How much straining is normal and can it cause strokes or heart attacks?

Hi, I'm a 32 year old woman and I got my J pouch in 2012 at the Mount Sinai Hospital in New York City. I had a confirmed case of UC.

I often have to push very hard when I go to the bathroom, especially when I have gas. I always just assumed it's normal because the small bowel doesn't have the same kind of muscle movements that the colon has. I mean it has peristalsis like the colon does, but I can't consciously cause the peristalsis contractions like I could with my colon. I haven't really had much of a problem with pouchitis.

So I have to overcompensate by pushing my abdominal and sphincter muscles harder. I also usually push on my stomach with my hand to give the muscles something to push against and create more pressure.

I often have this annoying very vague feeling that there's just a little more poop or a fart that's sitting just above the point where it wants to come out and it just won't move down. The feeling is always so vague that I still often question whether it's just my imagination. Even though at this point I should know it's not, because it's proven itself not to be. I know people will disagree with me I think it's because the small bowel doesn't have the same nerve endings as the colon does and therefore doesn't feel as much sensation as the colon does.

Getting up and walking around for 10-20 minutes often helps, but that's not so easy to do when I'm at work and don't want people to see me going to the bathroom repeatedly. By far, the most helpful thing is Metamucil. When I have enough of it in my system it helps this issue a lot. 

So to get to the point - the reason why I posted this - It scares me that years of straining like this when I go to the bathroom could one day cause a stroke or heart attack when I get older. I'm concerned about the fact that I'm so often doing something similar to the valsalva maneuver and raising my blood pressure at least temporarily in the moment. (It was normal at my last check up) I try not to do the valsalva thing, but it's hard not to do it. Sometimes my heart rate goes up or my face gets flushed when I do this. So:

1.Is it normal to have to strain this much when you haven't taken any Metamucil or other thickening agents? Or to have to sit on the toilet for an hour every night, waiting for a gas bubble to finally decide to come out? (btw, I've seen the advice on here about standing up or coughing when this happens. That doesn't work for me.)

2. If you strain a lot, what kind of damage can it do to the pouch?

3. Can you get a stroke or heart attack from it?

4. Can you cause liver problems from straining by causing blood to back up in your liver when you do it? (or in any other organ)     

Original Post

If Metamucil helps you, why not use it regularly enough to help all the time? I use it every day. It’s not good to strain so hard, but it won’t cause a stroke, heart attack, or liver problems. It can cause hemorrhoids and perhaps pouch prolapse. Is your stool hard or soft (when you are straining)?

Scott F posted:

If Metamucil helps you, why not use it regularly enough to help all the time? I use it every day. It’s not good to strain so hard, but it won’t cause a stroke, heart attack, or liver problems. It can cause hemorrhoids and perhaps pouch prolapse. Is your stool hard or soft (when you are straining)?

I do use Metamucil regularly. Ideally I like to have at least 2-3 glasses per day. But I'm not perfect. Sometimes I forget to take it or I run out before I'm able to get to the store. The straining is much worse when the stool is softer. Then it's like the muscle can't push as efficiently, sort of akin to trying to pick up water with your fingers. So I like it to be as firm as possible. The firmer the better! I feel like when it's firmer, it gives the muscles something to grip onto, so it can work better.

And I was told by my surgeon that I can't get hemorrhoids because he removed the tissue where you get them. I don't know if that's true for everyone. I was operated on by Adrian Greenstein at Mount Sinai. He told me he left almost no rectal cuff. I don't know if other surgeons do that.

I am concerned about the possibility of pouch prolapse because of this, though. I just wanted to know if this is normal and if other people experience this, since I've seen others on this site saying that they don't like Metamucil and they prefer looser stools because that makes it easier to go. I don't understand that at all.

NickP posted:

If I'm not mistaken, a stroke is caused by lack of oxygen to the brain via a blood clot. . .I wouldn't see how straining would cause that.  

That's only one type of stroke. They other type is basically the opposite event, but it causes similar brain damage either way. You have a blood vessel break and bleed into the brain. That's what I'm afraid of happening because of the straining.

Strokes can be caused by high blood pressure and I've heard that you temporarily raise your blood pressure when straining on the toilet, so that's why I'm concerned about it, even though my blood pressure is normal when I get it checked at the doctor's office. 

Strokes from straining are mostly an issue for those with high blood pressure or cardiovascular disease or both. Your bigger issue is potential pouch prolapse with chronic straining.

Extreme straining is not normal. It is true that the small bowel lacks the musculature to empty the pouch like the rectum. It primarily empties by gravity and relaxing the external sphincters, which are under voluntary control. The internal sphincters relax under pressure of a full pouch (or rectum). Bearing down some is OK, but serious straining is not. It is possible you have pelvic floor dysfunction and are not relaxing your external sphincters properly. Pelvic floor physical therapy might help.

It could be due to nerve damage during surgery. This is more likely to happen when the full rectal cuff is removed. Those nerves are in the transition zone between the rectum and anal canal.


Actually this is what killed Elvis Presley, straining on the toilet from constipation due to his addiction to prescription pain killers.  He was found keeled over in front of the toilet seat, pants around ankles, dead.  First of all, do not abuse pain killers.  Second, if you do get constipation from taking bowel slowers, counteract it with natural laxatives, or reduce the bowel slowers.  Last, don't strain.  Not only may it cause a fatal cardiac event, but even if you have a healthy heart, you may still get a nasty case of hemorrhoids.

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