Notes
Intermittent constipation is part of the human condition. Someone taking the occasional Milk of Magnesium, that's normal stuff
Pelvic floor contains of 3 different organs in women: a bladder, vagina, and rectum. Oddly, you can have 3 different doctors involved in the repair unless you've got a sub-specialist like a gynecologist who's done a fellowship in urology, or a urologist who has done a fellowship in gynecology.
As a general rule, if the front half of your body is falling out and you need a uro-gynecologist, a lot of times the back half is falling out; oftentimes the back half is what caused the front half to fall out because of this chronic constipation issue. So I like to intervene on patients with constipation even at a young age simply because the longer you have the crazy straining phenomenon, the more likely it is you're going to strain out your bladder and your vagina inside out with time and at some point in time you've destroyed everything and it cannot be fixed. Inly God can make this pelvis. Once you've made it that thin, and stretched out the nerves, and stretched out the muscles it's just surgically an impossibility to fix in the way that makes the patient happy in a way that makes them feel like they have normal function. Because that is the goal. So I like to intervene early and a lot of these older doctors will like to let you complain about constipation for 30 to 40 years, and meanwhile your pelvis is falling apart. So don't do that. If you've got any of those symptoms seek help sooner rather than later.
7:15. What does a normal workup look like? What do you do to build out . . . How am I going to fix this young lady?
THREE FORMS OF CONSTIPATION
The first thing that I like to do is this is like a board exam now the first thing that I like to do is meet the patient. Then tell me what you mean by constipation. A lot of people don't know this but there are three forms of constipation: one is you never have an urge to use the restroom. When I talk to the patients here's what I want to know are you someone who poops once every two weeks? Your butt does not know that you need to use the restroom it's your belly that gives a cue in other words you don't feel like you need to use the restroom. That's one form of constipation that may not be related to your pelvic floor at all.
The second form of constipation is where you have to really strain really hard to use the restroom. And no matter how hard you strain you just cannot empty your rectum. It's a vexing vexing problem to have.
And then the third form of constipation is actually stool consistency where you've got little bricks going through you. So you really do have to know you don't like what are we talking about here. Little bricks that's not a surgical problem. This really slow constipation Transit sometimes turns into a surgical problem but a lot of times you can medicate your way out of it. That's what this Trulance and Linzess is. That's the type of constipation that those medicines were designed for. It's the gymnastics on the toilet to empty your rectum that's not a Trulance, Lizness problem. And I know primary care doctors in gastroenterologists are giving that medicine for that type of constipation, and it's probably not the best approach. I'm not going to fault anybody for trying that but a lot of times that won't help. A lot of these people can't pass gas without the crazy gymnastics. It really can be quite a vexing problem.
9:27. So when patients have that blockage from the rectum obviously the first thing that I need to do is to look at your butt and prove that you don't have a cancer sitting there or a scarred down area some of these women have had babies and episiotomies some of these people have had hemorrhoid surgeries you kind of have to make sure there's no scar tissue, you know, that the hole is kind of normal. I usually start looking for things like how strong are the muscles, how good is the tone? Do they have a vaginal bulge? Are there any other organs that are falling out of place? I may or may not look you know do you have hemorrhoids? Some people with hemorrhoids will have similar complaints almost everyone with this form of constipation has hemorrhoids so a lot of these patients will come in with a hemorrhoid right they're not willing to tell people that they got the constipation thing they'll tell me that they have hemorrhoids. And then I'll look and I'll say well you have a lot more Brewing back here than just hemorrhoids there's no muscle tone anymore
10:27. That's the byproduct of you straining for 20 years.
Yes, exactly, and every now and then someone does have horrific hemorrhoids, and they won't give me the history of constipation. I'll ask them if they have constipation, but they won't tell me they've got the straining. I'll take them to the operating room to fix the hemorrhoids; in the process of fixing the hemorrhoids, holy smokes, like this person has an internal rectal prolapse, which is a surgical condition that I am looking for in these patients with their blockage scenario.
11:11. So how would Dr. Toker describe a hemorrhoid?
The issue is that with a patient who has an internal prolapse, that's a blockage. When someone has a rectum that wants to turn and twist inside out because of a series of hernias in the pelvis, those patients are strain, strain, strain. You can't see that in the office. There's no exam in the office that reveals, "Oh, my gosh this is an internal prolapse." An external prolapse I can see, everyone can see. When the rectum finally secedes and it will, turning all the way inside out, it's obvious to the world that once that happens that becomes hard to keep from rehappening after surgery. It's one of the reasons why I'm like look you got the hemorrhoids and constipation, let me see, let me make sure you don't have this one other condition. I'll fix it now while it's simple to fix before it becomes a problem. Every time I fix it, it's just going to come back in 6 months. So that's what I'm hoping to accomplish anyway. On exams, I will see actual hemorrhoids or I will see everything kind of looks normal except weak muscles. You can almost see the hernias in the bulging of the pelvis. They have what is called a "rocker bottom" defect, where the pelvis has this kind of rocker's bottom. These patients will also come in complaining of pain, heaviness, fullness. You've never been pregnant, Rob, but your audience will know. When you're pregnant, it feels like there's a bowling ball in your body. Who put the bowling ball in your body? I didn't expect that when I was pregnant with my first child. Like what is this sensation? It doesn't occur to you when you're young that, yeah, the baby has some weight. There's some weight there, and your body can feel it. So when your muscles are weak, all of your internal organs are trying to follow gravity.
13:15. That's weight, and the weaker the muscle are the more discomfort that causes. So some of those patients will come in, and no hemorrhoid complaints, no straining constipation complaints. They'll come in with, you know, I've just got this pelvic pain, this pressure pain, so all those are kind of constellations of symptoms that I find when I see that anatomy. The one test that can find that with definitive certainty is an x-ray. It's hard to find this x-ray. Not all doctors even know this x-ray exists. It's called a defecography. That sounds terrible. It's an x-ray of you pooping. That's right, I said it. It doesn't hurt. But it's weird okay, and I apologize to everyone before I send them for the X-ray. This is the weirdest thing anyone's ever done to you, okay. So just want you to know because you're going to be awake, and it's going to be odd, okay? So this is the X-ray. Should I tell people that? I might as well educate them, yeah, this is the answer. Before the X-ray you got to drink a bunch of bowel prep, like Miralax.
GOOD DESCRIPTION OF COLON AND PELVIS, REQUIREMENTS, LIMITATIONS.
22:00. Women need collagen because their large pelvis, compared to a mans, has to afford space for a baby's head. With age you lose musculature, you lose tone. So now you have all this muscular turn tone that's been filling the pelvis holding everything at bay and that disappears and so it becomes like a deep bowl, like a spaghetti bowl and you've got this . . . the way to imagine a uterus flopped in the middle of this bowl now it sinks to the bottom of the bowl. And the colon is not a rigid structure. It's a flexible structure, like a piece of spaghetti. So if you put one piece of spaghetti in a bowl, it'll just go to the bottom of the bowl into a coil.
