To the Editor-We read with great interest the recent article by Dawes et al, 1 who reported that sacral nerve stimulation for fecal incontinence in patients with rectoanal intussusception led to a significant improvement in incontinence and quality-of-life scores. This differs from the results of our study that found no such improvement. 2 Dawes et al stated that the conflicting results arose as we focused on test stimulation only-this is incorrect. Our study was designed on an intention-to-treat basis and looked at all patients who underwent a trial stimulation and permanent device implantation. The failure of Dawes et al to include the trial stimulation phase and document the subsequent success rate is a limitation of their study.In contrast, we attribute the differing outcomes to the ratio of patients with grade 3 versus grade 4 prolapse. Each study combined the 2 grades into a single group. Analysis of our unpublished data set revealed an even distribution of grade 3 and grade 4 prolapse, whereas the Dawes et al cohort consisted primarily of grade 3 prolapse, with only 17% of patients having grade 4 prolapse. This understandably influenced the outcomes of each study.Perhaps a safer conclusion in the Dawes et al article would be that sacral nerve stimulation is successful in grade 3 prolapse, but further evaluation is required to determine its effectiveness in grade 4. Ultimately, future work should be looking to separate these 2 grades when investigating rectoanal intussusception.