You are on page 1of 13


Oleh : Adelia Handoko
Pembimbing : dr. Harlina Soetjipto, MS



Original Article
Influence of body posture on defecation: a prospective study
of The Thinker position
S. Takano, D. R. Sands

Tech Coloproctol (2016) 20:117121

DOI 10.1007/s10151-015-1402-6
Received: 20 August 2015 / Accepted: 3 November 2015 / Published online: 21 December 2015
Springer-Verlag Italia Srl 2015

Fecal outlet obstruction lowers quality of life (QOL) of patient with
functional constipation
Outlet obstruction may be attributed multiple causes, like nonrelaxation of
puborectalis muscle, anismus, rectal prolapse, rectocele and rectal
Tsuchino et al. assessed rectal and anal pressure during defecation with the
patient in a bending position rather than a normal sitting position
The authors reported that this position resulted in higher rectal and lower
anal pressures. This position, described by Tsuchino, is reminiscent of Rodins
sculpture, Le Penseur
This study was to assess the influence of The Thinker position on
defecation during cinedefecography.

Fig. 1 Le Penseur = The Thinker sculpture by Auguste Rodin

Patients and Methode

Study protocol approved by Cleveland Clinic Florida Ethical Committee,

randomized, each patient gave written informed consent.

Inclusion criteria:

The criteria for enrollment in this study were patients with constipation, who were
scheduledto 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

Exclusion criteria

were patient age under 18 years,


and prior rectal surgery and patients who could evacuate the paste in the vertical
position on cinedefecography


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.

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
position involves bending the upper body forward and placing the elbow on
the knee

Common diagnoses that can be made by this test include nonrelaxing

puborectalis syndrome, perineal descent, rectocele, enterocele,
sigmoidocele, and rectoanal intussusception.

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
was defined as the angle between the axis of the anal canal and the distal half
of the posterior rectal wall

was considered as the vertical distance between the ARA position and a line
drawn between the pubic symphysis to the tip of the coccyx.

was measured as the distance between the ARA and the pubic symphysis.

The patients who could

evacuate the paste in
The Thinker position
have significant larger
PPD and longer PRL,
but no significant in
Also there is no
significant difference
with age and sex
between those two


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 thetoilet.

We think the body position during defecation is one of the

important elements of defecation.

While squatting for defecation continues to be the principal

position in Asia and Africa, Western populations have become
accustomed to sitting on a commode

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

Tagart reported that the ARA straightens with fully flexed

hipscorresponding to the squatting position assumed for
defecation and converts the rectoanal outlet into a
straight canal, thereby facilitating rectal emptying

Altomare et al. [14] noted that when the patient sits on a

commode, the ARA opens wider than it does in the
standing position.

Tsuchino et al. showed higher rectal pressure and lower anal pressure in this
position. Furthermore, they suggested this position creates higher
intraabdominal 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
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 forpatients with
fecal outlet obstruction.


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.