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Current guidelines from the British Society of Gastroenterology concerning the management of IBD in adults1 highlight that surgery remains necessary in up to 30% of patients with UC. First described by Parks and Nicholls,2 restorative proctocolectomy with ileal pouch–anal anastomosis (RPC) has become the established operation for patients with therapy-resistant UC, indeterminate colitis, familial adenomatous polyposis and for some patients with UC-related neoplasia.3 ,4
Ethnic variations in the incidence and prevalence of IBD in the UK are diminishing.5 IBD has increased dramatically in British South Asians,6 the majority of whom are Muslim. Intestinal surgery impacts on the lives of all patients, but we wish to highlight some issues specific to the Muslim population.
Daily prayer constitutes one of the five pillars of Islam and is deemed the most important after the shahadah (declaration of faith). Muslims pray up to five times a day and hold strict hygiene requirements for their prayer. This includes washing the perianal skin (called istinjāh) after every bowel movement. Faecal seepage invalidates istinjāh, and this must be repeated in order to resume prayers. Some Muslims with a stoma avoid or reduce congregational prayers as a result of perceived inferior hygiene, fear of seepage or inadvertent passage of flatus. This causes disruption to the religious aspects of the patient's lives, diminishing self-esteem and quality of life (QoL) compared with Muslims who retain bowel continuity after colorectal surgery.7
Like most patients, Muslims may opt for an RPC to avoid a permanent ileostomy. However, feedback from Muslim patients at our institution suggests that, although providing improvements in QoL, the operation causes similar religious disruption as for Muslims with a permanent stoma, largely due to a higher frequency of defaecation and the concern of inadvertent seepage from the pouch. Perianal skin excoriation and discomfort due to higher bowel frequency may lead to repeated istinjāh, which causes further skin damage.
According to results from the UK National Ileal Pouch Registry, median frequency of defaecation after RPC is five times per 24 h, usually including one at night, and urgency is eliminated in 95% at 1 year.3 Continence is satisfactory in most patients; seepage from the pouch typically occurs in only 4% of patients during the day and in 8% at night at 1 year. This proportion rises to 7% during the day and 15% at night after 15 years.3 Although the majority of RPC patients are highly satisfied with their pouch, it is known that stool frequency, urgency, incontinence and need for medication are major determinants of QoL after RPC.8 Such difficulties are particularly troublesome for Muslim patients due to the impact on the faith-related aspects of their lives.
Fatawās (rulings from respected Islamic scholars) can provide Muslim patients with guidance on how some of the rules of ritual ablution can be adapted after stoma surgery.9 Unfortunately, religious guidance related to RPC has until now been unavailable owing to limited awareness among faith leaders of the procedure. In collaboration with our Muslim patients, and now published on the website of the newly formed Muslim Ostomy Association (http://www.muslimostomy.com), we have commissioned an ileal pouch fatwā10; this has been well received by our local Muslim pouch patients.
The fatwā permits patients with RPC to reduce their frequency of prayers to three times daily, therefore allowing a reduced frequency of istinjāh. It also permits those patients reporting perianal discomfort due to higher frequency of washing, to perform istijmaar, an alternative form of ritual ablution where tissue paper is used instead of water to provide the necessary ritual cleansing. For patients who report repeated uncontrolled seepage between prayers, the fatwā instructs them to pray despite the appearance of faecal matter. Furthermore, if faecal seepage occurs or flatus is passed during congregational prayers, then a Muslim may continue praying, where in usual circumstances, it would necessitate breaking prayer and repeating ablution. The fatwā also provides advice for those patients who have been dispirited in attending congregational prayers, by encouraging Muslims to attend the mosque if they are able to conceal either the smell or seepage, which is possible for the majority of patients.8
There are several different Islamic sects and adherents will often look for specific guidance. The Muslim Ostomy Association has published a Sunni pouch fatwā, written by renowned scholar Shaykh Dr Saalih-ibn Abdul-Azeez as-Sindee of Saudi Arabia. Shiā Muslims will only accept fatawās from an Ayatollah (high-ranking Shiā cleric) and a Shiā-specific version of the fatwā is also available on the website.
Muslims may assume that, due to the higher degree of cleanliness compared with a permanent ileostomy, RPC will cause minimal religious disruption. We recommend that our colleagues should specifically discuss the implications of RPC on religious worship with Muslims. Patients with a stoma and those considering RPC, and their doctors, can find useful advice through the Muslim Ostomy Association website.
We thank Dr Sheikh As-Sindee of Madinah University Saudi Arabia, for the pouch fatwa; Sheikh Abul Abbass Naveed Ayaz for translating the Arabic text into English and Prof John R Nicholls for editorial consults.
Contributors FI—concept, design and writing; SZ—design and writing; DMB—review and edit of final manuscript; and CJV—review and edit of final manuscript.
Competing interests All authors have completed the Unified Competing Interest form and declare no support from any organisation for the submitted work and no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years. FI, SZ and DMB are founding trustees of the newly founded charity, Muslim Ostomy Association. FI holds a project grant from the Ileostomy and Internal Pouch Association to investigate QoL outcomes between ileal pouch and permanent stoma in Muslim patients.
Provenance and peer review Not commissioned; internally peer reviewed.
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