Managing bowel late effects after pelvic radiotherapy

Bleeding from the bowel Back to top

Bleeding from the back passage (rectum) after radiotherapy is common, but it’s usually mild and often doesn’t need treatment. Bleeding sometimes improves gradually and can stop on its own after a few years. Men who are taking blood thinning medicines, such as aspirin or warfarin, may have heavier bleeding.

Bleeding may not always be a result of previous radiotherapy. It can be caused by piles (haemorrhoids) or straining on the toilet. But even if you think you know the cause, always tell your cancer doctor or nurse specialist if you have any bleeding from the back passage. It’s important to find out the cause and to rule out serious problems. Your doctor will do an examination of your back passage and may refer you to have a test to look at the inside of your rectum (an endoscopy).

Treatment

If bleeding is minor and manageable, you probably won’t need any treatment. You’ll be given advice about your bowel habits to help minimise the bleeding and avoid constipation|.

If the bleeding is interfering with your day-to-day life or if you have become anaemic (when your body produces fewer red blood cells), you’re likely to need treatment. If you’re taking blood-thinning drugs, your dose may be reduced and monitored. Your doctor or specialist nurse will explain more about your treatment options and give you more detailed information.

The most commonly used treatment for bleeding from the rectum is a drug called sucralfate (Antepsin Suspension®), given as an enema. An enema is an injection of fluid into the rectum. Sucralfate works by coating the lining of the rectum, reducing inflammation and encouraging healing. It’s important to avoid constipation when you’re being treated with sucralfate.

A drug called formalin is also helpful for some people. It works by sealing the bleeding blood vessels. Your doctor can give it to you through a thin, flexible tube with a light on the end (endoscope), which is passed into the bowel. You can also have it done under a general anaesthetic.

If bleeding is higher up in the large bowel (colon), or isn’t reduced with enemas, other treatments may be helpful:

Argon plasma coagulation

This treatment directs heat at areas that are bleeding and is given during an endoscopy. The heat seals the blood vessels and destroys damaged tissue. Doctors don’t yet know how successfully this treats heavy bleeding. There’s a risk of complications, such as serious tissue damage, with this treatment. Your doctor will discuss this with you.

Hyperbaric oxygen therapy (HBO)

HBO| works by increasing the amount of oxygen reaching tissue that’s been damaged by pelvic radiotherapy. This can encourage new blood vessels to grow and may help tissues heal. Treatment takes up to eight weeks. This treatment isn’t widely available, so you may need to travel some distance for it.

Tenesmus Back to top

Tenesmus is the feeling of needing to go to the toilet often, although your bowel is empty. It can involve straining, pain and cramping. It’s probably due to cramp (spasms) in the muscles that stimulate the bowel, as radiotherapy can affect them.

The spasms can often be controlled by:

• doing pelvic floor exercises
• taking extra soluble fibre to bulk up the stool
• taking very low doses of certain antidepressant drugs.

Sometimes tenesmus can be caused by constipation. It’s also sometimes caused by a non-cancerous growth (a polyp) in the bowel, or it can be caused by a cancer. Your doctor will examine your back passage and may arrange for you to have a test, called a flexible sigmoidoscopy, to look at the rectum and lower part of the large bowel.

Fissure Back to top

After radiotherapy, some men develop a split in the skin (a fissure) where the back passage opens to the outside of the body (anus). It can cause very sharp, intense pain when you pass a stool (bowel motion). Your doctor will usually prescribe creams that you can apply to the area. It’s important to avoid constipation|, as this can make the fissure worse. Your doctor may prescribe a laxative to make it easier for you to go to the toilet.

If the fissure doesn’t improve, it can be treated with injections or botulinium toxin A (Botox®), which are given into the tissue lining the anus.

Bowel control problems Back to top

Feeling that you can’t wait when you get the urge to open your bowels can be stressful, particularly when you’re away from home. You may sometimes have leakage (incontinence). The degree of incontinence varies. You may just have a small amount that causes some staining on your underwear. But occasionally men may have an accident and leak a larger amount of stool. Although you might find this difficult to talk about, it’s important to let your doctor know as there is a lot that can be done to help.

What can be done

If you have bowel control problems, such as urgency, leakage, diarrhoea or constipation, there are several things that can help. The best way to manage any bowel control problems depends on the symptoms you have and what’s causing them, so it’s important you’re properly assessed. If your symptoms don’t improve, ask your GP to refer you to a gastroenterologist, a specialist nurse or a continence adviser for advice.

The most common methods of improving bowel control include:

• making changes to your diet
• using medicines to slow the bowel down
• strengthening the muscles used for bowel control.

Diet

What you eat affects your bowel. For example, fatty or spicy foods, or too much or too little fibre, can stimulate the bowel, making it more difficult to control. Ask your doctor to refer you to a dietitian for expert advice on managing your diet. If you’re losing weight because of bowel problems, it’s important to see a dietitian.

Foods affect people differently, so there may be some trial and error before you work out what’s best for you. Try to find out which foods cause constipation or make your bowel motions loose. You may be able to eat less of them without cutting them out altogether. Caffeine, alcohol and artificial sweeteners can also cause problems.

The food guide| below gives information about foods that can cause or improve bowel problems.

Some supplements (such as the mineral selenium, which is only needed in small amounts), can cause diarrhoea.

Fibre

Fibre is important in regulating how your bowel works. There are two types of fibre:

• Insoluble fibre, which is is found in bran, seeds, and multigrain, wholemeal or wholegrain foods, such as bread or cereals. It helps with managing constipation, but can also help with other bowel problems.
• Soluble fibre, which helps to bulk up and slow down bowel movements, so may help to reduce diarrhoea or soft stools. It’s found in oats, porridge, bananas, and in apples and pears with their skins removed (the skins contain insoluble fibre). Pulses, such as baked beans and lentils, are also high in soluble fibre, but they stimulate the bowel so aren’t recommended for people with diarrhoea or soft stools.

Your specialist nurse, continence adviser or gastroenterologist (if you’re seeing one) will advise you on the type of fibre you need and how much you should have.

If you’re adding fibre to your diet, do it gradually to give your body time to adjust. Start with small amounts and slowly increase the amount when you’re ready. Make sure you drink more water.

Adding more fibre won’t be right for everyone. After pelvic radiotherapy, you may not be able to cope with as much fibre in your diet as before. So ‘five a day’ won’t always be appropriate. Some high-fibre foods make the bowel produce a lot of gas (wind|). You may need to avoid these if wind is a problem for you.

Fibre supplements

Soluble fibre supplements, such as Normacol® (an insoluble fibre), are often prescribed for people who have frequent bowel motions or incontinence. They’re also used to prevent constipation. They work by absorbing water and expand to fill the bowel, making the stools bulkier and easier to push out. Fybogel® is another fibre supplement, but it makes the bowel produce a lot of gas (wind). Nomacol is often a better option. You can buy some fibre supplements at the chemist, or your doctor can prescribe them. Always make sure you’re drinking plenty of fluids each day (at least two litres) when you’re taking fibre supplements.

Food intolerance

Sometimes, radiotherapy can affect how well your bowel copes with certain food types, such as:

• lactose, which is found in dairy products
• fructose, a fruit sugar sweetener often found in products labelled ‘no added sugar’
• gluten, a wheat-based protein found in breads, cakes, biscuits and pasta.

Symptoms of food intolerance may include tummy cramps, feeling bloated and increased wind after eating a particular food. If you think you may have a food intolerance, ask your GP to refer you to a gastroenterologist.

Anti-diarrhoea drugs

If changes to your diet aren’t enough to control bowel problems, anti-diarrhoea drugs may help. It’s important to speak to your doctor or specialist nurse before taking any medicines.

The most commonly used treatment is loperamide (also called Imodium® or Diareze®). It slows down your bowel, making the stools more solid and less frequent. Taking loperamide regularly, half an hour before meals, works very well for some people. It’s safe to take it for as long as you need it, but discuss this with your doctor. The dose you take may need to be adjusted until you find what works best for you. Your doctor may recommend starting with a low dose and increasing this until it’s right for you. Loperamide is also available as syrup, so you can take less and adjust the dose as needed.

Other anti-diarrhoea tablets, such as codeine phosphate or diphenoxylate (Lomotil®), can also be prescribed. Your doctor or a continence adviser can advise you about the medicines that may be best for you.

Sometimes, low doses of anti-depressant drugs are prescribed to help slow down the bowel.

Ongoing diarrhoea

If you have diarrhoea and changes to your diet and anti-diarrhoea drugs don’t help, ask your doctor to refer you to a bowel specialist (a gastroenterologist). A number of things can cause diarrhoea, and a gastroenterologist will be able to assess the exact cause.

Radiotherapy can cause other conditions that can lead to ongoing diarrhoea: bile acid malabsorption and small bowel bacterial overgrowth.

Bile acid malabsorption

Normally, bile acids are made in the liver and transported to the small bowel to help us digest fats. They are then absorbed back into our system. Sometimes radiotherapy damages the small bowel so it can’t reabsorb the bile acids (malabsorption). This leads to diarrhoea.

Bile acid malabsorption can be diagnosed using a scan called a SeHCAT scan. Your doctor can tell you more about this. It’s helpful to have the scan before treatment, to confirm the diagnosis and the extent of its effect on you. If you have bile acid malabsorption, you’ll need to take a drug for the rest of your life to treat it, and/or stick to a low fat diet. So it’s important to get the diagnosis right.

Bile acid malabsorption can be treated with a drug called colestyramine (Questran®). It comes as a powder that you mix with water or fruit juice. Most specialists advise taking it at meal times, rather than on an empty stomach (as the instructions say), because they think it works better and is easier to take this way.

If your stool is sometimes pale, smelly and difficult to flush away, Questran may not work or may make things worse. If this happens, your specialist may prescribe a newer medicine, called colesevelam (Cholestagel®). You may also be referred to a dietitian for advice on managing a diet that’s lower in fat.

Small bowel bacterial overgrowth

A healthy small bowel contains almost no bacteria, although the large bowel contains lots of healthy or ‘good’ bacteria, which help us digest food. After pelvic radiotherapy, bacteria sometimes grow in places in the small bowel where there shouldn’t be any bacteria. These can cause a number of symptoms, but the most common is diarrhoea. Other symptoms include fatty stools, wind, bloating, constipation, feeling sick, vomiting or bad breath.

Small bowel bacterial overgrowth is usually treated with antibiotics.

Greasy and pale stools Back to top

Some men notice that, when their bowel motions are loose, they are also paler than usual and much more smelly. The stool may float and be more difficult to flush away, and there may be a film of oil on the toilet water. This is called steatorrhoea.

If you have these symptoms, you need to ask to be referred to a gastroenterologist, who should be able to help you. Steatorrhoea can usually be treated effectively.

It can be caused by:

• small bowel bacterial overgrowth
• bile acid malabsorption
• too much fat in the diet
• a lack of proteins (enzymes) normally made by the pancreas to break down fat.

Strengthening the muscles used for bowel control Back to top

Pelvic exercises| to strengthen the muscles used in bowel control can help you manage urgency, leakage and incontinence. Some men find they also help with wind|, bowel cramps and tenesmus|.

The exercises work the muscles around the back passage (anus) and a deeper layer called the anterior pelvic floor muscles. These muscles also help with bladder control and are used in sex.

Ask your doctor to refer you to a continence adviser to teach you how to do the exercises correctly.

The Bladder and Bowel Foundation| also produces a fact sheet with instructions on how to do these exercises.

It’s important to:

• do your pelvic floor exercises correctly, otherwise they won’t work
• practise regularly to build up your muscles (aim for three times a day)
• keep to a healthy weight, as being overweight puts extra stress on the pelvic floor muscles.

You need to do your exercises for at least three months to properly strengthen these muscles.

Biofeedback training

Normally our pelvic floor muscles work without us consciously controlling them. As a result, you may find it difficult to know if you’re doing the exercises correctly.

Biofeedback training| can help you with your pelvic floor exercises and bowel control. Your continence adviser can advise you on where you can get this training.

Other things you can do

In addition to making changes to your diet, taking medicines to slow your bowel and doing bowel control exercises, there are other things you can do to improve bowel control. Your doctor, specialist nurse or continence adviser can advise you about these.

Some of the following may also help:

• Keep a diary of your bowel habits to help your specialist work out what might help you.
• Try to go to the toilet at regular times each day - eating triggers bowel movement for many people, so this may be after meals.
• If you feel you need to go to the toilet several times a day, practice holding the stool. Over time this will help to increase the amount of stool your bowel can hold.
• Find ways of reducing stress.
• If you smoke, try to stop, as smoking stimulates the bowel.
• If you’re taking other medicines, ask your doctor or nurse if they could be making bowel problems worse - they may be able to prescribe an alternative that affects you less.

Refer to our section on coping with bladder or bowel changes| for advice on skincare, going out and lifestyle changes that may help you cope.

Wind Back to top

After radiotherapy, some men have more wind because their pelvic floor muscles are weaker. Although it can be an embarrassing problem, you may be more aware of it than people around you.

The amount of wind we produce is the result of how healthy bacteria and digestive enzymes in our bowel combine with the foods we eat. Some foods, particularly high-fibre foods, such as vegetables and pulses, cause more wind than others.

Too much wind can be caused by:

• eating certain types of foods - see the food guide
• constipation
• some medicines, such as fybogel and lactulose (another fibre product called Normacol® may work as well without causing a lot of wind)
• bowel conditions (such as diverticular disease)
• small bowel bacterial overgrowth.

Some tips that may help:

• Cut down on foods and drinks that can cause wind.
• Try to have meals at the same times each day, eat more slowly and try not to swallow air.
• Avoid eating and drinking at the same time.
• Try doing pelvic floor exercises.

Some people find one or more of the following helpful in controlling wind:

• peppermint oil
• live yoghurts or probiotic drinks
• aloe vera capsules or juice
• charcoal tablets
• chewing cardamom seeds.

Food guide Back to top

The following foods may cause or help bowel problems. This is only a guide, as foods can affect people differently.

Foods that may cause wind include:

• vegetables such as sprouts, broccoli, cabbage, cauliflower, cucumber, onions, radishes, spinach and sweetcorn
• baked beans, kidney beans, lentils, chickpeas and other pulses
• nuts
• dairy products
• drinks such as beer and fizzy drinks
• chewing gum
• sorbitol (a type of sugar found in some artificial sweeteners, some sugar-free foods and in apples, pears and peaches).

Foods that may help make your stools firmer include:

• apples and pears (with their skins removed), bananas and potatoes
• yoghurt, smooth peanut butter, pretzels and marshmallows
• white bread (not a high-fibre variety), white rice (boiled) and pasta (not a wholemeal variety)
• chicken and fish.

Foods that stimulate the bowel, and make stools softer or more frequent include:

• some types of fruit (fresh, tinned or dried) - grapes, fruits with stones (such as apricots, plums, peaches and prunes), and most berries (except blueberries)
• fruit juices, such as prune, orange, apple and grape juices
• vegetables such as broccoli, sprouts, cabbage, garlic, onions, peas, peppers, spinach and sweetcorn
• beans, especially baked beans, kidney beans and chickpeas
• bran and foods high in insoluble fibre
• greasy foods and fried foods
• spices such as chilli, curry and ginger
• caffeine in coffee, tea, chocolate drinks, cola drinks and energy drinks
• nuts, linseeds and popcorn
• sugar-free foods containing sorbitol, mannitol or xylitol (such as sugar-free chewing gum, some mints, sweeteners, diet drinks and foods)
• chocolate
• alcohol, especially beer and red wine.

These foods should be limited if you have problems with diarrhoea, loose stools or frequent bowel movements. These foods may be helpful if you have constipation.

Uncommon and rare late effects Back to top

Very occasionally, men may experience other bowel problems as a result of pelvic radiotherapy.

Anal stricture

Radiotherapy may cause a tight band of scar tissue to develop at the opening of the back passage. This causes it to narrow (anal stricture). This can cause difficulty and pain when you try to open your bowels. If it’s mild, your doctor will advise you to use a stool-softener laxative or fibre supplement to make it easier to go to the toilet, which will help stretch the stricture. If the narrowing is more severe, you may be referred to a bowel specialist to have the opening stretched (dilatation) or to have an operation under general anaesthetic to cut through the scar tissue.

Ulcerated bowel

An area of bowel tissue may break down (ulcerate) and not heal. This can cause watery diarrhoea with blood or mucus in it, and pain and cramping when you go to the toilet. It’s often treated with hyperbaric oxygen therapy|.

Bowel blockage

A blockage (obstruction) in the bowel can cause sickness (vomiting), pain in the tummy and constipation. You may be given fluids through a drip to rest the bowel and treatment for constipation. Sometimes an operation to remove the blockage is necessary.

Fistula

A fistula| is an opening that forms between two parts of the body. Rarely, an opening can develop between the rectum and urethra after pelvic radiotherapy. It’s more likely to happen in men who’ve had brachytherapy| for prostate cancer after a biopsy (removing a tissue sample) of the rectum.

Hole in the bowel wall

Very rarely, a hole may develop in the bowel wall. This is called a perforated bowel. This can make you suddenly unwell and is usually treated straight away with an operation to remove the affected part of the bowel.