Physiotherapy bowel management

Who is this information for?

This information is for anyone who might be suffering with bowel conditions such as constipation, faecal incontinence (leaking from the back passage), difficulty controlling wind or problems emptying the bowels.

Why do I have problems?

You may be at risk of developing problems if you:

• Have a history of straining to empty the bowel.
• Have been diagnosed with IBS (irritable bowel syndrome) or have other conditions such as diverticulitis.
• Have a nerve injury, such as spinal cord injury, Multiple Sclerosis or Parkinson’s Disease.
• Are taking medication which may harden stools such as codeine or iron tablets. Are pregnant or have just had a baby.
• Have an eating disorder.
• Have poor lifestyle or bowel habits.
• Have had a traumatic birth.
• Have a weakness in the back wall of your vagina (prolapse).

Normal bowel habits

It is normal to pass a bowel movement between once every three days to three times a day. When stool enters the rectum the internal anal sphincter muscle automatically relaxes and opens up the top of the anal canal. This is normal and allows stool to enter the upper anal canal to be ‘sampled’ by the very sensitive nerve cells in the upper anal canal.

People with normal sensation can easily tell the difference between wind (gas, also called flatus), which can safely be passed (without fear of soiling), if it is socially convenient without fear of soiling. Most people just know what is in the rectum without really having to think about it. If a normal stool is sensed and it is not convenient to find a toilet at that moment, bowel emptying is delayed by squeezing the external anal sphincter. Squeezing the external sphincter ensures that the stool is not simply expelled as soon as it enters the rectum and in fact the stool is pushed back up out of the anal canal.

Symptoms of anal incontinence

• needing to go to the toilet urgently
• unable to get to the toilet in time
• unable to control wind
• leakage after passing a stool
• difficulty wiping clean

Anal sphincter and pelvic floor muscle exercises

Research shows that anal sphincter and pelvic floor exercises are an effective treatment for bowel incontinence.

The back passage or anus has two rings of muscle around it:

• The inner ring is the internal anal sphincter; this should be working at all times except when opening your bowels. You have no voluntary control over this muscle and therefore cannot exercise it.
• The outer ring of muscle is the external anal sphincter which you can actively tighten if you have urgency or diarrhoea. This muscle can be exercised and strengthened.

Lying above these sphincters are the pelvic floor muscles. The pelvic floor muscles are firm supportive muscles that stretch from your coccyx bone at the base of your spine to the pubic bone at the front of your pelvis. The pelvic floor muscles work with the anal sphincter muscles.

Exercises

It is important to learn to do these exercises correctly and to check from time to time that you are still doing them properly.

Sit comfortably with your knees slightly apart. Now imagine that you are trying to stop yourself passing wind from your bowel or trying to pick up a marble. To do this you must squeeze the muscle around your back passage. Try squeezing and lifting that muscle as tightly as you can, as if you are really worried that you are about to leak. You should be able to feel the muscle move. Your buttocks, tummy and legs should not move. You should be aware of the skin around your back passage tightening and being pulled up and away from your chair. Try not to hold your breath when you tighten these muscles.

Practising your exercises

1. Sit, stand or lie with your knees slightly apart. Tighten and pull up your sphincter muscles as tightly as you can. Hold for . . . . . . . . . . . seconds and then relax. Repeat . . . . . . . times. This will work on the strength of your muscles.
2. Pull the muscles up to about half of their maximum squeeze. See how long you can hold this. Then relax for at least 10 seconds. Repeat at least five times. This will work on the endurance or staying power of your muscles.
3. Pull up the muscles as tightly as you can and then relax. Try and do this . . . . . . . . . times.

You should feel a gentle lift and squeeze if you are exercising the right muscle. To check you are doing this correctly you can look at the area in a mirror. You should see your anus pucker up as you squeeze it.

Please see the pelvic floor muscle exercise leaflet for more information.

Regaining control of your bowel

If you find you have to rush to get the toilet in time (urgency) or if you experience leakage on the way to the toilet you may find these useful.

Next time when you need to have your bowels open:

1. Sit on the toilet and hold on for as long as you can, use your pelvic floor and anal sphincter muscles before opening your bowels. If you can only manage a few seconds, don’t worry, it will gradually get easier. You may find it easier if you try to relax and concentrate on breathing very calmly. Gradually try to hold on for longer and longer each time. Don’t worry if you’re not able to do this for the first few times, but keep practising.
2. It may be helpful to take something with you to read. Remember to concentrate on relaxed and calm breathing.
3. Once you are able to delay opening your bowels for a few minutes sitting on the toilet, the unpleasant urge to go then disappears. Get up and leave the toilet. Return a few minutes later when there is no urge and try to have your bowels open.
4. Gradually you will find that you can increase the distance and time away from the toilet. This may take some time. The more practice you have at both your sphincter exercises and this programme, the sooner it will happen.

General advice

• Bowels routine so you may find it useful to try and open your bowels at a set time each day. You cannot hurry them so give yourself time. Try not to sit on the toilet for more than 10 minutes at a time. If nothing has started working for you, get up and walk around and try again later.
• Ensure you eat three meals a day to help your bowel get into a good pattern.
• The bowels have a natural reflex which makes them work better 15 to 20 minutes after a meal. Try to open your bowels after eating. Breakfast or your evening meal is a good time to try.
• To ensure that you empty your bowel fully, try sitting on the toilet with your feet raised on a small step or up on tip-toes if you do not have anything close by.

Diet and exercise

Try to drink at least 1.5 litres (six to eight cups) of fluid per day, unless advised otherwise by your doctor. Dehydration can result in constipation. Try to limit the amount of coffee and alcohol you drink as this can irritate the bowels.

Eating regularly is the best stimulant for your bowels. Skipping meals, especially breakfast, can lead to a sluggish or irregular bowel habit. Contrary to popular belief a high fibre diet is not always the best diet for people who suffer from constipation.

Regular meals and an adequate fluid intake are more important. Too much fibre can lead to an increase in bloating and discomfort. If you do feel your diet is short on fibre, try to use fruit and vegetables (soluble fibre) rather than cereals (insoluble fibre) as they are less bloating.

Be careful not to eat excessive amounts of fibre as this could lead to loose bowel motions that are difficult to control. In some people certain foods, such as liquorice, chocolate, prunes, figs and spicy food can act as natural laxatives.

Exercise can improve bowel habits as it helps to stimulate the bowel to work regularly, but be careful not to overdo it. If you lead a very inactive lifestyle (driving to work, at a desk job) even taking a regular walk at lunchtime can make a difference.

Please see Resources (at the end of this leaflet) for more diet advice.

Constipation

The word “constipated” can mean different things to different people. It can be a feeling that the stools are too hard or that the bowels do not work regularly or easily. Try to follow the previous diet advice to help.

You may find gentle abdominal massage can also help. You can try this sitting or lying down. Start by applying pressure with your hands on top of one another in the bottom right hand corner of your tummy. Apply pressure and move your hands up to the bottom of your ribs (in an ‘I’ shape). Start again in the bottom right hand corner of your tummy, apply pressure up to your ribs and then along to the left side (in an ‘L’ shape). Again repeat starting in the same place, apply pressure up to the ribs, slide along to the left and then down to the bottom left hand corner of your tummy (in an ‘n’ shape).

Medication

Some patients find that they need medication to help. If you would like further information please speak to your GP.

Bulk forming laxatives

These work by helping your stools to retain fluid. This means they are less likely to dry out. Bulk-forming laxatives also make your stools softer, which means they should be easier to pass. Commonly prescribed bulk-forming laxatives include Fibrogel.

Osmotic laxatives

Osmotic laxatives increase the amount of fluid in your bowels. This softens your stools and stimulates your body to pass them. Commonly prescribed osmotic laxatives include Movicol.

Stimulant laxatives

This type of laxative stimulates the muscles that line your digestive tract, helping them to move stools and waste products along your large intestine to your anus. A commonly prescribed stimulant laxative is senna.

Anti-diarrhoeals

Loperamide is one of a group of drugs called anti-diarrhoeals. These drugs are designed to thicken your stools and so to reduce diarrhoea. It will also firm up slightly soft stools.

Resources

• NICE IBS diet sheet (opens in a new tab)
• Low fibre diet (opens in a new tab)
• St Mark's Hospital Foundation - Explaining how to take Loperamide (opens in a new tab)

For further physiotherapy advice

For further advice you can leave a message for the pelvic health physiotherapists on 01223 217422.