Managing bowel control problems

Many bowel control problems can be managed or treated successfully. It’s important to talk to your doctor if you’re having problems. They can assess you and advise you on what may help.

They may suggest taking medicines to slow down your bowel, making changes to your diet or doing exercises that strengthen the muscles used in bowel control. Your emotions can affect your bowel control too. Managing stress and learning to relax may help to settle your bowel.

Some people are taught how to retrain their bowel by resisting the urge to empty it straight away. Your doctor, specialist nurse or continence specialist can give you advice about this.

If your bowel control problems don’t get better with these treatments, your doctor can refer you to a bowel specialist (gastroenterologist). Keeping a daily record of your bowel habits and what you eat can help your specialist to work out what might help you. They may also arrange for you to have tests so that they can give you the treatment that is best for you.

Bowel control problems

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). You may just have a small amount that causes some staining on your underwear. But occasionally some people 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 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 continence adviser for advice.

The most common methods of improving bowel control include:

  • changes to your diet
  • 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.

See our food guide for 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 helps with managing constipation, but can also help with other bowel problems. It is found in bran, seeds, and multigrain, wholemeal or wholegrain foods, such as bread or cereals.
  • Soluble fibre 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® or Fybogel (soluble 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. Some people find Fybogel®, can make the bowel produce a lot of gas (wind). 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.

Sometimes doctors prescribe other types of anti-diarrhoea tablets, such as codeine phosphate or diphenoxylate (Lomotil). Your doctor or a continence adviser can advise you about the medicines that may be best for you.

Doctors can also prescribe low doses of anti-depressant drugs 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 do a full assessment.

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

Bile acid malabsorption

Bile acids are made in the liver and travel 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.

A bowel specialist can diagnose bile acid malabsorption 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.

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. But 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 stool, wind, bloating, constipation, feeling sick, vomiting or bad breath.

You will usually have a breath test to find out if you have small bowel bacterial overgrowth. You can have the test as an outpatient and it takes around 2-4 hours. Your doctor or nurse can explain more about the test.

Small bowel bacterial overgrowth is usually treated with antibiotics.


Medicines that can increase bowel symptoms

Some medicines can make bowel symptoms such as wind or frequent bowel motions worse. These include:

  • non-steroidal anti-inflammatory painkillers (NSAIDs), such as ibuprofen and diclofenac
  • magnesium in antacids (for heartburn)
  • lactulose and Fybogel
  • metformin – a tablet used to treat diabetes
  • beta-blockers – tablets to treat high blood pressure
  • antibiotics
  • some types of antidepressants such as venlafaxine and citalopram.

If you’re taking any of these drugs and think they may be making your symptoms worse, talk to your doctor about whether there are any alternative drugs that might affect you less.


Strengthening the muscles used for bowel control

Exercises to strengthen the muscles used in bowel control can help you manage urgency, leakage and incontinence. They may 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. You can read more about pelvic floor exercises in our section on bladder changes.

The Bladder and Bowel Foundation also produces a fact sheet with instructions on how to do these exercises. You can order the fact sheet or download the information from their website.

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.


Wind

After radiotherapy, some people 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 the people around you.

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

Too much wind can be caused by:

  • eating certain types of foods
  • constipation
  • some medicines, such as Fybogel and Lactulose
  • bowel conditions (such as diverticular disease)
  • small bowel bacterial overgrowth.

If you have too much wind, these tips 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.
  • Talk to your doctor or specialist nurse about trying laxatives other than Lactulose and Fybogel, which may cause less wind.
  • Some people find peppermint oil, live yoghurts, probiotic drinks or charcoal tablets helpful in controlling wind.


Other things you can do yourself

As well as 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. Many people need to go to the toilet after eating, so your regular time might be after meals.
  • If you feel you need to go to the toilet several times a day, practise holding the stool. Over time this will help 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 whether they could be making bowel problems worse. If so, they may be able to prescribe an alternative that affects you less.

We have more information about skincare, going out and lifestyle changes that may help you cope with bowel problems.


Managing stress

Your emotions can also affect your bowel. Anxiety and stressful situations can make bowel movements looser and more frequent. If you don’t feel in control of your bowel, this in itself can be stressful.

Learning how to relax may help to settle your bowel and will be good for your general health. Stress reduction is taught at some continence clinics. Your doctor or specialist nurse can tell you about relaxation classes in your area. Some support groups also offer relaxation classes.

Relaxation tapes and CDs are available from bookshops and some health shops, and you can download relaxation podcasts from the internet. We have more information about relaxation techniques which you might find helpful.

Some people find that complementary therapies help them feel less stressed. We have more information about complementary therapies.


Bowel retraining

Having loose bowels or urgency can affect your confidence in your ability to ‘hold on’.

Worrying that you may not get to the toilet in time can make you very anxious. You may be very aware of any activity in your bowel, including wind, as you try to monitor your bowel for signs that you need to ‘go’.

Continence specialists can help by teaching you to retrain your bowel. The aim is to help you build up the length of time you can ‘hold on’. Bowel retraining will most likely be used in combination with other approaches such as anti-diarrhoeal medicines and muscle strengthening exercises.

With bowel retraining you learn to resist the urge to go right away. At first you start by getting to a toilet when you feel the urge. You then wait for a minute or so before actually sitting on the toilet to open your bowels. The aim is to gradually increase the time between feeling the urge to go and then emptying your bowel. This will build up your confidence and give you more control of your bowel.


Other treatments

Sacral nerve stimulation is a new treatment that is sometimes used to treat bowel symptoms that are very troublesome and haven’t been helped by other treatments.

Sacral nerve stimulation uses electrical pulses to stimulate the nerves to the bowel and regulate how it works. It involves placing electrodes under the skin in the lower back (sacral area) and connecting them to a pulse generator. This produces pulses of electricity that are thought to affect the nerves that control the lower part of the bowel and the anal sphincter.

The treatment is given in two parts. First you are tested with temporary electrodes to see if sacral nerve stimulation works for you. If the test is successful you’ll be offered an operation to have a small permanent implant fitted.

Back to Long-term and late effects

Changes in how your bowel works

Treatment for rectal cancer may lead to changes in how your bowel works. These can usually be managed successfully over time.

Managing bladder problems

There are ways to manage changes in the way your bladder works. It’s important to talk to your doctor if you’re having problems.