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.
Explore Support Groups: Visit http://www.ostomy.org or http://www.ostomycanada.ca for resources and community support.
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?