Physicians of the Zane Cohen Centre IBD Patients Problems Following Pelvic Pouch SurgeryPhysicians of the Zane Cohen Centre
Kegel Exercises
Improve your Pouch Functioning with Kegel Exercises
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.
What are Kegel, or pelvic muscle, exercises?
Pelvic muscle exercises, also called Kegel or pelvic floor exercises, have been shown to improve mild to moderate urge and stress incontinence. When performed correctly, these exercises help to strengthen the muscles at your bladder outlet as well as your stool outlet. Through regular exercise you can build strength and endurance to help improve, regain, or maintain bladder and bowel control.
After pelvic pouch surgery, the pelvic floor muscles may become weakened. These muscles extend from the spine to the pubic bone. The pelvic floor muscles can be envisioned as a hammock with several gaps that allow for the birth canal as well as the passage of urine and feces. With surgery, these muscles can be stretched and weakened with resultant sagging of the hammock and enlargement of the gaps. These muscles should be strengthened by performing Kegel exercises.
To perform Kegel exercises, imagine that you need to hold back gas. Squeeze and lift the rectal area, and for women also the vaginal area, without tightening the buttocks or abdomen. When you first begin your exercise program, check yourself frequently by looking in a mirror or by placing your hands on your abdomen and buttocks to insure that you do not feel your abdomen, thighs, or buttocks move. If there is movement, continue to experiment until you have isolated the correct muscles of the pelvic floor.
Another technique used to help you identify the correct pelvic muscles is to attempt to stop or slow the flow of urine. While urinating, partially empty your bladder then try to stop or slow the flow of urine. Do not be discouraged if you are unable to stop or change the flow. Slowing the flow is a good start.
There are two type of Kegel exercises - Type 1 and 2 . The first exercise, type 1, works on the holding ability of the muscles. It is done by slowly tightening, lifting, and drawing in the pelvic floor muscles and holding them to a count of five. Concentrate on lifting the muscles and holding the contraction while progressing slowly over a period of weeks. The goal should be 10 seconds. Rest for 10 seconds between each contraction.
The second exercise, Type 2, is a quick contraction. The muscles are quickly tightened, lifted up, and let go. This works the muscles that control urine and stool flow.
Adapted from the National Association for Continence (NAFC).
www.nafc.org or phone # 1-800-BLADDER.
Pouchitis
Pouchitis is an inflammation of the pelvic pouch that can result in a number of symptoms, including increased bowel movements, abdominal cramping and bloating, generalized fatigue/malaise, fever, and sometimes blood in the stools. In some cases, it can also result in joint pain and weight loss.
The etiology or cause of pouchitis is unknown, although it is believed to be related to an overgrowth of bacteria in the pouch. Approximately 30 to 50 per cent of individuals with the pelvic pouch will develop pouchitis at some point in their life. A small minority of individuals (less than one per cent) will develop chronic pouchitis and may require long-term treatment. The development of pouchitis also appears to be related to the underlying cause for the surgery itself. The incidence of pouchitis tends to be greater in those with a diagnosis of ulcerative colitis than in those with familial polyposis. The main symptom for most individuals with pouchitis is an abnormally large number of stools. An increase from four to six (on average) stools may occur. Individuals may also experience rectal bleeding, abdominal cramping, a sense of "urgency" before having a bowel movement, and fever.
Individuals who have any of the above symptoms listed above could have pouchitis. However, several other conditions could also cause similar symptoms. These include irritable bowel syndrome, small bowel obstruction from scar tissue, narrowing of the join (anastomosis) between the anus and the pouch, an intestinal infection with bacterial or parasites, and Crohn's disease. For this reason, individuals whose symptoms suggest pouchitis should be seen by either their colorectal surgeon or gastroenterologist to have a flexible sigmoidoscopy (examination of the pouch with a flexible lighted instrument). At this time, biopsies (tissue samples) of the pouch should also be obtained.
At Mount Sinai Hospital , approximately 40 per cent of our patients with the Pelvic Pouch will develop pouchitis at some point in their life. As more time passes since the creation of the pouch, the more likely it is that pouchitis will occur.
The cause of pouchitis is not known. Several theories have been suggested, including: an excess of bacteria in the pouch; a recurrence of inflammatory bowel disease in the pouch and misdiagnosis of ulcerative colitis. In a minority of patients, it may be difficult to differentiate between Crohn's disease and Colitis. Problems that may occur post-operatively could be related to the fact that the patient has Crohn's disease.
Individuals with pouchitis often improve with antibiotics, suggesting that bacteria are an important factor in the development of this condition. Pouchitis occurs more commonly in people with extraintestinal problems associated with ulcerative colitis (e.g. arthritis or abnormalities of the liver, skin, or eyes). These findings suggest that pouchitis may be a new type of IBD, which occurs in the pouch. The majority of individuals with pouchitis do not have Crohn's disease.
Research is being done to identify the cause of pouchitis. Some investigators are looking for "triggering" bacteria or disease markers, such as antibodies. One early finding is that pouchitis is more common in ulcerative colitis patients who have antineutrophil cytoplasmic antibodies (ANCA) in their blood. Not everyone who has ANCA will get pouchitis. The most likely cause is two fold: a genetic susceptibility to both ulcerative colitis and pouchitis, combined with a "trigger," such as bacteria, within the stool in the pouch.
Antibiotics are the most common treatment for pouchitis. The most common prescription is a combination of Ciprofloxin and metronidazole (Flagyl). Most, if not all, individuals initially improve after taking metronidazole, usually within one or two days. The length of treatment is usually one to two weeks. A small minority of individuals may require continual treatment for chronic pouchitis.
Italian researchers are reporting that high doses of probiotics (healthy bacteria) appear to be an effective therapy for maintaining remission in patients with chronic pouchitis. Other studies have shown that 5-aminosalicylates, steroids, immunomodulators, anti-TNF-alpha therapies, may also be effective in treating recurrent or chronic pouchitis.
Recently, there has been interest in the use of probiotics to treat pouchitis. Research has shown that certain bacteria in the bowel may promote inflammation while others may have a more protective role. Probiotics are an attempt to reintroduce protective bacteria into the bowel. Some probiotics may be available through health food stores or a pharmacy, but as they are not yet regulated. Probiotics will vary in their quality and in the viability of the bacteria and positive outcomes cannot be guaranteed.
Helpful suggestions that may reduce the risk of pouchitis include:
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Include a liberal intake of fluids to keep your system flushed.
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Include yogurt that contains the healthy bacteria acidophilus. Look for yogurts that contain the living strains of L. bulgaricus and S. thermophilus.
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Do not allow stool to stay inside the pouch for long periods of time. Going to the bathroom prior to sleep is recommended.
Pouchitis does not affect everyone with a pelvic pouch. Even people who do develop pouchitis report that their quality of life is better than when they had ulcerative colitis. In almost all cases, having an ileostomy can eliminate the problem of chronic pouchitis.
Sexuality
The potential for sexual dysfunction for either men or women after pelvic pouch surgery is very small, but the risk does exist. Sexuality must be discussed with your surgeon prior to surgery.
For men, there is a less than one per cent chance of impotence or retrograde ejaculation. For women, there may be dyspareunia (painful intercourse) and vaginal dryness.
Anal intercourse should be avoided. The actual opening of the pouch (the anastomosis) is narrow and dilatation of this may damage the sphincters, resulting in possible leakage or incontinence.
Some women following pelvic pouch surgery will initially complain of pain with intercourse and vaginal dryness. The pouch sits in very close proximity to the vagina and if the pouch is full, pressure can be placed in the region of the vagina. Ensuring that the pouch is emptied and experimenting with different positions may help alleviate discomfort. Vaginal dryness can be due to hormonal changes following surgery. If it occurs, it is usually temporary and can be remedied through use of vaginal hydrating gels. There is no time restriction in terms of resuming sexual relations — the key is to be ready and comfortable. Keep open dialogue and share concerns/fears.
Pregnancy
Some women may experience increased fertility due to removal of the inflamed colon. Unfortunately, others may have decreased fertility from adhesions or scar tissue that develop after the removal of the rectum. Additionally, with pregnancy, the method of delivery remains controversial (C-section versus a vaginal delivery), because any injury to the anal sphincter (control) muscles may lead to the inability to control the stool. It is important to inform your obstetrician of the changes in your anatomy as a result of the pouch so he/she can perform a C-section should any problems arise during the vaginal delivery.
Impotency and retrograde ejaculation (the sperm going into the bladder instead of out the end of the penis with ejaculation) are serious but relatively rare occurrences. It is essential that your surgeon be aware of any difficulties with intercourse following pelvic pouch surgery.
Eating
Following pelvic pouch surgery, there will be a period of adaptation that may take up to one year. Over time, pouch storage capacity will increase and the number of bowel movements per day will decrease. Stool consistency will thicken over time. Diet and medication can help to improve pouch function. It will be important to resume normal, healthy dietary patterns over the course of time.
The following includes general dietary tips as well as a list of foods that may contribute to stool looseness and frequency experienced during the period of adaptation.
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Try to develop regular eating patterns which allow your pouch to adapt and function in an appropriate manner.
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Smaller meals may be better tolerated, but it is important to eat more often to ensure adequate intake.
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Eat you meals in a relaxed environment. Take your time, chew your foods slowly and thoroughly.
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Drink plenty of fluids each day (i.e. more than 8 cups of liquid per day).
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Add "potential" problem foods to your diet gradually to see how your body responds.
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When a food causes a problem, it should be temporarily eliminated, and then tried again at a later date.
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Eat a balanced diet. Incorporate all food groups.
Remember to include foods and fluids high in potassium and salt during periods of stool looseness and frequency.
Foods or Beverages that May Cause Stool to Become Looser or Increase Pouch Output
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Foods that Thicken Stool or Decrease Pouch Output
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Foods that May Contribute to Anal Irritation
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Foods that Cause Gas
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While the above foods are common sources of gas, individuals may have their own experiences with foods that may cause gas. Some people report gas with greasy/high fat foods and chocolate.
Keep in mind that everyone's response following pelvic pouch surgery is very different. What may upset or create problems for one individual may be well tolerated by another. Try all foods and only avoid those that repeatedly cause unacceptable problems. Tolerance may change with time, so periodically retry small quantities of any foods avoided.
Gas and Bloating
Gas and bloating are a common complaint with pelvic pouch patients. While dietary choices may be a contributing factor, it is usually due to an overgrowth of bacteria in the pouch. Dietary changes should be considered first by avoiding foods that cause gas such as cabbage family vegetables, onions, sweet potatoes, turkey, asparagus, dried beans, beer, etc.
Frustratingly, sometimes the foods that cause gas are also the foods (high fibre foods) that may be helping to thicken stool. If this is the case, consult a dietitian to help review food choices that will lessen symptoms of gas and bloating, but will also allow you to maintain a thicker consistency for your stools. Some people find that over-the-counter preparations like Beano may be helpful in decreasing the amount of gas experienced with high fibre foods. Others have reported that eating yogurt (such as the Balkan yogurts) may decrease gas.
If dietary changes are not effective, antibiotics may be helpful to lessen gas and bloating. However, often the symptoms will return once the antibiotics have been completed.