Managing bowel late effects

If you have a bowel control problem, you may have:

• difficulty controlling when and how often you pass stools (poo) or wind
• problems controlling your bowel, leading to leakage or soiling, cramps, or bloating
• diarrhoea or constipation
• difficulty emptying your bowel completely.

Not feeling in control of your bowel can be stressful, particularly when you are away from home. Although you might find it difficult to talk about bowel control problems, it is important to tell your doctor or specialist nurse. There are many things that they can do to help.

Bowel problems may be caused as a late effect from pelvic radiotherapy, or as a result of late effects of bowel cancer treatment.

Your doctor or nurse will probably have helpful suggestions. The most common ways of improving bowel control include:

• changes to your diet
• drugs to regulate your bowel
• exercising and strengthening the muscles used for bowel control.

If your symptoms do not improve, you can ask your GP to refer you to a continence advisor, or a doctor who treats problems with the digestive system (gastroenterologist).

It is important to try to eat at regular times. This helps to encourage a regular bowel pattern. Skipping meals may make your symptoms worse.

You may notice certain foods make your stools loose or increase wind. You may want to try eating less of these foods, without cutting them out altogether. It is best to do this with the support of a dietitian. This is because it is important to continue to eat a wide range of different food types.

Your doctor can refer you to a dietitian for expert advice on managing your diet. The dietitian may ask you to keep a food and symptom diary. It lets them see the types of food you usually eat and what changes may help your symptoms.

Download our food and symptom diary [PDF]

Try to drink at least 1 to 2 litres (2 to 3½ pints) of fluids a day, unless your healthcare team tell you differently. Water is best. Drink smaller amounts through the day so that you do not drink lots of fluids with meals. Some types of drinks can make bowel problems worse. You may want to limit drinking:

• fizzy drinks
• caffeinated drinks (like coffee, tea or cola)
• alcohol
• sugar-free drinks that contain artificial sweeteners.

Changing the amount of fibre in your diet may help with bowel problems. Your doctor, nurse or dietitian will give you advice about the type of fibre you need and how much you should have. This depends on the treatment you had and the type of bowel problem.

There are 2 types of fibre:

• Insoluble fibre helps with managing constipation. It can also help with other bowel problems. You can get insoluble fibre from wholegrain bread and cereals, vegetables and fruit skins. It is also in bran and seeds.
• Soluble fibre helps bulk up and slow down bowel movements, so it may help improve diarrhoea or soft stools. You can get soluble fibre from oats and bananas, and from apples and pears with their skins removed. It is important to remove the skins, because they contain insoluble fibre.

If you are adding fibre to your diet, do it slowly. This gives your body time to adjust. Start with small amounts and slowly increase the amount when you are ready. Fibre absorbs fluid, so make sure you also drink more water. This helps the stool stay soft and move through the bowel easily.

Adding more fibre is not right for everyone. Following the 5-a-day plan for fruit and vegetables may not always be appropriate either. Your doctor, nurse or dietitian may give you advice about blending, slow cooking and peeling fruit and vegetables to reduce the amount of fibre you have.

Soluble fibre supplements

People with bowel control problems are often prescribed soluble fibre supplements, such as Normacol® or Fybogel®. They work by absorbing water and expanding to fill the bowel. This makes the stools bulkier and easier to push out. But some people find Fybogel® makes the bowel produce more wind.

If you are taking fibre supplements, make sure you drink plenty of fluids. You should drink at least 2 litres (3½ pints) of fluids every day.

Sometimes radiotherapy can affect how well your bowel copes with certain food types, such as lactose or fructose. Lactose is found in milk and some other dairy products. Fructose is found in sugar and fruit.

Symptoms of food intolerance may include:

• tummy cramps
• feeling bloated
• having more wind after eating a particular food.

If you think you may have a food intolerance, ask your GP to refer you to a gastroenterologist.

Food intolerance may improve over time, so it is worth trying foods again rather than avoiding them for long periods of time.

Drugs to treat constipation

If you have problems with constipation or difficulty emptying your bowel completely, you may be given one of the following treatments:

• Soluble fibre supplements – these include Fybogel^® or Normacol^®.
• Suppositories – you put these into your back passage or stoma. As they dissolve, they release a lubricant. This encourages the bowel to empty. They usually take about 10 to 30 minutes to work. It may be easier to use them at a time when you are able to stay near a toilet for a while after inserting them. You may not need to use them every day. Ask your doctor or nurse if you want to try using them at night so they have longer to work.
• Enemas – these contain a small amount of gel or liquid that you squeeze into the lower bowel. This stimulates the bowel to empty.

Drugs that can cause constipation

Your doctor can check whether you are taking any drugs that can cause constipation. They may be able to prescribe a different drug.

Medicines that may cause constipation include:

• opioid painkillers, such as codeine or morphine
• ondansetron, which is an anti-sickness drug
• iron tablets
• loperamide or other anti-diarrhoea drugs.

Exercises to strengthen the muscles used in bowel control are called pelvic floor exercises. These are sometimes called Kegel exercises. They may help with:

• urgency
• bowel incontinence
• difficulty emptying your bowel completely
• wind.

To avoid putting extra pressure on your pelvic floor muscles, try to keep your weight within healthy limits. You can also look after these muscles by avoiding getting constipated and not doing heavy lifting.

If you have ongoing problems with constipation or difficulty emptying your bowel, good toilet habits can help.

Most people find the best time to empty their bowel is about 30 minutes after a meal. But this can vary. You may already know what time works best for you. It is important not to push hard to try to pass a stool (poo). This can weaken your pelvic floor muscles and may cause problems with bowel control in the future.

If you have to wait for a long time on the toilet, you may be going to the toilet too soon. Or it may be a sign that you are constipated. Try not to go to the toilet until you have a strong urge to pass a stool. And try not to sit on the toilet for more than 20 minutes.

Sitting in the right position on the toilet can help you to empty your bowels. Lean forward a little and rest your elbows on your knees. Use a small footstool to raise your feet off the floor by about 20cm (8 inches). This will make your knees higher than your hips. Do not strain or hold your breath. Straining or holding your breath makes the muscles tighten, instead of relaxing them so you can pass stool. You may find using a relaxed breathing technique helps.

If you have had recent hip surgery, do not use this position. Always check with your doctor first.