The critical factor in patients with POP who decide to pursue interventional measures is the worsening of symptoms, rather than the anatomical progression of the prolapse . In our study, the waiting time of patients in group 2 (squatting position) to decide on surgery was shorter than that of patients in group 1 (sitting position) (p = 0.001). In addition, PFIQ and POPIQ scores were higher in group 2 patients than in group 1 patients (p = 0.001, p
Various factors influence women’s toilet behavior, including social, cultural, and medical factors. In Western countries, the widespread use of seated toilets began in the 19th century when sewage systems were developed to improve sanitation. . Women in various Asian and African countries urinate and defecate in a squatting position, while a sitting position is preferred in Western countries.
Pelvic floor health and AIP are critical components of voiding, defecation dysfunction, and POP etiopathogenesis in women. Changes in IAP and pelvic floor muscle loading differ in squatting and sitting positions. Studies have concluded that defecation is physiological in the squatting position; the pelvic floor muscles are more dilated . Although some studies have argued that the squatting position is better for defecation, there is no consensus on whether the position affects voiding function. In addition, there are no studies on the effect of toilet position on the natural course of POP.
AVWP, known clinically as cystocele, is the most common form of POP . The anterior vaginal wall is also the area with the highest rate of primary and recurrent supportive defects . Many risk factors for POPs have been proposed, and the cause is most likely multifactorial. The magnitude of AVWP is sensitive to peak abdominal pressure, and a decrease in the resistance of the levator ani muscle to stretch results in a larger hiatus size . Squatting movements are also considered to be one of the most intense actions that lead to increased abdominal pressure. Evidence has emerged that strenuous physical activity increases the risk of pelvic floor disorders, such as POP and urinary incontinence . The definition of “exhausting” is mostly subjective: in the pelvic floor literature, “exhausting” generally refers to activities believed to significantly increase IAP. . There is no established, evidence-based upper threshold used to guide activity restriction for safety purposes. In laboratory studies, a safety threshold value > 60 cmH2O is recommended as the maximum IAP. Activities that increase IAP above this threshold may be restricted .
Intrathoracic pressure (ITP), IAP and the Valsalva maneuver (VM) play an important role in the activities of movements of daily living . An increase in IAP is needed to maintain balance during trunk movement. IAP is lowest when the trunk is in an isometric position. VM-initiated increases in ITP and IAP are considered body techniques that increase body stability during physical activity . IAP levels change in response to trunk asymmetry. During flexion-extension movements of the trunk, the pressure in the abdomen can increase to 150 mmHg. With the twist of the body, the IAP also increases . The increase in IAP is achieved physiologically by reflex contracting the muscles of the anterior abdominal wall to provide stabilization of the trunk . There are no studies measuring IAP during toileting. However, following studies evaluating the effect of a squatting position on IAP, it can be expected that the IAP that occurs during a squat is higher than that during a sitting position. [4, 17, 20].
Patients with POP usually also have a high BMI. A high BMI is an important factor in increasing IAP. Patients with a high BMI may need to increase their IAP to maintain balance when squatting. Additionally, patients who perform urination and defecation in a squatting position do so by opening their legs and squatting low enough to bring their knees to shoulder level; this can cause the genital hiatus to open more than when sitting. In patients who defecate and urinate in a squatting position, increased IAP and greater opening of the genital hiatus may facilitate exit of the vaginal wall from the hymenal ring.
Evidence regarding the evolution of POPs is sparse and conflicting . Since AVWP is a disease with minimal morbidity, it is crucial to understand the factors that increase the likelihood that patients will choose intervention over observation. This will allow healthcare providers to provide more comprehensive advice to women who are considering treatment measures for this condition. Vaginal swelling that the patient can see or feel is the most specific symptom of POP . The complaint of bothersome vaginal swelling is associated with the final intervention decision. However, the intensity of the symptoms rather than the findings of the physical examination determines the patient’s treatment preferences. Vaginal bulge was considered the primary symptom when choosing surgery in most patients in our study. Specifically, vaginal bulge was the main symptom in 96.8% of patients in group 2 and the main symptom in 84.1% of patients in group 1. This difference may be related to the patient experiencing more vaginal swelling due to her IAP increasing when she squats and then stands up, rather than her IAP increasing after taking a squat position.
Most clinicians accept an association between AVWP and lower urinary tract dysfunction and often assume a strong association between worsening AVWP and worsening urinary symptoms. The decision to intervene is consistent with the changes or worsening of these associated conditions. In our study, it was observed that the rate of urge and incontinence in group 2 patients was higher than that of group 1 patients. However, the rate of splinting or fingering for urination was lower. in group 2. The reason for this may be the balance problem that patients may experience when performing the fingering action in a squatting position.
In current practice, there are two active therapeutic interventions for POP: the use of an intravaginal pessary or surgical correction. A third option, which avoids surgical and anesthetic complications, is observation. When discussing these treatment options with a patient, a healthcare professional should consider the patient’s preferences, lifestyle factors, size of prolapse, comorbidities, age, desires having children in the future and the risks and benefits of all treatment options. While informing the patient of treatment options, it is important to explain lifestyle changes aimed at reducing pressure on the pelvic organs. Of these recommendations, weight loss and avoidance of activities that increase PAI, especially in obese women, should come first. Additionally, given the data we obtained from our study, changing the toilet position may also be a lifestyle change option.
This study has some limitations. Patients’ IAP in the squatting and sitting positions was not measured with a rectal manometer. Also, it was asked whether patients did heavy housework such as lifting a sofa or a bed, but there are no data on the details of the type of housework.