Question: I would like to attach a copy of a report that I have received after a diagnostic Imaging-RF Proctogram-GI which I had on May 12, 2014 and am hoping that the next screen will help me to do that. In the meantime, let me outline my problem:

HISTORY
I first saw our family doctor as I had pain after intercourse (the length of pain-time increasing over a period of some 18 months or so before seeing him). Our doctor feared a prolapse and sent me to see Dr. Birch (see below). Then followed a series of tests plus appointments with different specialists as follows (throughout which time I have been successful in keeping my stools soft):
TESTS
•     November 26, 2012—Ultrasound (bladder)
•     December 6, 2012—CT-Scan (pelvis/abdomen)
•     January 3, 2013—Colonoscopy (had to be stopped halfway due to vitals dropping)
•     March 25, 2014—CT-Colonograph
•     May 12, 2014—RF-Proctogram
SPECIALISTS
•     March 4, 2014—Dr. XXXXXXX Birch (Gynaecologist, Prolapse Surgery)
•     April 9, 2014—Dr. XXXXXXX XXXXXXX (General Surgeon, specializing in the Colon)
• XXXXXXX 3, 2014—Dr. XXXXXXX Birch (Gynaecologist, Prolapse Surgery)
• XXXXXXX 20, 2014—Dr. XXXXXXX XXXXXXX (Laparoscopic Surgeon)
•     July 3, 2014—Dr. XXXXXXX Jarrell (Pain Specialist)
I am hoping also to be able to attach a list of my surgeries (the last one being in XXXXXXX of 2002). It would seem that none of the surgeons noted above are anxious to perform surgery on me. I have low blood pressure but I know not if that is the reason why.

My current problem is as follows:
BOWEL
1.     Four weeks prior to August 10, 2014, increased straining required to produce even soft stools
2.     Bowel movements incomplete
3.     As of August 10, no amount of straining will produce stools (only liquid stools and/or a few soft bits):
a.     August 10-13—frequent bowel urgency—unable to produce—abdominal cramps—bloating (temporary relief with Dicetel)
b.     August 13, pm—tried taking large quantity of prunes (natural laxative)—partial success—could only pass liquid stools—excessive bowel cramps
c.     Next 4 days—frequent bowel urgency—unable to produce—abdominal cramps—bloating (again, temporary relief with Dicetel)
d.     August 17, am—took 150 ml Magnesium Citrate—success—no bowel cramps—
liquid stools for 24 hours—straining still required to produce even liquid stools (i.e. flow of liquid stools stop when pausing to take a breath)
e.     August 19-21—frequent bowel urgency—abdominal cramps—bloating (temporary relief with Dicetel)
f.     August 21, pm—took 150 ml Magnesium Citrate—success—no bowel cramps but nauseous—liquid stools for 24 hours—straining still required to produce liquid stools
g.     August 23-25—frequent bowel urgency—few stools (thin and soft)—abdominal cramps—bloating (temporary relief with Dicetel)
h.     Straining now causing dizziness/light-headedness and exhaustion
4.     Pelvic floor pain immediately after passing stools which Dr. XXXXXXX (see above) believed was due to the rectal tear/fissure, which apparently is large although may be healing somewhat
5.     After bowel movements, pain in Rectum and Vagina (plus unpleasant open sensation in Vagina)
6.     Urination causes dull pain in both Vagina and in Rectum
BLADDER
1.     Recent weeks, bladder urgency
2.     Minor leakage on sneezing/coughing if needing Washroom
3.     Bladder stream intermittent (comes in stops and starts)
4.     Otherwise, no problems
OTHER PROBLEMS
1.     Hot Flashes throughout the day and waking me up at night
2.     Rectal tear
3.     Rectal tag
4.     Haemorrhoids
plus that which showed up on the Proctogram.

I have just come back from a further appointment with Dr. Birch (he has been away on vacation since early July and this was his first day back). I did not get to see him, but his nursing assistant. I have been waiting for a surgery date and was hoping that he would be able to provide me with one. However, instead, there will be no surgery date as I understand that Dr. Birch believes that surgery is not the answer. Apparently the prolapse is not that serious and he does not repair rectal tears. Dr. XXXXXXX (see above) does repair rectal tears but when he saw the results of the Proctogram, he arranged for his nurse to call me and tell me that he does not repair rectoceles or enteroceles; hence I went back to Dr. Birch.

My apologies for this lengthy message. I guess my main concern right now is how to produce stools. The nursing assistant at Dr. Birch's office said I should just continue to take the Magnesium Citrate seeing as that helps, but I know my own family doctor has already indicated that it is only a temporary solution. Unfortunately he is currently on vacation; hence my begging for your kind assistance not only with an immediate solution to the defecation problem but also I would greatly appreciate your all-round opinion as it what you believe would be a good long-term solution as Dr. Birch's nursing assistant said that I maybe should see a Gastroenterologist.
Thank you for taking the time to review my problem and to provide me with your valuable advice.
Yours sincerely, XXXXXXX XXXXXXX (Mrs)

Dr. XXXXXXX

Many thanks for your kind assistance. I didn't think to tell you about my diet when I first wrote my query, for which I apologize. It's possible that I am overdoing things with my diet so here's what I eat:

1) Ever since I had to start straining, I try to engineer my diet to keep the stools soft.
2) So I drink lots and lots of water, basically non-stop throughout the day, but mostly hot/warm water, although I maintain one glass of each and keep re-filling them both. Perhaps the hot/warm water is not good?
3) It's possible that I am eating too much fiber? For breakfast, I make a liquid shake of: 1 x Weetabix, 1 x ripe banana, 1 x other fruit, 2 tsp chia seeds, water and a tiny bit of milk. I sometimes add a sprinkling of instant coffee granules to the drink - possibly I shouldn't be doing that? For lunch I take a salad containing: lettuce, a sprinkling of cashew nuts, a few dried raisins, a tsp of Hellman's Olive Oil Mayonnaise, topped with a large quantity of Multi-Grain Cheerio's.
4) In between meals, I eat a satsuma orange or two.
5) For dinner, mostly a homemade soup of carrots, spinach, green beans, celery, a little potato/sweet potato, peas, and a handful of barley or some form of pasta. I usually make a big pot over the weekend which lasts us through the week. We don't eat much meat, just a little chicken now and then. We sometimes have a bowl of cooked oats for dinner.
I have to get ready for work right now but I would appreciate it if you could let me know where I can vary my diet. My stools are already very soft. Oh - and because I have low blood pressure, I drink just one coffee per day - just an inch of coffee topped up with hot water plus one cream.
Thanks again, XXXXXXX

Thanks again, Dr. XXXXXXX I have reviewed your recommendations in detail and will certainly go with them (will ask my doctor for the Xytocaine Ointment, probably only obtainable via prescription?). I should mention that I only drink filtered water and will avoid taking the mix of hot/cold, thank you. I already do a lot of brisk walking, at least 30 mns per day. I don't drink alcohol and I avoid all carbonated beverages, caffeinated beverages, and cookies.

In thinking over things today, two questions come to mind:

1) Could the posterior/anterior rectocele be pushing the sigmoid colon into the horizontal position?
2) If yes, would I require surgery to push the rectocele back into place?

Thank you for your patience in dealing with me.
XXXXXXX

Thanks for your further response, Dr. XXXXXXX I am still struggling to understand the problem, so forgive me for asking more questions.

First though, I would like to thank you very much for your earlier advice to increase my water intake and the vegetables. I spent the entire day yesterday (Tuesday) drinking filtered water non-stop (yes, even more than I do normally). My bowel started producing (soft formed stools) two or three times during the day and again after supper (vegetable soup) when the very soft stools turned into sheer liquid. I still had to strain every inch of the way - to produce both the soft and the liquid stools. There were no hard stools.

In looking over your latest reply, do I understand then that prolonged straining could produce a straightening of the angle and lead to bowel incontinence?

If I have understood that correctly, perhaps then the important issue is for me to avoid straining in order to prevent incontinence from occurring at a later date - would you agree? If yes, then perhaps we could further discuss my straining issue and try to find a solution.

Generally speaking, my stools are soft (either soft and formed, or mushy without formation). On the odd occasion, I have first produced a few very small hard bits followed by the soft stools. I am not sure why I went all those days without having a proper bowel movement recently, except perhaps, on looking back, we had an extremely busy time and obviously my water intake was not as good as usual. Also, we had been avoiding the soup for that period time as it was so hot over here. I guess if the stools had hardened I would not have known, as the magnesium citrate turned everything into mush and then liquid.

So back to the straining issue. Could there be any other cause for the straining, other than constipation (which may not be applicable in my case)? My youngest sister had a similar straining problem many years ago and it was discovered that during a prior surgery, a portion of her rectal wall had been stitched to the posterior perineum. However, in spite of all my surgeries, I have no knowledge of this having happened to me.

If we could maybe review the various things that can cause one to strain, perhaps we may hit on one that may be more applicable to my case?

Thanks again Doctor.
XXXXXXX

Dear XXXXXXX

Many thanks for your further response. I will certainly aim to abide by your suggestions. I should end our discussion here as I have already wasted plenty of your time. However, I had another thought today, and would like your comforting advice not to worry about it.

To put it simply, as best as I know how - imagine you have a very large, wide person who needs to get through a doorway. Obviously, one would open the door to its fullest extent, so that the person can pass through without injury. But what if the door were padded, so much so that the entrance-way would be reduced to a very narrow gateway. Would not the person have great difficulty squeezing through such a narrow opening, and would not that person have to heave and puff to make it through... no doubt with considerable discomfort and possible injury?

It would seem to me, in a similar vein, that my rectal tag and all of the other soft tissue that surrounds the rectal exit (not a rectal prolapse), are producing the same kind of difficulty that a large person would have trying to squeeze through a padded doorway.

Kind regards, XXXXXXX

Dr. XXXXXXX

Thanks again for taking the time to hear me out and provide me with your much appreciated good advice. I have taken next week off work (vacation time) so that I can implement your suggestions - and I have arranged an appointment with my doctor for a clinical examination of the anal fissure. Onward and up!

God bless you and thanks again,
XXXXXXX