Purpose. To evaluate the influence of the less expulsive defecation effort involved in a squatting defecation posture on the course of hemorrhoids.
Method. Sixty-eight consecutive patients presenting to family physicians with symptoms indicative of hemorrhoids were asked to assess the severity of their symptoms (on a scale of 0-4) before and after changing from a sitting to squatting defecation posture (trial) or before and after standard medical treatment (control). The treated patients whose symptoms were not relieved switched to a squatting posture during defecation thus serving as their own controls.
Results. Changing from a sitting to squatting defecation posture (trial group) caused a significant reduction in the intensity of all symptoms, while medical treatment (control group) led only to a reduction in bleeding and pain. A comparison of the two groups revealed a significant decrease in the bleeding and pain in the trial group compared to the control, but no significant difference in the extent of prolapse. The patients in the control group who switched to a squatting defecation posture reported significant reduction in the bleeding, prolapse and pain .The percentage of patients with complete cessation of bleeding and pain was significantly greater in the trial group and in patients who reverted to a squatting defecation posture after being treated medically.
Conclusion. Changing from a sitting to a squatting defecation posture causes a significant reduction in the intensity or a complete resolution of symptoms associated with hemorrhoids.

            The average individual strains significantly more during defecation while seated on a toilet bowl of standard or low height than in a squatting posture (1). There is common agreement in the literature that excessive straining during defecation is one of the major factors of hemorrhoids (2). We evaluated the influence of the reduced amount of straining that is required in the squatting defecation posture on the course of chronic internal hemorrhoids.

            The current study was performed by 12 primary care physicians in the setting of their practice of family medicine. Each of the physicians works separately at his own clinic. Six of the physicians followed up the patients who switched from a sitting to a squatting posture during defecation (trial group) and the other six did the same for the patients given standard medical treatment (control group). Each physician was asked to enroll in his group only six consecutive patients, in order to include an equal number of patients in the trial and control groups. The sample size calculation was based on observations from a preliminary report (3). The relatively large number of the physicians that took part in the trial can be explained by the aim to augment the objectivity of trial. The integration of the physicians in the trial was gradual, and the pace of patient recruitment varied from physician to physician. The trial lasted for one year.

            Entry criteria included chronic internal hemorrhoid disease defined by bleeding and prolapse as well as any accompanying symptoms. The other criterion for including the patients into the trial was the diagnosis of hemorrhoids during at least one visit in the course of their illness to proctologic or gastroenterological clinics. Exclusion criteria included the inability to assume a squatting posture for any reason and less than one or more than three bowel movements per day in order for the cohort to represent the majority (94%) of the population at large (4). Patients who had undergone any invasive proctologic procedure were excluded as well as patients with irreducible prolapse, grade four according to Goligher classification (5), as this stage is associated with irreversible destruction of hemorrhoid plexus.

            The stages of the hemorrhoids with their symptomatic equivalent were precisely defined (5, page 101) enabling diagnosis and follow up of the hemorrhoids based on clinical data. In addition the patients were asked to define the intensity of their symptoms on a scale of 5: nonexistent (0), very mild (1), mild (2), moderate (3), and severe (4). The attending physicians graded the symptoms of hemorrhoids based on the patient's subjective assessment of their symptoms as well as on the conventional staging of hemorrhoids (5).

            After the patients underwent physical examination, which included the inspection of the anal area and a digital examination of the ano-rectum, a standardized questionnaire on the type and severity of the symptoms was filled out. The questionnaire was identical for the trial and control groups and was administrated by the attending physician.

            A signed informed consent was received from the patients of the trial group and the study was conducted according to the ethical guidelines of the Declaration of Helsinki.

            In the trial group, after informing the patients about existing conventional methods of treatment of hemorrhoids they were instructed to defecate only in the squatting position and only in the flat container that was provided. The patients were strongly discouraged from attempting to squat over a standard toilet bowel since the typical water toilet bowel does not permit a convenient squatting defecation posture. Furthermore cases of standard toilet bowels breaking while people have squatted on its edges have been known to occur making it dangerous to do so.

            Patients in the control group received the standard conventional medical treatment with ointments, suppositories and bulk- forming agents (conventional doses of psyllium).

            The patients were questioned about any changes in the severity of their symptoms two weeks following bowel emptying in the squatting posture (trial group) or medical treatment (control group) and their subjective scores were recorded in the appropriate questioner administered by the attending physician. The decision regarding the duration of the trial was based on the observations from the preliminary report (3).

            The patients in the control group whose symptoms were not relieved as a result of the medical treatment were advised to discontinue treatment and to switch to defecating in a squatting posture and thus began the trial part of their own control study. The scores that were derived from their medical treatment were used as baseline values for the trial part of their own control study. The trial part of their own control study was conducted according to the same principles as described for the trial group.
Statistical analysis: The body mass index (BMI), age and baseline intensities of the symptoms (before medical treatment and before switching to a squatting defecation posture) of the two groups were compared based on the Mann-Whitney non-parametric test, and the gender of the participants according to the Chi-Square test. The group differences in the intensity of symptoms before and after medical treatment and before and after changing from a sitting to a squatting defecation posture and their interactions were analyzed using the Cochran - Mantel Haenszel test. The variation analysis was done using a mixed model. The paired analysis of the intensities of symptoms after medical treatment and after switching from a sitting to a squatting defecation posture in the own control part of the study was done by Wilcoxon Signed Ranks Test. Significance was set at P <0.05.

            The most important message of the trial is that six primary care physicians of the trial group and the six others of the trial part of the own control study found that such a simple act of changing from a sitting to a squatting defecation posture alleviates or completely eliminates hemorrhoid symptoms. Patients who switch to a squatting defecation posture early in the course of hemorrhoids experience a more distinct diminishment in the intensity of symptoms. In the progressive stages of hemorrhoids, such as prolapse, which is associated with anatomical changes of the hemorrhoid tissue (5) the alleviation of symptoms of hemorrhoids is less with the change in posture.

            Pain is not usually considered to be a symptom of chronic internal hemorrhoids (5) however as in our trial, Bennet et al. found some pain in 86% of 138 hemorrhoid patients (6) and Murie et al. in 54% of 82 patients (7). Anal irritation may accompany hemorrhoids (5, page 102) while a local skin condition in the perianal area can explain the itching.

            Partial or complete resolution of hemorrhoid symptoms among patients who switched from a sitting to a squatting defecation posture may be explained by the less expulsive effort needed to defecate in a squatting posture (1) thus preventing injury to the hemorrhoid plexus. The explanation for the diminished expulsive defecation effort in a squatting posture relates to the dynamics of the recto anal canal forming an approximate right angle (8, 9), which straightens with fully flexed hips-- corresponding to the squatting position assumed for defecation--and converts the recto anal outlet into a straight canal , thereby facilitating rectal emptying (10). For this reason, patients with less than one bowel movement per day were excluded from the trial since some of them suffer from constipation accompanied by an immobile perineum and an adynamic recto-anal angle (11).

            Burkitt D.P. found a very low prevalence of hemorrhoids in rural Africa and hypothesized that the high fiber diet which is typical for rural African populations is responsible for this phenomenon (12), ignoring the fact that people in these regions empty their bowels in a squatting posture in pit latrines (13). High fiber diets cause large rectal volumes (14) and evoke the recto anal inhibitory reflex (15) thus somewhat reducing the expulsive defecation effort (16).The major factor in the control of the passage of solid rectal content, however is not the anal sphincters but the angle between the rectum and that of the anal canal (17,18). Indeed, bulk-forming agents were tested in the treatment of hemorrhoids and were found to relieve the symptoms only slightly better (P< 0.025) than placebo after six weeks in one study (19), and no better than placebo after three months of treatment in another study (20).

            Numerous explanations have been offered to account for the development of hemorrhoids, such as hard stool, pregnancy, labor, violent exercise and others (5). We contend that these are only the triggers: the major factor that maintains and perpetuates the disease is the excessive expulsive defecation effort that is needed in the sitting posture. This explains why events common to all mankind, such as pregnancy, labor, occasional hard stool, violent exercise and others only rarely cause hemorrhoids in third world countries (12) in which squatting toilets are used, while the frequency of hemorrhoids has reached epidemic dimensions in the western world (21) in which the sitting defecation posture is commonplace. The occurrence of hemorrhoids can be traced back to antiquity (5), but so can sit toilet commodes for mostly the old, weak and handicapped, with the great majority of people habitually emptying their bowels in a squatting posture (22). Indeed, the widespread use of the sitting toilets in the Western world began only during the 19th century when sewage systems were developed to improve sanitation, as cities grew (22).
            The results of the present trial together with epidemiological data in the medical literature indicate that the prevalence of hemorrhoids in the Western World will sharply diminish by having people in the Western World switch to a squatting defecation posture.

Table 1 The percents of patients with complete cessation of symptoms.

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History of hemorrhoid research it is a history of great mistakes.