We have read with great interest the article “Predictors of unsuccessful of treatment for fecal incontinence biofeedback for fecal incontinence in female” by Murad-Regadas SM et al.(1). We congratulate the journal and the Authors for the publication of a paper on the indications, outcomes and modality of biofeedback treatment in patients with fecal incontinence. In the article, the Authors underlined and discussed the several causes of fecal incontinence, such as anatomical causes, sphincteral damage, neurological dysfunction and idiopathic disease, and moreover, admirably highlighted the potential predictive factors of efficacy of biofeedback treatment. Murad-Regadas and colleagues, as commonly happens, stratified patients on the basis of a clinical score (Clevaland Clinic Fecal Incontinence score), assigned them a continence level and selected patients to candidate to rehabilitative treatment as biofeedback. It is well known that biofeedback treatment allows, through a probe, a device and a dedicated monitor, the visualization and representation of the contraction and relaxation activity of the anal sphincter. It is worth to comment that, before beginning any kind of biofeedback or rehabilitative treatment, the physicians have to assess and verify the patient’ proprioceptive consciousness of the anal sphincter, namely the capacity of select it for the contraction. The authors, in their coloproctological evaluation, along with the Clevaland Clinic Fecal Incontinence score, considered the anamnesis of previous anal surgery, of hysterectomy and of previous vaginal deliveries; all predictive factors influencing the effectiveness of the rehabilitative treatment. Summarily, in the paper is reported that all patients were informed about the objective of biofeedback and of anatomy of the pelvic floor. Even though a such pretreatment teaching session, as reported by the Authors, is commendable and desirable, often it is not enough. The physicians, in fact, should assess the level of patients ‘acquisition of this fundamental information. The mere description of the anatomy and physiology of anal canal, i.e. that the anal sphincter contraction and relaxation obstruct and promote defecation respectively, does not imply a full comprehension and acquisition of the information. In this setting, it is of paramount Predictive parameters to identify incontinent patients amenable for rehabilitation treatment: the muscular synergies evaluation
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