Intra-rectal Injections of Botulinum Toxin Can Be a Long-term Treatment of Fecal Urge Incontinence

Abstract Background and aims: Unsuccessful first-line conservative treatments for managing fecal incontinence (FI) lead to considering predominantly invasive options, posing challenges in terms of cost and patient acceptance of benefit/risk ratio. Recent data from a prospective randomized study have highlighted intrarectal botulinum toxin (BoNT/A) injection as a promising minimally invasive alternative for urge FI, demonstrating efficacy at 3 months but lacking long-term evidence. This study aimed to evaluate the sustained efficacy and injection frequency of rectal BoNT/A injection in the treatment of urge FI. Methods: This retrospective monocentric study enrolled all patients who underwent rectal BoNT/A injection for urge FI after failed conservative therapy or sacral nerve stimulation (SNS). Injections were administered during sigmoidoscopy, delivering 200 U of BoNT/A at 10 circumferentially distributed sites. Treatment effectiveness was assessed using the Wexner score and a visual analog scale (VAS) for symptom severity, with reinjection performed upon symptom recurrence. Results: 41 patients (34 females) were included, with a median follow-up of 2 years. Eleven patients had previously failed sacral nerve stimulation. Significant reductions were observed in Wexner scores (median 11 vs 7, p=0.001) and VAS symptoms (median 4 [0-5] vs median 2 [0-5], p=0.001). The median interval between rectal BoNT/A injections was 9.8 months [5.3-47.9 ]. Conclusion: This study provides the first evidence of the sustained efficacy of rectal BoNT/A injection for urge FI. Further investigations are warranted to refine patient selection and reinjection criteria, evaluate socioeconomic impacts, and compare rectal BoNT/A injection with other therapeutic modalities.