Posterior Tibial Nerve Stimulation for the Treatment of Fecal Incontinence: A Systematic Evidence Review

Importance and Objectives: Posterior tibial nerve stimulation (PTNS) is a potential emerging therapy for fecal incontinence (FI). The aim of this study was to systematically review the literature regarding the efficacy of PTNS as a treatment of FI. Evidence Acquisition: We searched MEDLINE/PubMed, EMBASE, and Cochrane databases from inception through November 2013. We included English-language full-text articles reporting outcomes for FI with either percutaneous PTNS or transcutaneous techniques (transcutaneous electrical nerve stimulation). We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to assess study quality. Results: Our search yielded 1154 citations; 129 abstracts and 17 articles were included for full-text review. There were 13 case series and 4 randomized controlled trials. Fifteen studies were of low quality, none were of fair quality, and 2 studies were of good quality based on the Grades of Recommendation, Assessment, Development, and Evaluation system. In total, 745 subjects were studied, and of those, 90% were women and 10% were men. Studies involved percutaneous PTNS in 57% (428/745) of the subjects, transcutaneous electrical nerve stimulation in 30% (223/745), and sham technique in 13% (94/745). Therapy frequency, maintenance therapy, and follow-up time varied across studies. Eleven studies assessed FI episodes and bowel movement deferment time; all but 1 showed statistical improvement after therapy. Ten of the 11 studies that used the Cleveland Clinic Florida Fecal Incontinence score reported statistically significantly improved scores after treatment. Conclusions and Relevance: Multiple low-quality studies show improvement in FI after PTNS. High-quality studies with comparison groups and clinically meaningful outcome measures would further establish the utility of PTNS for FI. Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completing this activity, the learner will be better able to discuss the scope and impact of FI among women in the United States and initial treatment options; evaluate the available literature investigating bowel symptom responses after PTNS therapy for the treatment of FI; evaluate and explain the available literature investigating quality-of-life parameters after PTNS therapy for the treatment of FI; and analyze the available literature investigating adverse events with PTNS therapy for the treatment of FI.