Long-term results of postanal repair are poor. Many patients with neuropathic incontinence have evidence of anterior pelvic floor weakness. A more comprehensive surgical repair has therefore been developed that involves postanal repair, anterior levatorplasty, and external sphincter plication. Primary total pelvic floor repair was performed in 22 women with neuropathic fecal incontinence. Fourteen patients who remained incontinent after conventional postanal repair underwent secondary anterior levatorplasty and external sphincter plication (two stages). Neither resting nor squeeze anal pressures were influenced by any of these procedures. However, pelvic floor descent at rest and straining was significantly decreased following primary total pelvic floor repair and secondary pelvic floor repair (p less than 0.05) but not by postanal repair. Complete continence for liquids, solids, and flatus was achieved in 41% of patients after primary total pelvic floor repair and in 14% after secondary anterior levatorplasty and external sphincter plication, but in only 4% after postanal repair. Only one patient after primary total pelvic floor repair and one after secondary anterior levatorplasty and external sphincter plication had persistent incontinence compared with 18 (38%) after postanal repair.