You might be under the impression that you were done with potty training years ago. I certainly thought I had come through it aged three with flying colors — yellows and browns, for the most part. But of late, after sustained exposure to headlines telling me I’ve been “pooping all wrong,” and a growing bathroom subculture extolling the freeing euphoria that comes from adopting squat-like positions while sitting on the lavatory, it’s been slowly dawning on me that I might not have graduated after all.
I hesitate to call it a “movement,” but over the past few years there has been a steady stream of breathless evangelism dedicated to improving the typical passive perch most people assume to defecate. Devotees recommend ditching sitting in favor of either a full-on gymnastic squat while precariously balanced on the seat, or more commonly, a braced, ready-for-action crouch — ideally with both feet propped off the floor by a few inches, so your knees are lifted above your hips, and a maverick look in your eyes. Arranged like this, say these techniques’ proponents, you’re much more likely to experience the satisfaction of “optimal elimination,” an aspiration that’s become increasingly popular largely thanks to the phenomenon of the Squatty Potty — the foot stool that achieved cult status after it appeared on Shark Tank in 2014 and has since seen annual sales reach $33 million.
But the benefits of switching from “The Thinker” to “The Go-Kart Driver” seem to extend to much more than a gratifying evacuation; they’ve also been backed up by some strenuous research. One study in 2017 at the U.K.’s Loughborough University, for instance, found that pedestal-propped pooping made the process both slicker and quicker, with an average toilet time saved (compared to a standard sitting pose) of just under a minute, and for all but one of the 33 participants, “the use of the footstool resulted in a less strenuous method of defecation.”
Other studies have found similar results in evaluating “the straining forces applied when sitting or squatting.” It’s a revelation that should come as no surprise to well over half the world’s current population — and for that matter, almost all the people who ever lived in history — for whom squatting out their feces has always been the normal way to do it. But for those of us brought up to excrete with our knees at a refined right angle, removing the need to strain could have a surprising impact on our health — from easing constipation to preventing a number of nasty anorectal issues, and in certain extreme situations, possibly one day saving your life.
Dying through overexertion on the toilet is the stuff of royal legend. Famously, it’s what Elvis’ personal physician claimed triggered the King’s fatal heart attack aged 42, while the reign of George II of Britain was terminated by an aortic dissection he suffered on the toilet in 1760. Strokes and ruptured aneurysms also number among the ways pushing too hard might potentially kill you — though, for most of us, such lethal outcomes shouldn’t cause too much concern.
“It does happen,” says Kyle Staller, director of the Gastrointestinal Motility Lab at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School. “For the average patient it’s exceptionally uncommon, though,” he reassures, explaining that it’s only likely to be in “certain cases where somebody who’s ill for another reason, that sitting on the toilet may be the death knell for them.
A more frequently encountered consequence of straining is fainting on the toilet, an occurrence known as “‘defecation syncope.” In 2009, Judine Simms, a 43-year-old school custodian, petitioned the State of Delaware for compensation for suffering heat exhaustion in a bathroom with faulty air-conditioning. In the course of the hearing, it emerged that she had in fact passed out because, “She was straining with a bowel movement for 45 minutes at work and then had a syncopal episode.”
Accordingly, the state Industrial Accident Board found against Simms and her claim was voided.
“Pretty much anyone can have defecation syncope,” says Chris Simpson, vice-dean of the School of Medicine at Queen’s University, Ontario. “The vast majority of these episodes are relatively benign and happen in young, otherwise healthy people.”
When we’re straining, we’re putting our whole system under pressure by performing a “Valsalva maneuver,” the medical term for holding your breath and bearing down. “Straining is one common maneuver that temporarily reduces blood return to the heart,” explains Simpson, which can cause it to beat faster, and on rare occasions, to trigger a fainting response in the long vagus nerve that connects the heart, lungs and digestive tract to the brain. This results in a sudden drop in blood pressure, and it’s this, “which in turn reduces the amount of oxygenated blood delivered to the brain,” that leads to a temporary loss of consciousness.
“Some defecation syncope can occur without straining,” explains Simpson, and may be the result of the act of pooping stimulating this response directly (which is also what happens during “micturition syncope” — fainting while peeing). “Not all defecation syncope is the same,” says Simpson. “Sometimes it’s a signal that there’s something more seriously wrong, and so for this reason, everyone with defecation syncope should see their doctor. Fortunately, most cases turn out to have a non-sinister cause.”
Put simply, unless you’re having a baby, holding your breath and heaving hard internally isn’t a good idea. In general, advises Simpson, “People should avoid straining.”
A further incentive to rethinking your straining strategy is that you might be inviting hemorrhoids by doing so. As Kyle Staller explains, the veins that can turn into piles both inside and outside your anus, “are supported by tissue, and people whose tissue is less supportive are more likely to have hemorrhoids — because as you’re straining, the blood fills these hemorrhoids and they kind of bulge out.” You’re also more likely to get them if you spend “an abnormally long time” at stool, he warns. “Men in general tend to sit on the toilet for quite a while, mostly reading. This is a habit that generally we discourage.” (Please feel free to pause your reading at this point if you need to, and do what you’ve got to do.)
Coping with the Backlog
To head off all these straining issues at the pass, so to speak, and for a heap of other health reasons (some to do with the very ugly interior world of impacted fecal matter, which we’ve dipped into before), it’s clearly in your best interests to avoid becoming constipated. And especially, if it’s at all within your power to do so, to steer clear of developing chronic constipation.
According to a global review of chronic constipation treatment published in 2011, “for up to a quarter of the population it is more than a minor annoyance; for them, constipation can be chronic, sometimes severe, and has a significant, even debilitating, effect on their quality of life.” In a 1997 telephone survey of 10,000 people in the U.S., almost 15 percent said that they suffered from the condition — and 45 percent of these had done so for five years or more. Yet, despite its prevalence, it’s also one of the most under-reported common complaints, with an estimated 65 percent of patients choosing to self-medicate with laxatives rather than seek immediate medical advice.
Aside from the embarrassment of talking about it, one reason for this could be that what constitutes constipation isn’t universally understood. In Staller’s experience, a significant proportion of people who think they’re alarmingly blocked up actually aren’t. He regularly encounters people who are over-anxious about how regular they are, “who think that if they don’t have a perfect bowel movement that comes out perfectly formed, once a day at the same time, when it’s convenient for them, and then dances in the toilet after they’re done, they’re somehow abnormal.”
In reality, there’s a broad spectrum of what is considered healthy — and what isn’t is relatively straightforward to diagnose. Staller advises that a normal frequency ranges anywhere from three times per day to three times per week. And the bog-standard shape and consistency of healthy stools — an important indicator of how long it’s spent traveling through the bowels — is between a 3 and 5 on the Bristol Stool Scale (a kind of laminated diner menu that lists ideal and not-so-ideal ass products, a full taxonomy of which we’ve pondered over before), where Staller describes a 4 as “a nice, smooth, soft snake that’s really in the sweet spot.”
If your feces are dropping outside of those parameters — and if it’s been affecting your quality of life for six months or more — then you might be in a chronic constipation situation. And it might be a clog of your own creation. Gastroenterologists tend to see a lot of “truck drivers, teachers, nurses,” says Staller. “These are all people where if the urge hits, you often have to suppress that to the best of your ability.” While there’s little in the way of hard evidence (because “it’s difficult to make people withhold and then study them”) the thinking is that forming a habit of holding it in might cause a chronic condition to be established, making the rectum “less able to effectively push things out” when it needs to.
One person we can guess may have put himself at higher than average risk of a self-imposed shutdown was Lamarr Chambers, a suspected drug dealer from London, who was apprehended by U.K. police after a car chase in January last year. As officers approached him, he was seen to swallow a bag of what was assumed to be narcotics, so the police put him in a cell, then kicked back and waited for nature to take its course (and a conviction to fall into their laps). Chambers, however, had other ideas, deciding to withhold the evidence by going on an epic poop strike.
Incredibly, Chambers is reported to have lasted 47 days in police custody while literally holding his shit together to escape jail. And it worked, kind of: At six-and-a-half weeks, all charges were dropped out of a serious concern for his life and he was rushed to hospital — only to be re-arrested on a brand new set of charges. The moral here: Don’t obstruct due process.
“Forty-seven days sounds like an awful long time,” says Staller, “but humans can do extreme things under extreme circumstances.” Thankfully, the vast majority of constipation cases are far less dramatic, with most patients complaining of bloating and discomfort, while more severe episodes may result in damage or trauma to the anus (such as anal fissures due to hardened stools tearing the anal lining as they come out).
For anyone clenching at that thought, and who might now be even more concerned about their own ability to move product, there’s a wide range of remedial treatments. Before reaching for the laxatives, though, Staller recommends introducing more fiber into your diet. The majority of people in the U.S. aren’t getting near the recommended daily intake of 25 grams, and he says, “many people may actually do well if they just take a fiber supplement every day,” such as Metamucil or Citrucel. (“Give it about a week to get used to it,” Staller advises, “because some people can feel a little bit more bloated after using [one].”)
Over-the-counter laxatives should be approached with care, meanwhile. “There are some prescription laxatives that gastroenterologists like myself will use,” says Staller, but it turns out these are often not as powerful as those that are freely available. “Many people can go to their local pharmacy and get a laxative that’s incredibly potent — and that’s going to lead to some discomfort; it may not be the right answer for everyone.”
An effective alternative for rapid relief may be exercise, which, as we’ve pointed out before, can often get things moving and is good for you in any case. To ease chronic sufferers back into a regular pattern, Staller says that biofeedback therapy — a method of coaching patients to intentionally control bodily functions that usually take place without our conscious input — has had “a very good success rate in retraining people to defecate more effectively.” However, finding therapists trained in biofeedback techniques in your area might pose a challenge, as “it’s a very specialized field.”
Which leaves us back where we started: Squatting on the toilet. Is there really anything in that? Why, for instance, don’t we see dramatic differences in constipation rates between Western countries and cultures where squat toilets are the norm? “The prevalence probably does tend to be higher in the West,” says Staller, who has conducted a study examining constipation patients in India versus those in the U.S., but the divergence has usually been difficult to assess, due in part to the stark contrasts in what people from different cultures understand as normal. The study was conducted in referral hospitals, so, “Interestingly these were all patients who considered themselves constipated enough to seek out experts,” he says, “and the Indians were actually less constipated by a variety of measures compared to the Americans. So constipation is very much in the eye of the beholder.”
In a much less scientific spirit of deep-dive investigation, I can disclose that I have been test-driving the raised-knees method over a couple of weeks (not with a Squatty Potty, just an average, general-purpose Ikea footstool). I can report that, in my experience so far, the bowel does indeed seem to move in a slightly more jet-propelled fashion. Aside from a swifter transit of matter from man to pan, what’s struck me is a sensation of being more open to the elements, which goes — or so it seems — all the way up. As defecation M.O.s go, it’s not bad.
Staller isn’t at all surprised by my findings. “Yes, that’s what I’ve heard multiple times,” he says, and offers an anatomical explanation: “Your colon, at the end of it, has a natural bend that’s held in place by a certain muscle. When you bear down with the Valsalva maneuver, it should straighten that angle out — they call it the ‘anorectal angle,’ it’s just a kink at the end of the colon. And what raising your knees above your hips does is involuntarily straighten it out.” Which, before applying any degree of physical exertion, means it already “makes for a more efficient bowel movement.” Although, he confirms, “It doesn’t need to be a fancy Squatty Potty; I tell my patients any stool will do.”
Constipation can arise from a wide array of causes: From diet or lifestyle, or as a symptom of any number of underlying physical illnesses, or as a response to a psychological issue such as depression or the memory of a traumatic incident. But whatever the contributing factors, it all amounts to the same thing: An interruption in a finely balanced and highly sensitive set of interacting systems of essential bodily maintenance. In a world that’s full of stresses, both physical and mental, it’s perhaps little wonder it’s such a common complaint.
“When you have a bowel movement,” says Staller, “there’s really an elegant symphony of muscles and nerves that we don’t think about.” But from now on, with my feet up and my knees braced, I will be thinking about it. I will, in fact, think of it as Rimsky-Korsakov’s No.2.