Hi,

I had my take-down operation over 4 months ago, but I am still struggling with incontinence. I saw my surgeon almost 2 months ago and he said my sphincter tone is fine (both inner sphincter and external sphincter). He said it was strong enough to prevent incontinence. He said slowing my bowel down may help so he added 4 x 60mg of codeine per day to my 12 loperamide per day. This in fact caused my stool to become even more watery so I stopped the codeine and increased the loperamide to 16 per day, which was another option the surgeon gave me. My stools (poo) continued to be watery, so I reduced it to my previous 12 per day and now am on 10 per day. I take 5 before each of two meals, breakfast and lunch (midday). I used to eat a slice of bread and peanut butter in the evening, about 4 hours before bed, but it didn’t make much difference so I have stopped.

The surgeon put me on Cipro for 2 weeks before he saw me and he examined my pouch with a camera and said there was no inflammation, ruling out pouchitis. He said he would refer me for a manometry test to check my sphincter muscles. My nurse later requested a pouch scope. I am still waiting for these as they were put down as non-urgent, on the NHS.

I have been doing Kegel exercises since my operation and am trying now to squeeze as hard as I can to build up muscle strength, as of 4 days ago.

The stool just pushes through, however, especially when I walk. Wind often pushes it through.

I cannot understand why my muscles cannot hold the stool in if my surgeon said they have good muscle tone, enough to prevent incontinence. I have quite high frequency but often not a lot comes out. I can hold it in for a few hours but often go every hour or even more frequently if I feel burning.

My diet is quite bland: potatoes, fish, pasta, white bread, bananas, peanut butter, marmite. I also take a multivitamin with iron supplement. I avoid sugar. I am adding small amounts of vegetables just for a bit of variety, but no more than a desert spoon at a time.

My bowel is active on a night and usually empties by about midnight or in the small hours and I can then sleep properly.

I am wondering if my sphincters are damaged, or were cut too short during surgery, or whether they are simply weak. I had a bag for 5 years and my GP said my muscles will need strengthening because of that. Hence, I keep doing the Kegels. 

Any advice would be appreciated.

Thanks for taking the time to read this.

Original Post

The manometry will give you a definitive answer about sphincter strength. In the meantime, have you tried insoluble (edit: should be *soluble*) fiber, such as psyllium? In the right dose and frequency that can do wonders for watery stool.

Potatoes, pasta, and white bread pretty quickly turn to sugar in the gut. I’m not at all sure that’s your problem, but it’s best to know what you’re really eating. If you are avoiding sugar to try to influence your gut then you’d most likely have to avoid starches as well to achieve the intended change.

It sounds like your sense of urgency is experienced as a burning sensation, rather than fullness. Have I got that right? Are you really having accidents if you try to hold it in?

Hi Scott,

I may try insoluble fibre, thanks for the suggestion.

I noticed sugar made me burn a lot but I don't get that much burning now I have cut it out.

I don't get a sense of fulness but it is more a case of feeling the stool pushing through, or a burning sensation. I have occasional accidents if it is very watery.

Thanks for your comment.

If the bowel movements and incontinence are coming right after eating, you may have a motility issue.  Loperamide will not help for motility issues- it's an anti-diarrheal, not an anti-spasmodic.  You need to take an anti-spasmodic 45 minutes before meals and at bedtime if in fact that is the issue.  I had a lot of motility issues right after takedown.  It can be out of whack for a while after any bowel surgery.

CTBarrister posted:

If the bowel movements and incontinence are coming right after eating, you may have a motility issue.  Loperamide will not help for motility issues- it's an anti-diarrheal, not an anti-spasmodic.  You need to take an anti-spasmodic 45 minutes before meals and at bedtime if in fact that is the issue.  I had a lot of motility issues right after takedown.  It can be out of whack for a while after any bowel surgery.

Thanks, CTB,

the bowel movements are not coming right after eating, although maybe a little.

Not sure what a motility issue is. Something to do with the how the bowel moves the food through?

Scott F posted:

Nick, I meant to suggest soluble fiber (like psyllium) rather than insoluble fiber (like celery). I’ve edited my post above. My apologies. I hope it helps. I’ve been using it every day since my surgery 17 years ago.

Thanks Scott. I will check with my nurse. Do you take it with meals?

It is interesting that I took a course of antibiotics, Flucloxacillin, a couple of months ago for a week and my bms reduced to around 8 a day but went up again when it finished. But then the Cipro antibiotic didn't do anything for me.

I am taking a pro-biotic capsule a day to give the good bacteria an upper hand.

Also a peppermint oil capsule a day for wind and 2 x 30 mg of Omeprazole. 

Thanks, Scott. It definitely sounds as though it is worth trying. I am not sure that thickening my stool up would solve the problem as sometimes it pushes through when there isn't much there. Is this related to motility?

I am interested in finding out what a motility issue is. I sometimes get stool pushing through when there is nothing much to follow it. It is as if it is being pushed through by peristalsis, i.e. the rhythmic contraction of the ileum that moves food through. Is this related to motility?

Another point, I lost 10 kilos in weight since my surgery and have not started to put it back on yet. Is this something to do with recovery? I read elsewhere that someone tried to gain weight and then after 9 months out of nowhere she started to put it on.

Nick-

If your sphincter is providing enough back pressure, there are a couple of things that can push out stool involuntarily. CT mentioned a spasmodic pouch (“motility issue”), and if your doctor thinks that might be the cause, an antispasmodic (like Bentyl or Levin) could be worth trying. The most common cause of this is pouchitis, but the fact that it looks non-inflamed and Cipro didn’t help suggest that’s not it. If you run out of options, though, a course of Flagyl might be worth a try, just in case it’s pouchitis that doesn’t look like much and doesn’t respond to Cipro.

Bulking up the stool with soluble fiber makes it much easier for the sphincter to hold it back. I suggest you try psyllium first, and if that gives you gas or doesn’t work there are other options (Benefiber, Citrucel, etc.).

Good luck!

Hi all,

I am going to try metronidazole (Flagyl) for possible pouchitis.

I notice there is some kind of smallish nodule in my back passage, about an inch in, and wondered if this could cause a bad seal and make me incontinent?

Comments appreciated.

Thanks Scott - you said you don't think the nodule is making me incontinent - that is actually a relief as what could I have done about it? At least now I can focus on the exercises to strengthen the muscles and hope in some results from the Flagyl.

My nurse didn't encourage me about the psyllium. She said:

"As far as fibre is concerned- you can try it – but to be honest, I think hearing how your pouch is and how it is quite sensitive to different foods, the psyllium husk may irritate your bowel – I have had other people try it and it made them quite explosive and loose..."

So I am avoiding it for now.

Thanks again.

Nick, I think the nurse is giving you poor advice. I don’t know if the fiber will help you, but the experiment is easy, quick, and essentially risk-free. You’ll know the answer in a day or three. Some folks get benefit and some folks don’t.

It’t best not to change multiple things at once, though, so if you’re starting the Flagyl don’t add psyllium, too.

I second Scott’s suggestion of Metamucil. Seriously it can work wonders. post surgery it took me from 14 bm’s Per day to 6 formed ones with no urgency or leakage. Think of it like jello powder-it just soaks up and forms all the liquid to make it easier to contain and feel when it needs to pass, I had lots of the issues you are describing initially and Metamucil and eliminating dairy helped a ton. Have you met with a dietician? I would take their advice/suggestions over a nurse. Nothing against nurses who are wonderful human beings and professionals of course, it’s just not their area of expertise. 

Scott F posted:

I don’t think the nodule is likely to be contributing to the problem. Have you tried psyllium? Good luck with the Flagyl, Nick!

I wonder if my sphincter muscles were cut too short or something. Not sure how long the sphincter should be?

Thanks for your comments.

Scott F posted:

Nick, I think the nurse is giving you poor advice. I don’t know if the fiber will help you, but the experiment is easy, quick, and essentially risk-free. You’ll know the answer in a day or three. Some folks get benefit and some folks don’t.

It’t best not to change multiple things at once, though, so if you’re starting the Flagyl don’t add psyllium, too.

I see what you mean, Scott.

I will discuss it with her again when the Flagyl has finished.

Thanks.

duck11 posted:

I second Scott’s suggestion of Metamucil. Seriously it can work wonders. post surgery it took me from 14 bm’s Per day to 6 formed ones with no urgency or leakage. Think of it like jello powder-it just soaks up and forms all the liquid to make it easier to contain and feel when it needs to pass, I had lots of the issues you are describing initially and Metamucil and eliminating dairy helped a ton. Have you met with a dietician? I would take their advice/suggestions over a nurse. Nothing against nurses who are wonderful human beings and professionals of course, it’s just not their area of expertise. 

wow, that's an amazing improvement, from 14 bms to 6. I haven't met with a dietician, but it is something I can look into.

Thanks for your comment!

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