Download Regaining bowel control

Regaining bowel control –
practical tips
Jacquie Peck
Julie Storrie
Regaining Bowel Control
Jacquie Peck
Colorectal and Anal Cancer Clinical Nurse Specialist
UCLH
Hepatic
Flexure – 2%
Transverse
Colon – 5.5%
Splenic flexure
– 3%
Ascending
Colon – 5%
Caecum
– 12%
Rectum
– 38%
Descending
Colon – 4%
Recto-Sigmoid
junction – 7%
Sigmoid
Colon – 21 %
The large bowel (colon and rectum)
Surgical Resection

Anterior resection
Role of the Bowel
Small Bowel
o It is responsible for
absorbing most of the
nutrients found within food.
o The stomach / duodenum
breaks food down into
liquid form.
o Nutrients come into contact
with the blood vessels
which surround the small
intestine.

o
o
This blood then leaves the
small intestine, carrying
away nutrients, water
electrolytes, vitamins,
minerals, fats and
medications to the entire
body.
It takes three to six hours
for a meal to pass from
one end of the small
intestine to the other
Role of the Bowel
Large Bowel
o to transport waste
out of the body and
to absorb water from
the waste before it
leaves. The large
bowel connects with
the small bowel to
the north and
freedom (open air) to
the south.

o When
waste first
reaches the large
bowel, it dumps into
it like sludge from a
chute. The sludge
solidifies as it
travels through the
large bowel until it
reaches the rectum.
Role of the bowel

o
o
o
o
o
Normal defecation
Rectal distension stimulates
stretch receptors
Automatic contraction of the
rectal muscle layer
Simultaneous relaxation of
the internal sphincters
Perception of descending
faeces
Conscious voluntary control
of external sphincters to
contract or relax as
necessary
Effects of Surgery



40 % of patients post
surgery will have
return to normal bowel
function
60% will experience
post-surgery bowel
dysfunction
Post-surgical bowel
dysfunction includes
urgency, diarrhoea
and constipation
Diarrhoea

Definition – state in
which a normal person
experiences a change
in normal bowel habit
characterised by
frequent passage of
loose, fluid, unformed
stools.


Other definitions
relate to the weight,
volume and frequency
of stool.
Some define it as it
being 3 or more
motions per day
Bristol Stool Chart
Type 1–2 indicate
constipation
 Type 3–4 are ideal
stools as they are
easier to pass, and
 Type 5–7 may
indicate diarrhoea
and urgency.

Causes of Diarrhoea







Resection of bowel
Intestinal failure
Crohns / Ulcerative colitis
Irritable bowel syndrome
Bile acid malabsorption
Radiation enteritis
Chronic pancreatitis





Diabetes
Hypothyroidism
Alcohol
Medications including
chemotherapy, laxatives,
antibiotics, non-steroidal
anti-inflammatory drugs,
metformin
Infection
Symptoms







Increased frequency of stool
Loose or liquid stools
Increased frequency of bowel sounds
Abdominal pain
Cramping
Urgency
Change in colour of stool
Management of Diarrhoea
–
o Regular meals
o Drink a minimum of 8 cups
of fluids per day
o Restrict tea / coffee to 3
cups per day
o Reduce intake of alcohol /
fizzy drinks
o Avoid sorbitol found in
artificial sweeteners, sugarfree chewing gum, diabetic
and slimming products
o Diet
o It
may be helpful to limit
intake of high-fibre foods
such as wholemeal or highfibre flour breads, cereals
high in bran and whole
grains such as brown rice
o Reduce intake of ‘resistant
starch’ (resists digestion in
small intestine) often found
in processed or pre-cooked
foods
o If suffering from wind or
bloating eating oats /
linseeds may help
Management of Diarrhoea
Medical Management
o Loperamide – titrate
dose until soft formed
stool (Bristol stool
scale type 4)
o Take loperamide 30 –
60 minutes prior to
meals
o Codiene phosphate –
30 – 60mg 4 times per
day

Antispasmodics
o Buscopan (hyoscine
butylbromide) – 20mg 4
times per day
o Colpermin (peppermint oil)
1 – 2 tablets up to 3 times
per day
o Mebeverine 135 – 150mg
3 times per day 20 minutes
before meals

Management of Diarrhoea
Lifestyle –
o 30 minutes of
moderate activity 5
times per week
 If medical
management is not
helping referral to
functional bowel team
should occur.

Other treatments
o Hypnotherapy
o Cognitive behavioural
therapy
o Biofeedback

Constipation

Definition –
difficulty in passing
stools or
incomplete or
infrequent passage
of hard stools
(Bristol stool scale
type 1 – 2)
Bristol Stool Scale
Type 1–2 indicate
constipation
 Type 3–4 are ideal
stools as they are
easier to pass, and
 Type 5–7 may
indicate diarrhoea
and urgency.

Causes









Bowel surgery
Diet
Age
Depression
Diverticular disease
Multiple sclerosis
Rectocele
Stroke
Dementia







Parkinsons disease
Diabetes
Irritable bowel
syndrome
Hypo and
hyperthyroidism
Medication
Chronic kidney
disease
Inactivity
Symptoms







Stomach ache and cramps
Feeling bloated
Feeling nauseous
Loss of appetite
Lack of energy
Being irritable, angry or unhappy
Foul-smelling wind and stools
Management of Constipation
Diet –
o Increase fibre to 25g
per day.
o High fibre foods
include wholemeal or
high-fibre flour
breads, cereals high
in bran and whole
grains such as brown
rice

o Increase
fluid to
minimum 8 cups per
day
o Add bran to diet
Management of Constipation
Types of Laxatives
o Bulking Agents – absorb
liquids in the intestines and
swell to form a soft bulky
stool e.g Fybogel
o Stool Softeners – help
liquids mix into the stool
and prevent dry hard stool
e.g. Milpar / docusate
sodium
o Lubricants – coat the bowel
and stool mass with a
waterproof film so stools
remain soft e.g liquid
paraffin

laxatives –
encourage bowel
movements by acting on
the intestinal wall e.g.
senna, codanthramer
o Osmotic agents – draw
water into the bowel from
surrounding body tissues,
providing a soft stool e.g.
Lactulose, Movicol
o Stimulant
Management of Constipation
Large Bowel Laxative
and small bowel
laxative
Large bowel laxative
and softener
Large bowel laxative
Step 2
Step 1
Rectal Measures PRN
Step 3
Management of Constipation
Lifestyle –
o 30 minutes of
moderate activity 5
times per week
o Toileting advice
o Address any relevant
psychosocial issues
o If medical
management is not
helping referral to
functional bowel team
should occur.

Other treatments
o Hypnotherapy
o Cognitive Behavioural
therapy
o Biofeedback

Questions
Bowel Retraining
What patients say when they
come to clinic…
• “When I feel pressure in the bowel, I need to get
to the toilet within 2 minutes”
• “I just can’t go to the toilet”
• “I can’t control them”
• “Chaos. It can go from going to the toilet all
the time to not going at all.”
• “Soiling overnight”
• “Flatulence with leakage”
Predominant symptoms following
anterior resection
•
•
•
•
•
•
Urgency
Frequency during the day and night (up to 30x a day)
Rectal hypersensitivity
Incomplete evacuation:
Stool consistency = semi-formed to loose stools
Incontinence – can be urge or passive (post anterior
resection 50% have faecal incontinence at 3 months)
Bowel retraining can address these symptoms…
With bowel retraining….
• Think: sink, plug, contents
• “Chunk” treatment
• 1st appointment – assessment and brace – for
incomplete evacuation
• 2nd appointment – sphincter exercises,
loperamide advice etc.
Assessment of symptoms and explanation
•Predominant symptom
•Frequency (day and night)
•Stool consistency
•Blood/mucus
•Need to digitate
•Incomplete evacuation
•Strain
•Pain
•Bloating
•Urgency
•Incontinence / post-defaecatory staining
•Continent of flatus
•Bowel medications
•Diet
•Skin problems around back passage
•Other information
• Use diagrams
What is “The Brace” ?
...to help improve
incomplete evacuation
BIOFEEDBACK PROGRAMME
THE BRACE TECHNIQUE
1. CHECK YOUR SITTING POSITION ON THE TOILET (SLOUCH )
Lean forward with your forearms resting on your thighs. Relax. Lower
your shoulders. Try to “let go” with all of your muscles. Breathe slowly and
gently.
2. NOW TRY TO OPEN YOUR BOWELS
Remember NOT to hold your breath ie: do not take a big breath i n first.
a) Slowly brace outwards (widen your waist). When fully braced
push/propel from your waist back and downwards into your back
passage. DO NOT STRAIN!
b) Relax for a second.
c) Brace outwards and push downwards agai n. This should be repeated.
You should be using your brace as a pump.
Remember, this will take time and practice.
Biofeedback Therapist:
Telephone Number: 020 3447 7982
Tuesdays, Thursdays & Fridays
Unit Reception Number: 020 3447 9130
Reviewed by Julie Storrie 2011
Explosive stools ? Use the
Champagne Bottle Technique
For incontinence:
•
•
•
•
•
•
•
•
•
•
•
•
•
BIOFEEDBACK PROGRAMME
ANAL SPHINCTER MUSCLE EXERCISES
WHAT ARE THE ANAL SPHINCTER MUSCLES?
The anal sphincter muscles are two rings of muscles which wrap around the anus/back passage.
The inner ring is the internal anal sphincter muscle. It should be closed at all times, except when
you are trying to open your bowels. You cannot control this muscle. The outer ring is the external
anal sphincter muscle. You can control this muscle and tighten it up to close it more firmly if you
need to.
If these muscles become weak or damaged you may be incontinent of wind or faeces. However,
exercises can help. If the internal anal sphincter muscle is weak or damaged you cannot exercise
this to strengthen it. You can exercise the external anal sphincter muscle. Exercise should make
this muscle stronger and help to prevent incontinence.
LEARNING TO DO THE EXERCISES
Sit on a chair and relax.
Lower your shoulders and breathe slowly and gently.
Imagine you are trying to stop yourself passing wind from your back passage. Try squeezing and
lifting your back passage muscle as tightly as you can. You should be able to feel the muscle
move. Try and feel your back passage tightening and being pulled up and away from the chair.
(Your buttocks, abdomen and legs should not be moving and you should not be holding your
breath!)
This is an anal sphincter muscle exercise!
Now imagine that your back passage is a lift. If you are relaxed your lift is resting on the first floor.
Pull your lift: up to second floor  up to third floor  up to fourth floor
You cannot hold that level of squeeze for very long. Relax. Now take your lift just to the second
floor. (Like a half squeeze.) You will be able to maintain the level of squeeze for longer.
•
BIOFEEDBACK PROGRAMME
•
•
•
•
ANAL SPHINCTER MUSCLE EXERCISES
•
•
•
•
1. STRENGTHENING EXERCISE
Sit, stand or lie with your knees slightly apart. Squeeze and pull up the back passage/ anal
sphincter muscle as tightly as you can. Hold tightened for as long as you can. Relax for 10
seconds.
Repeat at least 5 times.
2. ENDURANCE EXERCISE
Remember your lift. Relaxed, it is resting on the first floor. Do not pull up to the fourth floor but
rather just up to the second floor. Time how long you can hold this for. Relax for 10 seconds.
Repeat at least 5 times.
•
•
3. CO-ORDINATION EXERCISE
In quick succession pull up your muscle as tightly as you can, let go, do it again! Count how
many times you can do this before you get tired. Try for at least 5 quick pull ups.
•
Try and do these exercises a few times every day. As the muscle gets stronger you will find that
you can squeeze tighter, hold for longer and do more quick pull ups before you get tired. Get into
the habit of doing the exercises when you do something else regularly-when you turn a tap on, or
when you are in the car, waiting for the traffic lights to change from red to green!
You will need to do anal sphincter muscle exercises every day for several months before you
notice an improvement.
DON’T GIVE UP!
•
Frequency, urgency and stool
consistency
• 5-5-5 breathing technique
• Diet (caffeine, artificial sweeteners, fruit veg
and fibre, nuts)
• Loperamide advice: may need syrup – aim for
soft/firm stools
• Fybogel for some – can help to bulk stools
• Coloplast Peristeen anal plugs for passive
incontinence
One patient case scenario
• 64 year old woman
• Low anterior resection, temporary ileostomy,
chemo–radiotherapy
On assessment
•
•
•
•
Hard to Semi-formed stools 10-15 times a day
Incomplete evacuation
Urgency daily
Urge incontinence of a little stool a few times
a week
After bowel retraining
•
•
•
•
•
Soft and sometimes loose stools 1-5 times a day
Emptying a little more effectively
Urgency less frequent and less “intense”
Urge incontinence once a week
Loperamide syrup occasionally
What else ?
• Percutaneous tibial nerve stimulation
• Trans-anal irrigation
Percutaneous tibial nerve stimulation
Trans anal irrigation
Peristeen
Qufora
Thank you