Faecal incontinence in systemic sclerosis: A narrative review

Although associated with impaired health-related quality of life, faecal incontinence (FI) is underscreened in cases of systemic sclerosis (SSc). Its pathophysiology is complex and multifactorial, encompassing vasculopathy, fibrosis and probably (autoimmune) neuropathy. FI prevalence in SSc seems to be 5-6-fold higher than in the age- and sex-matched general population and is severe in nearly 15% of cases. FI is associated with diarrhoea, small intestinal bacterial overgrowth, constipation, urinary incontinence, anticentromere positivity and some features of vasculopathy. FI should be regularly screened in all SSc patients. Simple self-questionnaires are useful tools, completed by meticulous digital rectal exam for anal and puborectalis tone and by neurological examination. In case of unexplained chronic constipation or diarrhoea, endoscopic explorations are mandatory first to search for organic cause. Anorectal manometry is recommended in case of suspected anorectal dysfunction. Management should be multidisciplinary and, in general, follows the recommendations applied to the general population. It consists mainly in diet and lifestyle modifications and biofeedback therapy. Loperamide or laxative/transanal irrigation could be proposed as options in case of chronic diarrhoea or terminal constipation respectively. Nerve stimulation and faecal microbiota transplantation require further studies before conclusions can be drawn.