Coloproctology (COLON CANCER + BUTT FUN) with Carmen Fong

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• Colorectal surgeons (like Dr. Carmen Fong) differ from gastroenterologists in that they perform abdominal operations and focus more on anal-rectal procedures, whereas GIs focus on advanced endoscopy.  Copied to clipboard!
• Sitting on the toilet for extended periods while scrolling is contributing to a rise in hemorrhoids among younger populations.  Copied to clipboard!
• Regular rectal bleeding, even if painless, should not be ignored and warrants a medical evaluation, as it is a key symptom that needs checking, especially given the rise in early-onset colorectal cancer.  Copied to clipboard!
• Routine douching is unnecessary for cleanliness before anal activity, as a good fiber diet typically suffices to clear the rectal vault.  Copied to clipboard!
• Bidets are strongly recommended for improving anal health by reducing irritation and issues caused by excessive wiping, and they connect to clean water supplies.  Copied to clipboard!
• Sharp shooting rectal pain, known as Proctaljafugax, is often a muscle spasm in the pelvic floor, which can be exacerbated by chronic clenching.  Copied to clipboard!

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Surgeon Training and Specialties

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(00:03:31)

• Key Takeaway: Colorectal surgeons perform abdominal operations and focus on true proctology (anal-rectal procedures), unlike GIs who focus on advanced endoscopy.
• Summary: Colorectal surgeons and gastroenterologists have similar training lengths, but surgeons handle more abdominal operations. A key difference is that colorectal surgeons perform extensive anal-rectal work, which constitutes true proctology. Gastroenterologists primarily focus on endoscopic procedures, though they also perform colonoscopies.

Abdominal Anatomy Visualization

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(00:06:53)

• Key Takeaway: The intestines resemble empty tube socks within the abdomen, while solid organs are compared to very squishy dough.
• Summary: During abdominal surgery, intestines are temporarily moved aside and allowed to naturally settle back into place due to gravity when the patient stands. The colon is described as being shaped like a boxy horseshoe, with sections named ascending, transverse, and descending. Empty bowels deflate and settle in the pelvis when the patient has not eaten.

Foreign Body Extractions

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(00:10:05)

• Key Takeaway: Colorectal surgeons frequently remove foreign objects from the rectum, with common items including dildos, candles, and even glass lamp globes.
• Summary: Dr. Fong confirmed removing various foreign bodies, citing a memorable case involving a pink highlighter. Removal of smooth, round objects like a glass globe required specialized tools like a ‘divor’ retractor after suction failed. All such extractions are performed while the patient is sedated for safety.

Butt Plug Safety PSA

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(00:12:26)

• Key Takeaway: Butt plugs must always have a handle or a base to ensure they can be safely retrieved.
• Summary: A public service announcement was issued regarding the safety of anal toys. It is critical that any object inserted anally possesses a handle or a base. This prevents the object from becoming lodged and requiring emergency surgical removal.

Sphincter Function and Control

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(00:13:07)

• Key Takeaway: The external anal sphincter is voluntary, while the internal anal sphincter is involuntary and utilizes a ‘rare response’ to differentiate gas from stool.
• Summary: Sphincters are round muscles that close openings, found throughout the body, including the anus and along the intestines to separate chambers. The internal sphincter uses a reflex to discern gas from solid matter, allowing farts to pass while retaining stool. Hirschsprung’s disease involves non-functioning sensory nerves in the lower bowel, preventing the body from recognizing when to release waste.

Hemorrhoid Types and Causes

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(00:17:38)

• Key Takeaway: Internal hemorrhoids cause painless bleeding, while external hemorrhoids cause pain and appear as bluish-purplish lumps on the skin.
• Summary: Hemorrhoids are classified based on their location relative to the dentate line: internal ones are above it (painless, may prolapse) and external ones are at or below it (painful, palpable). Anal fissures, often mistaken for hemorrhoids, are tears at the dentate line causing sharp, paper-cut-like pain and bleeding. Sitting on the toilet for long periods while scrolling is a confirmed factor increasing hemorrhoid incidence in younger people.

Hemorrhoid Treatment Options

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(00:20:41)

• Key Takeaway: Compound ointments containing muscle relaxants like nitroglycerin are superior to over-the-counter treatments like Preparation H for treating hemorrhoids and anal spasms.
• Summary: Preparation H may temporarily shrink vessels but can thin the skin over time, leading to worsening symptoms; it is humorously noted as only being good for puffy eyes. Compound ointments treat both sphincter spasm and swollen vessels via ingredients like nitroglycerin and calcium channel blockers. Botox injections into the internal anal sphincter are highly effective (85-88%) for treating painful anal fissures by relaxing the muscle.

Rectal Bleeding Guidelines

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(00:26:38)

• Key Takeaway: If rectal bleeding is provoked (e.g., after straining), it often stops within two to three days, but any unprovoked or recurring bleeding requires immediate medical investigation.
• Summary: Approximately 89-90% of rectal bleeding is due to anal or hemorrhoidal disease, but any bleeding warrants checking, especially with rising early-onset colorectal cancer rates. Unprovoked bleeding should always be checked out promptly. If bleeding is self-limited and stops after a few days following a known trigger, it is less alarming.

Colon Cancer Screening and Stages

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(00:28:04)

• Key Takeaway: The recommended screening age for colonoscopies is now 45, but cancer is increasingly diagnosed in people in their 20s and 30s, making diagnostic colonoscopies crucial when symptoms arise.
• Summary: Screening colonoscopies are performed when asymptomatic to remove precancerous polyps, while diagnostic colonoscopies are performed when symptoms like bloating or bleeding are present. Stage zero cancer is a precancerous polyp, while Stage four means the cancer has spread to distant organs like the liver or brain. Avoiding colon cancer is highly preventable through screening, which is described as a ‘cakewalk’ compared to cancer treatment.

Ostomy Destigmatization

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(00:30:03)

• Key Takeaway: An ostomy, a life-saving detour for waste leaving the body, should be destigmatized as it is a necessary intervention for severe conditions like cancer or diverticular disease.
• Summary: An ostomy creates a new opening in the abdomen for waste to exit into a sealed pouch, which can be temporary or permanent. While not a desired outcome, it can be life-saving when the lower intestines require removal or rest due to disease. Online creators are actively showing that living with an ostomy is manageable.

Constipation Causes and Frequency

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(00:42:44)

• Key Takeaway: Normal bowel movement frequency ranges from one to three times per day to every three days, often triggered by the Migrating Motor Complex (MMC) sweeping the gut after meals.
• Summary: Constipation is often functional, resulting from a mix of physiology, diet, activity, and electrolyte balance. The MMC, or migrating motor complex, is the sweeping action that moves waste through the gut, often causing a bowel movement shortly after a large meal. Fiber intake should be 25-35 grams daily, requiring adequate water intake to prevent it from forming ‘concrete’.

Fiber Dosing and Bezoars

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(00:46:14)

• Key Takeaway: Fiber intake must be increased gradually (e.g., by 5 grams weekly) to avoid bloating, and excessive fiber intake can lead to the formation of a bezoar (a hard, indigestible mass).
• Summary: Psyllium husk (Metamucil) is highlighted as an effective soluble fiber supplement, but it must be consumed with large amounts of water to move through the system. Bezoars, which can be formed from undigested material like excessive fiber, are hard masses that sometimes require surgical removal. Fecaliths, or ‘poop rocks,’ can also block the appendix, causing appendicitis.

Douching and Anal Hygiene

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(00:54:01)

• Key Takeaway: Douching is unnecessary for being ‘bottom-ready,’ as a high-fiber diet cleanses the rectum sufficiently, and excessive douching or enemas can damage the mucosal lining and flush out beneficial gut bacteria.
• Summary: The average human rectum is only four to five inches long, and after a normal bowel movement, this final chamber is generally clean. Repeatedly flushing the colon with large volumes of water, as done in colon hydrotherapy or excessive enemas, risks mucosal injury and perforation. Washing out the beneficial microbiome disrupts regularity, similar to the temporary effect of a colonoscopy prep.

Douche Dependence and Rectal Vault

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(00:54:18)

• Key Takeaway: The rectal vault is the final, small portion of the rectum that needs to be clean, and a good fiber diet is sufficient preparation.
• Summary: Routine douching is unnecessary, as the average human rectum is four to eight inches long, and the final eight centimeters (the rectal vault) should be clean after a normal bowel movement. Sharp-tipped douching devices or shower head attachments can cause fissures or hot water injuries. The A-ball, a hydrogel product, is mentioned as an innovation to temporarily block the sigmoid colon/rectosigmoid junction to prevent unexpected bowel movements before sex.

Anal Sex Safety and Hygiene

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(00:56:05)

• Key Takeaway: Anal sex requires ample lubrication and slow progression, potentially using a butt plug first to relax the area.
• Summary: For those butt-curious, using lots of lube and going slow is advised, possibly incorporating a butt plug beforehand. Frequent washing of the immediate anus with soap destroys the natural anal microbiome, leading to pruritus ani (itchy anus). Gentle rinsing with warm water and fingertips is sufficient for the immediate anal area, though soap on the surrounding crack and cheeks is acceptable.

Bidet Benefits and Wipes Danger

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(01:02:21)

• Key Takeaway: Bidets are highly recommended for improving anal health by preventing issues caused by over-wiping, and flushable wipes cause severe plumbing issues like Fatbergs.
• Summary: Bidets are considered essential for improving anal health, reducing hemorrhoids and fissures caused by excessive wiping; they use clean water, debunking old UTI concerns. Users should ensure the spray pressure is directed externally, not internally like an enema. ‘Flushable’ wipes should be avoided as they contribute to massive sewer blockages known as Fatbergs.

Squatty Potty Efficacy and Travel Constipation

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(01:06:33)

• Key Takeaway: Squatty Potties are helpful for 10-50% of people by adjusting the anorectal angle, but limiting toilet time to 2-5 minutes is more crucial.
• Summary: Squatting angles are naturally ideal for defecation, but stools only benefit a minority of people by altering the anal rectal angle. Spending too long on the toilet (over five minutes) suggests the stool is either not ready or too hard, necessitating movement and reattempting later. Travel constipation is a trifecta of dehydration, poor diet, and stress, which inhibits digestion via the fight-or-flight response.

Period Pain and Pelvic Floor Spasms

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(01:09:14)

• Key Takeaway: Period-related bowel changes stem from hormonal fluid absorption shifts, while sharp rectal pain is often Proctaljafugax, a pelvic muscle spasm.
• Summary: Hormonal increases in estrogen and progesterone during menstruation increase water absorption in the colon, potentially causing both constipation and diarrhea. Sharp shooting pain, Proctaljafugax, is a muscle spasm, common in women who hold stress in the pelvis, causing the muscles to clench until they spasm.

Pregnancy, Delivery, and Fistula Repair

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(01:11:15)

• Key Takeaway: Obstetric anal sphincter injuries (third/fourth degree tears) involving the anus can lead to rectovaginal fistulas requiring surgical repair if not healed within six months.
• Summary: Pregnancy worsens constipation and hemorrhoids due to hormones and increased abdominal girth compressing the pelvis. True obstetric injuries involving the anus (third/fourth degree tears) can create abnormal tunnels (fistulas) between the rectum and vagina, causing gas or stool leakage. If inflammation doesn’t resolve in six months, colorectal surgeons can repair fistulas using sutures or advancement flaps.

Prostate Massage and Fart Odor/Sound

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(01:13:04)

• Key Takeaway: Prostate massage can be done via the anus to stimulate the P-spot, but excessive stimulation may cause chronic prostatitis, and fart sound is related to butt cheek size, not hair removal.
• Summary: The prostate, located anterior to the rectum, can be massaged through the anus or externally via the perineum (taint/gooch) for potential orgasm. Over-massage can lead to burning during urination or ejaculation, warranting a urologist visit. Fart loudness is primarily determined by the size and clapping of the butt cheeks, while anal hair primarily traps odor rather than affecting sound.

Endometriosis in the Rectum

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(01:15:52)

• Key Takeaway: Endometrial implants can uninvitedly grow in the rectum, causing severe pain, bleeding, and painful bowel movements, often requiring surgical removal by a colorectal surgeon.
• Summary: Endometriosis involves uterine-like tissue growing outside the uterus, which can implant in the rectum, causing excruciating pain, especially around menstruation. Diagnosis averages nearly a decade, and symptoms include severe period pain, pain during sex, and painful bowel movements. Colorectal surgeons remove these implants, often coordinating with gynecologic surgeons in the operating room.

Diarrhea Heat and IBD vs IBS

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(01:18:31)

• Key Takeaway: Diarrhea feels hot due to inflammation and the natural warmth of bile acids, and IBD (autoimmune) is distinct from IBS (functional disorder).
• Summary: The heat felt during diarrhea is caused by inflammation irritating the tissue and the warmth of the exiting bile acid. Explosive diarrhea up to three times daily can be normal, often linked to gas-producing foods like broccoli or certain drugs like metformin. Inflammatory Bowel Disease (IBD, like Crohn’s) is autoimmune and chronic, requiring medication or surgery, whereas Irritable Bowel Syndrome (IBS) is a diagnosis of exclusion related to abdominal hypersensitivity and microbiome changes.

Buttload Volume and Job Realities

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(01:22:01)

• Key Takeaway: A ‘buttload’ is an archaic volume measurement equivalent to about 120 gallons, and the toughest part of colorectal surgery is diagnostic uncertainty, not dealing with graphic patient photos.
• Summary: A hogshead cask holds about 80 gallons, making a ‘butt’ (500 liters) approximately 120 gallons, and the stopper for a barrel is called a bung, creating a bunghole. The most challenging aspect of being a colorectal surgeon is the inability to solve a medical mystery, rather than the graphic nature of the work. The favorite part of the job is relieving patient embarrassment and encouraging earlier help-seeking, especially to catch cancer early.