Which toileting postures and breathing techniques best reduce straining during bowel movements?
Executive summary
Modern evidence and pelvic-health guidance converge on two clear levers to reduce straining during bowel movements: adopt a posture that mimics a natural squat (or use a footstool to raise the knees above the hips) to straighten the rectoanal angle and relax the pelvic floor, and use slow diaphragmatic breathing with gentle, audible exhalation-driven pushes rather than breath-holding Valsalva-type strains [1] [2] [3].
1. Squatting vs. sitting: the core posture debate
Controlled studies and scoping reviews find that squatting reduces the time and subjective effort of defecation compared with standard sitting toilets, with volunteers reporting markedly less straining and faster sensation of complete emptying in the squat position [1] [4]; however, sitting toilets with ergonomic adjustments can still be effective for people with mobility needs or older adults who require stability [4].
2. Footstools and “potty stools”: a practical compromise
For those using Western toilets, elevating the feet on a footstool to place knees above hips—often called a “toilet stool” or Squatty Potty—mimics the squat angle and has been linked to reduced defecation time and subjective straining in multiple reports and trials, although some studies show angle changes without objective improvements for all measures, so benefit may be individual [2] [4].
3. Breathing mechanics: diaphragmatic breathing and exhalation-driven pushing
Pelvic health clinicians recommend belly/diaphragm-focused breathing—“belly big” on inhale, relax and exhale while gently pushing—to relax the pelvic floor and create coordinated abdominal pressure; this technique avoids breath-holding and the high-pressure Valsalva manoeuvre that increases hemorrhoid and pelvic-floor strain [3] [5] [6]. Practical cues include softening the face and hands, an audible exhale while pushing, and repeating short attempts (3–5) with normal breaths between attempts rather than prolonged straining [5] [7].
4. Position details and adjunct cues that help
Lean slightly forward with elbows on thighs to help align the pelvis, keep feet flat on a stool or ground so heels are not lifted, imagine the pelvic floor relaxing downward, and use a gentle abdominal squeeze timed to exhalation to assist passage; clinicians warn against sitting longer than about 10 minutes and against forceful bearing down, advising to stand and walk if nothing comes after a few attempts [8] [6] [2] [7].
5. Who benefits, when to seek help, and limits of the evidence
Most healthy adults with occasional constipation report symptom improvement from posture and breathing adjustments, and pelvic-floor therapists use these as first-line behavioral strategies, but evidence is heterogeneous—some trials find clear benefits while others show limited objective change—so persistent constipation, blood in stool, or pain warrants medical assessment rather than repeated straining [4] [2] [1]. Reporting is robust on short-term symptomatic improvements and plausible mechanisms (rectoanal angle straightening; pelvic floor relaxation) but less definitive on long-term outcomes across diverse patient groups [4] [1].
6. Bottom line and actionable protocol
To reduce straining: raise knees above hips with a footstool or adopt a true squat when feasible, lean forward, breathe into the lower belly, then exhale while gently pushing (audible exhale, 3–5 gentle attempts), avoid breath-holding or prolonged bearing down, limit toilet time to under ~10 minutes, and consult pelvic-floor physical therapy or a clinician if problems persist—these steps reflect clinical guidance and controlled studies showing reduced effort and faster evacuation in squat-like postures combined with diaphragmatic, exhalation-timed pushing [2] [5] [1] [3].