Movements

Stool Frequency and Consistency

Following the pelvic pouch procedure, the average person at six months has between four to six movements a day. However, everyone's response is different. There is a period of adaptation with the pelvic pouch. The pouch has to learn to expand and hold onto stool and this takes time.

While improvements will happen over time, as the pouch expands and more water is absorbed from the stool, there are some measures that can be done to help the situation. Suggested measures include:

• The first changes usually suggested are dietary ones: certain foods can help to thicken stool. Try food items such as smooth peanut butter, tapioca, oat bran muffins, white rice, applesauce, old cheddar cheeses, potato chips and bananas. If dietary changes are insufficient, then adding an over-the-counter (OTC) product like psyllium mucilage (Metamucil) may be helpful as this absorbs excess water and adds bulk to the stool. While usually small amounts are insufficient to make a noticeable difference, start with one to two teaspoons twice daily and gradually increase to one to two tablespoons two to three times daily, as needed.

• Remember, the stool from a pelvic pouch should never be formed or solid. Another OTC drug that is available and may be helpful is loperamide (Imodium). Imodium slows the transit time of stool through the bowel, and is also thought to improve anal sphincter tone. If used correctly and according to instructions, it can have minimal side effects. Try the liquid form or the quick-dissolve tablets, as these may be more readily absorbed than the regular tablets. If diet changes and OTC formulas are not sufficient to help slow the frequency and improve the consistency, other prescription drugs like codeine or Lomotil (available through your doctor) may be required.

• Unfortunately, the pouch does not stop functioning at night. Some people notice an increase in the number of bowel movements at night, which can be exhausting. Try having your largest meal at lunch, rather than during supper. Avoid eating four to six hours and avoiding large volumes of fluids before going to bed. Taking Imodium before bedtime may also be beneficial.

• Try not to respond to every urge to have a movement. Deep breathing, tightening the sphincter muscle and allowing the sensation to disappear may help to decrease the number of stools.

• Limiting the intake of fried and fatty foods, milk/milk products, spices, rich sauces with tomato base, sugars, caffeine beverages, raw fruits and vegetables may also help.

Stool Leakage

Improvement in stool leakage is largely a function of time. Suggestions to improve this situation include:

• Kegel exercises (used often for treating urinary incontinence) may be helpful. Kegel exercises require practice and commitment in order to be helpful, as the strengthening of the muscles and subsequent improvement in leakage does not happen quickly.

• Leakage may also initially be due to "misinterpretation" of messages from the new pouch. At the beginning, it is often difficult to differentiate between stool or gas in the pouch, and incorrect guesses may result in some stool leakage. For the first few months, always assume that any urge from the pouch is for stool, and sit on the toilet. Your capacity to differentiate between stool and gas may return over time.

• Leakage may occur at night, as the sphincter relaxes during sleep. Continue to wear a pad/panty-liner and barrier cream at night to prevent irritation. Make sure that you empty the pouch before going to bed. Some individuals suggest that sitting on the toilet for a longer time before bed and allowing the pouch to completely empty is helpful.

Night-Time Movements

Sleep interruption to use the bathroom can be exhausting. Most people eat the largest meal in the evening due to a typically busy work schedule. There are several suggestion to decrease the problem of nighttime movements. Suggestions include:

• Limiting what you eat four to six hours before bedtime. This also includes avoiding large quantities of liquids (especially carbonated beverages) and evening snacks. Eating your largest meal at lunchtime is encouraged.

• Taking medications such as Lomotil or Imodium before the evening meal and/or at bedtime may also be helpful. Medications should only be taken in consultation with your surgeon or gastroenterologist.

• Protecting the anal skin at night is important because during deep sleep, there can be small amounts of stool or mucous which may escape when the sphincter muscles are relaxed. If this does occur, it is usually temporary and often due to the very loose stool that is initially produced.

Emptying Problems
Allowing time for movements is an important factor in successful movements. The rectum normally contracts to squeeze stool out like you would squeeze toothpaste from a tube. This is why going to the bathroom is normally fairly quick and easy. A pelvic pouch, however, has to empty by gravity and this can take time. If individuals with pouches spend only a few seconds on the toilet they may only empty stool from the bottom quarter of their pouch. Then, 10 minutes later stool in the upper part of the pouch falls into the lower part and there is another trip to the toilet. Suggestions which may help emptying problems include:

• Sit and rest. Let the pouch completely empty and there will be more time between toilet stops.

• Imodium or Lomotil is helpful in slowing the bowel but Imodium may also create additional problems. By thickening the stool too much and by reducing peristalsis even more it may make emptying the pouch more difficult and make matters worse. Sometimes a semi-liquid stool is an advantage.

• Shifting on the toilet, standing and sitting allows for a better, more complete evacuation.

• Sit for longer periods of time on the toilet. While you may have an initial "gush" of stool and gas, this does not necessarily mean the pouch has completely emptied. Sit a bit longer and you may pass more gas and stool.

• Bear down slightly: a little increase in abdominal pressure by bearing down may also help to empty the pouch.

Continued difficulties with evacuating or emptying the pouch should be discussed with your surgeon as there may be other factors contributing to the problem, such as strictures/narrowing at the lower end of the pouch, or the type of pouch constructed.

Hemorrhoids

Hemorrhoidal tissue is left behind with the surgery. Hemorrhoids can develop due to the increase in stool frequency. Hemorrhoidal treatment would not vary. Suppositories or creams can be safely used following the pelvic pouch procedure.