I sometimes need to really rush to the toilet. I get a spasm in the lower part of my abdomen on the left, and I know that if I don’t reach a toilet quickly, I will mess myself. It can happen at any time, but it usually happens on the way to work. Most of the time I’m OK, but the fear of soiling myself in public has come to haunt me. I’ve tried taking Imodium, but it just makes me constipated, and then it’s all worse. What can I do?
Having to rush to the toilet is called ‘urgency of stool’. This is common in irritable bowel syndrome, but it is usually intermittent, occurring mainly in the morning rather than at night. If your urgency does not settle with the simple measures such as taking a small dose of loperamide, it’s possible that there is a more serious problem than irritable bowel syndrome irritating the rectum. You should see a doctor with a view to having a telescopic examination of your rectum (called flexible sigmoidoscopy) to see whether there is inflammation in the wall of your rectum (colitis) or even a polyp (a small mushroom-like growth, usually not yet malignant) or a tumour.
As you have discovered, it’s important to avoid constipation. If your rectum is full, it’s much more likely to spasm and force you to rush to the toilet. Ideally, you should have an empty rectum before leaving home in the morning. This means giving yourself enough time. It may mean having breakfast and waiting long enough before leaving home for your bowel to empty. Filling your stomach with food or drink is a natural way to stimulate your bowels to work. It is called the gastrocolic reflex and involves a subconscious message from the stomach to the brain informing the brain that the stomach is full, followed by a message from the brain to the bowel increasing its muscular activity. In some people it is a strong reflex, particularly in the morning, in others it hardly exists.
. . . I’ve tried to give myself enough time before and after breakfast. I may go several times, but I still get caught short half way to work! What can I do?
You can try taking a glycerine or bisacodyl suppository when you get up. They work quite quickly and will help to clear the rectum. If one or other isn’t enough, you can try both together. The glycerine will draw water into your rectum and elicit a call to stool, while the bisacodyl will stimulate the rectal muscles to clear the rectum.
If suppositories are not effective enough, you can use an enema. Sodium citrate enemas (Micralax and Relaxit Micro-enema) are available without prescription. They come in single-dose disposable packs with a nozzle. Each dose is only 5 ml (about one teaspoonful) of liquid. They are effective and work quickly.
This may sound rather drastic but it is better than being caught short. Moreover, with time, this approach may habituate your bowel to clearing itself in the morning such that you no longer require the suppositories.
I can empty my rectum with a suppository, but I still get a terrible urge to go to the toilet on the way to work. I hold on, and by the time I get to work, there is little or nothing to pass. Even so, it can make my journey a nightmare. I’m always afraid of soiling myself.
It may be that your bowel is simply very active in the morning or that is has somehow got into the habit of reacting this way to the stress and tension of the start of the day. In either case, you can try to reduce spasm with antispasmodic medication such as dicycloverine (dicyclomine) or mebeverine (these require a prescription in most countries), or plant extracts such as alverine citrate or peppermint oil, which are usually available over the counter. The most effective solution might be to clear your rectum with a suppository and then take loperamide before going out. But this does run the risk of making you constipated and perpetuating the problem.
Would changing the fibre content of my diet help?
Some people find that bulking up their stool with extra fibre does give them more control and less spasm. Others find that more fibre makes their diarrhoea worse, sometimes much worse. It’s a matter of experimenting. Eating less fibre may well give you harder stools, which are easier to hold in, but on the other hand if you become constipated, the whole problem could be much worse. It is also worth trying to avoid stimulants to the bowel such as caffeine. Caffeine is present in coffee and to a lesser extent in tea, cola drinks and chocolate.
I frequently feel the need to go to the toilet urgently, but I only pass small soft or sometimes hard pellets. And despite the urgency, I actually have to strain fairly hard to get them out. It never feels like I have cleared my rectum. What can I do?
You may have a sensitive rectum in which even the minimal distension caused by a small pellet of stool makes you feel you want to go to the toilet urgently. We all find it difficult to pass small pellets, and it’s never satisfying. You may well improve with more fibre in your diet. Extra fibre will change pellet-like stools to more sausageshaped stools, which are easier to pass and more satisfying.
I don’t get diarrhoea as such, but I do leak small amounts of stool and mucus. It’s terribly irritating as well as embarrassing. What can I do?
Firming up your stool with small doses of loperamide will probably help. Loperamide also tightens the anal sphincter – the muscle that stops stool leaking out.
A weak anal sphincter may be your problem. It may be weakened with age, but giving birth is the most common cause of damage. One study has demonstrated that over a third of women have damage to their anal sphincter after their first vaginal delivery. If the delivery is difficult and forceps are used, up to 80% may have damage to their anal sphincter. The consequence is faecal leakage in later life. It usually isn’t severe, but even a little can be very irritating and disruptive.
Is there anything I can do to strengthen my anal sphincter?
You can try to strengthen your anal sphincter by exercising it. This means repeatedly tightening and relaxing your anus. The sphincter is a muscle, and just like any other muscle, it should strengthen with exercise. In fact, if you want to tighten your anal sphincter, it’s necessary to work all the muscles in your pelvic floor. So this exercise is recommended for women with stress incontinence (leakage of urine occurring with normal physical activity such as laughing, coughing, lifting or other exercise) and for men with incontinence following prostate surgery, as well as for people with faecal leakage. It is also said to improve sexual function in women by strengthening the vaginal muscles. In the USA, pelvic floor exercises are called Kegel exercises after their originator, Dr Arnold Kegel.
What do pelvic floor (Kegel) exercises feel like?
First, sit on the toilet and start to urinate. Try to stop the flow of urine in midstream by contracting your pelvic floor muscles. Try not to contract your abdominal, thigh or buttock muscles – they should remain relaxed. Repeat this action several times until you become familiar with the feel of contracting the correct group of muscles.
Some people find this exercise very easy to do, whereas others have a problem identifying the group of muscles that form the pelvic floor and keep contracting their abdominal wall or thigh muscles. Another approach is to place a finger in the rectum or vagina and to tighten your muscles around it, squeezing against the resistance of the finger, holding and then releasing.
This is called an isometric exercise. In this, the length of the muscle is unchanged but the exercise increases the tone of the muscle, so it’s tighter at rest. The strength of the muscle contraction is also increased, allowing a better control of urinary or faecal urgency.
A woman may also strengthen these muscles by using a vaginal cone, which is a weighted device that is inserted into her vagina. She can then try to contract the pelvic floor muscles in an effort to hold the device in place.
I have heard of biofeedback as a treatment for incontinence. What exactly does it involve?
For those people who are unsure whether they are performing the procedure correctly, biofeedback and electrical stimulation may be used to help to identify the correct muscle group to work on. Biofeedback is a method of positive reinforcement. Electrodes are placed on the abdomen and along the anal area. Some therapists place a sensor in the vagina if the person is a woman, or the anus if a man, to monitor the contraction of the pelvic floor muscles. A monitor displays a graph showing which muscles are contracting and which are at rest. The therapist can then help to identify the correct muscles for performing pelvic floor exercises. Simple biofeedback equipment can be purchased for use at home.
Electrical stimulation involves using low-voltage electric current to stimulate the correct group of muscles. The current may be delivered using an anal or vaginal probe. The electrical stimulation therapy may be performed in the clinic or at home. The electrical stimulation helps the patient feel which muscles she should be working. The monitors will show her if she is working the right muscle groups, and by trial and error help her learn to better control them.
Simple biofeedback equipment can be purchased for use at home. The electrical current is just strong enough to cause muscles to contract but below the level that would cause pain. There is thus minimal if any discomfort. Once the woman has learnt to perform the exercises correctly, the biofeedback equipment is no longer necessary.
How much should I exercise my pelvic floor?
There are different recommendations, but essentially the more you do, the more likely you are to improve. You can do these exercises any time and anywhere – no one needs to know, and no one will notice.
You should do two kinds of pelvic floor exercises: short squeezes and long squeezes. To do the short squeezes, tighten your pelvic floor muscles quickly, squeeze hard for 2 seconds and then relax the muscle. To do the long squeezes, tighten the muscle for 5–10 seconds before you relax. Do both of these exercises 40–50 times each day.
How long will it take for these exercises to make a difference?
Some people will improve within a couple of weeks, whereas with others it may take 6 weeks or more. You should plan on continuing the exercises for at least 6–12 weeks. Sadly, not everyone will improve even with biofeedback.
ITCHY ANUS (PRURITUS ANI)
Why do I get a terrible itching in my anus?
There are many possible causes of this, and it’s very common in people with loose stools or incontinence of the stools. The skin of the anus is easily irritated by frequent wiping. Tiny amounts of faeces repeatedly contaminate the sore skin around the anus, leading to more irritation. This itching is almost impossible to resist, and we can even scratch unconsciously in our sleep. The scratching damages the skin even more, leading to soreness. Healing is then associated with itching, and an itch–scratch cycle develops. The skin never gets chance to heal properly, so the problem continues.
How should I look after my anus?
First of all, keep it clean and dry. Wash the skin with water after each stool whenever possible. You may wish to carry a small bottle of water with you when you are out or at work. At least, moisten the toilet paper with water and be gentle. Pat the skin dry, and do not rub it, however tempting this may be. Some people with hairy bottoms use a hair-drier. Wear loose clothing and avoid nylon to reduce sweating.
Next, avoid irritants. Soaps and scents can irritate the skin. Spicy foods, tomatoes and fruit can also cause anal irritation in some people. Along with other high-fibre foods, they can cause loose stools and flatulence that will make anal hygiene more difficult.
Finally, you can try creams and ointments. Many creams and ointments are available to soothe the anus. Most are marketed for treating haemorrhoids (piles), but they will also help with itching and soreness. Those containing a local anaesthetic (such as lignocaine) are especially effective. Unfortunately, it is possible to become sensitised to one or more of the ingredients in these preparations, especially to the local anaesthetic. Once you are sensitised, the cream only gives temporary relief and may exacerbate the problem by causing dermatitis (eczema) in the anal area. It is worth using these preparations for a few days to a week when the problem starts or if it is severe, to help you interrupt the itch–scratch cycle.
What’s the difference between a cream and an ointment?
Creams are a mixture of oil and water, whereas ointments contain no water and are just grease based. This difference is important. Because of their water content, creams must contain preservatives, to which our skin can become sensitive. Creams are more absorbable and wash off easily, whereas ointments leave a greasy layer on the skin. Ointments will therefore offer more protection to the anal skin from irritants in the stool, moisture and friction. The choice of ointment or cream is one of personal comfort, but if you have a difficult or persisting problem, an ointment is probably better both to protect the skin and to avoid preservatives.
Which cream or ointment should I use?
It’s perfectly all right to use an ointment or a cream with local anaesthetic in to relieve the torture of anal soreness or itching. Use whichever preparation you find most comfortable; most are available without prescription. But bear in mind that your skin can become sensitised to these preparations within weeks or days, so try and use them for as short a time as possible and concentrate on anal hygiene. If you need to use something, get as bland a preparation as possible. Petroleum jelly (Vaseline) or the creams and ointments produced to prevent nappy rash in babies may also work in adults.
What about steroid-containing ointments?
These can be useful to break the itch–scratch cycle or help anal dermatitis (eczema). They should be for short-term use only, otherwise they will thin and damage the skin.
I have a terrible problem with anal itching at night. What can I do?
You can try a sedating antihistamine tablet before bed. Chlor – phenamine (Piriton) is available without prescription. It will reduce itching and help you sleep (the sedative effect). It can be used in the long term and is not addictive.
You may also scratch in your sleep without realising. To help this, wear loose cotton briefs at night to reduce your unconscious access to your anus, keep your fingernails short to limit any damage done to the skin and consider wearing cotton gloves at night to prevent sharp scratching with the fingernails
. . . . I’ve tried all of these things but I still have a terrible problem with anal itching. What should I do?
It’s worth seeing your doctor. There are other possible causes of anal itching, including skin conditions such as eczema or psoriasis, infections such as threadworms or thrush, and occasionally anal tumours.
What are threadworms?
Threadworms are small intestinal worm parasites. The female worm lays many tiny eggs around the anus, and around the vagina and urethra in girls. This usually happens at night, when the infested person is asleep. When laying the eggs, the female worm also secretes an irritant mucus, which causes the person to scratch the itchy area. The eggs then stick under the fingernails and on the fingertips, and can be transferred to the mouth to cause reinfestation. The worms may be seen in the stool or on the anus and look like threads of cotton about 2–13 millimetres long.
Threadworm infection is most common in young children and can be prevented or treated by strict hygiene. A single dose of the medication mebendazole will kill all the worms; it can be purchased without a prescription.
I’m very embarrassed by this problem. Do you have any other advice?
Good advice sheets are available at www.patient.co.uk or www.prodigy.nhs.uk.
CONCLUSION
In terms of comfort and long-term health, it is probably marginally better to be on the loose side than to be constipated. It certainly does no harm to be loose, or even to have frank diarrhoea, providing you drink enough to keep well hydrated. But it can be inconvenient and may lead to a sore anus. Diarrhoea in irritable bowel syndrome usually responds to small doses of loperamide. If it does not, the diagnosis should be reconsidered. Weight loss, night-time diarrhoea and blood in the stools are not features of irritable bowel syndrome and should prompt investigation for more serious pathology. An urgent need to go to the toilet, especially if there is any faecal leakage or anal irritation, can be particularly troublesome. There are several approaches to try and you should not be embarrassed to ask for advice.
SUMMARY
About one third of people with irritable bowel syndrome have diarrhoea as one of their main problems (IBS-D).
A number of conditions can masquerade as IBS-D, including lactose intolerance, fructose intolerance, coeliac disease, small bowel bacterial overgrowth, mild inflammatory bowel disease and giardiasis.
Diarrhoea in irritable bowel syndrome is usually easily controlled with small doses of loperamide.
Diarrhoea occurring at night is unlikely to be due to irritable bowel syndrome.
Diarrhoea associated with involuntary weight loss is unlikely to be due to irritable bowel syndrome.
A change in bowel habit to looser, more frequent stools in a person over the age of 50 should be investigated to exclude bowel cancer, which is a possible cause.
Pelvic floor exercises are the key to controlling incontinence but need to be continued for at least 6 weeks.
Consult your doctor. Your local hospital may have a Nurse Continence Advisor.
Anal cleanliness is the key to controlling anal itching.
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