Adapted from episode 144 of The Perfect Stool podcast edited for readability with Dr. Carmen Fong, MD, Co-Director of the Hemorrhoid Centers of America – Atlanta, double board-certified surgeon in General Surgery and Colorectal Surgery, and the author of the 2024 book: Constipation Nation: What to Know When You Can’t Go*.
Lindsey:
So let’s just launch right in and let me ask you what the official definition of constipation is and how common it is.
Carmen Fong, MD:
Yeah. So it’s estimated that about one in five to one in three people in America have constipation or have experienced constipation at some point in their lives. 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 three times a week. And for the other ones, it has been 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, really 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.
Lindsey:
So three times a week, I’ve got to 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 got to be missing, right?
Carmen Fong, MD:
Exactly. So I usually go by the rule of thumb that most people in the normal, average range, have one to three bowel movements every one to three days, right? So it’s like, if you’re within that range, you’re doing pretty well, but if you’re going less than three times a week, right? That’s every two or three 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 or medicines and stuff like that.
Lindsey:
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?
Carmen Fong, MD:
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 my household, so 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 two, and already she has this weird thing, and I don’t know where she got it from, like, being my kid, that she’s like, 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? Because I’m always like, hey, it’s normal. You got to 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 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 great lengths to not poop in public, right? So they will run to the next building so that they can go somewhere where nobody knows them. And all these things have been invented, like Poo-Pourri and a sound machine so that you basically extinguish the smell and sounds of having to poop.
Lindsey:
Yeah, I actually 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 . . . well she had to have overcome that obviously when she got married.
Carmen Fong, MD:
Yeah, exactly, yeah. And, what do you do when you get married? They’re going to find out that you poop.
Lindsey:
Yeah, if they didn’t know already!
Carmen Fong, MD:
Exactly, all right, yeah. It’s like there is 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.
Lindsey:
Yeah. So we’re going to get into diet and supplements and medications later, but let’s start with basic bathroom habits. What should people be doing with regard to using the bathroom, sitting on the toilet, etc., if they’re constipated?
Carmen Fong, MD:
Yeah, so everybody should be spending two to five minutes on the toilet, max. No more, like 10 minutes in the bathroom, 20 minutes in the bathroom, reading a book, scrolling through your phone. They actually used to say in the old days, like a 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, 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 in the bathroom, the more that pressure is causing swelling in your perineum and causing anal rectal problems like hemorrhoids, fissures and whatnot. So two to five minutes on the toilet, max.
The other issue that I commonly run into is itching, itching around the anus, pruritus ani, and this is usually caused by over-wiping, 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 really gently like it’s a baby’s butt, like you wouldn’t be scrubbing it so much if it were a baby, so don’t do that to your own butt.
Lindsey:
Yeah or get a bidet thing.
Carmen Fong, MD:
100% get the bidet. Christmas is in two weeks, and I’ve actually told a lot of my patients, get yourself a Christmas present. Get a bidet. That’s actually one of my 10 bowel commandments, “Bidet is the way”. In our country, we just do not use the bidet enough, I think. And it does take care of so many problems, and really does help with feeling clean afterwards. So you’re not avoiding the bathroom, because some people also have a little bit of poop avoidance and being like, I don’t want to go the bathroom because I want to pretend that I don’t poop.
Lindsey:
Yeah, 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.
Carmen Fong, MD:
Agreed, yes, 100% and that’s where I’m like, I love talking about the perfect stool. There is a perfect stool that is achievable. And if it’s so messy that you’re wiping eight times, it’s too sticky, you’re having too much fat or whatever.
Lindsey:
Yeah. What are the first line interventions for constipation, meaning the least potentially harmful and most potentially beneficial interventions?
Carmen Fong, MD:
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 fiber a day, and then two to three liters of water. So fiber wise, this was one of the reason 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 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 forms the gel in your colon, and then you have the skin, which is the insoluble part, the roughage, that 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, two to three liters, and they traditionally said about eight glasses a day, which is a lot for most people, but it’s going to be even more if you’re active, if you’re in a really warm climate, or if you’re pregnant, where you’re a circulating blood volume increases by about 40%.
Lindsey:
So I actually read in your book that for women it was less. It was something like 6.67 or . . .
Carmen Fong, MD:
Correct, yes. So it’s slightly less for women. So if you’re on the smaller female side, you can be on that lower side of 2.2 liters. I would still say, when I’ve seen pregnant women in the office, they should be closer to three liters.
Lindsey:
Yeah, drinking for two.
Carmen Fong, MD:
Exactly.
Lindsey:
Okay. And so for fiber you’re talking about through the diet, or you’re talking about supplemental fiber?
Carmen Fong, MD:
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, just some kind of a salad. I actually hate salads; that’s my secret. I really do not like salads, but I really like cooked vegetables, because I just think that you have to have so much lettuce for there to be an adequate amount of fiber.
Lindsey:
Yeah, it’s like an entire bowl is like a gram or two.
Carmen Fong, MD:
Exactly. So Iceberg lettuce really does not provide the fiber that you think you’re getting. And so I’m like, if you have to do cooked spinach, cooked kale, cooked broccoli, green leafy vegetables are always better. And then my go to whenever I recommend to my patients is actually sweet potatoes. So again, a 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 dieting or eating, but only protein shakes throughout the day, you actually don’t have the bulk to form a good stool.
Lindsey:
Yeah, I like to say beans, because those bang for your buck, you’re not going to get more fiber.
Carmen Fong, MD:
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.
Lindsey:
Yeah, they do. And I was shying away from them for various reasons. I started eating a lot more lately, and I soak them overnight, stick them in my Instapot for five minutes. They’re done. They’re ready to go. Keep them in the fridge. Just throw them on salads, make a soup, eat them as a side dish, whatever. I just did it, and I can’t tell you how much this transformed my stool.
Carmen Fong, MD:
100% like, I’ve had patients who are like, I just started eating lentils every day. And it does work.
Lindsey:
Yeah.
Carmen Fong, MD:
The other thing though, is that your body gets used to the gas.
Lindsey:
Oh yeah, there was no gas.
Carmen Fong, MD:
Yeah. Or, if you have a little bloating, your body actually adapts to it.
Lindsey:
Yeah, yeah, no, I had no gas at all when I started them, given that I was soaking them and doing it properly.
Carmen Fong, MD:
Yes, exactly, right. So you were already soaking off the starch, yeah.
Lindsey:
What about exercise and movement, how that relates to constipation?
Carmen Fong, MD:
Yeah, having some exercise is important. So I usually like the moderate activity level of 30 minutes three times a week is great. But what I do warn people, because 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. So basically, it’s a sympathetic response being like, hey, there’s a line. 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. So moderate exercise is good, but too little exercise, and you’re too sedentary, and you’re not simulating 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.
Lindsey:
I’m a personal fan of just moving around the house, doing the basic things like cooking and doing dishes. I don’t regret the time I spend doing those things, because that’s time that I’m not sitting on my butt.
Carmen Fong, MD:
Yeah, I love that. And it’s just me playing with the kids or being outside doing yard work, and even just taking a walk is totally enough. I’m not saying you have to go run five miles every day.
Lindsey:
Yeah. So if somebody just can’t seem to manage to get the fiber from their diet, are there supplemental fibers you like?
Carmen Fong, MD:
Yeah, I actually have a few that I like. And brand wise, there’s actually Coloflax*, which is a great one. It’s actually a flax seed 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, 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.
Lindsey:
Yeah, I like to send people to just plain psyllium husk, because Metamucil has additives, it’s got food coloring and stuff you don’t really need. The psyllium husk is gross, but it’s probably gross in Metamucil too.
Carmen Fong, MD:
It is gross in Metamucil, most people don’t like mixing it in water and having it turn into a gel. So I’m like, if you’re going to do that [take it in less water or as a powder], just drink two glasses of water after it. I love flax seed and psyllium husk. So both ground flax seed and psyllium husk, on top of salads and smoothies, works really well. Again. I think it’s pretty good bang for your buck.
Lindsey:
Yeah. And, of course, the flax, alpha linolenic acid. If you take enough of it, it’ll turn into your good omega threes, your EPA and your DHA.
Carmen Fong, MD:
The other one that I’ve heard is actually chia seeds, which is great, but having too much chia seeds can also be a problem. So I try to stay away from that. Because when you tell people one thing is good, they try to do a lot more of it.
Lindsey:
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?
Carmen Fong, MD:
Yeah, so this is always a good question. And technically, evidence wise, MiraLAX is the least harmful. It’s an osmotic laxative. So really, it just drawing water into your stool. In theory, you can take it long term without really negative effects. Obviously, people who have kidney problems, heart failure, 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 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 addictive potential, and so therefore those are ones that you would not want to use for long periods of time, generally, six months or more. If you’re using for the short term, once in a while, you’re like, on vacation, haven’t pooped in five days, and you really need something, sure. And in those cases, I would always try to do a suppository before you do something systemic, because 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.
Lindsey:
Would the suppository be a stool softener? Or what would that be?
Carmen Fong, MD:
No so you can actually do either a glycerin suppository, which has both stimulating and lubricating effects, or Dulcolax comes in a suppository.
Lindsey:
Ah okay.
Carmen Fong, MD:
So you can actually have a stimulant laxative as a suppository. And then last but not least, you have magnesium oxide, or 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 want to take those when you have electrolyte imbalances.
Lindsey:
Okay, yeah. And what about magnesium citrate, using that longer-term.
Carmen Fong, MD:
Same, yep. So you wouldn’t want to do that with an electrolyte imbalance. But people who can’t tolerate MiraLAX, you can use a bottle of magnesium citrate, and it’ll clear you out. Now, that’s different when you’re taking the concentrated bottle, versus if you’re taking a supplement, if you’re taking 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. 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 always loved it for sleep, for relaxation, and then for your bowel habits.
Lindsey:
Yeah I find that people are very successful with that. 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. How did you not hear about this?
Carmen Fong, MD:
Yeah, it’s really funny what people see and what people don’t see. Yeah, most of my patients have not heard of Natural Calm now that you mentioned it, yeah.
Lindsey:
How do you feel about vitamin C or using a vitamin C flush in particular, if you’re totally backed up.
Carmen Fong, MD:
So I think that vitamin C has potential, because we know that it has antioxidants that will help with simulating the rectum. I just don’t love flushes in general. So either a total cleanse, or a high colonic, you’re going to be disrupting some anal rectal mucosa. You’re going to be causing some mild trauma or injury. And then the problem with long-term use of these things is that it disrupts the microbiome and so you might have more problems in the future with irritation, with having mucus production and things like that.
Lindsey:
Yeah. So what does somebody do? If I’ve heard of clients who’ve said I went to the hospital and they said my entire colon is full, I’m just completely backed up. What do you do at that point?
Carmen Fong, MD:
Yeah. So say it’s that patient, it’s been like, nine 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, provided they can tolerate it and they’re just not vomiting everything back up. And then I would do Dulcolax suppositories times two, and then an enema. So then you’re going to do a short, rectal enema, usually just tap water or saline, and then 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.
Lindsey:
Okay, so this is when you’re getting intervention with a medical professional?
Carmen Fong, MD:
Exactly. Don’t disimpact yourself, please.
Lindsey:
Are there any probiotics that you recommend to patients who are constipated?
Carmen Fong, MD:
So I actually love and, based on my research, this was one of the most exciting areas for me, was that there are certain strains that work better than others: Lactobacillus, Bifidobacterium, L. casei, L. rhamnosus. But it’s funny, because 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 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, trunature one, and lately I’ve actually really liked the brand by Seed*, which is created by Emeran Mayer, 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.
Lindsey:
Yeah, I take that one, DS-01. Yeah, I can’t take it at night, though. I tried; they say to take it at night, and I felt all gurgly and uncomfortable when I took it at night. So I just take one with a meal. They’re also kind of expensive, so I just take one a day. I don’t go for two.
Carmen Fong, MD:
They are expensive, and I think part of it is the branding. But I’m hoping that in the future, we’re going to have a lot more of these probiotic strains that are 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.
Lindsey:
Patented ones.
Carmen Fong, MD:
Yeah, they’re patented combinations of strains. I feel like they probably shouldn’t do that, but, you know.
Lindsey:
Yeah, yeah, it would certainly make research better if there were patented combinations. But of course, if you’ve got the patent, you don’t want to sell it to everybody else. You just want to keep it.
Carmen Fong, MD:
Exactly but wider availability to the public.
Lindsey:
Yeah, I don’t know if they can. I guess they can patent them . . . if they’re just a natural substance, I don’t think they can be patented. You can’t patent a bacteria because you didn’t create it. If you genetically modify it, then you could.
Carmen Fong, MD:
Right, and then if you patent the certain combination, is what they’re doing.
Lindsey:
Although I do know that there’s definitely, maybe it’s a trademark. Yeah no, I think what they do is they trademark like PyloPass for H. pylori is trademarked, right, I think. But not patented.
Carmen Fong, MD:
That’s not patented, correct? Oh, interesting. Yeah.
Lindsey:
Anyway, so what about prescription medications for constipation? Which ones do you like the best?
Carmen Fong, MD:
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.
Lindsey:
What’s the brand name of Lubaprostin?
Carmen Fong, MD:
Lubiprostone is Amitizia, I think.
Lindsey:
Oh, okay. I hear people mentioning IBSrella.
Carmen Fong, MD:
Ibsrella. I actually don’t even think I’ve heard of that one.
Lindsey:
Or maybe it’s IBSrella, I don’t know.
Carmen Fong, MD:
IBSrella. A lot of people take Linzess.
Lindsey:
Linzess, yeah, that one I’ve heard a lot about.
Carmen Fong, MD:
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 then 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.
Lindsey:
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?
Carmen Fong, MD:
Yeah, yes. You know, that was the whole chapter in the book. And there’s technically no research that says coffee makes you poop. But there are certain compounds, the phenyls in coffee actually can simulate your GI tract motility. And there’s also the added effect of warm water stimulates better GI tract motility. And so I tell people, if coffee works for you and you drink one cup in the morning, or it’s a Pavlovian that you smell coffee and you immediately have to go the bathroom, then that’s great. But otherwise, if you’re drinking coffee, only coffee exclusively five times a day, and not drinking any water, it almost has, I call it a negative water effect. You’re minus one 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, one cup a day, if you can. We use it for both the simulating effects and the warm water effects of going to the bathroom. But you can’t drink only coffee, and can’t drink only iced coffee. But people would be like, Oh, I only drink iced coffee all day. And I’m like, There’s no nutrition in that. What do you think about coffee?
Lindsey:
I don’t drink coffee, so it’s not an issue for me. I just never was a coffee drinker. I never liked the taste.
Carmen Fong, MD:
Yeah, no. And I love green tea. And honestly, I think green tea is very good for you.
Lindsey:
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, yeah, so many good things.
Carmen Fong, MD:
Exactly, yeah.
Lindsey:
And I happen to have a cup of it every morning, so I’m like, yay for me. Okay, you mentioned that colonics and such might be bad for us. What about the colonoscopy prep? I always thought, I don’t want to get a colonoscopy because I’ve been working so hard on my microbiome, I don’t want to wash it all out. Is that dangerous to our microbiomes or do they recover?
Carmen Fong, MD:
They do recover. I’ve seen where sometimes it takes almost six 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 post colonoscopy prep syndrome that is starting to become more recognized. Because at first, people would 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 in your colon right? So if you can’t poop for two 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 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, allowing either soft foods or bland foods the day before, so you have some substance. There’s actually a brand called Happy Colon Foods. 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 stimulant laxative, but they allow you to have 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.
Lindsey:
Okay, good luck with that, with insurance and everything else, picking and choosing your doctor on the basis of the colonoscopy prep. But I love it in theory.
Carmen Fong, MD:
Yeah no, when I talked to them, it was actually a huge thing. I was like, if insurance doesn’t cover it, nobody’s going to 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.
Lindsey:
Yeah, so you might actually just disobey your doctor and go buy it on your own. Is it available over the counter?
Carmen Fong, MD:
Yes, you can buy it online. I think it’s 38 bucks. You can buy it online. And then what you can actually do, though, is tell your doctor and say, hey, are you okay with this prep? This is the evidence for it. I would allow it 100%.
Lindsey:
And what about using a colonoscopy prep if you’re totally backed up?
Carmen Fong, MD:
Yes, you can do that. So polyethylene glycol 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 four liters. So if you’re going to be drinking four liters of any fluid, you’re probably going to get cleaned out anyway. I would say, if you’re that backed up, you can try colonoscopy prep, but start with MiraLAX and just up the dose.
Lindsey:
So I have a confession to make. I had a colonoscopy about a year ago. Didn’t finish the prep stuff. I just I was like, listen, it’s been pure liquid for the last eight hours. I’m not taking any more of this. This is absurd. Yeah, no, and that was fine. It was totally clean.
Carmen Fong, MD:
Yeah, it’s really a lot. It’s actually a little bit of overkill. But when I was a fellow, I can’t tell you how many times people called me at 3 am being like, please, I cannot finish this prep. Like, I’m throwing it up, I’m pooping all over the place, and I’m like, It’s okay. Most of the time it’s going to be okay. Four liters is more than the amount you need, but they also make some better in divided doses now, like two bottles or something, and then you add some Gatorade in between. So there’s options, less torturous options.
Lindsey:
I did not tend towards the constipated, so I knew I was going to be fine. And I was like, this is the end. I’m done with this.
Carmen Fong, MD:
I wouldn’t think you were, that you tended toward constipated.
Lindsey:
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,
Carmen Fong, MD:
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, that 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. The other things that would distinguish it would be on an intenal exam, when I’m feeling and your sphincter tone is completely fine and there’s no signs of damage or whatever.
Lindsey:
Okay, so if you were having that and you weren’t constipated, then that would be the time to see a doctor and find out about your sphincter tone.
Carmen Fong, MD:
Yes ma’am, yep, exactly. So, the most telling thing is if you sneeze and you end up having an accident and or you’re having accidents at night.
Lindsey:
Okay? And what can one do about loose sphincter tone?
Carmen Fong, MD:
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 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 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 a sphincter tone and the nerves around it, to see if there’s really any damage that can be repaired.
And then, in the old days, you either would have to do a sphincteroplasty, which tightens the sphincter and/or some other 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 also works in constipation, and especially mixed constipation and incontinence.
Lindsey:
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?
Carmen Fong, MD:
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 a 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 over wiping. And so when people try to wipe the inside of the anus, it actually stretches that mucosa out a little bit. It causes mucosal atrophy. And since that pink layer is on the outside, you actually see more mucus on the outside. 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.
Lindsey:
Okay. And what about if somebody’s not done those things? Could it be just inflammation?
Carmen Fong, MD:
It could just be inflammation. 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.
Lindsey:
And what about, so often people are using biofilm busters, is that something that causes mucus to come out?
Carmen Fong, MD:
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.
Lindsey:
Okay, so what causes hemorrhoids and anal fissures and how are they treated?
Carmen Fong, MD:
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 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 intraabdominal pressure, or you’re putting more pressure on the perineum, will make those blood vessels engorge, to 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 seven or eight times a day. Sometimes people with IBS, they’re causing external hemorrhoid thrombosis, you’re tearing that skin in that blood vessel.
Fissures are the same thing, sitting for too often, more than two to five 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 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.
Lindsey:
Pregnancy for hemorrhoids.
Carmen Fong, MD:
Pregnancy! Yes, the gift that keeps on giving, pregnancy. Yes, for hemorrhoids.
Lindsey:
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?
Carmen Fong, MD:
You can actually go on your own these days, if you feel like this is something you need. A lot of places I’ve talked to, 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.
Lindsey:
What’s that?
Carmen Fong, MD:
Yeah, so levator ani syndrome is where you either feel pain in the butt when you’re having a bowel movement, or 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 a 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, some people will have what’s called a paradoxical contraction, where, over time, we were 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.
Lindsey:
Okay, so when should someone be concerned that their constipation could be indicative of something more serious, like cancer?
Carmen Fong, MD:
Yeah, it has to be a constellation of symptoms. And I would say that constipation, in and of itself, is not a great symptom. But if it’s been chronic, if it’s been over like three to six 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 thing, if you weren’t completely obstipated, would be blood in the stool.
Lindsey:
If you weren’t completely what?
Carmen Fong, MD:
Obstipated, so not passing gas either.
Lindsey:
Okay.
Carmen Fong, MD:
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.
Lindsey:
Yeah, and constipation is, in and of itself, a risk factor for cancer, right? Not just colon, but other cancers.
Carmen Fong, MD:
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 going to change. We know that 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 is a second factor, you have a good chance. I think our society’s diet and exercise does not help our cause at all.
Lindsey:
Yeah, no, I thought that it was a risk factor for breast cancer, because you just have these toxins sitting there and not getting out of the body.
Carmen Fong, MD:
Correct, yes, for breast cancer, it is. It’s not a direct risk factor for colon cancer, though.
Lindsey:
Okay.
Carmen Fong, MD:
Yeah, yeah. I know I’ve looked and looked because I really thought it would be and there’s no evidence for it.
Lindsey:
Okay, they changed the age that you’re recommended to do a colonoscopy to 45 didn’t they?
Carmen Fong, MD:
Yes, they did. Yep, it’s 45 now.
Lindsey:
What was that about?
Carmen Fong, MD:
So this was about, I think it was two or three years ago. Now, remember, it was just after COVID. It’s been about three years. It’s 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 that if your mom was diagnosed with cancer at the age of 45, you would go get screened at 35.
Lindsey:
Okay, and given you only get screened every 10 years, right, is it that it’s just super slow growing, or why so infrequently?
Carmen Fong, MD:
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 five years even, 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. They’re the fastest 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 a previous colonoscopy, you’re going to be three years before follow up screening, if you have three polyps. Five years for one or less polyps, and then usually between 5 and 10 years if you have a history of IBD. So 8 to 10 years of IBD is a high risk factor for developing colonic dysplasia.
Lindsey:
Okay, yeah, as I said, I didn’t really want to do the colonoscopy, so I did the Cologuard first, because I thought, I’ve never really been regularly constipated, so maybe just get away with this. And then I thought, okay, Lindsey, suck it up. You’re a gut health specialist. Just get your colonoscopy.
Carmen Fong, MD:
Was your Cologuard negative?
Lindsey:
Yeah, the Cologuard was negative, but I waited three years, and then I did the colonoscopy.
Carmen Fong, MD:
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.
Lindsey:
Yeah, but a poop sample. This is not a big intervention. That’s not a big ask. I’m not like, oh, I ruined that whole thing by getting the Cologuard.
Carmen Fong, MD:
I know, you know, what’s funny, though, is that I have sent Cologuards, and patients will be like, I do not want to 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 nine months. And I’m just like, can you please do it and send it in? Whereas, if I schedule a colonoscopy, you have to come in on this date and do a prep, they will come in and do it because there’s a deadline. Maybe I have to put a deadline on the Cologuards.
Lindsey:
Yeah, yeah. This will explode if you do not use it by this date.
Carmen Fong, MD:
Correct, yeah. They should put that on the box.
Lindsey:
Yeah, that’s true. No, my own husband, said he went through the Cologuard process, and he’d rather just do the colonoscopy the next time.
Carmen Fong, MD:
See? Yeah, people are like, I don’t want to put poop on my card.
Lindsey:
Yeah.
Carmen Fong, MD:
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 the stool-based 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 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.
Lindsey:
Yeah, yeah. Certainly no reason we should be getting colon cancer these days. 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.
Carmen Fong, MD:
Agreed. Yeah, yeah, 100%.
Lindsey:
So anything else you would like to share with my audience before we go?
Carmen Fong, MD:
Yeah, I think because this is called the Perfect Stool podcast, I’ve been thinking about it a lot; 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 two to five minutes, it’s out. 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 am 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 the microbiome. And then last, but not least, my one bowel commandment is go when you have to go and don’t go when you don’t have to go.
Lindsey:
Okay, great. And your book, I will just do quick show. I’ve got mine here, Constipation Nation.*
Carmen Fong, MD:
Did you like it?
Lindsey:
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, because I have a book club that’s been taking up my reading time. So I don’t have much time for work related reading.
Carmen Fong, MD:
I totally get it. I think it’s actually been doing pretty well on Amazon, but the only person I know who finished it is my dad. And actually, one of my patients told me she read the whole thing the other day because she was asking me really specific questions about my wife being pregnant. I was like, wait, how do you know that? And she was like, it’s in your book. And I was like, what?
Lindsey:
Yeah, that is unusual, because most people don’t know anything personal about their doctors.
Carmen Fong, MD:
Oh, I know it is weird, but also, 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 that’s how I wanted it to be.
Lindsey:
Yeah.
Carmen Fong, MD:
Yeah. Well, thank you so much for having me.
Lindsey:
Yeah. Thank you so much for being here. I really appreciate you sharing your knowledge.
If you’re dealing with gut health issues of any type (diarrhea, constipation, bloating, SIBO, IMO, H2S SIBO/ISO, IBS, IBD, gastritis, GERD, H pylori, diverticulitis, candida, etc.) or have an autoimmune disease and need some help, I see individual clients to help them resolve their digestive issues or reverse autoimmune disease naturally, You’re welcome to set up a free, 30-minute breakthrough session to see if you’d like to work with me. I also have my own two products, Tributyrin-Max, which is particularly helpful for loose stool and diarrhea as it slows your motility and firms up your stool, and SBI powder, which is an all around gut pathogen binder, which is super safe and won’t harm beneficial bacteria, and is usually the first line of treatment I educate my clients about in order to avoid stronger antimicrobial herbs.
*Product and dispensary links are affiliate links for which I’ll receive a commission. Thanks for your support of the podcast by using these links. As an Amazon Associate, I earn from qualifying purchases.
