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GUIDE TO BOWEL CONTROL Lesson

January 15, 2017

Learning Objectives and Purpose

After finishing this course, the CNAs will be able to:

  • Describe the symptoms of fecal incontinence
  • Be able to recognize the causes of fecal incontinence
  • Be able to assist patients suffering from constipation and loose stools
  • Be able to encourage lifestyle changes that include dietary modifications as efforts to regulate bowels
  • Be comfortable assisting patients during the bowel retraining program

 

Fecal incontinence, also called bowel incontinence, is the unintentional loss of stool (feces) or gas (flatus) due to a failure of one or more of the components that allow the body to control the evacuation of feces. It is the inability to control bowel movements, causing feces to leak unexpectedly from the rectum. Fecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control. For those suffering from fecal incontinence, it can be an embarrassing condition affecting their quality of life

A normal bowel movement requires a complex interaction and feedback system between the nervous and muscular system of the rectum and anus. The rectum, anus, pelvic muscles, and nervous system must work together to control bowel movements. If there is a disconnect with any of these systems, it can cause incontinence. Not being able to control bowel movements can lead to social isolation and depression. However, most people can be treated successfully with nonsurgical measures and improve their quality of life. The optimal goal for stool consistency is a formed, soft stool. Hard stools are difficult to evacuate causing constipation and leakage is more likely if stools are liquid.

In adults aged 65 years and older, women tend to have more problems with bowel control more often than men. Most adults who experience fecal incontinence only have an occasional bout of diarrhea. But some patients have recurring or chronic fecal incontinence which may affect their quality of life. They may be unable to resist the urge to defecate, which comes on so suddenly that they don’t make it to the bathroom in time. This is called urge incontinence. Passive incontinence is another type of fecal incontinence which occurs when patients are not aware of the need to pass stool.

 

Symptoms of fecal incontinence

Symptoms of fecal incontinence include:

  • Inability to resist the urge to defecate
  • Inability to make it to the toilet in time
  • Being unaware that you have passed stool
  • Diarrhea
  • Constipation
  • Gas and bloating

 

Causes of Fecal Incontinence

The most common cause of fecal incontinence is damage to the muscles around the anus, also called anal sphincters. Anal sphincters or their nerves can be damaged during vaginal childbirth which is why women are affected by accidental bowel leakage about twice as often as men. Anal surgery due to medical conditions like cancer can also damage the anal sphincters or nerves, leading to bowel incontinence. It is important to note that more than one cause for bowel incontinence is frequently present and it is not unusual for bowel incontinence to occur without a clear cause

There are many other potential causes of bowel incontinence, including:

  • Diarrhea, often due to an infection like C-diff (Clostridium difficile) or from a disease like irritable bowel syndrome
  • Impacted stool due to severe constipation common in older adults
  • Constipation where incontinence is caused by leakage of loose or small pieces of stool past the mass of constipated stool.
  • Nerve damage to the pelvic floor caused by chronic straining from constipation
  • Inflammatory bowel diseases like Crohn’s disease or Ulcerative Colitis.
  • Nerve damage due to Diabetes, Spinal cord injury, Multiple Sclerosis, Stroke or other medical conditions
  • Nerve injury caused by a tumor or radiation damage to the rectum such as after treatment for  prostate or rectal cancer
  • Cognitive impairment such as after a stroke or advanced Alzheimers or Dementia
  • Colon cancer
  • Rectal prolapse which is the result of the rectum dropping down into the anus can cause fecal incontinence
  • Rectocele; in women, fecal incontinence can occur if the rectum protrudes through the vagina

 

As you can see, there are multiple causes of bowel incontinence and in most cases, a patient may have one or more causes. Patients who suffers from chronic constipation are at a high risk of developing fecal incontinence. Constipation causes the anus muscles and intestines to stretch and weaken, leading to diarrhea and stool leakage around the impacted stool. Fecal impaction is usually caused by chronic constipation which leads to a lump of stool that partly blocks the large intestine. Bowel incontinence can also be caused by long-term laxative use or bowel surgery like colectomy. Sensory damage where a patient may not be able to sense that it’s time to have a bowel movement is another issue. Severe hemorrhoids or rectal prolapse can also be a risk factor for bowel incontinence.

 

Guide to Bowel Control For Patients with Loose Stools

  • To regulate bowel movements, patients should be encouraged to try to have a regular bowel movement daily after breakfast to prevent “accidents” later.
  • They should try to achieve normal stool consistency through dietary intake high in fiber. Dietary fiber refers to the parts of the food that humans are unable to digest. Formed but soft bowel movements are easier to control.
  • Patients should be taught how to strengthen their rectal (pelvic floor) muscles to improve bowel control. There are ideal exercises that improve bowel control like pelvic floor rehabilitation and pelvic floor exercises.
  • Nurse Assistants can also provide a commode in the patient’s room for those patient who have urge incontinence and cannot make it to the bathroom in time.

For those having liquid loose stools, the goal of bowel control is to have formed but soft bowel movements. This can be achieved by increasing the following foods in their diet like ripe bananas, Apples, Legumes (kidney, pinto, garbanzo, and lima beans, lentils), Dried fruit, Bran, and Ginger tea. Patients with loose stools should avoid Caffeinated coffee, tea, sodas, Chocolate, Milk products, Fruit juice, Fatty and greasy foods. Patients should also be instructed to avoid large meals. It is important to note that some medications like antibiotics and magnesium may cause or worsen bowel movements.

Some medications can be prescribed by the doctor for patients having loose stools. There are also over the counter lacto acidophilus capsules  and over the counter Imodium (loperamide) which can also help stop loose stools. Imodium is an over-the counter medication to treat loose, frequent bowel movements. Imodium has the side benefit of increasing muscle tone in the internal anal sphincter muscle, which may also help with incontinence.

Steps to Bowel Retraining for Patients with Loose Stools

Bowel training or retraining refers to behavioral programs designed to help people with bowel disorders establish control. Individuals with symptoms of inability to control bowel movements, incomplete emptying, or chronic constipation may benefit from these programs. Bowel retraining works by teaching new strategies to develop a routine and predictable schedule for fecal evacuation. The goal of bowel retraining is to prevent constipation and decrease unpredictable elimination.

Nurse assistants can help patients retrain their bowel with the following steps:

  • Have the patient sit on the toilet and encourage the patient to try to wait for 1 minute before having the
    bowel movement. Ask the patient to gradually increase this amount of time to 5 minutes. This will not happen overnight but with practice the patient will gain control and will be able to hold the urge.
  • When the patient have mastered the first step, have the patient repeat it, but hold on for 10 minutes before allowing himself to have a bowel movement. You can provide the patient with a book or magazine to read while he waits.
  • Once the patient is able to delay his bowel movement for 10 minutes while sitting on the toilet, it is time to begin to move away from the toilet. In the next stage, when the patient needs to have a bowel movement. Have the patient sit near the toilet on a chair inside or just outside the bathroom and hold for at least 5 minutes. Once he is able to do this, repeat the waiting exercise, increasing to 10 minutes.
  • When the patient is able to delay his bowel movement for 10 minutes while off the toilet, he should gradually move farther away from the toilet. As his muscles become stronger, he should be able to hold on for 10 minutes and, as he feel more confident, increase the distance between him and the toilet.

 

This exercise may take some time to master and will need the Nurse Assistant to be patient and available to wait with the patient, but if it is practiced together with the pelvic floor exercises, the patient will fully regain his bowel control.

 

Constipation

A person with a long history of constipation or have chronic constipation may take several months to accomplish regular emptying of the bowel. There are three principles of successful bowel training:

  1. Normalize the consistency of the stool. As mentioned above, soft but formed stools are more easily controlled.
  2. Have the patient establish a regular pattern for bowel movements. This helps prevent the stool from staying in the rectum for long periods, which leads to hardening of the stool and results in constipation.
  3. The patient should stimulate the bowel to empty on schedule. This helps prevent sudden emptying of the bowel at unpredictable times.

 

Steps for Constipation Management and Bowel Training

  • The first step is to clean out colon of hard stool on day one. Communicate with the nurse who can ask the doctor for an order of an oil-retention enema .
  • The next step is to set a routine schedule for a daily bowel movement (usually after breakfast). This will take advantage of what is known as the “gastrocolic reflex.” Filling the stomach with a meal causes a “movement” of the lower colon within a half-hour to 11⁄2 hours. This movement only lasts about 5 minutes. If your patient does not respond to this urge, he may lose his opportunity and the stool will become dry and hard leading to constipation.
  • Encourage dietary intake that includes breakfast with fiber. Fiber can help with constipation by drawing water into the stool so that hard stools and diarrhea do not occur. Softer and bulkier stools pass through the body more easily. This also helps with leakage of stool. The average American diet contains less than half of the recommended 30 grams of fiber per day. It is important to note that fiber is not found in meat or dairy products. It is found in whole grains, beans, legumes, fruits, and vegetables. Eating a high-fiber diet may also reduce the risk of heart disease and colon cancer.
  • Encourage patients to eat a well-balanced, regularly timed meals that are high in fiber preferably small meals rather than three large meals. As already mentioned, fiber adds bulk to the stool, eliminates excess fluids, and promotes more frequent and regular movements.
  • Encourage your patients to drink 12 to 16 ounces of hot liquid (coffee, tea, or hot water with lemon). Caffeine can help stimulate a bowel movement. With increasing fiber it is important to drink enough fluids. If fluid intake is inadequate, the stool becomes hard because less water is retained in the large intestine. The amount of fiber and fluids necessary for optimal bowel function varies among individuals. Dietitians are experts in evaluating and adjusting diets.
  • Encourage your patient to walk for 15 to 30 minutes after breakfast. This will increase the chance that he will stimulate the urge to have a bowel movement.
  • Instruct your constipated patient to respond to the slightest urge to have a bowel movement immediately. It is important to take advantage of the urge immediately otherwise ignoring the urge will lead to more constipation.
  • For a constipated patient who still do not have an urge for a bowel movement after the above measures, have him sit on the toilet for 5 minutes. Remind him not to bear down until he feels an urge to defecate.

 

Steps to Bowel Retraining for Patients with Constipation

  • Encourage your patient to perform abdominal breathing (abdomen goes in and out with each breath instead of his chest) or abdominal exercises (tighten and relax abdominal wall). This exercise is helpful in creating an urge to have a bowel movement or a colon contraction.
  • Be careful with patients who have a bulge at the vaginal or rectal opening (prolapse). Patients with rectal prolapse should not sit on the toilet for extended periods of time until the prolapse has been treated. Hemorrhoids can also be worsened by sitting and straining during a bowel movement.
  • Nurse Assistants should encourage patients to eat a diet with enough fiber like whole-wheat grains, fresh vegetables, and beans. They should avoid constipating foods, such as dairy products and low-fiber foods.
  • Have your patients drink at least 2 to 3 liters of fluid a day (unless they have a medical condition that requires them to restrict fluid intake like renal failure).

 

Dietary Modifications

Nurse Assistants should encourage patients to adapt the following diet modifications;

  • Add more fiber foods to their diet to avoid gas.
  • Use fresh fruits and raw or crisply cooked vegetables instead of juice.
  • Choose high-fiber cereals and whole-grain breads rather than sweetened cereals, bagels, or pasta.
  • Choose beans, peas, and lentils instead of chicken and meat.
  • Avoid bananas, white flour, and white rice because they may be constipating and break down into sugars quickly, contributing to weight gain.
  • Choose fiber from foods rather than supplements because foods supply important vitamins and minerals

 

When adding fiber to the diet, it is best to do so slowly over a period of weeks. If gas, bloating or distention occur, try reducing the dose of fiber and reducing consumption of gas-producing foods.

Examples of gas-producing foods to watch out for include:

  • beans
  • cabbage
  • legumes (e.g., peas, peanuts, soybeans)
  • apples
  • grapes
  • raisins

 

Tips on Adding Fiber

The following tips are recommended for adding fiber to a patient’s diet.

1. Vegetables~Cook only until tender-crisp to retain taste and nutrients

2. Beans~Presoaking reduces the gas-producing potential of beans if you discard the soaking water and cook using fresh water

3. Fruit~Fruits makes great healthy snacks. Use fresh and dried fruit in muffins, pancakes, quick breads, and on top of frozen yogurt

4. Grains~Choose whole-grain varieties of breads, muffins, bagels, and English muffins. Mix barely cooked vegetables with pasta for a quick pasta salad

 

BOWEL TRAINING

It is possible to use digital stimulation to trigger a bowel movement by inserting a lubricated finger into the anus. The finger should be moved in a circle until the sphincter muscle relaxes which may take a few minutes. Talk to the charge nurse who can be able to use digital stimulation if it is appropriate for your patient.

  • Assist your patient while in the bathroom and encourage him to contract the muscles of the abdomen and bear down while releasing the stool. It may be helpful to bend forward while bearing down for this increases the abdominal pressure and helps empty the bowel.
  • If digital stimulation does not work, talk to the charge nurse who can request a doctor’s order for using a suppository (glycerin or bisacodyl) or a small enema.
  • You can also provide your patient with warm prune juice or fruit nectar which can also stimulate a bowel movement in your patient.

Have your patient maintain a regular schedule for a bowel retraining program and set a regular time for daily bowel movements. Choose a time that is convenient for your patient. The best time for a bowel movement is 20 to 40 minutes after a meal, because feeding stimulates bowel activity.

Be patient with your patients during the bowel training program. It might take a few weeks before your patient is able to establish a regular routine bowel movements.

 

KEGEL EXERCISES

Exercises to strengthen the rectal muscles may help with bowel control in people who have an incompetent rectal sphincter. Kegel exercises that strengthen pelvic and rectal muscle tone can be used for this. These exercises were first developed to control incontinence in women after childbirth. To be successful with Kegel exercises, the patients need to use the proper technique and stick to a regular exercise program.

Medications That Can Worsen Constipation

• Opiates (codeine, morphine, Vicodin, OxyContin, Percocet)
• Anti-parkinsonian drugs
• Chlorpromazine
• Calcium-containing antacids (including Tums)
• Calcium supplements
• Nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen,
naproxen)
• Anti-urinary urge incontinence medication

 

Fecal incontinence treatment

Treatment for fecal incontinence involves lifestyle and dietary changes to relieve diarrhea or constipation, exercise programs to strengthen the muscles that control the bowel, medications to control diarrhea or constipation, and surgery. The treatment approach for a patient with fecal incontinence is individualized and is aimed at treating the underlying cause. The goal of treatment is to regulate bowel movements, decrease their frequency, and increase stool firmness and consistency. These measures will involve dietary changes and the use of medications that bulk the stool.

Increasing the strength of the muscles of the pelvic floor might also be helpful in regulating bowel movements. Kegel exercises and pelvic floor exercises may be recommended. If the incontinence persists even after maximum medical therapy has been attempted, surgery may be an alternative. If damaged, attempts can be made to repair the muscles of the pelvic floor including the external anal sphincter. The internal anal sphincter function may be enhanced by injecting materials like silicone, carbon beads, or collagen. As a last resort, where all other options have failed, a colostomy may be performed to divert the colon through the abdominal wall to empty into a removable bag.

 

 

 

References:
Journal of Wound, Ostomy, and Continence Nursing (JWOCN) 28(3): (May 2001
Johanson, J. American Journal of Gastroenterology, 1996.

National Digestive Diseases Information Clearinghouse: “Fecal Incontinence.”

O’Brien, P. Diseases of the Colon and Rectum, 2004.

https://medlineplus.gov/ency/article/003135.htm

Camilleri M. Disorders of gastrointestinal motility. In: Goldman L, Schafer AI, eds. Goldman’s Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 136.

Madoff RD. Diseases of the rectum and anus. In: Goldman L, Schafer AI, eds. Goldman’s Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 147

International Foundation for Functional Gastrointestinal Disorders. www.aboutincontinence.org
Wound, Ostomy, and Continence Nurses Society. www.wocn.org

Keeping Control: Understanding and Overcoming Fecal. Incontinence, by Marvin M. Schuster, MD, and Jacqueline
Wehmueller (Johns Hopkins University Press, 1994Bottom of Form