OBJECTIVES: To evaluate the cost-utility of including sacral nerve stimulation (SNS) in different treatment pathways for refractory fecal incontinence (FI). METHODS: The treatment pathways of two populations, with a surgically repairable sphincter defect (SD) and without (WSD), were modeled through a patient-level simulation model. Three comparators to SNS were included: sphincter repair (SR), NASHA/Dx and percutaneous tibial nerve stimulation. Colostomy or conservative treatment were modeled as last resort. Clinical data were based on a systematic literature review and expert opinion (EO). Resource use was based on EO, whilst cost data were based on hospital costs and national tariff lists (GBP 2015-16). The UK NHS perspective (threshold: 30,000 GBP/QALY) and a lifetime horizon were adopted. RESULTS: For SD patients, the most effective treatment pathway was SNS followed by SR, however it was not cost-effective vs SR followed by SNS (ICUR = 44,562 GBP/QALY). Adding SNS after or before SR was cost-effective vs SR only. In case of SNS used after SR the gain in QALY was equal to 0.48, with ICUR equal to 5,607 GBP/QALY. Adding SNS before SR corresponded to a QALY gain of 0.62, with ICUR 14,357 GBP/QALY. The most cost-effective treatment pathway for WSD patients was NASHA/Dx followed by SNS, with a maximum ICUR of 5,928 GBP/QALY vs the other treatment pathways analysed. In comparison with treatment pathway excluding SNS, 0.55 QALY are gained. CONCLUSIONS: SNS is a relevant treatment for FI in patients who have failed conservative management. Including SNS into the treatment pathway for refractory FI may provide value-for-money in the UK NHS perspective.