Quantifying patient improvement following sacral neuromodulation: is it time for a new scoring system for fecal incontinence?

Abstract

The Cleveland Clinic Florida Fecal Incontinence score is widely used to assess the severity of fecal incontinence. We hypothesized that the Cleveland Clinic Fecal Florida Incontinence score is useful at establishing baseline disease severity, but it may underestimate the response to treatment following sacral neuromodulation because of the large number of patients who still wear a pad despite improved continence, as well as the inability to track improvements in urgency. Data were obtained from prospectively maintained database of patients treated with sacral neuromodulation for fecal incontinence at 2 institutions beginning in 2011. A retrospective review of the individual components of Cleveland Clinic Fecal Florida Incontinence scores in response to treatment with sacral neuromodulation was performed. The study was conducted at 1 academic medical center and 1 community medical center. One hundred twenty-one consecutive patients were treated with sacral neuromodulation for fecal incontinence. No interventions occurred. Individual components of posttreatment Cleveland Clinic Florida Fecal Incontinence scores and subjective improvement in fecal urgency were the primary outcomes measured. The median preoperative Cleveland Clinic Fecal Florida Incontinence score of 14 decreased to 3 (interquartile range, 2-4) at 12 months. Of the patients, 66.1% reported still wearing a pad after the procedure. The reason for wearing a pad was residual fecal incontinence (41%), habit despite normal continence (35.3%), and urinary incontinence with complete fecal continence (23.5%). Of patients who report wearing a pad, 59% have falsely elevated Cleveland Clinic Fecal Florida Incontinence scores owing to wearing a pad despite complete fecal continence. Additionally, 96.3% of patients reported improvement in fecal urgency. This retrospective study did not include a comparison with an alternative scoring system. Although the Cleveland Clinic Fecal Florida Incontinence score is a validated scale, which is simple to use for baseline disease severity, it may underestimate patient response to treatment. Additionally, it does not capture improvement in urgency. The ideal scoring system would be easy to use in clinical practice, and would account for improvement in fecal urgency.