Abstract
Purpose:
The objective of this study was to assess toileting behaviors in community-dwelling adult women.
Materials and Methods:
Women age 18 years or older were recruited through a national registry of research volunteers, and asked to complete validated questionnaires assessing urinary symptoms and toileting behaviors, specifically place preference for voiding, convenience voiding, delayed voiding, straining during voiding, and position preference for voiding. The patient perception of bladder condition (PPBC) assessed the participant’s impression of their bladder health. Analyses determined the prevalence of each toileting behavior (reported to occur “sometimes” or more often), and differences in toileting behaviors between women with and without self-perceived bladder problems based on their PPBC response.
Results:
The 6695 women completing the questionnaires ranged in age from 18-89 (mean 41.4 ±15 years), with 79.9% identifying as white and 71.0% college-educated. Almost all women (98.8%, n=6613) reported place preference for voiding. Women reporting a bladder problem (n=3552, 53.1%) were more likely to report convenience voiding, delayed voiding, and strained voiding behaviors. While 99.4% (n=6657) of women reported sitting to void at home, only 76.2% (n=5108) of women reported sitting when using public toilets.
Conclusions:
Certain toileting behaviors, some of which may be considered unhealthy, were common in this sample of adult women, and most were associated with a perception of bladder problems. Voiding positions other than sitting were frequently used when away from home. These data have important implications for defining bladder health and for implementing behavior-based interventions for women with lower urinary tract symptoms.
Keywords: toileting behavior, urination, bladder, health behavior, women’s health
Introduction:
A healthy bladder is arguably a fundamental aspect of overall quality of life1. Bladder health encompasses both external and internal influences, including toileting behaviors, whether as a causative agent (i.e. toileting behaviors contribute to healthy or unhealthy bladders) or as an effect (i.e. bladder health impacts toileting behaviors). Many factors, including environmental, social and cultural norms, and normal and abnormal physiology may impact toileting2. However, few data exist about the specific toileting behaviors of adult women as they relate to a healthy bladder.
Toileting behaviors of urinary elimination are thought to include four domains: 1)voiding place preference, 2)voiding time, 3)voiding position, and 4)voiding style3. Concerns over cleanliness and hygiene may prompt women to avoid using public toilets or adopt alternatives to sitting on the toilet, such as hovering, squatting, or standing4. These adaptations in turn may affect bladder function as changes in urodynamic parameters have been demonstrated in hovering compared to sitting5. In children, it is well-recognized that certain toileting behaviors are associated with dysfunctional voiding and functional bladder disorders, which may persist into adulthood as overactive bladder (OAB)6,7. Yet, the relationship between toileting behaviors in adult women and bladder conditions remains poorly understood.
An unhealthy bladder is often characterized by symptoms, but implicit in the concept of bladder health is the individual’s perception of their bladder as a problem or not. While much of the information regarding toileting behaviors derives from studies assessing associations with lower urinary tract symptoms (LUTS)8-10, a knowledge gap exists regarding what types of behaviors may be representative of a healthy bladder and how toileting behaviors may differ between women with and without a perceived bladder problem. The aim of this study was to assess toileting behavior prevalence in a large sample of community-dwelling women and determine whether these behaviors differed between those who did and did not perceive that they had a bladder problem. Our hypothesis was that women with self-perceived bladder problems would report certain toileting behaviors more frequently than women without bladder problems.
Material and Methods:
This was an Institutional Review Board approved study of adult women recruited from ResearchMatch and Research Notifications Distribution List between October and December 2017. ResearchMatch is a national registry with 87,574 adult women volunteers supported by U.S. National Institutes of Health as part of the Clinical Translational Science Award program. Participants were additionally recruited through the Research Notifications Distribution List which is available to institutional researchers and has 18,500 male and female volunteers. In total, 106,074 volunteers received a single email titled “Toileting habits of women” soliciting participation to complete an anonymous, electronic survey consisting of validated questionnaires to better understand the “relationship between women’s bathroom habits and bladder and bowel issues”. Inclusion criteria included women 18 years or older who were able to read and complete the electronic research materials in English. Transgender women (n=4), individuals with a history of cystectomy (n=14), and incomplete surveys (n=1122) were excluded from the analysis.
The International Consultation on Incontinence Questionnaire- Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) is a validated questionnaire consisting of 12 questions with subscales of filling (score range:0-16), voiding (score range:0-12), urinary incontinence (score range:0-20), and OAB (score range:0-16) 11,12. Higher scores indicated more severe symptoms. Frequency >8 voids per day and nocturia >1 were chosen as cut-points due to previously published data regarding increased degree of bother above those voiding frequencies13,14. Urgency without leakage was defined as a positive response to rush to the toilet to urinate and a negative response to leakage prior to reaching the toilet. Women with urinary incontinence were categorized into mutually exclusive groups based on urgency urinary incontinence (UUI), stress urinary incontinence (SUI), or mixed urinary incontinence (MUI) defined by affirmative responses to leakage of urine before reaching the toilet, urine leakage in response to activity, or both, respectively. Urinary urgency included all women with urgency without leakage, UUI, and MUI.
The Toileting Behavior Scale is a measure that assesses five domains with a 5-point Likert scale: 1)place preference for voiding, 2)convenience voiding, 3)delayed voiding, 4)straining during voiding, and 5)position preference for voiding15. Convenience voiding is emptying the bladder in the absence of the sensation to void16 and delayed voiding is waiting to void despite an urge. Place preference describes any predilection for voiding at home or away. Position preference during voiding refers to the posture used on the toilet; sitting, hovering, squatting, or standing. Responses of “sometimes”, “often” and “always” were considered positive for that behavior.
The Patient Perception of Bladder Condition (PPBC) is a single-item instrument that measures global patient-reported assessment of bladder condition based on a scale of 1-617. Women reporting that their bladder condition causes them no problems were compared to women reporting any problem with their bladder condition. Specifically, women responding “My bladder condition does not cause me any problems at all” (PPBC score =1) were compared to women with a PPBC score >1 (at least “some very minor problems”).
Statistical Analysis:
This was considered an exploratory analysis. Chi-squared tests were performed to compare prevalence of toileting behaviors associated with women reporting problems related to their bladder condition versus women without problems based on the PPBC. ICIQ-FLUTS subscale scores were not normally distributed therefore non-parametric testing with Mann-Whitney U tests were performed to compare scores between women with and without bladder problems. Associations at a 2-sided p< 0.05 were considered significant. Statistical analyses were preformed using SPSS statistical software (IBM SPSS Statistics for Windows, version 24.0; IBM, Armonk, NY).
Results:
A total of 6695 women over the age of 18 years (range: 18-89, mean 41.4±15 years) completed the questionnaires and were included in the analysis for an estimated response rate of 6.3%. Overall, 3143 (46.9%) women reported no bladder problems (PPBC=1), while 3552 (53.1%) reported at least some very minor problems (PPBC>1). Specifically, 1866 (27.9%) responded as having a bladder condition that causes “very minor problems” (PPBC=2), 1034 (15.4%) had “minor problems” (PPBC=3), 530 (7.9%) had “moderate problems” (PPBC=4), 95 (1.4%) had “severe problems” (PPBC=5), and 27 (0.4%) had “many severe problems” (PPBC=6). The majority of women were white, college educated, employed, and married (Table 1). Women reporting no bladder problems were more likely to be younger, white, college educated, single, nulliparous, and ambulatory.
Table 1.
Demographic data of cohort
| Bladder condition causes… | ||
|---|---|---|
| No problems PPBC =1 | Some problems PPBC >1 | |
| No. of women (%) | 3143 (46.9) | 3552 (53.1) |
| Age, mean (± SD) | 37.5 (13.9) | 45.0 (15.3) |
| BMI, mean (± SD) | 26.6 (6.8) | 28.9 (8.1) |
| Race, no. (%) | ||
| White | 2,477 (78.8) | 2,871 (80.8) |
| Non-white | 666 (21.2) | 681 (19.2) |
| Education, no. (%) | ||
| Less than college graduate | 760 (24.2) | 1184 (33.3) |
| College, graduate or professional degree | 2383 (75.8) | 2368 (66.7) |
| Employment, no. (%) | ||
| Employed, student, or volunteer | 2521 (80.2) | 2819 (79.4) |
| Not employed, disabled, or retired | 622 (19.8) | 733 (20.6) |
| Marital status, no. (%) | ||
| Single | 1494 (47.5) | 1129 (31.8) |
| Married | 1298 (41.3) | 1726 (48.6) |
| Divorced/Separated | 296 (9.4) | 573 (16.1) |
| Widowed | 55 (1.7) | 124 (3.5) |
| Parity, no. (%) | ||
| Nulliparous | 1815 (57.7) | 1357 (38.2) |
| Multiparous | 1328 (42.3) | 2195 (61.8) |
| At least one vaginal delivery | 861 (64.8) | 1603 (73.0) |
| At least one caesarean section | 382 (28.8) | 578 (26.3) |
| Mobility, no. (%) | ||
| Use of assistive device* | 56 (1.8) | 197 (5.5) |
PPBC = Patient perception of bladder condition
Assistive devices included cane, walker, scooter, or wheelchair
Women with some bladder problems had higher ICIQ-FLUTS scores across all subscales, including filling, voiding, incontinence, and OAB (Table 2). Further categorization of incontinence types into SUI, UUI, and MUI showed that women without bladder problems on the PPBC were more likely to have pure SUI, while women with bladder problems had higher rates of UUI and MUI.
Table 2.
Comparison of lower urinary tract symptoms among women with and without bladder problems
| Bladder condition causes… | |||
|---|---|---|---|
| No problems PPBC =1 (n=3143, 46.9%) | Some problems PPBC >1 (n=3552, 53.1%) | p-value | |
| ICIQ-FLUTS Subscales, mean (95% CI) | |||
| Filling | 1.88 (1.8, 1.9) | 3.98 (3.9, 4.1) | <0.001* |
| Voiding | 1.15 (1.1, 1.2) | 2.12 (2.0, 2.2) | <0.001* |
| Incontinence | 1.27 (1.2, 1.3) | 4.49 (4.4, 4.6) | <0.001* |
| OAB | 2.04 (2.0, 2.1) | 4.59 (4.5, 4.7) | <0.001* |
| Nocturia >1, no. (%) | 376 (12.0) | 1133 (31.9) | <0.001† |
| >8 voids per day, no. (%) | 310 (9.9) | 887 (25.0) | <0.001† |
| Urgency (without leakage), no. (%) | 830 (26.4) | 600 (16.9) | <0.001† |
| Urgency urinary incontinence, no. (%) | 277 (8.8) | 484 (13.6) | <0.001† |
| Stress urinary incontinence, no. (%) | 606 (19.3) | 361 (10.2) | <0.001† |
| Mixed urinary incontinence, no. (%) | 638 (20.3) | 2155 (60.7) | <0.001† |
| Urinary urgency‡, no. (%) | 1745 (55.5) | 3239 (91.2) | <0.001† |
OAB = overactive bladder; PPBC = Patient perception of bladder condition
Mann-Whitney U statistical test
Chi-squared statistical test
Includes urgency (without leakage), urgency urinary incontinence, and mixed urinary incontinence
In all, 98.8% (n=6613) of women demonstrated at least one place preference behavior for voiding, including worrying about the cleanliness of public toilets (88.3%), avoiding the use of public toilets (61.1%), emptying bladder before leaving home (93.8%), or holding urine until returning to home (55.3%) (Table 3). Only bladder emptying before leaving home was significantly different between women with and without bladder issues. If busy, 85.1% (n=5700) of women would delay emptying their bladder and 53.1% (n=3552) would wait until they cannot hold their urine any longer. Women reporting problems with their bladder were more likely to have straining behaviors to begin voiding, throughout voiding, to empty their bladder completely, and to empty bladder faster than those women without bladder problems.
Table 3.
Descriptive data of the Toileting Behavior Scale with comparisons of women with and without bladder problems
| Bladder condition causes… | ||||||||
|---|---|---|---|---|---|---|---|---|
| Never | Rarely | Sometimes | Often | Always | No problems PPBC =1 (n=3143, 46.9%) | Some problems PPBC >1 (n=3552, 53.1%) | p-value* | |
| Place preference for voiding, no. (%) | ||||||||
| Worry about cleanliness of public toilets | 101 (1.5) | 685 (10.2) | 1856 (27.7) | 1591 (23.8) | 2462 (36.8) | 2754 (87.6) | 3155 (88.8) | 0.128 |
| Avoid public toilets | 794 (11.9) | 1738 (26.0) | 1884 (28.1) | 1426 (21.3) | 853 (12.7) | 1921 (61.1) | 2242 (63.1) | 0.092 |
| Empty bladder before leaving home | 133 (2.0) | 280 (4.2) | 808 (12.1) | 1929 (28.8) | 3545 (52.9) | 2913 (92.7) | 3369 (94.8) | <0.001 |
| Wait until home to void | 1098 (16.4) | 1833 (27.4) | 2055 (30.7) | 1160 (17.3) | 549 (8.2) | 1738 (55.3) | 2026 (57.0) | 0.152 |
| Convenience voiding, no. (%) | ||||||||
| At home | 2456 (36.7) | 2408 (36.0) | 1246 (18.6) | 358 (5.3) | 227 (3.4) | 642 (20.4) | 1189 (33.5) | <0.001 |
| Away from home | 3672 (54.8) | 1859 (27.8) | 832 (12.4) | 243 (3.6) | 89 (1.3) | 338 (10.8) | 826 (23.3) | <0.001 |
| At the home of someone else | 3899 (58.2) | 1914 (28.6) | 623 (9.3) | 178 (2.7) | 81 (1.2) | 245 (7.8) | 637 (17.9) | <0.001 |
| In a public place | 4369 (65.3) | 1668 (24.9) | 487 (7.3) | 120 (1.8) | 51 (0.8) | 180 (5.7) | 478 (13.5) | <0.001 |
| “Just in case” | 2105 (31.4) | 1942 (29.0) | 1718 (25.7) | 649 (9.7) | 281 (4.2) | 988 (31.4) | 1660 (46.7) | <0.001 |
| Delayed voiding, no. (%) | ||||||||
| If busy | 244 (3.6) | 751 (11.2) | 2403 (35.9) | 2489 (37.2) | 808 (12.1) | 2739 (87.1) | 2961 (83.4) | <0.001 |
| Until cannot hold urine any longer | 930 (13.9) | 2213 (33.1) | 2263 (33.8) | 1047 (15.6) | 242 (3.6) | 1532 (48.7) | 2020 (56.9) | <0.001 |
| Wait too long (strong urge or leakage) to empty bladder at work | 2123 (31.7) | 1802 (26.9) | 1468 (21.9) | 1005 (15.0) | 297 (4.4) | 1051 (33.4) | 1719 (48.4) | <0.001 |
| Straining to void, no. (%) | ||||||||
| To begin voiding | 3728 (55.7) | 1539 (23.0) | 879 (13.1) | 381 (5.7) | 168 (2.5) | 456 (14.5) | 972 (27.4) | <0.001 |
| During voiding | 3492 (52.2) | 1550 (23.2) | 1016 (15.2) | 456 (6.8) | 181 (2.7) | 515 (16.4) | 1138 (32.0) | <0.001 |
| To empty bladder completely | 2955 (44.1) | 1641 (24.5) | 1212 (18.1) | 603 (9.0) | 284 (4.2) | 703 (22.4) | 2156 (60.7) | <0.001 |
| To empty bladder faster | 2313 (34.5) | 1804 (26.9) | 1713 (25.6) | 677 (10.1) | 188 (2.8) | 1075 (34.2) | 1503 (42.3) | <0.001 |
PPBC = Patient perception of bladder condition
p-values represent Chi-squared testing of toileting behaviors reported at least “sometimes” between women with and without bladder problems based on PPBC. Statistically significant values bolded.
At home, 99.4% (n=6657) of women sit to void. When away from home, only 76.3% (n=5108) of women sit at least sometimes and 11.9% (n=796) never sit. Women without bladder problems were more likely to sit away from home (78.2 v. 74.6%, p=0.001), while women with problems were more like to hover at home (6.3 v. 9.4%, p<0.001) and away from home (54.5 v. 60.0%, p<0.001) and squat away from home (8.4 v. 10.1%, p= 0.019).
Discussion:
In this population-based sample of community-dwelling women, most women, including those with no perceived bladder problems, reported what may be considered unhealthy toileting behaviors in each of the four proposed domains (i.e. voiding place preference, voiding time, voiding position, and voiding style)3. Generally, those with a bladder problem reported higher rates of certain toileting behaviors than those with no problems, especially related to convenience voiding, delayed voiding, and straining, reinforcing that there is an association between toileting behaviors and bladder problems, although cause and effect cannot be determined in this cross-sectional study. These findings are of clinical importance in discussions with women about behavioral factors related to bladder health and of societal importance when considering influences on women’s toileting behaviors.
In our study, 50% of all women reported at least one behavior of convenience voiding, as did a greater proportion of those who perceived some problems with their bladder. This may be an adaptive behavior in those women with bladder problems to prevent symptoms, as they may assume that frequent voiding would avoid urgency or incontinence episodes. However, Naoemova and colleagues have shown an association between increased 24-hour voiding frequency and incontinence suggesting that despite more frequent voids, incontinence persists18. Based on our data, it is unknown whether women with bladder problems adapt the behavior of convenience voiding to avoid urgency and incontinence or if convenience voiding predisposes to bladder problems.
Delayed voiding, which was frequently reported in this study, including by women without a perceived problem, is presumed by clinicians to be a risk factor for the development of LUTS. In studies of employed women, those who waited too long to empty their bladder at work causing a strong need to urinate or urinary leakage were also more likely to self-report urinary urgency8 and LUTS in general10. Encouraging women to avoid delayed voiding to the point of severe urgency or incontinence may help to improve symptoms as well as overall perception of bladder problems. Evidence that this hypothesis is true (i.e. that this behavior change does work) is presently lacking; however, if verified, the frequency of which this behavior is reported in the current study suggests there is a great opportunity for education in affecting delayed voiding behaviors.
Straining to void was more commonly reported by women with bladder problems, although the specific impact of straining on bladder function remains unclear. In one study of postmenopausal women with urinary symptoms, straining was associated with increased time to maximum flow rate and urethral resistance on urodynamic study19. It is difficult to elucidate whether this behavior is a result of lower urinary tract dysfunction or if this is a learned behavior, since even in women without urinary symptoms, straining is common20.
Most women participating in this study reported a preference for voiding at home, with 88% worrying about the cleanliness of public toilets and 62% avoiding public toilets at least sometimes. Another study showed that 75% of women worried about the cleanliness of public toilets and concerns regarding cleanliness have been associated with non-sitting voiding positions8,21. Previous studies have found that 25-85% of women hover when using public toilets4,5,8. Hovering over the toilet seat during voiding is associated with reduced urine flow rates and elevated residual urine volume, hypothesized to be the result of poor pelvic floor relaxation5. In the present study, women most commonly sat to void, independent of toilet location. However, there was a large proportion of women who hovered to void outside of their home. The relationship between squatting and improved voiding is less clear. Increased intra-abdominal pressures and relaxation of the levator hiatus occurs in the squatting position which may facilitate bladder emptying22, however studies showed no differences in uroflowmetric parameters between sitting and squatting21,23. Additionally, a major constraint in populations not accustomed to squatting is the ability to fully squat, which was limited to 43% in one study23. It may be that voiding in the position (sitting versus squatting) to which the individual is most accustomed also influences uroflowmetric parameters24. Currently, a relaxed position during voiding is recommended as an important behavior for promoting and maintaining bladder health1.
There are several limitations to the study. The survey methods extended to a limited sample of participants, of whom the majority were white and college-educated; therefore, the results are not likely to be generalizable to other women. As such, this study does not represent a prevalence study representative of all women, but rather a convenience sample, although large in size. The response rate of 6.3% is a conservative estimate as the gender make-up of the Research Notifications Distribution List was unknown. Nonetheless, other epidemiologic research suggests that response rates <10% are reliable if there are a large number of responses, as in our study25. Due to the large sample size, attention to interpreting statistically significant values within a clinical context is necessary as actual differences in data may not be clinically meaningful. Women with urinary symptoms may have been more likely to participate in the study introducing a potential selection bias, although prevalence of LUTS was similar to other studies14,26. It was not possible to determine demographic or clinical factors of non-respondents as all volunteers were anonymous, unless they chose to respond to the questionnaire. Dichotomization of the PPBC variable at a cut-point can also introduce bias, however it was felt that categorization of women into those with and without perceived bladder problems was practical for interpretation of this data in a clinical context of women with subjectively healthy versus unhealthy bladders. Lastly, as a cross-sectional survey, it is impossible to determine temporal or causal relationships between long-standing toileting behaviors and bladder conditions, but evaluating associations with the perception of bladder problems and toileting behaviors can help guide counseling discussions in those women with LUTS.
Despite these limitations, this study highlights several important findings that relate to care of women with and without perceived bladder problems. Behavioral therapies are proposed as first line management for OAB according to American Urological Association guidelines27. In addition to fluid intake modifications and pelvic floor exercises, toileting behaviors are often discussed as a means to improve LUTS. In this study, convenience voiding, delayed voiding, and straining to void were associated with bladder problems. These findings suggest that these behaviors may be a result of underlying pathophysiology or that bladder problems develop because of these behaviors. A causal relationship cannot be established within the context of study, but the associations are significant nonetheless. Exploring a woman’s usual toileting behaviors and subsequently counseling her on specific factors is important in the treatment of bladder conditions. Suggestions to sit on the toilet rather than using alternative positions, to avoid delayed voiding, and to avoid straining may improve overall bladder health.
Conclusions:
Unhealthy toileting behaviors are commonly reported by adult women. While differences were small for some toileting behaviors, women with a bladder problem were consistently more likely to have behaviors related to convenience voiding, delayed voiding, and strained voiding. Although the majority of women sit to void at home; away from the home, women commonly used other voiding positions and this was more prevalent in women with bladder conditions, as well. These findings have important implications not only for defining bladder health and toileting behaviors, but also for implementing behavior-based interventions for women with lower urinary tract symptoms.
Acknowledgments
We acknowledge Tamara Bavendam, MD for her comments during editing of this manuscript.
Funding
This work was supported by the Office of Medical Student Research at Vanderbilt University School of Medicine and through the Vanderbilt Institute for Clinical and Translational Research by Clinical Translational Science Award number UL1 TR002243 from the National Center for Advancing Translational Sciences and the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number 1K23DK103910-01A1.
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