Period Pain and Pelvic Floor

Oh hey, it's the fitted sheet that really doesn't care how you fold it. Allie Ward, welcome to Oligies. I'm proud of you for listening to this one. It might save your life or it might make you horny. We'll see. Either way, this guest is thrilling. They are a colorectal surgeon and the author of the acclaimed book Constipation Nation: What to Know When You Can't Go. They have been decorated with so many medical awards. They got their MD at Michigan State University. They did their surgery residency at Mount Sinai Beth Israel, then a fellowship in colon and rectal surgery at Stonebrook, and is a double board certified general and colorectal surgeon in private practice as a co-director of the Hemorr hoid Centers of America. They're so funny, so charming, no question is too sensitive, and you need to send this to everyone you know with a butthole. Even your grandparents. You think your granddad never had a finger up his butt. I got a bridge to sell you. It comes with a free dildo. But first, thank you to everyone via Patreon.com slash ologies for supporting the show for a dollar or more a month and submitting your questions. Thanks to everyone out in Ollogies Merch from Ollogies Merch.com. And as always thanks to the folks who review the show for me to read which helps people discover it so much uh this latest one is from srforstner who wrote one minute i'm learning about volcanic lightning the next i'm emotionally invested in Salamanders. SR Forstner, thank you to that, and thank you to sponsors of the show who make it possible for us to donate each week to a related charity. Quick question: Do people come to you for answers at work? Maybe you're managing projects, training new hires, or just the one everyone relies on. That's leadership. Through UVA Darden's part-time MBA and Roslyn, we help professionals like you turn real-world experience into recognized leadership credentials without stepping away from your career. Whether you work in healthcare, education, government, or business, this is how you take the next step. Learn more at darden. edu backslash ptmba . Hi. Sorry, did I startle you? When you're used to hearing a certain type of commercial, something like this can, well, take you by surprise. That's kind of how it is with the Lexus RX, a vehicle that has continued to defy expectations for over 25 years, from the first luxury vehicle of its kind to the first hybrid luxury vehicle, to the only plug-in hybrid worthy of the RX name. We understand you want more than the everyday SUV. And isn't being understood an amazing feeling? Click the banner to discover more. Experience amazing at your Lexus Dealer. One thing I love about my long-term friends is I'm still learning things about them, especially if we travel together. But maybe you have a buddy that you brought on a weekend trip who you didn't know has to do scream yoga at dawn. Surprise! But verbo, verbo does not surprise you. When you book a verbo vacation rental, verbo care and 24-7 live support from real humans are included. If something is not as described or isn't working, Virbo can step in to help make it right. I don't know what to tell you about the screen yoga though. Book today on the Verbo app. If you know your Verbo, terms apply. See Okay, come along with me into the world of your colon. Also, I did an episode a few years ago called Field Trip, My Butt, a colonoscopy how to and ride along. And since so many of you will be listening to that one next, we're going to re-release it this week as a bonus episode because I've gotten so many letters from listeners the past couple years that told me that it helped them catch and treat diseases, including cancers. So we're going to link that, re-air it. But colon comes from the Greek, colon, which means colon, and proctology derives from the Greek for anus. So coloproctology, we get deep. Sit tight or walk around for prost ate orgasms, shady polyps, colon cancer branding, hot dog habits, endometriosis, diver ticulitis, butt plugs, heartburn, douches, bidets, farts, vacation constipationation in the n, fiber maxing, ostomy awareness, second sphincters, the most fascinating crown jewels, pregnancy, agonies, roids, fissures, fixes, IBS, hydrotherapy, a shocking shower revelation and how a blissful colonoscopy could change and save your life with surgeon, author, earthly delight, and coloproctologist, Dr. Carmen Fong. I love her. We're vibing. We're vibing, dude. I there's so many questions. I hope you know how excited people are to learn about butt health. I can imagine. Honestly. I mean, I I listened to your colonoscopy episode and I loved it. And I was like, oh my god, everybody needs to listen to this colonoscopy episode before they go in. And then I was like, I'm actually surprised you haven't talked to like a gastroenter ologist or like a you know proctologist but yeah people love cuts okay hold on let's back up a sec. Oh yeah my name is Carmen Fong and my pronouns are she her they cool. Um okay. Gastroenter ology, proctology. Can you disambiguate this for the uninitiated? A hundred percent. Okay. So I'm a colorectal surgeon and I guess that does get confused with GIs a lot. And of course they do colonoscopies and like really advanced endoscopic procedures and things like that. But they're technically not surgeons, surgeons. So the training is actually the same amount of time, but we are more doing a lot of like the abdominal operations. Most of us will actually also do phonoscopies, but the one major difference is that colorectal surgeons do a lot of anal rectal stuff, which is like true proctology. Oh, does it stop if you're a gastroenterologist once you're no longer in the intestines, that sphincter this is it the sequel sequel the iliocecle valve. Right. Thank you. So that's the valve or the gate between your small intestine to your large intestine. And a large intestine is also called a colon. There's a few different regions of your colon. And I also wonder if people called it intestinal cancer instead of colon cancer, if they would be less shy about screening or treatment. We can start calling it intestinal cancer and start a trend or revolution, a bowel movement, if you will. Once it crosses that barrier, is that like a different jurisdiction? That's interesting. So, no, actually. Oh, so gastronologists will scope, like do an upper endoscopy, which is basically the mouth to the stomach. And then you can actually do some like really fancy advanced endos copy, like a push endoscopy, and push through the stomach and go into the small intestine, look through there a little bit. In some cases we've helped with doing like a laparoscopy at the same time, which is a kind of a crazy procedure. So an endoscopy, endo means inside, scope, meaning look around. It means that you get a camera in your body. And an upper endoscopy, it starts at the mouth and it heads down. And a colonoscopy starts at the other end, goes up. And if they don't use one of those two holes, they may make a little portal through an incision, which is a laparoscopy. So finally, your guts are the main character and you get an exclusive screening for things. But then they cannot go all the way down into the small intestine. And then the other end is, you know, pun intended, they go from the bottom up and they scope from the bottom to the colon. So they can go from gum to bum the same way that we do from gum to bum. It's just that we end up almost inside the body a lot more rather than just in the intestine. When you were going through med school, did you have a lot of rotations and did you just land on on butts and intestines and you're like, I'm home. Oh my God. No. Um, so I actually went into this because I wanted to be a plastic surgeon because my um my background is an art. I was a visual artist in college. And so I was like, I'm gonna be a plastic surgeon. I'm gonna make people beautiful. I'm gonna fix like baby cleft lips and cleft palettes. And to this day, my parents and my aunts rue the fact that I'm not a plastic surgeon. They're like, why didn't you do something useful? Um dare you! But then now that you know they're all older, they're thanking me. Um but then when I went through residency and I was in training, I was like, Oh, you know, but I love general surgery. I actually really love it being inside the abdomen and being able to like diagnose and treat and reconnect butts and guts because I really love being like the master of the abdomen and knowing everything that's going on inside your body. Mm-hmm. I've heard recently that when you are getting an operation, they throw your intestines to the side and then they just shove them in there and let them rearrange themselves later. Correct. Is that true? Yes. Do you know people ask me that a lot? They're like, once you're inside the belly, does it look like that plastic figure where you put the little plastic pie ces back in, you know? Yeah. And it's not. And then somebody else asked me, like if you're looking at your colon, is it more like a pipe? But it's actually more like an empty tube sock. Oh. So it's like a big cavernous space inside your abdomen and, there's empty tube socks, which is the bowels, and then there's the solid organs, which I kind of liken to like really squishy dough almost. Like the squishiest ones are like the pancreas, which you really can just like put your thumb through, but then the harder ones like your liver. So there's like you know, squishy pieces and and tube sock pieces. And yeah, you just throw it all back in. You don't have to stitch it back to the lining. In the old days actually in the 1800s, they actually thought that things had to be stitched back up because when they dissected cadavers, I just read about this, which was crazy. Cool. Lay it on me. When they dissected cadavers, they were always on their back. And so they thought that the organs should be like laying in this, you know, flat plane on your back. But when people stand up, they' s gravity. And so things actually kind of all naturally drop to the bottom. So let's say that you haven't eaten, you wake up empty stomach, empty guts or whatever. Does that mean that it's sort of like an empty tube sock or like one of those an imal uh balloons that you haven't yes pumped up yet. Yeah, it's just sitting in the bottom of your pelvis. And so then when there's food moving through it, then it kind of inflates like a bubble wood. Yeah. Oh no way. Like a bubble, like with their if there's gas, right? Like if you're about to fart, there's gonna be gas. Or if there's stool, it kind of fills up. And so you can actually feel like on the left side of your abdomen, if you're constipated, you can probably feel almost like a little cylinder in this left side of your abdomen. That's your sigmoid colon that's full of poop. When it's full. Okay, so large intestine, the colon, it's kind of like shaped like a boxy horseshoe under your abdomen. So on the right side of your body, it travels north, and that's called the ascending colon. And then it takes a turn to travel across your abdomen over your belly button. That's the transverse colon. And then it takes another turn on your left hand side to head south. And that is your descending colon. And that descending colon is kind of like the home stretch to your bottom hole, which is why massaging that descending colon or laying on your left side can help people poop or you can get the gas out. Also at the end of this colon tube is the sigmoid colon, which is kind of like the very backstage area where poop waits to make its big debut into the rectum and then out your anus into the glare of the limelight. I always wonder how when doctors are palpating a stomach, how they know what the fuck's going on down there? Cause I'm like, how do you it doesn't feel like anything? How are you trained to do that? You know, that's a really good question. I I mean we did a lot. We do it a lot like in medical school and I think probably some people still fake it. They're like, uh, you know, this feels like but um we are losing a little bit of that, like the art of physical examination because of CT scans and MRIs and all that. Just like uh scan you and we'll find out what's wrong. Have you ever been called to get things out of a butt? Oh a hundred percent. I knew this question would come up. I'm sorry. I didn't even think I had the question until I was like, wait a minute, how have I done out? Talk to me. Actually, it's a joke that like at 3 a.m., you know, if they call me, it's gonna be like uh get Dr. Fong's foreign body extraction tray because that means that I'm gonna need the tongs and the clamp and the speculum. But yes, I I have removed some things. Anything that you're at liberty to share? Anything really wow, yeah? You know, most of it is like a long time ago , but my favorite one was a pink highlighter because my resident still texts me to this day and is like once in a while she'll be like, remember that pink highlighter ? Like, how could we forget? Um, but definitely tons of dildos, you know, and like no sex shaming or anything, you know, do what you do you. A ton of dildos and people just kind of like underestimate the length and the width of them sometimes. Uh throughout the years, we've had like Starbucks bottles, candles, cucumbers. I had like a piece of a lamp once that was like a like a glass globe. Oh no. That was pretty cool and hard to get out. Like if you try to get like a round, smooth object out of a tight cylinder, yeah. That was difficult. If you would like to know more about foreign objects rescued from the depths of an orifice, please enjoy our radiology episode. I got two words. Wine bottle. If it's glass, uh how I mean you must need like the gentlest of touches. Yeah. Gentlest touch. You know, we were literally like tried suction almost like when they suction a baby out. We almost tried that. That didn't work because it was so heavy. But we ended up using it's called a deaver, which is like a little retractor that has like a little scoop on the end, and that scooped perfectly around it. We tried every tool in the OR that n ight. Did you have to sedate the patient? They were sedated, absolutely yes. Oh that I mean I would be like, wake me up like a month later. Yeah. And we we have that, you know, that full conversation beforehand, like sorry, we tried to get this out while you're awake, and so you know, we gotta put you to sleep just for your safety, so you're not moving around. And also if there's any kind of complication, right? Because the worst case scenario is there's some kind of perforation, you know, we puncture the colon or something and we have to fix it. Yeah. Then you should be asleep. Fortunately, knock on wood. That's never happened. Uh do you have a PSA now for um for butt plugs with a foot? A hundred percent. Important have a foot at the end of your butt please please have a handle you know make sure there's a handle make sure you can have a good grab on it if you can oh saving lives saving pride saving butts I'm sorry that that's one that you get asked so much, but no, people wanna know, you know? Yeah. Well, okay, so I w studied biology in college, right? Mm-hmm. As a biomajor, so I always think about the order of sphincter s. And I remember hearing that there were sphincters inside the body and being blown away by that. Just a side note: a sphincter, it's just a round muscle that closes an opening. You have them in your excretory system, such as for example your anus, but also all along your intestines to kind of close off chambers. So imagine like a train with doors between the cars. And you can thank a ton of nerve end ings in your lower bowel for being able to discern the pressure of a gas versus a solid and act as kind of a bouncer to let farts through. Which means every time you enjoy a fart, you're not pooping, most of the time. Aren't you glad you can do that? Of course you are. And one in five thousand people are born with a condition it's called Hirschsprung's disease, where those very sensory nerves don't function. Your body can't really tell the difference, and sometimes it doesn't want to let anything out and that part of the bowel has to be removed and that or ulcerative colitis or even shagged disease can also lead to a condition called megacolon, which sounds like a marble character, but it's more painful and potentially lethal. So according to the paper megacolon, acute, toxic, and chronic, a constipated and stuffed colon with a diameter nearing five inches is mega , obviously, and can require surgical correction to address whatever the underlying causes are. And there's one legendary patient. It's a man who was so impacted. He was known in sideshow circles as balloon man. And when he died in eighteen ninety-two at the age of twenty-eight, while straining to pass his cargo, the medical examiner found an eight-foot-long colon, nearly nine inches in diameter and carrying 40 pounds of excrement. And scientists say upon examination now it's apparent that he had suffered from that Hirschsprung's disease where your nerves are just not on board to let things pass. And I was like, dang, who is Hirsprung who got the honor of being named for this? And it was a late 1800s doctor from Copenhagen, and Harold Hirsprung, he described this condition and he actually went against orders from the government and he provided free health care to children who needed it while charging those who could afford it. And though the queen wanted each child's hospital bed to be surrounded by biblical passages, he was like, no, Hag, I'm putting animal pictures up. Hirschsprung. I like him. But yet there are sphincters also in your blood vessels, your eyes. Sadly, I just found out and I had to re-record the end of this aside that your mouth and my mouth have been demoted and they're no longer a sphincter, which is Pluto levels of heartbreak, but all we can do is soldier on. So from the bottom, um, from the bottom. So we have the external sphincter, which is actually the part that you kind of feel, right? So I always tell people: like, if you're feeling your anus, like when you get to the tightness of your anus, that's the external sphincter. That's the part where you have voluntary control, where you're like, oh my gosh, I have to poop, I'm gonna hold it. That's the part you're squeezing. And then there's just above that the internal sphincter. The internal sphincter is the part that's involuntary control, which means that your body actually amazingly when it senses poop it will actually kind of close and there's a response called a rare response where it kind of senses whether it's poop or gas so that it can let out gas if it's gas and then we'll hold to the poop if it's poop. I know. I'm always fascinated by this. There's a couple of rectal valves above that and then there's the iliocecal valve which is the connection between the the colon and the small bowel. And then if you go above that there's like the pylorus which isn't technically a sphincter but, that connects the small bowel to the stomach. And then right up at the top of the stomach is the esophageal sphincters. Oh, so that's the part that controls your GERD. So if you don't know what GERD is, congratulations. It stands for gastroesophageal reflux disease. It's like wicked heartburn. It's when stomach acid just like pops into your esophagus, like, hey, what's going on up here? Because that sphincter is just on break. So if you have like a loose esophageal sphincter, you have really bad GER becauseD when you lay on your back, you know, everything kind of like sloshes back up. Or if you're pregnant, it relaxes your esophageal sphincters and everything kind of sloshes back up. Oh, that's why that happens? Yeah. Well, it's the pressure from your abdomen, but also the relaxin, which is the hormone that relaxes all your muscles to allow you to fit the baby. Um, relaxes everything else. It's kind of crazy. And you mentioned before we started recording that you've been pregnant, you're wearing a shirt right now that says got hemorrhoids. Correct . Question mark. Okay Where are the hemorrhoids? Which sphincter are the hemorrhoids? Where are those coming from? That's an excellent question. So technically there's two kinds of hemorrhoids. There's internal hemorrhoids, which start just above the dentate line, which is like almost at the internal sphincter. So the dentate line is like a border between your anus and your intestines. And it's usually just kind of a faint line, but it is like a border on a map. So much so that medicine often refers to it as a landmark. And depending on your interest, it can be a fun tourist destination for fingers and other objects. More on that later. So internal hemorrhoids you can't feel because there's no sensation. You feel pressure but not sharp pain. And so internal hemorrhoids tend to prolapse as and they pop out of your anus. They they can bleed, they can cause pressure and a little bit of itching, but generally not painful. So I usually say, you know, internal hemorrhoids are painless bleeding. So that's inside your hole. And then there's external hemorrhoids, which start at the dentate line, kind of where the sensation is, like, and I compare this to being like literally on the skin. So external hemorrhoids are the ones that you can feel. There's like a little bluish-purplish lump on the outside. You get those residual external hemorrhoidal skin tags after the external thrombosis goes away. And that's external hemorrhoids, which tend to be more pain and not bleeding. And then there's also something in between, which is an anal fissure, which people ask me a lot about, and that really commonly gets mistaken for hemorrhoids and you get both pain and bleeding, but that's more of a sharp paper cut pain because it's literally a tear at that dentate line. So right between the sphincters. So a fissure, it's like a crack or a tear inside there. And it can happen from straining or dehydration or lack of fiber, which we're gonna address a lot in a bit, or some other bowel changes. And if fissures are ruining your life, treat your butthole gently, take a stool softener, drink more water , maybe consult an Etsy witch, whatever it takes. But as for roids, about five percent of younger people tend to get hemorrhoids, but fifty percent of folks over 50 do because of tissue weakening. It's like if you drove an older car, you're gonna have some seals, some hoses are gonna underperform. True or false? More people are having hemorrhoids younger because they're sitting on the toilet scrolling. Is that true? A hundred per cent. Yes. Is that real? Yes. Tell me everything. Yeah. So I mean part of the reason I I wrote this book was that I was seeing so much more constipations, so much more hemorrhoids. And right during the COVID pandemic, people were still coming in for hemorrhoids like three, six months afterwards. And I was like, wow, like the amount of hemorrhoids is like skyrocketing. And you know, we thought it was because people were sitting at home a lot more, right? So they were working from home. were They sitting in front of the computers eight hours a day. So a lot more sedentary lifestyle. And then on top of that, a lot of people were like drinking and eating junk. You know, not gonna lie, that was me as well. Yeah. And so they were like constipate it too on top of that and spending more time on the toilet. So yeah, no, hemorrhoids are not a disease of the old anymore. Like tons of people have it. I see tons of people in their 20s, 30s, 40s, all the way up. And do over-the-counter things like tux and preparation H, do those actually work? And do you have you heard, speaking of plastic surgery, have you heard of people using preparation H under their eyelids c when they're puffy, like beauty contestants? Uh yes. So actually that's the only thing I I think preparation age is good for is for puff is for puffy eyes. Honestly, I I know. Sorry, preparation age. Um I don't love it because what it does is the preparation age can kind of thin uh shrink the blood vessels, but then it also thins the skin. And so a lot of people when they're trying to apply this for something that's like itching, burning, bleeding, blah blah, very small instances, I've seen it work. And then I end up seeing again, pun intended, the end result of preparation H not working, where people come in, they're like, oh my god, this is worse, this is itchy, this is bleeding, this is scratchy. Part of it is just like over application. It's kind of like thin the skin over time. And then also It soothes it a little bit, but it doesn't heal it. Better things to use are a compound ointment. Find a colorectal surgeon who will prescribe a c compound ointment. And it actually works a lot better because it's treating both the sphincters and the spasm as well as the swell with blood vessels. What's in a compound ointment? Yeah. So compound ointments include things like nitroglycerin, calcium channel blockers like deltaism, and niphetopene, also some lidocaine and some pupifacine, so some long and short acting like numbing agents. And then in some cases we'll add hydrocortisone, which is like the steroid, which helps with the inflammation, but also thins the skin. But the key ingredient is really that muscle relaxation. It allows all those swollen blood vessels kind of to reabsorb back up a lot better and then also decreases the spasm in your anus, which is like the secondary result of having hemorrhoids. Your body clamps down. It's like, eh, don't move. I don't want anything to move. This hurts. That clamping is what makes everything worse. Ah what about hemorrhoid surgery? That has sometimes you've got to pull out the big guns. Yes, absolutely. So, you know, when we're trained, we actually learn like eight to nine different ways of treating hemorrhoids, which is crazy. Yes. Yeah. We can laser them, we can do infrared coagulation on them, we can inject them with a phenol solution, which kind of shrinks them down. We can tie them up, you know, either with stitches and then the most common things though are rubber brand legation, which is like banding a hemorrhoid, and then the excisional surgery, which is like the dreaded surgery that nobody ever wants and kind of always, you know, they fear on Reddit, um, from what I've heard. Let's saunter over to the Reddit form about hemorrhoids where anonymous souls share their agony. And on a thread titled, What's Worse Than Hemorrhoid Surgery? Getting chicky with it, a survivor of hemorrhoid surgery wrote, I have been through cancer, chemotherapy, immunotherapy, and a double massectomy. I have had my gallbladder out and chronic back pain surgery, bad enough I can barely walk at times. I had one baby vaginally and I had triplets via C section. The recovery from the hemorrhoidectomy was more painful than any of those things. And Shy David Zero Zero chimed in. I was crying from the pain, even on maximum doses of painkillers, fainting on the toilet, not sleeping for days, not fun, but Shai David says, worth it. A hundred percent. Well the problem is is like unlike putting your arm in a sling, like you have to use your butthole every day. Yeah. you could be me. That is exactly what I tell people. Like, if I cut a nodule off your hand, I can slap a band-aid on and be like, hey, don't touch it for two weeks. But it's your butt. And so you have to sit on it, you have to poop on it. The really bad pain is usually the first three or four days because your body actually swells a little bit before it gets better. So the really bad swelling is the first three or four days. And then by the end of the first week or two weeks, your body actually kind of goes back down to normal. Most of the dissolvable stitches have dissolved. And then it just feels like ugh you're like uncomfortable, but it's not like a sharp cut on your butt pain. What do you feel like are some of the most common reasons people say, Dr. Fong, take a look at me. Yeah. I think bleeding and pain. So pain and bleeding are usually the most common reasons people come in. Especially if it's like bleeding where it's like a ton of blood that's really scary, totally understandable, and you want to go get it checked out, especially with like the rise of early onto colorectal cancer. So I'm always like, if you have some bleeding that's like outside of normal range, which for most people, any bleeding is outside of normal. It's like something that has to get checked out. Just go get it checked out. So if there's bleeding and it's painless bleeding, I usually have to ban the hemorrhoids, which is like a quick, really minimally invasive, painless procedure. It takes like 20 seconds and it does work. It bans the hemorrhoids, it kind of squeezes them, makes them, you know, die and dry out. They fall off within a couple days and that hemorrhoid column is actually gone, like that blood vessel is gone. So it can't bleed, I can't swell anymore. So that's for bleeding. The painful part, that is usually because of fissures. And so if it's a fissure, I treat it with a couple of things, either with that topical compound we talked about. Lately though, in the last ten or fifteen years, we've actually been doing a lot of Botox injections into the sphincter. Yeah. So I know, I love it. The same stuff that works in your wrinkles, you know, you can put it in your internal anal sphincter. Okay, sounds good. Very low risk of of incontinence, but um it actually really, really works. Like 85 to 88% of the time, people do not need the traditional internal sphincterotomy surgery, which is where I have to cut the whole muscle to relax it.. It works People are like, oh my God, thank you. My fissure is healed. It's gone. No . Is that covered by insurance ? It is. It is. Yeah. Are they like, as long as you've got the vial out? Oh., okay The number of times people ask me that, they're like, can you just put a little up here into my crow's feet right here? Oh my gosh. The only problem is I never have any left. Like I usually put every last drop into the internal anal sphincterin. And yeah, insurance covers it. Nice. Botox for your butt. Yeah. Well bleeding is a huge question though. Mm-hmm. So what amount of bleeding is normal? Yeah, because so many people, especially, I mean, also an absolute ramp up to a soapbox here on colorectal cancer in younger people and when to start getting colonoscopies, all of that stuff. Cause so many people ignore symptoms like bleeding or they, think it has to be bleeding in order for it to be cancer. So yeah, uh you see blood on the teepee. Yes. What what the hell do you do? Blood on the T , go get a check down. You know, so if you see a little blood on your toilet paper and it was provoked, so say you like, you know, you feel a lump on your butt, you recently went on like an eight hour car ride or a sixteen hour plane ride, you know, you were traveling and you got constipated, you see a little blood, it's most likely nothing to be alarmed about, right? So 89-90% of the time rectal bleeding is truly because of hemorrhoids or anal rectal disease. I would still say though, if you're seeing it for the first time, most of the time hemorrhoidal bleeding is self-limited and it will stop in about two to three da ys. If it keeps going, 100% get it checked out. If it recurs, 100% uh get it checked out. And then if it wasn't provoked, you would want to get it checked out, right? So bottom line is most of the time, like even if you're young, don't ignore rectal bleeding, at least have someone look at it. And that's like my soapbox, which is that like you go to a lot of like providers and sometimes we're like, here's some hydrocortisone, and like, you know, we think it's a hemorrhoid, but just make sure someone looks at it. Okay. That's all. And then colonoscopy wise, right? So as you know, like the age is forty five now. We've decreased it in the last couple of years, which is awesome. We you know decreased the screening age from fifty to forty-five. Nice. Which means that you know we're catching more people, but now that we're still seeing a ton of people who are developing cancer in their 20s and 30s, the youngest I've seen is 28, honestly. Yeah. And it was like super, super sad. But I've seen a ton of people in their like 30s, like 35, 38, 39, and those are before the screening age. So just to throw out there the difference between screening and diagnosis, right? So screening means you don't have symptoms and you're still getting checked out because you can have small polyps inside your colon that can can be greencerous, like yours, right? Um, and develop into cancer, and you want to catch them early and remove them so it doesn't turn into cancer. So that's what screening is for. But the diagnosis part is when you already have symptoms and then in those cases you're already having like abdominal bloating or some constipation, some bleeding. And then so you actually go in for a diagnostic colonoscopy to see what they can find. I would see the problem though sometimes is that in younger people, these colonospies aren't getting covered unless you have very, very good reason. And then obviously it's like a whole insurance issue that I fight with insurance all the time about. There's also genetic links as well, right? So if someone like my dad died from colon cancer. Sorry. And you know, it was funny. He was like, Well, you know, I had uh black stools and I I didn't I didn't think much of it. He thought it was just related to his chemotherapy, but he had multiple myeloma and then a side effect of the chemotherapy was on colon cancer. I feel like everyone should know having colon cancer and what you have to deal with, and also like the indignity that you have to deal with is so much worse than a colonoscopy. Like 100%. If you're embarrassed by a colonoscopy, uh, like just wait until you try to deal with colon cancer. Like , yeah. What? Yeah. You know? Exactly. Yeah. Or like a lot of people would be like , you know, uh the embarrassment of dealing with an ostomy, which, you know, for me, I try to destigmatize ostomies as well. It's like sometimes just like a very temporary thing, but a very necessary thing that can be life saving, especially if you're like removing like a cancerous portion of the colon or a portion with really bad diverticular disease and it's like the safe thing to give you a temporary ostomy. And then in some cases like a permanent ostomy. Anyway, okay, I digressed. And an ostomy, if you are not familiar, it's a detour for pea or poop to leave the body. So let's say that your lower intestines are permanently or temporary closed due to construction. So a surgeon can make a new opening in your abdomen to have waste leave the body into a sealed pouch that you can empty periodically. And sure, I hear you, an ostomy, it may not be on your birthday wish list, but it can save your life. And while there has been stigma around them, there are so many creators online. I've seen a bunch that are showing it's really not that big a deal. You get used to it, you live with it because nobody doesn't make poop. But if you want to avoid a colon cancer ostomy or chemotherapy or surgery or death, get checked. When it comes to catching cancer in early, incredibly treatable stages, a colonoscopy is a cakewalk, man. It's a cakewalk. It is like the easiest thing that can happen to your butt. Yeah. Like ever. And you get a really good nap. You get the best nap of your life. And also you have free reign to go enjoy the best breakfast ever. Right. The waffles I ate after my colonoscopy were the best I've ever had. Best you've ever had. And then like the peace of mind you get with, you know, with having like a clear colon and then you're like, hey, your colon's good and you get another ten years before you have to do it again. It's kind of like jury duty. You get like that peace of mind for a few years. But I'm wondering too like these rates of young people with colon cancer. I know that Chadwick's death really shocked a lot of people he was so young. I have a friend who in his early 30s was diagnosed with stage four. So sorry. A cousin of mine as well. And like, so okay, number one: if you're 45, get your colonoscopy. Just do it, enjoy the nap, enjoy the waffle. Yep. We have a whole how-to. But what about that line of like you're worried about it, but it's not quite time for you to get it checked out? Anything for that in between generation. Yeah, which is like most of us right now, right? So that would be you. Yeah, exactly me. So if you have any kind of symptom, go get it checked out. And the sooner you do it, the better because a lot of times people who who do colonoscopies, they're booked out like six, eight weeks, right? So if you're like waiting for end of year, your deductible has been met, just go see the person sooner, like either a GI or a colorectal surgeon, so that you can get on the schedule. If you have a symptom, it'll be covered. I don't know if it's just my news feed that's tweaked by the algorithm, or if it is becoming more and more widely known that this is something people have to pay better attention to? I think the the celebrities really, really helped. Obviously so sad about Chadwick Boseman. And then I think it was James Vanderbeek, wasn't it? Recently too. So Chadwick Boseman, this incredible actor who portrayed Black Panther among a ton of other roles, he passed away in August of 2020 at just 43 years old from colon cancer, which came as a shock to millions of people around the world who didn't even know he was battling it. He was diagnosed at stage three in 2016 and then continued to film seven movies at the height of his career while undergoing treatment. And one 2021 paper titled Internet Interest in Colon Cancer Following the Death of Chadwick Bozeman, Infovalence Study, found that there was, quote, a significant increase in web -based activity related to colon cancer following Chadwick Bozeman's death, particularly in areas with a higher proportion of black Americans. And it continues, this reflects a heightened public awareness that can be leveraged to further educate the public, which is especially relevant as colon cancer rates are higher in black Americans as well as indigenous populations. And at the time of this recording, James Vanderbeek, the star of Dawson's Creek, was also fighting colon cancer. And since I had this chat with Dr. Fong, he passed away at the age of forty eight. And some factors that increase your risk of colon cancer are genetic, like something called Lynch syndrome, which increases cancer risk, particularly of the colon and uterus, but lifestyle and diet definitely increase the likelihood of colon, shall we say, large intestine cancer. So what can you do? Dr. Fong says eat veggies with every meal, keep that fiber intake up, hydrate, exercise a little every day to keep everything moving, and avoid ultra-processed foods, sugary drinks, and processed me ats. Fried and char grilled meats have more carcinogens and can also damage your colon cells and up the risk for cancer. So sorry salamis, sorry hot dogs, sorry char grilled burgers. And statistics show colon cancer ranks the highest form of deadly cancer among men under 50 and the number two cause of deadly cancer among women under 50. And according to this recent article I read that Randon Forbes, one colorectal surgeon, said that someone born in the nineteen nineties is four times more likely to have rectal cancer than someone born in the nineteen fifties. And James Vander beek was vocal about his story, he said many times, in hopes that it inspired people to get literal life-saving preventative screenings. And again, for an in-depth how-to and a ride-along, as well as some surprising findings from mine. See the field trip, my butt episode that we made a few years back. So many people have told me that you listened to it and it helped you a bunch, which is great. And then Ryan Reynolds, how does Colonel Osk be on camera? about something that will most definitely save lives. Going in. Going in. That's enough motivation for me to let you in on a camera being shoved up my s right. And then I love that Ali Wong did a piece about it in her comedy special. And camera up your ass and I was so nervous, but what I didn't know was that right before the procedure, they give you propofol and I have to say that as a working mother of two , getting to take a drug-induced nap for an hour. And so those people really getting it out there, it's like, hey, you know, colonoscopy is really not that bad. It's totally necessary. Colon cancer deaths are like preventable. That's the only thing I want to say. It's like a hundred percent can be preventable. So there are of course the stages of cancer, and obviously it,'s because of math, we know that the higher number is less good. So let's run through colon cancer stages real quick. So stage zero is a colon polyp with some abnormal or precancerous cells, stage one is a can cerous polyp on the wall of the colon. Stage two, this one has a few substages, but for simplicity, the cancer has grown from the polyp into or through the wall of the colon. Stage three, it grows through it through the outer wall of your colon or it hits the nearby lymph nodes which means that cancerous cells can kind of hit the superhighway in your body and then stage four the final stage the cancer has made it to other organs like distant lymph nodes or your liver or your ovaries or even your brain. So if you have a colonoscopy and they snip something off, they biopsy it and then they wait for the pathology report for a week or two. I've wondered this what it's like when you have a diagnosis for someone like I got lucky, I had a precancerous situation that they snipped out and I was one and done, right? But what is that like when you see something like that? Yeah. Um I always get like a really sinking feeling in my stomach as I think anybody would. And then what you have to do is then you have to tell the patient that you're gonna get a biopsy first and then you know in 10 to 14 days have to break the news. So I would generally kind of like temper it with, hey, this looks suspicious, but we will know in two weeks and I promise I will call you. And I think most people are are okay with that. And then for the actual break in the news, and you know, we do this a lot in medical school and we have to sit down, we have to look them in the eye, which I think always help helps. I always try to do it in person, you know, and I think people, for whatever reason, whenever you say that, they know already and then they just need to hear it. Mm-hmm. But you know, hey, I have bad news, you know, the pathology report show that says it's cancer. And then people like the statistics, this is the outcomes and the these are next steps is very useful. Having a another person there or having an advocate is super helpful too, someone who can actually listen and take notes while that person is probably still in shock and processing it. What is the surgery like when you're performing surgery? You've got to go through the abs and everything, right? Yes. There's a couple ways to do the surgery. So when we used to do it laparoscopically, we make small incisions like through the belly button, like several small holes that are five millimeters each, and we put instruments through. About the diameter of a pencil eraser. If you do an open surgery, I make a big cut kind of right in the middle and have to open everything up, put retractors in and kind of scoop everything out. It's rare that I have to do an open surgery at all these days because most things you can actually accomplish laparoscopically or robotically. And then in those cases, you actually have much less incision pain. You have like a lot faster return to work, get out of the hospital, a lot faster passing flatus and and starting to eat and stuff. So we try to do things laparoscopic and robotically. I save robotic for last because people always ask me, like how do you do a robot surgery? Yeah. So the the same way that you do laparoscopy, which so it's almost like a little tube that goes in through your belly button that you do cut through the abs and then once you're in you put the camera in and then the robot arms dock next to the bed while I sit at a console like on the other side of the room and control the robot arms. I love doing robot surgery because you actually get like a very fine disse ction and like the very fine visual field through the robot apparatus . So it's not an automated robot doing your surgery. It's Dr. Fong in a fucking mech suit. Amazing. What's the benefit of robot? Is it a finer cut? Is it a even a scalpel or is it like a cauterization? It's actually more of a cauter ization. So okay almost like a tiny little pinpoint cauterization that allows you to cut and seal at the same time. Oh and I can look right inside because I can direct the camera. And in some cases you have to do like a total abdominal colectomy and take the entire colon out and all they have is like small bowel connected to your erectum. It has to kind of like adapt and become more like colon . Can you live without a whole large intestine? Yes. Yeah. Really? Yeah, I know. It's weird because you wouldn't think that you could, but your small bowel adapts, you know, you have a rectum and you still have nutrient absorption. And one of the fascinating things is in the eighteen nineties there was this guy, he actually used to take out the colon routinely for people who had constipation. And he was like, you know, this is because of auto toxicity. That's what he called it. And so like, all, these toxins were being like stored in your colon and your poop. So he would just take out the colon for like all the time. And since then, that's literally been debunked. We don't do that anymore for regular run-of-the-mill constipation. We only do it for things like if you have IBD, like inflammatory bowel disease and like there's a a lot of disease colon, or if you have total colonic dysmatility. So some people can be born with a like a colon that just doesn't move. And in those cases you go down like a bunch of steps for diagnosis, like MRIs, and before we were like, hey, your colon really doesn't move, we're gonna take the whole thing out. Oh okay. Constipation. Yeah. Let's talk about it. Most people have functional constipation, where it's like a combination of factors like your physiology, the things you're eating, the amount of activity you're having, and then like the electrolyte imbalance in your body. So some people are like chronically constipated. They're like, I'm a constipation girly. And then others, for example, like my husband, is like once a day is not enough. I call I sometimes call myself a toilet widow because I'll just be oh god. I haven't heard that one. I'll be at a restaurant. You know? Like that's a new one. Yeah. It's like a war widow where you're just watching, you know, you don't know if they're coming back. You're just watching the door. That's so good. I'll look like I got stood up on a date, but I'm like, he's just doing him. We're gonna talk about IBS in a minute, of course. But when it comes to constipation, is that like a microbiome problem? Is that a fiber problem? Is that a hydration problem? What are the common causes? And why does it happen when people are on vacation? And they're like three days into a vacation, I haven't taken a shit, what's going on? So yeah, no. So I'm gonna start with like the first answer, which is how often should people poop? Right. So I've kind of digested it down to one to three times a day, every one to three days. So the normal human colon should move food through in about literally it's like 12 to seventy two hours, but most people in about three days you should have a poop. The other thing that happens though is that about ninety minutes after each meal, you know, you have like a an MMSC, which is like a mass mo m um mass mo oh my god. This is a tough one. So I dare you to remember that empty stomach growling or that post meal gurgling in your guts is called the migrating motor complex. MMC baby. Okay. Where it kind of sweeps everything out and moves everything through after you eat. And so that accounts for the fact that most people will poop after a large meal, right? Within an hour or two after a large meal. So that's actually normal, right? And so people when people tell me that you're like a toilet widow, I'm like, does he eat like three large meals a day and then he's just like pooping all the time? And it's like, so that's actually totally normal to poop, you know, one to three times a day and not crazy. And then but it's also normal to poop like every three days if you're not having large meals or if you're not having a ton of fiber or if that's just the way your colon moves. So the factors that go into it, right, are the amount of fiber, both soluble and insoluble fiber. It should be like twenty five to 35 grams a day, but that's like you know fruits and vegetables and and beans and legumes and whole grains. And the soluble fibers kind of gel everything up and move everything through almost like a little like jelly-like mass. But I always tell people that if you don't drink water with your fiber, it will just turn into concrete and it won't move. So you have to have fiber and water. And the green leafy things like kale and like spinach and stuff, that is insoluble fiber. So while that stuff is also good, because it actually kind of acts as a broom and sweeps everything out, it also triggers some irritation in your colon, which simulates contractions. So you need both, and you really need a good mixture of both. And I think it's going to be different for different people. But you need both soluble and soluble fiber plus water. And what is psyllium husk and how do we feel about like a metamucle habit? Yeah. Love it. Metamusile, take it every day for the rest of your life. I actually don't because I really eat a ton of fruits and vegetables. But if you needed that extra five grams of fiber, psyllium husk is the best way to go. It's the only one that's been really proven so far that in kiwis and metamucil if you get it in the store just make sure you get the actual psyllium husk one because you can do psyllium husk every day and that is a soluble fiber that will help with constipation. And you just gotta really water it up, right? Yeah. So I always tell people like stir it in the glass of water or juice or whatever, drink it and then chug a glass or or two of water afterwards. So you don't wanna just like mix it in your coffee and be like, that's it for the day. You really do it. Put it in a Coke and you're like, Good to go in your Celsius for the morning. Iced coffee for the day. No, that's not gonna do it. That's the only thing that's worked for for Jared's IBS. At one point when everyone still had Twitter, he unfollowed everyone except for Meta Musile, because he was like, I'm just gonna only follow MetaMusle. So he's a MetaMusile T Bou T. You know, and I always tell people, especially for IBS, fiber will firm up loose soles, but it will also soften hard sools, right? It does both things. Fiber, fiber is great. You don't want to overdo fiber. Like I saw like this fiber maxing trend on recently. Fiber maxing. Everyone's talking about it. And we and I was like, you actually can have too much fiber. You probably can't have too much psyllium, especially if you're mixing with water. It does get washed out. But I've had a couple of cases of people who just ate kale for like 30 days and then you can get like a giant fecalith, like a stool ball that just doesn't get digested. Yeah, it's called a bzord. Um it's just like stuff that doesn't get digested and you have to go in and scoop Sometimes it's hair, sometimes it's undigested coconut fibers, sometimes it's an impacted green ball formed in the fourth stomach of a goat and prized for its folk remedy as an antidote to poison. Sometimes a bez or is encrusted in gold and kept in Queen Elizabeth's collection of crown jewels, according to a delightful historical paper titled The Fascinating History of Bezores. And yeah, I'm gonna link that for you to read. And the word comes from the Arabic for stone used as an antidote to poison. But honestly, I would call the poison control hotline instead, because Bzores, they're really hard to come by. And I bet they'd be expensive. Now speaking of things that are hard, not quite bez ors, but little stony nuggets in your bowels are called fecoliths, which means pooparock, and you don't want them because they can get in places that they are not welcome, such as the portal to your little finger-sized pouch off the start of your colon. If you still have yours. And can't that block your little appendix? Yeah. Mm-hmm. It can block your appendix. Yes. Oh. Like an appendicolus. That's what I had. Wait, did you have you you had a not a there's nothing that's TMI, are you kidding? So you had your appendix out? I have. I I had it actually in medical school and I had a a little fecal lift like a little blockage and I swear it was the Taco Bell I had the night before when I was studying for my renal exam. But and so I've sworn off Taco Bell since then. Good choice. Do they build up over time like a blackhead or can it just be like a boop? Yeah, that's a good question. So it can build up. And now we know there's like a bunch of lymph nodes in the appendix too. And so it does, you know, serve some purpose. It's not completely like vestigial, but it can build up. Yes. Like if it sits there. So you don't want things to back up into your appendix. And also you want an on-ramp into fiber additions, right? Yes. You don't want to just dump it all at once, right? Thank you for that. Yes, yes, absolutely. So people are like, I've never eaten any fiber before. Like I only ate chicken nuggets and suddenly they're like 50 grams of fiber a day. Um no, you want to surf like usually I'm like do five grams a day for like a week and then go up to ten, go up to fifteen every week, every two weeks. The other reason being is that you'll get super bloated if you don't gently increase your fiber dosing. And I imagine those fiber gummies also, like you got to chug with a lot of water, right? Yes. Yeah. I have a couple fiber gummies that I love and I do take them with water because of the the gel, like the kerragen in that actually can cause a lot of blockage. So drink water, lots of water. And then on top of that is activity. So gravity, you know, moderate activity, you know, 20, 30 minutes, three times a day. Those things get your colon moving. And then a lot of people will be like, hey, doc, you know, I I eat a ton of fruits and vegetables, I drink a lot of water, I work out, you know, I still can't poop. And then there are kind of like definitely like medical and hormonal reasons that people can't poop. So like in pregnancy, you actually have like increased progesterone and you know kind of slows everything down, you have increased water absorption. Or if you have thyroid disease, you know, if you're hypothyroid, you can be pretty constipated because of the water absorption. And then people have like electrolyte imbalances. So we now know pretty well that magnesium is a great muscle relaxant that works for like sleep, it works for restless leg, but also works for constipation. Taking magnesium every day can actually kind of get you over that hump. And then the last part of your question is the probiotics. There's a ton of research out there. I love the microbiome. I think that's where the future is headed. And we now know that there's certain bacteria that work better if you're constipated. There's certain bacteria that work better if you have like antibiotic associated diarrhea. And there's certain bacteria that work better if you have just general IBS or like other symptoms. And they're now fine-tuning these strains. So fiber helps with the consistency of soul but probiotics helps with the regularity of soul can I ask you some questions from do you have time for me to ask you some listen yeah of course yeah yeah sorry I just blabber on so no no, I have a million questions. All right. But first let's get rid of some cash and let's send it to a cause of Dr. Fong's choosing. And this week it's headed to fight colorectal cancer.org, which fights to cure colorectal cancer and serve as relentless champions of hope for all affected by this disease through informed patient support, impactful policy change, and breakthrough research endeavors. They remain steadfast, saying every day we are moved by the collective heartbeat of people who bring hope and healing to people yearning for more seconds, hours, days, and years with the people they love. You can find out more at fightcolorectalcancer.org. And thank you to the sponsors of the show for making these weekly donations possible. So, Ollie, which is one of my favorite vitamin brands, I eat them every day. They just launched a new line of probiotics, and they're made to deliver benefits beyond just your gut. They have this new precise probiotics. They're made with clinically studied strains to support not just the immune and your gut health, but your metabolism, your skin health, even your stress response. So your gut, as you know, we've talked about this, it does more than just digest food it's at the center of all these different systems and functions in your body so as science gets smarter about this you can get more intentional about giving your body what it needs and precise probiotics target specific areas of your gut microbi ome that are connected to all sorts of other systems in your body, like skin and cortisol levels and metabolism. I'm a big fan of my gut and I want to take care of it like the friend that it is. I also love Ollie, so this is exciting for me. You can shop precise probiotics with skin stress response or metabolism support at a Walmart near you. This product is not intended to diagnose, treat, cure, or prevent any disease. We have to say that. Listen, times are weird. 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Millions of business owners rely on Spectrum Business to keep them connected. I myself am a spectrum business customer. This show would not get to your ears without spectrum. And I have totally different needs than someone who has a different kind of business. I need fast internet, I gotta upload, I gotta download quick. There's also mobile, so I could go work out of the house. And yeah, and I've had to call and be like, help me reset my modem, and they've been very helpful. So it's working for me. Visit spectrum.com slash business to learn more. That's spectrum.com slash business. Restriction supply services not available in all areas . Here's what I like. I like to think less and look better. Who doesn't want that? That's why every single time I record an ad for quince, I'm like, guess what I'm wearing right now? You guessed it, I've got a quince sweater on. Why, Allie? Because everything looks nice, it's classic, it's high quality, I feel good, and I look put together. 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Oliver Callis, Megan Walker, Matt Thompson, and first-time question asker, Cheryl Strogetto. Colon hydrotherapy. Yay or nay is what Cheryl wants to know. Matt Thompson is like, what is the danger of doing colon cleanses outside of pre-colonoscopy? Colon cleanses, what's the deal? Yeah. So uh it's actually a nay for me for a colon hydrotherapy. There's a couple reasons you would do it. Like if you were like, hey, you know, this week I I feel especially bloated and I just want to try it and you did it like once a year or once in your lifetime, fine. But I've had people be like, hey, I go every month, I go every six months. There's two things that I think are kind of dangerous. It's a super large volume of water. And so you're actually just like flushing everything in and then flushing like 60 liters of fluid back out. Like I've seen the TikTok videos of things they get out, those are things that are gonna come out on their own. And no, gum does not stay in your intestines. But if you have little inflamed pou ches in your colon, which is a condition called diverticulitis, you can get seeds stuck in them, which is why no seeds for you. Seeds are off the menu if you have diverticulitis. If not, I don't know, go for it. But back to colon hydrotherapy, which yeah, involves a tube up the butt, kind of like a less traumatic uh warm water pressure hose. You hold it in and then you release it several times over about 45 minutes. But the high volume of water has caused some mucosal injury. So it can cause damage to the lining of the inside of your colon, like small tears and stuff. And in in some severe cases, like not to scare people, but it can cause perforation. And I've definitely seen that where then you have to go get a surgery, blah, blah blah. You don't want that. The second thing that it can mess up though is your microbiome because you're actually flushing out all the good bacteria that should be there. And I've had people where they like, hey, you know, I get a colon cleanse like every month, and I still can't poop. And part of it, I think we're gonna find is that the good bacteria are actually getting flushed out. Oh yeah, so it messes up your microbiome. The same way that when you get a colonoscopy, you know, if you're doing that four-liter colon prep befor e, some people will tell me that they can't poop for a couple of weeks afterwards. And because your microbiome is messed up, you know, is one thing. The second thing obviously being that you flushed out all that poop and it's going to take a few days to come back. Oof. Okay . So this brings me to um let's talk about sex prep back there. Yeah. Anonymous, Derek, DVNC, Ben wanted to know. Penn says, with the internet's obsession with being bottom ready and spotlessly clean at all times, as long as I eat enough fiber, is that okay? Um, DVNC said I sometimes hear people warn about douche dependence. Yeah. And Derek wanted to know if it's possible to overdo it. Uh Anonymous wanted to know, is it true that too many enemas can wash out that beneficial bacteria? Also want to note when they're asking uh for men , obviously, all kinds of genders take it back there as 100% question for all kinds of people. Awesome question. Love that question. So short answer being: you do not need to douche a good fiber diet, actually will get people clean ed out sufficiently. So if you poop, you know, in the morning, you know, poop a couple hours before you go. Because your rectal vault is really just that l last portion, just that last like eight centimeters or so, and you know, eight centimeters, hopefully is is enough but um eight centimeters or so it's completely clean like they're ever all the poop should actually stay above it right after you poop and um nothing goes into the vault. So yeah the average human rectum the final chamber of travel for your lunch. It's about four to five inches long. Although in taller, larger people, like those assigned male at birth, it might be closer to seven or eight inches. And at the top of that, you would have to go through this bent kind of askew sphincter, the recto sigmoid sphincter, deeper, which gets you into the sigmoid colon, which is the backstage vault where the poop is waiting, if I may paint you a picture . I need you also to know that I was working on this in public at a cafe, a very crowded cafe. And as soon as I clicked on the 2017 Vice article titled In a Loud, Vivid Font. How much can I fit up my ass? I realized it was time to pack it up and go home to work. But also on that note, some tips say that if you have been curious about having things up your ass, but are afraid that it will feel like your lover is literally tearing you a new one. Lots of lube, go slow, and you can even try a butt plug during your four stuff to relax things a lot before replacing it with the main act. But yes, let's hear some more tips for those who are butt curious but want to go about it with fewer surprises. So that's the first thing. If you have to poop, there are totally safe ways to do it. The safest way I usually recommend is just like a fleet's enema bottle full of warm tap water. You don't actually need all of that sodium phosphate solution. You really don't need like mineral oil or like blah blah blah, all those things. It's just like warm tap water in a bottle with a soft tip. I actually did a review for these people once where they sent me like a whole bunch of like anal douching things and they come in like bulbs with sharp tips and shower heads. Some of those things I don't love the sharp tips because I've seen people give themselves fissures with the sharp tips. I seen people give themselves some like hot water injuries with the shower head kind of attachment things. So I love the fleet denema. They actually just developed this awesome product in the UK, which I hope comes here soon. It's called an abol, which is like a little hydrogel that you can stuff up in your butt and it sits right at the sigmoid rectosigmoid, and then it stops the poop from coming down. So instead of having to, you know, do immediately before sex, which kind of like takes out that, you know, the the sexy vibe, right? You just like put something up there, stops everything up, and you go about your way, which I love the idea of. Of course I looked into this for you. And this is an innovation from Polari Labs in the UK. And yes, it's called an A -ball, A like the letter, dash ball. Their website lays out an elevator pitch. It says, Who has time for a 45-minute toilet tango? Not you. Our ball gets you butt ready in half a minute. So you can skip the waiting and slide straight into the good stuff. But how? You ask on the edge of your toilet seat. Okay. So they say that the A ball gets shoved up during the fun and it parks itself at the top of the rectum, like a VIP bouncer, making sure no uninvited guests, aka poop, crash the party. So remember at the top of your rectum, there's that sigmoid colon. And so it kind of like boop, right there. So you don't get to that backstage waiting area. It's kind of like a hydro gel butt tampon that cleans things up along the way and then stands guard for you. And if four bucks a pop, I priced it out, it's about the same price as a buzz ball. This could revolutionize what some people call dirt road journeys, making it more like just a smooth cruise on asphalt. I feel like the A-ball people are gonna clean up with this. And going back to that, Jillan, jamstress, Iris, Beanbag the Cat, David, Robin, first time question asker, Janelle, um, which is my sister's name, but I don't think it's her. Um, Ether Dog, Alex Minor, and RJ wanted to know. I mean, um RJ Deutsch says, okay, as a gay, what should we know that we don't? Because they don't teach it in health class or people are too embarrassed to ask. And other people wanted to know, jam stress, are there health risks of doing anal ? What qualifies is too deep? Dylan wanted to know does anal sex lead to any health problems later? So a lot of people want to know butt stuff. Yeah. Yay or nay from my gosh, we could do a whole episode and just I know what I was telling you. The butt stuff. Um okay, so no real health problems, right? So my counseling usually is just be safe. So you do want to be protected if you are worried about any kind of like discharge, bleeding, pain afterwards, get it checked out? Make sure you're getting swabbed regularly for STIs and get those treated. Get you and your partners treated. Oh, we have a really great STI episode with Dr. Ina Park that just came out a few weeks ago, and it's every question you have ever wanted to have addressed, please do listen. And yes, we've have these crotch episodes like back to back. And I I don't know what to do about it. I think the one thing people are usually trying to ask here is if things going in your butt all the time causes incontinence. I think that's what people are worried about because then the anus does stretch, right? So the anus does stretch and it can cause like a little bit of laxity over time. I have seen people have fecal leakage over time but most of the time it's not super common it does cause hemorrhoids right so it can make inflamed hemorrhoids worse because of all the friction and stuff like that so I'm like use a lot of lube you can do a lot of gentle preparation and foreplay that will allow a larger size and you know length and girth for penetration. And all of that is okay as long as you stay safe. The one thing I don't love is actually washing your anus. Washing the anus itself for like rimming, it kind of destroys the microbiome of your anus and that causes a lot of paritis ani, which is itchy anus. So you don't actually need to use soap to wash your body. Yeah. Because of the anal microbiome, it has its own microbiome and it cleans itself and i always tell people you don't actually need to use soap when you wash your butt you know you wash the rest of your body use a little water warm water use your fingertips just rinse and then pat dry that's the best thing you can do and leave it alone when you're scrubbing it with a washcloth and and soap and whatever, you're actually stripping that top layer of skin off and stripping off that natural microbiome layer, which then causes things to itch because it's trying to heal. No. So wait. So you're in the shower. Can some gentle soap go in the crack or what? Yes. Crack is okay. Cracking cheeks are okay. Okay. So yeah, 100% you should wash cracked cheeks because that is skin and that is like a totally different thing. But what I mean is like the immediate anus, which is kind of like the dark wrinkly area, you really don't need soap there. Oh my gosh. So many questions. Y'all, I did my best to humiliate Dr. Fong and debunk this, but unfortunately, every article I've found from experts is like, water's fine. Keep the natural skin barrier healthy. And since we did this recording, I want you to know, this is very personal, I have ignored this advice. I'm sorry, my skin barrier. Soap it is. I can't give you up. But there are gentler ones out there, so you can consider that. Because you definitely do not need like bora x or a Mr. Clean magic eraser or a spray bottle of Clorox. Oh, speaking of different kind of bleaching. Anal bleaching, yes or no? No. No . You don't need it. I know. Ain't I ain't I are supposed to be the color of the way they are. It's totally fine, you know. Right. Thank you. I wouldn't worry about it. Okay. Well, speaking of washing. Oh, this was a popular one. Iris, Alex, Agamemon, Sean, Katie, Brit, John, first time question asker, Thoruposaurus, Jess, Tony Vessels. John says, why do we not all use bidets? Katie says bidets. Do we love them or love them? Sean says bidets. Truly better than toilet paper alone, right? Ag amemon says, I love my bidet, I will forever be having a bidet. That said, too much of a good thing can be bad. Can it be too much water on the butt? Water pressure, especially they had great questions. Iris, do they have any effect on rectal health? Yeah. One of my ten bowel commandments is bidet is the way. So yes, everybody should have a bidet. I don't know why we don't have them in the US. You know, in Asia and Europe, people have them. Yes, they improve anal health, they improve hemorrhoids, they improve fissures for sure because of the overwiping that people do. And you know, bidet, you wash, rinse, pat pad, dry, and you 're done. In terms of pressure, there isn't like a firm number on like you know too high pressure. But what I usually tell people is the spray shouldn't be going inside your butthole, right? Like you're not trying to give yourself an enema. You're you're actually just washing the outside. So make sure your anus is closed and then spray, rinse, pat dry. Love it. It actually just gets rid of so many of those problems that people get from like wiping all the time and f issures and skin tags and hemorrhoids and all those things. Love bidets. I think part of the reason was in the early 80s, I want to say, but um, there was this like study that said that bidets made women have more UTIs, but that has since been debunked because it's actually clean water, right? You're attaching your bidet to the clean water supply. And so it's clean water that goes up into your butt. It's not the toilet water. It's clean bot water goes into your butt and then just drops back in the toilet. And for people who are afraid to use a bidet because they're like, well, what do I do afterward? You can dab yourself dry with the toilet paper. Pat dry with toilet paper. Okay. They make like toilet towels, but you can just pat dry with toilet paper. Okay. And you're talking to someone who has two bidets in the house. One hundred percent of our toilets have bidets. So I'm just I'm asking the questions that other people are probably like, Do I No, those are excellent questions. Yeah. Okay. Like we want to get it from all angles.. Right Yeah. And I know you can go like high end Japanese that's got more buttons than my car and then to like a a tushy or something that's pretty much like a one knob. Yeah, I got one that was called like big cow and it works great for like twenty bucks. I I just want to try it out. Like to be like what a twenty dollar bidet is like. Yeah. Works great. I understand that in the UK, bidets are illegal because l their water supply is not like up to clean standards. Right, yeah. So I think that's a little bit different because they're not using like the fresh water in their septic system. But that's not the case here. Okay. At least as far as I know. And then as you know, wipes clog septic teams in septic systems. So they're not great for the environment at all. Don't do it. I mean, look up Fat Berg and never again. So gross. Fat berg has gotta be the absolute worst noun. It's gotta be the worst object yeah that I can imagine. In an effort to save you some money on plumbing bills, I'm gonna de influence you on so-called flushable wipes. Okay, Google Fat Berg and send me the invoice for the psychotherapy. It's worth it. I will tell you that in one photo, a London sewer worker is holding up this greasy chunk that's about the size of a small marlin , were he a fisherman? I was horrified. I was traumatized to notice he was not wearing gloves. He was just raw dog in his fat burg. My mind raced and raced. I was like, why does he hate himself ? How is his brain not capable of feeling fear? What is happening? Why? Why? Why? And I zoomed in on the picture and I was very relieved to see that his rubber gloves were just the same ruddy peach color as his skin. But that was a rough, rough 30 seconds from a psyche. And I'm not grossed out by much, but I will tell you that is Fat Berg, dude. They're up there with a rat king. Like they're so it's bad. Okay, well, speaking of toilet accessories, Miranda Paner, Kari Heiser, Page Manking, Alex Minor, Chris Moore, Kestrel Wolgamouth, Kestrel One, no, Squattie Potties. Actually helpful or a little silly. And Paige says real or phlim phlam. And then also do they have an effect on hemorrhoids? Chris wants to know. And then Paige said I've found I've become rather dependent on it since I got one, which has made travel related constipation the worst. So yeah, tell us about it. So you'll you'll see the studies where it says that the ideal pooping angle is people squatting because that's how we were like naturally meant to poop is like in a squatting angle. The studies that look at squatty potties or some kind of like stool show that only 10 to 50% of people need them because of the way that it adjusts the anal rectal angle, which I thought was kind of cool. So for some people, it really will help because of the way that your anatomy is. And for the rest of the people, you actually probably do not need one. The more important thing though is that when you're pooping, you're spending about two to five minutes on the toilet max. If you're straining for that long that you think that you need a squatty potty and you're sitting there like looking at your phone for an hour, your poop probably isn't ready yet. You know, it's either isn't ready yet or it's too hard. So I'm always like, get up, go do the dishes, walk around, do something else, like drink a glass of water, and then come back and try again. That is going to be way more helpful in general than purely like a a stool type device. Okay. Yeah. So in some people it works and then in some people it most people you really don't need it. Travel constipation, I think you actually asked that question earlier. The reason it's so terrible is because it's like the trifecta, right? So you're dehydrated because you're trying not to drink when you're on the airplane, you know, and you don't want to pee on the airplane. You're eating junk from airports and you don't have your usual healthy diet. You're also sedentary. And then there's also stress. Stress is like a huge factor in in constipation that we're now seeing is totally true. So people who work out too hard, you know, the fight or flight response, right? Makes it so that you can't digest. And so you're like, hey, you're stressed out, your body's not gonna digest food. You're actually more worried about pumping blood to your heart and your brain so that you need to run away in an emergency and not worried about digestion. So actually that's four things that makes travel constipation worse. The way I usually get around it is I keep my water bottle with me, you know, if I have to be like excuse me, excuse me, like eight times a day, you know, get around the person to go pee, I try to bring some fruits and vegetables with me. I try to bring my fiber gummies, my probiotics, and then I'm one of those people who get to the airport three hours early. So ha ha I gotta get eyes on the gate. How to get eyes on the gate. Teryn Delaney Smith, a travel influencer, calls this L E O T G or Leo T lay eyes on the gate. I think about it every time I go to an airport. All right. This is a great question a bunch of people had. Jennifer, Corinne, Jay, Nick Ryder, Tuha, Annalise DeYoung, Honeydew , Marta, Katie O, Emily wanted to know Honeydew says why is there sometimes a sharp pain in the booty hole during the period? And Nick says secondarying the period butt pain question. Jennifer wants to know why does getting your period affect your bowel movements? As if it wasn't a crapshoot, ha ha already, they say. That's going on. Um, so period affects your bowel movements because of the hormonal changes. So increase of estrogen and progesterone makes it so that it actually increases the water absorption in your colon and makes your stools firmer. So we know that like around the time of your period you actually can get more constipation and diarrhea. Really both because of the way your body absorbs fluids. The sharp shooting pain, though, is actually something a little bit different. That's called proctalgiafugax. And so that's more common in women, but it it's also super, super common in men. Like I don't want to leave men out of this because people will come in and I kind of joke that my practice is uh proctology, pionidal cyst and pelvic floor, the three Ps, because I do so much pelvic floor and we're just now finding out that there's so much we don't know about the pelvic floor and the way that the pelvic muscles interact with the rectum. And so women tend to hold a lot of stress in your pelvis. So literally we'll just walk around like keeping our butts clenched all the time, like uh literally tight ass. And and the more you clench it, the more the muscle spasm and the more it's like, Hey, you know, we're supposed to be like this. And eventually when it starts to go and you feel that sharp pain, it's being like, Hey, we're in spasm, can something let me out now? In some cases it'll be like some gas triggering this response, some sool in the rectal vault triggering this response, but it's actually a muscle spasm, that sharp shooting pain. Okay. And again, you've been pregnant, you and your wife have three kids now. Yep. Addison, Alley says as an OBGYN, I'm interested in what advice you would give to women or pregnant people who experience anal sphincter injury from delivery. Yeah. And also just in general, like pregnancy and butt stuff, why yeah, yeah. Pregnancy and postpartum. So constipation gets worse because of all the things we talked about, like increased relaxin and hor monal changes and things like that. The increased abdominal girth, like you actually have more weight sitting on your pelvis. So everything is kind of getting squished out. So preventatively, in your first and third trimesters, the constipation and the hemorrhoids are usually the worst because you're like the first trimester because of the hormones, the third trimester because of the anatomical differences. You do all the same things preventatively, right? The fiber, the water, the exercise. You know, use some of the compound ointments prophylactically if you can . The obstetric injuries, that is a really good question. So when you have like a first degree or second degree tear, it's usually kind of just through the skin, not a big deal. Sometimes when you get to a third or fourth degree that involves the anus. And I can always tell because they're usually anterior, right? So the tears between the vagina and the and the anus. The teaching is erectovaginal fissula when it becomes like a little abnormal tunnel that goes from your rectum to your vagina and then when you fart, there's like air coming out of your badge or like some stool. Really, really horrible to deal with. People get so much like shame and embarrassment from it. The teaching is that generally a true obstetric injury like that heals in about six months. Oh , okay. Because this in six months the inflammation will go down and the skin will heal. If it hasn't, I would definitely say see a colorectal surgeon because there's a ton of things we can do. We could put like a little cet on ring through it, which is like a little rubber band. There's things we can do, such as like closing the fissula with a suture or an endal anal advancement flap where I kind of pull like a flap over the rectal side and just close it up. So I don't want women to be embarrassed by this. I want you to go fix it because it 's super, super like quality of life, you know, issue. Mm-hmm. Going from uterine to prostates, Orion, Potato Puffer, David Greg, Malay, my eye, my Alex Minor, Katie Hammond, Potato says prostate massage. Should we be doing it? Also, Malay says, I don't have one, and I'm curious what's going on in there. I mean, it's right in front of it, right in front of your okay. So literally the the front surface or the anterior surface of your rectum is the prostate. So yeah, prostate massage, sure, if it feels good, you're literally just poking your finger in the anus and and massaging it a little bit. There are things where you know doing it too much but can cause a little bit of chronic prostatitis, and I've seen that happen. So just be cautious, you know. And if it starts hurting, or if you're starting having like burning with urination, burning with ejaculation, things like that, go check it out, see a urologist. Okay. We do have a whole urology episode with your favorite urologist, Dr. Fenwa Milhouse. It's just waiting for you. But back to the prostate. It's a walnut-sized gland. It lies between a rectum and a urethra in humans with penises. And if you will, please allow me to read from the book of Webb MD. So it says the prostate is sometimes called the male G-spot or the P spot, and prostate massage can be a sexual activity. Inserting a finger, penis, or device into the anus, and stimulating the prostate from there can lead to orgasm for some people. You can also stimulate the gland from the outside by massaging the prostate through the perine um, which is the area between the anus and the scrotum, also known as the taint or the gooch. Whip M D didn't say that last part, but it continues. Orgasm achieved slowly through perennium massage is sometimes known as a perennium orgasm. Such a good drink. But let's cool things down. Just a sec. Spencer wants to know why do some farts smell way worse than others. Shelley Bean wants to know if someone gets the hair removed from the butthole, our farts typically louder. Whoa wow, I thought I've heard everything. Like when the tree falls. Um I'm gonna say hairs, no, because it's really more body habitist from what I've seen than the actual hair itself. Because normal anal canal is like, you know, six to eight centimeters or so. But you c some people have like really large butt cheeks, right? So the butt cheeks can actually go far beyond. And that farting, the clapping there is going to be way more important than the few hairs that are around your anus. Um the hairs, what they do do is trap odor. Oh. And actually, I'm all for like leave it natural and stuff like that. But what I have noticed is that when people were worried about more of an odor issue, it's actually the hair. It's not the poop. Right. So like, okay, in those cases use a little gentle soap. But yeah, it's I don't know that it's like like a a anuditory thing, more like an odor thing. Okay. Are you ever in there? This is a question from Quinn, Lillian, Anonymous, Bree, Lena, and Jay. Are you ever in there and you see endometriosis. Yes. What the fuck? Yes. That's it's not common, but it isn't a differential, which is that if you are having like chronic rectal pain or you know, pelvic pain and you've had a laparoscopy, you've seen a gynecologist and they can't diagnose it, you can have endometrial implants in your rectum that are causing that pain and spasm and bleeding. So endometriosis, if you're lucky enough to not know about this, it is when tissue that's similar to uterine tissue shows up absolutely uninvited in places that are not your uterus. And so what? Except that it's excruciatingly painful, particularly around one's period. Some symptoms are period pain in weird places or so bad that it doubles you over and makes you wish that you were born a tree. Pain during or after sex or orgasm hurts. Painful bowel movements , heavy bleeding, infertility, and you can also experience pain. Uh the pain is very bad pain. Another symptom of endometriosis is called gaslighting on the part of doctors who tell you the periods are supposed to hurt that bad. Now I am lucky enough to not have this, but I have friends who do. And if you've ever seen someone having to pull over because their period pain is so bad, you know that shit is not normal. But it takes on average nearly a decade to get properly diagnosed. And remember, that's on average, which means some people a lot longer. Treatment for endometriosis involves surgery to find and remove that errant tissue from wherever it has taken root, which might be your intestines. Uh it's not common, but you do definitely see that on colonoscopy and on sigmoidoscopies and stuff. Yeah. My God. And do you have to remove it, or then do you have to get an OBGYN surgeon back in there? Oh yeah, no, I remove it. Okay. That's not something they would remove. They're like not going to touch the rectum. So I remove that and then send it to pathology. A lot of times it is a multidisciplinary thing. So if they have to be there to remove other endometrial implants in the pelvis, we do that like all jointly in the OR. Okay. Kimberly Butts, first time question asker, says, I feel it's my time to shine. My last name is Butts. Butts? Yeah. So we straight up Butts. Uh a first time question asker, long time listener. Why did smoking certain types of weed give me diarrhea? Is it similar to food sensitivity? Amy Oslin says my father has explosive diarrhea every day. He thinks it's normal. And Katie wants to know, super weird. Feel free to skip, but why does diarrhea feel hot? Like since it's more water, shouldn't it feel cooler? What's happening? So do certain drugs cause diarrhea? Is explosive diarrhea ever normal? And is it an irritation of the butt tissue that's hitting that ac Okay. And then also like the bile acid, you know, as it's coming out, it actually should be warm , right? It's not a cold liquid that's coming out. It's like a hot liquid. So that's the first thing. Explosive diarrhea can be normal. And actually I remember now what that other question was. It was why does some heart smell worse? Yes. So all of it is related to what you eat, right? So things that are fermented by more gas producing bacteria will cause more gassiness and different smells. So, like, you know, obviously we know that broccoli smells worse, asparagus smells worse, because those things have to be fermented by certain bacteria, by photobacterium that kind of digest it and causes like gassiness and explosive bite diarrhea. I would say like three times a day is technically within normal limits still. Like if it's an explosive gassy stool. Diarrhea technically is defined by four or more stools a day. Like four or more runny stools where you can't keep up with your hydration. So I mean I probably just see what he's eating. Like is it a lot of beans? That that would do it. Can weed do that? Yes, we can do it. So weed does irritate the colon. It kind of stimulates contractility. But then I always tell people it's bugs or drugs too, right? So bugs or drugs have a huge influence on your colon. And we know that for example, opioids can constipate you, but things like metformin, like diabetes medication, can actually cause you to have diarrhea. And then there's certain bacteria like C. diff that will cause you to have diarrhea, but then there's also a consti pating type of of C. diff where you can actually have constipation. So