Hi friends! When you are ready to pee, do you sit on the toilet, squat and hover over the toilet, or stand at the toilet? Did you know that your position may impact your ability to pee and empty your bladder effectively?
There are many factors that can affect the position that you try to pee. Social norms, the ability to get on/off the toilet, your balance, the cleanliness of the toilet/bathroom, and more. One study found that 85% of women hover over public toilet seats and 37% of women would not sit on a friend’s toilet (Moore, 1991). In Western counties standing at the toilet is more common for men, while in Eastern and Asian counties sitting and crouching is more common (de Jong, 2014).
So what position should you be in to pee? The simple answer to that is researchers aren’t sure. There have been several studies done on this topic and we will discuss them, but many of the studies have had low sample sizes and have not been high-quality studies. Overall, these studies have found that there may be a difference in position in individuals that have pelvic floor muscle dysfunction or lower urinary tract symptoms and that sitting may be best.
Lower urinary tract symptoms include (Lepor, 2005):
Hesitancy to pee
Poor urine stream
Straining to pee
Dribbling
Feeling of incomplete bladder emptying
Peeing frequently
Urinary urgency
Getting up at night to pee (nocturia)
Urge incontinence
Now why might our position make a difference in how well we are able to pee? One theory is that crouching or squatting contracts the hip adductor muscles and this encourages the pelvic floor muscles to contract as well (Moore, 199). The pelvic floor muscles wrap around the urethra. The pelvic floor muscles need to relax and lengthen to allow the urethra to open so that pee can exit the body. It is also thought that contraction of the hip adductor and pelvic floor muscles can limit the ability of the bladder muscle to squeeze to get urine out (Moore, 1991).
Most studies that looked at toileting positions use post-void residual (PVR), the medical term for how much urine is left in the bladder after we pee, as the measurement to determine how well we pee in each position. In general, the lower the PVR is after peeing means we have emptied our bladders better. It is commonly accepted that if the PVR is less than 150 ml the bladder is probably emptying effectively (Khayyami, 2016).
Most of the studies have looked at either males or females but not both at once, so we will talk about them separately in this blog as well.
For individuals born with male anatomy, one factor that often impacts voiding is a condition called benign prostatic hypertrophy (BPH), also known as an enlarged prostate. With BPH the prostate is larger than normal and this can place extra pressure on the bladder and the urethra. Part of the urethra passes through the prostate. When the prostate is enlarged, this can place extra pressure on the urethra can make it more difficult to pee—imagine kinking a hose.
A few studies researched different positions for peeing in individuals with BPH. One study found no difference in PVR for patients in a standing or sitting position (Usal, 2004). While a different study found that patients with lower urinary tract symptoms, the PVR was improved with sitting compared with standing to pee, but with patients with no symptoms there was no difference between the two positions (de Jong, 2014).
Another study found that patients with BPH had improved urinary flow rates when sitting but no significant difference in PVR (Koc, 2013). This means that when sitting, the men with BPH emptied their bladders more quickly but there was no difference in the amount of urine they were able to empty compared with those who stood to pee.
So what does this mean? If you were born with male anatomy and have no urinary or prostate issues, you can probably continue to stand to pee if you desire with little impact. However, if you are dealing with any symptoms, it may be best to try sitting to pee.
For individuals born with female anatomy, one study found a significant difference in PVR with squatting/hovering over the toilet versus sitting on the toilet (Moore, 1991). However, another study found no significant difference in PVR between the two positions (Duenas-Garcia, 2019). Similar to the studies done with males, the studies that looked at individuals without any symptoms, there was no different between the two positions.
While higher quality studies are needed to make a solid recommendation, it is a good habit to sit on the toilet instead of hovering when peeing, especially if you have any urinary symptoms or signs of pelvic floor dysfunction. Regardless of your position, studies have shown that making sure your feet are on the ground (or at least supported) and not dangling can improve your ability to pee (Rane, 2008).
If you are hovering to pee, it’s important to have strong leg muscles and good coordination of the pelvic floor muscles so that you can relax them while you hover. Check out the video below for exercises to improve your ability to squat and hover.
If you are experiencing any symptoms of pelvic floor muscle or urinary dysfunction, it is important to talk with your healthcare providers. A pelvic floor physical or occupational therapist can be a great resource and help address any issues with difficulty peeing or issues like urinary incontinence. Find a therapist near you at www.mypfm.com/find-a-pt.
To learn more about your pelvic floor muscles, check out these great resources:
Watch our YouTube playlist on Bladder Concerns and Your Pelvic Floor
Watch Netflix for Your Pelvic Floor at Pelvic Flicks
Visit our Amazon store for our favorite pelvic health products
Sign up for our email newsletter
For providers, check out myPFM Academy to learn more so you can better help your clients. With two membership options, you have access to courses, a growing library of patient handouts, hundreds of custom sharable images and infographics, and multilingual resources. At myPFM Academy you’ll find courses like:
Pelvic PT for Benign Prostatic Hyperplasia (BPH) with Sarah Prestegard, PT, DPT
Overactive Pelvic Floor Muscles with Jeanice Mitchell, PT, MPT, WCS, BCB-PMD
Understanding Chronic Prostatitis for Health Professionals with Dr. Susie Gronski, PT, DPT, PRPC, WCS
Written by Emily Reul, PT, DPT
References
De Jong Y et al. Urinating standing versus sitting: position is of influence in men with prostate enlargement. A systematic review and meta-anaylsis. PLoS One. 2014;9(7):e101320.
Duenas-Garcia OF, Matta-Gonzalez M, Fuller K, Fang W, Shapiro RE. The effect of toileting position on uroflow curves in young healthy nulliparous women. Scientifica (Cairo). 2019;3:2019:5273083.
Khayyami Y, Klarskov N, Lose G. Post-void residual urine under 150 ml does not exclude voiding dysfunction in women. Int Urogynecol J. xi2016;27:467-473.
Koc G et al. The effect of alpha blockers on uroflowmetric parameters in different voiding positions. Can Urol Assoc J. 2013;7(5-6):329-332.
Lepor H. Pathophysiology of lower urinary tract symptoms in the aging male population. Rev Urol. 2005;7:S3-S11.
Moore KH, Richmond DH, Sutherst JR, Imrie AH, Hutton JL. Crouching over the toilet seat: prevalence among British gynaecological outpatients and its effect upon micturition. Br J Obstet Gynaecol. 1991;98(6):569-572.
Rane A, Corstiaans A. Does micturition improve in the squatting position? J Obstet Gynaecol. 2008;28(3):317-319.
Unsal A, Cimentepe E. Voiding position does not affect uroflowmetric parameters and post-void residual urine volume in healthy volunteers. Scand J Urol Nephrol. 2004;38:469-471.
Unsal A, Cimentepe E. Effect of voiding position on uroflowmetric parameters and post-void residual urine volume in patients with benign prostatic hyperplasia. Scand J Urol Nephrol. 2004;38:240-242.