Influence of body posture on defecation- a prospective study of ‘‘The Thinker’’ position

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Tech Coloproctol (2016) 20:117–121 DOI 10.1007/s10151-015-1402-6

ORIGINAL ARTICLE

Influence of body posture on defecation: a prospective study of ‘‘The Thinker’’ position S. Takano1 • D. R. Sands1

Received: 20 August 2015 / Accepted: 3 November 2015 / Published online: 21 December 2015 Ó Springer-Verlag Italia Srl 2015

Abstract Purpose We hypothesized that bending the upper body into what we have termed ‘‘The Thinker’’ position facilitates defecation. This study aimed to assess the influence of ‘‘The Thinker’’ position on defecation. Methods This is the prospective single-group study. Patients who could not evacuate the paste in normal sitting position on cinedefecography between January and June 2013 were enrolled in this study. Cinedefecography was first performed in the sitting position; if the patient was unable to evacuate the paste, images were obtained in ‘‘The Thinker’’ position. Patients who were able to evacuate the paste were excluded from the study. Anorectal angle (ARA), perineal plane distance (PPD), and puborectalis length (PRL) during straining in both positions were measured from the radiographs. Results Twenty-two patients unable to evacuate the barium paste underwent cinedefecography in ‘‘The Thinker’’ position. Seventeen patients were female, average age of 56 (range 22–76) years. ‘‘The Thinker’’ position had significantly wider ARA than the sitting position (113° vs. 134°, respectively; p = 0.03), larger PPD (7.1 vs. 9.3 cm, respectively; p = 0.02), and longer PRL (12.9 vs. 15.2 cm, respectively; p = 0.005) during straining. Eleven patients could evacuate completely in ‘‘The Thinker’’ position. Conclusion ‘‘The Thinker’’ position seems to be a more efficient method for defecation than the sitting position. Poster pre´sentation American Society of the Colon and Rectal Surgeons annual meeting, Hollywood, Florida, May 17–21, 2014. & S. Takano [email protected] 1

Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA

This technique may be helpful when retraining patients with constipation. Keywords Defecation posture
Defecography
Anorectal angle
Constipation
Fecal outlet obstruction

Introduction Fecal outlet obstruction lowers quality of life (QOL) of patient with functional constipation and presents a challenging dilemma to the practicing physician. Outlet obstruction may be attributed multiple causes, like nonrelaxation of puborectalis muscle, anismus, rectal prolapse, rectocele and rectal hyposensitivity. Reports in the literature indicate that the squatting position is superior to the commonly used sitting position for defecation [1, 2]. However, sudden changes in defecation habits, such as altering the position from sitting to squatting or introducing a special commode, may add psychological stress and cause incomplete evacuation [2]. Tsuchino et al. [3] assessed rectal and anal pressure during defecation with the patient in a bending position rather than a normal sitting position (Fig. 1). This position was achieved by bending the upper part of the body forward over commode (Fig. 1b). The authors reported that this position resulted in higher rectal and lower anal pressures. This position, described by Tsuchino, is reminiscent of Rodin’s sculpture, ‘‘Le Penseur’’ (Fig. 2). For this reason, we have called it ‘‘The Thinker’’ position. We hypothesized that ‘‘The Thinker’’ position facilitates defecation, and therefore, the aim of this study was to assess the influence of ‘‘The Thinker’’ position on defecation during cinedefecography.

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Fig. 1 a The sitting position and b ‘‘The Thinker’’ position with the upper body bent forward

about risk of additional X-ray exposure was given to the patients and each patient gave written informed consent after being fully informed on the aims of the investigation. Inclusion criteria: The criteria for enrollment in this study were patients with constipation, who were scheduled to undergo cinedefecography, and who could not evacuate the paste in the sitting position. The indication for defecography was constipation. Diagnosis of constipation and outlet obstruction were made using the criteria for functional defecation disorders of ROME III [4]. Exclusion criteria were patient age under 18 years, pregnancy, and prior rectal surgery and patients who could evacuate the paste in the vertical position on cinedefecography. Cinedefecography technique

Fig. 2 ‘‘Le Penseur’’ = ‘‘The Thinker’’ sculpture by Auguste Rodin

Patients and methods Study protocol approved by Cleveland Clinic Florida Ethical Committee. After approval, a prospective nonrandomized study was undertaken. A complete explanation

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Patients were administered a phosphate enema 30 min prior to the procedure. Patients were placed in the left lateral decubitus position, and 200 ml liquid barium and approximately 50 ml barium paste were injected into the rectum. The barium paste was mixed with oatmeal to create a stool consistency in Bristol type 4. The patient was then asked to sit on a commode. Lateral films of the pelvis are taken during the pushing phase in a sitting position (Fig. 1a). If the patient could not evacuate the paste, the patient was asked to assume ‘‘The Thinker’’ position and additional films were taken. If patient could evacuate the paste, the patient was excluded from the study. ‘‘The Thinker’’

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Fig. 3 Pushing phase on cinedefecography with the patient in the a vertical position and b ‘‘The Thinker’’ position

position involves bending the upper body forward and placing the elbow on the knee, as shown in Fig. 1b. Interpretation of data Patient demographics (gender, age, comorbidity, and prior perianal surgery) were retrospectively collected from the medical records. Anorectal angle (ARA), perineal plane distance (PPD), and puborectalis length (PRL) during straining were measured from the radiographs (Fig. 3). ARA was defined as the angle between the axis of the anal canal and the distal half of the posterior rectal wall [5–7]. PPD was considered as the vertical distance between the ARA position and a line drawn between the pubic symphysis to the tip of the coccyx. PRL was measured as the distance between the ARA and the pubic symphysis [7, 8]. Statistical analysis Power analysis: Previous studies have determined that the mean pelvic floor location increased from 1.3 cm compared to the recumbent and sitting positions [9]. Therefore, the effect size to determine a clinically relevant difference for this study was set at 1.3 cm on PPD. With an alpha of 0.05 and a beta of 0.9, approximately 20 patients were needed for this study. The paired t test was used to compare sets of measurements on both positions, and p values\0.05 were considered statistically significant.

Results A total of 22 patients [17 females; mean age 56 (range 22–76) years] could not evacuate the paste in the sitting position and continued to have films taken in ‘‘The

Table 1 Comparison of cinedefecography measurements between the vertical position and ‘‘The Thinker’’ position Sitting position

Thinker position

p value

ARA (o)

113 ± 29

134 ± 31

0.03

PPD (cm)

7.1 ± 2.9

9.3 ± 3.2

0.02

PRL (cm)

12.9 ± 2.7

15.2 ± 2.8

0.005

ARA anorectal angle, PPD perineal plane distance, PRL puborectalis length

Thinker’’ position. Twenty-one of 22 patients complained of constipation only, and one patient had both constipation and fecal incontinence; 16 (72.7 %) patients had comorbidities, and the most common were hypertension in 6 (27.3 %) followed by hyperlipidemia in 5 (22.7 %). The final diagnosis of 22 patients was dyssynergic defecation. However, after changing posture to ‘‘The Thinker’’ position, 14 of the patients experienced a reversal in the dyssynergic defecation disorder. None of the patients had rectocele or any other anatomical abnormalities. The mean values of ARA, PPD, and PRL during straining in the sitting and ‘‘The Thinker’’ positions are shown in Table 1. There were statistically significant differences between the sitting and ‘‘The Thinker’’ positions in terms of ARA, PPD, and PRL (p = 0.03, 0.02, and 0.005, respectively) (Table 1; Fig. 4). In all patients, ARA, PPD, and PRL were increased in ‘‘The Thinker’’ position (Fig. 4). Fifteen patients could evacuate completely in ‘‘The Thinker’’ position. The mean values of ARA, PPD, and PRL during straining with patients who could evacuate the paste and who could not in ‘‘The Thinker’’ position are 139 vs. 128o (p = 0.44), 9.8 vs. 8.8 cm (p = 0.02), and 16.2 vs. 14.2 cm (p = 0.005), respectively. The patients who could evacuate the paste in ‘‘The Thinker’’ position have

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Fig. 4 Individual values for ARA, PPD, and PRL during attempted defecation in the vertical position and ‘‘The Thinker’’ position. ARA anorectal angle, PPD perineal plane distance, PRL puborectalis length

significant larger PPD and longer PRL, but no significant in ARA. Also there is no significant difference with age and sex between those two groups.

Discussion Defecation is so important part of human life. Fecal outlet obstruction is ‘‘difficulty in evacuation or emptying the rectum which may occur even with frequent visits to the toilet’’. We think the body position during defecation is one of the important elements of defecation. Historically, man has squatted in order to defecate [10], and this practice continues today in underdeveloped countries [11]. While squatting for defecation continues to be the principal position in Asia and Africa, Western populations have become accustomed to sitting on a commode [1]. The widespread use of a sitting toilet began during the nineteenth century when sewage systems were developed to improve sanitation as cities and populations grew [12]. Compared with the sitting position, squatting was associated with significantly less time to achieve a sensation of satisfactory bowel emptying and a lower degree of subjectively assessed straining [1]. Rad reported that ARA and PPD were greater in subjects who squatted versus those who sat (ARA 132 vs. 92; PPD 8.4 vs. 6.6 cm, respectively) [2]. Tagart reported that the ARA straightens with fully flexed hips—corresponding to the squatting position assumed for defecation— and converts the rectoanal outlet into a straight canal, thereby facilitating rectal emptying [13]. Other authors have reported differences in various positions. Altomare et al. [14] noted that when the patient

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sits on a commode, the ARA opens wider than it does in the standing position. Rao et al. [15] reported on the influence of body position on defecation using a waterfilled balloon and manometory. In the prone position, onethird of the subjects had dyssynergia and half could not expel the paste (artificial stool). When sitting with a distended rectum, most subjects displayed normal defecation patterns and the ability to expel stool. The authors reported that the sitting position appears to be more conducive to defecation than the lying position. In addition, the manometric recordings during attempted defecation showed that the intrarectal pressure was lower in the left lateral position than in the sitting position. In this study, we did not assess manometric recordings; however, we did find that ARA, PPD, and PRL were significantly increased in ‘‘The Thinker’’ position. ARA is believed to provide one of the most important contributions to anal continence [14]. Although the role of the ARA has been questionable in view of the disappointing results after postanal repair for restoration of continence, it is a common clinical finding that patients with incontinence have a wider ARA than normal controls [7]. There is mounting evidence that abnormal location and mobility of the pelvic floor play a major pathogenetic role in traction neuropathy and in several anorectal disorders such as chronic constipation, fecal incontinence, rectal prolapse, and solitary rectal ulcer [16–20]. However, some authors reported no relationship between the degree of perineal descent and defecation disorders [9, 21]. Tsuchino et al. [3] showed higher rectal pressure and lower anal pressure in this position. Furthermore, they suggested this position creates higher intraabdominal

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pressure and the combination of increased rectal pressure and ARA helps to facilitate evacuation. The findings suggest that The Thinker position helps the levator ani relax which then allows for an increase in the pushing effort caused from higher intraabdominal pressure. In this study, The Thinker position showed wider ARA. This means the position makes more relaxation of puborectalis muscle than vertical position. It was suggested that The Thinker position makes easier evacuation for patients with fecal outlet obstruction.

Conclusion ‘‘The Thinker’’ position appears to be more efficient method for defecation than the sitting position. This technique may be helpful for retraining of defecation for patients with constipation. However, this study has some methodological biases. Farther studies are required. Compliance with ethical standards Conflict of interest of interest.

The authors declare that they have no conflict

Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study.

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