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Background Fecal incontinence (FI) is under-treated in elderly women in rural areas due to limited access to healthcare resources. Sacral neuromodulation (SNM) of the third sacral nerve (SN3) is a novel treatment option for FI. This retrospective study evaluates the efficacy and safety of SNM for severe refractory FI in elderly women in a rural community in Texas, United States.Methods This is a retrospective analysis of FI questionnaires given to elderly women before and after undergoing SNM within two years in a rural community in Texas. The questionnaires assessed the frequency (never = 0 points, rarely = 1 point, sometimes = 2 points, usually = 3 points, and always = 4 points) of 5 types of FI (solid, liquid, gas, wearing pads, and lifestyle changes). Pre- and post- SNM scores were compared using a T-test analysis; p<0.05 indicated statistical significance.Results Twenty consecutive women of an average age of 72.35 years (59-89, SD 7.88) completed the peripheral nerve evaluation and underwent permanent implantation of SNM (Axonics, Irvine, California) of the bilateral SN3 foramina. All patients had failed conservative treatments (fiber supplements, medications, lifestyle changes). No incidences of complications required the removal of the implanted device. Pre-SNM average score was 12.70 (8-20, SD 3.39). Post-SNM average score was 3.75 (0-8, SD 2.07). T-value was 9.82 (95% CI 7.15-10.75), p<0.00001.Conclusions FI affects 24% of women over 40, significantly impacting their quality of life. Current treatment options are limited with poor long-term efficacy. Our study shows that SNM is an effective and safe treatment for elderly women with severe refractory FI, resulting in significant improvement of FI symptoms with no serious complications. SNM should be considered for elderly women with severe refractory FI.