What helps improve stools after surgery and ostomy removal?

I’m really sorry to hear about the ongoing challenges you’re facing with runny, pasty stools and fecal incontinence since your rectal surgery and ostomy reversal in 2019. It sounds incredibly frustrating, especially after trying interventions like the InterStim implant in 2022 without the relief you hoped for. Based on the information available and the experiences shared in similar contexts, I’ll outline some potential reasons for your symptoms, what might have been tried already, and additional approaches that could be worth exploring. I’ll also address the InterStim implant’s role and effectiveness for muscle recovery in this scenario.

Understanding Your Symptoms
Runny, pasty stools and fecal incontinence after rectal surgery and ostomy reversal are not uncommon, particularly when the surgery involves the rectum or lower colon. Here are some key factors that might be contributing to your symptoms:

Post-Surgical Changes in Bowel Function:
Rectal Surgery Impact: Surgery involving the rectum, such as a low anterior resection or similar procedure, can disrupt the nerves and muscles (anorectal sphincter) responsible for bowel control. This can lead to conditions like Low Anterior Resection Syndrome (LARS), which includes symptoms like frequent, urgent bowel movements, diarrhea, and incontinence. LARS can persist for months or even years, and for some, it becomes a long-term issue.
Ostomy Reversal Effects: After ostomy reversal, the bowel needs time to regain normal function. The anorectal muscles and nerves, which may not have been used during the ostomy period, can remain weak or uncoordinated, leading to incontinence or loose stools. One study noted that about a third of patients experience fecal incontinence that doesn’t improve over time.
Altered Bowel Anatomy: If part of your colon or rectum was removed, the remaining bowel may absorb less water, resulting in looser stools. This is especially true if a significant portion of the large intestine was resected, as it’s responsible for forming solid stool.
InterStim Implant and Muscle Recovery:
The InterStim implant (sacral nerve stimulation, or SNS) is designed to modulate the sacral nerves, which control the pelvic floor muscles and anal sphincter, to improve bowel control in cases of fecal incontinence. It’s often used when conservative treatments (diet, medications, physical therapy) fail.
Effectiveness: Studies show InterStim can be effective for many patients, with success rates of around 82% for overactive bladder and 59–71% for fecal incontinence in reducing symptoms like leaks. However, success depends on the underlying cause of incontinence.
Why It Might Not Be Helping: If your incontinence is due to structural damage (e.g., severe sphincter injury), significant nerve damage from surgery, or ongoing inflammation, the InterStim may not fully restore control. Additionally, if the implant settings aren’t optimized or if there’s an underlying issue (e.g., infection, device malfunction, or poor candidate selection), effectiveness can be limited.
Other Potential Causes:
Dietary Triggers: Certain foods (e.g., caffeine, alcohol, fatty or spicy foods) can worsen diarrhea and incontinence. Even with dietary changes, identifying specific triggers can be challenging without a systematic approach.
Inflammation or Infection: Conditions like diversion colitis (inflammation in the unused bowel segment during ostomy) or infections (e.g., Clostridium difficile) could contribute to ongoing loose stools.
Pelvic Floor Dysfunction: Weak or uncoordinated pelvic floor muscles, even after InterStim, may require targeted retraining.
Psychological or Neurological Factors: Stress or neurological conditions affecting bowel control could play a role, though this seems less likely given your surgical history

What You’ve Likely Tried
From your description, it sounds like you’ve followed your doctors’ recommendations, which may include:
Dietary Modifications: Avoiding trigger foods (e.g., caffeine, alcohol, high-fiber vegetables) and eating smaller, more frequent meals. Foods like bananas, rice, applesauce, and toast (BRAT diet) are often recommended to firm up stools.
Medications: Anti-diarrheal drugs like loperamide (Imodium) or fiber supplements (e.g., psyllium) to bulk up stools.

Pelvic Floor Exercises: Kegel exercises or pelvic floor physical therapy to strengthen sphincter muscles.
InterStim Implant: Placed in 2022 to stimulate sacral nerves and improve muscle control.
Incontinence Products: Using Depends for protection, which suggests significant impact on daily life.
Additional Approaches to Consider
Since your symptoms persist despite these interventions, here are some strategies and questions to discuss with your healthcare team, along with insights from others’ experiences:
Re-Evaluate the InterStim Implant:
Device Check: Ask your doctor to verify the InterStim’s functionality (e.g., battery, lead placement, programming). Sometimes, adjusting the stimulation settings or repositioning the device can improve outcomes.
Candidate Suitability: Confirm whether your incontinence is primarily nerve-related (where InterStim is most effective) or due to structural issues (e.g., sphincter damage), which may require other treatments.
Trial Period Review: Reflect on whether the trial period (InterStim Stage 1) showed any improvement. If it didn’t, the implant might not be the best fit for your condition.
Consult a Colorectal Specialist or NSWOC:
A colorectal surgeon or Nurse Specializing in Wound, Ostomy, and Continence (NSWOC) can assess for complications like anastomotic leaks, strictures, or low anterior resection syndrome. They may recommend tests like:
Anorectal Manometry: To evaluate sphincter strength and coordination.
Defecography: To visualize bowel function and identify obstructions or leaks.
Endoscopy or CT Scan: To check for inflammation, stenosis, or recurrent disease.
An NSWOC can also provide tailored advice on skin care (to prevent irritation from frequent bowel movements) and incontinence products.
Advanced Pelvic Floor Therapy:
Biofeedback: This involves working with a physical therapist to retrain pelvic floor muscles using sensors to monitor muscle activity. It’s been shown to help some patients regain sphincter control after ostomy reversal.
Pelvic Muscle Retraining (PMR): Targeted exercises to strengthen the anal sphincter, especially if the InterStim hasn’t fully addressed muscle weakness.
A physiotherapist specializing in pelvic floor dysfunction can guide you through these therapies.
Dietary Fine-Tuning:
Food Diary: Keep a detailed log of foods and symptoms to pinpoint triggers. Work with a registered dietitian to create a personalized plan. For example, avoiding high-fiber foods initially and gradually reintroducing them can help.
Probiotics: Some patients find probiotics help regulate bowel movements, though evidence is mixed. Discuss with your doctor before trying.
Hydration: Ensure you’re drinking enough fluids (8–10 glasses/day) to prevent dehydration, especially with loose stools.
Medications and Other Therapies:
Anti-Diarrheals: If loperamide isn’t enough, ask about other options like diphenoxylate-atropine or bile acid binders (e.g., cholestyramine) if bile acid malabsorption is suspected.
Solesta Injections: A bulking agent injected into the anal canal to improve sphincter closure. This is less invasive than surgery and may be an option if InterStim hasn’t worked.
Sphincteroplasty: A surgical repair of the anal sphincter if damage is confirmed. However, long-term success rates vary, with some studies showing deterioration over time.
Surgical Options:
Re-Evaluate Ostomy: In severe cases where incontinence significantly impacts quality of life, some patients opt to reinstate a permanent colostomy or ileostomy. This is a last resort but can restore control and comfort for some.
Other Neuromodulation: If InterStim isn’t effective, newer devices like Axonics (another sacral neuromodulation system) might be considered, though evidence for switching is limited.
Support Groups and Emotional Support:
Coping with chronic incontinence can be isolating. Joining an ostomy or colorectal surgery support group (e.g., through Ostomy Canada or the United Ostomy Associations of America) can connect you with others who’ve had similar experiences. They may share practical tips, like specific incontinence products or dietary hacks.
Consider counseling to address the emotional toll, as frustration and embarrassment are common.

Experiences from Others
While I don’t have direct access to personal anecdotes from patients in your exact situation, online forums and studies provide some insights:
Ostomy Reversal Challenges: On forums like the United Ostomy Associations of America, patients report varied outcomes after reversal. Some experience loose stools and incontinence for months but find improvement with pelvic floor therapy or medications like loperamide. Others, like you, struggle long-term and explore surgical options or permanent ostomies. One patient mentioned managing loose stools with a strict diet (no sweets, spicy foods, or gas-causing foods) and felt “very manageable” after 23 months.
InterStim Outcomes: Some patients with InterStim for fecal incontinence report significant improvement (e.g., 50% reduction in leaks), but others note persistent symptoms if the underlying issue isn’t nerve-related. A patient on a medical forum mentioned needing multiple programming adjustments to see benefits.
Rectal Discharge: While not identical to your symptoms, some patients post-ostomy report mucus discharge or loose stools, managed with barrier creams, pads, and pelvic exercises.
Questions to Ask Your Doctor
To move forward, consider asking your healthcare team:
Could my symptoms be due to Low Anterior Resection Syndrome or another specific condition?
Is the InterStim implant functioning correctly, and are there adjustments we can try?
Would tests like anorectal manometry or defecography reveal new insights?
Am I a candidate for biofeedback, Solesta, or sphincteroplasty?
Could a permanent ostomy be a better option for my quality of life?
Can I be referred to a colorectal specialist or pelvic floor therapist?
Next Steps
Schedule a Follow-Up: Contact your colorectal surgeon or gastroenterologist to discuss your ongoing symptoms and request a comprehensive evaluation.
Connect with an NSWOC: They can offer practical advice on managing incontinence and skin care.

Dietitian Consultation: A dietitian can help refine your diet to minimize loose stools.
Final Thoughts
Your situation is complex, and it’s disheartening that the InterStim and other interventions haven’t resolved your symptoms. However, persistent runny, pasty stools and incontinence after rectal surgery and ostomy reversal are challenges others face, and options like advanced pelvic floor therapy, medication adjustments, or even revisiting surgical solutions may still offer relief. The key is a thorough re-evaluation to pinpoint the exact cause—whether it’s nerve dysfunction, sphincter damage, or altered bowel anatomy—and tailor treatment accordingly. You’re not alone, and connecting with others through support groups may provide both practical tips and emotional encouragement.
If you’d like, I can search for specific studies or forums for more patient experiences or help draft questions for your doctor. Let me know how I can assist further!

Hi @2runny, welcome. I added your question to the Ostomy support group as well as the Colorectal Cancer support group. I'm also tagging fellow members like @bea1972 @verol65 @michaelfromsf who may be able to share their experiences.

It sounds like you have tried many things to help improve your pelvic muscle function such as InterStim implant surgery. As @roywalton pointed out in one of his responses even after implant surgery it may be recommended to work with a physical therapist to retrain pelvic floor muscles.

@2runny, have you consulted with a physical therapist who specializes in pelvic floor dysfunction? What changes to your diet have helped?

Have you tried Loperamide (Imodium) over the counter?

@roywalton has given you very good and quite complete information, @2runny .

Did you have a low anterior resection (LAR, removal of (part of) the rectum and&or sigmoid when you had your ostomy?

I had a low anterior resection which took away my whole rectum, my whole sigmoid, and my mesorectum, without having an ostomy. My diet at first was very simple and bland, everything peeled and simply cooked: chicken, white fish, potatoes without skin, rice, white bread, apples, pears, and carrots; the only raw food were bananas. With the help of a clinical nutritionist/dietitian, I added some more food, one a week, to observe how I reacted. First foods we added were all peeled, seeded and cooked like zucchini, turkey, guavas, asparagus (not peeled), green bell pepper, corn tortillas. As that worked well, she told me to go ahead and add other foods, following the rule of peeling, seeding, and cooking, and once a week only. Then I started adding raw foods, not cooking the apples, etc., always once a week. I kept a diary in the app "My Symptoms". That is how I pretty much eat anything. I avoid onions (using them only to give flavor, not eating them), eat very little broccoli and cauliflower, because the provoke severe gases usually, but I am eating an otherwise normal diet a year and 3 month after my surgery.

I also had 5 long sessions of pelvic floor therapy with biofeedback and PTNS (Percutaneous Tibial Nerve Stimulation) to help with fecal control. At first I used menstrual protectors in my underwear. I no longer do, except very occasional, in special circumstances where I don't have control over the food or my meal schedule is not respected.

You can join support groups on FB like the Living with Low Anterior Resection Syndrome, or various Colontown support groups on FB, going first to their website to follow the process to be added to the groups.

Wishing you improvement soon.

Don't do that unless your surgeon says it is okay!

Yes I would like that, I’m gonna call my Dr tomorrow 5-8 and see to make an appt and ask some questions cause I’m getting very tired of this.

2Runny - this must be so frustrating for you..... I understand you would like some references to studies pertinent to your case., so I ran a quick check and found these.... There is a lot of information here but you may want to scan the topics that are most interesting to you, and possibly print out the titles of the articles and a few questions to share with your doctor.... I apologize for the amount of information but I wanted to be as complete as possible knowing your appointment is tomorrow

sphincter control.
Relevance: Probiotics could be a low-risk option to try for your runny stools, though they may not address incontinence.
Access: Available via Wiley Online Library (DOI: 10.1111/codi.15463).
Sacral Nerve Stimulation in Fecal Incontinence: Efficacy and Safety
Source: Agri (2004)
Citation: Ozyalçin NS, et al. Agri. 2004;16(3):35-44.
Summary: This review evaluates sacral nerve stimulation (InterStim) for fecal incontinence. Findings:
Effective in reducing incontinence episodes in 50–80% of patients, particularly those with intact sphincters but nerve dysfunction.
Complications include pain at the implant site, infection, or lead migration (rare).
Relevance: Your lack of improvement with InterStim may suggest a non-nerve-related cause (e.g., sphincter damage or LARS), warranting further investigation.
Access: Available via PubMed (PMID: 15382003).
How to Access These Studies:
PubMed: Search by PMID or title at pubmed.ncbi.nlm.nih.gov. Many abstracts are free; full texts may require institutional access or purchase.
Academic Databases: Use Elsevier, Wiley, or The Lancet through a university library or public medical library.
Ask Your Doctor: Your colorectal specialist may have access to these journals and can provide copies or summaries.

2Runny - knowing your appointment maybe tomorrow morning I drafted some questions for you to print out and discuss with your doctor..... You may want to scan through these and only select those that you think are most relevant for you now

Drafted Questions for Your Doctor
To help you get clarity and explore next steps, here’s a list of targeted questions to ask your colorectal specialist, gastroenterologist, or InterStim programmer. These are tailored to your situation (rectal surgery in 2019, ostomy reversal, InterStim in 2022, ongoing runny stools, and incontinence requiring Depends):
Diagnosis and Underlying Cause:
Could my symptoms (runny, pasty stools and incontinence) be due to Low Anterior Resection Syndrome (LARS)? If so, can we assess its severity using the LARS score?
Are there other conditions, like bile acid malabsorption or diversion colitis, contributing to my loose stools?
What tests (e.g., anorectal manometry, defecography, or endoscopy) can we do to pinpoint the cause of my incontinence and bowel dysfunction?
InterStim Implant Evaluation:
Is my InterStim device functioning correctly? Can we check the battery, lead placement, or stimulation settings?
Did I show improvement during the InterStim trial phase? If not, does this suggest it’s not the right treatment for my condition?
Could my incontinence be due to structural damage (e.g., sphincter injury) rather than nerve dysfunction, making InterStim less effective?
Alternative Treatments:
Would pelvic floor biofeedback or advanced pelvic floor therapy help strengthen my sphincter muscles and improve control?
Are there medications (e.g., bile acid binders, higher-dose loperamide, or diphenoxylate-atropine) we haven’t tried that could firm up my stools or reduce incontinence?
Am I a candidate for Solesta injections or sphincteroplasty to improve sphincter function?
Could transanal irrigation or anal plugs be effective for managing my symptoms?
Diet and Lifestyle:
Should I consult a dietitian to identify dietary triggers or try a specific diet (e.g., low-FODMAP, high-fiber) to improve stool consistency?
Are probiotics worth trying to regulate my bowel movements, based on recent studies?
Surgical or Long-Term Options:
If my symptoms don’t improve, would reinstating a permanent ostomy (colostomy or ileostomy) be a viable option to restore quality of life?
Are there newer neuromodulation devices (e.g., Axonics) or other surgical approaches we should consider?
Support and Referrals:
Can you refer me to a Nurse Specializing in Wound, Ostomy, and Continence (NSWOC) for tailored incontinence management strategies?
Is there a pelvic floor physiotherapist you recommend for specialized therapy?
Are there local or virtual support groups for post-rectal surgery patients you can connect me with?
Expectations and Prognosis:
How long might it take for my symptoms to improve with the right treatment, or is this likely a permanent issue?
What can I realistically expect in terms of regaining bowel control, given my surgical history and current symptoms?
Tips for Your Appointment:
Bring a Notebook: Write down answers to track recommendations and next steps.
Mention Studies: Reference the studies above (e.g., “I read about LARS in The Lancet” or “A study on InterStim showed varying success rates”) to show you’re informed and guide the discussion.
Be Specific: Describe your symptoms in detail (e.g., frequency of accidents, stool consistency, impact on daily life) to help your doctor tailor solutions.
Request a Multidisciplinary Approach: Ask if a team (e.g., colorectal surgeon, gastroenterologist, dietitian, physiotherapist) can collaborate on your care.

Can you please let us know how your appointment went and what you're thinking?