Bowel control

Introduction

Loss of control of your bowel (faecal incontinence) can happen to different degrees and can happen to men and women of all ages. You must not be embarrassed about asking for help as there are ways in which we can treat the problem. Most people take bowel control for granted and naturally do not think about the processes involved. Bowel control is actually a complex process, dependent upon many factors some of which can change.

In general there are three factors that we can try to alter to improve bowel control. They are:

• The strength of the muscles around your back passage (the anal sphincter).
• The consistency of the bowel contents (stool), and
• Anxiety which may worsen symptoms

Where are the muscles?

There are two rings of muscles around the anus (the back passage). These form the anal sphincters and act to hold in the bowel contents.

The inner ring is the internal anal sphincter muscle. It should be closed at all times, except when you are trying to open your bowels. You cannot control this muscle.

The outer ring is the external anal sphincter muscle. You control this muscle and tighten it up to close it more firmly if you need to. Both muscles wrap 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 is 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.

If these muscles are damaged or weakened they may not close properly and 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 you may leak gas, liquid or stools.

When you pass a stool, there is usually some residue of the stool left behind in the anal canal (see diagram). Normally, the sphincter muscles ‘snap shut’ after you have finished opening your bowels to close off the back passage. This squeezes out any residue. You can then wipe clean and there is no further leakage.

If the muscles have become damaged or weak, they may not close immediately or completely after you have been to the toilet. This often makes it difficult to wipe clean, and you may find that you leak for a while after opening your bowels. This may be a small or a large amount and may last only a few minutes, or several hours. You may also find that you leak during strenuous exercise, lifting heavy weights or when you walk any distance. Some people find that a small amount of a stool is passed with wind.

Other people have a ‘funnel shaped’ anus. The weak sphincter muscle does not close properly and so stool gets stuck in the anal opening and does not make wiping easy.

How can exercises help?

By improving the strength of these muscles so that they offer more support, you may be able to improve bowel control and stop leakage. To do this you will need to practice squeezing the area many times each day to exercise the muscles. Like all muscles the more you exercise them the stronger they will become.

Learning to do the exercises

It is important to learn to do the exercise in the correct 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 the 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 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!

Next imagine your sphincter muscle is a lift. If you are relaxed your lift is resting on the ground floor. When you squeeze as tightly as you can it rises up to the third floor. You cannot hold that level of squeeze for very long as the muscle tires easily and will not get you safely to the toilet. Relax. Now take your lift just to the first floor. See how long you can hold this for.

Practising your exercises

Thinking of that outer ring of muscle, you need to tighten this around the back passage. This is known as a ‘squeeze’; you need to pull up this muscle as tightly as you can and do the following exercises:

Exercise 1

Squeeze for five seconds and then relax for five seconds.
Repeat five times.

Exercise 2

A half squeeze – squeeze very tightly, then relax the squeeze half way – hold for five seconds then relax completely.
Repeat five times.

Exercise 3

Imagine you are going up in a lift. Imagine you have a marble in your bottom and pull up to the first floor, pull up to the second floor and then pull up to the third floor – hold for five seconds and then relax completely.
Repeat 5 times

Exercise 4

Complete 10 quick squeezes.
Repeat five times.

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.
2. Get into the habit of doing your exercises with things you do regularly; every time you touch water if you are at home or 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 the 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 puts strain on the 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.

Remember – you can do these exercises wherever you are. Nobody need know what you are doing!

Stool consistency

Ideally stool should be soft and formed but the consistency can vary from liquid to hard lumps. The looser the stool the more difficult it may be to hold on to.

Some people find that by making changes to their diet, for example cutting back on high fibre foods such as fruit and vegetables, the stool becomes less bulky and firmer and this may improve your ability to control your bowels. Drugs such as loperamide (immodium), codeine phosphate or Lomitil may be used to firm up the stool. These drugs slow down the passage of stool through the bowel, so that more water can be absorbed and the stool becomes firmer and so less likely to leak. Medications such as Fybogel, Celevac or Normacol can help to produce a firmer stool by mopping up excess fluid in the bowel and may help some people.

Do not panic!

If you have had the horrible experience of losing control of your bowels you will understandably be anxious about it happening again and even panic if it does happen. Unfortunately, this can make the problem even worse as most people find that their emotions have an influence on their bowel actions. There are several ways in which you can improve this by remaining calm and practicing ‘holding on’.

By considering all of the above factors you can improve your bowel control but remember it is not easy and it will take time and practice.

Do you have any questions?

This leaflet is designed to help you with bowel control. If you have any problems with the exercises or if you do not understand any part of the leaflet please ask your nurse to help you.

Do your exercises regularly and you should begin to see good results in a few weeks.

Special instructions

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Contacts/ Further information

Biofeedback team - 01223 348106