Flares & ER
Bowel urgency, tenesmus, and incontinence are among the most common symptoms of ulcerative colitis, and among the hardest to talk about. A global real-world study published in Crohn's & Colitis 360 found that rectal urgency affected patients across all disease activity levels, including those in clinical remission. The 2025 ACG Clinical Guideline Update for Ulcerative Colitis now includes resolution of bowel urgency as a treatment target alongside normal stool frequency and absence of rectal bleeding. That shift reflects what patients have long known: controlling inflammation is only part of the picture when urgency, tenesmus, and incontinence continue to shape daily life.
Understanding Why These Symptoms Persist
Ulcerative colitis urgency, tenesmus (the persistent sensation of needing to pass stool even when the rectum is empty), and incontinence can each have different underlying causes, and they do not always resolve together. Active rectal inflammation is the most direct driver, particularly for tenesmus, which occurs when the inflamed rectal lining sends constant signals to the brain that evacuation is needed. According to the Cleveland Clinic, tenesmus happens because inflammation disrupts normal communication between the colon, rectum, and nervous system.
But even after inflammation is controlled, structural and functional changes to the rectum and pelvic floor can keep these symptoms going. A narrative review in the American Journal of Gastroenterology found that bowel urgency persists in approximately 45% of UC patients in remission, likely due to reduced rectal compliance (the rectum's ability to stretch and hold stool), chronic nerve sensitization, and pelvic floor muscle dysfunction that develops over years of pain and diarrhea. If your urgency or incontinence continues despite good endoscopic results, the problem may be anorectal dysfunction rather than ongoing disease activity, and that distinction matters because the treatments are different.
Medication Strategies for Urgency and Tenesmus
Controlling rectal inflammation remains the foundation. For ulcerative colitis tenesmus driven by active proctitis, rectal formulations of 5-aminosalicylic acid (5-ASA) delivered as suppositories, enemas, or foam can reduce local inflammation more directly than oral medications. The American Academy of Family Physicians notes that topical rectal therapy is the first-line recommendation for mild-to-moderate ulcerative proctitis precisely because it targets the source of tenesmus.
For patients with moderate-to-severe UC whose urgency persists on standard therapy, newer biologics are showing promise. Results from the phase 3b LUCENT-URGE study showed that patients treated with mirikizumab experienced a 55% reduction in daily urgency episodes by week 12, and nearly one-third could delay using the restroom for at least 15 minutes after feeling urgency, up from just 4% at baseline. The updated ACG guidelines also position JAK inhibitors and anti-integrin therapies as options when urgency does not respond to initial treatment. If urgency remains your most disabling symptom, bring that specific concern to your gastroenterologist, because medication adjustments targeting urgency are now part of evidence-based UC care.
Pelvic Floor Therapy for Ulcerative Colitis
When ulcerative colitis incontinence and urgency persist in the absence of active inflammation, pelvic floor rehabilitation becomes one of the most effective available interventions. A systematic review in JGH Open found that 80% of IBD patients who completed pelvic floor therapy for fecal incontinence showed measurable improvement. A separate prospective study found that 62% of patients with quiescent IBD rated their symptoms as moderately or substantially better after pelvic floor behavioral treatment.
Pelvic floor therapy UC programs typically include biofeedback using electromyography (EMG) sensors, urge resistance training (learning to tolerate the initial wave of urgency without rushing to the bathroom), rectal balloon training to improve rectal capacity, and targeted strengthening or relaxation of pelvic floor muscles. An important consideration from the research is that patients should have their disease confirmed as quiescent before starting pelvic floor therapy, since active rectal inflammation can interfere with results. Ask your GI for a referral to a pelvic floor physical therapist with experience in bowel dysfunction, not only bladder conditions.
Products, Planning, and Day-to-Day Management
Having practical strategies in place reduces the anxiety that makes urgency worse. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) recommends wearing absorbent pads or protective underwear as a first-line management tool for fecal incontinence while pursuing other treatments. For UC patients, choosing products designed for bowel (rather than urinary) incontinence matters, because stool containment and odor control require different materials than simple absorbency.
Beyond products, bowel urgency management involves daily habits that build confidence:
Practice timed toileting by using the bathroom at consistent intervals rather than waiting for urgency to dictate your schedule
Map restroom locations before outings and keep a go-bag with wipes, barrier cream, a change of underwear, and disposal bags
Use proper positioning on the toilet (leaning forward with feet elevated) to support complete evacuation and reduce the chance of tenesmus afterward
The Crohn's & Colitis UK bowel incontinence guide also recommends nonmedicated barrier creams and odor neutralizers as helpful additions for managing skin irritation and reducing anxiety about odor.
The Emotional Toll and Where to Find Support
The Canadian Digestive Health Foundation reports that fear of bowel urgency is one of the primary reasons UC patients avoid social activities, exercise, and travel. This pattern of avoidance creates a cycle where isolation worsens mental health, and worsened mental health amplifies symptom perception through the gut-brain axis. Research in the Journal of Clinical Medicine found depression prevalence of 23% and anxiety prevalence of 32.6% among UC patients, with bowel urgency identified as a significant contributing factor.
Breaking this cycle starts with acknowledging that urgency, tenesmus, and incontinence are medical symptoms that deserve clinical attention, not personal failures to manage. Cognitive behavioral therapy (CBT) has a strong evidence base for IBD-related anxiety, and the Crohn's & Colitis Foundation maintains resources for finding therapists experienced in chronic illness. Talking to your GI team about the emotional weight of these symptoms is also worthwhile, since providers increasingly recognize that addressing the psychological burden of urgency is part of comprehensive UC care.
Track your urgency patterns with Aidy to identify triggers and bring data to your GI about treatment options. A clear record of when urgency, tenesmus, or incontinence episodes occur, what you ate, your stress levels, and which interventions helped gives your care team the specifics they need to adjust your treatment plan with precision.