The Healthy Bowel

• How the Healthy Bowel Works
• Healthy Bowel Habits
• Common Questions and Answers

How the Healthy Bowel Works

How food passes through the digestive system

A Food is chewed in the mouth. This takes up to one minute.

B Food is swallowed, taking three seconds to pass through the oesophagus.

C Digestion starts in the stomach, where food stays for 1-3 hours.

D Liquidised food takes about 2-6 hours to travel through the small intestine. By now it is fully digested.

E By the end of its stay in the large intestine (12-48 hours), most of the water content has been absorbed.

F Stools and gas are stored in the rectum until they are expelled through the anus.

The food we eat moves through the stomach, the small intestine and the large intestine to the rectum, where it is stored until expelled through the anus. Digestion starts in the stomach, and is completed in the small intestine, where the nutrients we need are absorbed. In the large intestine, excess water is absorbed, and the residue - gas and the solid waste known as stools - is then stored in the rectum until we are ready to pass it to the outside world.

There is considerable variation between individuals. For example, the time food takes to move through the system can range from under 20 hours to over 100. The time people go between successive openings of their bowels is similarly variable: anything from three times a day to three times a week is normal.

Most of the ways the bowels work are outside the scope of this website. We are concerned with the maintenance of control over emptying the bowels.

When the rectum fills, we are able to tell whether the material is solid stools, liquid (as with diarrhoea) or wind. The anus has two concentric sphincter muscles - called the internal and external sphincters - which normally keep the anus closed and prevent leakage. You can voluntarily squeeze the external sphincter, and if the rectum is full this will have the effect of pushing the material back up the anal canal.

Healthy Bowel Habits

You can help keep your bowel regular by following these simple guidelines:

Bowels benefit from routine!  About half an hour after meals is the most usual time for a bowel action. Eating reasonably regularly can help your bowel get into a predictable pattern. And don't miss breakfast!

Only take as long as you need: don’t sit for ages on the toilet. You should be able to empty the bowel with minimal effort. Try not to strain: allow yourself enough time and privacy to empty the bowel properly and relax!

When you feel the need to empty the bowel - respond! If you keep ignoring the bowel (because you are busy or there are too many people around) you can make yourself constipated. In fact, by continuing to ignore the urge to pass a stool, you can slow down the entire workings of your gut.

Eat properly. Fibre can improve your bowel habit. Best advice is to eat five portions of fruit or vegetables a day for health. However, if you have trouble controlling the bowels or suffer severe constipation, too much fibre can make things worse or cause a lot of wind.

Limber up! Regular exercise can stimulate the bowel to work regularly.

Common Questions and Answers

How often should I empty my bowel?

Anything between three times a day and three times a week is normal.

When should I seek medical advice?

Most bowel disorders are minor, but some are serious. Always see your doctor if:

• you see any blood with your stools,
• you have a change in bowel habit you cannot explain that lasts more than a few days,
• you lose weight without trying,
• you have pain in you abdomen or when you pass a motion, or
• you cannot control your stools or leak from the back passage.

Some medicines can upset bowel habit. Ask your pharmacist or doctor if you suspect this.

How common are bowel control problems?

Many people - about one in 50 - have some experience of poor bowel control. More about numbers

Bowel Control Problems

• Bowel Control
• Causes of Bowel Leakage
• Getting Help
• Treatments and Management
• Questions You May Be Asked

Bowel Control

This page is based by permission on an article by Christine Norton, Nurse Specialist (Continence) St. Mark’s Hospital, Northwick Park, Harrow, that was first published in the newsletter of Incontact in winter 1998/99)

The loss of bowel control, also known as faecal incontinence, can be a devastating problem. There can be few things more embarrassing than a bowel accident that other people notice, and few conditions that create so much anxiety. It can result in an almost constant fear that it might happen.

Faecal incontinence affects men and women of all ages. More than one adult in every hundred has this problem. Many people go untreated because they are too embarrassed to ask for help. This is a pity as for many people there are effective treatments that can help, or even cure, the problem. However, this has long been a neglected subject, and for some problems we do not yet have completely effective treatments.

Causes of Bowel Leakage

There are many different possible causes of loss of bowel control. The most common causes are summarised below:

Anal sphincter damage

Probably the most common cause of faecal incontinence is damage to one or both of the two rings of muscle around the back passage - the anal sphincter muscles. People with a weak or damaged external sphincter muscle typically experience urgency (needing to rush to the toilet as soon as the need is felt) and, if the toilet is not reached in time, urge incontinence (accidental loss of stool on the way to the toilet). Typically someone has to drop everything and find a toilet with very little warning.

People with a damaged internal anal sphincter usually complain of passive soiling, soft stool or small pellets of stool just leak out without the person realising it is happening and with no control. This may either be after the bowels have been emptied (often lasting for an hour or two after each bowel action), or stool comes away when you walk, bend, or with more vigorous physical exercise such as playing sport.

Diarrhoea

Another cause of loss of bowel control is severe diarrhoea. People with diarrhoea often have very high pressure waves in the bowel, and this pressure can be so great and create such extreme urgency that it is impossible to reach the toilet unless it is very close by.

Constipation

It may sound contradictory that severe constipation, or difficulty with bowel emptying, can itself be a cause of faecal incontinence. But it can happen that the bowel becomes so overloaded with stool that small lumps break off and come away, usually without the person feeling that it is happening. Alternatively, the wall of the bowel is irritated by the hard stools and so produces more fluid and mucus, which then leaks out through the anus.

Nerve injury or disease

As bowel control involves complex co-ordination of nerves and muscles, any damage or disease of the nerves can make control precarious. This includes people who have had a spinal injury, or who have multiple sclerosis. Nerve damage may mean that someone does not get the right messages when the rectum is full. Or the rectum may just empty automatically without feeling or control as soon as it fills.

Getting help

If your problem is limited to controlling wind and smells, you may wish to try self-help first: see the advice on this website.

You may also, if you believe your problem stems from a weak sphincter, wish to try exercising your anal sphincter.

Another problem for people with bowel control problems is skin care: again, we can offer some advice.

In general, however, if you have a problem with bowel leakage, it is a good idea to get professional help. Many doctors still do not realise how common faecal incontinence is, or that anything can be done about it, and so may try to tell you that you just have to learn to live with it. In a few cases this is true, but not without proper investigations and trying treatment first.

The best place to start is usually your own family doctor (General Practitioner) or a practice nurse, district nurse or Continence Nurse Specialist. If you really do not want to face anyone to start with, you can call the Continence Foundation Helpline, in confidence, and talk to a trained nurse who knows all about these problems.

In most cases a doctor or nurse will be able to get important clues as to where the problem lies just by talking to you. She or he will ask you a number of simple questions.

In some instances it will be best for you to see a specialist doctor with an interest in faecal incontinence (such as a colorectal surgeon or a gastroenterologist). The doctor will need to examine your sphincter muscles with a finger. This causes slight discomfort, but is not painful and only lasts a few seconds.

What tests might you need? In many cases two tests are necessary to define the exact nature of the problem. Neither of these tests is painful, and you should try not to feel embarrassed as the person doing the tests probably does them all day every day!

Anorectal physiological studies - which test how the nerves and muscles around the anus and rectum are working. These tests take about 20 minutes and are done as an outpatient.

Anal ultrasound - this test uses sound waves to form an image of the muscles around the anal canal. A small ultrasound probe the size of a finger is inserted into the anal canal and the radiologist can then see if there is any damage to the muscles. This test takes 5-10 minutes as an outpatient.Both anorectal physiological studies and anal ultrasound are available only in specialist centres, so you may need to travel further than your local hospital for them.

Treatments and Management

The treatment suggested will depend on the cause of the faecal incontinence, how severe the problem is, and how bothered you are by your symptoms. This is not a problem that you must be treated for, it is up to you. Some people are happy just to have had things checked out and to be reassured that there is no sign of serious disease or illness. Most are understandably anxious to get rid of the problem.

Some people will be treated by their own doctor, district nurse or Continence Adviser. In other cases treatment is best supervised by the hospital

Drug therapy

Sometimes medicines are helpful. They work by solidifying liquid or soft stool or making the bowel squeeze less strongly. If you are opening your bowels more than once each day and have soft or loose stool, your doctor may suggest some medicine such as loperamide (Imodium) or codeine phosphate to slow down the bowel.

Sphincter exercises

Sphincter exercises can help you to improve your bowel control, especially if your main problem is urgency. When done correctly, these exercises can build up and strengthen the external anal sphincter to help you to hold both gas and stool in the back passage. A specialist nurse or physiotherapist can teach you these exercises. Sometimes a course of biofeedback therapy will be suggested. This involves using a computer or machine to show you how your muscles are working, and how well you can co-ordinate the use of these muscles with a full bowel, and to teach you how to improve your control. More Information

Bowel habit

Some people find that the bowel responds well to a regular habit. Reasonably regular mealtimes, with a healthy diet, and sitting on the toilet at the time most likely for a bowel action (20-30 minutes after a meal or a warm drink), will encourage the bowel to develop a regular pattern for some people. If you know when the bowel is likely to work, you can plan to be in a place that you can deal with this, even if your control is not perfect. More information

Resisting "the urge"

Some people who have had the horrible experience of a bowel accident in public understandably become very sensitive to anything arriving in the rectum. It is a natural reaction to try and prevent an accident by immediately finding a toilet. However, with time this can develop into a bad habit. As soon as you have the slightest feeling that you might need the toilet you drop everything and rush to the nearest toilet. It is easy to see how this can develop into a vicious circle. The more you worry, the worse it gets. The worse it gets, the more you worry. In the end it can almost be a self-fulfilling prophecy - you do not make it to the toilet because you are convinced that you cannot do so. It can be very useful to practice hanging on - on the toilet to start with, gradually getting further and further away as you urgency gets less. (Techniques to control the urge are much the same for bowels as for bladders, on which there is more Information on this site.)

Keeping the bowel empty

Sometimes the best approach to regaining bowel control is to plan to empty the bowel as completely as possible at a time that suits you, rather than the bowel dictating to you and ruling your life. The simplest method of stimulating the bowel to empty when you want it to is to use a suppository, which you insert through the anus into the rectum with a finger, and then hold on to for as long as possible (usually about 10-20 minutes) before going to the toilet. Some people with nerve damage find that a bowel washout is effective.

Can food or drinks have an effect?

Yes! The bowel is designed for processing food, and so naturally what you put in can have an effect on what comes out. However, it is not easy to offer advice on this as it seems to vary from person to person, and there is very little research on which foods can make incontinence better or worse. It is worth experimenting a little to see if you can find anything that upsets your control. Food rich in fibre is the most common contributor to poor bowel control, but other foods, such as very spicy or hot food, can upset some people. Some people have a bowel that seems to be very sensitive to caffeine, which is in coffee, tea, cola drinks and expensive chocolate.

Surgery

For some problems that cause faecal incontinence it is possible to do an operation. For other problems there is no operation which can help. If the external anal sphincter is damaged, it can often be overlapped again. The results of sphincter repair operation are usually good, with 4 out of 5 (80%) of people reporting some improvement 2 years after the operation. For people with more extensive sphincter damage, it is possible to construct a new sphincter, although this is largely experimental at present.More Information

Managing Bowel Leakage

There are no perfect answers to the problem of coping with leakage from the bowel. It is very difficult to find anything that reliably disguises bowel leakage and smell and which keeps you feeling comfortable. It is hoped that in future more time and investment will go into developing products to contain this embarrassing problem. All of the disposable pads used for urinary incontinence are suitable, but none is designed specially for bowel leakage.

An anal plug (see under Devices for Bowel Incontinence) has been developed to help people with bowel leakage. It is designed to be worn inside the rectum to plug the exit from the anus from the inside. It comes in 2 sizes, small and large and only trying it will tell which is best. The manufacturers, Coloplast Ltd., will send samples on request.

The Future

There are many exciting prospects for the future in this area, and at last time and money are being devoted to the subject. Many new treatments are under trial. It seems likely that the next few years will show a great increase in the treatment options available. So even if it is not possible to completely control your problem now, it will be worth staying in touch with services that can tell you when new methods do become available.

Further Reading

Two useful books are available through the Continence Foundation Book Service:

Your Bowels, by Dr Kenneth Heaton (a BMA Family Doctor Guide, Dorling Kindersley, London 1999)

Bowel Control - Information and Practical Advice, by Christine Norton and Michael Kamm (Beaconsfield Publishers, Bucks., 1999)

The Digestive Disorders Foundation (3 St. Andrew’s Place, London NW1 4LB) publishes a range of useful leaflets.

Questions you may be asked

• When did it start?
• How often do you open your bowels?
• Do you have to rush to the toilet?
• Do you always get to the toilet in time?
• Do you have to strain to empty your bowels?
• Is it painful to empty your bowels?
• Are your stools hard, soft but formed, or loose (runny)?
• Do you ever see any blood when you open your bowels?
• Do you have difficulty wiping clean after opening your bowels?
• Do you get leakage of stool from the anus after you have opened your bowels?
• Do you ever lose stool when you walk, run, or in bed at night?
• Do you need to wear a pad? If you are losing stool - how often, how much, what is the consistency (lumps or liquid)?
• Are you taking any medicines or tablets?
• You will also be asked some general questions about your health, past operations, childbirth and your diet and fluid intake.