Northwestern University Feinberg School of Medicine Fecal Incontinence: A Primer for Individuals with Scleroderma Darren M. Brenner, MD Assistant Professor of Medicine and Surgery Northwestern University—Feinberg School of Medicine
Jun 03, 2015
Northwestern University Feinberg School of Medicine
Fecal Incontinence: A Primer for
Individuals with Scleroderma
Darren M. Brenner, MD
Assistant Professor of Medicine and Surgery
Northwestern University—Feinberg School of Medicine
Prevalence of Fecal Incontinence: General Population Versus Scleroderma
Overall prevalence of fecal incontinence: 9.0%1
Prevalence in patients with scleroderma (SSc)
22-38%2,3
*Data from NHANES 2005/2006 and 2009/2010 surveys. N=52,195.
Ditah I et al. Am J Gastroenterol. 2012;107:S717. Abstract 1762.; Omair and Lee. J Rheumatol 2013;39:992-6.; Trezza.Scand J Gastroenterol 1999;34;409-13.
Anatomy of the Anorectum
Internal Anal Sphincter
(IAS)
External Anal Sphincter
(EAS)
Rectum (Compliance)
Fecal Incontinence Subtypes
FI
Passive
Overflow
Urge
Stress
•Unconscious loss of stool
•Primarily related to IAS dysfunction
Passive FI
•Secondary to constipation/fecal impaction
•ImpactionInhibition of IAS tone
Overflow FI
•Conscious knowledge of stool loss with inability to control
•Primarily related to EAS dysfunction
Urge FI
•Uncommon and a/w (+) recto-anal gradient
Stress FI
Common Deficiencies Identified in SSc Patients
• Loss of RAIR
• Decreased Anal Sensation
• Thinning of the IAS
• Fibrosis of the IAS
• Decreased Anal Pressure
• Diarrhea/ Constipation
Thoua et al. AJG 1012:107:597-603. Thoua et al. Rheumatology 2011;50(9):1596-602. Fynne et al. Scand J Rheumatol 2011;40(6):462-66. Koh et al. Dis Colon Rectum 2009;52(2):315-18.
Indicative of Neuropathy (Functional)
Indicative of Myopathy (Structural)
Stool Characteristics
Structural and/or functional
Diagnostic Evaluation
• History
• Physical exam, including digital rectal exam
• Diagnostic tests
Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.
HistoryFecal Incontinence--Initial Clinic Visit
Onset:
Frequency:
Stool Texture: Bristol Stool Scale
Severity: (Qol)
Subtypes: Passive: Urge: Stress: Overflow: Seepage
Precipitants:
Diagnostic Testing
Physiologic Test
Measurements Evidence
Anorectal manometry1
Quantifies sphincter pressures, sensation, rectal compliance and recto-anal
reflexes
Good
Endoanal ultrasound
Assesses IAS and EAS thickness, integrity Good
Surface EMG1 Provides information on
normal or weak tone Fair
Adapted from: Rao SSC. Clin Gastroenterol Hepatol. 2010;8:910-919.
Anorectal Manometry
High-Res Manometry Catheter:• 10 distal sensors• 2 Proximal sensors
High-Def Manometry Catheter:
Resting Pressure
Normal Weak
Internal Anal Sphincter Thinning
Normal IAS Thinned IAS
Non-pharmacologic Management of Fecal Incontinence
Whitehead WE, Bharucha AE. Gastroenterology. 2010;138:1231-1235.
Intervention Mechanism of Action Side Effects Comments
Incontinence pads
Provides skin protection; prevents soiling; conduct moisture away from skin
Skin irritationDisposable provides better skin protection than nondisposable
Enemas Evacuates rectum, decreasing likelihood of FI
Inconvenient; side effects from specific preparations
Anorectal biofeedback
Improves rectal sensation; coordinates external anal sphincter contraction; may increase anal sphincter tone
None
Success is more likely if the patient is motivated, with intact cognition, absense of depression, and with some rectal sensation; availability and cost can be problematic
Pharmacologic Management of Fecal Incontinence
• Antidiarrheals
• Tricyclic antidepressants
• Bile acid binding resins
No pharmacologic treatments have been adequately evaluated in large, randomized, controlled studies in patients with fecal incontinence
No pharmacologic treatments have been evaluated in controlled studies in Scleroderma patients with fecal incontinence
Injectable Gel Treatment for FI
• Biocompatible gel of dextranomer microspheres in hyaluronic acid
• FDA-approved for the treatment of fecal incontinence in patients aged ≥18 years who have failed conservative therapy
• Administration
• Done in physician office or hospital outpatient department
• Four injections through an anoscope
• Injected into submucosal layer of the anal canal
• No anesthesia requiredSolesta [package insert]. Oceana Therapeutics, Edison NJ, 2012. Accessed April 1, 2013 at: http:www.solestainfo.com/pdf/solesta-pi.pdf
Solesta ® Injection Pivotal Trial: Primary Endpoint Data
*Responder = ≥50% reduction in incontinence episodes as compared with baseline.Graf W et al on behalf of the NASHA Dx Study Group. Lancet. 2011; 377: 997–1003.
Significantly higher responder rates in injection group at 6 months (Responder)*
52%n=136
31%n=70
0
20
40
60
80
Injection Sham
Pro
po
rtio
n r
esp
on
der
s(%
)
Median number of incontinence episodes during 2 weeks in the active treatment group decreased from 15.0(IQR 9.6–27.5) at baseline to 6.2 (2.0–15.5) at12 months (P<.0001)
P=.0089
Sacral Nerve Stimulation System
1. Tined lead is placed parallel
to the sacral (S2, S3, or S4)
nerve
2. Implantable neurostimulator
generates mild electrical
pulses that are delivered
through the lead electrodes
3. Clinician and patient
programmers are used to set
the parameters of the
electrical pulses
1
2
3
InterStim II Neuromodulator [manual]. Medtronic, Inc. Minneapolis, MN. 2012.
SNS Placement
Sacral Nerve Stimulation In SSc
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
0
5
10
15
20
25
Pre-SNSPost-SNS
• 5 women
• All failed conventional therapy
• Liquid and solid stool
• Median # weekly FI episodes=15
• Duration SSc=13 yrs
• Duration FI=5 years Kenefick et al. Gut 2002;51:81-83
Weekly Incontinent Episodes
Patient 5: lead displdged in 1st 24 hoursMax response time 60 monthsImprovements in urgency, QoLElevations in resting pressures identified
Summary
FI is a common and debilitating disorder
Due to anatomical/functional pelvic floor abnormalities and changes in stool characteristics
Types: Passive, Urge, Overflow, Stress
Diagnostics: ARM and US primary studies
Therapeutics: None a panacea but rapidly improving outcomes