Combating Constipation: What To Do When You Can't Go with Carmen Fong, MD

Welcome to The Perfect Stool: Understanding and Healing the Gut Microbiome. This is your host, Lindsey Parsons, and today I'll be speaking with Dr. Carmen Fong, MD, FACS, co-director of the Hemorrhoid Centers of America Atlanta and specialist in proctology. She's a double board certified surgeon in general surgery and colorectal surgery. Dr. Fong earned a Doctor of Medicine from Michigan State University College of Human Medicine and completed a general surgery residency at Mount Sinai Beth Israel and a fellowship in colon and rectal surgery at Stony Brook University Hospital NYU Winthrop and is the author of the 2024 book Constipation Nation: What to Know When You Can't Go. But before our conversation, if you haven't yet followed or subscribed to the show, be sure to do so. If you want to get transcripts of the podcast, pop over to my website, HighDesertHealthCoaching.com, and sign up for my newsletter. You'll also get my free ebooklet, Finding Your Root Cause Through Stool and Organic Acids Testing When when you sign up. And if you haven't done my quiz yet on which stool test would help you get to your root cause, you can find a link in the show notes and take that. Now onto the show. Welcome to the podcast, Dr. Fong.

Hi Lindsey, thank you so much for having me.

It's my pleasure.

So let's just launch right in and let me ask you what the official definition of constipation is and how common it is.

Yeah, so it, it's estimated that, you know, about 1 in 5 to 1 in 3 people in America have constipation or have experienced constipation at some point in their lives. There's a, the official definition by the medical textbook is that if you have difficulty evacuating, feelings of incomplete evacuation, hard or firm stools, or you go less than 3 times a week. And for the other ones, it has to be like more than 25% of the time you're feeling those things. That is the official definition of constipation. Now, whenever I ask patients, have you had constipation? And if I say those things, they're like, eh. Probably no. But if you're like, do you feel like your poop is hard sometimes? They'll be like, yeah. I think our bodies don't go by the textbook at all.

So 3 times a week, I gotta push back on that a little bit, and I know that is the official definition, but surely someone who's not having at least a daily bowel movement couldn't be optimally healthy or eating the optimal amount of fiber or drinking the optimal amount of water or getting enough movement or something's gotta be missing, right?

Exactly. So. I usually go by the rule of thumb that most people in the normal average range have 1 to 3 bowel movements every 1 to 3 days, right? So it's like if you're within that range, you're doing pretty well. But if you're going less than 3 times a week, right? That's every 2 or 3 days. There's definitely something that can be optimized. About 89% of the time, 85 to 89% of the time, it's actually something that we can change with behavioral and lifestyle modifications. It doesn't require surgery, medicines, and stuff like that.

Yeah. Okay, great. So how do you think that we have as a society shame people about this basic biological function and how can we undo this training?

Yeah, I think it starts from birth. So I have to tell you, like when I was writing this book, I was pregnant and now that I've had two kids, I can totally see where potty training and potty shaming is a very real thing. So in, in my household, even when we have different nannies and babysitters, I'm like, we do not poop shame, right? We don't say that poop is stinky. We don't say that it's yucky. We don't say that it's gross. Like, it's a normal human function. Everybody does it. And I think that the sooner we start from birth, the better. My daughter is about to turn 2, and already she has this weird thing, and I don't know where she got it from, like, being my kid, that she's, oh no, I have poop in my diaper. It's yucky. I don't want to have it changed because I don't want to smell it. I don't want to have to go. And I'm like, where did this come from? 'Cause I'm always like, hey, it's normal. You gotta go. And I think it's some of our babysitters and some of our nannies have been like, ew, stinky, yucky. So it starts from birth. It starts from normalizing pooping behaviors from birth. And then it extends into teen, your teenage years and adulthood where one of the quoted articles in my book is the New York Times article about women being poop shamed and going to like great lengths to not poop in public. Right. So they will run to the next building to, so that they could go somewhere where nobody knows them, where all these things have been invented, like poopery and sound machines so that you basically extinguish the smell and sounds of having to poop. Yeah.

I actually, I had no idea that people did that until I found out a relative of mine had that issue and absolutely could not go in the same house as her boyfriend or— that, that overcame that obviously when she got married. Yeah.

Yeah, exactly. Yeah. And like, what do you do when you get married? You're gonna, they're gonna find out that you poop.

Yeah. If they didn't know already.

Exactly. All right.

Yeah.

Yeah. And it's like a, there is like a true, a true fear of it, but I think most of the time it can be overcome and societal norms can be adjusted to accommodate for the fact that everybody poops.

Yep. So we're gonna get into diet and supplements and medications later, but let's start with basic bathroom habits. Should and shouldn't people be doing with regard to using the bathroom, sitting on the toilet? Toilet, et cetera, if they're constipated?

Yeah. So everybody should be spending 2 to 5 minutes on the toilet max. No more like 10 minutes in the bathroom, 20 minutes in the bathroom, like reading a book, scrolling through your phone. They actually used to say in the old days, like the generation older than me, keep your library out of the bathroom. And now I'm like, keep your phone out of the bathroom. I know plenty of my patients will be like, hey, that's my 20 minutes of me time where I can play Sudoku or whatever, Candy Crush or whatever. I'm like, can you do it somewhere else? Do it on your porch or whatever. And I get it, right? Like it's where you can hide from your kids, but at the same time, the more minutes you spend on the bathroom, the more that pressure is swelling, causing swelling in your perineum and causing anal-rectal problems like hemorrhoids, fissures, and whatnot. So 2 to 5 minutes on the toilet max. The other issue that I commonly run into is itching, itching around the anus. So pruritus ani, and this is usually caused by overwiping where people will be like, oh, I'm having all this itching. And so I'm using hemorrhoid wipes, witch hazel wipes, baby wipes and whatnot. Those actually tend to be a little more irritating on the skin. And so usually to break that vicious itching, wiping, itching, wiping cycle, I tell people stop everything, but use Vaseline or Aquaphor, treat it like really gently, like you're, it's a baby's butt. Like you wouldn't be like scrubbing it so much if you were, if it were a baby. So don't do that to your own butt. Yeah.

Or get a bidet, get a bidet thing if you've got such mess. 100%.

Get the bidet. I, it's Christmas is in 2 weeks. And I've actually told a lot of my patients like, get yourself a Christmas present, get a bidet. That's actually one of my 10 bowel commandments. Bidet is the way, right? In our country, we just do not use bidets enough, I think. And it does take care of so many problems and really does help with feeling clean afterwards. So you're not like avoiding the bathroom cuz some people also have a little bit of poop avoidance and being like, I don't wanna go to the bathroom cuz I don't want to, I wanna pretend that I don't poop.

Mm-hmm. Yeah. But if somebody is having a messy enough bowel movement to have to be wiping multiple times, then they're also not having an optimal stool.

Agreed. Yes, 100%. And that's where I'm like, we, I love talking about the perfect stool. There is a perfect stool that is achievable. And if it's so messy that you're like wiping 8 times, it's too sticky. You're having too much fat or whatever.

Yeah. Protein. What are the first line interventions for constipation? Meaning like the least potentially harmful and most potentially beneficial interventions?

Yeah.

So the first things I would start with are always fiber and water.

Rule of thumb, 25 to 35 grams of fiber, a good mix of both soluble and insoluble fibers a day, and then 2 to 3 liters of water. So fiber-wise, this was one of the reasons why I wrote this book, is that I felt that I was telling patients 25, 30 times a day how much fiber to take and what kinds of fiber. And I realized that in medical school, we really don't discuss What kind of fiber and how much fiber? You go to the ER with a hemorrhoid and they'll be like, eat more fiber. And they're like, what does that mean? And then I found that soluble and insoluble fiber is really ideal. So you, so a good example is an apple, right? So an apple has both soluble and insoluble fiber. The soluble is in the flesh, it's in the pectin, which kind of forms like the gel in your colon. And then you have the skin, which is the insoluble part, the roughage that kind of causes a little bit of colon irritation and makes things move through. So I really think an apple a day does keep the doctor away for the most part, or at least helps with your bowel movements. And then water-wise, 2 to 3 liters. They traditionally said about 8 glasses a day, which is a lot for most people, but it's gonna be even more if you're active, if you're in like a really warm climate, or if you're pregnant where your circulating blood volume increases by about 40%.

So I actually read in your book that for women it was less, it was something like 6 point 6, 7, or—

Correct. Yes. So it's like slightly less for women. So if you're on that, on the smaller female side, you can be on that lower side of 2.2 liters. I would still say pregnant ladies, when I've seen pregnant women in the office, they should be closer to 3 liters.

Yeah.

Yeah.

Drinking for two.

Exactly.

Yeah.

Okay.

And so for fiber, you're talking about through the diet or you're talking about supplemental fiber?

Yes. Yep. So mostly through the diet and I would say having a good mix of good variety of fruits and vegetables is best. So if you can apples and oatmeal for breakfast and lunch, some kind of a salad. I actually hate salads. Like that's, that's like my secret. I really do not like salads, but I really like cooked vegetables. Cause I just think that you have to have so much lettuce for there to be an adequate amount of fiber.

Yeah. It's like an entire bowl is like there's a gram or two.

Exactly. So iceberg lettuce really does not provide the the fiber that you think you're getting. And so I'm like, if you have to do cooked spinach, cooked kale, cooked broccoli, like green leafy vegetables are always better. And then my go-to whenever I recommend to my patients is actually sweet potatoes. So again, like good mix of soluble and insoluble fibers. It's easy to digest, relatively low in calories, and has a lot of vitamins with it. And it also provides that bulk that some people need because if they're otherwise like dieting or eating only protein shakes throughout the day, you actually don't have the bulk to form a good stool. Yeah.

I like to say beans because those bang for your buck, you're not gonna get more fiber.

You're right. That is also true. So legumes, lentils are a great source. I just know that a lot of people shy away from beans because of the gas factor.

They do. Yeah.

Yeah.

And I was shying away from them until various and sundry reasons. So I started eating a lot more of 'em lately. Yeah. And I soak 'em overnight, stick 'em in my Instant Pot for 5 minutes. They're done. They're ready to go. Keep 'em in the fridge, just throw 'em on salads, make a soup, eat 'em as a side dish, whatever. I just did this. Amazing. Yeah.

Amazing.

I can't tell you how much this transformed my stool.

Yeah, no, 100%. Like I've had patients who are like, I just started eating lentils every day and it does work.

Yeah.

Yeah.

It really does.

For sciatica. The other thing though is that your body gets used to the gas. Like I always tell people. Oh yeah.

There was no gas.

Yeah. Like it, or if you have a little bloating, your body actually adapts to it.

So, yeah.

Yeah.

No, I, I had no gas at all when I started them, when given that I was soaking them and doing it properly.

Yes, exactly. Right. So you were already soaking out the starch.

Yeah. What about exercise and movement, how that relates to constipation?

Yeah. Having some exercise is important. So I usually like the, the moderate activity level of 30 minutes, 3 times a week is great. But what I do warn people, cuz I see this more and more, is that too much exercise can actually cause a little constipation because you're stimulating a fight or flight response in the body, right? So basically it's a sympathetic response being like, hey, there's a lion, you have to run away. And so when all the, when all your blood flow is being diverted towards your muscles and you're trying to run away, it's not doing the rest and digest that your stomach needs. Or so moderate exercise is good, but too little exercise and you're too sedentary and you're not stimulating that GI motility. That your body needs and actually gravity helps too. And then too much exercise is bad. So everything in moderation, including moderation. Yeah.

I'm a personal fan of just moving around the house, doing the basic things like cooking and doing dishes. Like I don't, I love that. I don't regret the time I spend doing those things because that's time that I'm not sitting on my butt.

Yeah. I love that. And it's just me playing with the kids or like being outside doing yard work and, or even just taking a walk, which is totally enough. Yeah. I'm not saying you have to go run 5 miles every day.

Yeah. So if somebody just can't seem to manage to get the fiber from their diet, are there supplemental fibers you like?

Yeah, I actually have a few that, that I like. And brand-wise, there's actually Colaflax, which is a great one. It's actually a flaxseed supplement, but it has both soluble and insoluble fibers. Otherwise, most of the over-the-counter ones that you can get are fine. I think it's just important to make a distinction, or like when you're looking at the label, like Metamucil tends to be psyllium husk, Benefiber tends to be wheat dextrin. And so if one of them doesn't work for you, switch to a different one or try one that has a combination of fibers.

Yeah. I like to send people just to plain psyllium husk because Metamucil has additives. So it's got food coloring and stuff.

Yeah.

You don't really need the psyllium husk is gross, but it's probably gross in Metamucil too.

So it, it is gross at Metamucil. Like most people don't like mixing it in water and having it turn into a gel. So if when do that, I'm like, if you're gonna do that, just drink 2 glasses of water after it. I love flaxseed and psyllium husk. So both ground flaxseed and psyllium husk, like on top of salads and smoothies. Mm-hmm. Works really well. Again, I think it's pretty good bang for your buck.

Yeah. Yeah. And of course the flax. Yes. Alpha-linolenic acid.

Exactly.

Turns into, turns in, if you take enough of it, it'll turn into your good omega-3s, your EPA and your DHA.

So the other one that I've heard is actually chia seeds.

Mm-hmm.

Which is great, but having too much chia seeds That could also be a problem. So I try to stay away from that because when you tell somebody, people, one thing is good, they try to do a lot more of it. Right?

Yeah.

Okay.

When it comes to over-the-counter medications for constipation, which are the least harmful versus the most potentially harmful or the ones you shouldn't be using long-term?

Yeah. So this is always a good question. And technically, like evidence-wise, Miralax is the least harmful. It's an osmotic laxative. So really it's just drawing water into your stool. In theory you can take it long-term without like really negative effects. Obviously, you know, people who have like kidney problems, heart failure, and should not be taking things that are osmotic laxatives that are drawing too much water out of your body and causing electrolyte imbalances. But that's the one that's pretty safe. Senna is thought to be like natural, right? And so therefore it is considered to be pretty safe. It does work, but with senna and Dulcolax, these are stimulant laxatives and those do have an addiction addictive potential. And so therefore, those are ones that you would not wanna use for long periods of time, generally 6 months or more. If you're using for a short term, like once in a while, you're like on vacation, haven't pooped in 5 days and you really need something, sure. And in those cases, I would always try to do a suppository before you do something systemic, 'cause you're actually just stimulating from the rectum versus taking it from the top down and who knows if it'll even get down there.

Hey, this is Lindsey here, just letting you know that if you're tired of dealing with digestive issues like bloating, indigestion, soft stool, diarrhea, constipation, reflux, IBS, IBD, or the numerous health conditions that come about when your gut is off, like brain fog, weight gain, UTIs, fatigue, mental health issues, or complex conditions like fibromyalgia and ME/CFS, that's my specialty. With my 3 or 5 session gut health coaching packages, We'll discuss different stool and functional medicine tests to find out the root cause of your symptoms. I'll interpret the results and provide clear explanations, empowering you to make informed choices for your gut and overall health. And together we'll develop a customized action plan based on your test results so you can find relief and regain your health and vitality. I come from a functional medicine perspective, trying to incorporate the latest peer-reviewed research and educating you on protocols used by functional medicine practitioners, but devoting lots of time and support to my clients the way a doctor simply can't. If you're interested in a 3 or 5 session coaching package, you can sign up for complimentary 30-minute breakthrough session. Or if you can only afford one appointment at a time, you can book an initial 60-minute consultation.

Links for those are in the show notes.

Now back to the show.

Would the suppository be a stool softener or what would that be?

No. So you can actually do either a glycerin suppository, which has both stimulating and lubricating effects, or Dulcolax comes in a suppository.

Oh, okay.

So you can actually have a stimulant laxative as a suppository. Okay. And then last but not least, like you have like magnesium oxide or like milk of magnesia. And in those cases, that is also very good as a laxative. It tends to be gentler on the stomach, but you would also not wanna take those when you have electrolyte imbalances.

Okay.

Yeah.

And, and what about magnesium citrate using that longer term?

Same. Yep. So you wouldn't wanna do that with a electrolyte imbalance. Light imbalance, but people who can't tolerate Miralax, you can use like a bottle of magnesium citrate and it'll clear you out. Now that's different when you're taking like the concentrated bottle versus if you're taking like a supplement, if you're taking like Natural Calm or something, that is okay. And actually I love Natural Calm. I usually do recommend it.

That's the one I always recommend too.

Yeah. I love Natural Calm. I've been taking it since 2009 or something like that when I first discovered it. And this was before I even did any poop or constipation work. And I've just, I've always loved it for sleep, for relaxation, and then for your bowel habits.

Yeah. I find that people are very successful with that, that even, and it's funny because I'm thinking, how did you not try anything like this? Like, this is everywhere. It's all over the internet. Like, how did you not hear about this? Yeah.

It's really funny. Like what people see and what people don't see.

Yeah.

Most of my patients have not heard of Natural Calm. Now that you, yeah, now that you mention it. Yeah.

How do you feel about vitamin C or using like a vitamin C flush in particular if you're like totally backed up?

So I think that vitamin C has potential because we know that it has like antioxidants that will help with stimulating the rectum. I just don't love flushes in general. So either, either like a total cleanse or like a high colonic, you're going to be disrupting some anal rectal mucosa. You're gonna be causing some mild trauma or injury. And then the problem with long-term use of these things is that it disrupts the microbiome, we believe. And so you might have like more problems in the future with irritation, with having mucus production and things like that.

Yeah.

So what does somebody do if I, I've heard of clients who've said, I went to the hospital and they said my entire colon is full. Like I'm just completely backed up. What do you do at that point?

Right. Yeah. So say it's that patient, it's been like 9 days, you haven't pooped, like literally on the x-ray, it's like full of poop. And you— I do a top-down approach, but then a top-down and bottom-up. So I would do Miralax from the top, right? Provided they can tolerate it and they're just not vomiting everything back up. And then I would do Dulcolax suppositories times 2 and then an enema. All right. So then you're going to do like a short, a rectal enema, usually just tap or saline, tap water or saline. And then not definitely on more than one occasion, you might actually have to do some manual fecal disimpaction just to get that firmer ball of stool out to let everything else through.

Okay. Yeah.

So this is when you're getting intervention with a medical professional.

Exactly.

Like, okay. Yeah.

Don't disimpact yourself, please.

Okay. Are there any product probiotics that you recommend to patients who are constipated?

Yeah. So I actually love, and, and Based on my research with— this was one of the most exciting areas for me, was that there are certain strains that work better than others. Lactobacillus, Bifidobacterium, Cassius rhamnosus. But it's funny cuz there wasn't much research until after the book came out about Lactobacillus acidophilus. And it seems like that does work too. I usually recommend a good mix of strains as well. You don't want a probiotic that's just like a few strains, and then you want more than 100 billion CFUs. The ones that I like are Physician's Choice, or I use, I just take the Costco brand True Nature one. And lately I've actually really liked the brand By Seed, which is created by Emeron Meyer, or he's part of the board. And it has a coating that doesn't get digested in the stomach and makes it to the colon.

Yeah, I take that one. DS01.

Yeah. Yeah. DS01.

I can't take it at night though. I tried to take, they say to take it at night and it just, I felt all gurgly and uncomfortable when I took it at night. Oh, I just take it. I just take one with the meal. They're also kind of expensive, so I just take one a day. I don't go for two.

They are, they are expensive. And I think part of it is like the branding, but I'm hoping that in the future we're gonna have a lot more of these probiotic strains that aren't like, what do they call it now when they name the certain combination of strains like DS-01, and then there's one that's like GS-111 or something like that.

You mean patented ones?

Yeah. They're like patent, patented combinations of strains. I feel like they probably shouldn't do that. You know.

Yeah. Yeah. It certainly would make research better if there were patented combinations. But of course, if you've got the patent, you don't wanna sell it to everybody else. You just wanna keep it.

Exactly. But wider availability to the public. Yeah.

I don't know if they can, I guess they can patent them if they're not, if they're just a natural substance, I don't think they can be patented. Like you can't patent a bacteria cuz you didn't create it. Correct. But if you genetically modify it, then you could.

Right. And then if you patent the certain combination is what they're doing.

Although I do know that there's definitely a, maybe it's a trademark. Yeah, no, I think what they do is they trademark like Pylorpass for H. pylori is trademark, I think, but not patented.

No, that's not patented. Correct. Oh, interesting. Yeah.

Anyway, so what about prescription medications for constipation? Which ones do you like the best?

Yeah, I would say I generally try to stay away from them as much as possible. But then when we do have to use them, either lubiprostone or most of the time it's actually lubiprostone because lubiprostone has a generic form. And so I would say that tends to work. Obviously there's a bunch of newer ones and I just don't think that they've really proven their value yet.

What's the brand name of lubiprostone?

Lubiprostone is Emetizia, I think.

Oh, okay. I hear people mentioning Ibsrella.

Ibsrella. I actually don't even think I, I've heard of that one.

Or maybe it's like IBSrella. I don't know. Okay.

IBSrella. A lot of people take Linzess. Linzess. So I know that a lot of my—

Oh, Linzess. Yeah, that one I've heard a lot about.

Yeah. Yeah. So a lot of people will come in and they'll be like, oh, I had constipation for one day and, you know, somebody threw me on Linzess. The problem with Linzess is that it does take a while to work, right? So it's not like you could take it for one day and it starts working. And then once it starts working, it almost works like an osmotic laxative, draws all the stool in, and in some— draws all the water in too well and then starts giving you diarrhea. So then you have to titrate the dose. So I wouldn't say that it doesn't work. It's just that you have to titrate a little bit better. And then in some people, if you're not drinking water, it still won't work for you.

Oh, okay.

Yeah.

So lots of people tell me they drink coffee and that immediately stimulates a bowel movement and often a loose one. Is coffee good for us in this respect?

Yeah. Yes. You know, that was a whole chapter in the book and there's technically no research that says coffee makes you poop, but there are certain compounds, the phenols in coffee actually can stimulate your GI tract motility. And there's also the added effect of warm water stimulates better GI tract motility. And so I, I tell people if coffee works for you and you drink one cup in the morning or it's Pavlovian that you smell coffee and you immediately have to go to the bathroom. Then that's great. But otherwise, if you're drinking coffee, like only coffee exclusively 5 times a day and not drinking any water, it almost has, I call it a negative water effect. You're like minus 1 cup of water that day because the caffeine is actually dehydrating you and you actually need to drink more water to compensate for it. So bottom line is I would say coffee is great. I love coffee, but 1 cup a day if you can. We use it for both like the stimulating effects and the warm water effects. Of going to the bathroom, but can't drink only coffee and can't drink only iced coffee. But people will be like, oh, I only drink iced coffee all day. And I'm like, there's no nutrition in that. Yeah. What do you think about coffee?

I don't drink coffee, so it's not a, oh, it's not an issue for me. I just never was a coffee drinker. I never liked the taste.

Yeah, no. And I love green tea and honestly I think like green tea is very good for you.

Yeah. And any number of illnesses, I'll be like, oh, I wonder what supplements go with that? And I'll look it up and I'll be like, oh, green tea, EGCG.

Yes.

Yes. So many good things.

Exactly. Yes.

And I happen to have a cup of it every morning, so I'm like, yay for me.

Yay.

Yeah. Okay. You mentioned that colonics and such might be bad for us. What about the colonoscopy prep? I always thought I don't wanna get a colonoscopy because I don't want to I've been working so hard on my microbiome. Like, I don't wanna wash it all out. Is that dangerous to our microbiomes or do they recover?

They do recover. They do recover. I've seen where sometimes it takes almost 6 weeks to recover. And you go back on probiotics if you were on them, or you start taking probiotics if you weren't on them. It's actually like a, a post-colonoscopy prep syndrome that is starting to become more recognized. Cuz at first people will be like, what are you talking about? You can't poop. After your colonoscopy, but that's not a thing. First of all, you have the fact that you've been completely cleaned out, so you have no solid substance and you're cold, right? So if you can't poop for 2 days afterwards, that's totally normal. But then your body goes into this mode of being like, hey, we don't know what we're doing anymore. There's nothing in here. That and all that regular microbiome is gone, been totally washed out. So I just usually tell people, resume your regular diet as soon as possible. And if you can actually see if you can find a gastroenterologist or colorectal surgeon who does colonoscopies is allowing either soft foods or bland foods the day before so you have some substance. There's actually a brand called Happy Colon. I don't know if you've heard of it, but they actually make a bowel prep that's gentler on the stomach. It's mostly Senna-based, so a stimulant laxative, but they allow you to have like crackers and then clear soup and stuff like that. Things that are low fiber so that it can be washed out slowly or completely., but that you can also have something in your colon and it is gentler on the colon, on the intestinal tract.

Okay. Good luck with that, with insurance and everything else, finding, picking and choosing your doctor on the basis of the colonoscopy prep. But I love it. I love it in theory.

Yeah, no, I, when I talked to them, I was actually like a huge thing. I was like, if co— if insurance doesn't cover it, nobody's gonna use it. I wish that insurance would cover these things, but I wish insurance would cover a lot of things. So that's a whole different issue.

Yeah. So you might actually just disobey your doctor and go buy it on your own. Is it available over the counter or?

Yes, you can buy it online. It, I think it's $38. You can buy it online. And then what you can actually do though is tell your, the doctor and say, hey, are you okay with this prep? Like, this is the evidence for it. I would allow it 100%. Okay. Yeah.

And what about using a colonoscopy prep if you're totally backed up?

Yes, you can do that. So polyethylene glycol is actually, is the same stuff that Miralax is made out of. It's just that Miralax comes in 17-gram powder form and GoLytely comes in 4 liters. So if you're gonna be drinking like 4 liters of any fluid, you're probably gonna get cleaned out anyway. I would say if you're that backed up, you can try a colonoscopy prep, but start with MiraLAX and just up the dose.

So I have a confession to make.

Uh-huh.

I had a colonoscopy about a year ago.

Okay.

And I didn't finish the prep stuff. I just, I was like, listen, it's been pure liquid for the last 8 hours. Oh God.

Yeah.

Like, I'm not taking any more of this. This is absurd.

Yeah. Yeah. Nope.

And I was fine. It was totally clean. Yeah.

It's really a lot. It's actually a little bit of overkill. And when I was a fellow, I can't tell you how many times people called me at 3:00 AM being like, please, like I cannot finish this prep. Like I'm throwing it up. Like I'm like pooping all over the place. And I'm like, it's okay. It's most of the time it's gonna be okay. 4 liters is more than the amount you need. They also make some that are in divided doses now, like 2 bottles or something. And then you add some Gatorade in between. So there's options. Less torturous options.

I did not tend towards the constipated, so I knew I was gonna be fine. And I was like, this is the end. I'm like, I'm done with this.

I wouldn't think you were, that you tended toward constipated.

So I saw you had a chapter about fecal incontinence in your book. Can you talk about why that may happen in someone who's constipated?

Mm-hmm. The most common reason is that you have overflow incontinence, and that means that if you're backed up and you have a stool ball inside your colon, if you try to eat other things, drink a lot of liquid, do Miralax, the liquid stool will actually just flow around it and flow out of your anus. And so it seems like you're incontinent because you have some mucus and stool leakage, but you're really backed up. You can usually tell this by history though. If people are saying, okay, I'm having some incontinence, but I'm also super bloated. I feel like I haven't had a full bowel movement in days. It's more likely going to be overflow incontinence rather than true incontinence. Uh, the other thing that would distinguish it would be like on anal rectal exam when I'm feeling and your sphincter tone is completely fine and there's no signs of like damage or whatever.

Do you have unspecified gut health issues and haven't gotten tested yet or diagnosed SIBO, IBS, IBD, or Candida? My newest supplement, Serum Bovine Immunoglobulin or SBI powder, may be the perfect thing to try. In a randomized double-blind placebo-controlled study of adults with IBS-D, GI symptoms including loose stools, hard stools, flatulence, and incomplete evacuation were significantly improved with a 5-gram-a-day dose of SBIs after 6 weeks. And abdominal pain, bloating, and urgency were also significantly decreased after 6 weeks of use at a dose of 10 grams a day of SBI powder. It's basically the immune system of a cow derived from plasma and made into a powder, so it binds and neutralizes a wide array of pathogenic bacteria and fungi and carries them out with your stool. Without hurting your beneficial microbes like antibiotics or even strong antimicrobial herbs will. It's also been shown to decrease intestinal permeability, decrease fat in the stool, increase the absorption and utilization of nutrients, and increase lean body mass. So give it a try today at perfectstool.com, where you can also find my supplement Tributrin-Max, which helps solidify stool and slow down motility for people with diarrhea or loose stool.

Okay, so if you were having that and you weren't constipated, then that would be the time to, to see a doctor and saying, and find out about your sphincter tone.

Yes, ma'am. Yep, exactly. So if you're having complete leakage, the most telling thing is if you sneeze and you end up having an accident and/or you're having accidents at night.

Okay. And what can one do about loose sphincter tone?

The first thing is actually add fiber, which is weird, right? But I always tell people that people think that you take fiber for constipation, but it firms up loose stool just as well as it softens hard stool. So it Start with a fiber supplement, start drinking a lot of water, especially if you're losing a lot of fluid. Bulking up will work. And then we start going into like the medications and stuff, which is like adding ammonia, adding to, again, slow down the stool. But then after that, it's a couple of things. Pelvic floor physical therapy, usually to assess the muscles and strengthen the muscles. If you see me in the office, I might do anal manometry, which is a test of the sphincter tone and the nerves around it to see if there really is any damage that can be repaired. And then in the old days, you either would have to do like a sphincteroplasty, which tightens the sphincter and/or some other kind of like major surgery. But these days we actually put in a sacral nerve modulator, an SNM or an SNS device, which stimulates the S3, S4 nerves and helps that muscle contract. It actually works really well. It's shown to work about 92% of the time. It works better for people with incontinence than constipation, but there is some evidence that it also works in constipation, and especially like mixed constipation and incontinence.

So you mentioned mucus in the stool, and I know, you know, that excessive mucus coming out and often with blood is very common in colitis, but what else could be causing it in people without IBD? And is a certain amount, like enough for the poop to slip out nicely, normal?

Yes. Yep, exactly. So IBD, bloody mucusy stool is a sign of ulcerative colitis, but your body actually physiologically produces mucus in the rectum. And that's what makes the stool slippery. That is also one of my other favorite chapters, which is how much mucus it takes to make your stool slip out. All mammals poop in 12 seconds because of this mucus layer in the rectum. So normal mucus is physiologic, is normal., but you shouldn't be seeing a ton of it. When you see a ton of it, there's usually one of two reasons. And the most common one I think is overwiping. And so when people try to wipe the inside of the anus, it actually stretches that mucosa out a little bit. It causes mucosal atropion. And since that pink layer is on the outside, you actually see more mucus on the outside. Right. And then the other thing is either using enemas or colonics. Because you're disrupting that mucus layer and literally ripping it off. And so you're dripping mucus out.

Okay. And what about if somebody's not done those things? Could it be just inflammation?

It could just be inflammation. Okay. You can have a small amount of mucus if you're sick too. If you have a viral illness and some inflammation in the colon or rectum. Okay.

Yeah.

Yeah. Yeah.

And what about, so often people are using biofilm busters. Is that something that often causes mucus to come out?

So I think that Biofilm Busters tends to be, it really shouldn't, but I think that if you are using it very frequently, then yes, because anything that disrupts that, that microbiome layer in the rectum and anus.

Okay.

So what causes hemorrhoids and anal fissures and how are they treated?

Yeah. So hemorrhoids are free bundles of blood vessels that are in the human body. Everybody has them. Everybody's born with them. When they become symptomatic is when we start to treat them, when they become a problem. So internal hemorrhoids are above the level of the sensory nerves or above the dentate line, which generally means that they tend to be painless bleeding, but they can do a couple of things. They can prolapse, so they can pop out of the anus and then they can bleed and generally, again, painless though. External hemorrhoids are below the level of the dentate line. And so they tend to be more painful, but not bleeding. Because they form a little blood clot on the outside and it feels like a blueberry or a grape. So it can be extremely painful, but usually no bleeding. And then you can have fissures, which are somewhere in the middle, and these tend to be both pain and bleeding. Most of the time people will come to see me and they think that they have hemorrhoids, but it's really a fissure, right? Because pain prompts people to go see the doctor more than anything else. Things that make hemorrhoids worse. Constipation, but also diarrhea. So constipation because you're straining, you're sitting on the toilet, any amount of intra-abdominal pressure where you're putting more pressure on the perineum will make those blood vessels engorge and swell to the point where they might pop out and bleed. Diarrhea because you're going so often that it's irritating the anal and rectal lining. Technically it's the anus. And then you're wiping more often as well. So I've actually seen patients where they'll be wiping often because of going to the bathroom 7 or 8 times a day. Sometimes people with IBS that they're causing external hemorrhoid thrombosis because you're tearing that skin and that blood vessel. Fissures is the same thing, sitting for too often, more than 2 to 5 minutes on the toilet. But the one other thing that causes fissures, which is a little bit different, is actually stress. So young people, and actually I think all people these days, we hold our stress in our pelvis. So literally we walk around like squeezing our butt so tight and we don't realize it. And when you're squeezing that butt tight, it actually constricts the blood flow so that if you do have a little cut or a tear in there, it can't heal. So one of the primary treatments we do for that is actually apply a topical ointment that gently relaxes that internal sphincter, that smooth muscle, so that the overlying tissue over it can heal. Yeah. So basically everything that causes hemorrhoids and fissures are Similar, except for the stress. So sitting too often, long plane rides, long car rides, sitting on the toilet.

Pregnancy for hemorrhoids. Pregnancy. Yes.

The gift that keeps on giving pregnancy. Yes. For hemorrhoids.

So when should someone seek out the help of a pelvic floor therapist? Is that something they would be referred to always from a doctor, or is that something they can do on their own?

Mm-hmm. You can actually go on your own these days if you feel like this is something you need. A lot of places I, I've talked to will take like you can just walk in and tell them the problem you're having. I refer a lot to pelvic floor PT for a variety of reasons. It used to be mostly for fecal incontinence because they can strengthen the muscle, but these days it is for a lot of pelvic floor pain and anal fissures that are a chronic pelvic floor contraction or levator ani problems.

What's that?

So yeah, so levator ani syndrome is where you either feel pain in the butt when you're having a bowel movement, it hurts for hours afterwards. Classically, it's always on the left butt cheek because there's a little trigger point right there. It usually comes from sitting too often. So you're just actually putting a lot of pressure on this muscle, and the muscle is just continuously contracted. Things they can do to help that at pelvic floor physical therapy are leg stretches, hip stretches, back stretches, but then also some internal massage, some biofeedback, which is where they put either like a balloon sensation, like a little probe inside. To say, hey, you should breathe like this. And when you relax, you're expanding your intra-abdominal cavity and relieving the pressure on your pelvis. The other thing it does is actually retrain your brain how to go to the bathroom when you go. And some people will have what's called a paradoxical contraction where over time— we're talking about poop shaming before— you actually just hold your muscle in so tight that it forgets how to relax. And so even when you go to the bathroom, most people, their anal canal and their anus should open when you go to the bathroom. Some people, when they try to push, it actually closes. So retraining your brain to open that when you go to the bathroom. Yeah. That's actually one of the main things I send for.

Okay. So when should someone be concerned that their constipation could be indicative of something more serious like cancer?

Yeah, it has to be a constellation of symptoms. And I would say that constipation in and of itself is not like the great symptom, but if it's been chronic, if, if it's been over like 3 to 6 months or so, I would say definitely get a colonoscopy. If you have other concerning symptoms like obstipation where you're not farting at all, that tends to be a pretty late stage tumor where it's completely obstructing, then go to the ER. Do not pass go, do not collect $200. But the other things that if you weren't completely obstipated would be blood in the stool.

If you weren't completely what?

Obstipated, so not passing gas either.

Okay.

Yeah. Yeah. If you're not passing stool and gas, go directly to the ER. But if you are passing stools, passing some gas, but still chronically constipated, if you have blood in the stool, unintentional weight loss, or a strong personal or family history, then I would seek some earlier medical attention and say get a colonoscopy.

Yeah. And constipation is in and of itself a risk factor for cancer, right? Not just colon, but other cancers.

It's funny because it is a sign of inflammation, right? And does cause some colonic irritation. As far as I know, there's no direct link to colon cancer, but I think that's gonna change it. We know that it— there's a two-hit hypothesis for colon cancer, which is that you have to have the genetic predisposition and then a second factor, and if constipation and chronic irritation as a second factor, you have a good chance. I think our society's diet and exercise does not help our cause at all.

Yeah. No, I thought that it was like a risk factor for breast cancer because you just have these toxins sitting there and not getting out of the body.

Correct. Yes. For breast cancer it is. It's not a direct risk factor for colon cancer though.

Okay.

Yeah. Yeah. I know I've looked and looked cuz I really thought it would be and there's no evidence for it.

Okay.

They changed the age that you're recommended to do a colonoscopy to 45, didn't they?

Yes, they did. Yep. It's 45 now. When was that? So this was about, I think it was 2 or 3 years ago now. Remember it was just after COVID. It's been about 3 years. It's, it changed to 45 from 50. So it's 45 if you have no other risk factors. So 45 is when you start screening and getting a screening colonoscopy. If you have any family history of cancer. Colon cancer, it's going to be 10 years before the youngest age of diagnosis in a first-degree family member. Which means, yeah, which means that if your mom had cancer, was diagnosed with cancer at the age of 45, you would go get screened at 35.

Okay.

And given it's only, you only get screened every 10 years, right? Is it that it's just super slow growing or why such an infrequent?

Correct. It used to be that we have our adenoma hypothesis, which is that these polyps turn into cancer. And so by the time it's 10 years, you could conceivably catch it again. I think a lot of it is changing though in clinical practice. Most providers will do every 5 years even.

Oh, okay.

Because we're finding a lot more young people with colon cancer. So actually it's been in the headlines lately that people younger than age 45 are getting diagnosed. So that's just the growing population of people with colon cancer in the country. Again, I think diet and exercise and calcium and vitamin D levels. But the other things I should add are generally if you have any polyps on previous colonoscopy, you're going to be 3 years for follow-up screening if you have 3 polyps, 5 years for 1 or less polyps. And then usually if you have between 5 and 10 years, if you have an history of IBD. So 8 to 10 years of IBD is a high risk factor. For developing colonic dysplasia. Okay.

Yeah. So I did, uh, I was really, as I said, I didn't really wanna do the colonoscopy, so I did the Cologuard first cuz I thought I've never really been regularly constipated, so maybe I could just get away with this. And then I thought, okay, Lindsey, suck it up. You're a gut health specialist. Just get your colonoscopy.

And did, was your colon Cologuard negative?

Yeah, the Cologuard was negative, but I waited 3 years and then I did the colonoscopy. Ah.

Okay. Okay. Yeah. I think that when you have low risk, Cologuard is totally fine as a screening test. Again, 92% sensitive, right? So it's really not bad. It's just that if you do have a positive Cologuard, you end up having to get a colonoscopy anyway.

Yeah. But a poop sample, this is not a, this is not a big intervention. That's not a big ask. I'm not like, oh, I ruined that whole thing by getting, using the Cologuard.

I know. You know what's funny though, is that I have sent Cologuards and patients will be like, I do not wanna put a poop sample on a card. And I've had patients who left it. They're like, oh, it's on the kitchen counter. It's been there for 9 months. And I'm just like, can you please do it and send it in? Whereas if I schedule a colonoscopy, I'm like, you have to come in on this date and do a prep. They will come in and do it. Yeah. Because there's like a deadline. Maybe I have to put a deadline on the Color Guard.

Yeah. Yeah. This will, this will explode if you do not use it by this date.

Correct. Yeah. We, they should put that on the box. Yeah.

That's true. No, I, my own husband said he, he went through the Cologuard process and he'd rather just do the colonoscopy the next time.

See? Yeah. People are like, I don't wanna put poop on a card.

Yeah.

In the, in Europe, in the UK, they're actually starting to screen a little bit sooner, which I think is totally necessary. There was one study where they tried to screen kids who are 25 to 35 with just fecal immunohistochemistry testing, FIT tests. So again, like a little bit of a poop on a card where if it's a positive, then you get a colonoscopy. And if it's negative, then you can continue on for a few years and then, you know, scope or do the test again later. But at least it's a low-cost intervention and we're screening earlier because of these earlier incidences of cancer. I think we need to go to that. Yeah. Yeah.

Yeah. Certainly no reason anybody should be getting colon cancer these days.

Yeah.

Yeah. I wish I could say that about any kind of cancer, but at least we have some interventions that aren't too hard for diagnosing colon cancer compared to some of the others.

Exactly. Agreed. Agreed. Yeah.

Yeah.

100%.

So anything else you would like to share with my audience before we go?

Yeah. I think because this is called the Perfect Stool Podcast, I've been thinking about it a lot. Like the perfect stool is achievable. I think that a little bit of tinkering, a little bit of knowing your body, but generally the ideal stool, actually you go to the bathroom, 2 to 5 minutes, it's out. It doesn't, it's not sticky. It's not too wet. You don't have to wipe 18 times. It's not too hard and irritating. And it comes from a good diet of fiber, soluble and insoluble fibers, water, and generally some probiotics. And once you get to that point, I actually I'm a firm believer that your body will go on autopilot and will be like, okay, most of the time, like you have one hiccup now and then, but it's much easier to get back on track when you're doing good. And it has to do with microbiome. And then last but not least, my one vow commandment is go when you have to go and don't go when you don't have to go.

Okay, great. And your book, I will just do quick show. I've got mine here, Constipation Nation.

Yeah.

I will put a link to that in the show notes.

And did you like it? Did— yeah.

Yeah. It's been great. I'm about halfway through, I have to confess, but I did start paging through to get the questions ready cuz I have a book club. It's been taking up my reading time, so I'm not as much time for work-related reading.

I totally get it. I think it's actually been doing pretty well on Amazon, but the only person I know who's finished it is my dad. And actually one of my patients told me she read the whole thing the other day cuz she was like asking me like really specific questions about my wife being pregnant and I was like, wait, how do you know that? And she was like, it's gotta be weird in your book. And I was like, what?

Yeah. That is unusual cuz most people don't know anything personal about their doctors.

Oh, I know. It, it is weird, but also like I knew this going into it that my patients will be like, oh, the book, it just sounds just like the way you talk. And I'm like, that's how I wanted it to be.

Yeah.

Yeah.

Well, thank you so much for having me.

Yeah, thank you so much for being here. I really appreciate you sharing your knowledge.

No, of course.

That was great. Lots of really practical info in there. And just an FYI that because I was talking to a gastroenterologist, I was focusing more on physical, nonfunctional GI disorders. So we didn't get into SIBO or EMO or topics I cover regularly otherwise that can cause constipation. So you can check out other episodes like 131 or 114 or 83 or 36 for more info on those issues. Tune in next time to hear my conversation with Zach Abbott of ZBiotics, who make genetically modified probiotics including one called Pre-Alcohol and another called Sugar to Fiber. If you'd like to support the podcast, you can buy supplements at a discount from my FullScript dispensary, order tests at a discount from my Rupa Health Lab store, or use my affiliate links to iHerb, which is available worldwide, or Amazon. If you'd like to connect with me online, you can follow my High Desert Health Facebook page, join my Healing Facebook group or join my newsletter list at HighDesertHealthCoaching.com, as well as follow me on X, Instagram, TikTok, and Pinterest. Links for those are in the show notes. Thanks for joining me today, and here's wishing you all the perfect stool.