Fecal incontinence exercises

A program of bowel retraining, Kegel exercises, or biofeedback therapy may be used by people with:

• Fecal incontinence
• Nerve problems (such as from multiple sclerosis or other conditions)
• Severe constipation

The bowel program has several steps that help with regular bowel movements. Within a few weeks of beginning a bowel program, most people can have regular bowel movements.

Before starting a bowel training program, get a thorough physical examination. Your health care provider can find the cause of the fecal incontinence and treat any correctable disorders, such as a fecal impaction or infectious diarrhea. The doctor will use your history of bowel habits and lifestyle as a guide for setting new bowel movement patterns.

DIET

The following dietary changes can help promote regular, soft, bulky stools:

• Add high-fiberfoods to your diet, including whole-wheat grains, fresh vegetables, and beans.
• Use products containing psyllium, such as Metamucil, to add bulk to the stools.
• Try to drink 2 - 3 liters of fluid a day (unless you have a medical condition, such as kidney or heart disease, that requires you to restrict your fluid intake).

BOWEL TRAINING

You can use digital stimulation to trigger a bowel movement:

• Insert a lubricated finger into the anus and make a circular motion until the sphincter relaxes. This may take a few minutes.
• After you have done the stimulation, assume a normal posture for a bowel movement. If you are able to walk, sit on the toilet or bedside commode. If you are confined to the bed, use a bedpan. Get into as close to a sitting position as possible, or use a left side lying position if you are unable to sit.
• Try to get as much privacy as possible. Some people find that reading while sitting on the toilet helps them relax enough to have a bowel movement.
• If digital stimulation does not produce a bowel movement within 20 minutes, repeat the procedure.
• Try to contract the muscles of the abdomen and bear down while releasing the stool. Some people find it helpful to bend forward while bearing down. This increases the abdominal pressure and helps empty the bowel.
• Perform digital stimulation every day until you establish a pattern of regular bowel movements.
• You can also stimulate bowel movements by using a suppository (glycerin or Dulcolax) or a small enema. Some people drink warm prune juice or fruit nectar to stimulate bowel movements.

Consistency is crucial for the success of a bowel retraining program. Establish a set time for daily bowel movements. Choose a time that is convenient for you, keeping in mind your daily schedule. The best time for a bowel movement is 20 - 40 minutes after a meal, because feeding stimulates bowel activity.

Within a few weeks, most people are able to establish a regular routine of bowel movements.

KEGEL EXERCISES

Strengthening the tone of the rectal muscles may help achieve some degree of bowel control in people who have an incompetent rectal sphincter. Kegel exercises strengthen pelvic and rectal muscle tone. These exercises were first developed to control incontinence in women after childbirth. To be successful with Kegel exercises, use the proper technique and stick to a regular exercise program.

BIOFEEDBACK

Biofeedback gives you sound or visual feedback about a bodily function, such as muscle activity. In people with fecal incontinence, biofeedback is used to strengthen the rectal sphincter.

A rectal plug is used to monitor the strength of the rectal muscles. A monitoring electrode may be placed on the abdomen. The rectal plug is then attached to a computer monitor, which displays a graph showing rectal muscle contractions and abdominal contractions.

You are taught how to squeeze the rectal muscle around the rectal plug. The computer display guides you to make sure you are using the correct technique. You should see an improvement in your symptoms after three sessions.

The hepatitis virus panel is a series of blood tests used to detect current or past infection by hepatitis A, hepatitis B, or hepatitis C. It can screen blood samples for more than one kind of hepatitis virus at the same time.

Antibody and antigen tests can detect each of the different hepatitis viruses.

Note: Hepatitis D only causes disease in people who also have hepatitis B. It is not routinely checked on a hepatitis antibody panel.

Hepatitis A antibody test; Hepatitis B antibody test; Hepatitis C antibody test; Hepatitis D antibody test

Blood is typically drawn from a vein, usually from the inside of the elbow or the back of the hand. The site is cleaned with germ-killing medicine (antiseptic). The health care provider wraps an elastic band around the upper arm to apply pressure to the area and make the vein swell with blood.

Next, the health care provider gently inserts a needle into the vein. The blood collects into an airtight vial or tube attached to the needle. The elastic band is removed from your arm. Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding.

In infants or young children, a sharp tool called a lancet may be used to puncture the skin and make it bleed. The blood collects into a small glass tube called a pipette, or onto a slide or test strip. A bandage may be placed over the area if there is any bleeding.

The blood sample is sent to a laboratory for examination. Blood ( serology) tests are used to check for antibodies to each of the hepatitis viruses.

No special preparation is needed.

When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing.

Your doctor may order this test if you have signs of hepatitis. It is used to:

• Detect current or previous hepatitis infection
• Determine how contagious a person with hepatitis is
• Monitor a person who is being treated for hepatitis

Other conditions under which the test may be performed:

• Chronic persistent hepatitis
• Delta agent (hepatitis D)
• Nephrotic syndrome

A normal result means no hepatitis antibodies are found in the blood sample. This is called a negative result.

Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

There are different tests for hepatitis A and B. A positive test is considered abnormal.

Abnormal results on hepatitis A tests:

• IgM anti-hepatitis A virus (HAV) antibodies -- recent infection with hepatitis A
• Total (IgM and IgG) antibodies to hepatitis A -- previous or current infection, or immunity to hepatitis A

Abnormal results on hepatitis B tests:

• Hepatitis B surface antigen (HBsAg) -- acute or chronic hepatitis B infection
• Antibody to hepatitis B core antigen (Anti-HBc) -- previous hepatitis B infection
• Antibody to HBsAg (Anti-HBs) -- immunity to hepatitis B
• Hepatitis B type E antigen (HBeAg) -- chronic, contagious hepatitis B infection or acute infection

Antibodies to hepatitis C can usually be detected 4 - 10 weeks after the infection occurs.

Veins and arteries vary in size from one patient to another and from one side of the body to the other. Obtaining a blood sample from some people may be more difficult than from others.

Other risks associated with having blood drawn are slight but may include:

• Excessive bleeding
• Fainting or feeling light-headed
• Hematoma (blood accumulating under the skin)
• Infection (a slight risk any time the skin is broken)

Hoofnagle JH. Acute viral hepatitis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 151.

Feeding - gastrostomy tube - pump; G-tube - pump; Gastrostomy button - pump; Bard Button - pump; MIC-KEY - pump

Your child's gastrostomy tube or "G-tube" is a special tube in your child's stomach that will help deliver food and medicines until your child can chew and swallow. Sometimes, it is replaced by a button, called a Bard Button or MIC-KEY, 3 - 8 weeks after surgery.

These feedings will help your child grow strong and healthy. Many parents have done this with good results.

You will quickly get used to feeding your child through the tube, or button. It will take about the same time as a regular feeding, around 20 - 30 minutes.

There are two ways to feed through the system: the syringe method and the gravity method. Each method is described below. Make sure you follow all of the nurse's instructions as well.

Your doctor will tell you the right mix of formula or blended feedings to use, and how often to feed your child. Have this food ready at room temperature before you start, by taking it out of the refrigerator for about 30 - 40 minutes. Do not add more formula or solid foods before you talk to your child's nurse.

Feeding bags should be changed every 24 hours. All of the equipment can be cleaned with hot, soapy water and hung to dry.

Remember to wash your hands regularly to prevent the spread of germs. Take good care of yourself as well, so that you can stay calm and positive, and cope with stress.

You will clean your child's skin around the G-tube 1 - 3 times a day with mild soap and water. Try to remove any drainage or crusting on the skin and tube. Be gentle. Dry the skin well with a clean towel.

The skin should heal in 2 - 3 weeks.

Your provider may also want you to put a special absorbent pad or gauze around the G-tube site. This should be changed at least daily or if it becomes wet or soiled.

Do not use any ointments, powders or sprays around the G-tube unless told to do so by your provider.

Make sure your child is sitting up either in your arms or in a high chair.

If your child fusses or cries while feeding, pinch the tube with your fingers to stop the feeding until your child is more calm and quiet.

Feeding time is a social, happy time. Make it pleasant and fun. Your child will enjoy gentle talk and play.

Try to keep your child from pulling on the tube.

Since your child isn't using their mouth yet, your doctor will discuss with you other ways to allow your child to suck and develop mouth and jaw muscles.

Gather supplies:

• Feeding pump (electronic or battery powered)
• Feeding set that matches the feeding pump (includes a feeding bag, drip chamber, roller clamp, and long tube)
• Extension set, for a Bard Button or MIC-KEY (this connects the button to the long tube on the feeding set)

Your nurse will show you the best way to use your system without getting air into the tubes. Follow these steps to feed your child:

• Wash your hands.
• Check that the formula or food is warm or room temperature by putting a few droplets on your wrist.

Follow these steps, and any steps your child's nurse gave you, to feed your child:

• Start with the feeding set, close the roller clamp and fill the feeding bag with food. If your child has a button, connect the extension set to the end of the feeding set.
• Hang the feeding bag high on a hook and squeeze the drip chamber below the bag to fill it at least half way with food.
• Open the roller clamp so that the food fills the long tube, leaving no air in the tube.
• Close the roller clamp.
• Thread the long tube through the feeding pump. Follow the directions on the pump.
• Insert the tip of the long tube into the G-tube and open the clamp. If your child has a button, open the flap and insert the tip of the extension set into the button.
• Open the roller clamp and turn the feeding pump on. Make sure the pump is set to the rate ordered by your provider.

When the feeding is done, your nurse may recommend that you add water to the bag and let the water flow through the feeding set to rinse it out.

If your child has a G-tube, clamp the G-tube and close the roller clamp before disconnecting the feeding set from the G-tube. If your child has a button, close the clamp on the feeding set, disconnect the extension set from the button, and closet the flap on the button.

The feeding bag should be changed every 24 hours. Food (formula) should not be left in the bag for more than 4 hours. So, only put 4 hours (or less) worth of food in the feeding bag at a time.

All of the equipment can be cleaned with hot, soapy water and hung to dry.

If your child's belly becomes hard or swollen after a feeding, try venting or "burping" the tube or button:

• Attach an empty syringe to the G-tube and unclamp it to allow air to flow out.
• Attach the extension set to the MIC-KEY button and open the tube to the air to release.
• Ask your doctor for a special decompression tube for "burping" the Bard Button.

Sometimes you may need to give medicines to your child through the tube. Follow these guidelines:

• Try to give your child medicine before a feeding so that they work better. You may also be asked to give your child medicines on an empty stomach outside of mealtime.
• The medicine should be liquid, or finely crushed and dissolved in water, so that the tube does not get blocked. Check with your doctor or pharmacist on how to do this.
• Always flush the tube with a little water between medicines. This will make sure that all the medicine goes in the stomach and are not left in the feeding tube.

Call your child's nurse or doctor if your child:

• Seems hungry after the feeding
• Has diarrhea after feedings
• Has a hard and swollen belly 1 hour after feedings
• Seems to be in pain
• Has changes in their condition
• Is on new medication
• Is constipated and passing hard, dry stools

Also call the doctor if:

• The feeding tube has come out and you do not know how to replace it.
• There is leakage around the tube or system.
• There is redness or irritation on the skin area around the tube.

Altman GB, ed. Feeding and medicating via a gastrostomy tube. Delmar's Fundamental and Advanced Nursing Skills. 2nd Ed. Albany, NY: Delmar Thomson Learning; 2003: 742-749.

Review Date: 11/11/2010

Jennifer K. Mannheim, ARNP, Medical Staff, Department of Psychiatry and Behavioral Health, Seattle Children's Hospital; and George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

According to the US News and World Report rankings, here are the top 10 Adult Gastroenterology and GI Surgery hospitals:

1. Mayo Clinic (Rochester, MN)
2. Cleveland Clinic (Cleveland, OH)
3. Johns Hopkins Hospital (Baltimore, MD)
4. Massachusetts General Hospital (Boston, MA)
5. UCLA Medical Center (Los Angeles, CA)
6. UPMC Presbyterian Shadyside (Pittsburgh, PA)
7. Mount Sinai Hospital (New York, NY)
8. Mayo Clinic (Phoenix, AZ)
9. Cedars-Sinai Medical Center (Los Angeles, CA)
10. Mayo Clinic Jacksonville (Jacksonville, FL)