I had a virtual follow up appointment with my GI doctor today. I learned that the anorectal manometry I did indicated that my anal sphincter is not relaxing as it should and that is why I have to strain so much to have a BM. I think he said this is called anismus. He said it's like trying to blow up a balloon with your mouth closed. He said a normal rectum contracts and helps you have a BM but the j-pouch cannot do this so having a BM can only happen with a combination of gravity, using your abdominal muscles and having the anal sphincter relax but that last part isn't working very well for me. He said this is related to my IBS diagnosis which is being treated with amitriptyline. Sounds like I will probably end up to taking more of that as well as more MiraLAX. He also said I could try biofeedback. My final option is to have a permanent ostomy which seems like what he is pushing me towards. The appointment felt very rushed and I only got to ask a few questions so my head is still kind of spinning, but I wanted to share this update with you guys.