Most of us have seen the squatty potty ad with the unicorn by now and if you haven’t, take a look entertaining right? Of course it is! That’s one of the best ads out there, but is it legit?
The simple answer, yes! But what is this puborectalis muscle they are talking about and why haven’t we heard of it before this unicorn’s perfectly formed rainbow poop?
Pelvic outlet obstruction (POO), is a form of constipation that occurs due to a paradoxical contraction of the pelvic floor muscles during defecation. Simply put, rather than relaxing to allow the anus to stay open so stool can escape, the pelvic floor contracts causing a restriction in the canal leading to inability to fully expel the stool. The puborectalis muscle plays a large role in this as it slings around the rectum causing an angle between the rectum and the anus, known as the anorectal junction. If this angle decreases by the puborectalis muscle shortening and contracting, it will become harder for stool to pass. However, if the anorectal angle is increased by puborectalis relaxation, the stool will easily pass through. This is the idea behind the squatty potty. By elevating the knees above the hips (squatting) the angle is increased and voilà. But is it really this easy? For some it may be but others may need pelvic floor physical therapy.
Contraction of the pelvic floor during defecation is known as pelvic floor dyssynergia or a paradoxical contraction, meaning, the pelvic floor does the opposite of what it was supposed to. Biofeedback and pelvic floor down training can be very useful for patients with a paradoxical contraction. A pelvic floor therapist may use either external sensors or an internal probe to monitor pressures in the anal canal during simulated bearing down from the patient. The patient receives visual feedback from the computer screen which displays real time EMG activity. If the pelvic floor contracts, the EMG will increase, this would be the paradoxical contraction. The patient is then given external verbal and positional cues from the physical therapist in order to achieve proper pelvic floor relaxation while bearing down. Through trial and error the visual feedback should eventually display a decrease in EMG activity i.e. pelvic floor relaxation.
The diagram shows normal defecation (control, left) with coordinated relaxation of the pelvic floor muscles. However, in patients with dyssynergic defecation (patient, right), we see a failure to relax, or inappropriate contraction of the pelvic floor (1).
Biofeedback is showing promising results for patients with outlet obstruction. In fact, randomized controlled trials have evaluated the efficacy and concluded that biofeedback is consistently superior to laxatives, standard therapy, sham therapy, placebo, and diazepam. Success rates have been reported in the range of 70 to 80 percent (2).
In addition to pelvic floor relaxation, there must also be an increase in rectal pressure which is achieved through what pelvic floor therapists call the “abdominal pressing out maneuver”. Ideally, increased intra-abdominal pressure comes from the abdomen rather than valsalva (breath holding) to cause an increase in rectal pressure that is simultaneous with pelvic floor relaxation which can be seen with the top row of both the control and patient graphs. Valsalva can lead to further contraction of the pelvic floor or even passing out on the toilet which I have had reported in the clinic, so no, it is not far fetched.
The first step to the abdominal maneuver is to make your belly soft and just let it all hang! We tend to suck our stomachs in all day long, but when you’re trying to poop, simply don’t, it can cause the pelvic floor to contract even further. Next, make the belly big (like you are pretending to be pregnant) and then make it hard (fill it with air) with your exhale breath. At the same time try to relax your anus and pay attention, if it contracts and cuts your stool off, try to relax again. All the while using the squatty potty to further relax the pelvic floor.
I have had excellent results with biofeedback neuromuscular retraining while simultaneously using the squatty potty. Several patients of mine have gone from suffering with constipation for years to having bowel movements daily. I have seen the results time and time again and I’ll end this post with a section of a referring physician’s report on a patient of mine that I treated for outlet constipation.
GENERAL: Well-appearing, pleasant woman, not acutely distressed.
GI: With the help of wonderful pelvic floor physical therapy,
Colace 20 mg daily and the Squatty Potty, the patient has had
soft, almost daily bowel movements and feels her constipation is
the best it has been.
1. Motility testing: When does it help?. Anthony J Lembo, MD
2. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. AUChiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G SOGastroenterology. 2006;130(3):657.