Anal Sphincter Exercises

Introduction

This leaflet will tell you about anal sphincter exercises. These exercises are designed to help people who sometimes leak stool (poo) from their bowel.

Sphincter exercises can help you to reduce any leakage from the bowel. When the exercises are done correctly, they can build up and strengthen the muscles to help you to hold both gas and stool in your bowel.

Where are these muscles?

The back passage, or anus, has two rings of muscle around it (see diagram).

The inner ring is the internal sphincter. This is an involuntary muscle which means it normally works automatically and you do not need to control it. It should be closed at all times, but should open when you need to open your bowels and have a poo.

The outer ring of muscle is the external sphincter. This is a voluntary muscle, which means you can control it and have to think about opening or closing it.

Both of these muscles wrap right around the anus. The external sphincter (outer ring of muscle) is something you can close more firmly if you have diarrhoea or need to go to the toilet urgently.

Either or both of these sphincter muscles can become weak. This can happen for a few reasons. A couple of reasons can be due to childbirth, constipation and straining, or general wear and tear. Sometimes there is no obvious reason why.

If these muscles are weak, you may leak gas or liquid or solid stools.

Normally when you go to the toilet there is some stool left behind in the anal canal (see diagram below). Normally the muscles ‘snap shut’ after you have finished opening your bowels to close off the back passage. This squeezes out any residue, and you can then wipe and there is no leakage.

If the muscles are damaged or weak, they may not close immediately or close completely after going to the toilet. This often makes it difficult to wipe clean, and you might find that you leak for a while after going to the toilet.

This might be a small or large amount, and it can last for a few minutes, or several hours.

You might also find that you leak during heavy exercise, lifting heavy weights (shopping bags, children etc.), or when you walk a long way. Some people find that a small amount of stool is passed when they pass wind.

Other people with weak muscles have a ‘funnel-shaped anus’. The weak muscle does not close completely at skin level, and stool can be trapped inside the anal opening. This cannot be removed easily by wiping.

How can exercises help?

The internal sphincter, which is often the reason for leakage, cannot be strengthened by exercises. Because it is an involuntary muscle which you cannot control this means you cannot exercise it.

You can exercise the external sphincter. The aim is to exercise this muscle enough to make it thicker and stronger so that it gives more support. This means it can compress the internal sphincter to help prevent leakage.

By exercising the external sphincter you can also speed up its reaction time. This can help with passing wind.

Like any muscle, the more you exercise and use it, the stronger it becomes. However this will be difficult and often takes several months to work.

Learning to do the exercises

It is important to learn to do the exercises in the right way, and to check from time to time that you are still doing them correctly.

1. Sit comfortably with your knees slightly apart.

• Now imagine you are trying to stop yourself passing wind from the bowel. To do this you must squeeze the muscle around your anus (back passage).

• Try squeezing and lifting the muscle as tightly as you can, as if you are really worried that you are about to leak. You should be able to feel the muscle move. Your buttocks, tummy and legs should not move at all. You should be aware of the skin around your back passage tightening and being pulled up and away from your chair. Really try to feel this.

You are now exercising your anal sphincter. You should not need to hold your breath when you tighten the muscles.

• Now imagine that the sphincter muscle is a lift. When you squeeze as tightly as you can your lift goes up to the 4^th floor. But you cannot hold it there for very long, and it will not get you safely to the toilet as it will get tired very quickly.

• So now squeeze more gently, take your lift only up to the 2^nd floor. Feel how much longer you can hold it then when you squeeze harder.

Practising your exercises

1. Sit, stand or lie with your knees slightly apart. Tighten and pull up the sphincter muscles as tightly as you can. Hold tightened for at least 5 seconds, then relax for about 4 seconds.

Repeat five times. This will work on the strength of your muscles.

• Next pull the muscles up to about half of their maximum squeeze. See how long you can hold this for. Then relax for at least 10 seconds.

Repeat this twice. This will work on the endurance, or staying power, of your muscles.

• Pull up the muscles as quickly and tightly as you can and then relax and then pull up again, and see how many times you can do this before you get tired.

Try for five quick pull-ups.

Do all three of these exercises – five as hard as you can, two as long as you can, and five quick pull-ups – four to six times a day, every day.

As the muscles get stronger, you will find that you can hold for longer than five seconds, and that you can do more pull-ups each time without the muscle getting tired.

It will take time for the exercises to make the muscle stronger. You may need to exercise regularly for several months before the muscles gain their full strength.

Tips to help you

At first it is probably a good idea to set aside some time for these exercises and really concentrate on getting them right.

But quite soon they should become easy to do wherever you are. Nobody needs to know what you are doing.

Get into the habit of doing your exercises with things you do regularly. Every time you answer the phone if you are at the office, or if you are at home every time you sit down. Whatever you do often.

If you are unsure that you are exercising the right muscle, put a finger on the anus as you squeeze to check. You should feel a gentle lift and squeeze if you are exercising the right muscle. You can also look at the area in a mirror. You should see the anus pucker up as you squeeze it.

Use your muscles when you need them. Pull up the muscles if you feel that you are about to leak. But remember that you cannot hold your tightest squeeze for very long, so you are better to use a gentler squeeze that you can hold for longer.

Tests and treatments

There may be some tests and treatments that could help:

• Anorectal physiology: this is to test how well the muscles and nerves in your anal canal are functioning. It involved passing a small tube into your bottom and passing water through the tube to measure the strength of the muscles.

• Endoanal ultrasound: this is an ultrasound scan which can identify any defects or damage to the sphincter muscles.

• Medication: this can help to improve the consistency of your stool.

• Biofeedback training: this may improve co-ordination and function of your anal muscles.

The better you empty your bowel on the toilet, the less there will be to leak. So take your time on the toilet and do some exercises before you wipe. This may ‘milk out’ any residue.

Some people find that raising their feet on a footstool about 20 to 30cm high in front of the toilet helps to empty the bowel more completely.

Reducing intake of high fibre cereals, caffeine and artificial sweeteners can sometimes help your stools to be more formed.

If you have sore skin or itching you can ask your nurse or GP for advice on skin care.

Watch your weight. Extra weight can put an extra strain on your muscles.

Once you have regained control of your bowel, don’t forget your exercises. Continue to do them a few times each day to ensure that the problem does not come back.

Remember – you can do these exercises wherever you are – nobody need know what you are doing!

Do you have any questions?

This information sheet is designed to teach you how to exercise your anal sphincter muscle to improve your bowel control. If you have problems doing the exercises, or if you don’t understand any part of this information, ask your doctor, nurse or physiotherapist for help.

Contact numbers

If you need any further advice or have any problems please contact the colorectal unit.

University Hospital North Tees

Telephone: 01642 624399

Monday to Friday 8am to 4:30pm

References

NICE (CG49) 2007, https://www.nice.org.uk/guidance/CG49/chapter/Recommendations

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