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21 General introduction and outline of the thesis Pharmacological treatment of functional nonretentive fecal incontinence Unlike the pharmacological treatment of FC, the use of oral laxatives in children with FNRFI is contraindicated. 26 Oral laxatives may even increase the fecal incontinence frequency by making the stools too soft to retain. 39 Anecdotal evidence suggests that loperamide may have a beneficial role in the treatment of FNRFI. 77 As an opiate receptor agonist, loperamide decreases peristalsis and increases the internal anal sphincter tone. 39 Moreover, loperamide may improve sphincter function and thereby prevents involuntary loss of stools. When prescribing loperamide, it is important to carefully monitor patients to prevent the development of constipation. Based on scarce evidence, the antidepressant imipramine may also have a beneficial role in treating FNRFI. 78 Imipramine has an anticholinergic action, its mechanism of action may be similar to that of loperamide decreasing motility and increasing sphincter tone. However, due to cardiovascular side effects and the risk of suicidal ideation, tricyclic antidepressants should be prescribed only under close clinical supervision. 39 Transanal irrigation Transanal irrigation is an advancedmedical treatment optiondesigned to assist in evacuating stools from the bowel, it can be used in both FC and FNRFI if (non)pharmacological treatment options have failed. During transanal irrigation, water is infused into the colon through a rectally inserted irrigation device to mechanically wash out feces. If timed well and adequately performed, these washouts can induce regular emptying of the colon resulting in a continent state. Although study samples have been small, this form of colonic irrigation has been shown to be effective in the management of fecal incontinence due to constipation in children with neurogenic defecation disorders (e.g. spina bifida or Hirschsprung’s disease), anorectal malformations, FC and FNRFI. 79–89 A study on treatment efficacy and parental satisfaction in children with intractable FC treated with transanal irrigation is presented in chapter 13 . SURGICAL MANAGEMENT In severe cases of FC, when pharmacological treatments have failed, surgery is sometimes considered as a treatment of last resort. Currently, there are no evidence-based guidelines for the surgical management of FC and approaches vary between centers. In chapter 14 , we assess the diagnostic and surgical approach of pediatric surgeons and pediatric gastroenterologists towards children with intractable FC.