Improving Your Bowel Function

Glossary

• symptoms - a feeling of a physical change / bothersome change
• rectum/back passage - where stool / faeces / poo is stored just before a bowel movement
• anus - the opening at the end of the rectum where the stool comes out
• incontinence - loss of urine or stool when it was not intended
• pelvic floor muscles - the group of muscles spanning the base of your bony pelvis, from the pubic bone in front to the tailbone at the back, held in place by ligaments which support the pelvic organs. Pelvic floor muscle exercises / Kegels will help keep these muscles strong
• bladder - where urine is stored until you go to the toilet to pass water/ have a pee
• vagina - a muscular tube from the external genitalia (labia and vulva) to the end of the uterus (cervix)
• uterus - the hollow organ in which a foetus / baby develops in pregnancy (sometimes called the womb)

Improving Your Bowel Function Bowel

problems can occur at any age and the type of problem you have may influence the treatment you are offered. This leaflet outlines some conservative (non-surgical) treatments you may be offered and some changes you may be able to make yourself to help your symptoms.

Certain bowel problems require immediate attention to rule out any significant pathology. If you are reading this leaflet and have not yet sought medical help for your problem, you should see your GP if you have any of the following symptoms:

• Bleeding from the bottom or blood  in your poo without any obvious reason such as local soreness, piles or a tear.  
• Any change in bowel habit that last for 3 weeks  or more, especially if    you are going to the toilet more often or experiencing unexplained looser stools or ribbon like stools.
• Any constant, unexplained pain in the abdomen especially if it is severe.
• An unexplained lump in your abdomen, especially if it is on your right hand side.
• Unexpected  weight loss perhaps due to loss of appetite or feeling bloated or sick. 
• Unexplained tiredness, dizziness or breathlessness (symptoms of anaemia).

Please note that most people with these symptoms do not have anything serious, but your GP will certainly want to examine you and may refer you or do further tests.

Normal Bowel Function

It is normal to open your bowels from between three times a day, to three times a week. Everyone’s bowel function is individual and varies with many factors, such as diet, fluid, lifestyle and age. We should all be able to:

1. have an awareness of the need to open our bowels

2. hold on to go to the toilet at an appropriate place and time

3. open our bowel completely, without straining when we sit on the toilet.

The process of digesting food we eat starts in the mouth where the food is chewed properly before arriving in the stomach.

The food is further broken down in the stomach and then passes through the small intestine where nutrients are absorbed, before moving on to the large intestine.

As food passes around the large intestine, it absorbs fluid  to become a   formed motion. The formed motion is stored in the lower part of the large intestine called the rectum until it is passed out of the body.

The stool consistency can vary depending on how long it has stayed in the rectum. Ideally this is a soft, smooth shape which is easy to pass. This relies on having good muscle function around the anal sphincters through which the passage of stool is controlled.

Common Bowel Disorders

The following types of symptoms are commonly seen:

Constipation means the bowel does not move easily or regularly. This may mean having a bowel movement fewer than every three days and the bowel motion may be hard and difficult to pass. Some people who are constipated find it painful to have a bowel movement and often describe straining, bloating, the sensation of a full bowel or a sense that the bowel has not emptied properly. To move waste through the colon we need a healthy balanced diet rich in fibre and f luids, as well as exercise. Slower passage of waste through the colon can cause the bowel motion to become dry and hard and thus more difficult to pass.

Obstructed defaecation is the inability to evacuate contents from the rectum even with excessive straining. There is often the sensation of anal blockage during defaecation and the feeling that the bowel has not emptied properly. People can describe having to use their fingers to assist emptying the bowel. This type of problem can be caused by poor muscle coordination when sitting on the toilet (sphincter muscles can tense/close instead of relax/open) or by the presence of a prolapse when the bowel motion can become trapped in a pouch/ bulge in the lower rectal wall making it difficult to empty.

Faecal incontinence is the leakage of gas, solid or liquid from the back passage due to the reduced ability to control bowel closure. Leakage can range from a smearing of underwear to loss of a full bowel motion.

Faecal urge incontinence happens when you are not able to get to a toilet quickly enough when you get the feeling of needing to go.

Passive faecal incontinence is when you are unaware of the leakage from your back passage of wind or stool.

Causes of faecal incontinence include:

1 Muscle weakness, making it difficult to hold on when you need to go to the toilet. Possible causes can be: muscle trauma e.g. childbirth, chronic constipation (straining a lot to go to the toilet) or general muscle weakness.

2 Softer, less formed motions or diarrhoea are more difficult to control and can lead to faecal incontinence. It can also be a problem to wipe clean after a bowel movement.

3 Nerve damage from local trauma or neurological conditions can cause  loss of sensation or muscle control.

Physiotherapy Management

Physiotherapy management is a “package” of care and may include biofeedback if appropriate:

Advice and education

You will be given support and information including education explaining how normal bowel function works and the common causes of bowel problems such as faecal incontinence and constipation. Pictures, models and other visual aids may be used to help you improve your understanding of your symptoms.

Life-style modification

You will be advised on ways to adjust your life-style in order to help manage your bowel symptoms.

This may include advice on; stopping smoking, type and level of exercise and anxiety management e.g. mindfulness or Cognitive Behavioural Therapy.

Diet

This is a key component in helping improve bowel management, whatever your symptoms.

It can be difficult to work out which food types affect your bowels. It is important to remember that each individual varies enormously in their response to diet and what works for you may not work for someone else, even if they suffer the same symptoms.

You may be asked to complete a food and fluid diary which means recording what you eat and drink, alongside your bowel activity, every day for at least a week. This will then provide valuable information from which your physiotherapist may make some suggestions to changes to your diet and fluid intake which may help relieve your symptoms.

The aim is to achieve a normal bowel motion which is a soft smooth shape and easy to pass.  A motion which is too hard, like small round pellets, is  much more difficult to pass and a motion which is too soft or loose, with no formed shape, is more difficult to control and wipe clean. By changing what we eat and drink we can influence the type of motion produced and help symptoms.

Onward referral to a Nutrition and Dietetic specialist can sometimes be   appropriate.

Pelvic Floor Exercises

The pelvic floor muscles act like a hammock to support the pelvic organs. Pelvic floor muscle exercises will also strengthen the anal sphincter muscles. These exercises will improve pelvic organ support, continence and sexual function.

Pelvic floor muscle exercises (sometimes called Kegels) should include long squeezes as well as short, quick squeezes. You should work the muscles until they tire and do the exercises regularly to help the muscles become stronger and more effective.

Imagine that you are trying to stop yourself from passing wind at the same time as trying to stop passing urine. You should feel a squeeze and a lift    inside. Do not hold your breath.

Long squeezes

• Tighten    your    pelvic    floor    muscles,    hold    them    tight,    then    release    and    let    them    fully relax. How    long    can    you    hold    the    squeeze?   
• Repeat    the    squeeze    and    hold    until    the    pelvic    floor    muscles    tire. How    many    times    can    you    repeat    the    squeezes?    

Short squeezes

• Quickly    tighten    your    pelvic    floor    muscles,    then    immediately    let    them    go    again.    How    many    times    can    you    do    this    quick    squeeze    before    the    muscles    get    tired?    
• Always    let    the    muscles    fully    relax    after    each    squeeze.    

Pelvic Floor Muscle Exercises 

• Aim    to    do    10    long    squeezes,    holding    each    for    10    seconds,    relax    the    muscles    for    10    seconds    then    do    10    short    squeezes
• You    may    need    to    start    with    ‘little    and    often’    if    you    find    that    you    can    only    hold    the    squeeze    for    a    short    time,    or    only    do    a    few    before    the    muscles    tire
• You    should    do    your    pelvic    floor    muscle    exercises    at    least    3    times    each    day.    You    may find it easier to start your programme when you are sitting or lying down.
• Build    up    your    exercise    routine    gradually    over    the    next    few    weeks    and    months.    You    should    notice    an    improvement    in    3    -    5    months    and    then    keep    practising    your pelvic floor muscle exercises once a day to maintain the improvement
• As    your    muscles    improve,    aim    to    do    your    exercises    in    other    positions    such    as    standing up. Eventually you can practise these exercises whilst doing activities such as walking and bending

The Knack

Draw  up  and tighten your pelvic floor muscles before any activity which   increases the intra-abdominal pressure, such as coughing or lifting to help the pelvic floor resist the downward movement of pelvic organs.

It is important that you do your pelvic floor muscles exercises correctly. If you are having difficulty ask to be referred to a specialist physiotherapist for proper assessment, and further advice (see inside back cover).

Defaecation Techniques

You may be taught simple ways to enable you to pass a stool without straining. This involves adjusting your posture on the toilet and using special breathing patterns to keep you relaxed and improve the efficiency of your bowel movement.

It is important to avoid constipation. This puts extra strain on the pelvic floor muscles and can worsen prolapse symptoms. Eating plenty of fruit, vegetables and fibre can help. Make sure you are also drinking enough (between 1.5 to 2 litres of fluid per day).

• Do not strain
• Sit fully on the toliet: do not 'hover'
• Have your feet apart and raised up on a stool/support with your arms resting comfortably on your legs
• Keeping your tumming relaxed; don't tighten your absominal muscles
• Avpid breath holding; try to have a relaxed breathing pattern
• A slight bearing down will help the stoll to open the back passage for the bowel movement

Some women may find it helpful to support the perineum (the area between the anus and the vagina) when emptying their    bowels.    Applying    some    pressure    vaginally on the bulging wall towards the back passage may help to empty the bowels more fully and effectively. 

Holding On Programme

This is a technique whereby you are taught to increasingly resist the urge to open your bowels in a safe environment, in an effort to overcome faecal urgency.

Start by using your pelvic floor muscles and try to hold on for an extra few seconds the next time you need to empty your bowels. Try to see if this can allow you to then walk calmly to the toilet and not feel rushed. Gradually try to increase how long you can hold on and thereby regain greater control of the back passage muscles.

It can also help relieve faecal incontinence by teaching you to “hold on” for longer and more successfully. This focuses on effective use of the pelvic floor muscles.

Biofeedback

Biofeedback is the process by which we relearn bodily functions that were previously performed at a subconscious level.

There are several different types of biofeedback:

Computer Assisted

An    electrode    is    placed    in    the    rectum    to    record    the    signal    produced    as    the    pelvic    f loor muscles contract and relax. You would not expect to feel any discomfort during this process.

The resulting trace on the screen helps you to retrain the correct muscle technique.

Sensory Rectal Balloon Catheter Retraining

A small rectal balloon catheter is inserted into  the back passage. The    balloon is then inflated slowly, mimicking a stool arriving in the rectum, which creates the initial urge to open your bowels. This method is a useful way of retraining many aspects of normal bowel function.

Pelvic Floor Muscle Stimulation

This is where pelvic floor muscle contractions are stimulated via an electrode in the back passage.

Further Management

Medication

A    review    of    your    current    medication    with    your    GP    or    Pharmacist    may    identify    whether these are contributing to your bowel symptoms.

There are several types of medications which act in different ways to help relieve bowel symptoms.

Laxatives/stool modifiers and anti-diarrhoeal medications should be not be considered for long term use unless prescribed by your GP.

Ano-rectal Irrigation

A    variety    of    irrigation    systems    using    warm    water    are    available    to    stimulate    more    complete and effective evacuation by flushing out the lower bowel.

Additional Help

Various devices are available which are designed specifically to help you develop practical coping strategies on a daily basis. This helps you to feel more confident with your bowel management.

Containment products such as anal plugs/inserts can reduce the risk of faecal leakage.

The skin around the back passage is best washed with warm water only. Barrier creams can help prevent irritation around the back passage. Skincare products may be discussed further with your physiotherapist, GP or local pharmacist.

Other aids and toilet adaptations are also available.

Getting help

If you have any difficulty with the exercises in this booklet, or find that your symptoms are not improving, ask to be referred, or if available, refer yourself to a physiotherapist with experience in treating women with pelvic floor muscle problems.

To find your nearest specialist physiotherapist visit: thepogp.co.uk/patients/physiotherapists/ 

Women with complex needs

If your ability to follow the advice in this booklet is affected by any health problem we suggest that you contact your local specialist women’s health physiotherapist, who will be able to assess you and offer specific alternatives, suitable for your needs.

Other relevant booklets are available from: thepogp.co.uk

Further information and resources

• https://thepogp.co.uk/patient_information/pelvic_health_advice.aspx
• http://www.nhs.uk/conditions/incontinence-bowel/Pages/Causes.aspx
• https://www.bladderandbowelfoundation.org/bowel/bowel-problems/
• www.theibsnetwork.org
• www.wcrf-uk.org
• www.beatingbowelcancer.org