Special Bowel Topics

• Imodium (Loperamide Hydrochloride)
• Controlling Wind and Smells
• Exercises For Your Anal Sphincter
• Skin Care
• Your Sphincter Repair Operation

Imodium (Loperamide Hydrochloride)

If your doctor prescribes loperamide hydrochloride (the generic drug) or Imodium (the branded version) as part of your treatment for faecal incontinence, you may wish to have the following information about the drug and how it can help improve your incontinence.

Faecal incontinence may be due to:

1. Stools which are too loose (diarrhoea). Most people have had to rush to the toilet at some time in their lives. If your stools are loose it can be difficult to reach the toilet in time.
2. Excessively strong contractions of the bowel wall pushing the stools out and causing a feeling of urgency to reach the toilet.
3. A problem with the muscles that close the anus - these are called the anal sphincter muscles and they hold back the stools until you are able to reach a toilet.

Continence or the ability to hold on to stool in the bowel depends on all these factors. If one factor is unfavourable it is usually possible to counteract this by improving another factor. For example, some people with very loose stools have very strong muscles to hold the liquid back. Equally, if you have weak muscles, firming up the stools will reduce the workload put on the muscles.

What is Loperamide (Imodium)?

Loperamide hydrochloride (Imodium) is one of a group of drugs called anti-diarrhoeals. These drugs are designed to thicken stool and so to reduce diarrhoea. It will also firm up slightly soft stools. It works by slowing down the passage of food through the gut. The longer food takes to travel through the gut the more time there is for the water to be absorbed from it through the gut wall. The stools that are then produced are thicker and firmer.

What dose do I take?

The drug comes in capsules or as a syrup. As the syrup is often used for children it can only be obtained on prescription in this country. It is best to take it half an hour before eating a meal and if needed, just before going to bed. It is a very safe drug which is not addictive and can be taken in doses of up to 8 capsules (16mg) daily. However, as with any medical condition, if self-medication does not clear up your problem within (say) a week, you should see your doctor, in case there is an underlying problem that needs treatment.

The higher the dose the firmer the stools become. Some patients will be started on the tablets and some on the syrup. It is best to start on a low dose and to work up slowly until the stool is of a suitable consistency. You do not want to become so constipated that you are uncomfortable or have to take laxatives. The dose can be adjusted up and down depending on the thickness of the stool.

N.B. Contra-indications and side effects to taking loperamide (Imodium) can be discussed with your pharmacist.

Controlling Wind and Smells

This section is adapted with permission from a leaflet from St Mark's Hospital, Northwick Park, Harrow HA1 3JUs

When you have a bowel problem you cannot always control the passage of gas or wind (flatus) from the back passage, and any wind that you do pass may seem to smell offensive. This can lead to feelings of embarrassment. There is no single simple solution if this is a problem for you, and different people find different things helpful. Here are a few things that you might like to try.

Remember: everyone passes wind many times a day. Most people expel about 600ml. (a pint) of gas a day, but some produce up to 2 litres (three-and-a-half pints). The average person at any time has about 200ml. (a mugful) of gas in the gut. We are all a lot more sensitive to our own smells than other people are. If you know that you have passed wind, you may detect - or think you detect - a smell that no-one else has noticed.

Food and Eating

There is no doubt that some foods tend to create more wind than others - especially foods high in fibre: when the normal bacteria in the bowel digest these, they produce gas as a by-product. However, this is very individual and food that produces a lot of wind for one person may not do so for someone else. It is worth experimenting a little, to see if eating certain foods makes things worse for you, and if avoiding those foods then helps.

Some other foods or drinks have a reputation of being helpful in controlling wind and smells, although there is almost no scientific research on this. Again, this is a matter of individual reaction.

Products which some people find helpful

There is almost no scientific research on this, so the following suggestions are simply products that some people have said they found helpful in reducing wind or the smell from wind. Again, this is very individual.

Possibly helpful in controlling wind and smells

• Peppermint oil
• Fennel tea
• Cranberry juice
• Buttermilk
• Pineapple capsules
• Live natural yoghurt or lactobacillus drink ("Yakult")
• Charcoal tablets
• Aloe Vera capsules or drink
• Ido-Air (Nature's Best, 1 Lamberts Road, Tunbridge Wells, Kent TN2 3EQ).

Possibly unhelpful

• Beans (including baked beans and kidney beans)
• Peas, lentils and other pulses
• Nuts (especially peanuts)
• Muesli
• Bran cereal or other foods high in bran
• Brown rice or wholemeal pasta
• Cabbage, cauliflower, carrots and broccoli
• Eggs
• Shellfish
• Milk and milk products
• Salad (especially cucumber)
• Jacket potato skins
• Leeks, swede and parsnips
• Apples, raisins, prunes
• Onions

‘Slimming foods’ containing fructose or sorbitol can also be troublesome; and hot spicy food, especially if you are not used to it, can increase the speed with which food travels along the bowel and increase wind production. Rich, fatty food affects some people.

Sometimes the way in which you eat means that you swallow a lot of air with your food. Try eating a little more slowly, chew each mouthful carefully (especially if the food is high in fibre), take care not to swallow air, and avoid talking too much while you are actually eating. Even if you are in a hurry, do not be tempted to wash down half-chewed food with a gulp of drink.

Eating little and often, rather than one huge meal a day, can make it easier for your intestines to cope and decrease wind production. Regular meal times can help, as an empty bowel produces more wind and gurgles.

None of this means that you should make your life difficult or miserable by having to think about everything you eat and avoiding foods you particularly like. But do try to eat a balanced diet, and to notice if anything on the list - or any other particular food - makes a difference for you. Then you have a choice.

Drinking

Caffeine (in tea, coffee and cola) has a tendency to increase bowel activity for some people and may increase wind. Try decaffeinated tea and coffee for a week or so to see if this makes a difference.

Fizzy carbonated drinks, beer and lager also increase wind for some people. Usually you will burp this up, but a few people seem to experience more wind with these drinks. Excess alcohol intake will cause more wind than usual the next day for most people.

Eating and drinking at the same time can also increase the amount of air that you swallow, so try drinking before or after food, rather than with it.

Personal hygiene

If you are troubled by any leakage from the bowel good personal hygiene will be important in avoiding smells.

• After a bowel action, always wipe gently with soft toilet paper, or ideally with the newer moist toilet paper (available from larger pharmacies and some supermarkets). Discard each piece of paper after one wipe, so that you are not re-contaminating the area you have just wiped.
• Whenever possible, wash around the anus after a bowel action. A bidet is ideal (portable versions are available). If this is not possible, you may be able to use a shower attachment with your bottom over the edge of the bath. Or use a soft disposable cloth with warm water. Avoid flannels and sponges, as they can be rough and are difficult to keep clean. Sometimes a little ingenuity is needed, especially if you are away from home. Some people find that a small plant spray, watering can or jug filled with warm water makes washing easy on the toilet or over the edge of the bath.
• Do not be tempted to use disinfectants or antiseptics in the washing water as these can sting, and many people are sensitive to the chemicals in them. Plain warm water is best.
• Avoid using products with a strong perfume - such as scented soap, talcum powder and deodorants - on your bottom. Choose a non-scented soap (e.g., ‘Simple’ or a baby soap). Many baby wipes contain alcohol and are best avoided.
• Wear cotton underwear to allow the skin to breathe.
• Avoid using any creams or lotions on the area, unless advised to do so. Sphincter strengthening exercises Sometimes doing some exercises to strengthen the sphincter muscles and their speed of reaction can improve your control of wind. Ask your nurse, doctor or physiotherapist if this is likely to be helpful for you. Controlling or disguising smells If you are producing a lot of wind that you cannot control, some of these ideas may be of help:
• Try to ensure good ventilation of the room you are in.
• Use an aromatherapy oil burner, scented candle, joss stick or incense stick, or a dish of pot pourri (but remember to renew it regularly as the scent wears off).
• Use aerosol air freshener with care - some smell very obvious, or even worse than the smell you are trying to disguise!
• There are many solid block air fresheners that work all the time - available from chemists or supermarkets.
• Essential oils such as lavender or lemon oil can be useful.
• Try striking a match and then blowing it out immediately and allowing the small plume of smoke to drift into the room.

Deodorants

Your chemist may stock some deodorants specifically designed to control smells from urine or faeces. Neutradol spray or gel (MS George Ltd), Atmocol (Seton Healthcare), Chironair (Sims Portex), Daydrop (Loxley Medical) are among the most commonly available.

Excercises for your Anal Sphincter

This section is adapted with permission from a leaflet from St Mark's Hospital, Northwick Park, Harrow HA1 3JU

Sphincter exercises can help you to improve your bowel control. When done correctly, these exercises can build up and strengthen the muscles to help you hold both gas and stool in the back passage.

Where are these muscles?

The back passage, or anus, has two rings of muscle around it (see illustrations Side view and View from below). The inner ring is the internal sphincter, an involuntary muscle, which should be closed at all times, except when you are actually trying to open your bowels. This is normally automatic, you don't have to think about doing it.

The outer ring of muscle is the external sphincter, which is a voluntary muscle which you can tighten up to close it more firmly if you have urgency or diarrhoea.

Both muscles wrap right around the anus. When a stool comes into the rectum the internal sphincter relaxes and allows the stool to enter the top part of the anus. Very sensitive nerves in the anal canal can tell you if it gas or stool waiting to come out. If it is stool, you squeeze your external sphincter to stop it from coming straight out. This squeezing moves the stool back into the rectum, where it waits until you get to the toilet.

Either or both of these sphincter muscles can become weak. This may be because of childbirth, constipation and straining or general wear and tear. Sometimes there is no obvious reason why. If you have weak muscles and cannot squeeze enough to hang on, you will feel urgency and may leak gas, liquid or even solid stool. (See illustration Stool moves down)

How can exercises help?

Exercises can strengthen these muscles so that they once again give support (see illustration External sphincter squeezes). This will improve your bowel control and improve or stop leakage of gas or stool. Like any other muscles in the body, the more you use and exercise them, the stronger the sphincter muscles will be.

Learning to do the exercises

It is important to learn to do the exercises in the right way, and to check from time to time that you are still doing them correctly.

Sit comfortably with your knees slightly apart. Now imagine that you are trying to stop yourself passing wind from the bowel. To do this you must squeeze the muscle around the 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 much at all. You should be aware of the skin around the back passage tightening and being pulled up and away from your chair. Really try to feel this. You are now exercising your anal sphincter. You should not need to hold your breath when you tighten the muscles.

Now imagine that the sphincter muscle is a lift. When you squeeze as tightly as you can your lift goes up to the 4th floor. But you cannot hold it there for very long, and it will not get you safely to the toilet as it will get tired very quickly. So now squeeze more gently, take your lift only up to the 2nd floor. Feel how much longer you can hold it than at the maximum squeeze.

Practising Your Exercises

1. Sit, stand or lie with your knees slightly apart. Tighten and pull up the sphincter muscles as tightly as you can. Hold tightened for at least 5 seconds, then relax for at least 10 seconds.Repeat at least 5 times. This will work on the strength of your muscles.
2. 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 at least 5 times. This will work on the endurance or staying power of your muscles.
3. 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 at least 5 quick pull-ups.
4. Do these exercises - 5 as hard as you can, 5 as long as you can and as many quick pull-ups as you can - at least 10 times every day.
5. As the muscles get stronger, you will find that you can hold for longer than 5 seconds, and that you can do more pull-ups each time without the muscle getting tired.
6. 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.

Tips to help you

1. At first it is probably a good idea to set aside some time for these exercises and really concentrate on getting them right. But quite soon they should become easy to do wherever you are. Nobody need know at you are doing!
2. Get into the habit of doing your exercises with things you do regularly; every time you touch water if you are a housewife, every time you answer the phone if you are at the office whatever you do often.
3. If you are unsure that you are exercising the right muscle, put a finger on the anus as you squeeze to check. You should feel a gentle lift and squeeze if you are exercising the right muscle. Or look at the area in a mirror - you should see the anus pucker up as you squeeze it.
4. Use your muscles when you need them - pull up the muscles if you feel urgency and that you are about to leak. But remember that you cannot hold your tightest squeeze for very long, so you are better to use a gentle squeeze that you can hold for longer. Your control will gradually improve.
5. Watch your weight - extra weight puts extra strain on your muscles.
6. Once you have regained control of your bowel, don't forget your exercises. Continue to do them a few times each day to ensure that the problem does not come back.
7. Do your exercises regularly. Have faith in them. You should begin to see good results in a few weeks.

Do you have any questions?

This information sheet is designed to teach you how to exercise your anal sphincter to improve your bowel control. If you have problems doing the exercises, or if you don’t understand any part of this information sheet, phone Continence Foundation Helpline or ask your doctor, nurse or physiotherapist for help.

Skin care for people with Bowel Incontinence

This section is adapted with permission from a leaflet from St Mark's Hospital, Northwick Park, Harrow HA1 3JU

Why is good skin care important?

Anyone who has frequent bowel motions, diarrhoea or accidental leakage (faecal incontinence) may get sore skin around the back passage from time to time. This can be very uncomfortable and distressing. Occasionally, the skin may become so inflamed that it breaks into open sores. These are then difficult to heal.

Taking good care of the skin around your back passage can help to prevent these problems from developing.

Why may I get sore skin?

There are several different reasons why your skin may become sore:

• The scientific reason for itching is that it is due to chemicals contained in the bacteria of the bowel motions.
• Your bowel contains digestive juices and acid which break down your food to enable your body to use the nutrients in it. If you have very fluid bowel motions, the diarrhoea will still contain these juices and acid, which start to eat away any skin which they contact.
• If you have faecal incontinence, the small quantity of juices and acid left in even normal stool can damage the skin.
• If you open your bowels very frequently, repeated wiping can damage the sensitive skin of your anus.
• With some anal conditions, it is very difficult to wipe your bottom effectively - a little always seems to get left. This stool starts to make you sore.
• Sometimes, the area around the anus becomes infected.
• •If you have incontinence of the bladder and bowel, you will be more likely to get sore, as the urine and faeces react together.
• People who are not eating a healthy balanced diet, not drinking enough or not taking much exercise are more prone to soreness, as are people who are generally unwell and not very active or mobile. Tips to prevent soreness With careful personal hygiene it is often possible to prevent soreness, even if you have a bowel problem.
• After a bowel action, always wipe gently with soft toilet paper, or ideally the newer moist toilet paper (available from larger pharmacies and some supermarkets). Discard each piece of paper after one wipe, so that you are not re-contaminating the area you have just wiped.
• Whenever possible, wash around the anus after a bowel action. A bidet is ideal (portable versions are available). If this is not possible, you may be able to use a shower attachment with your bottom over the edge of the bath. Or use a soft disposable cloth with warm water Avoid flannels and sponges, as they can be rough and are difficult to keep clean. Sometimes a little ingenuity is needed, especially if you are away from home. Some people find that a small plant spray, watering can or jug filled with warm water makes washing easy on the toilet or over the edge of the bath.
• Do not be tempted to use disinfectants or antiseptics in the washing water as these can sting, and many people are sensitive to the chemicals in them. Just plain warm water is best.
• Avoid using products with a strong perfume such as scented soap, talcum powder, deodorants on your bottom. Choose a non-scented soap (e.g. 'Simple', or a baby soap). Many baby wipes contain alcohol and are best avoided.
• When drying the area be very gentle. Pat gently with soft toilet paper or a soft towel. Do not rub. Treat the whole area as you would a newborn baby's skin. If you are very sore, a hair dryer on a low setting may be most comfortable (use carefully!).
• Wear cotton underwear to allow the skin to breathe. Avoid tight jeans and other clothes that might rub the area. Women are usually best to avoid tights and to use stockings or crotchless tights instead. Use non-biological washing powder for underwear and towels.
• Avoid using any creams or lotions on the area, unless advised to do so. A few people who are prone to sore skin do find that regular use of a cream helps to prevent this. If you do use a barrier cream, choose a simple one (such as zinc and castor oil), use just a small amount and gently rub it in. Large amounts stop the skin from breathing and can make the area sweaty and uncomfortable. Make sure that the old layer of cream is washed off before applying more. Some people are allergic to lanolin, and creams containing this should be avoided.
• Your doctor or nurse may suggest using a barrier wipe which forms a protective film over the skin, especially if you have diarrhoea and are opening your bowels very frequently (available on prescription).
• If you need to wear a pad because of incontinence, try to make sure that no plastic comes into contact with your skin and that you use a pad with a soft surface. The Continence Nurse can advise you on which pads are best.
• Whenever possible, unless you have been advised not to for other reasons, eat a healthy, balanced diet, drink plenty and take as much exercise as you can. Some people find that certain food or drink makes them more prone to soreness, especially citrus fruit such as oranges. It may be worth cutting these out on a trial basis, and more permanently if this helps.

Note: Women are advised always to wipe front to back, i.e. away from the bladder and vaginal openings as bacteria from the bowel can infect the bladder and vagina if you wipe from back to front.

If you are already sore

• Follow all the advice above on prevention. In addition:
• You may find that damp cotton wool is most comfortable to use for wiping.
• Use a barrier cream or ointment as recommended by your doctor or nurse. If you have to choose your own, try Sudocrem or a small amount of Metanium. These are available from your chemist.
• If drying the skin after washing is difficult or uncomfortable, you may try using a hair dryer on a low setting.
• Try not to scratch the anal area, however much you are tempted, as this will make things worse. If you find that you are scratching the area in your sleep at night, you may consider wearing cotton gloves in bed (available from your chemist).
• Try to allow the air to get to the anal area for at least part of every day.
• Very sore skin may need specially prescribed barrier cream such as Chiron or a spray-on barrier such as Cavilon.
• Don't struggle on forever alone! Talk to your nurse or doctor, especially if your skin is broken. If you have persistently sore skin you may have an infection which needs treatment, and there are other products which can be prescribed to help heal the soreness.

Your Sphincter Repair Operation

This section is adapted with permission from a leaflet from St Mark's Hospital, Northwick Park, Harrow HA1 3JU

How will the operation help me?

The sphincter repair operation is beneficial for people whose anal sphincter is found on investigation to be damaged or very weak, giving them trouble with controlling their bowels. Research has shown that a sphincter repair operation is successful for 4 out of 5 people (80%) in this situation. This is the best treatment currently available.

During the operation the surgeon overlaps the damaged muscle ends to form a complete ring of muscle around the anus (see diagram). 

Preparation before the operation

You will probably go into hospital the day before the operation. Usually it is necessary to clear the bowel before this operation, so you will be given a strong laxative and be asked to drink only clear fluids. You will also have the routine blood tests done before any operation. You will be asked questions about your general state of health by the nurses and doctors on the ward, and this is a good time to discuss any further questions you have about the operation. You will also be visited by the anaesthetist before you go to the operating theatre.

Will I need a colostomy?

Some surgeons feel that a temporary colostomy (an artificial opening through the skin to empty the bowel) is sometimes advisable to rest the healing area and avoid exposing the healing wound to stool. Your surgeon will discuss this with you if he or she feels that it is required.

After the operation

You will probably have a dressing in place over the wound around your anus and this will usually be held in place by net pants. You will have a tube (catheter) in the bladder for a day or so until you are able to get to the toilet easily yourself. There is often quite a lot of bruising and swelling in the area and this can be rather uncomfortable for a few days. Painkillers will be available: ask your nurse if you need something to help with the discomfort. It is better to maintain your comfort by taking regular pain relief than to wait until you are uncomfortable before you take anything. Some people find that lying on the side with a pillow between the legs is the most comfortable position at first.

When you are awake you will be able to eat and drink as you wish, and to get up as soon as you feel able. It is advisable to stay on the ward until the effects of the anaesthetic have completely worn off.

When can I have a bath?

You will normally have a bath the next day and this will soak the dressing off. It is quite possible that you may bleed a little in the bath (do not be alarmed - this can make the water look very red!). Ask your nurse for assistance if you are concerned. You will probably find that frequent baths are soothing to the area. Do not put any additives into the bath water and avoid using soap on your wound. The nurses will usually re-dress your wound twice a day at first. They will show you how to do this for yourself as soon as you are able.

You may have some stitches on your skin. Sometimes the surgeon leaves the wound unstitched to allow better healing in the deep part of the wound. The stitches used will probably be soluble and will not need to be removed.

Opening your bowels after the operation

From the day after your operation you will be given laxatives. This will soften the stools and stimulate a bowel action. You may not open your bowels for a day or two, and when you do some discomfort and a little bleeding may be present. This is to be expected. The hospital will aim to control any discomfort by giving you pain killers as you require them. It is often a good idea to take pain killers 15-20 minutes before you try to open your bowels.

It is very important not to strain and to avoid constipation, and the hospital will therefore want you to have very soft stools. You may need to take laxatives to keep the stools soft. Unfortunately, this may mean that you will leak stool during this early period immediately after the operation. This does not mean that the operation has been a failure. It is necessary to wait a few weeks before judging the final results of the operation.

Personal Hygiene

It is important to keep the area around your wound clean. While you are in hospital you should take a bath or shower, or use the bidet after each time you open your bowels. It is especially important to keep clean if you are leaking stool. You may find that using a mirror helps you to ensure that your wound is clean.

You will probably find that a wet cloth, moist toilet tissue or alcohol-free wet wipes are more comfortable than dry paper for wiping (and women should remember to wipe front to back, away from the wound and vaginal area). You will need to change the gauze over your wound each time you open your bowels and if it gets wet when you pass urine. It is normal for your wound to ooze quite a bit of blood-stained fluid, and you will need to wear a pad to protect your clothes.

Length of stay in hospital

You will probably stay in hospital for 5-7 days after the operation, but this varies between individuals.

Care at home

Before you go home your nurse will discuss with you how your wound should be dressed once at home. You may be able to manage this yourself, or you may need some help from someone at home or from the district nurse. Until the wound is healed you should continue to use saline to clean it. You will find that tight clothes such as jeans are not comfortable in the early days. Healing can take several weeks, especially if your wound was not stitched, and you may find that you need to continue to use a mild painkiller such as paracetamol. It is quite common, particularly where the stitches were under some tension, for the wound to open up a little once you are home - this does not mean that the operation will not be a success. Neither does an infection in the wound mean that the operation will fail. The area will heal with time.

Once you are home, bathing every time you open your bowels may become less practical, but you should continue to wash after a bowel action if at all possible for 3-4 weeks after the operation. Sitting on the edge of the bath and using a shower attachment (if available) can make washing easier.

You should try to avoid excessive walking or sitting still until your wound has healed. Resume physical activity gradually and start with gentle walking. It would also be unwise to go swimming as the chlorine in the water can affect wound healing and you may pick up or pass on an infection.

You can resume sexual activity after 6-8 weeks if you feel comfortable.

It is not unusual for your bowels to need 6-8 weeks to get back to normal function. Do not be concerned if your bowel control is not perfect during this time. It is important to keep the wound as clean as possible until it has completely healed and to avoid constipation and straining to open your bowels by keeping your motions very soft, with a laxative if necessary. Use a mild bulking laxative such as Normacol to keep the stools soft if you need it, or if you are having difficulty emptying, a stimulant laxative such as Milpar can help. Both are available from your chemist. If you do get severely constipated you should contact the ward where you had your operation for advice.

Outpatient follow-up

You will probably be invited for an outpatient check-up 6-8 weeks after the operation. It is important that you talk to the doctor about any concerns that you have at that time. If your control is not yet perfect, you may be advised to do some exercises to strengthen your muscles around the anus. You should not start to do these exercises before you have been for this check-up as it is important that everything has healed properly first. You may like to ask to see the Continence Nurse if you need more advice at this time.

Going back to work

The time taken to get back to normal activities varies a lot for different people. You should do as much as you feel comfortable doing. If you need to take painkillers these may make you drowsy, so you should avoid driving or operating machinery. You should not start to drive again until your strength and speed of movement are up to coping with an emergency stop. You should also make sure that you are not drowsy from any painkillers and that your concentration is good. Most people do not start to drive for at least two weeks, and some take longer. If lifting causes you discomfort you should avoid it. Most people need a few weeks off work, but this will depend on what you do. It is important to pay attention to your body, and only do as much as you feel able to.

Where to get further information

If you have a problem or any questions immediately after you go home you should contact the ward where you were an inpatient. If a problem occurs after a few days at home, you should contact your own family doctor or district nurse for advice.