This pack has been produced with by Frimley Health NHS Trust in partnership with Healthier Together
Explaining the different problems that can occur in toileting, it helps to understand how the bowel works.
Food Goes Into The Mouth - When we eat food, we first chew it into small pieces making it more manageable to swallow.
Chewed Food Goes Into The Stomach - When the chewed up food enters the stomach, the food is mashed up to the point of a ‘soupy’ mixture.
Soupy Food Mixture Goes Into The Small Intestine - Here, the nutrients are taken out of the soupy food mixture, and used by the rest of the body.
Waste Is Produced - The waste liquid, watery poo, then travels down into the large intestine. The large intestine has strong muscles which push the food mixture along. The body absorbs water as the food mixture is pushed along, turning it into the soft, smooth, sausage shaped poo you recognise.
Poo Reaches The Rectum - When the poo reaches the rectum, the lowest part of the bowel, it stretches and a message is sent to the brain that you need to do a poo.
Stool’ and ‘bowel movement’ are just other words for poo!
The Bristol Stool Chart is widely used as a research tool to evaluate the effectiveness of treatments for various diseases of the bowel. The chart is used to describe the shapes and types of stools. It is also used as a tool to diagnose constipation, diarrhoea, and irritable bowel syndrome.
The bowel is the part of the digestive system that allows people to absorb nutrients from food and expel the waste that the body cannot use. If faeces pass too quickly or too slowly, it may indicate a problem with the bowels.
Characterizing the stool based on its consistency can help identify if it is a healthy bowel movement.
What is ‘constipation’?
Constipation is described as the inability to poo regularly, or to completely empty the bowel. Someone may be constipated if they do fewer than four poos in a week. Type 1 and 2 stools on the Bristol Stool Form Scale indicate constipation.
What causes constipation?
There are many causes of constipation, including:
Unhealthy Diet. Diets lacking in water and fibre mean the bowels do not move as they should. A healthier diet that includes high fibre foods (fruits, vegetables, and wholegrains) prevent poo from becoming hard and dry. People with diets high in processed foods, cheeses, white breads and meats may find they become constipated more often.
Not enough exercise. Moving around helps food to travel down the digestive system; not getting enough physical activity can contribute towards constipation.
Stress. Some may find they become constipated when they are stressed or anxious. Stress can impact how the digestive system works, resulting in constipation, or the opposite, diarrhoea.
Fear of the toilet. This can also be associated with pain or discomfort when passing stools.
Irritable Bowel Syndrome (IBS). IBS can cause either constipation or diarrhoea, as well as stomach pain and gas.
Withholding poo. Avoiding the toilet, even when you have the urge to go, can cause constipation. Ignoring the urge can make it harder to go to the toilet later on.
Medication. Some medication, like those used to treat iron deficiencies, can lead to constipation.
What are the signs and symptoms of constipation?
Different people have different bathroom habits; someone who doesn’t do a poo every day is not necessarily constipated. Some people may have bowel movements three times a day, whereas others may only have one every 2 days. However, if you are going less than normal, or you are finding it painful to poo, you may be constipated. A person with constipation might:
Feel full and bloated
Experience pain when attempting to poo
Have to strain to do a poo
Stomach aches, with occasional nausea.
What is soiling?
Soiling happens when poo comes out in underwear, on the floor, or in other inappropriate places. For younger children this may be because they are still learning to recognise when they need to go. However, some individuals may have a more regular and persistent difficulty.
What causes soiling?
Constipation. Constipation is the most common cause of soiling. When you do not have regular bowel movements, the bowel can become loaded with large stools which are hard to pass. This is sometimes referred to as ‘faecal impaction’. Soiling occurs when runny poo leaks around the hard lump that is blocking the way; or if there has been a longstanding problem of constipation and the lower bowel and rectum have become overstretched and de-sensitised. Soiling can happen several times a day as the child does not always receive the message that they need a poo, or is not always aware that the poo has come out.
Withholding poo. This can be due to fear of the toilet, which can be associated with pain or discomfort.
Lack of a toilet routine. Some children and young adults have such busy lives that it can be difficult to find time to sit and relax on the toilet each day. Some children may not want to interrupt play or other activities.
Resistance to toilet training. This may be an insistence that a nappy be put on to poo in.
Diet. Too little fibre or low fluid intake in the diet.
Anxiety and emotional upset. Anxiety may be caused by any significant changes, including changes in routine.
In many children there is likely to be a combination of several of these factors.
Signs and symptoms of soiling
Soiling can affect people in different ways. You may have a problem if:
You have sudden urges to poo that you cannot control
There is leakage or liquid poo in your underwear
You are constipated, with dry and hard poos
You avoid bowel movements
There are long periods of time between doing poos
You have a lack of appetite
You experience abdominal (tummy) pain
You are increasingly getting bladder infections
It is affecting your daily life. For example, stopping you from socialising with friends.
A child may withhold their stool due to a fear of using the toilet, pain when passing a stool, or simply because they do not like using the toilet in certain environments.
The rectum continues to fill, causing the muscles in the rectum to get stretched. When the stretched muscles try to tighten, they cannot do so very well. The muscles have got out of shape! The signallers in your bowel are like telephone lines; they send a message to the brain when you are ready to do a poo. These signallers also become stretched when the rectum gets full up, making it difficult to do their job effectively. The good news is that you can train these stretch signals to be strong again!
With a loss of sensitivity and an overstretched bowel, the brain ignores the urge to do a poo. The poo sits in the bowel, where much of the water is absorbed from it. This makes the poo hard and painful to pass, and therefore children are naturally more likely to withhold poo.
Over time, liquid poo can start to leak around the dry, hard, and impacted stool, making attempts at withholding even more likely.
The constipation cycle explains how soiling develops, and how it continues.
The important parts to remember are that:
Children have no control over this process
It is no-one's fault
Your GP may advise you to take ‘Movicol’ or ‘Laxatives’. Movicol is a powder that comes in sachets that you mix with water. Laxatives are also a medicine used to treat constipation. Children and young adults who are eating solid foods may be prescribed laxatives to help reduce constipation.
It is important to eat a diet high in fibre, fruit, and vegetables e.g. whole wheat products (like brown rice and pasta), peas, broccoli, carrots, sweetcorn and oranges, apples. Tip: Add more vegetables to soups and stews, have baked and boiled potatoes and keep the skins on, swap white bread for brown bread.
Drink lots of fluids, at least 6-8 cups!
Exercise stimulates the bowel, so exercise just before the toilet routine can be helpful.
Give the recommended amount of milk for the child’s age. Too much milk can have a constipating effect on some children.
Regular toilet routine: sit on the toilet for 5-10 minutes everyday after breakfast and evening meals.
Implement a regular toilet routine for your child/young adult. You can use a toilet reward chart in conjunction with a toilet routine to encourage your child to use the toilet. There are natural times for using the toilet, such as after meals. Encourage your to sit on the toilet several times a day; the most important times are after breakfast, after school, and after dinner for 5-10 minutes a time (if they open the bowels before this time period ends, they can leave the toilet after). Tip: we use the same muscles for blowing as we do for pooing, so find some bubbles or a toy trumpet and you can get blowing whilst you use the toilet!
Be Positive and Encouraging
Evidence of your support, encouragement, and understanding will help your child to relax and eventually move forward in their journey to overcoming soiling, constipation, and withholding. Your support and understanding is VITAL – they can do it if you think they can.
Normalise The Toilet
It is important to talk openly and honestly about going to the toilet.
The ‘Lets Talk About Poo’ campaign aims to raise awareness of children’s toileting problems among parents, health professionals and educators so that we all know how to identify when a child may be struggling with toileting, and so we can comfortably talk about it. This allows those close to the child to intervene at an early stage with simple measures to help them poo.
Allowing your child to observe normal toileting behaviour, such as seeing parents use the toilet frequently, shows the child that the toilet does not need to be feared.
Sometimes it is necessary to build up confidence to sit on the toilet and relax before the child can comfortably open their bowels on the toilet. Suggest that children who insist on using a nappy to poo do so in the toilet area. Adopt a gradual exposure approach; encourage the child to sit on the toilet with the nappy on, and over time gradually remove it. It is important to create an environment without anxiety and pressure.
Child Friendly Space
You can help reduce strain by giving your child a low foot stool to put their feet on when doing a poo. Foot stools encourage children to adopt a squatting position, which encourages the pelvic floor muscles to relax. This in turn reduces the amount of strain necessary to pass a bowel movement.
Comfort is important, feet should be able to touch the floor/stool to help pushing. Sitting on the toilet can be reinforced by providing children with interesting activities, such as reading a book or completing a Rubik’s Cube or similar puzzle.
Promote a Healthy Bladder
Whatever level of continence your child is going to achieve, promoting a healthy bladder and bowel is vital. Untreated constipation can lead to frequent, loose bowel actions which can cause sore skin. A full bowel occupies the space the bladder needs, resulting in frequent, small wees and a big risk of Urinary Tract Infection (UTI). All children need to drink plenty of fluids, to avoid constipation, and should have their wees and poos monitored.
Set an initial goal . This initial goal should not be too difficult, it needs to be achievable by the child. For example, sitting on the toilet for 5 minutes. Offer extra reward/praise for opening bowels during this period. Reward charts can be set up to help with this goal (see page 12 for an example). It is best to have only 1-2 target behaviours at any time.
Rewards should be appropriate and reasonable, such as a sticker, or a small treat like 10 minutes on the iPod. You can tailor rewards and reward charts based on your child’s interests. The sooner praise/reward are given after the target behaviour, the faster learning occurs. All members implementing this must be consistent in their application of the system, parents, wider family, and school staff.
Parents and anyone else working with the child should be careful to create a facilitative environment to support with soiling and constipation. This environment should send the message that:
The child is loved and respected regardless of any toileting difficulties. They are offered praise and encouragement for progress, no matter how small the progress is.
Soiling is a problem which is non-intentional and experienced by the child as uncontrollable. The child should not be scolded or punished for a lack of bowel control.
Parents believe the child has great courage for coping with soiling. Children will be encouraged if you have faith that they can learn bowel control by jointly working with the parent and healthcare providers.
Calming The Body - Feeling relaxed can help reduce symptom severity
Progressive Muscle Relaxation (PMR)
Muscle tension is commonly associated with stress and anxiety, it is the bodies natural response to potentially dangerous situations. Even when there is no danger, our bodies can still respond in the same way. You may not always realise that your muscles are tense, it may be as subtle as your jaw clenching, or as obvious as your shoulders feeling really tight and hunched. PGR is a deep relaxation technique which is based upon the simple practice of tensing one muscle group at a time . This is followed by a relaxation phase with release of tension. This is very useful before bedtime.
During deep breathing your blood is oxygenated, triggering the release of endorphins, whilst also decreasing the release of stress hormones, and slowing down your heart rate.
Calming The Mind - Strategies for managing the anxiety and stress that is often associated with abdominal pain
Help yourself to feel more relaxed by thinking about things that make you feel calm and rested. For example, picturing your favourite place. This can be either independent, or you can take a guided visualisation approach. A guided visual imagery relaxation task has been provided in this pack.
Safe Place Visualisation
A powerful stress reduction and relaxation tool, that can be applied at any time, in any location.
The Ladder Hierarchy
Help yourself to change how you cope with toileting difficulties, by gradually exposing yourself to different toileting scenarios over time.
Developing Coping-Self Talk
These are phrases that you can say to yourself that are supportive. For example “Just because it has happened before it does not mean it will happen again”
Mindfulness and Sleep:https://www.smilingmind.com.au/
Meditation and Sleep:https://www.calm.com/
Progressive Muscle Relaxation: https://www.thinkpacifica.com/
ERIC, the Bladder and Bowel Charity website:
There is a free downloadable Guide to Children’s Bowel Problems. ERIC have also created Poo and Wee characters and a range of videos for children and parents.
Let’s Talk About Poo: http://web.archive.org/web/20161008172049/http://letstalkaboutpoo.eric.org.uk:80/about-the-campaign/
Bladder and Bowel UK website : https://www.bbuk.org.uk/children-young-people/
‘Beating Sneaky Poo’ leaflet published by Dulwich Centre Publications ©(available online)
Free Online Counselling: https://www.kooth.com/
Stress and Anxiety: https://www.moodcafe.co.uk/for-children-and-young-people/feeling-worried,-frightened,-stressed-or-anxious.aspx
Relaxation Techniques: www.getselfhelp.co.uk/relax.htm
Relaxing Imagery: www.getselfhelp.co.uk/imagery.htm
Thought Distancing: www.getselfhelp.co.uk/cbtsetp6.htm