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.


What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.


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