Bowel Cancer Care Advice

Treating bowel function problems after bowel cancer surgery

There are a number of ways bowel problems can be treated. Treatments to help reduce bowel function problems are often based on one or more of these.

Which treatments are likely to work best for you will depend on your symptoms and what is causing them, so it’s important that you see a doctor to be properly assessed.

Slowing down bowel transit time

Slowing down the passage of stools through your bowel will help to reduce the frequency of bowel motions. It will also mean your stools are less liquid. If you have firmer bowel motions, they will be easier to control  and it will be easier for you to completely empty your  bowel.

Diet, anti-diarrhoeal medicines and stress management can all help slow bowel transit time. However,  if these don’t work, ask your GP for a referral to a gastroenterologist who might suggest other treatments which could be useful.

Diet

It’s important to try to continue to eat a wide range of different food types. If you’re very limited in what    you can eat because of how food affects your bowel, it’s definitely worth getting advice from a doctor or dietitian. It may be that another treatment, such as anti-diarrhoeal medicine, would help you to manage your bowel symptoms better and allow you to eat a wider range of foods.

Your doctor or dietitian may recommend making changes to your diet to help with bowel symptoms. This may involve eating at regular times or adjusting the amount of fibre in your diet..

Skipping meals may make your symptoms worse by making your bowel habits unpredictable. Eating at regular times helps to encourage a regular bowel pattern.

It’s important to drink at least 1-2 litres of liquid a day. Water is best. Drinking smaller amounts throughout the day is better than drinking large amounts of liquid with meals.

Some people notice that certain types of food increase their bowel symptoms. If you think certain foods are making your symptoms worse talk to your doctor about this. You may benefit from seeing a dietitian who can advise you on whether adjusting your diet may be helpful and how best to do this.

Keeping a daily diary of what you eat and how this affects you can help you to work out if certain foods make your symptoms worse

Foods affect people differently, so if you’re making changes to your diet there may be some trial and error.

Fibre

Fibre is important in regulating how your bowel works. There are two types of fibre; insoluble fibre and soluble fibre:

  • Insoluble fibre speeds up bowel motions. It’s useful for treating constipation but avoid it if you have soft, frequent bowel motions or leakage. Insoluble fibre is found in bran, seeds and foods such as bread or cereals labelled as multigrain, wholegrain or wholemeal.
  • Soluble fibre can help to firm up and slow down bowel motions, so it may help to reduce diarrhoea or soft stools. It’s found in oats, porridge, bananas, and in apples and pears with their skin removed (the skin contains insoluble fibre).

Pulses such as peas, beans and lentils are also high in soluble fibre, but pulses stimulate the bowel so are not recommended for people with diarrhoea or soft stools.

Your dietitian, specialist nurse, continence adviser or bowel specialist will advise you on the type of fibre you need and how much you should have.

Fibre supplements

Soluble fibre supplements such as sterculia (Normacol®) and ispaghula (Fybogel®) are often prescribed for people who have frequent bowel motions, incontinence or incomplete bowel emptying (difficulty emptying the bowel). They’re also used to prevent constipation.

Fibre supplements work by absorbing water and expanding to fill the bowel, making stools bulkier and easier to push out. Fybogel can make the bowel produce a lot of gas (wind).

If this is a problem for you, sterculia (Normacol®) works as well, but without causing excessive wind.

Always make sure you’re drinking plenty of fluids each day (at least two litres) when you’re taking fibre supplements.

If you’re adding fibre to your diet, do so gradually to give your body time to adjust. Start with small amounts and slowly increase this when you’re ready. Some high-fibre foods can make you produce more gas, so you may need to avoid these if you have problems with wind and bloating. You should also make sure you drink more water if you are adding more fibre to your diet.

Eating more fibre won’t be right for everyone. If you’ve had radiotherapy to your bowel, you may not be able to cope with as much fibre in your diet as before. So, eating the recommended five portions of fruit and/or vegetables every day may not always be appropriate.

Medicines

It’s important to speak to your doctor or specialist nurse before taking medicines to treat bowel symptoms.

Anti-diarrhoeal drugs

Anti-diarrhoeal drugs work by slowing bowel transit time and drying out the bowel   motions.

The most commonly used anti-diarrhoeal drug is loperamide (also called Imodium® or Diareze®). It slows down your bowel; making the stools more solid and less frequent.

Taking loperamide regularly, half an hour before meals, works very well for some people. Loperamide is also available as a syrup, so you can adjust the dose as needed. It may take time to find what dose works best for you. Your doctor may recommend you start with a low dose and increase this until it’s right for   you.

It’s safe to take loperamide for as long as you need it, but you should discuss this with your doctor. Other anti-diarrhoeal medicines, such as lomotil or codeine phosphate, are also sometimes used.

Medicines that can increase bowel symptoms Some medicines can make bowel symptoms such as wind or frequent bowel motions worse. These include:

  • non-steroidal anti-inflammatory painkillers (NSAIDs), such as ibuprofen and diclofenac magnesium in antacids (for heartburn)
  • lactulose and Fybogel
  • metformin – a tablet used to treat diabetes
  • beta-blockers – tablets to treat high blood pressure antibiotics
  • some types of antidepressants such as venlafaxine and  citalopram.
  • If you’re taking any of these drugs and think they may be making your symptoms worse, talk to your doctor about whether there are any alternative drugs that might affect you less.

Managing stress

Your emotions can also affect your bowel. Anxiety and stressful situations can make bowel movements looser and more frequent. If you don’t feel in control of your bowel, this in itself can be   stressful.

Learning how to relax may help to settle your bowel and will be good for your general health. Stress reduction is taught at some continence clinics. Your doctor or specialist nurse can tell you about relaxation classes in your area. Some support groups also offer relaxation classes.

Relaxation tapes and CDs are available from bookshops and some health shops, and you can download relaxation podcasts from the internet. Some people find that complementary therapies help them feel less stressed. Our cancer support specialists can give you details of what is available in your area.

Emptying your bowel more effectively

After rectal surgery some people may find it difficult to completely empty their bowel. Signs that your lower bowel may not be emptying completely can include:

  • Feeling there is still something in your bowel after you have passed a stool
  • Having faecal leakage after you have been to the toilet
  • Feeling there is still something in your bowel after you have passed a stool
  • Feeling the need to return several times after having a bowel movement.

It’s best to hold off going to the toilet until the urge to pass a stool is strong. For most people the best time to empty the bowel is around 30 minutes after eating a meal (breakfast or main meal).

Straining to try to complete a bowel movement can weaken your pelvic floor muscles and cause problems with bowel control in future. If you have to wait for a long time after sitting down this may mean that you’re going to the toilet too soon or that you’re constipated.

Sitting in the right position is very important in helping you to empty your bowels effectively. Lean forward a little and rest your elbows on your knees. Have your knees higher than your hips. It may help to place a small footstool or telephone book under your feet. Don’t strain or hold your breath. You may find using a relaxed breathing technique helps.

toilet_correct_position

This is the correct position for emptying your bowels

Caution: if you have had recent hip surgery don’t use this position, and always check first with your doctor.

If you have constipation, include more fibre in your diet and eat more foods that encourage (stimulate) your bowel to empty.

A food and symptom diary will help you to learn how different foods affect   you.

Some people may need to take laxatives to stimulate their bowel as well as making dietary changes. Your doctor or a continence adviser can assess your need for laxatives.

Bowel motions that are too soft can also cause problems with incomplete emptying. Look at our suggestions on diet and anti-diarrhoeal medicines for help in dealing with this. If you still have difficulty emptying your bowel completely; suppositories, enemas or bowel irrigation may be recommended for you. Your doctor or a continence specialist can talk through these options with you and help you to decide which might suit you     best.

Suppositories

You put these into your back passage or stoma. As they dissolve they release a lubricant, such as glycerin, which encourages the bowel to empty. They usually take about 10-30 minutes to work.

Enemas 

These contain a small amount of gel or liquid that you squeeze into the lower bowel to stimulate it to empty.

Bowel or colostomy irrigation

This is a way of emptying the bowel by introducing warm water into it. Some people use bowel irrigation to help control an irregular bowel habit.

It means you can empty your bowel at a time that suits you and that you are less likely to have leakage or incontinence at other times.

Irrigation can also be used to regulate a stoma (this is called colostomy irrigation). This can mean fewer worries about a stoma becoming active at inconvenient times.

You place a narrow, flexible tube (catheter) into your back passage or stoma and then introduce water into the bowel through this. You usually do this every day or every other day. It takes about half an hour.

Some people find bowel or colostomy irrigation too time-consuming, but others say they feel more in control of their bowel and more confident as a result. If you want to know more about bowel or colostomy irrigation, ask your continence specialist or stoma nurse. If it’s suitable for you, you’ll be taught how to do it and given the equipment you need to carry it out.

You should only use bowel or colostomy irrigation if recommended by a healthcare professional.

Exercises to strengthen the muscles used for bowel control

If you have leakage from your bowel, learning exercises to strengthen the muscles that are important for bowel control can help.

There are two main groups of muscles that are important for bowel control. These are the sphincter muscles in the back passage (anus) and the pelvic floor muscles, which are also important for bladder control and sexual function.

Pelvic floor exercises (sometimes called Kegel exercises) may help if you have problems with leakage of wind or stool from your back passage. A continence specialist can tell you if these exercises are likely to help you and can teach you how to do them. The Bladder and Bowel Foundation also produces a fact sheet with instructions on how to do them which you can order or download from its website.

It can take at least 12 weeks of practising pelvic floor exercises three times a day to get the muscles back into shape. As your muscles improve, try doing the exercises while you’re doing everyday  jobs.

Biofeedback training

If you find it difficult to learn the exercises, you may be offered biofeedback training to help you. As you squeeze your pelvic floor muscles, the pressure is measured by sensors. This helps you to know when you’re squeezing in the right way. Ask your continence adviser for more information about this.

Bowel retraining

Having loose bowels or urgency can affect your confidence in your ability to ‘hold on’. Worrying that you may not get to the toilet in time can make you very anxious. You may be very aware of any activity in your bowel, including wind, as you try to monitor your bowel for signs that you need to ‘go’.

Continence specialists can help by teaching you to retrain your bowel. The aim is to help you build up the length of time you can ‘hold on’. Bowel retraining will most likely be used in combination with other approaches such as anti-diarrhoeal medicines and muscle strengthening exercises.

With bowel retraining you learn to resist the urge to go right away. At first you start by getting to a toilet when you feel the urge. You then wait for a minute or so before actually sitting on the toilet to open your   bowels.

The aim is to gradually increase the time between feeling the urge to go and then emptying your bowel. This will build up your confidence and give you more control of your bowel.

Treating bile acid malabsorption

If you’ve had radiotherapy to the bowel, or surgery to the right side of the colon (a right hemicolectomy) and you have episodes of diarrhoea (that aren’t helped by anti-diarrhoeal medicines) you may have bile acid malabsorption.

This can be treated by a drug called colestyramine (Questran®). It comes as a powder that you mix with water or fruit juice. Most specialists advise taking it at mealtimes rather than (as the instructions say) on an empty stomach, because they believe it works better and is easier to take this way.

If your stool is sometimes pale, smelly and difficult to flush away, colestyramine may not work or it may make things worse. If this happens, your specialist may prescribe a newer medicine called colesevelam (Cholestagel®). You may also be referred to a dietitian for advice on following a diet that’s lower in fat.

Sacral nerve stimulation

This is a new treatment that is sometimes used to treat bowel symptoms that are very troublesome and haven’t been helped by other treatments.

Sacral nerve stimulation uses electrical pulses to stimulate the nerves to the bowel and regulate how it

works. It involves placing electrodes under the skin in the lower back (sacral area) and connecting them to a pulse generator. This produces pulses of electricity that are thought to affect the nerves that control the lower part of the bowel and the anal sphincter.

The treatment is given in two parts. First you are tested with temporary electrodes to see if sacral nerve stimulation works for you. If the test is successful you’ll be offered an operation to have a small permanent implant fitted.

Specialist products

If you have problems with bowel leakage or incontinence, you may want to wear an absorbent pad in your underwear in case of accidents.

Pads and pants with charcoal linings, and stoma bags with filters can help to minimise odours from leakage or wind. There are a wide range of products available and a continence specialist or stoma nurse can help you select what type best suits your needs.

If you have a stoma, it can take some time to find the right equipment that works best for you. It’s important that you get expert support and advice from your stoma nurse while you’re doing this.

Anal plugs are used by some people who have leakage from their bowel. They are made from soft foam and stop leakage for up to 12 hours. A cord attached to the plug allows you to remove it when you’re ready.

Some people find anal plugs uncomfortable to begin with but most people get used to them after using them a few times.

Late effects clinic

If any of the above symptoms persist 6 months after completion of treatment. Please ask to be referred to the Late effects service, which is part of the Hunts Community Cancer Network run by Gini Melesi.

Peripheral Neuropathy after bowel cancer treatment

Peripheral neuropathy (also called neuropathy) is a term used to describe damage to nerves that carry messages between the brain, the spinal cord and the rest of the body.

Nerve damage can cause symptoms such as pins and needles, numbness, weakness, or pain in the hands and feet. For a few people this may lead to problems with balance and walking.

Treatment with the chemotherapy drug Oxaliplatin is the most common cause of peripheral neuropathy in people who’ve had treatment for bowel cancer. After treatment is over, most people find their symptoms gradually improve as the nerves slowly recover. This usually takes several months. But for some people the nerves don’t completely recover and some nerve damage is long-term.

Despite this, many people find that their symptoms become less troublesome over time as they adapt and find ways of coping with the changes.

Treating pain

Nerve pain can be treated in different ways. Some drugs alter nerve impulses and so help to relieve nerve pain. Drugs that can do this include: some antidepressants, anticonvulsants (drugs used to treat epilepsy) and some heart drugs. Drugs such as morphine can also sometimes be helpful.

If your pain is difficult to treat, you can ask for a referral to a pain clinic where you can get expert help from specialist doctors and nurses.

Transcutaneous electrical nerve stimulation (TENS) uses pads, put onto the skin, that give off small electrical pulses to stimulate nerves close to the pain. This may block pain messages sent from the nerves to the brain and is unlikely to cause side effects.

Acupuncture uses very fine needles that are placed through the skin at particular points. It isn’t clear exactly how this works, but it may help to block pain messages from being sent to the brain. Some hospitals and GP surgeries offer acupuncture on the NHS. You can read more in our section about cancer and complementary therapies.

Other support

A physiotherapist will be able to offer treatment and advice for problems with balance or walking.

If you’re having difficulty carrying out daily tasks, you can ask to be referred to an occupational therapist. They can assess your needs and recommend aids and equipment to help you.

If your symptoms continue for more than six months and cause you difficulty in walking or carrying out daily activities, you may be entitled to financial help. You can contact our cancer support specialists for more information.

What you can do to help yourself

If your hands and/or feet are affected it’s important to protect them as much as possible. If your balance, coordination or walking is affected, it’s important to reduce your risk of accidents and falls.

Here are some general tips:

  • Keep your hands/feet warm – wear gloves and warm socks in cold weather. Wear well-fitting shoes or boots.
  • Wear gloves when working with your hands, for example when doing household chores, gardening or DIY.
  • Use potholders and oven gloves to avoid burning your hands when cooking. Avoid walking around barefoot and check your feet regularly for any   problems.
  • Test the temperature of water with your elbow to make sure that it isn’t too hot before baths or showers.
  • Turn the temperature control to a lower setting for hot water or have a temperature control (thermostat) fitted.
  • Make sure rooms are well lit, and always put on a light if you get up during the   night.
  • Keep areas that you walk through, such as halls, free of clutter and make sure there aren’t things such as loose rugs that you could trip over.
  • Get advice from a physiotherapist about walking aids if your balance is affected.