Bowel Urgency & Radiation Proctitis Management

Do not wait for your next visit. NCI's instruction is direct: "Tell your health care team if you have symptoms of radiation proctitis."

Two situations carry extra weight.

• On diarrhea severity, grades 3 and 4 mean seven or more bowel movements above your normal daily number. NCI says these "can be life-threatening and may require treatment in a hospital."
• On chronic bowel damage, severe cases may lead to "bowel obstruction, a life-threatening condition that causes severe pain, gas, and constipation."

Ask your team directly what number of bowel movements should trigger a call, and which number to call. If you have ever had radiation to the abdomen or rectum, tell any doctor who treats you later. Bowel symptoms years afterward may trace back to it.

Radiation aimed at the pelvis passes near the rectum. The National Cancer Institute (NCI) explains that "radiation proctitis can happen when radiation therapy damages the lining of the rectum." It is most common after radiation to the rectum and sigmoid colon, and after treatment for rectal, prostate, and cervical cancer.

An irritated rectal lining loses its ability to hold and wait. That is why urgency, rather than volume, is often the symptom people find hardest. NCI lists the symptoms as diarrhea, "frequent or persistent urges to have a bowel movement," abdominal pain or cramps, and "blood or mucus in stool." When radiation also affects the small intestine, NCI calls it radiation enteritis. That adds appetite loss, nausea, and vomiting.

NCI describes acute radiation proctitis this way. It "begins shortly after you start radiation treatment and goes away a few weeks after radiation treatment ends." So for most people, urgency that starts during treatment is a temporary problem. It settles in the weeks after the last session.

A chronic form exists and behaves differently. NCI's late effects guidance says bowel and rectal damage from radiation can appear "months or years after cancer treatment." Chronic radiation proctitis can cause rectal bleeding, rectal pain, and "diarrhea with mucus that does not get better." In severe cases it can lead to fistulas and loss of bowel control. Chronic radiation enteritis can cause trouble absorbing nutrients, anemia, dehydration, and weight loss.

NCI lists these risk factors.

• Large pelvic radiation areas.
• High radiation doses.
• Prior pelvic surgery.
• Chemotherapy given at the same time.
• Diabetes.
• Inflammatory bowel disease.
• High blood pressure or other vascular disease.
• Tobacco use.

Newer delivery methods, including stereotactic body radiation therapy and intensity-modulated radiation therapy, "may help avoid damage to the rectum's healthy cells."

Diet. NCI's advice for proctitis is frequent small meals, low-fiber foods, and foods high in sodium or potassium. Low-fiber options include white bread, pasta, and canned fruit. High sodium and potassium foods include peeled boiled potatoes, soup, bananas, applesauce, and crackers. Foods to avoid include alcohol, milk and dairy, spicy foods, caffeinated drinks, dried beans, high-fat foods, fruit juices, and sugar-free gum and candies. For enteritis, NCI notes a dairy-free diet is sometimes advised.

Fluids. NCI says to "drink lots of water or other fluids." It suggests clear liquids such as water or broth, taken at room temperature.

Medicines. NCI names loperamide (Imodium) and diphenoxylate with atropine (Lomotil) for diarrhea, along with probiotics and fiber supplements such as Metamucil. Its instruction is direct: "Check with your doctor before taking these or other medicines and supplements." For proctitis and enteritis, prescribed medicines can also ease abdominal pain, nausea, and vomiting.

Skin and pain relief. NCI suggests a warm, shallow bath (a sitz bath) to relieve pain and irritation from diarrhea. For diarrhea, it says to "keep your anal area clean and dry," using warm water and baby wipes or a warm, shallow bath.

For chronic disease. NCI says treatment includes diet changes and medicines for diarrhea and pain. Severe cases may need nutritional support, or surgery for obstruction, fistulas, strictures, and tearing.

• Is my urgency expected at this point in treatment, or is it more than expected?
• How many bowel movements above my normal should trigger a call, and to which number?
• Which anti-diarrhea medicine is safe for me, and at what dose?
• Should I stop dairy or fiber, and for how long?
• Is any bleeding I am seeing from radiation, or does it need to be looked at another way?
• If this does not settle after treatment ends, who manages it then?

• National Cancer Institute, Radiation Proctitis.
• National Cancer Institute, Radiation Enteritis.
• National Cancer Institute, Diarrhea and Cancer.
• National Cancer Institute, Late Effects of Cancer Treatment.