Functional and Anatomical Analysis of the Anorectum of Female Scleroderma Patients at a Center for Pelvic Floor Disorders

Abstract

BACKGROUND: Scleroderma or progressive systemic sclerosis is characterized by a chronic inflammatory process with proliferation of fibrous connective tissue and excessive deposition of collagen and extracellular matrix in the skin, smooth muscle, and viscera. The smooth muscle most involved in scleroderma is that of the esophagus, and dysphagia is the most commonly reported symptom. However, the internal anal sphincter may also be impaired by degeneration and fibrosis, leading to concomitant anal incontinence in scleroderma patients. These patients may neglect to complain about it, except when actively questioned. OBJECTIVE: To assess anorectal function and anatomy of female scleroderma patients with symptoms of anal incontinence through Cleveland Clinic Florida Fecal Incontinence Score (CCFIS), anorectal manometry and endoanal ultrasound at the outpatient clinic of colorectal and anal physiology, Clinics Hospital, University of São Paulo Medical School (HC-FMUSP). METHODS: Female scleroderma patients were prospectively assessed and questioned as to symptoms of anal incontinence. The anorectal manometry and endoanal ultrasound results were correlated with clinical data and symptoms. RESULTS: In total, 13 women were evaluated. Their mean age was 55.77 years (±16.14; 27-72 years) and their mean disease duration was 10.23 years (±6.23; 2-23 years). All had symptoms of fecal incontinence ranging from 1 to 15. Seven (53.8%) patients had fecal incontinence score no higher than 7; three (23.1%) between 8 and 13; and three (23.1%) 14 or higher, corresponding to mild, moderate, and severe incontinence, respectively. Ten (76.92%) patients had hypotonia of the internal anal sphincter. Three-dimensional endoanal ultrasound showed tapering associated with muscle atrophy of the internal sphincter in six cases and previous muscle defects in three cases. CONCLUSION: A functional and anatomical impairment of the sphincter is an important factor to assess in patients with progressive systemic sclerosis and it should not be underestimated.

The Involvement of Smooth Muscle, Striated Muscle, and the Myocardium in Scleroderma: A Review

“…Internal anal sphincter involvement may also be present due to neuropathy or myopathy, although it is usually not reported by patients. Studies show that the internal sphincter’s function is altered, with severe hypotonia due to tissue fibrosis and excessive collagen deposition [ 70 , 77 , 78 ].…”

Too Much Information. What to Do?

“…There are current themes that deserve attention from the specialist such as intestinal constipation, swallowing, diagnostic methods of gastroesophageal reflux, proton pump inhibitors, achalasia, anorectal function evaluation. The edition consists of four reviews/updates with critical analysis of the literature (1)(2)(3)(4) and nine original works of research/standardization of study methods (5)(6)(7)(8)(9)(10)(11)(12)(13) . Particularly draws attention the medical centers involved (Faculdade .…”