Nurse Led Coping Advice By Yvette Perston
This is obviously very important for women with bowel control problems and the fear of not being able to find a toilet can lead to social isolation. The following can help give confidence and reassurance when out. Disabled toilets are available for use by women with bowel control problems and are not just for people in wheel chairs.
The RADAR National Key Scheme (NKS) offers key holders access to around 8,000 locked accessible public toilets around the country. RADAR publish the national key scheme guide with listings of all RADAR Key Scheme toilets around the UK. Radar keys can be obtained from the local council, many health care professionals and are available to buy from www.radarkey.org
Need A Loo?
The Need a Loo? web site seeks to list all the publicly accessible disabled toilet facilities in the United Kingdom, with maps showing their locations. www.loo.org
ToiletFinder is a web application for sharing, locating and rating publicly accessible toilets. www.toiletfinder.org
Just Can’t Wait toilet card
Several companies have produced the Just Can’t Wait toilet card. This card can be shown when out shopping or socialising and it may help you gain access to a toilet. The card states that the card holder has a medical condition which requires the urgent need of a toilet. Although the card does not guarantee you access to a toilet many places will be willing to help.
They can usually be obtained from the local continence or colorectal nurse.
This is obviously very important for women with leakage problems and something which they worry about. Using a shower or bidet after a bowel action is ideal but not always possible.
The skin around the back passage (and the genital area) is known as the perineal area. It is very sensitive and is easily irritated by enzymes present in faeces. When bowel motions are frequent and loose, the skin in the perineal area can become red, raw, sore, itchy, and prone to bleed.
Moist toilet tissue
Moist toilet tissue can be very useful to aid this. Available in both home and travel size they are widely available from most supermarkets and have the advantage over wet wipes of being flushable.
To prevent breakdown a moisturiser or skin barrier cream can be used. There are many available on the market which are available over the counter or on prescription.
A sitz bath is a warm, shallow bath that cleanses the perineum (the space between the rectum and the vulva or scrotum). A sitz bath can be used for everyday personal hygiene. It can also provide relief from pain or itching in the genital area.
A Bidet Shower
A bidet shower (bidet spray, bidet sprayer, or health faucet) is a hand-held triggered nozzle, similar to that on a kitchen sink sprayer, that delivers a spray of water to assist in anal cleansing and cleaning the genitals after defecation and urination. The bidet shower is very common in parts of Asia where water is considered essential for anal cleansing. Many plumbers are able to fit these for use with Western-style (sitting) toilet installations
Loperamide works by slowing down the passage of food through the gut and encouraging more uptake of water from the waste in the lower bowel. The stools that are then produced are thicker and firmer. This makes it easier to control the urge to pass stool.
Loperamide is a very safe drug to take and does not inter-react with other medication. It is safe to take long term to help control symptoms. It can result in constipation if too high a dose is taken. It is usual to start with one capsule/tablet (2mgs) once a day but some people will require a larger dose. People vary a lot in their response to loperamide, so it can sometimes needs some experimentation to find the correct dose.
Loperamide comes in capsules / tablets or as syrup. The tablets are available over the counter or on prescription. As the syrup is often used for children it can only be obtained on prescription in this country. The syrup is useful for people who only need a small dose to control their bowel and so helps to prevent constipation. It is best to take loperamide half an hour before a meal. This will help to slow down the usual gut activity that is stimulated by eating. Most people find that the bowel is most active in the morning and so loperamide will help most if taken before breakfast. The medicine starts to work within half an hour of taking it and is effective for eight to 12 hours.
Most people take loperamide on a daily basis but it is equally as useful taken when required if stools are loose, or 30 minutes before going out.
Loperamide can be used with glycerine suppositories to help prevent leakage of stool. The loperamide makes the stool firmer and the glycerine suppositories empty out the back passage so that there is no stool present to cause leakage. Most people need to use the loperamide and suppositories daily to achieve this. Experimentation with the dosage and timing can lead to more controlled bowel actions.
Diet can obviously make a difference to bowel control by altering the consistency of the stool. The following are general rules but everyone reacts slightly differently so good results can be achieved with trial and error.
Food/drink which may exacerbate faecal incontinence in people with loose or soft stools.
|Fibre||Fibre supplements, wholegrain cereals/bread Porridge/oats may cause fewer problems than whole wheat-based cereals|
|Fruit and vegetables||Rhubarb, figs, prunes and plums best avoided as contain natural laxative compounds
Beans, pulses, cabbage and sprouts
|Spices||For example, chilli or curry|
|Artificial sweeteners||May be found in special diabetic products such as chocolate, biscuits, conserves, and in some sugar-free items including many nicotine replacement gums|
|Alcohol||Especially stout, beers and ales|
|Lactose||While small amounts of milk (for example in tea or yoghurt) are often tolerated, an increase in the consumption of milk may cause diarrhoea. For more information on lactose intolerance see http://www.eatwell.gov.uk/|
|Caffeine||Excessive intake of caffeine may loosen stool and thus increase faecal incontinence|
|Vitamin and mineral supplements||Excessive doses of vitamin C, magnesium, phosphorus and/or calcium supplements may increase FI.|
|Olestra fat substitute||Can cause loose stools|
Adapted from NICE CG49, 2010
Dietary fibre or roughage is the indigestible portion of food derived from plants.
There are two main components:
- Soluble fibre, which dissolves in water. Soluble fibers tend to slow the movement of food through the system.
- Insoluble fibre, which does not dissolve in water Insoluble fibres tend to accelerate the movement of food through the system.
Soluble fibre is found in varying quantities in all plant foods, including:
- legumes (peas, soybeans, and other beans)
- oats, rye, chia, and barley
- some fruits (including avocados, plums, prunes, berries, ripe bananas, and the skin of apples, quinces and pears)
- certain vegetables such as broccoli, carrots, and Jerusalem artichokes
- root tubers and root vegetables such as sweet potatoes and onions (skins of these are sources of insoluble fibre also)
- psyllium seed husks (a mucilage soluble fibre) and flax seeds
- nuts, with almonds being the highest in dietary fibre
- A fibre supplement called ispaghula powder is also available from pharmacies and health food shops.
Sources of insoluble fibre include:
- whole grain foods
- wheat and corn bran
- legumes such as beans and peas
- nuts and seeds
- potato skins
- vegetables such as green beans, cauliflower, courgette, celery.
- some fruits including avocado, and unripe bananas
- the skins of some fruits, including kiwifruit, grapes and tomatoes
Balancing the amounts of each type of fibre or increasing soluble fibre over insoluble may result in a firmer stool and less urgency.
Most wind is due to the production of gases from bacteria that live in the large bowel and break down undigested food. Some is due to what is swallowed while eating or talking. It is normal to produce some each day and the amount varies from person to person, depending on the diet and the type of bacteria that live in the bowel. Some people pass small amounts of wind often, whereas others pass larger amounts less often. If the anal sphincter muscles are weak or damaged, there may be problems controlling wind from the back passage.
If you pass wind more often than the usual range of 7 to 25 times per day, it may simply mean that you are consuming food or drink that disagrees with you, even though someone else eating the same food has no problem.
Some habits that can lead to increased wind include talking while eating; drinking from a water bottle or fountain; sipping hot drinks; sighing deeply; smoking and chewing gum.
Foods that cause flatus/wind:
cabbage family vegetables (cabbage, Brussels sprouts, broccoli and cauliflower)
- fizzy drinks
- dairy products
- chewing gum
Products which some people find helpful
People’s response to these products are very individual. Some people find that one or more of the following products reduces wind, or reduces the smell from wind:
- Peppermint oil
- Rennies and other over-the counter indigestion medicines
- Charcoal tablets
- Mint tea
- Cardomom seeds (chewed)
- Aloe Vera capsules or juice
- Probiotic drink (e.g. Yakult, Actimel)
- Acidophilus (from health food shop).
The Low FODMAP Diet
(FODMAP=Fermentable Oligo-Di-Monosaccharides and Polyols)
FODMAPs are carbohydrates (sugars) that are found in foods. Not all carbohydrates are considered FODMAPs.
The FODMAPs that occur in the diet are:
- Fructose (fruits, honey, etc.)
- Lactose (dairy)
- Fructans (wheat, onion, garlic, etc.)
- Galactans (beans, lentils, legumes such as soy, etc.)
- Polyols (sweeteners containing sorbitol, mannitol, stone fruits such as avocado, apricots, cherries, nectarines, peaches, plums, etc.)
FODMAPs are osmotic which means they pull water into the intestinal tract. They may not be digested or absorbed well and can be fermented by bacteria that natural occurs in the intestinal tract when eaten in excess. This causes symptoms of gas, bloating, cramping and diarrhoea. Some people are more sensitive to these effects than others. In these people a low FODMAP diet may help reduce symptoms.
The low FODMAP diet was developed for people with irritable bowel syndrome (IBS). Follow the diet for 6 weeks. After this, add high FODMAP foods one at a time back into the diet in small amounts to identify foods that could be “triggers” to your symptoms. Limit foods that trigger your symptoms.
Some people find that taking pro-biotics can improve their symptoms of loose stool and flatulence. This can be in the form of live yoghurt drinks such as Actimel and Yakult that are available from most supermarkets. If these are not helpful VSL#3 is available on prescription and may reduce unwanted symptoms. They need to be taken for at least a month to achieve maximum effect.
Pelvic floor muscle training
Pelvic floor exercises are important in maintaining control of anal sphincter
muscles. The ability to control these muscles is one of the key factors in preventing leakage of gas or faeces. Both women and men should do pelvic floor exercises every day. The exercises help to prevent problems, as well as improve any existing problems. The exercises are simple and can be done any time at home or when out.
Practising the exercises
- Sit, stand or lie with your knees slightly apart. Slowly tighten and pull up the sphincter muscles as tightly as you can. Hold tightened for at least five seconds, and then relax for about 4 seconds.
Repeat five times. This will work on the strength of your muscles.
- Next, pull the muscles up to about half of their maximum squeeze. See how long you can hold this for. Then relax for at least 10 seconds.
Repeat twice. This will work on the endurance or staying power of your muscles.
- Pull up the muscles as quickly and tightly as you can and then relax and then pull up again, and see how many times you can do this before you get tired. Try for about five quick pull-ups. This will work on the response of your muscles.
- Do these exercises – five as hard as you can, two as long as you can and five quick pull-ups – four to six times every day.
- As the muscles get stronger, you will find that you can hold for longer than five seconds, and that you can do more pull-ups each time without the muscle getting tired.
- It is helpful to do these exercises both sitting and standing as working against gravity will help strengthen the muscles.
- It takes time for exercise to make muscle stronger. You may need to exercise regularly for several months before the muscles gain their full strength.
(Norton & Chelvanayagam, 2004)
Bowel habit training
For women experiencing urgency it can be helpful to try a progressive programme of urge resistance. This consists of waiting for slightly longer each time there is an urge to defaecate. To start with this can be done by sitting in the bathroom but resisting the urge for minutes. The length of time for resisting can slowly be increased until a reasonable time can be achieved and so reduce the urgency feeling. This training can be coupled with pelvic floor exercises as contraction of the muscles will help to reduce the urge.
Many people notice that leakage is made worse by heavy lifting, squatting and strenuous physical activity. If possible these activities should be avoided wherever possible, especially when bowel motions are particularly soft. If they can’t be avoided, it is best to do them in the morning when pelvic floor muscles are generally stronger.
It is important to remain active and everyone should try to do some gentle exercise such as walking for at least 30 minutes most days of the week. Daily exercise helps to promote regular bowel activity and benefits overall health.
EVB sports shorts
These are available via the internet and are designed to help support pelvic floor especially during exercise. They are triple layer moisture wicking material and have a feature designed to hold a pad if required. They also provide support for the lower back and abdominal muscles particularly after stretching during pregnancy and childbirth.
For women with control issues it is ideal for them to be able to predict when they have a bowel action so they have confidence to continue with their normal day to day life. As bowels are unpredictable it may be helpful to initiate a bowel action by using suppositories, enemas or washouts, thus emptying the bowel and so avoiding accidents later in the day.
Glycerine suppositories are used to empty the back passage of stool. As they are very efficient in emptying the back passage they can be used in the treatment of faecal leakage. This is effective because when the back passage is empty there is nothing there to leak out and so cause an accident.
When used for people with leakage problems this emptying of the lower bowel prevents leakage of stool for the rest of the day and so helps with confidence. They can be used with loperamide in this situation as the loperamide slows the bowel movement down, and the suppositories help in emptying the back passage completely.
They should be inserted into the back passage and retained for 10 minutes, they will then produce a bowel action. They can be used on a daily basis or when required and are available on prescription or over the counter.
Microlax enemas are used to empty the back passage of stool which can help in the management of faecal leakage. This is effective because when the back passage is empty there is nothing there to leak out and so cause an accident. They can also be used to treat the symptoms of a rectocele, which is a bulge in the wall of the rectum into the vagina.
When used for people with leakage problems this emptying of the lower bowel prevents leakage of stool for the rest of the day and so helps with confidence. They can be used with loperamide in this situation as the loperamide slows the bowel movement down, and the enema helps in emptying the back passage completely.
The Peristeen Anal Plug
The anal plug is a soft foam tampon which is designed to go into the back passage. They are made of soft foam which is coated to allow the plug to be inserted. This coating then dissolves in the warmth and moisture of the back passage. Once in place the plug gently expands to fit the rectum and so prevents leakage of stool. They only work if the stool is formed, they do not work for people with loose stool. There are two sizes available to ensure the best fit. The anal plug is designed to be used to prevent accidents and so most people use them for reassurance when they are going out. They can be used on a daily basis or occasionally to provide confidence. They are available on prescription.
Renew inserts are made from silicone so they are soft and adapt to fit. They sit inside the anal canal to provide a seal to prevent bowel leakage. They are safe to wear day and night and are expelled with a bowel movement. They are inserted using a fingertip applicator and are single use. They are available on prescription.
Rectal irrigation is a method of emptying the back passage and bowel by using warm water. It is done while sitting on the toilet and can help with bowel leakage as it empties the bowel so preventing accidental soiling. There are several kits available to achieve this which use cones or catheters to instill the water. There are mini systems which enable the instillation of approximately 50-75mls water (Qufora mini & Aquaflush compact) and larger systems which instill 500-1000mls (Qufora cone, Qufora catheter, Aquaflush quick). There are also some electrical pump systems available, these use both cones and catheters to instill the water (Braun, Wellspect, Navina) . All these systems need to be recommended and taught by health care staff and are all available on prescription.
Bladder and Bowel Foundation
Helpline: 01926 357220
Tel: 0207 486 0341