209. Booty Problems and Hernias

This week, the topic of discussion was: 

• Anus
• Anorectal disorders
• Constipation 
• Hemorrhoids
• Anal fissure
• Anal pain
• Rectal pain
• Pelvic floor spasm
• Anal hygiene
• Anal skin tags
• Colonoscopy
• Diverticula

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh, call +1-310-358-5020 or email info@beverlyhillsherniacenter.com.

Guest: Dr Talar Tejirian, Surgeon and Founder of BootyMD

If you find this content informative, please LIKE, SHARE, and SUBSCRIBE to the HerniaTalk Live channel and visit us on www.HerniaTalk.com.

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Transcript

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Dr. Shirin Towfigh (00:00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m your host, Dr. Shirin Towfigh. Many of you are joining me on Facebook on my Beverly Hills Hernia Center page. Thank you for joining me. We’re here for your questions, so you can also follow me on Instagram at Hernia Doc. And if you want to see what I do on my academic side where most doctors follow me, you can go on X where I am also at Hernia Doc. And remember, if you love to listen to podcasts or if you want to catch up on episodes, I am on all of your podcast stations, apple, Spotify, et cetera. And you can watch these videos on YouTube or up to 200 and something episodes. So really excited. We’ve had some really, really great downloads, and please do like and share in that way more people can be able to see us. So I’m super excited because I’ve been asking this friend of mine to be on as a guest for many years. Her name is Dr Talar Tejirian, and she’s a surgeon and founder of Booty md. You can follow her at Booty MD on Instagram. And if you’re into TikTok, I highly recommend that you also visit her on TikTok. She is going viral, and I’m super excited that she’s a guest today because we’re going to talk about everything. Booty. Hi, how are you?

Dr. Talar Tejirian (00:01:39):
Good. Well, thanks for having me on.

Dr. Shirin Towfigh (00:01:43):
Thank you so much. So someone sent a text saying, what do you mean by booty and hernias? You want to explain your why you use the word booty.

Dr. Talar Tejirian (00:01:54):
Well, for booty, I use that word instead of the technical term, which is what? Which is

Dr. Shirin Towfigh (00:02:01):
Anus. Yeah. No one likes the word anus.

Dr. Talar Tejirian (00:02:05):
Yeah. Medically speaking, anus is the word that’s in the anatomy textbooks. I mean, that is the anatomical medical language that we use for the part of the body that passes stool. That’s what it’s called. It’s called an anus. Now, people are uncomfortable with that word, and people are even more uncomfortable when you turn the word anus into an adjective, right?

Dr. Shirin Towfigh (00:02:33):
Like anal.

Dr. Talar Tejirian (00:02:35):
Anal, right? Anal, technically speaking is an adjective, right? Anal pain, anal itching

Dr. Shirin Towfigh (00:02:45):
Or anal rectal, they use that sometimes.

Dr. Talar Tejirian (00:02:48):
But in society, or I guess, I don’t know what the word is, it’s become a verb, right? The adjective has become

Dr. Shirin Towfigh (00:02:57):
Verb to be.

Dr. Talar Tejirian (00:03:00):
So the word has changed a little bit and people are uncomfortable with that word. And really people are uncomfortable about talking about any private parts. True, true per se. So there’s no good word of making people comfortable yet talking about that specific part of the body.

Dr. Shirin Towfigh (00:03:21):
And I feel like that’s been the impetus for Booty md because you’re an educational forum, right?

Dr. Talar Tejirian (00:03:29):
Yes. Booty MD is really a nonprofit organization, and the reason why I came up with it was because it was almost 10 years ago, I met a local health reporter, the Channel seven health reporter from over here in LA abc. I told her, you need to do a story about people and their problems of their anus. There’s a lot of problems. No one talks about it. There’s so much misinformation out there. I just see patients suffering every single day. Patient after patient with poor information suffering for years, scared to come out, you should do story on it,

Dr. Shirin Towfigh (00:04:11):
Which is why we’re doing this podcast. But go ahead.

Dr. Talar Tejirian (00:04:14):
So she came out, well, she said, I need to record you. And I said, I don’t want to be on tv, but she’s like, you need to be in the actual show, but you have to give two topics. So I said, okay, my two things that I do, I do hernias, proctology, like booty problems. So she came out, she recorded both of them and they aired the hernia one right away, but no one allowed her to air the one about the booty hole problems. No way. And I watched what she did, she produced it very well. And then I said, what’s the problem? She said, number one, you can’t say the word anus. I said, what do you want me to call it? What do you want me to say? She’s like, well, we’ll say rectum. I said, but that’s not the same thing.

Dr. Shirin Towfigh (00:05:02):
Yeah, explain that there’s a difference between anus and rectum.

Dr. Talar Tejirian (00:05:06):
Yeah. So anus is the last part. The part that passes stool and rectum is the higher part that holds the stool before you pass it as a simple definition. So you can’t call the anus, the rectum, they’re different body parts

Dr. Shirin Towfigh (00:05:22):
And they have different diseases.

Dr. Talar Tejirian (00:05:24):
Yeah, different everything. So as a physician, a surgeon, a proctologist, whatever you want to call me, I’m not going to use the wrong word when I’m education. So at that point I realized we need a different word. People were comfortable with the term booty. So we went with the term booty, and then I decided that I need to do this education however I can because the information needs to be out there. And not only is the public not educated about booty hole problems, but physicians aren’t because think about how much time you spent in medical school or anything learning about it, little to none. It’s a very misunderstood part of the body. And because of that, people suffer.

Dr. Shirin Towfigh (00:06:13):
So one of the questions posed was, I don’t understand why you’re talking about, because our topic is booties and hernias. You’re a hernia surgeon and you’re a booty specialist. So you understand how the two connect.

Dr. Talar Tejirian (00:06:25):
Yes. I mean, they can connect in a lot of ways because number one, they’re sort of in the general vicinity. They’re both, a lot of hernias are closer down to the pelvis area and the booty hole is down there. So when people have problems, oftentimes it could be vague and they could just feel problems down there and they’re not sure what they’re feeling. So that’s one

Dr. Shirin Towfigh (00:06:50):
Down there. Yeah, I hear the word down there.

Dr. Talar Tejirian (00:06:56):
The other point is people are embarrassed to talk about it because again, it’s in a sensitive part of the body, whether it’s a hernia or booty hole problems. And there’s a lot of other things that are connected, like constipation and hernias are connected a lot. Things like you can have pelvic floor spasm that can be either pelvic pain or anal rectal pain, different things like that.

Dr. Shirin Towfigh (00:07:23):
Yeah, that’s so true. There’s already a question up here. It says, is there a difference between the rectum and the sigmoid rectum, or I guess some people call it rectal sigmoid.

Dr. Talar Tejirian (00:07:32):
So the sigmoid is the last part of the large intestine, and then it becomes the rectum, and then there’s the rectal sigmoid junction where they connect, and then it goes down into the anus. So I have my netter anatomy book. I should probably bust that out and bring it. It’s holding up my computer right now.

Dr. Shirin Towfigh (00:07:57):
So I would say when they talk about cancers, right, there’s a difference between sigmoid cancers and rectal cancers, and the treatment is different. So the sigmoid is just above the rectum, but sometimes they loop it all as like rectal sigmoid, because diverticulitis, you can have include the rectum and the sigmoid, but that’s distinctly different from the anus because anal cancers are different. You get anal fistulas, anal skin disorders, anal skin tags, hemorrhoids are part of the anus. Is that correct?

Dr. Talar Tejirian (00:08:32):
Correct. Yes. They’re normal. Part of the hemorrhoidal tissue is normal anatomy. Now, when hemorrhoidal tissue acts up, that’s when it becomes a

Dr. Shirin Towfigh (00:08:42):
Problem.

Dr. Talar Tejirian (00:08:44):
But actually everyone has hemorrhoidal tissue. That’s part.

Dr. Shirin Towfigh (00:08:48):
Okay. So the things I’d love to learn from you related to our patient’s needs, which are mostly hernia related. One is talk about all the anal or pelvic disorders that I don’t treat that maybe you treat that are related to pelvic pain or groin pain, et cetera. And then the second one is how is it that, are there diseases where if you have a hernia, you’re more likely to have an anal disorder and vice versa? And then what are some treatable problems that affect the anal disorder that can help reduce or reduce your risk of getting hernias? And then the last thing I really want you to tell me or educate our patients is how to prevent, whether it’s post-op, pre-op, all the anal disorders you can prevent as a hernia patient.

Dr. Talar Tejirian (00:09:43):
Alright, so I don’t know where to start. That’s so much. Let’s start with the most common anal problems that people have, and then we can move on to the rest. Great. So most commonly, when someone has a problem in their booty hole area, all they think about is, I have hemorrhoids, right? But then we have to think, what is the problem? Do you have pain? Do you have bleeding? Do you have itching? Is something sticking out? These are all important things to think about when you have an issue about it. So if you have a problem down there, don’t think automatically, I have hemorrhoids say, what am I feeling right now? Because that’s going to help figure out what problem you have. Now, one of the most common problems actually, that’s not talked about too often, that causes a lot of pain and discomfort for people. And also bleeding are anal fissures. Fissures.

(00:10:43):
Fissures. Yeah. I talk about this a lot because it’s mistaken for hemorrhoids very commonly. And it’s because people have pain and bleeding, which often people think about as hemorrhoids, and they’re very hard to see on exams sometimes, especially because when someone’s having pain, they’re clenching. And what a fissure is, is that it’s a cut in the anal area and it happens from passing a hard stool or anything that stretches the anus. And then you get a cut in there, it could hurt terribly. You can have bleeding because it’s cutting, and you can also have spasm because now you’ve hurt yourself. So that muscle is spasming and then it spasms, you clench, and then that clenching then makes the cycle worse. So it’s a big problem. They’re often hard to see on exam unless you’re looking very closely or you know what you’re looking at. And sometimes when you have a fissure, you get a little piece of skin right next to it. And people often mistaken that as a hemorrhoid. And it’s not. It’s a little skin tag. We call it a sentinel tag next to the fissure. And that’s just from that irritation and that cut being there,

Dr. Shirin Towfigh (00:12:08):
I feel like it’s so easy just cause call hemorrhoids, and then most doctors don’t even examine. They just ask questions like, okay, so here’s some hemorrhoidal cream or

Dr. Talar Tejirian (00:12:24):
Yeah, are you supposed to use hemorrhoidal cream? Don’t get me started on that. I know. So one of the biggest problems that I see amongst medical practice is that physicians prescribe steroid creams for anal complaints.

Dr. Shirin Towfigh (00:12:43):
Is that preparation? H

Dr. Talar Tejirian (00:12:44):
No. Steroid creams are like hydrocortisone or different things like that, but prescription.

(00:12:51):
And they have names like proctor, whatever. There’s no reason to prescribe a steroid cream for, let’s say you have a fissure. A fissure is a cut. The last thing you want to do is put a steroid cream that impairs healing. Or if someone has itching, they’ll give a steroid cream to it and then it thins out and irritates the area. So steroids should only be used for a very, very small select problems, and most people should not be getting it. So this is a big part of the education that I’ve done for physicians, which is don’t prescribe steroids. But you’re correct. The exam is not always easy, especially in a regular exam table because in our proctology clinics, we have a special exam table. You go to the gynecologist, they have special exam tables because you’re looking at a midline structure. So you need to be able to see it in the proper way, especially when someone is in pain and they’re clenching. I think exams are, and people are uncomfortable showing their booty holes to even doctors. So yeah, that’s true. Shy away from wanting to get examined. Anyway, so that’s why there’s a big misdiagnosis of problems. And that’s also very common, being misdiagnosed. So that’s very common. Anal fissures.

Dr. Shirin Towfigh (00:14:17):
What’s the preparation H then

Dr. Talar Tejirian (00:14:22):
It’s like rich hazel. Why don’t we talk about that now? Okay, so preparation H in my opinion is a placebo. Okay,

Dr. Shirin Towfigh (00:14:30):
No way.

Dr. Talar Tejirian (00:14:32):
So the active ingredient is standard preparation. H is phenylephrine, and rine is

Dr. Shirin Towfigh (00:14:40):
Cough syrup.

Dr. Talar Tejirian (00:14:41):
Yes. And when you’ve been sick, have you taken phenylephrine versus have you tried the two?

Dr. Shirin Towfigh (00:14:53):
I don’t even know what the difference is.

Dr. Talar Tejirian (00:14:54):
Okay, well, I’m going to tell you it’s very different. So pseudoephedrine is the real pseudo fed that was available before they started limiting pseudo ephedrine because people were making methamphetamines with it, right? So right now, for you to get pseudoephedrine, you have to go and ask for it behind the counter and show your id. You can get it, but it’s limited. So what they put outside now is phenylephrine. It doesn’t work when you have a stuffy nose. Let me be quite honest, I’ve tried both of them when I’ve been sick. So phenylephrine, even when you swallow it as a pill, does nothing. Now in that cream, they’re putting, I think, don’t quote me on this, 0.1% or some tiny amount of phenyl, and then that’s the active ingredients. It doesn’t do

Dr. Shirin Towfigh (00:15:44):
Anything. Is it just a cleansing cream then?

Dr. Talar Tejirian (00:15:48):
It’s not even a cleansing cream. It’s this yellow horrible smelling thing that I just wouldn’t use ever. It

Dr. Shirin Towfigh (00:15:56):
Makes so much money.

Dr. Talar Tejirian (00:15:57):
Yes, I know. It’s just something that I would never recommend to patients. And

Dr. Shirin Towfigh (00:16:03):
What about the tux pads?

Dr. Talar Tejirian (00:16:06):
I think the tux pads are witch hazel.

Dr. Shirin Towfigh (00:16:09):
Witch hazel. Yeah.

Dr. Talar Tejirian (00:16:10):
Yeah. So that’s just a cleansing pad. It’s fine. Some people find it too. It’s

Dr. Shirin Towfigh (00:16:13):
Astringent.

Dr. Talar Tejirian (00:16:15):
Yeah, I think some people like it, some people don’t. I think it’s, it’s neither here or there as far as I’m concerned. But anyway, we’re going sort of into the weeds.

Dr. Shirin Towfigh (00:16:27):
Sorry. These are all questions I’ve been wanting to ask you for years.

Dr. Talar Tejirian (00:16:31):
The problem is I could talk about this for five hours, so you got to stop me because I feel very passionate about this topic. So then we have hemorrhoids, right?

Dr. Shirin Towfigh (00:16:44):
Okay.

Dr. Talar Tejirian (00:16:45):
So hemorrhoidal tissue, that’s part of our normal bodies. It can cause you problems in two categories. Number one, you can have internal hemorrhoidal problems, which are bleeding. When your internal hemorrhoids bleed, it does not hurt. It’s painless bleeding.

(00:17:05):
So if you have pain and bleeding, don’t think that you have hemorrhoids. So that’s number one. Number two, you can have external hemorrhoid problems, which is like a blood clot, like a little marble that shows up at the outside of the booty hole. You feel that? That’s called a thrombo, external hemorrhoid. It really hurts. You feel this marble out there, and usually it’s worse in the first 72 hours and then it goes away. So usually that does not have bleeding with it. So the reason why I’m saying this is that if you have pain and bleeding, you have to think more along the lines of, is this a fissure? And if you have painless bleeding, you think internal hemorrhoids and you just have pain with a marble on the outside, you think thrombo, external hemorrhoid, right? So that’s the, I

Dr. Shirin Towfigh (00:17:58):
Feel like that’s so confusing. Most family doctors aren’t going to be able to figure that out.

Dr. Talar Tejirian (00:18:04):
I mean, it’s pretty simple, right? I can draw it out on a diagram I’ve written. I was the senior author on a paper about this called Anal Healthcare Basics.

Dr. Shirin Towfigh (00:18:15):
Anal what?

Dr. Talar Tejirian (00:18:16):
Anal Healthcare Basics. Oh yeah. It’s in

Dr. Shirin Towfigh (00:18:19):
PubMed. Anyone just watch it, read it?

Dr. Talar Tejirian (00:18:22):
Yeah, you just under in. Actually, if you type in Google anal healthcare basics, it should pop up hopefully as the first thing.

Dr. Shirin Towfigh (00:18:31):
And

Dr. Talar Tejirian (00:18:31):
You could read it and you have, there’s pictures and everything on there. It’s meant for physicians, but it’s easy enough to read where everyone could read it. So these are the most common things that I would talk about. And any kind of spasm down there, anything that causes pain is going to make you spasm.

Dr. Shirin Towfigh (00:18:50):
And

Dr. Talar Tejirian (00:18:51):
That spasm can also spread and be like pain in your pelvis in general. You might not just feel

Dr. Shirin Towfigh (00:18:56):
It down there. I feel like sometimes what happens is patients will have, let’s say, hernia surgery and then not by me, I don’t prescribe narcotics. I know it’s not a friend of hernias, but it’s common for doctors to give narcotics, actually any surgery, but let’s say hernia surgery and then afterwards like, oh, I saw blood in my stool, or I have rectal, sorry, anal pain or something. So if it were fine and they just have this, is it good to assume, oh, they just probably have hemorrhoids or That’s hard to,

Dr. Talar Tejirian (00:19:37):
Well,

Dr. Shirin Towfigh (00:19:38):
And then what do you do about it?

Dr. Talar Tejirian (00:19:39):
As we know, the opioids, or even if you don’t have opioids postoperatively, sometimes the anesthesiologist gives it to you during the operation. You’re also commonly dehydrated because let’s say you haven’t been eating or drinking or different things like that. So it’s very common to have constipation after surgery. Now the problem is that often when you have that constipation, and if you’re taking opioids like Vicodin or Norco, it’s going to make you even more constipated. The problem is that you need to, the regular stuff that you try for constipation is not strong enough to combat this opioid post-surgical constipation that you have

Dr. Shirin Towfigh (00:20:28):
Coase that never works.

Dr. Talar Tejirian (00:20:30):
Yeah, coase, otherwise known as Docusate, is one of the most commonly prescribed medications for constipation.

Dr. Shirin Towfigh (00:20:38):
And

Dr. Talar Tejirian (00:20:38):
There’s zero evidence that it works. Zero evidence. I’m going to put this out in your podcast too. If anyone could produce one article, quality article that shows that Colase works, I will send you a present because it does not exist. Coase does not work. And then they give you colase and people are taking this medication and they’re like, I’m still constipated. I don’t know what to do. And then the problem becomes, let’s say you don’t poop for two, three days right after surgery. What happens at the first part of the poop? That first part is a rock. That rock has to come out. So the rest of the stuff comes out. That rock coming out can tear your anus,

Dr. Shirin Towfigh (00:21:25):
And

Dr. Talar Tejirian (00:21:25):
Then you’re going to get a fissure on top of the pain that you have from your surgery. And then now you have anal pain, bleeding, likely from a fissure. You have to pass that rock. That’s that stool. So my laxatives, right? So there’s stool softeners, which is what we talked about. The colase or

Dr. Shirin Towfigh (00:21:48):
Yeah, no, no, not helpful.

Dr. Talar Tejirian (00:21:50):
Not helpful. But laxatives, those could be helpful after surgery.

Dr. Shirin Towfigh (00:21:55):
So I tell my patients, especially those I really don’t either have a tendency or they had a big operation, I give them milk, magnesia, MiraLax, and sometimes mineral oil, all the m’s. Is that good or bad?

Dr. Talar Tejirian (00:22:10):
I think that’s a pretty good combination that you give them. Do you tell them to take it in a specific order or However?

Dr. Shirin Towfigh (00:22:19):
I usually start with milk and magnesia two or three times a day. Most people don’t mind the taste of it, and it’s mild. If they need more, I give ’em MiraLax once a day. And then most people don’t like mineral oils. That’s my third choice. But some people prefer mineral oil, so just take a tablespoon with a meal.

Dr. Talar Tejirian (00:22:38):
Yeah, I think that’s pretty good because milk and magnesia is a good laxative, and if they take it early on, it’s going to prevent that little rock forming, that little rock hard stool forming at the end. So that’s going to be really great. It’s also acts like a, it acts a little bit as a stimulant. So milk magnesia, magnesium in many forms is good. MiraLax in my mind is almost like a manmade fiber. That’s how I think of it. So I don’t think it’s strong enough to combat postoperative constipation or constipation of those medications. It doesn’t hurt, but I think by itself, it’s just not enough. And mineral oil is like a lubricant, so I think it’s fine for temporary basis. The problem with people that use it all the time, it can coat your lining and prevent you from absorbing the minerals in your food or the nutrients in your food. Sorry, I should

Dr. Shirin Towfigh (00:23:43):
Say, what about sna? Some people love Sena, but other people feel really bloated and crampy with it.

Dr. Talar Tejirian (00:23:50):
Senna and dulcolax are both stimulant laxatives. I think they are good to fight the postoperative constipation, and that’s because the medication you get makes your colon lazy, right? The opioids, they stop your colon from working, and the Senna and the dulcolax, they stimulate your colon. But yes, it can cause cramping because it’s stimulating it, right?

Dr. Shirin Towfigh (00:24:22):
There’s sent a tea as well, right?

Dr. Talar Tejirian (00:24:26):
Yes, it’s the same thing. It’s the same thing. The problem is you don’t know how much you’re getting in the tea, right? You don’t know how much, and any of these laxatives, you don’t want to use that.

Dr. Shirin Towfigh (00:24:38):
But I know you’re a big fan of foods that are naturally high in fiber. So I’ll just give you my little story that other people don’t know. When I had my, I think it was the first time I needed surgery, it was for my neck, and Dr. Tejirian here, she got me a goodies bag, and it had everything you need to prevent constipation. It included thick newtons and I don’t know, did you have dates or kiwi or something? And then she even had, she had butt cream. She had definitely fiber and some fiber crackers I’m sure had there lidocaine cream, I think for the butt. I don’t know what she thought I was going to end up doing, but it was the cutest, most thoughtful goodie bag for my postoperative constipation prevention.

Dr. Talar Tejirian (00:25:42):
I hate it when patients suffer unnecessarily. So the times that I think about it is postoperative patients suffer, and you know who else suffers? Women that just gave birth. There’s this level of suffering that is unnecessary because we have stuff out there that helps you. Why are we tortured? Just use it for that time being, get through that tough period and stop suffering with it. You know what I’m saying? Not only that, but even women during their menstrual cycle, there’s times where they’re constipated and it’s very common during that time for them every month to get a fissure. A fissure, why are we suffering? Let’s use what we have at our disposal. The other thing I want to talk about that people are scared of are enemas. Can we talk about enemas?

Dr. Shirin Towfigh (00:26:35):
Okay. So from a lay person, I know of two types of enemas. There’s a fleets enema, you can buy it from the store. And then there’s what we call a tap water enema. And when we were residents we’re told to order soap suds, enemas, and there were some people that were used to always giving themselves enemas, which I thought was not normal. But I’m taught instead of pushing from above, below, you’re pushing cleaning out from below.

Dr. Talar Tejirian (00:27:11):
So the best time that an enema works is when you have that rock that I talked about. You haven’t been to the bathroom, you just had hernia surgery.

Dr. Shirin Towfigh (00:27:20):
You

Dr. Talar Tejirian (00:27:21):
Haven’t pooped in three days. You have this little rock at the end, no matter what you put up top, it’s not going to break up the rock, right? Sitting right here at the anus. So you got to go from the bottom to break this up, and the most common one is the fleet’s enema that you’re talking about.

Dr. Shirin Towfigh (00:27:43):
It’s easy. You just buy it.

Dr. Talar Tejirian (00:27:46):
I wish I had a sample so I could show people how to use it. I have a sample in my closet, but I don’t want to go get it. So basically, and it’s basically pushes liquid up there just to break up that rock. That’s pretty much what it’s doing. It has a little bit of a stimulant effect when it’s that fleet’s enema, but they also make mineral oil enemas. They actually sell that too. That seems

Dr. Shirin Towfigh (00:28:17):
Messy

Dr. Talar Tejirian (00:28:18):
Configuration. It doesn’t work as well because the higher the volume you put in there, the better it’s going to break things up. And the mineral oil is not as high volume, but honestly, they even make enema containers and you could just fill warm water and it’s fine. Now, the thing that I would tell patients is that when you read the instructions on the fleet’s enema, it looks scary. I look at it, I was like, what are these positions that people have to be in to use this enema? It is crazy. They’re like, you have to lay down with your leg. It’s like acrobatics to get it in. You don’t have to do that. Why are the instructions like this? It’s like you have to just lubricate it a little more and just squat down a little bit. And for women, I tell them it’s like using a tampon, but a little further back. You don’t get into a weird position. No woman lays down on their side, whatever to get a tampon and you don’t need to.

Dr. Shirin Towfigh (00:29:27):
Maybe the legal, the lawyers got involved.

Dr. Talar Tejirian (00:29:30):
Yeah, I have to show you one day I wish I brought it from my cabinet so I could show you now. But anyways, it’s not necessary. It’s not scary. It doesn’t hurt, and people are afraid of putting things up there, but it’s really thin. Yeah,

Dr. Shirin Towfigh (00:29:46):
Soft tip. Yeah.

Dr. Talar Tejirian (00:29:47):
Yeah. Once you relax, it is just fine. It really helps prevent that first part of a hard stool, and then it just prevents so many problems later on.

Dr. Shirin Towfigh (00:30:00):
So if someone’s preparing for surgery, any surgery, honestly, we’re talking about hernia surgery, should they just go buy a fleece enema or wait, or

Dr. Talar Tejirian (00:30:12):
I think if they’re normally not constipated, it’s probably not necessary because especially because we don’t really prevent people from eating. We don’t do the old school only do liquids for 72 hours. We’re not doing those things. So they could be eating their fiber, having their water beforehand. I think it’s only later and not everyone’s body is going to get constipated.

Dr. Shirin Towfigh (00:30:41):
That’s

Dr. Talar Tejirian (00:30:41):
Another thing. Everyone’s body reacts differently. It is so individual. So I don’t think I can make a blanket statement about anything. You have to see how your body reacts.

Dr. Shirin Towfigh (00:30:51):
And I know you’re a big fan of the natural way of preventing constipation, whether it’s around the time of surgery or in your daily life. As we know, constipation is the number one cause of hernias that is treatable, especially in the United States. But what are some tips about dietary changes or natural ways to prevent constipation?

Dr. Talar Tejirian (00:31:20):
I think a lot of people have heard that we recommend, or the recommendation is 25 to 35 grams of fiber a day. When you look at what that is, it’s not all that much. If you’re eating whole foods, natural foods, and the more the food looks like it came from nature, the more fiber it’s going to have. So if an apple looks like an apple, it’s going to have a good amount of fiber. If an apple turns into apple juice, it’s going to have little to no fiber in it. So the food has to look like it came from nature for you to maximize the fiber that you are going to get from it. So if you’re eating a lot of vegetables, a lot of fruits, some grains, things like that, and drinking a good amount of water, typically you will get a good amount of fiber in it. Now, the problem is a lot of people don’t because it’s the culture that we live in, the society that we live in, we eat a lot of packaged foods that takes the fiber out of foods, or they put in these weird kind of aftermarket fibers, I call them. Even in the hospital, I look on patients’ trays sometimes what they’re having, and someone had apple juice that they had supplemented with corn fiber in the apple juice. Why are we making this product? You’re extracting fiber from corn and then putting it in apple juice, whereas if you eat an apple,

Dr. Shirin Towfigh (00:32:59):
Apple would be better. Yeah,

Dr. Talar Tejirian (00:33:00):
It’s giving you enough.

Dr. Shirin Towfigh (00:33:02):
And

Dr. Talar Tejirian (00:33:02):
There’s fiber supplements that are sold that are not necessarily great, and some of them are really great, some of them aren’t. For example, fiber pills I think are a super waste of money.

Dr. Shirin Towfigh (00:33:16):
Really? Yeah.

Dr. Talar Tejirian (00:33:17):
Fiber pills are normally, there’s something called cilium husk fiber. You’ve heard of cilium husk, like it’s stuff in Metamucil, except Metamucil mixes it with orange chemicals. So if you’re going to take cilium husk fiber, just get the pure natural cilium husk. You don’t need the orange chemicals with it. They take that and then they put it into pills, and they put half a gram of fiber in a pill. Now if you think

Dr. Shirin Towfigh (00:33:50):
Half a gram, half a gram,

Dr. Talar Tejirian (00:33:51):
So it says 500 milligrams if you look on the label. Oh wow. You’re right. Yeah. So if an apple has five grams of fiber, you have to swallow 10 of those fiber pills to equal the amount of fiber in an apple.

Dr. Shirin Towfigh (00:34:08):
That’s crazy.

Dr. Talar Tejirian (00:34:09):
Yeah,

Dr. Shirin Towfigh (00:34:12):
I didn’t know that. Oh my god. Wow.

Dr. Talar Tejirian (00:34:15):
It’s sort of when you start to read labels and look deeply into it, you’re like, what are we doing? Because if we just eat good natural foods, we’re going to get fiber in a lot of ways. And there are good ways of supplementing fiber too, like the cilium husk fiber. There’s other kind of powders that are good natural fibers you can add to your food. That’s fine

Dr. Shirin Towfigh (00:34:38):
Too. Chia. Yeah, chia seeds I heard are really high in fiber, and those are the ones you can leave overnight and they become really tasty, right?

Dr. Talar Tejirian (00:34:47):
Yes. It can give you a little gas in the beginning. So if you’re going to ramp up on your fiber, you want to start slowly and go up on it, because if you go from zero to 50 grams of fiber,

Dr. Shirin Towfigh (00:34:59):
You’re going

Dr. Talar Tejirian (00:35:00):
To be really bloated.

Dr. Shirin Towfigh (00:35:04):
I heard kiwis have a lot of fiber. Is it blueberries?

Dr. Talar Tejirian (00:35:12):
Blueberries, raspberries have a

Dr. Shirin Towfigh (00:35:13):
Lot of raspberries. Yeah. I didn’t think berries would have fiber, but I guess berries have fiber

Dr. Talar Tejirian (00:35:21):
Plus they have so many other amazing nutrients.

Dr. Shirin Towfigh (00:35:23):
Yeah,

Dr. Talar Tejirian (00:35:25):
Green leafy vegetables a great way of getting fiber.

Dr. Shirin Towfigh (00:35:30):
Yeah. All the salads, I assume.

Dr. Talar Tejirian (00:35:32):
Yeah. And then the more you mix in, the better combination that you’re getting, the better it is for you. Anything that takes a long time to chew, basically.

Dr. Shirin Towfigh (00:35:43):
Okay. Here’s a question. What is the correct way to insert a rectal suppository? And are there any dangers to using such as anal erosion?

Dr. Talar Tejirian (00:35:54):
So suppositories, I guess the question is what is it being used for? If it’s being used for constipation, the question is using that versus an enema. So as far as I’m concerned, if you need something from below to break up the hard rock stool and enema, iss going to work better. Hands down,

Dr. Shirin Towfigh (00:36:21):
You can try this. There’s a doco suppository and there’s the glycerin suppository, right?

Dr. Talar Tejirian (00:36:26):
Yeah. You can try them, but for it to break up that hard stool and enema is going to work better. The suppository is just sitting in the anal canal, right? So it’s just sitting

Dr. Shirin Towfigh (00:36:38):
Doesn’t go up higher

Dr. Talar Tejirian (00:36:39):
Unless you push it up, which is hard for people to do. But again, a correct way is to put lubrication on it. Anything that could make it slippery and just relax and it shouldn’t hurt you. That’s the main thing. Don’t do anything that hurts. If it hurts, you need to stop. And it could be hurting because you’re clenching.

Dr. Shirin Towfigh (00:37:02):
That’s

Dr. Talar Tejirian (00:37:03):
Often very common. The clenching could make it hurt or it could be hurting. Something’s wrong down there and you need to see a doctor and get an exam.

Dr. Shirin Towfigh (00:37:11):
Got it. So I learned this suppository for pelvic floor spasm. That’s compounded, and it includes, let me get this right, Baclofen, ketamine and Valium. I believe these three ingredients, and it works really well for pelvic floor spasm.

Dr. Talar Tejirian (00:37:32):
Yes.

Dr. Shirin Towfigh (00:37:32):
But there’s no risk of anal erosion, right?

Dr. Talar Tejirian (00:37:34):
No. No. I’ve never heard of that being a problem. Never heard. I mean, because whatever you put in there is going to dissolve. Erosion would happen if something is in there for a long time and just causing that

Dr. Shirin Towfigh (00:37:46):
Pressure to happen. Here’s another question. Can you describe the quality and location of the pain associated with pelvic floor spasm? Is it aching, burning, sharp, stabbing, or burning?

Dr. Talar Tejirian (00:38:00):
Yeah, it could be any of those things. Interesting, because pelvic floor spasm goes into multiple categories. So there’s the stuff I deal with more, and then there’s the stuff you deal with more. So if the pelvic floor spasm is coming from something like the muscles of the pelvic floor around the rectal area, the levator ani syndrome, that feels like a dull kind of aching pain that can be chronic and last a long time. Then there’s proctalgia that can be sharp, just lasting a few seconds, those kinds of pain. And then there’s a spasm associated with the anal fissures. And that usually is worse while you’re having a bowel movement or while you’re clenching. Or for some people, it’s like when you’re stressed, some people get migraines, some people get abdominal pain. Some people clench their pelvic floor or their anal area and they get pelvic floor spasm or they get fissures. So I tell a lot of my patients, it’s like maybe your cousin gets migraines. This is what you have when you’re stressed out. So we got to learn how to rely.

Dr. Shirin Towfigh (00:39:23):
I did not know that because they’re definitely a class of people that are just prone to pelvic floor spasm, and it’s just so hard to treat them. Some of ’em get Botox in the pelvic floor. They get complications related to the suppository and all that. I would say related to what I do, I have learned that hernias can cause pelvic floor spasm. You fix the hernia and the pelvic floor spasm goes away. And I learned that because I would have patients that would have hernias and at the same time had lots of pelvic floor physical therapy for pelvic floor spasms. And as a side effect of the pelvic floor spasm, they would have urinary frequency because the urethra goes through that pelvic floor muscle that’s spasming. Or they’ll have pudendal neuralgia because the pudendal nerves go through the pelvic floor muscle that’s spasming, but then you fix the, or they get anal rectal anal pain.

Dr. Talar Tejirian (00:40:31):
Well, it could both could get all nervous around you depending on where they’re getting the spasm.

Dr. Shirin Towfigh (00:40:37):
Yeah, anal rectal pain. And then you fix the hernia and all those downstream side effects eventually go away because the pelvic floor spasm goes away. So they don’t need to see the urologist anymore. They don’t need to see the proctologist anymore. They don’t see the gynecologist or neurologist because the hernia repair fixed everything. And I started seeing this pattern. So we’re trying to get that kind of out there to teach people that hernias can cause pelvic floor spasm.

Dr. Talar Tejirian (00:41:07):
The problem is that it’s such a complex area. The pelvis is such a complex area, and it’s complex for everyone. And when you don’t see an obvious cause, you look on exam, you don’t see anything. You get imaging, you don’t see anything. And the problem is that a lot of radiologists are not as focused on these nuances that you, when you’re looking at hernias, right?

Dr. Shirin Towfigh (00:41:35):
Yeah.

Dr. Talar Tejirian (00:41:36):
And as surgeons, we’re not trained in looking at MRIs. You are obviously knowledgeable about that, but most are not. They’re difficult exams to look at. So it becomes frustrating for the surgeon. It becomes frustrating for the patient. We can’t find it. That’s why it’s amazing to have people that have this specialty knowledge like you do, right?

Dr. Shirin Towfigh (00:42:01):
Yeah. Yeah. But it’s because you just see the same thing over and over again. I didn’t learn this in medical school.

Dr. Talar Tejirian (00:42:06):
Yeah. Yeah.

Dr. Shirin Towfigh (00:42:07):
I have a great question for you. It says, I have done a colonoscopy and hemorrhoids were found. What shall I do? And what kind of treatments are available?

Dr. Talar Tejirian (00:42:17):
Alright, so I love this question. Thank you for asking it. Okay, I’m getting ready to answer What I think about,

Dr. Shirin Towfigh (00:42:24):
That’s pretty common actually, that you do colonoscopy like Oh yeah. Finding hemorrhoid

Dr. Talar Tejirian (00:42:29):
Everyone. Okay, let me tell you why. What do you do right before you have a colonoscopy?

Dr. Shirin Towfigh (00:42:36):
Bowel prep.

Dr. Talar Tejirian (00:42:37):
Bowel prep, right? You’re drinking, you’re pooping 500 times. You’re sitting on the toilet. That’s what makes the hemorrhoidal tissue swell up sitting on the toilet, the gravity. And when you’re spending the entire day before colonoscopy on the toilet, your hemorrhoidal tissue is going to be swollen. I mean, it’s

Dr. Shirin Towfigh (00:43:02):
Veins, it’s just basically, it’s like varicose veins of the

Dr. Talar Tejirian (00:43:05):
Yeah, it’s an tissue and it’s tissue and its veins and it’s going to swell when you sit in any position where your anus is hanging. So if you sit on a donut, it’s going to swell. Don’t sit on donuts,

Dr. Shirin Towfigh (00:43:23):
Don’t sit on donuts,

Dr. Talar Tejirian (00:43:24):
Don’t sit on donuts, please. But you’re prepping the day before you’re sitting on the toilet almost the entire day. Of course your hemorrhoidal tissue is going to swell up. So it’s a very common finding on colonoscopy because you’ve been bowel prepping the day before. To me as a surgeon, that finding means nothing. Okay? The question is, are you having any symptoms? Right? Are you having any kind of painless bleeding? Are you having those thrombosis, external hemorrhoids? Do you have skin tags? What is the issue? So that’s one thing. The second thing I want to tell everyone is that a colonoscopy never takes the place of a proper examination of your anus. If you’re having problems of the anus, the colonoscopy is not enough. When they do colonoscopy, they are not looking in depth at it. They’re looking at the rest of your colon. So if you have problems of the the booty hole, you got to get an examination of the booty hole.

Dr. Shirin Towfigh (00:44:36):
Well, oftentimes they stick the, not to be gross about this, but they stick the tip of the scope through the anus part, and then they start looking. So they stick that in. Then they start looking through the whole colon, including the rectum. But I mean, I’m sure there are great gastroenterologists that also examine the anus, but a colonoscopy in and of itself is not meant to do a good anal exam. It’s a rectum and above, which is why the terms are important.

Dr. Talar Tejirian (00:45:07):
Exactly. And plus, they often just look at the anus from the outside, but they’re in the stark room, you’re on your side. It’s not an ideal position at all. And I have to be honest, I don’t want to scare people, but the number of misdiagnosis of cancer, anal cancer for hemorrhoids is astounding. And it’s because people are not getting exams. It’s because just assume problems are hemorrhoids. So the main thing is don’t assume you have hemorrhoids, get a good exam. Your doctor needs to have looked at many booty holes to be able to give a good exam. That’s the main thing that I could say about it, because it’s not something that is practiced commonly unless you’re doing it all the time.

Dr. Shirin Towfigh (00:46:02):
Yeah. Read another question, but it’s a hernia question. It says, one surgeon said that the mesh complication will occur in the groin on average at four years. Is this correct? That makes no sense.

Dr. Talar Tejirian (00:46:19):
I can even answer that.

Dr. Shirin Towfigh (00:46:23):
That is not correct. Correct. So I would say the hernia recurrences can occur around maybe average four years, but actual mesh complication occurs shortly after you place the mesh. Because if it’s folded, it happens early. It doesn’t happen years later if it’s infected. Very uncommon. But that’s either an early pro happens early as well, and other things are not mesh complications like nerve injuries and I guess inflammation from the mesh. That also occurs early. Even the mesh and platinum illness, which is super rare, also occurs early. So if you don’t have a complication from your hernia in the first, I would say several months to a year, it’s not a mesh related complication, it’s a hernia recurrence. The stuff that happens later is usually a recurrence. Any thoughts or comments about that?

Dr. Talar Tejirian (00:47:22):
I was just thinking and tell me if I’m correct. For hernia repair, a lot of the problems are blamed on the mesh, right?

Dr. Shirin Towfigh (00:47:32):
Yes, all the time.

Dr. Talar Tejirian (00:47:33):
It’s the same as for the anus. A lot of the problems are blamed on hemorrhoids.

Dr. Shirin Towfigh (00:47:38):
There you go.

Dr. Talar Tejirian (00:47:39):
And I think we could both say that neither of those statements are true,

Dr. Shirin Towfigh (00:47:43):
Right? That’s true. That’s true.

Dr. Talar Tejirian (00:47:45):
It’s very nuanced and you need to get to the bottom of it to be able to treat patients, to be able to treat patients properly and to give them the care that they need.

Dr. Shirin Towfigh (00:48:00):
Okay, here’s another question. Hi doctors. Are you able to speak about the butt slash hip pain from hernia surgery piriformis slash quadratus femoral area Booty is fine. Sorry if I’m off topic. LOL. So in other words, butt and hip pain from hernia surgery. I would say hernias can cause pain reading around to the lower back, but it doesn’t technically cause hip pain or butt pain. That’s usually a hip disorder problem,

Dr. Talar Tejirian (00:48:42):
Or are you talking about groin hernia?

Dr. Shirin Towfigh (00:48:45):
Yeah, if you have groin hernia, you can have pain radiate to your lower back from a groin hernia, but technically not the buttock. The buttock is usually a hip disorder that cause actual buttock pain or it’s like a spine problem.

Dr. Talar Tejirian (00:48:59):
Could it be situation where the hernia repair has nothing to do with the, I think the question was after hernia repair, right?

Dr. Shirin Towfigh (00:49:10):
Yeah, I think you’re right. I think sometimes people have a hernia, so it’s obviously like the hemorrhoid, right? But that’s not the reason for their pain. They have a hip disorder or a spine disorder that’s causing their butt or hip pain, and then they see a doctor who says, oh, it’s your hernia. I can see this big bulge in my face. And then they get distracted to getting hernia surgery, and it’s not the hernia after all. I hope I answered that correctly. I don’t know if that was the intention of the question. Okay. So here’s another, so the same person asked about the four years of mesh complication said mesh will degrade over time after being implanted in the body. Is that correct? Not really. This is why I worry about hernia mesh. Is there a best hernia mesh available? So there’s no clinically relevant degradation of mesh in the body. We did have surgeons that explanted meshes for whatever reason, and then looked at that mesh. Bruce Ramshaw being a classic surgeon who did that one of our previous guests, and then looked at that mesh under the microscope. And if you look at it under the microscope, you can see some meshes in some patients. So not all patients and not all meshes.

(00:50:30):
The fiber wasn’t perfect. It had a little bit of flaring. We don’t really call it mesh degradation. It’s still the same mesh, just microscopically. It looks different. And what they notice is that same product in a different patient will look totally normal. So it’s unclear how each patient, it’s unpredictable how each patient can react to a mesh, but no. So degradation over time of mesh is not any issue we ever talk about with hernia surgery. It’s not something a patient should worry themselves about. Right?

Dr. Talar Tejirian (00:51:11):
Unless the surgeon is using one of those meshes that absorbs, are they

Dr. Shirin Towfigh (00:51:17):
Dispose to degrade?

Dr. Talar Tejirian (00:51:18):
Yeah. Yeah. I guess unless it’s specifically about that.

Dr. Shirin Towfigh (00:51:23):
And then the question is, is there a best hernia mesh available?

Dr. Talar Tejirian (00:51:27):
Oh, I’m going to defer to you on that one. But I would imagine that the answer not yet.

Dr. Shirin Towfigh (00:51:38):
Not yet. Everything has pros and cons.

Dr. Talar Tejirian (00:51:40):
Yeah, individual you have to pick based on the individual, right?

Dr. Shirin Towfigh (00:51:46):
Yeah. I mean you can prefer certain meshes over others for that tailored care, right? So some larger hernias and heavier weight meshes, some really small hernias may not need any meshes. So there’s a variety, variety of options. But do we have the perfect hernia mesh right now? I would say no. We can still improve everything about our mesh implants.

Dr. Talar Tejirian (00:52:15):
Yeah.

Dr. Shirin Towfigh (00:52:15):
Okay. Going back to the patient that talked about the hip and butt pain, they’re wondering if you can have potential nerve entrapment in the AL area from the mesh that then causes butt or hip pain? I would still say no to that because the only nerves you can cause entrapment if it’s an open repair is the ileal hypogastric nerve, maybe the genital femoral nerve. None of those cause hip or butt pain. You can have pain rating to your lower back, but not lower because it’s an L one L two, so it’s an upper lumbar. And then robotically, you can have lateral femoral cutaneous nerve or general femoral nerve injured laparoscopically. Same situation. None of those give buttock or hip pain. So I’m going to say if you have buttock or hip pain, you probably have a hip disorder and maybe it’s spinal problem. It’s not your mesh or your nerve or it’s not related to that. That’s what I’m going to say.

Dr. Talar Tejirian (00:53:30):
I think again, it highlights how complex the whole pelvic area is, the anatomy, how complex it is. Diagnosing problems can be complex and different things like that. That’s why I think it’s great when doctors are just focused on that area all the time. Because someone like you who sees it all the time, you are better able to differentiate because again, it’s a very complicated, anatomically complicated part of the body.

Dr. Shirin Towfigh (00:54:02):
Agreed. A follow-up question on the patient who had the colonoscopy and had the hemorrhoids. I have done a colonoscopy and diverticula were also found. What shall I do and what kind of treatments are available?

Dr. Talar Tejirian (00:54:18):
So diverticula are outpouching and portions of the colon, and there’s several theories of why they exist. And one of the ones that we believe is because of a lack of fiber in the diet that’s causing increasing diverticula for people as we go away from eating high fiber foods. So when someone has diverticular disease, the question that we have to ask is, again, are they symptomatic or not? So there’s something called diverticulitis, which is inflammation of a diverticulum or these outpouching. And when that happens, usually people are in a lot of pain, they can have fevers and they get seen in the emergency room, typically get a CT scan and you see inflammation of the colon. So that has its own treatment as far as what you do. If you find diverticular incidentally in a colonoscopy, meaning the person has never had problems in their life and you just happen to see them again, the endoscopist who did the colonoscopy has to say, is it just scattered? Is it a lot of them? Is it a little? But at the end of the day, we believe that fiber, good nutrition, fiber, adequate water is one of the best helpful things to prevent diverticuli from forming in the first place, which is also something really important for the colon

Dr. Shirin Towfigh (00:56:08):
And

Dr. Talar Tejirian (00:56:08):
Prevent diverticulitis from happening. And there were recommendations, and you still hear them, a lot of don’t eat nuts and don’t eat seeds. But the last time I checked those were debunked because the concern is you don’t chew.

Dr. Shirin Towfigh (00:56:27):
That’s true.

Dr. Talar Tejirian (00:56:29):
Stuck in the little outpouching and they can contact,

Dr. Shirin Towfigh (00:56:31):
Yeah, they said no popcorn, no seeds, no, I don’t. Things with little strings. Was it beans or certain spin on lettuces or something? Yeah,

Dr. Talar Tejirian (00:56:45):
Like nuts and different like that. You get stuck. So that’s a common thing that you hear. But the last time I checked, I think that theory had been debunked, but I would have to look that up to make sure that there’s no current information about that. But for anything for colon, for colon, rectal, anal health, the best thing you could do is healthy diet. Lots of high fiber foods, adequate hydration, not sitting more than one or two minutes on the toilet, raising your knees on the toilet, like using a stool or something to raise your knees. You can even lean forward to get a good position.

Dr. Shirin Towfigh (00:57:31):
Oh, so is that good for anal health?

Dr. Talar Tejirian (00:57:33):
Yes.

Dr. Shirin Towfigh (00:57:35):
Because

Dr. Talar Tejirian (00:57:35):
That is putting your body in a natural position to poop normally. So if you have your phone, almost everyone has their phone now when they’re on the toilet, right? Yeah. Put a timer, put a timer when you sit. Don’t sit more than two minutes, right? I’ve heard some people say five minutes, a little too long, if you haven’t finished, at least get up and come back or at least lean forward. Take that pressure off that anal area, do some things where you’re not just sitting there with that pressure on the anus. And then when you’re

Dr. Shirin Towfigh (00:58:12):
Done, what if you answer all your emails while you’re sitting in the bathroom? Listen, there are word I got to your New York Times wordle.

Dr. Talar Tejirian (00:58:22):
There are some people that are very lucky and they never have problems, but the chances that you will have hemorrhoidal problems from sitting on the toilet increases substantially the longer time you spend on the toilet.

Dr. Shirin Towfigh (00:58:37):
And can you explain why that’s bad? We still want to have hemorrhoids

Dr. Talar Tejirian (00:58:40):
Because you’re basically sitting and your anus is hanging down and gravity is pulling it, right? And that’s making all the blood and all the pressure rush to those hemorrhoidal tissue with the veins. And then you have the swelling. And that’s commonly why people will either get the internal hemorrhoids that are big and bleed, or when the blood rushes to the external hemorrhoid, they’ll get a blood clot, which is the very painful hemorrhoid. And that’s because of that pressure and sitting down with nothing on the bottom, but gravity’s pulling you down.

Dr. Shirin Towfigh (00:59:20):
And that’s very painful. And our guest last week, which was Dr. Zaghiyan, she made very clear, or two weeks ago, she made it very clear that one of the most painful operations you never, ever, ever want to have is hemorrhoid surgery.

Dr. Talar Tejirian (00:59:36):
Yeah, exactly. So not sitting on the toilet for a long time is prevention number one.

Dr. Shirin Towfigh (00:59:43):
Okay. I’m going to ask you our final question because we’re out of time. Now that you sat for your two minutes. Can you wipe your ass with your booty? Can you wipe your booty with those cleansing wipes? These the baby wipes? Is that the best way to clean?

Dr. Talar Tejirian (01:00:08):
Yeah. No

Dr. Shirin Towfigh (01:00:09):
Baby wipes.

Dr. Talar Tejirian (01:00:10):
I wish

Dr. Shirin Towfigh (01:00:11):
I had unscented. I wish I had a, oh, natural unscented baby wipes.

Dr. Talar Tejirian (01:00:21):
I would throw those in the bonfire with the preparation H and the steroids, whatever. No, that is not the best way. It can cause a lot of skin problems actually. And itching of the booty hole is a very common problem, and it’s often because of chemicals that are in the wipes or even wiping too hard, cleaning too much with the toilet soap, cleaning with water is the best way to do it. And then you could pad it dry with

Dr. Shirin Towfigh (01:00:56):
In the old country. In the old country,

Dr. Talar Tejirian (01:00:58):
Yes, when they did it, right when they pooped in the hole in the ground, that was the right way of doing it. You can’t scroll on your phone for three hours while you’re squatting in the woods. You know what I’m saying? That’s the right way. So cleaning with water gently padding it dry is sort of the best way of doing it. You can even get handheld little water dispensers. You don’t need to get a fancy bidet toilet, although those are very nice. Way better to spend your money on that than on whatever shoes, purses or whatever.Dr. Shirin Towfigh (01:01:36):
So I know Dr. Tejirian personally, she has custom made bidets and custom made stools in every bathroom in her house.

Dr. Talar Tejirian (01:01:50):
Yes. And you’ll never find any kind of expensive clothing or purses or anything on me because I would rather spend whatever money on a nice toilet that’s going to keep my booty hole healthy. So I have all this information on our website, so bootymd.org. I have some articles on there on how to Clean your Booty on how to prevent postoperative constipation on one of the articles is named, do I have Hemorrhoids, which goes through the different things that you can have in there. Oh,

Dr. Shirin Towfigh (01:02:30):
That’s a good one. Yeah.

Dr. Talar Tejirian (01:02:32):
I have one about how th underwear is not

Dr. Shirin Towfigh (01:02:35):
Goods are bad for you.

Dr. Talar Tejirian (01:02:37):
Yeah, only word if you have to. And I’m always open to suggestions on what other topics people are interested in. So we could write about that. But that information is there and available. And soon we’ll have some more downloadable guides and things like that that we’re working on right now to put on the website.

Dr. Shirin Towfigh (01:02:59):
So that’s on your website, booty md.org. You are a nonprofit. And for the love of God, if you want to have fun with booty stuff, do follow Dr. Tejirian on TikTok. She

Dr. Talar Tejirian (01:03:14):
Is hilarious. I have to tell you, I was looking, I was like, what is my handle on TikTok? I should know this. It’s

Dr. Shirin Towfigh (01:03:22):
At Dr. T Booty, md Dr.

Dr. Talar Tejirian (01:03:25):
T? No, it’s just at Booty. It’s just at Booty md.

Dr. Shirin Towfigh (01:03:29):
Is it at

Dr. Talar Tejirian (01:03:30):
Booty? MDT is the X one that we’re not really focused on right now. So Booty md.

Dr. Shirin Towfigh (01:03:37):
Okay. At Booty md. Very good at

Dr. Talar Tejirian (01:03:39):
Booty md. Yeah, we’re going to go in a different direction for that too, because I’m not really a mean person, so No, you’re very

Dr. Shirin Towfigh (01:03:48):
Nice people. Person.

(01:03:50):
Okay. It’s so much fun. The hour went by so quickly. I love it. Thank you so much. Well, you learned it here. No thong. Two minutes on the bathroom. Don’t spend your money on preparation H and do prevent constipation. There’s so many great health benefits, including no hernias. That’s it for us at Hernia Talk Live. Thanks everyone. I will see you again next week. Don’t forget and follow me on YouTube and any of my podcast channels to listen to everything including this podcast, this episode, all prior episodes at Hernia Doc. And I’ll see you on Instagram where we’ll have fun. Thank

Dr. Talar Tejirian (01:04:39):
You. Thank you, Dr. Towfigh. You’re the best. Hi. Thank you.