The Ileoanal Pouch

The ileoanal pouch, also known as ‘ileal pouch’, ‘IPAA - Ileal Pouch-Anal Anastomosis’, ‘RPC - Restorative Proctocolectomy’, ‘ileo-anal pouch’ or ‘ipouch’, is formed once the entire colon and most of the rectum are removed. Then the pouch is constructed from the last part of the small intestine – the ileum and connected to the rectal cuff above the anal canal.

There are different surgical options:

3-stage surgery - The pouch is made in a 3-stage surgical approach. In the first stage, the diseased colon is removed while the rectum and anus remain intact; this is called a subtotal colectomy surgery. An end ileostomy is formed. The rectal stump can either be oversewn and left inside the abdomen or brought out as a mucous fistula. At the second stage, the end ileostomy is taken down, most of the rectum is removed, and the end of the small intestine is used to form an ileoanal pouch. The pouch is then connected to the rectal cuff above the anal canal. A temporary loop ileostomy is formed above the pouch to protect the anastomoses. And finally, during the third stage, the loop ileostomy is closed, and the pouch begins to function.
2-stage surgery - The pouch is made in a 2-stage surgical approach. During the first stage, the entire colon and most of the rectum are removed while the anus remains intact. The end of the small intestine is used to form an ileoanal pouch. The pouch is then connected to the rectal cuff above the anal canal. A temporary loop ileostomy is formed above the pouch to protect the anastomoses. At the second stage, the loop ileostomy is closed and the pouch begins to work.
In some cases, the 2-stage surgery may be modified and be very different. During the first stage, a subtotal colectomy is performed, as the diseased colon is removed while the rectum and anus remain intact, and an end ileostomy is formed. The rectal stump can either be oversewn and left inside or brought out as a mucous fistula. While at the second stage, the end ileostomy is taken down, most of the rectum is removed, and the end of the small intestine is used to form an ileoanal pouch. The pouch is then connected to the rectal cuff above the anal canal. The pouch begins to function.
1-stage surgery - The pouch is made in a 1-stage surgical approach. During the surgical procedure, the entire colon and most of the rectum are removed while the anus remains intact. The end of the small intestine is used to form an ileoanal pouch. The pouch is then connected to the rectal cuff above the anal canal and begins to work.

The many configurations of ileoanal pouches:

These ileoanal pouches come in different shapes, each with unique structural and functional characteristics.
Each pouch type is tailored to the patient’s anatomy, lifestyle, and surgeon’s expertise. The J-pouch has become the most common type,
but the S-pouch and W-pouch configurations offer alternatives for specific needs.

J-pouch: The pouch is formed by folding two limbs of small intestine into a shape resembling the letter ‘J’.
Pros:
- Most commonly used and well-studied configuration.
- Simpler to construct, requiring only two limbs.
Cons:
- Smaller capacity than other pouch types.
- May require more frequent emptying, especially initially.
S-pouch: Constructed using three limbs of small intestine, folded to resemble an "S" shape.
Pros:
- Larger reservoir capacity than the J-pouch.
- May reduce urgency and frequency of bowel movements.
Cons:
- More complex to construct.
- Longer surgery and recovery time.
- Due to its shape, evacuation difficulty may be common.
‘W’ pouch: Made by folding four limbs of small intestine into a "W" shape, creating a larger and more capacious reservoir.
Pros:
- Largest volume capacity of all pouch types.
- Fewer daily bowel movements.
Cons:
- Technically demanding and time-consuming to build.
- Higher risk of complications due to complexity.
- Not commonly used due to surgical difficulty and known evacuation difficulties.

Suitable Candidates for iPouch Surgery:

Not everyone from the list below is a suitable candidate for ipouch surgery, however, those who meet certain criteria,
and require surgery to remove their colon and rectum, can be considered for ipouch surgery.

Ulcerative colitis patients unresponsive to medical treatment
Colitis-associated neoplasia
Familial Adenomatous Polyposis (FAP)
Colorectal cancer requiring proctectomy
Indeterminate colitis
iPouches are generally contraindicated in people with known weak sphincter muscles (incontinence), obesity, Crohn’s disease, etc. .

What is Normal for an iPouch?

An ileoanal pouch is considered to be functioning acceptably when it meets these clinical and quality-of-life benchmarks:

🧻 Bowel Motions Frequency

Daytime: 4–7 bowel movements daily
Nighttime: 0–1 per night

💧 Continence

No urgency
Minimal to no leakage, occasionally some seepege at night
No episodes of incontinence
Ability to defer defecation comfortably

🚽 Evacuation

Pouch empties effectively without prolonged effort, with no excessive straining
No persistent sensation of incomplete evacuation

🔥 Comfort

No significant pain, pressure, or cramping associated with pouch function
No signs of pouchitis or cuffitis (pouch or rectal cuff inflammation), unless occasional and well-controlled

📆 Stability & Good Quality of Life

Predictable routine without interference in daily activities
No need for regular medication to regulate function
Patient feels confident and unrestricted in diet, work, travel, and social settings
Sleep is uninterrupted or minimally disturbed
Ability to enjoy social life, including working, travelling, attending events, etc., without having to worry about your pouch
Normal sexual function

It’s worth noting that pouch function can vary depending on individual healing, anatomy, and pouch configuration.
Some people adjust easily, while others may need time and support to achieve consistent function.

iPouch Function Immediately After Surgery:

When your ipouch starts working for the first time, it may need a few weeks or months to adjust and settle into a routine.
During this period the ipouch may be unpredictable and more erratic.

Innitially ipouch frequency may be 10–15 times over 24 hours
Output may be of liquid to semi-liquid consistency
Perianal skin soreness and pain inside the anal canal
Incontinence and some urgency may also occur initially

The ipouch will need to go through a period of bowel adaptation & retraining, which requires some time to become confident with the way the ipouch works.

During this period of adaptation, some important adjustments may help manage the erratic pouch function:

Low fibre diet

Medications that slow down gut movements
Urge resistance

Hints & Tips for New Pouches…

Bowel Adaptation & Retraining:

After ileoanal pouch surgery, your body needs time to adjust to its new plumbing.
The small intestine takes over the role of the colon, which means stool consistency, frequency, and urgency can all change.
Retraining helps you regain control and comfort.

🔄 What Is Bowel Adaptation?

Physiological changes: The small intestine gradually settles down and learns to absorb more fluid.
Stool consistency: Initially loose, but over time becomes thicker and semi-liquid.
Frequency: Starts high (8–12 times/day) and typically reduces to 4–7 times/day.

🏋️‍♂️ What Is Retraining?

Retraining involves behavioral techniques to improve pouch function and continence:

Correct sitting posture: As shown in the image, knees higher than hips helps relax pelvic muscles and ease evacuation.
Timed toileting: Going at regular intervals, even without urge, helps establish routine.
Pelvic floor exercises: Strengthens muscles for better control.
Dietary adjustments: Low-residue foods early on, then gradual reintroduction of fiber.
Avoiding triggers: Caffeine, spicy foods, and high-fat meals may increase urgency.

It is important to remember that it takes time but it does get better.
Most patients see significant improvement in pouch function within 3–6 months.
Support from ipouch nurses, and other clinicians, dietitians, and peer groups can make a huge difference.

Dietary and Hydration Adaptation:

🍽️ Dietary Guidance for iPouch - If you are learning to navigate diet, it is worth noting that individual tolerance varies,
some people can reintroduce small amounts of these “avoid” foods over time. Keeping a food diary can help track what works and what doesn’t.

✅ Foods to Include

These are generally low-fiber, easy-to-digest options that help reduce stool frequency and prevent blockages:

Refined grains like white bread, pasta, and rice are gentle on the gut.
Smooth textures (e.g. mashed veg, pureed fruit, smooth peanut butter) reduce mechanical irritation.
Dairy and protein sources like yogurt, eggs, tofu, and lean meats support healing.
Low-residue fruits like bananas and applesauce provide nutrients without bulk.
Clear liquids and smooth soups help maintain hydration and electrolyte balance.

🚫 Foods to Avoid

These tend to be high-fiber, gas-producing, or difficult to digest, which can lead to discomfort, urgency, or even obstruction:

Whole grains, nuts, seeds, and dried fruit are harder to break down.
Raw or unpeeled produce can irritate the pouch.
Gas-producing vegetables like cabbage, broccoli, and cauliflower may cause bloating.
Spicy foods and tough meats can increase urgency or cause irritation.
Legumes and fibrous foods (e.g. mushrooms, corn, popcorn) are common culprits for blockages.

💧 Hydration Tips for iPouch - If hydration is a struggle, sipping small amounts frequently is better than chugging.
And pairing fluids with salty snacks (like pretzels or crackers) can help your body hold onto water more effectively.

✅ Best Choices for Hydration

These drinks help replenish fluids without irritating the gut or causing rapid transit:

Decaf & herbal teas (excluding green/black): Gentle and soothing.
Water & coconut water: Great for hydration and electrolytes.
Milk & kefir: Provide protein and probiotics, which may aid gut health.
Savory broths (Bovril®, Oxo®, Knorr®): Rich in sodium, which helps retain fluids, especially important to prevent dehydration.
Non-fizzy sports drinks: Lucozade®, Powerade®, Gatorade® offer electrolytes without carbonation.
Water-rich foods: Melon and yogurt are sneaky hydration heroes.

🚫 What to Avoid

These can either dehydrate you or irritate the pouch/stoma:

Alcohol: Diuretic and irritating.
Caffeinated drinks: Increase output and may cause urgency.
Sugary/artificial drinks: Can cause bloating or diarrhea.
Fizzy drinks: Gas-producing and uncomfortable.

Skin Care for iPouch:

Maintaining healthy skin around the anus and stoma site is essential, especially when stool frequency is high or output is loose.

Here's a practical checklist that could accompany your image:

Clean gently after each bowel movement - Use warm water or pH-balanced wipes. Avoid harsh soaps or rubbing.
Pat dry, don’t wipe - Moisture can lead to breakdown. Patting helps preserve skin integrity.
Apply barrier cream or ointment - Zinc oxide or silicone-based creams protect against irritation and moisture.
Use soft, unscented toilet paper or wipes - Fragrances and alcohol can cause stinging or allergic reactions.
Avoid talcum powder or drying agents - These can cake and worsen irritation or interfere with pouch adhesion.
Wear breathable, cotton underwear - Helps reduce moisture buildup and friction.
Monitor for signs of skin breakdown - Look for redness, itching, weeping, or pain—and report changes early.

💡 Extra Tip: If output is frequent or acidic (common with new pouches), using a skin barrier film spray before applying creams can add an extra layer of protection.

For detailed skin care advice, check out out skin care page.

Managing Excessive Wind with iPouch:

Here’s a breakdown of the foods and drinks that may cause excess gas or bloating:

🚫 Gas-Producing Foods

Cruciferous veggies: Broccoli, cauliflower, cabbage, sprouts
Legumes: Lentils, soy, beans, peas
Dairy: Creamy foods, cheese, milk (especially if lactose intolerant)
Fizzy drinks & alcohol: Carbonated drinks introduce air into the gut
High-fiber items: Bran, dried fruit, nuts, seeds
Others: Mushrooms, onions, garlic, eggs, peanut butter, cucumber, sweetcorn, asparagus, fruit skins, chewing gum

✅ Tips to Reduce Wind

Eat slowly and chew thoroughly - Swallowing air while eating is a major culprit.
Avoid straws and chewing gum - These increase air intake.
Keep a food diary - Everyone’s gut reacts differently—track what triggers you.
Try peppermint tea or capsules - They can help soothe the digestive tract.
Consider enzyme supplements - Like lactase or alpha-galactosidase for specific foods.

All advice provided should always be discussed with an ipouch specialsit. Do not self-treat without having a conversation with a specialsit. You can always reach to us as we have vast experience managing ipouch-related challanges.