Squatting improves rectal evacuation among younger women with defecatory dysfunction
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Squatting assist stools improved rectal evacuation in defecatory dysfunction among women who were younger with normal stool consistency and lower resting anal sphincter pressure, according to research presented at ACG.
“The squatting assist stool (SAS) has become popularized in the last decade. In theory it works by straightening the anorectal angle to improve mechanics of evacuation,” Lauren Ulsh, MD, a second-year resident at Stanford University Medical Center, said. “We hypothesized that squatting can help some individuals with defecatory dysfunction overcome anorectal dyssynergia.”
To identify characteristics and anorectal pressure profiles of patients with defecatory dysfunction who may benefit from SAS, researchers conducted a retrospective review of 657 participants (524 women) evaluated for defecatory dysfunction by anorectal manometry (ARM) and balloon expulsion test (BET). They provided SAS to the 249 women (38%) who initially failed with abnormal BET after 2 minutes of testing.
Among these 249 women, 16% (n = 40) then passed with SAS and 84% (n = 209) failed with or without SAS. Patients who benefitted from SAS were younger (P = .003), had a higher BMI (P = .022), normal stool consistency (P = .007), less laxative use (P = .023) and abdominal pain (P = .046) and had higher Cleveland Clinic Fecal Incontinence scores (P = .039). When researchers compared ARM data, women who benefitted from SAS vs. failed had lower anal resting tone and residual pressures during defecation without differences in rectal pressure, the percentage of anal sphincter relaxation and rectal sensation. Younger age (< 50 years; OR = 0.93; 95% CI, 0.891-0.971; P = .001), normal stool consistency (OR = 3.862; 95% CI, 1.209-12.34; P = .023), lower resting anal sphincter pressure (OR = 0.97; 95% CI, 0.95-0.99; P = .004) and positive anorectal pressure gradient (OR = 1.02; 95% CI, 1.001-1.038; P = .038) were independent factors associated with successful BET with SAS in women.
“Squatting may facilitate rectal evacuation in a subgroup of patients with functional defecatory disorders. Women who benefited from squatting had certain clinical characteristics and significantly different symptom severity scores: younger women with normal strong consistency, lower anal tone and a greater anorectal pressure gradient are likely to benefit from the squatty assist stool,” Ulsh concluded. “It's unclear whether squatting facilitates defecation by a change in anorectal pressure and/or anorectal alignment.”
Perspective
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Christine Lee, MD
The rectum is designed to hold stool until time of elimination. A U-shaped muscle called the puborectalis wraps around the rectum. This muscle helps keep the lower part of your rectum bent to hold the stool inside until time of defecation, much like folding the end over to prevent things from spilling out.
In sitting position, it keeps the bend in the lower colon, sometimes resulting in incomplete or partial evacuation and the need to “push” or bear down especially if unable to relax this bend on demand.
Squatting can further help relax the puborectalis muscle and straighten out the lower colon leaving a straighter route out. A stool that raises the knees above the hips can mimic the squatting position, helping those suffering from defecatory dysfunction yielding in more effective evacuation and requiring less straining.
Ulsh and colleagues show squatting assist stools can indeed improve rectal evacuation in some defecatory dysfunction. However, more studies are needed to determine if squatting assist stools help defecation by improving the alignment, altering anorectal pressure or both.It is an effective measure and can be safely tried by those who suffer from defecatory dysfunction particularly in those of younger age who have normal stool consistency, lower resting anal sphincter pressure and positive anorectal pressure gradient.
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Ulsh L, et al. Utilizing anorectal manometry to predict the phenotype of patients who will benefit from a squatting assist stool. Presented at: ACG Annual Scientific Meeting; Oct. 22-27, 2021; Las Vegas (hybrid meeting).
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