|Year : 2016 | Volume
| Issue : 2 | Page : 77-82
Analysis of correlation between defecation posture and risk of urinary tract infections among adolescent populations
Subramani Parasuraman1, Lim Ee Wen1, Aaseer Thamby Sam2, Parayil Varghese Christapher1, Krishnamoorthy Venkates Kumar3
1 Units of Pharmacology, Faculty of Pharmacy, AIMST University, Jalan Bedong-Semeling, 08100 Bedong, Kedah, Malaysia
2 Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, AIMST University, Jalan Bedong-Semeling, 08100 Bedong, Kedah, Malaysia
3 Pharmaceutical Technology, Faculty of Pharmacy, AIMST University, Jalan Bedong-Semeling, 08100 Bedong, Kedah, Malaysia
|Date of Submission||02-Apr-2016|
|Date of Acceptance||03-May-2016|
|Date of Web Publication||4-Jul-2016|
Unit of Pharmacology, Faculty of Pharmacy, AIMST University, 08100 Bedong, Kedah
Source of Support: None, Conflict of Interest: None
Objective: To assess the correlation between defecation posture and risk of urinary tract infection (UTI) rates among a representative adolescent sample in Malaysia
Methods: The study was conducted between February 2015 and September 2015 using Google forms. A total of 568 enrolled and 551 participated in the study. The online questionnaire was divided into three sections viz., informed consent info; demographic details; knowledge and attitude analysis. The form was circulated online to obtain the responses.
Results: The mean age of study participants was 23.99 6.04 years. Majority of the study population used western type of toilet and felt comfortable with it. In the public context (movie halls, shopping malls etc.), most of the study participants preferred to use Indian/squatting type of toilet to avoid bodily contact with the toilet bowl. The study population was Malaysian. The respondents normally defecated at least once a day and normally took <10 min to defecate. About 38.8% of the respondents who were having sharing accommodation were not sure about the frequency of toilet cleaning. Totally, 10.7% of the study participants had previous history of UTIs, with the average duration of infection being around 5 days to 3 weeks.
Conclusion: Defecation is an important physiological event and many of the study participants required more education on normal physiological methods of defecation postures. Appropriate education is required to improve the personal health and reducing the risk of acquiring UTIs.
Keywords: Sitting, squatting, toilet posture, urinary tract infections
|How to cite this article:|
Parasuraman S, Wen LE, Sam AT, Christapher PV, Kumar KV. Analysis of correlation between defecation posture and risk of urinary tract infections among adolescent populations. Environ Dis 2016;1:77-82
|How to cite this URL:|
Parasuraman S, Wen LE, Sam AT, Christapher PV, Kumar KV. Analysis of correlation between defecation posture and risk of urinary tract infections among adolescent populations. Environ Dis [serial online] 2016 [cited 2018 May 21];1:77-82. Available from: http://www.environmentmed.org/text.asp?2016/1/2/77/185305
| Introduction|| |
Urinary tract infections (UTIs) are the second most common type of infections in the human body and affect millions of people globally each year. Females are more prone to UTIs and reasons for which are not well understood. Among males, incidences of UTIs are less common than females, but are very serious when they do occur. UTIs are categorized by clinical syndromes and by gender (i.e., acute cystitis in young women; acute pyelonephritis, catheter-related infection in men, and asymptomatic bacteriuria in the elderly).  Rates of UTIs and incidences of fungal infections are high among people who use public and Western/sitting toilets. In males, UTIs can be classified as acute prostatitis, chronic prostatitis, nonbacterial prostatitis, and prostatodynia. Males mostly acquire UTIs in the prostate area. In females, UTIs can be classified as symptomatic bacteriuria, acute cystitis, acute pyelonephritis, and nonbacterial cystitis. Females acquire UTIs in urinary bladder, urethra, and kidneys. ,
A common cold, shortness of the urethra, bacteria from fecal matter (from the anal opening can be easily transferred to the urethral opening), recent or frequent sexual activities, and certain type of contraceptives are risk factors in females for UTIs development. , Disease states such as diabetes (in females) and polymorphism in SPA1B, CXCR1 and 2, TLR2, TLR4, and TGF-β1 genes increase the risk of UTIs and recurrent UTIs. , Mostly men who have issues with the prostate gland such as benign prostatic hyperplasia, enlargement of the prostate gland may cause obstruction in the urinary tract, thereby increasing the risk of UTIs. UTIs in men are more serious than in women, and more likely to result in hospitalization. , In children, UTIs are very common and highly prevalent among boys than girls.  In American, 3% of children develop UTIs during first few months of birth. UTIs are very common among pregnant women and are caused by Escherichia coli. Further infection can lead to development of cystitis or pyelonephritis. 
Mpotane et al. studied the role of toilets in the transmission of vaginitis and UTI's among the resident of Huis Welgemoed University campus. From the study (questionnaire-based), they concluded that 46% of the respondents had one or more episodes of vaginitis and UTI's, which included vaginal itching, burning sensation during urination, discolored urine, pain around the bladder area. 
Social factors such as using public and open toilets are one of the main reasons to acquire UTIs because of large numbers of bacteria and virus seeding in toilets.  Nearly 40% of the world's population lack the access to toilets and this has serious impact on health and social development. Approximately, fifty bacteria per square inch in toilets results in transmission from person-to-person via the toilet seat. In USA, 50% women do not sit on toilet seats in a public bathrooms to avoid restroom paranoia for suspicion of infections caused by Streptococcus, Staphylococcus, E. coli and Shigella bacteria, hepatitis A virus, the common cold virus, and various sexually transmitted organisms.  Barker and Jones studied the spreadability of infection caused by aerosol contamination in domestic toilets and they concluded that "many of individuals may be unaware of the risk of air-bond dissemination of microbes when flushing the toilet." This may be true because most people are unaware about the disadvantages of using common toilets.  Hence, this present study was planned to determine the toilet posture and analyze the frequency of UTI rates among a representative adolescent population in Malaysia.
| Methods|| |
The study was conducted after obtaining permission from the Institution Ethics Committee. Details of the study subjects will be maintained confidentially as per the Declaration of Helsinki. The study was conducted among the adult populations of Malaysia. The customized online questionnaires were used to assess the awareness of usage of common toilets and rate of UTIs [Annexure 1]. The study participants were invited by personal communication and by social media. The study was conducted between February 2015 and September 2015 using Google forms. Informed consent forms with the requisite information and study summary were placed on first page of the survey form. The first page of the survey form briefed about the study and provided information about the principal investigator. A total of 568 Malaysians were enrolled in the study and 551 consented participate in this online study. The online questionnaire was divided into three sections viz., inform consent info, demographic details, and knowledge and attitude analysis.
The frequency of knowledge and attitude about usage of common toilets, UTIs frequency, and binary logistic regression for infection rate common toilet usage were calculated using Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc. USA).
| Results|| |
Totally 568 subjects enrolled in the study and 551 (97%) subjects participated in the study. About 17% of study participants' questionnaires were excluded from the analysis due to the incomplete nature of the returned forms. The mean age of the study participants were 23.99 ± 6.04 (mean ± standard deviation) years. The study participants were from various parts of Malaysia and the population was homogenized with different races. Most of the study participants were students (%) with sharing accommodation. The demographic details of the study populations are summarized in [Table 1].
Majority of the study population are using western type of toilet and feeling comfortable with it. In the public context, however most of the study participants prefer to use Indian/squatting type of toilet to avoid bodily contact with the toilet bowl. Types of toilet used by the study populations are summarized in [Table 2]. The study populations have the habit of defecating at least once a day (52.5%) and normally take <10 min to defecate (68.1%). A significant proportion of the study population (42.5%) was cleaning their toilets at least once a week. The study participants (38.8%) who were having sharing accommodation were not sure about the frequency of toilet cleaning. The process of defecation is a normal physiological and relaxation technique, but few of the study population indulge in certain activities such as using mobile phones (31.9%), reading novels/newspaper (6.7%), and reading office notes (1.1%) while defecating. About 60.3% of the study participants did not do any other activities during defecation. Almost all the study participants (98.5%) were using water (34.3%) or liquid soap (65.7%) for washing hands after defecation [Table 3].
The education about the UTI is needed for the general public. The study data showed that around 43.2% of study participants were not having adequate knowledge about UTIs. Totally 10.7% of the study participants had previous history of UTIs, with the average duration of infection around 5 days to 3 weeks. When compared to males, females are more prone to UTIs [Table 4]. 10.7% of study participants had a known family history of UTIs, with higher incidences among females. Common toilet usage has 2.031 (95% confidence interval of 0.936-4.406) times higher risk of development of UTIs. Frequency of UTIs among study participants and family history of UTIs are summarized in [Table 4]. The symptoms had/felt by study subjects are summarized in [Figure 1] and [Figure 2], which are characteristic of/indicative of UTI risk.
|Figure 1: Symptoms of urinary tract infection among female participants (N = 394)|
Click here to view
|Figure 2: Symptoms of urinary tract infection among male participants (N = 308)|
Click here to view
| Discussion|| |
Our study revealed that majority of the respondents use common toilets in their residence (76.2%) and is comfortable with the western type of toilet (58.8%). In the public scenario, most of the study participants prefer Indian type of toilet (69.1%) to avoid bodily contact with the toilet. The result also indicates that the study participants using western toilet have more incidence of UTIs than others. Vyas et al. reported that the personal contact area with western toilets is high because many of the people adopt the sitting position, which may increase the chances of infection. 
UTIs are the most common bacterial infections affecting 150 million people globally. This present study also showed that females have experienced more incidences of UTIs than men. Compared to males, females are more prone to have UTIs and they have estimated the incidence of 0.5-0.7% UTIs per year.  In our study, 75.5% of study participants are in the age group of 18-25 years and 10% of study participants had history of UTIs. Foxman also reported that females have higher incidences of UTIs than males and nearly 1 in 3 women had at least 1 episode of UTI requiring drug therapy by the age of 24 years.  In many of the studies, it was reported that greater age group has more incidence of UTIs because of their poor health conditions. Apart from UTIs, an advance in the age also increases the chances of bacterial, fungal, and protozoal infections. 
The rate of UTIs may also depend on time spent in toilets and frequency of toilet cleaning. Many of the study participants use common toilets and are not aware about the cleaning frequency of their toilet. Tumwebaze and Mosler suggested that cleanliness of the shared toilets are mainly dependent on users' cleaning frequency and cooperation. They found that 14.4% of study population do not participate in cleaning the toilets. 
More than 50% of study participants adapt a sitting posture for defecation, which is not a healthy practice. Squatting posture is far superior in terms of preventing UTIs and is practiced by the users of Indian/Japanese type of toilets. In any toilet, squatting posture is advisable for the users to maximize the efficiency of elimination. In sitting posture, user places their knees at a 90°C angle to their abdomen, which hinders elimination by pinching of the anal canal.  To avoid the sitting posture in western toilet, users can use Squatty Potty to avoid hindrance to fecal elimination by pinching of the anal canal. UTIs are most common in women than men and about 50-60% of women will develop UTIs at least once during their lives.  We also observed the same in this study. The frequency of the UTIs is more with the participants who are using sitting posture in toilet than squatting posture. Squatting may be discomfort to the user but this will be a healthy defection posture and preventing development of hemorrhoids/piles.  About 68.1% of the study participants spend <10 min for defecation, and 52.5% of study participants defecate at least once a day (highly dependent on food habits). Heaton et al. studied the frequency of defecation in East Bristol and found that 40% of males and 33% of females regularly defecate one time in every 24 h cycle.  From this study, we also observed that >50% of participants are regularly defecating one time in every 24 h cycle. 
Normally, engaging in any other physical activity is not advisable during defecation. However, 39.7% of the study participants were engaged with any one of either hand phones, reading, etc., which may reduce the anal muscle centrality and increase the risk of constipation. Usage of liquid soap for washing hands after defecation should be reinforced to the general public. The sample of these study participants is representing the general public and 34.3% of study participants were using only water for washing hands after defecation. Hand washing is an important event after any physical activity, which will prevent/control the rate of disease spread. 
| Conclusion|| |
Defecation is an important physiological event, and the public requires more education on normal physiological methods of defecation posture. Squatting method of defecation is advisable and this method prevents gastrointestinal disorders and improves the muscular strength in lower limbs. This study also identified the need for educating the public regarding their personal hygiene in the context of using toilets, the defecation postures, and reducing the risk of acquiring UTIs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Additional file 1]
| References|| |
Orenstein R, Wong ES. Urinary tract infections in adults. Am Fam Physician 1999;59:1225-34, 1237.
Urinary Tract Infections in the Adult Person, Clinical Practice Guideline. Healthscope Medical Centers. Available from:
. [Last accessed on 2014 Oct 31].
Mody L, Juthani-Mehta M. Urinary tract infections in older women: A clinical review. JAMA 2014;311:844-54.
Foxman B, Gillespie B, Koopman J, Zhang L, Palin K, Tallman P, et al. Risk factors for second urinary tract infection among college women. Am J Epidemiol 2000;151:1194-205.
Dienye PO, Gbeneol PK. Contraception as a risk factor for urinary tract infection in Port Harcourt, Nigeria: A case control study. Afr J Prim Health Care Fam Med 2011;3:4.
Geerlings SE, Stolk RP, Camps MJ, Netten PM, Collet TJ, Hoepelman AI; Diabetes Women Asymptomatic Bacteriuria Utrecht Study Group. Risk factors for symptomatic urinary tract infection in women with diabetes. Diabetes Care 2000;23:1737-41.
Zaffanello M, Malerba G, Cataldi L, Antoniazzi F, Franchini M, Monti E, et al. Genetic risk for recurrent urinary tract infections in humans: A systematic review. J Biomed Biotechnol 2010;2010:321082.
Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64:118-40.
Roehrborn CG. Benign prostatic hyperplasia: An overview. Rev Urol 2005;7 Suppl 9:S3-S14.
Urinary Tract Infection - Adults. Available from:
. [Last accessed on 2014 Nov 01].
Delzell JE Jr., Lefevre ML. Urinary tract infections during pregnancy. Am Fam Physician 2000;61:713-21.
Mpotane T, Ntswabule V, Mcpherson C, Botes E. The Role of Toilet Hygiene in Transmission of Vaginal and Urinary Tract Infections in Huis Welgemoed, Cut Campus. Available from:
. [Last accessed on 2014 Nov 08].
Gerba CP, Wallis C, Melnick JL. Microbiological hazards of household toilets: Droplet production and the fate of residual organisms. Appl Microbiol 1975;30:229-37.
5 Germs You Really Can Get from a Toilet. Available from:
. [Last accessed on 2014 Nov 02].
Barker J, Jones MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol 2005;99:339-47.
Vyas S, Varshney D, Sharma P, Juyal R, Nautiyal V, Shrotriya V. An overview of the predictors of symptomatic urinary tract infection among nursing students. Ann Med Health Sci Res 2015;5:54-8.
Kucheria R, Dasgupta P, Sacks SH, Khan MS, Sheerin NS. Urinary tract infections: New insights into a common problem. Postgrad Med J 2005;81:83-6.
Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs. Am J Med 2002;113 Suppl 1A:5S-13S.
Zielinski MD, Kuntz MM, Polites SF, Boggust A, Nelson H, Khasawneh MA, et al. A prospective analysis of urinary tract infections among elderly trauma patients. J Trauma Acute Care Surg 2015;79:638-42.
Tumwebaze IK, Mosler HJ. Shared toilet users′ collective cleaning and determinant factors in Kampala slums, Uganda. BMC Public Health 2014;14:1260.
Mercola. Want Better Bowel Movements? Squat, Don′t Sit! Available from:
. [Last accessed on 2016 Jan 10].
Saravanan M, Sudha R. Survey on urinary tract infection associated with diabetes mellitus. J Acad Ind Res 2014;6:258-62.
Dimmer C, Martin B, Reeves N, Sullivan F. Squatting for the Prevention of Haemorrhoids? Townsend Letter for Doctors & Patients; 1996. p. 66-70. Available from: https://www.uow.edu.au/~bmartin/pubs/96tldp.html. [Last accessed on 2016 Jan 14].
Heaton KW, Radvan J, Cripps H, Mountford RA, Braddon FE, Hughes AO. Defecation frequency and timing, and stool form in the general population: A prospective study. Gut 1992;33:818-24.
Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA. Hand washing promotion for preventing diarrhoea. Cochrane Database Syst Rev 2015;9:CD004265.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]