Invited commentary

More needs to be known about the pathophysiology of incontinence, the role of the pelvic floor and anal sphincters [21, 22], the most useful tests, and the pharmacology of the anal sphincters [23]. Patients need to be carefully characterized in clinical trials and in practice, and covariates must be included in the appraisal of therapeutic efficacy. Methods to deliver nonoperative treatment and to measure the outcomes of treatment need to be improved and standardized to permit meaningful, large, randomized controlled trials. The clinician is left with few evidenced-based options. Alas, the patient is left with the frustration and embarrassment of a socially stigmatizing disorder that may, indeed, be devastating and costly in the absence of suitable reimbursement for the therapist-intensive biofeedback. As Sir Winston Churchill stated in a speech at the height of the devastation of London in 1942: Now this is not the end. It is not even the beginning of the end. But, it is, perhaps, the end of the beginning.