Various factors influence the toilet behavior women prefer, including social, cultural, and medical factors. In western countries, the widespread use of sitting toilets began in the 19th century when sewage systems were developed to improve sanitation [5]. Women in various Asian and African countries void and defecate in a squatting position whereas, the sitting position is preferred in western countries.
Pelvic floor health and IAP are essential components of voiding, defecation dysfunction, and POP etiopathogenesis in women. The IAP changes and pelvic floor muscle load differ in the squatting and sitting positions. Studies conclude that defecation is physiological in the squatting position; the pelvic floor muscles are more dilated [6]. Although some studies have argued that the squat position is better for defecation, there is no consensus on whether the position affects the voiding function. In addition, there is no study on the effect of toilet position on the natural course of POP.
The AVWP, known clinically as cystocele, is the most common form of POP [7]. It is also the compartment with the highest rate of primary and recurrent support defects [8]. Many risk factors have been proposed for POP, and the cause seems most plausible to be multifactorial. The size of the AVWP is sensitive to maximal abdominal pressure and, a decrease in the resistance of the levator ani muscle to stretching results in a larger hiatus size [9]. The squat movement is also considered one of the most strenuous actions that enhance abdominal pressure. Evidence has emerged that strenuous physical activity increases the risk of pelvic floor disorders, such as POP and urinary incontinence [10]. The definition of ''strenuous'' is subjective primarily: in the pelvic floor literature, strenuous usually refers to activities thought to increase IAP significantly [11]. There is no established, data-based maximum IAP threshold used to guide activity restriction for safety purposes. In laboratory studies, a safe threshold value of > 60 cmH2O is recommended for maximal IAP. Activities that increase IAP above this threshold may be restricted [12].
Intrathoracic pressure (ITP), IAP, and the Valsalva maneuver (VM) play important roles in activities of daily life movements [13]. The IAP increase is needed in order to maintain balance during trunk movements. Intra-abdominal pressure was lowest when the trunk was in an isometric position. Increases in ITP and IAP initiated by the VM are considered body techniques that increase the stabilization of the body during physical activity [14]. The IAP levels change in response to trunk asymmetry. During the flexion-extension movement of the trunk, the pressure in the abdomen can rise up to 150 mmHg. As the body torsions, the IAP increases [15]. Increasing the IAP is provided physiologically by contracting the anterior abdominal wall muscles as a reflex to ensure trunk stabilization [16]. There is no study on measuring IAP during toilet positions. However, as a result of the studies, it can be expected that the IAP that occurs while performing the squat position will be higher than the sitting position.
Patients with POP generally also have a high BMI. This elevation is considered an important factor in increasing IAP. Patients with high BMI may need to increase their IAP in order to maintain their balance while taking the squat position. In addition, patients who perform voiding and defecation in the squat position do so by opening their legs and squatting low enough to bring their knees to shoulder level; this may cause the genital hiatus to open more than the sitting position. In patients who have defecation and micturition in the squat position, increased IAP and greater opening of the genital hiatus may make it easier for the vaginal wall to exit out of the hymenal ring.
The critical factor in patients with POP deciding to take intervening measures was the worsening of the symptoms rather than the anatomical progression of the prolapse [17]. In our study, the waiting time for Group 2 patients (squat position) to decide on the operation was shorter than Group I (sitting position) patients (p = 0.001). In addition, the PFIQ and POPIQ scores were higher in Group 2 patients compared to Group I (p = 0.001, p < 0.001). In addition, when the pain scores of each group of patients thought were questioned, the mean VAS score of the patients in the squatting position was significantly higher (p < 0.001). Among the patient groups with similar demographic data, the increase in the symptom scores and VAS scores of the patients who use the squat position may affect their decision to have the operation earlier. In addition, no statistical difference was found between the UIQ scores of the patients in both groups. As a result of these values, it can be thought that the toilet position does not affect the lower urinary tract symptom score in our patient groups. Publications concluding that defecation in the squat position is more physiological than sitting position [6]. No difference was observed in the Colo-Rectal-Anal Impact Questionnaire scores among our patient groups (p = 0.797).
Evidence regarding the evolution of POP is scarce and conflicting [17]. Given that AVWP is a disease with minimal morbidity, it is very crucial to understand the factors that increase the likelihood of patients choosing an intervention over observation. This allows healthcare providers to provide more comprehensive counseling to women considering therapeutic measures for this disease. Vaginal swelling that the patient can see or feel is the most specific symptom of POP [17]. The complaint of a disturbing vaginal swelling was associated with the final intervention decision. However, the intensity of symptoms rather than physical examination findings determines the patients’ treatment preferences. The most important factor in initially choosing observation and then choosing a therapeutic intervention is the worsening of symptom disturbance [18]. Vaginal bulging was seen as the predominant symptom in most patients in our study when deciding on the operation. Particularly, vaginal bulging is the leading symptom in 96.8% of patients in Group 2, while it is the leading symptom in 84.1% of Group 1 patients. This difference may be related to the fact that the patient feels the vaginal bulging more due to the increase in IAP while performing the squat position and then standing up, rather than increasing the IAP after taking the squat position.
Most clinicians accept an association between AVWP and lower urinary tract dysfunction and often assume a close association between worsening AVWP and worsening urinary symptoms. The decision to intervene is consistent with changes or worsening of these associated conditions. In our study, it was observed that the rate of urgency and incontinence in Group 2 patients was higher than in Group 1. However, the rate of splinting or digitation for urination was lower in Group 2. The reason for this may be the balance problem that the patients can encounter in performing the digitation action in the squat position.
In current practice, there are two active therapeutic interventions for POP treatment: the use of intravaginal pessary or surgical correction. A third option is an observation to avoid surgical and anesthetic complications. While discussing these treatment options with the patient, the healthcare professional should consider the patient's preference, lifestyle factors, prolapse size, co-morbidities, age, future childbearing desire, and the risks and benefits of all treatment options. While informing the patient about treatment options, it is important to explain the lifestyle changes related to reducing the pressure on the pelvic organs. Among these recommendations, weight loss and avoidance of activities that increase IAP, especially in obese women, come first. In addition, considering the data we obtained from our study, questioning the toileting position may also contribute to lifestyle changes.