Abstract

Bowel symptoms can influence the organisation of an entire day. Toileting may involve repeated visits, difficult movements, preparation and recovery, with consequences for work, study, relationships and community participation. Occupational therapy assessment needs to describe these demands even when a person completes the task without physical assistance.

This paper considers environmental and assistive approaches for people with Crohn’s disease, colitis, irritable bowel syndrome and diverticulitis. It explains the clinical distinctions relevant to assessment, then examines the relationship between the person, the activity and the setting. It proposes a process for identifying barriers, comparing options, assessing equipment and reviewing outcomes in the person’s chosen occupations.

A wash and dry toilet may be relevant where it addresses an assessed cleansing difficulty. Its suitability depends on the person’s presentation, preferences, trial findings and the arrangements required to use it. A recommendation should connect an identified demand with a response that can be evaluated. The intended outcome is a more workable everyday life, alongside appropriate medical care.

Scope and evidence

This is a practice white paper based on selected clinical information, the World Health Organisation’s functioning framework, outcome-measure developer information and manufacturer instructions. It is not a systematic review or an evaluation of product effectiveness. The assessment examples and proposed decision process are clinical reasoning applications. They should not be read as tested interventions for every person with the conditions discussed.

The clinical sources explain symptoms and management context. Manufacturer sources explain equipment features and operation. Neither on its own, establishes that an adaptation will achieve a particular occupational outcome. This paper makes no claim that washing toilets treat bowel disease, prevent infection or produce guaranteed care savings. The accompanying Maya case study is fictional.

Different conditions and overlapping demands

Person holding their stomach in pain/discomfort

Crohn’s disease is an inflammatory bowel condition with a variable course. Symptoms may include altered bowel habits, abdominal or anal pain and fatigue. Symptoms outside the gut, including joint pain, can also be relevant to movement and self-care. Assessment should establish the current presentation rather than infer it from the diagnosis (NHS, 2025a).

Irritable bowel syndrome, or IBS, is a disorder of gut–brain interaction. It may involve diarrhoea, constipation or a mixed pattern. It should not be conflated with inflammatory bowel disease (National Institute of Diabetes and Digestive and Kidney Diseases, 2017). Urgency, bloating and a sense of incomplete emptying can influence the organisation of everyday routines (NHS, 2025c). The gut–brain description is not a reason to dismiss symptoms or attribute an access problem solely to anxiety.

Diverticulosis describes the presence of diverticula without symptoms. Diverticular disease can cause symptoms, while diverticulitis involves inflammation or infection of the diverticula. During illness and recovery, the timing of intervention matters (NHS, 2023). A person’s temporary transfer difficulty should prompt assessment of recovery and their wider health, alongside any consideration of equipment. It does not establish a permanent requirement for a raised seat or a washing toilet.

For each condition, ask how symptoms affect the actual routine. Someone who transfers easily may have a cleansing difficulty. Someone who manages hygiene may struggle to reach an available toilet. Similar referral wording can therefore lead to different recommendations.

Medical review and professional boundaries

An established diagnosis should not explain away new symptoms. Unexplained weight loss or rectal bleeding in someone describing IBS warrants medical assessment. NHS advice identifies these among reasons to seek urgent GP or NHS 111 advice (NHS, 2025c). The route used in practice should reflect the person’s presentation and local clinical arrangements.

Severe abdominal pain with vomiting, abdominal swelling or inability to pass stool or wind, heavy rectal bleeding, or features suggesting sepsis require emergency assessment. NHS advice directs people with these presentations to call 999 or attend A&E (NHS, 2023). Routine equipment assessment must not delay that response.

For non-emergency concerns, establish whether pain, skin problems, wounds, recent surgery or complications require advice from the person’s treating team before a hygiene trial. Specialist continence, gastroenterology, stoma or tissue-viability input may be appropriate to the issue identified. Dietary treatment also needs suitable expertise. For example, the NHS describes dietitian involvement in low-FODMAP advice for IBS (NHS, 2025b). This paper addresses occupational and environmental management, not prescribing or dietary regimens.

Functioning in context

The International Classification of Functioning, Disability and Health provides a framework for considering functioning alongside activity, participation and contextual factors (World Health Organization, no date). For our practice, the value lies in asking how an observed difficulty relates to the life the person wants to lead.

Occupation includes the things people need and choose to do, and the roles and meaning attached to them. Toileting is an occupation in its own right. It can also determine whether someone remains at work, travels or accepts an invitation. An activity analysis breaks the routine into its component demands without losing sight of that wider purpose.

The environment includes physical space, equipment and the availability of other people. It also includes how access is organised. A locked toilet, an unavailable key or a requirement to wait for classroom cover can matter as much as a threshold. An assessment limited to bathroom dimensions will miss some of these barriers.

For students, the practical distinction is between describing a feature and explaining its effect. “The dispenser is behind the toilet” is an observation. The reasoning needs to describe whether its position requires a movement this person finds painful or unstable, and what would be different if it moved.

The effort inside independent performance

An independence rating often describes the help a person needs. It may tell us less about discomfort, preparation or what they give up afterwards. Ask about the whole episode, including the return to work, sleep or another activity. A routine that is possible once may become difficult when repeated through a morning.

Women laying on her side holding her stomach in pain/discomfort

Fatigue deserves its own enquiry. Crohn’s & Colitis UK gives approximate estimates of seven in ten people with Crohn’s or ulcerative colitis experiencing fatigue during a flare-up and four in ten during remission. These figures concern those conditions, not IBS or diverticulitis, and are not an individual prognosis (Crohn’s & Colitis UK, 2025). A person’s report of remission should therefore not close the functional conversation.

Explore what the person can sustain, what requires recovery and which occupations they have reduced. Support for fatigue should connect with assessment of its causes, not simply instruct the person to conserve energy. In environmental work, the question is whether avoidable demands can be reduced without creating a new difficulty elsewhere in the routine.

An assessment that follows daily life

Begin with an occupational goal in the person’s language. “Manage toileting” may describe the referral but not the priority. The person may want to stay through a working morning, sleep with fewer disruptions or manage personal hygiene with greater privacy. Establish what success would mean before comparing equipment.

Hand reaching for the toilet roll

Ask about a recent day rather than relying entirely on general descriptions. Explore the timing and frequency of the difficult activity, the help involved and the circumstances in which it becomes harder. A short diary may be useful if the person wishes, but should be proportionate. Recording must not become another exhausting task.

Assessment of fluctuation should bring together the person’s account, relevant clinical information and observation where appropriate. A good performance during an appointment does not invalidate difficulties at other times. Equally, a difficult episode should not automatically be treated as the permanent baseline. Explain the uncertainty and what additional information would change the recommendation.

Intimate assessment requires consent and a clear purpose. Discuss what can be established through conversation, a clothed demonstration or review of the environment. Where observation is necessary, agree the approach and respect the person’s boundaries. Use an interpreter or other communication support where needed, without making family involvement the default for sensitive information.

Ask separately about home, work, education and community settings. The person may use a method at home that is impossible elsewhere. An adaptation’s location is part of its clinical rationale: it must address a difficulty in a setting that matters to the goal.

Analysing the toileting sequence

The sequence below is a starting point for discussion. It must be adapted for the individual, including people with stomas or different continence routines.

Part of the routineExamples of demands to investigate
Reaching the toiletRoute, lighting, availability and delay
Managing clothingFastenings, speed, reach and balance
Transferring and using the toiletSupport, seat height, foot contact and comfort
Cleansing and dryingPainful movement, access to supplies and an acceptable hygiene result
Dressing and washing handsReach to clothing, basin, soap and drying facilities
Returning to the occupationRecovery, assistance and the time away from the activity

NHS bowel-incontinence information includes practical attention to toilet access and clothing, alongside assessment and treatment (NHS, 2024). Occupational analysis can develop these enquiries into an explanation of where a particular person needs a change. We should document the limiting step rather than use the entire sequence as an undifferentiated justification for equipment.

Assessing the room and its wider setting

Consider the route into the bathroom and the space used during the task. Door movement, obstacles and the position of fixtures may interact with a walking aid, transfer technique or assistance. Look at the room as the person uses it, including at relevant times of day. An arrangement that works with clear floors and full lighting may work differently in the usual routine.

Evaluate a proposed support through its effect on movement. A rail may assist standing but obstruct a lateral transfer or access for help. A change in seat height should include assessment of foot support, sitting balance and the method of getting on and off. No single dimension establishes suitability for all users.

Closomat Palma Vita with fold down support arms in a home bathroom.

Hygiene supplies, spare clothing, disposal and handwashing facilities also need usable positions. A person should not have to surrender support or make a painful reach to access the item introduced to help them. Consider maintenance access and the needs of others sharing the room before fixing a layout.

For substantial alterations, work with the relevant housing and technical professionals to establish services, structure, permissions and installation feasibility. The OT recommendation should explain functional need and the configuration assessed. Technical design and approval need the appropriate expertise. A drawing that meets a general access specification still needs testing against the intended user’s routine.

Access beyond the home

Information can affect participation before a journey begins. In Euan’s Guide’s 2024 survey, 77% of respondents had avoided going somewhere because accessible-toilet information was unavailable, and 73% had encountered an accessible toilet they could not use. More than 6,500 people took part overall, including disabled people, relatives, friends and carers (Euan’s Guide, 2025, pp. 2, 4).

These are voluntary survey findings about disability broadly. They do not estimate prevalence in Crohn’s disease, IBS or diverticulitis. The responses can overlap and should not be added together. Their relevance here is the need to ask about information and reliability as part of access.

Workplace assessment should explore what the person needs to make the day workable and what they consent to share. Crohn’s & Colitis UK’s employee guide provides a resource for that discussion (Crohn’s & Colitis UK, 2026). Practical arrangements may involve toilet availability, breaks or a dependable way to leave a task. Check what happens when the usual colleague is absent or a facility is closed. A fallback needs to be usable, not simply named in a plan.

Matching assistance to the assessed difficulty

The range of options may include rearranging supplies, changing a routine, providing transfer support or considering a different cleansing method. Their relevance depends on the barrier identified. Low-cost equipment also deserves assessment: grip demands, cleaning, storage and acceptability can determine whether a seemingly simple aid is used.

Wash and dry toilets combine toilet functions with water cleansing and air drying (Closomat, c). They may be worth assessing where the person has a hygiene difficulty that the method could address. Reduced reaching during cleansing is a different outcome from reducing straining during bowel emptying. A recommendation must not blur those mechanisms.

Before a trial, consider the current clinical presentation, comfort, positioning and the person’s preferences. Establish whether any specialist advice is needed. A person who has no cleansing difficulty should not be directed towards a washing system solely because of a bowel diagnosis.

Configuration matters. Closomat describes alternative controls and accessories for the Palma Vita (Closomat, b). Assess the configuration the person would actually receive, including the support and control method. Avoid assuming that successful use of one demonstration arrangement transfers to another seat, control or setting.

Designing and recording a useful trial

An equipment trial should focus on the difficulty the person wants to overcome. If reaching to manage personal hygiene is painful, the trial can explore whether a wash and dry toilet allows them to clean and dry themselves comfortably and effectively. Discuss what matters to the person beforehand, then assess how the equipment works for them in practice, including comfort, ease of use and satisfaction with the result.

Establish the current method as a comparison where appropriate. Record the help required and the person’s experience. Include the whole routine rather than testing only whether the wash can be activated. Clothing, transfers, positioning and getting up afterwards may change the conclusion.

Closomat Palma Vita with a touch sensitive hand/foot switch showing the washing function.

For the Palma Vita’s standard elbow-pad operation, the manufacturer describes holding the pad while seated for washing and releasing it for drying. The instructions state that douche temperature and pressure adjustments should be carried out by Closomat engineers familiar with the equipment (Closomat, no date a). These details matter when assessing the control action and planning support.

A successful demonstration can support further consideration, but does not establish performance through a working day or during a flare. Any additional assessment should be proportionate and should not require a person to provoke symptoms to prove need. Record what remains uncertain and how it will be addressed.

Reviewing occupational outcomes

Review should connect three questions: did the difficult step change, how does the person experience the routine, and what difference has this made to the occupation they chose? A report that equipment was delivered answers none of them.

The Canadian Occupational Performance Measure supports identification of personally important occupational problems and review of perceived performance over time. Use its manual and administration requirements when using the measure (COPM Inc., no date).

Record other changes, including medical treatment, symptoms and the support available. Improvement after installation does not establish that the equipment caused every benefit. Although, an improved hygiene routine may still matter even if another barrier prevents a return to work. Describe both findings rather than force the outcome into a single success label.

Reasoning that another clinician can follow

A clear recommendation should identify the occupation, the limiting demand and the context. It should distinguish what the person reported from what was observed, explain the alternatives considered and state the trial findings. Record the configuration recommended, any dependencies and who will review the result.

For students, supervision can focus on the link between evidence and decision. Which source explains the condition? Which establishes the equipment’s operating requirements? What comes from the person’s own priorities? What is a clinical hypothesis that still needs assessment? These distinctions enable confident reasoning while remaining grounded in the information available.

The same process can lead to different plans. Maya’s fictional cleansing difficulty may justify an assessed trial. Sam’s difficulty leaving a classroom may require dependable cover. Joan’s difficulty standing during recovery may require temporary support and reassessment. The occupation and its demands determine the enquiry.

Conclusion

Bowel conditions can place demands on time, movement and access that remain hidden in a brief account of independence. Housing and equipment practice can make those demands visible and identify changes worth assessing.

The clinical task is to understand what the person wants to do, examine the routine in its actual setting and evaluate a response to the difficulty found. Medical care, personal choice and a workable plan for ongoing use remain part of that reasoning. The measure of an adaptation’s usefulness is the difference it makes to the person’s life, including what they are able to do after leaving the bathroom.

References

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