Lets talk about Faecal incontinence (FI) in Scleroderma

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1 Lets talk about Faecal incontinence (FI) in Scleroderma Dr. Shamaila Butt Gastroenterology Research Registrar GI Physiology unit University College Hospital London

2 GI manifestations in Scleroderma Oesophagus 70-90% Stomach up to 50% Intestine 20-50% Anorectum 50-70%

3 Faecal Incontinence Involuntary loss of faeces Can affect up to 40% of patients with scleroderma

4 Faecal incontinence can be a devastating problem. It can disable patients socially and psychologically

5 Faecal Incontinence can have an adverse effect on quality of life can cause severe social restriction is a stigmatising condition

6 Faecal Incontinence causes UCH data

7 Why does this happen in Scleroderma? There are two muscles involved in continence These are in the anal canal 4cm in length

8 Anal Canal 1. External sphincter Used on demand to preserve continence

9 Anal Canal 2. Internal Sphincter Unconscious control and responsible for 80% of resting continence

10 Internal Sphincter In scleroderma the disease process causes the internal sphincter Muscle is thinned Nerves controlling the sphincter are damaged

11 Faecal incontinence Symptoms Notice soiling of underwear Usually a surprise can also be on rushing to toilet urge incontinence Affects work wear dark trousers, wear pads Embarrassed

12 Can be exacerbated by other factors Not only does scleroderma affect the sphincters Diarrhoea Constipation Delivered a baby injury to sphincters Rectal prolapse Age your sphincters thin as you get older

13 Don t suffer in silence!

14 What you should do Inform your GP or Rheumatology doctors/nurses Treat possible causes Medications causing diarrhoea/constipation Referral to Gastroenterology

15 Friendly Gastroenterologist Clinic assessment Medical history, examination Assess impact on your life Arrange appropriate investigations which may include: Physiology MRI proctogram Endo anal Ultrasound

16 Physiology This examines the nerves and muscles in the anal canal Determines how well these work

17 Physiology Water perfused catheter Internal Sphincter External Sphincter

18 Normal physiology trace

19 MR proctograms Gives an anatomical view of stool passage from the rectum Demonstrates abnormalities in Pelvic floor that can cause faecal incontinence Eg Rectal Prolapse

20 MR proctogram Bladder Rectal prolapse

21 Endo-anal USS Looks at the structure of muscles in anal canal

22 Endo-anal ultrasound demonstrating an intact internal and external anal sphincter Internal sphincter External sphincter

23 Scleroderma Internal Sphincter Thinned Internal Sphincter

24 Treatments for Scleroderma FI Can include Medications Trials of Loperamide Biofeedback therapy Nerve modulation SNS PTNS

25 Loperamide Aka Imodium over the counter Can give temporary relief Problems Can make constipation worse

26 Biofeedback Therapy Bowel and muscle retraining programme Nurse specialist led The therapy involves teaching you how to retrain the muscles used to empty and control your bowels

27 Nerve Modulation: Sacral Nerves These are in the bottom of your spine Involved in the control of your bowel and continence

28 Nerve Modulation Stimulating these nerves by implanting a device has shown some encouraging results in Scleroderma Faecal incontinence1 SN S Problems: major operation / 1Kamm GUT 51 (6) inpatient stay

29 Better way to stimulate these nerves No operation necessary Stimulate these nerves externally using an electrical device

30 Posterior Tibial Nerve Stimulation (PTNS) An electrode is placed on a nerve in the leg -the posterior tibial nerve Connected to the sacral nerves Stimulated for 30 mins Weekly for 12 weeks

31 Posterior Tibial Nerve Stimulation PTNS Already used in Bladder incontinence because of well established trials confirming benefit See a benefit in faecal incontinence due to other causes e.g child birth injuries/ nerve injuries Our department has seen promising preliminary results already with Scleroderma patients having PTNS

32 We now need trial evidence to confirm PTNS benefits Scleroderma faecal incontinence

33 This is where I come in. Scleroderma clinic Thursdays.. A randomised trial of PTNS for faecal incontinence and constipation in scleroderma

34 Male or female No age limit Participants Symptoms of incontinence ± constipation Trial duration is 12 weeks

35 If you participate. A full assessment of your faecal incontinence/constipation symptoms Benefit improvement in your faecal incontinence!

36 If you are interested in participating Please approach me today for more information in clinic all day Thursdays GI physiology Secretary You can me on