255" "titulo" => "Congenital fecal incontinence" ] ] ] ] ] 19 => array:2 [ "identificador" => "sec0260" "titulo" => "Posterior tibial nerve stimulation (PTNS)" ] 20 => array:3 [ "identificador" => "sec0265" "titulo" => "Less common procedures" "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0270" "titulo" => "Artificial anal sphincter (AAS)" ] 1 => array:2 [ "identificador" => "sec0275" "titulo" => "Magnetic anal sphincter (MAS)" ] 2 => array:2 [ "identificador" => "sec0280" "titulo" => "Bulking agents" ] 3 => array:2 [ "identificador" => "sec0285" "titulo" => "Injection of mesenchymal cells" ] 4 => array:2 [ "identificador" => "sec0290" "titulo" => "Radio frequency (SECCA)" ] 5 => array:2 [ "identificador" => "sec0295" "titulo" => "TOPAS (Trans Obturator Posterior Anal Sling)" ] 6 => array:2 [ "identificador" => "sec0300" "titulo" => "Malone anterograde continence enema (MACE)" ] 7 => array:2 [ "identificador" => "sec0305" "titulo" => "Acupuncture" ] 8 => array:2 [ "identificador" => "sec0310" "titulo" => "Pyloric valve transposition" ] 9 => array:2 [ "identificador" => "sec0315" "titulo" => "Colostomy" ] ] ] 21 => array:2 [ "identificador" => "sec0320" "titulo" => "Funding" ] 22 => array:2 [ "identificador" => "sec0325" "titulo" => "Conflict of interests" ] 23 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-18" "fechaAceptado" => "2023-07-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1834458" "palabras" => array:6 [ 0 => "Fecal incontinence" 1 => "Sphincteroplasty" 2 => "<span class="elsevierStyleItalic">Biofeedback</span>" 3 => "Sacral nerve stimulation" 4 => "Posterior tibial nerve stimulation" 5 => "Transanal irrigation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1834457" "palabras" => array:6 [ 0 => "Incontinencia fecal" 1 => "Esfinteroplastia" 2 => "<span class="elsevierStyleItalic">Biofeedback</span>" 3 => "Neuromodulación de raíces sacras" 4 => "Neuromodulación tibial posterior" 5 => "Irrigación transanal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La incontinencia fecal (IF) constituye un importante problema sanitario, tanto a nivel individual como para los diferentes sistemas de salud, lo que origina una preocupación generalizada para su resolución o, al menos, disminuir en lo posible los numerosos efectos indeseables que provoca, al margen del elevado gasto que ocasiona.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Existen diferentes criterios relacionados con las pruebas diagnósticas a realizar, y lo mismo acontece con relación al tratamiento más adecuado, dentro de las numerosas opciones que han proliferado durante los últimos años, no siempre basadas en una rigurosa evidencia científica.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Por dicho motivo, desde la Asociación Española de Coloproctología (AECP) nos propusimos elaborar un Consenso que sirviese de orientación a todos los profesionales sanitarios interesados en el problema, conscientes, no obstante, de que la decisión terapéutica debe tomarse de manera individualizada: características del paciente/experiencia del terapeuta.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Para su elaboración optamos por la técnica de grupo nominal. Los niveles de evidencia y los grados de recomendación se establecieron de acuerdo a los criterios del <span class="elsevierStyleItalic">Oxford Centre for Evidence-Based Medicine</span>. Por otra parte, en cada uno de los ítems analizados se añadieron, de forma breve, recomendaciones de los expertos.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of study \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic review of randomized clinical trials (with homogeneity) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Randomized clinical trial with a narrow confidence interval \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical practice (all or none) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic review of cohort studies (with homogeneity) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cohort studies of randomized clinical trial with low quality \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Outcomes research; ecological studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic review of case-control studies (with homogeneity) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case-control study \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Series of cases or cohort studies and low-quality case-control studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expert opinion with no explicit critical assessment or based on physiology \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3563191.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Levels of evidence according to the criteria of the Oxford Centre for Evidence-Based Medicine (CEBM).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level of evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level 1 studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leve 2–3 studies, or extrapolated Level 1 studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level 4 studies, or extrapolated Level 2–3 studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level 5 studies, or inconclusive studies of any level \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3563192.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Grades of recommendation (CEBM).</p>" ] ] 2 => array:5 [ "identificador" => "fig0005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 754 "Ancho" => 1333 "Tamanyo" => 141875 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:176 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of anal incontinence in a working population within a healthcare environment" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/00365521.2017.1378713" "Revista" => array:5 [ …5] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Faecal incontinence in older people: evaluation, treatment and new surgical techniques" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impacto económico del tratamiento a largo plazo de la incontinencia fecal grave" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ciresp.2021.04.008" "Revista" => array:6 [ …6] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Critical appraisal of international guidelines for the management of fecal incontinence in adults: is it possible to define what to do in diferent clinical scenarios?" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10151-021-02544-2" "Revista" => array:6 [ …6] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of the Delphi and other consensus group methods in medical education research: a review" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ACM.0000000000001812" "Revista" => array:6 [ …6] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Entre el consenso y la evidencia científica" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1157/13071820" "Revista" => array:6 [ …6] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, et al. «Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document)». Oxford Centre for Evidence-Based Medicine. Available from: <a target="_blank" href="http://www.cebm.net/index.aspx?o=5653">http://www.cebm.net/index.aspx?o=5653</a>." ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current management of fecal incontinence" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7812/TPP/12-064" "Revista" => array:6 [ …6] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fecal incontinence: etiology, diagnosis and management" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11605-015-2905-1" "Revista" => array:6 [ …6] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Onset and risk factors for fecal incontinence in a US community" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2009.594" "Revista" => array:6 [ …6] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for faecal incontinence in older women" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2012.364" "Revista" => array:6 [ …6] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The prevalence of occult obstetric anal sphincter injury following childbirth-literature review" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/14767050701412917" "Revista" => array:6 [ …6] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of digital and manometric assessment of anal sphincter function" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/bjs.1800760934" "Revista" => array:6 [ …6] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating faecal incontinence" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00384-006-0217-3" "Revista" => array:6 [ …6] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Etiology and management of faecal incontinence" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/BF02050307" "Revista" => array:6 [ …6] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective comparison of faecal incontinence grading systems" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/gut.44.1.77" "Revista" => array:6 [ …6] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does the St. Mark’s incontinence score reflect patients’ perceptions? 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