The Squattypottymus: could reducing childhood constipation help prevent adult pelvic pain?

In Pelvic Floor Physical Therapy by Elizabeth Akincilar2 Comments


By guest blogger Steve Hodges, MD with an introduction from Elizabeth Akincilar


As pelvic floor physical therapists, we often notice a common denominator among our patients suffering with pelvic pain: CONSTIPATION. Probably more frequently than not, our patients with pelvic pain also struggle with constipation currently, or have at some point in their lives. Many of them will report that they’ve always struggled with constipation, some since childhood. This clinical observation begs the question, can a history of constipation lead to pelvic pain? When I combed through the research, I came up with zilch. I didn’t come across one research article that studied a correlation between constipation and pelvic pain. There are several articles that link a history of sexual abuse to bowel dysfunction, most often IBS. As discussed later in this blog post, there is a clear correlation between childhood constipation and enuresis (bedwetting) and encopresis (fecal incontinence). But, no link between constipation and pelvic pain has been reported. To the best of my knowledge, it hasn’t yet been studied.


I challenge our colleagues who conduct research to consider studying this possible correlation. Although completely anecdotal, we see it so often with our patients with pelvic pain, I would find it surprising if there wasn’t a correlation. Consider this, if there is a link between a history of constipation and developing a pelvic pain syndrome, think of how many people could avoid or reduce their chance of developing a pelvic pain syndrome by preventing constipation or treating constipation as soon as it occurs.  And, as you’ll read below, constipation is a childhood epidemic in the Western world! Are we setting up our kids to develop pelvic pain as adults by not effectively treating, or altogether preventing, constipation? I suggest yes.


Our adult patients often ask us questions about their children’s bowel and bladder woes. This, coupled with our suggestion that pediatric constipation could lead to adult pelvic pain prompted us to reach out to Dr. Steve Hodges, a pediatric urologist and contributor to the Squattypottymus, a device to help kids poop the right way. Here’s what Dr. Hodges had to say on the matter.


Plenty of modern inventions have improved life on Earth (praise the iPad!), but let me tell you: The toilet isn’t one of them. Human beings were designed to squat while pooping. We’ve been doing it for all of human history—oh, about half a million years. Even today more than one billion people on the planet, mostly in Asia, the Middle East, and Africa, squat when they poop. I’d bet few of them are constipated.


Not so in the Westernized world, where chronic constipation is epidemic and causing high rates of enuresis (pee accidents), encopresis (poop accidents), urinary frequency/urgency, and urinary tract infections, not to mention stomach aches. Our kids’ pipes are clogged for many reasons — including our highly processed diet, rush to potty train, and restrictive school bathroom policies — but toilets make the problem worse.


That’s because human plumbing is not what it seems. You’d think sitting upright on the john would make gravity work in your favor, giving poop a straight shot downward. But the reverse is true. When you stand, your rectum is bent, a position that helps keep poop safely inside; when you squat, the rectum straightens and poop falls out easily, no pushing required.


Anyone who’s camped in the woods knows how easily you poop when you use nature’s facilities. Sitting upright on the potty, by contrast, is like trying to poop uphill.


Want proof? Search Digestive Diseases and Sciences for a fun Israeli study that found pooping in a squat is more comfortable and faster than pooping on a toilet. The subjects pooped in a speedy 51 seconds (no iPad needed!) while squatting, compared to a laborious 2 minutes and 10 seconds while sitting on a standard toilet.


Or, check out a Japanese study, published in Lower Urinary Tract Symptoms, that recorded the abdominal pressure of six volunteers as they pooped and found they strained less while squatting.


Toilets, because of their height, are especially tough on kids, who are forced to poop with their feet dangling. Think about it: Do you fully relax your body when you’re sitting on a barstool without a footrest? No! Kids instinctively clench their inner thighs and pelvic floor muscles to keep from falling in. We can’t see kids clenching, and they may not know they’re doing it, but I assure you, they are.


The upshot: kids don’t fully evacuate. They may appear to be “regular” — tons of severely constipated kids poop daily — but in reality, poop is piling up in the rectum, which was not designed as a storage facility.


Over time, the stool mass grows and hardens (X-rays in my clinic reveal softball-sized poop masses!) and stretches the rectum, often to twice its diameter. The poop-stuffed rectum presses against and aggravates the neighboring bladder. The bladder goes haywire, hiccupping and emptying without notice, before the child can wake up or get to the toilet.

(Note that bedwetting is not caused by “deep sleep,” an “underdeveloped bladder,”  stress, or behavior issues; it’s all about constipation.)


But that’s not all! A stretched-out rectum is like a stretched-out sock: It loses springiness. The floppy rectum can’t squeeze down to expel the entire load of poop, and because the intestinal walls have lost tone, some of the poop just falls out. A floppy rectum also loses sensation, so these kids may not feel the urge to poop or notice when they have a poop accident. Even more poop piles up, further stretching the rectum and compromising its tone and sensation.


It’s a vicious cycle, but it can be stopped. To reverse chronic constipation, kids must fully evacuate every single day. This means they should poop in a squat. And if your home has a toilet rather than a hole in the ground, this means your child needs a foot stool.


For more than a decade I’ve been insisting my patients poop with a stool. Not just any stool, but one tall enough to place them in a full squat. I made this point in It’s No Accident: Breakthrough Solutions to Your Child’s Wetting, Constipation, UTIs, And Other Potty Problems, published back in 2011. But at the time, no stool was both tall enough for my young patients and specifically designed for pooping.


Eventually I approached the folks at Squatty Potty and suggested a children’s version of the stool. Turned out, they already had one in mind: the Squattypottymus. I’m thrilled the Squattypottymus is now available and proud to have a small financial stake in this product.


The Squattypottymus is taller than the Squatty Potty, so it places kids in just the right position to relax while pooping. The height is, cleverly, adjustable: Put the “hat” on the hippo, and you have a 12.5-inch-high stool perfect for kids who are potty training. Remove the hat, and the stool is 10.5 inches tall, suitable for older children. Little ones should use the contoured potty seat, which keeps them from falling into the toilet — or worrying about it.


Squattypottymus: For Potty Training and Beyond


Kids who potty train with a tall stool such as the Squattypottymus will have healthy pooping posture — and more confidence — from the get-go. They’ll evacuate more fully and be less prone to constipation.


Of course, a stool won’t prevent every kid from getting backed up. As my research shows, children who toilet train too early — before they have the judgment to heed their body’s signals — are at great risk for becoming constipated. In fact children who train before age 2 face triple the odds of developing wetting problems, as I explain in our guide “7 Super Important Rules for Potty Training Success.”


A potty stool won’t compensate for a diet of chicken nuggets and hot dogs, either. Children, like the rest of us, need to eat whole foods, especially fruits and vegetables, and limit the highly processed foods relentlessly marketed to them.


But I know pooping with a stool helps in a big way. And it’s just as critical for 3rd graders as it is for the potty-training set. In fact, one reason so many kids are clogged is a lack of follow up. Once a child is trained, we parents tend to stop paying attention to their peeing and pooping habits. We’re so thrilled to have ditched the diaper bag! But the years following potty training actually require more of our attention, because once the holding habit takes root, it’s difficult to reverse.


Learning to heed your body’s urge to poop requires daily reinforcement, and that’s not part of our culture. If healthy toileting were taught in preschool and reinforced in grade school, and if we monitored our kids for the subtle signs of constipation, we’d have a lot fewer cases of enuresis and encopresis.


Instead, we have a crisis. Consider:



Bedwetting and accidents are so common that many doctors consider them “normal.” But they are not normal. These conditions are a sign of chronic constipation and require aggressive treatment.


For children who have accidents, a tall stool is an essential component of this treatment. Pooping with a stool is part of the Modified O’Regan Protocol, the enema-based regimen I spell out in The M.O.P. Book: A Guide to the Only Proven Way to STOP Bedwetting and Accidents.


I’ve found that for children with milder symptoms, like stomach aches or the urgent or frequent need to pee, pooping with a stool can go a long way toward resolving their problems.


I think pooping with a stool is so important that I’ve featured foot stools, including the Squattypottymus, in my children’s books, Bedwetting and Accidents Aren’t Your Fault and Jane and the Giant Poop.


The modern toilet is not only here to stay but is actually getting taller. Standard toilets, 14 inches from floor to rim, have given way to 17-inch “comfort height toilets.” Companies boast that taller toilets “make sitting down and standing up easier for most adults, ensuring extra comfort.”


Of course, what these toilets actually ensure is more pooping problems, especially for kids.


So if you don’t plan to replace your family’s toilet with a hole in the ground — and I don’t! — I say: Get your kid a Squattypottymus.




Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and coauthor of five books, including The M.O.P. Book: A Guide to the Only Proven Way to STOP Bedwetting and Accidents, Bedwetting and Accidents Aren’t Your Fault, and Jane and the Giant Poop.

We thank Dr. Hodges for his contribution to our blog! To learn more about adult and pediatric pelvic floor disorders please visit our website.


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