Humans mostly use one of two types of defecation postures to defecate: squatting and sitting. People use the squatting postures when using squat toilets or when defecating in the open in the absence of toilets. The sitting posture on the other hand is used in toilets that have a pedestal or "throne", where users generally lean forward or sit at 90 degrees to a toilet seat.
The sitting defecation posture involves sitting with hips and knees at approximately right angles, as on a chair. So-called "Western-style" flush toilets and also many types of dry toilets are designed to be used in a sitting posture.
In Europe, America and other western countries most people are accustomed to sitting toilets, [1] although this fashion has only been present for around 100 years. [1] Sitting toilets only came into widespread use in Europe in the nineteenth century. [2]
Sitting toilets requires users to strain in an unnatural position. [3] In the sitting position, the puborectalis muscle chokes the rectum, [1] and the anorectal angle is unfavorable, at almost 90 degrees. [1] This may lead to constipation symptoms such as incomplete evacuation of stool, [1] irregular bowel movements, [1] hard stools [1] and the need for excessive straining. [1] [3] Compared to the more natural squatting position, western-style toilets may lead to health issues [1] such as inflamed hemorrhoids. [3]
The squatting defecation posture involves squatting, or crouching. It requires standing with knees and hips sharply bent and the buttocks close to the ground. Squat toilets are designed to facilitate this posture. Squatting is considered the natural, traditional and most common defecation posture in Asian and African countries. [1] However in some urban areas of India people are gradually switching to western style sitting toilets. [4]
The Indian Society of Gastroenterology stated that, in the context of constipation, the squatting defecation posture is more physiological (i.e., natural), ideal and relaxed compared to the sitting posture. However, they found limited evidence of benefit. [4] The squatting position also increases intraabdominal pressure. [3] It is thought that the squatting posture allows for better relaxation of the puborectalis muscle and hence straightening of the anorectal angle, [4] [1] [3] and for faster, easier and more complete evacuation of stool. [4] The squatting position therefore prevents excessive straining, [4] [1] and hence protects stretching of the nerves, such as the pudendal nerve. [4] Damage of these nerves can lead to permanent problems with urinary, defecation and sexual function.
Excessive straining in the squatting position while defecating may increase the risk of severe hemorrhoids, [5] or increase the tendency of prolapse of hemorroids, because of increased perineal descent and intraabdominal pressure. [6] Prolonged and repeated straining on a sitting toilet has the same effect. [5]
People who are not used to squat toilets, and people who do not have the flexibility, strength, or balance needed to lower into, sustain, or rise from a squatting position without pain or assistance may not find it easy to use the squatting posture. This may include the elderly, people with disabilities, overweight people or people suffering from a skeletal or muscular disease.
An assisted-squatting position can be achieved by placing a wrap-around foot stool or box under the feet while using a sitting toilet. [1] This raises the legs and allows for some degree of widening of the anorectal angle. [1] The anorectal angle can be further increased by leaning forwards in this semi-squatting position. [1] Using a box to raise the legs has been recommended for various straining related medical conditions such as obstructed defecation syndrome, [7] and solitary rectal ulcer syndrome. [8]
For elderly people or people with mobility issues, this "assisted-squatting" position is closer to the more natural [3] squatting position, [1] and gives some of the benefit of the squatting position such as reduced need for straining. [3] The semi squatting position is one of the practical solutions for avoiding constipation. [1] Various "squat assist devices" are also commercially available. [1]
Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus or cloaca. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.
Hemorrhoids, also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term hemorrhoid is often used to refer to the disease. The signs and symptoms of hemorrhoids depend on the type present. Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating. External hemorrhoids often result in pain and swelling in the area of the anus. If bleeding occurs, it is usually darker. Symptoms frequently get better after a few days. A skin tag may remain after the healing of an external hemorrhoid.
Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.
The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis.
An anal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and undergarments, or sometimes in the toilet. If acute they are painful after defecation, but with chronic fissures, pain intensity often reduces and becomes cyclical.
Hematochezia is a form of blood in stool, in which fresh blood passes through the anus while defecating. It differs from melena, which commonly refers to blood in stool originating from upper gastrointestinal bleeding (UGIB). The term derives from Greek αἷμα ("blood") and χέζειν. Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed. The difference between hematochezia and rectorrhagia is that rectal bleeding is not associated with defecation; instead, it is associated with expulsion of fresh bright red blood without stools. The phrase bright red blood per rectum is associated with hematochezia and rectorrhagia.
A squat toilet is a toilet used by squatting, rather than sitting. This means that the posture for defecation and for female urination is to place one foot on each side of the toilet drain or hole and to squat over it. There are several types of squat toilets, but they all consist essentially of a toilet pan or bowl at floor level. Such a toilet pan is also called a "squatting pan". A squat toilet may use a water seal and therefore be a flush toilet, or it can be without a water seal and therefore be a dry toilet. The term "squat" refers only to the expected defecation posture and not any other aspects of toilet technology, such as whether it is water flushed or not.
A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.
Functional constipation, also known as chronic idiopathic constipation (CIC), is defined by less than three bowel movements per week, hard stools, severe straining, the sensation of anorectal blockage, the feeling of incomplete evacuation, and the need for manual maneuvers during feces, without organic abnormalities. Many illnesses, including endocrine, metabolic, neurological, mental, and gastrointestinal obstructions, can cause constipation as a secondary symptom. When there is no such cause, functional constipation is diagnosed.
Rectal tenesmus is a feeling of incomplete defecation. It is the sensation of inability or difficulty to empty the bowel at defecation, even if the bowel contents have already been evacuated. Tenesmus indicates the feeling of a residue, and is not always correlated with the actual presence of residual fecal matter in the rectum. It is frequently painful and may be accompanied by involuntary straining and other gastrointestinal symptoms. Tenesmus has both a nociceptive and a neuropathic component.
Blood in stool looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.
Rectal bleeding refers to bleeding in the rectum, thus a form of lower gastrointestinal bleeding. There are many causes of rectal hemorrhage, including inflamed hemorrhoids, rectal varices, proctitis, stercoral ulcers, and infections. Diagnosis is usually made by proctoscopy, which is an endoscopic test.
Levator ani syndrome is a condition characterized by burning pain or tenesmus of the rectal or perineal area, caused by spasm of the levator ani muscle. The genesis of the syndrome is unknown; however, inflammation of the arcus tendon is a possible cause of levator ani syndrome.
Defecography is a type of medical radiological imaging in which the mechanics of a patient's defecation are visualized in real time using a fluoroscope. The anatomy and function of the anorectum and pelvic floor can be dynamically studied at various stages during defecation.
Rectal pain is the symptom of pain in the area of the rectum. A number of different causes (68) have been documented.
Anorectal manometry (ARM) is a medical test used to measure pressures in the anus and rectum and to assess their function. The test is performed by inserting a catheter, that contains a probe embedded with pressure sensors, through the anus and into the rectum. Patients may be asked to perform certain maneuvers, such as coughing or attempting to defecate, to assess for pressure changes. Anorectal manometry is a safe and low risk procedure.
Solitary rectal ulcer syndrome or SRUS is a chronic disorder of the rectal mucosa. It commonly occurs with varying degrees of rectal prolapse. The condition is thought to be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation. Treatment is by normalization of bowel habits, biofeedback, and other conservative measures. In more severe cases various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.
Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.
Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.
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