Fecal incontinence (FI) is a complex, multifactorial health problem. FI is defined as the partial or total loss of the ability to voluntarily control gas and stool expulsion. The severity of FI is evaluated principally by determining the frequency and type of incontinence [1].

Recently, sacral nerve stimulation (SNS) and percutaneous posterior tibial nerve stimulation (PPTNS) have been shown to effectively improve the treatment of FI. Studies have generally reported high success rates and low morbidity rates [2, 3]. Nevertheless, no study has been done comparing the efficiency of both.

We conducted a prospective cohort study on men with FI treated with SNS or PPTNS in the University General Hospital of Elche and Reina Sofia of Murcia between January 2010 and December 2011. The preoperative assessment included a physical examination, anorectal manometry, and anal endosonography. Anal continence was evaluated using the Wexner continence grading system [4].

The SNS technique and PPTNS technique have been previously described [2, 3]. Statistical analysis was performed using SPSS 20.0 (SPSS, Chicago, IL, USA). We used Student’s t test and ANOVA to compare paired variables (when following a Gaussian distribution) and Mann–Whitney and Kruskal–Wallis tests for variables without a normal distribution.

Nineteen patients were included. All patients had already undergone conservative treatment, including drugs, a constipating diet, and biofeedback physiotherapy for at least 2 years. Patient characteristics are shown in Table 1.

Table 1 Patient characteristics and results
Full size table

Sacral nerve stimulation

Ten patients underwent percutaneous nerve evaluation (PNE). Nine had a reduction of at least 50 % of incontinence episodes or days with incontinence, at which time they received a permanent implant (Medtronic Models 3023 InterStim I or 3058 InterStim II). SNS improved FI in nine of the ten patients (90 %). The mean Wexner score decreased significantly from a median of 14 (12–16) (preoperative) to 4 (1–8) (6-month revision) (p = 0.007). The other results are shown in Table 1.

Percutaneous posterior tibial nerve stimulation

Nine patients underwent the PPTNS. Seven of the nine patients (77.78 %) completed the treatment. Two patients did not continue therapy because of lack of clinical improvement of FI. PTNS improved FI in seven of the patients. The mean Wexner score decreased significantly from a median of 12 (11–19) (preoperative) to 5 (4–7) (6-month revision) (p = 0.018). The other results are shown in Table 1.

Sacral nerve stimulation versus posterior tibial nerve stimulation

Both treatments produced symptomatic improvement without statistical differences between them. Regardless of the treatment used, patients showed similar improvement in Wexner score and quality of life results. Manometric results showed no difference compared to baseline in both groups.

In women, parity, traction, and/or compression of the pudendal nerves during vaginal delivery, age-related neuropathy, and the alteration of progesterone and estrogen levels after menopause were the main cause(s) of FI. However, in men, the etiology is usually simpler and mainly involves local changes, either due to direct injury to the sphincter or due to the loss of rectal reservoir capacity, or due to previous surgery or radiotherapy. We think that this simpler etiology may be the reason that we do not find differences between men treated with SNS and men treated with PPTNS.

The comparative efficacy of PPTNS and SNS is currently unknown. However, it seems to be clear that PPTNS is a less invasive and cheaper treatment that appears to be just as effective as SNS, according to the results previously presented. We believe that PPTNS should be the first treatment used for these patients.

In conclusion, in men PPTNS has a similar efficiency to SNS in terms of Wexner score, ability to defer defecation and manometric findings; nevertheless, studies that analyze long-term results are needed.