Cover image An Australian Government Initiative
IMPROVING BOWEL FUNCTION
AFTER BOWEL SURGERY
Practical advice

Contents

Introduction

Major abdominal surgery is usually part of the modern treatment of bowel cancer and other conditions such as Crohn’s disease, diverticular disease and ulcerative colitis. Bowel cancer treatment may also include chemotherapy or radiotherapy or both. It is not surprising, therefore, that treatment of your bowel disease may change the way in which your bowel functions.

Aim

The purpose of this booklet is to explain how and why bowel function changes after bowel surgery and to give you some simple guidelines for keeping things under control. This booklet does not deal with stoma care after a colostomy or ileostomy. If you need information about these procedures, talk to your surgeon and your nurse. A stomal therapy nurse will give you information about care of your stoma and will help with bowel care after your surgery.

What happens to the bowel during surgery?

Some of the more common types of bowel surgery are illustrated below. These are:

Left Hemicolectomy

—removal of the left side of the colon (large bowel).

Left Hemicolectomy

Diagram A shows a tumour (cancer).

Diagram B shows the dark shaded area as the part of the bowel removed during surgery. Similar procedures are used to remove parts of the bowel for other bowel conditions.


Right Hemicolectomy

—removal of the right side of the colon (large bowel).

Right Hemicolectomy

Anterior Resection

—removal of the left part of the colon and the upper part of the rectum.

Anterior Resection

Ultra-Low Anterior Resection

—removal of the left part of the colon and all of the rectum.

Ultra-Low Anterior Resection

Normal bowel function and what can go wrong after bowel surgery

This is a complex question. Most people think that having a bowel action once a day is “normal” and that going more often is better still. This is not strictly correct. The important elements of normal bowel function are:

For all of these three important functions to occur, a number of equally important elements need to be in place. These are:

SUMMARY—Problems with bowel function after bowel surgery

When a part or all of the large bowel is removed, and especially if that includes removal of part or all of the rectum, you are likely to experience softer and more frequent bowel actions that may be accompanied by:

The effects of removing part of the bowel might be made worse during treatment with both chemotherapy and radiotherapy. More lasting effects on bowel function might be seen after radiotherapy because of the permanent changes this treatment can create in otherwise healthy tissue.

Some people may experience constipation after bowel surgery. Information about constipation can be obtained from the National Continence Helpline or the Continence Foundation of Australia. Contact details are at the back of this booklet.

Flatus

A few words about flatus (gas from the back passage)

Most flatus is due to the production of gases from bacteria that live in the large bowel and break down undigested food. It is normal to produce some flatus each day and the amount varies from person to person, depending on the diet and the type of bacteria that live in the bowel. Some people pass small amounts of flatus often, whereas others pass larger amounts less often.

If the anal sphincter muscles are weak or damaged, you may have problems controlling flatus (ie passing gas from the back passage).

If you pass flatus more often than the usual range of 7 to 25 times per day, it may simply mean that you are consuming food or drink that disagrees with you, even though someone else eating the same food has no problem. There are some foods and drinks that tend to cause excess flatus and these are listed at the back of this booklet. More detailed information about foods that affect your bowel is in the section on diet, ahead.

Some habits that can lead to increased flatus include talking while eating; drinking from a straw, water bottle or fountain; sipping hot drinks; sighing deeply; smoking and chewing gum.

Some medications for flatus are available—talk to your doctor or a pharmacist.

Treating problems with bowel function

How can problems with bowel function be treated?

Although bowel function after bowel surgery is often disturbed, it is nearly always possible to bring it under satisfactory control with simple treatment.

The first thing to emphasise is that bowel function is at its worst immediately after bowel surgery (or the closure of a temporary colostomy or ileostomy if you have had one constructed).

Bowel function often improves quite rapidly in the first few months and can continue to do so for up to one year. even if you had your bowel surgery many years ago, you may still see improvement by following the advice in this booklet. So do not be disheartened if your bowel function is particularly difficult at first. It is likely to keep getting better over time.

The important steps to help improve your bowel function are quite simple:

1. Slow down your colonic transit time

Colonic transit time refers to the time it takes for the bowel contents to move along the length of the bowel.

After your surgery, it is much better for you to have solid, dry and slower bowel motions than soft, moist and frequent ones. Although this seems to contradict much of the advice that we give to the general population, the situation for people who have had part of the large bowel removed is often quite different. When bowel motions are firm, they are more easily controlled and the rectum will empty more effectively.

There are a few simple techniques available to you for making your bowel motions more solid, less liquid and generally slower and less gassy.

Diet

The correct approach to diet rests with identifying those foods that make our bowel motions too fast, too soft and too gassy—and then restricting them in our diet. These foods include:

Although we all need to have a balanced diet, many people who have had part of their bowel removed and are having problems with soft, fast moving bowel motions benefit from reducing (not necessarily eliminating) the food and drink listed in these groups.

The food chart at the back of this booklet provides a summary list of foods that may stimulate your bowel. People react differently to the same foods, so you need to find out which ones cause problems for you. If you suspect that particular foods or drinks irritate your bowel, it is best to eliminate them one at a time and wait for a few days to see the effect, before removing another. Combinations of certain foods may also be a problem.

The food chart also lists foods that generally help to firm up bowel motions. Finding the right balance between foods that stimulate the bowel and foods that help to make bowel motions firmer and slower takes time and patience. It is worth persisting to ensure that your diet is not only suitable for your bowel, but is also healthy and satisfying.

Do not reduce your total fluid and food intake in the false hope that this will reduce leakage from the bowel (for example, fasting before you go out). This can make your bowel habits more unpredictable. It is important to set up a healthy bowel pattern by eating food at regular times and drinking plenty of fluids, most of which should be water.

The amount of fluid you need to drink depends on your size, activity, diet and the weather. The best guide is to drink enough to satisfy your thirst. Some situations in which you may need to drink more are: taking fibre supplements, eating a high fibre or high protein diet; vomiting, diarrhoea, fever, physical activity, hot weather and plane flights. Certain medical conditions may require you to limit your fluid intake (eg kidney disease, some heart conditions). If in doubt, check with your doctor.

If you would like more specialised advice about your diet, you may wish to consult a continence adviser or dietician.

Fibre and fibre supplements

There are two types of dietary fibre - soluble and insoluble. Most plant foods have a mixture of both. In general, fibre absorbs water and makes stools bulkier.

Insoluble fibre speeds up bowel motions and is useful for treating constipation. Major sources of insoluble fibre are wholegrain wheat, wheat bran, corn and wholegrain rice cereals, fibrous vegetables such as carrots and celery and the skins of fruits and vegetables. This type of fibre should be avoided or reduced if you have soft, frequent bowel motions or leakage.

Soluble fibre turns into a gel during digestion. In people with diarrhoea, this can help to firm up and slow down the bowel motions. Therefore soluble fibre may help to prevent leakage associated with soft, frequent bowel motions. Sources of soluble fibre are oats, barley, rye, legumes (lentils, kidney beans, chick peas), peeled fruits and vegetables.

Fibre supplements There are many different types of fibre supplements, each with different actions. People react differently to each type of fibre, so you may need to try a few to see what works best for you. You can find some of these in supermarkets*. Others can be found in health food stores or pharmacies. Examples of soluble fibre supplements include:

In some people, these fibres may have no effect or may even aggravate diarrhoea, especially if high doses are taken. When first starting to take fibre supplements people sometimes experience uncomfortable side effects such as bloating, flatus and abdominal pain. These effects usually disappear within a week. It is best to begin with small amounts of fibre until your body adjusts, then gradually increase the amount over a few weeks until your bowel motions firm up. Some fibre supplements such as Normacol, may contain bowel stimulants and, therefore, may make diarrhoea worse.

When taking any form of fibre, it is important to drink more water, otherwise bowel motions will be difficult to pass.

A continence adviser can assist you in choosing the most appropriate fibre for your needs.

Medications

For many people who are experiencing problems with their bowel motions after bowel surgery, dietary restriction on its own is not completely effective. For others such as diabetics or vegetarians it can be almost impossible to make the necessary dietary changes. In this situation, it is useful to use anti-diarrhoeal medication that slows the colonic transit and dries out the bowel motion.

The safest agents available are loperamide (Imodium, Gastrostop) and lomotil. Many patients who have had bowel surgery, particularly those who have had treatment for rectal cancer including radiotherapy, find that regular use of loperamide capsules or tablets greatly improves their bowel habit and their quality of life. Taking loperamide before meals may help to prevent the bowel urgency that some people experience immediately after eating. Your family doctor will be able to advise you on anti-diarrhoeal medications and can provide an Authority Prescription if you require a large supply.

Of course, excessive intake of anti-diarrhoeal medication can cause troublesome constipation. These medications should always be commenced at low dosage and steadily increased until a satisfactory effect has been achieved. The advantage of loperamide over other agents is that prolonged use does not lead to tolerance. Therefore it remains effective and can be taken safely for long periods—for life, if necessary.

Another medication that may be prescribed for the treatment of diarrhoea is codeine phosphate (also found in Panadeine and Panadeine Forte). This agent can produce side-effects such as drowsiness and nausea and must only be taken as directed.

There are numerous medications that can cause diarrhoea or make it worse. The most common of these are:

If you are on these medications and have diarrhoea, you may need to discuss with your doctor the feasibility of using an alternative. Pharmacists may also do a comprehensive review of all your medications for a fee, to identify those likely to be causing diarrhoea.

Stress management

Stressful situations and feeling anxious can make your bowel actions loose and more frequent. It may not be possible to avoid stress altogether, but there are many ways to manage stress and reduce its negative effects on the body. Learning how to relax your body and calm your mind may help to settle your bowel and may also benefit other aspects of your health. Your family doctor can help you get started, and you can also find information in books and on the internet (see HeAlTHInsite in the Useful Contacts (National) section at the back of this booklet.

2. Empty your bowel more effectively

The first step in effective evacuation is keeping your bowel motions firm, so that the rectum can push them out more easily. Other important strategies are:

Good toileting habits

Always hold on until the urge is strong!

Getting your bowels to open effectively depends upon you reaching the toilet when the urge to evacuate is strong. This is even more important if your bowel actions have been made harder, drier and slower using the steps outlined earlier. It is vitally important that you never attempt to evacuate your bowels until the urge to do so is strong.

If you find that when you sit on the toilet, you must wait a long time for your bowel motions to get going, this almost certainly means that you have sat down before the urge was sufficiently strong. In that event, you should get up and leave and return only when you are absolutely certain that a bowel action is imminent.

Good posture when sitting on the toilet is important for effective evacuation. It allows the bowel to empty properly and it reduces straining. The diagram on the page below shows the correct position.


Good toileting posture


CAUTION: If you have had recent hip surgery do not use this position (check first with your doctor).


Lean forward a little and rest your elbows on your knees. At the same time, have your knees higher than your hips. You can do this by lifting your heels (as if your feet are on tip-toes). It may help to place a small stool or telephone book under your feet. Push your lower belly out to help relax your anal sphincter muscles (avoid this step if you have a hernia or weak abdominal muscles after repeated abdominal surgery).

Don’t get into the habit of straining at the end of the evacuation, thinking that this will prevent leakage from occurring later. Straining like this is harmful because it weakens the pelvic floor muscles, which then leads to leakage. As well as being harmful, straining can be frustrating and even exhausting.

Assisting rectal evacuation

Quite frequently after removal of part or all of the rectum, the usual pattern of rectal emptying is disturbed. Evacuation can often feel as if it has not been completed and, if a pouch or neorectal reservoir has been created, faecal matter may build up. This can then result in delayed leakage of stool, with soiling and irritation of the skin around the anus. This may cause embarrassment as well as genuine discomfort and soreness.

If you are not having success with simple strategies such as firming up the bowel motions with diet, soluble fibre and medication, you may wish to try suppositories and enemas. These help to clean out the remaining stool. Simple glycerine suppositories are the easiest to obtain and use. The usual dose is just one or two suppositories inserted into the rectum (back passage) after a bowel action. Enemas (Microlax, Fleet) can also be used but require an Authority Prescription for long term use.

Another highly effective strategy is irrigation of the lower part of the bowel, which requires training by a nurse expert in this technique. Once mastered, however, it is a simple and extremely useful way of improving bowel function, particularly when the rectum has been replaced by a pouch or neorectal reservoir. Stomal therapy nurses and continence nurses are likely to be the local experts in this useful technique.

3. Improve your ability to “hold on”

As discussed earlier, keeping you bowel motions firm will make them easier to control. Also remember that straining to empty your bowel will weaken your anal sphincter muscles. Other strategies that are important for controlling your bowel include pelvic floor muscle training and a sensible approach to physical activity.

Pelvic floor muscle training

Pelvic floor exercises are important in maintaining control of your anal sphincter muscles. The ability to control these muscles is one of the key factors in preventing leakage of gas or faeces. Pelvic floor exercises should be done every day by both women and men. The exercises help to prevent problems, as well as improve any existing problems. The exercises are simple and can be done any time at home. Pamphlets on pelvic floor muscle training are available from the National Continence Helpline and the Continence Foundation of Australia. You can also learn these exercises from a continence nurse or physiotherapist. Contact details are at the back of this booklet.

Physical activity

Many people notice that leakage is made worse by heavy lifting, squatting and strenuous physical activity. Avoid these activities wherever possible, especially when bowel motions are particularly soft. If you cannot avoid such activities, it is best to do them in the morning when your pelvic floor muscles are generally stronger.

It is important to remain active and you should try to do some gentle exercise such as walking for at least 30 minutes most days of the week. Daily exercise helps to promote regular bowel activity and benefits your overall health.

SUMMARY—How to improve bowel function

The most important steps you can take to improve your bowel function and bowel control are:

  1. Slow your colonic transit (make bowel motions firmer and slower):
  2. Empty your bowel more effectively:
  3. Improve your ability to “hold on”.

Skin care

Skin care (Practical assistance for a raw, sore bottom)

The skin around the back passage (and the genital area) is known as the perineal area. It is very sensitive and is easily irritated by enzymes present in faeces. When bowel motions are frequent and loose, the skin in the perineal area can become red, raw, sore, itchy, and prone to bleed. This condition is known as dermatitis.

Although it is vitally important that you slow down your colonic transit and firm up your bowel motions (using the steps outlined earlier), you might need some help in the meantime to protect your skin in this area and allow it to heal.

What causes perineal skin problems?

  1. Excess moisture - due to perspiration, wet pads, urine and faeces.
  2. Chemical irritation—from soaps, some skin care products (especially those containing fragrances and alcohol), urine and faeces.
  3. Mechanical damage—from too much wiping and rubbing, especially with dry toilet paper and rough washcloths.
  4. Infection—by bacteria or fungi. Infections tend to occur when skin is damaged by excess moisture, chemical or mechanical means.

How can perineal skin problems be prevented and treated?

The two key principles are (1), gentle cleaning of the skin and (2) preventing breaks in the skin or, if already damaged, helping the skin to heal. These principles are discussed in detail below.

Cleaning the skin

Gentle washing once or twice a day is sufficient if your skin is healthy and there is no leakage of faeces. If you have leakage, then clean the area very gently after each bowel action.

Skin should be cleaned with products that are “pH-balanced” and do not contain soap, alcohol, or fragrance. Use of soap removes the natural skin oils and increases the pH of the skin. This weakens the skin, increases the risk of breakdown and slows healing. Special skin cleansers are available from your pharmacy or from medical supply companies (see contacts at the back of this booklet).

Dry toilet paper and rough wash cloths can easily damage the skin. Try not to overwipe or overwash the perineal area because this irritates the skin and prevents healing of raw skin.

If the bowel motions are soft, or your skin is sore, non-alcoholic baby wipes can be used to gently clean the perineal area after a bowel motion. “Flushable” toilet wipes from supermarkets should be used with caution, as some may contain alcohol or fragrance. You may wish to try pre-moistened, disposable washcloths designed for cleaning the perineal area (Comfort Shield Perineal Care Washcloths). These also contain a moisturiser and barrier product to soothe and protect the skin.

Preventing skin breakdown and assisting healing

The first, vitally important step is to avoid or reduce contact with faeces and moisture. This involves firming up the stools to prevent leakage and keeping the skin clean, as previously mentioned.

Next, you should apply a moisturiser and, if the skin is sore or you have leakage, use a barrier skin cream. These may be combined in a single product. If your skin is broken or you have frequent leakage, a protective barrier film should be considered. These products are described in the next section (skin care products).

To reduce perspiration in the perineal area, wear cotton underwear, rather than synthetics (polyester, lycra, or nylon).

To absorb leakage away from the surface of the skin, different types of pads and disposable absorbent underwear are available for people with incontinence. These contain super-absorbent (and odour-reducing) substances to protect the skin from damage. You should change these when they become wet or soiled. Products can be purchased from a pharmacy or you may get a discounted price from a supplier. You may need to try different types to find the one that suits you (a nurse continence adviser can assist).

It is best to avoid using women’s sanitary products because these are not designed to absorb faecal material effectively.

Skin care products

Skin care products have an important role in cleaning, moisturising and protecting the skin. There are many different types available. You can use separate products for each purpose, or you can buy combination products that incorporate two or three skin care steps (cleaning, moisturising and barrier protection) into a single product. Some combination products are available as towelettes or wash cloths.

New, improved products appear on the market from time to time, so it is best to discuss your needs with a continence adviser, your local branch of the Continence Foundation of Australia, or the National Continence Helpline. Medical supply companies may also provide information and free samples to try. Contact details are at the back of this booklet.

Types of products

Applying creams, ointments and protective films

Before applying any of these products, ensure that the skin is clean and dry as described in the section on cleaning the skin. When indicated, medicated creams and ointments should be applied according to the prescription and if possible, after a bowel action.

Apply anti-fungal preparations sparingly, because too much can make the skin too moist and vulnerable to further breakdown.

SUMMARY—How to protect and heal the skin

The most important steps you can take to protect and heal skin in the perineal area are:

  • Avoid or reduce contact with moisture, perspiration, urine and faeces.
  • Clean the skin gently with a product that is pH-balanced and free from soap, alcohol and fragrance. Avoid rubbing and rough wash cloths.
  • Apply a moisturiser (may be combined with cleanser in the same product).
  • If the perineal area is sore, or if you have leakage, use a barrier skin cream or alcohol-free protective barrier film.
  • Use absorbent incontinence products for leakage and change when wet.
  • See a nurse continence adviser or your doctor if your skin does not improve. Prescription products may be needed.
  • After surgery

    Sexual activity after bowel surgery

    Normally, it is safe to have sexual intercourse 6 to 8 weeks after your bowel surgery, if there have been no complications. If you are female and your surgery involved the rectum, you are advised to wait for 10-12 weeks before having vaginal intercourse. After this time, if you are having difficulties such as discomfort or pain, you may find it helpful to try different positions to increase your comfort during sexual activity. If you are male, it is not unusual to have problems with erections after bowel surgery. Regardless of whether you are female or male, if you continue to have any problems with sexual activity after surgery, you should talk to your family doctor who can refer you to a specialist.

    What if things are not getting better?

    If the simple strategies outlined in this pamphlet are not proving successful, you will need to see your family doctor or your specialist surgeon for further advice. Other potential sources of assistance include such people as a stomal therapy nurse (if you have had a colostomy or ileostomy you will know this person well), continence nurse advisers and physiotherapists who specialise in incontinence. They can be contacted through the services listed on the following pages.

    Useful contacts

    National contacts

    National Continence Helpline

    Phone: 1800 33 00 66 (free call)

    The National Continence Helpline is a national continence advisory service funded under the Australian Government’s National Continence Management Strategy. The Helpline is a confidential service staffed by a team of experienced continence nurse advisors who provide information, education and advice to callers with incontinence or who are caring for someone with incontinence. The Helpline also provides information and advice to health professionals.

    Continence Foundation of Australia

    Internet: www.continence.org.au

    The Continence Foundation of Australia (CFA) is the national peak body for continence management, promotion and advocacy. The CFA website provides comprehensive information on living with incontinence, information resources, education and training options.

    The CFA also has a branch or representative in each State and Territory working to meet the mission of the CFA by raising the profile of incontinence and linking in with local health networks. To contact your local State or Territory branch visit the above website or contact the National Continence Helpline. (See above).

    The National Public Toilet Map

    Internet: www.toiletmap.gov.a

    The National Public Toilet Map identifies the location of more than 16,000 public toilet facilities in Australian towns and cities, including rural areas, and along major travel routes. Useful information is provided about each toilet, such as opening hours and access for people with a disability. If you cannot access the internet, the National Continence Helpline can assist you to obtain maps. (See above).

    Department of Health and Ageing—National Continence Management Strategy

    Internet: www.bladderbowel.gov.au

    This website promotes bladder and bowel health for consumers, health professionals, service providers, researchers and others. A range of bladder and bowel health publications developed through the National Continence Management Strategy are also available for download.

    Australian Health Map

    Internet: http://www.abc.net.au/health/healthmap/

    The Australian Health Map is a state by state guide to health resources, statistics and other health related information.

    Australian Government HEALTHInsite

    Internet: http://www.healthinsite.gov.au/

    Through this site you will find a wide range of up-to-date and quality assessed information on important health topics including information on stress and relaxation techniques found in the A-Z Health Topics section.

    Cancer Council Australia

    Cancer Helpline Phone: 13 11 20

    Internet: www.cancer.org.au

    The Cancer Council Helpline is a free, confidential telephone information and support service run by Cancer Councils in each state and territory. This helpline is available to answer questions about cancer and offer emotional and practical support for patients, people living with cancer, their families, carers and friends, teachers, students and health care professionals. Visit the Cancer Council website or call the helpline to locate your local State or Territory branch.

    Australian Physiotherapy Association

    Internet: www.physiotherapy.asn.au

    The Australian Physiotherapy Association (APA) is the peak body representing the interests of Australian physiotherapists and their patients. The APA website or toll free helpline provides advice and assistant with locating services.

    Food chart

    Food chart

    The following food chart lists foods that can cause or help bowel problems. This is only a guide as foods can affect people differently.

    Foods that cause flatus/gas/wind

    Foods that make bowel motions firmer

    Foods that make bowel motions softer and more frequent

    See the section on Diet for more information.



    Disclaimer: This booklet is intended to give a general overview of how to improve bowel function after surgery. However it is acknowledged that it is no substitute for obtaining professional assessment.



    Improving Bowel Function after Bowel Surgery

    ISBN: 1-74186-880-7
    Online ISBN: 1-74186-881-5
    Publications Approval Number: P3-5321


    Copyright Statements:

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    This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to the Department of Health and Ageing.

    Acknowledgment:

    This project was funded by the Australian Government Department of Health and Ageing, National Continence Management Strategy.

    National Continence Management Strategy    Sir Charles Gardiner Hospital     Edith Cowan University