A Multi-site Focus Group Study of U.S. Adult Women’s Beliefs and Assumptions about Bladder Health and Function

Abstract

Aims:

This analysis explored and characterized the ideas adult women have about how the bladder works, the assumptions guiding their bladder-related behaviors, and the beliefs they hold about how their behaviors affect bladder health.

Methods:

This was a directed content analysis of qualitative data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study conducted at seven United States research centers (July 2017-April 2018). Participants were 316 adult women organized by four age categories (age range: 18–93 years). Analysis and interpretation focused on the “bladder assumptions and beliefs” code using a transdisciplinary lens and inductive approach.

Results:

During their focus group discourse, participants exhibited a speculative mode of thinking about bladder health and function characterized by uncertainty about how the bladder works. They described the bladder as a mechanism for cleansing the body of impurities, viewing it as part of a larger interconnected bodily system to enable the body to stay healthy. They saw it as susceptible to anatomical changes, such as those related to pregnancy and aging. The women also postulated perceived relationships between bladder function and several health behaviors, including eating healthy foods, staying hydrated, engaging in physical activity and exercise, and adopting specific toileting and hygiene practices.

Conclusions:

The findings underscore the importance of guidance from health care professionals and systematic community based educational programs for promoting women’s understanding about bladder health and empowering them to exert agency to engage in healthy bladder behaviors.

Introduction

The literature on women’s understanding about how the bladder functions is limited¹ and often uses a symptom-focused approach to identify gaps in women’s awareness of the etiology and management of lower urinary tract symptoms (LUTS). Women’s beliefs about bladder function represent potentially modifiable risk and protective factors that can shape bladder health practices and influence prevention and management of LUTS.² Thus, identifying women’s bladder-related assumptions can inform the work of healthcare and public health professionals in the development of LUTS prevention strategies across the life course.

Qualitative research with adult women revealed that formal and informal social norms,³ personal and situational context, and behavioral strategies⁴ can be influential in shaping public or private toileting behaviors. Women’s beliefs about the risks for lower urinary tract disorders often lack scientific evidence and are based on lay understandings that associate LUTS with social and behavioral factors of daily life, including consuming a lot of water, engaging in frequent sexual behavior, and experiencing too much psychosocial stress.⁵

Notions of what constitutes normal bladder function among adult women with LUTS have been investigated and reveal a multifaceted depiction of the attributes of a healthy bladder, including the absence of symptoms, a seamless voiding process, voiding regularity, and the ability to delay voiding and exercise bladder control.⁶ Studies exploring women’s knowledge about overactive bladder (OAB) found that while awareness of the condition, its impact, and treatment options were common,⁷ women exhibited limited understanding of underlying physiological mechanisms associated with bladder control and the etiology of OAB.⁸

The aim of this study was to use qualitative methods of data collection, analysis, and interpretation to characterize community-based adult women’s ideas about how the bladder works, the assumptions guiding their bladder related behaviors, and the beliefs they hold about how their behaviors affect bladder health.

Materials and Methods

Overview

This was a directed content analysis of qualitative data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE) focus group study. The SHARE study explored community-based adolescents’ and adult women’s experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course.⁹ The SHARE study was conducted by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, a transdisciplinary network which, at the time of data collection, was composed of seven geographically diverse US research centers and a Scientific and Data Coordinating Center. PLUS was established to expand research related to the prevention of LUTS and the promotion of bladder health in adolescent and adult women.¹⁰

Participants

SHARE participants were adolescents and adult women recruited at each of the seven research centers. Participants were organized into six age categories: early adolescents (11–14 years); adolescents (15–17 years); young adult women (18–25 years); adult women (26–44 years); middle-aged women (45–64 years); and older women (65+ years). Only women participants aged 18 and above were included in the current analysis. Participants were included without regard to LUTS status, which was only assessed following focus group participation. The study was approved by the University of Pennsylvania Institutional Review Board (IRB), the central review board for six of the seven centers, and a local university IRB at the remaining site. All participants provided informed consent.

Procedures

Focus groups were conducted in either English or Spanish between July 2017 and April 2018. Each session followed a semi-structured focus group guide informed by the PLUS conceptual framework, based on the social ecological model.¹¹ The guide covered the following domains: healthy bladder beliefs and attitudes, bladder knowledge acquisition, LUTS experience and care seeking, terminology, and public health messaging. The focus group sessions were audio-recorded and transcribed verbatim and the Spanish language transcripts were translated into English. Following the focus group sessions, the Lower Urinary Tract Symptom Tool was used to assess LUTS status.¹²

Data Analysis and Interpretation

Focus group transcripts and field notes were entered into Dedoose, a computerized program for storing, organizing, analyzing textual data.¹³ Guided by a 4-member team, the iterative process of analysis and interpretation used consensus building, involving (1) memoing transcripts, (2) using directed content analysis to formulate a priori deductive codes derived from the focus group guide, and (3) identifying emergent inductive codes. During the analytic process, all relevant quotes initially were assigned to corresponding coding categories. As part of the interpretative phase, the investigative team selected quotes to illustrate the breadth of responses and eliminate redundancy. For the current analysis, the “assumptions and beliefs” code was subject to a second layer of data analysis and interpretation using a transdisciplinary lens and inductive approach. After immersing in the data, a transdisciplinary team of clinical, public health, and social behavioral investigators used a consensus building strategy to develop interpretive insights and articulate findings.

Results

Sample Characteristics

The 316 participants ranged in age from 18 to 93 years with a mean of 50.2 years (SD=19.3) and were assigned to focus group sessions by age category The age group distributions were: 18–25 years (16.1%), 26–44 years (22.8%), 45–54 years (13.6%), 55–64 years (19.3%), and ≥ 65 years (28.2%). The number of participants varied by focus group, ranging from 5 to 12 women with a mean of 8.7. The sample was diverse with respect to race (39.2% White; 29.7% African American; 19.9% other) and ethnicity (34.2% Hispanic). The majority (68%) were urban dwellers, 17.7% were suburban, and 14.2% were rural. Regarding LUTS status, 82.9% self-reported at least one symptom. The most common symptoms were urinating too frequently (58.5%), urgency (51.6%), nighttime urination (41.5%), dribbling after urination (38.9%), and stress urinary incontinence (33.5%).

Qualitative analysis and interpretation of the focus group data revealed several themes related to women’s understanding of bladder function. The themes are articulated below, using exemplary quotes from across age groups to provide context, illustrate the depth and breadth of the focus group discourse, and give voice to women’s perspectives on bladder health.

Speculative Nature of Woman’s Understanding of Bladder Health

Participants exhibited a speculative mode of thinking about bladder health and function. Except when referencing input from medical professionals, the discourse was characterized by uncertainty about how the bladder works.

I guess what I would do is to like be as, be more knowledgeable of what really is going on with the bladder. I, it’s no worse; listening today, very few people knew much about the bladder is that we know we have problems sometimes, but we don’t know what makes it tick, what makes it do this or that. [Age group: 65+]

When articulating an understanding of bladder function, participants provided tentative notions, often exhibiting lack of confidence in their explanations, stating they were unsure of the accuracy of the information, and seeking confirmation from others in the group. Dialogue from a focus group of 45–64-year-old women illustrates this point:

Participant 1: So don’t the kidneys filter our fluids and then I don’t know where the bad stuff goes but the urine part, the good stuff comes out. Where does, if there’s any bad things, I don’t even know what I’m saying really but I know what the kidney’s our filter and then it somehow gets to the bladder and then that’s how it gets eliminated. - -

Participant 2: Get rid of the bad stuff I think, right?

Participant 1: So the bladder should be releasing purified urine. I don’t know.

Participant 3: That’s the bad stuff.

Participant 4: So and I’m no doctor and I don’t know necessarily.

How Women Explain Bladder Function

Participants characterized the bladder as a mechanism for cleansing or flushing the body of impurities, viewing the bladder as part of a larger interconnected bodily system involving the kidneys, bowels, vagina, uterus, stomach, and liver. In this interrelated system, anatomical changes, such as those related to pregnancy and aging, were perceived as negatively affecting bladder function. Participants speculated about the mechanisms connecting the bladder to other organs and described how development of health conditions including obesity and other diseases can impact the bladder. Table 1 provides exemplary quotes illustrating how women used an interconnected bodily system perspective to frame their understanding of how the bladder works.

Table 1:

Illustrative Quotes: Explaining Bladder Function

• I just feel like it’s probably one of those things that like does it on its own like the kidneys regulate everything and then you know clean the rest of your body, which cleans the rest of you know your bladder. [Age Group: 26–44]

• When you urinate, your bowels before you, before your bowels move, you urinate. Well that’s the way my body works. And then my bowels move. So it’s connected there some type of way. [Age Group: 65+]

• I know like some people are more prone to UTIs than others. I’ve never had one but my mom and sister have them like all the time. But I also am not very good at like the tract down there, like I just don’t know a lot about our anatomy, I guess, but like I wonder if you have the people that have more partners than others, like sexually active partners, if that has something to do with it versus not. I wonder that, too, but I don’t know if that would be more of like your vagina or your bladder. I don’t think it would be your bladder. but it’s all connected, so. [Age Group: 18–25]

• So one thing that, that I know is that the bladder is very close to the uterus and so especially during pregnancy and the like you know it causes because you know the baby’s growing and it’s in close proximity you know it causes frequency of urination and things like that because just size and the like. … And then, of course, that the bladder is suspended and that sometimes in midlife that you can have issue with like prolapse and things like that. [Age Group: 26–44]

• I have the idea that I get, that I get the urge at nighttime more, to go to the restroom when my stomach is very, very, let’s say, it is not the correct word but full, that, that I ate much. And I think that it is when the stomach is pressing the bladder and that makes me go to the restroom. I think so, also at nighttime, one of the things. [Age Group: 65+]

• Okay, so umm I think that being overweight, allowing yourself you know to, to be overweight can also affect a lot of areas. Like I know some people have like a fatty liver you know due to the overweight and having fatty li-, a fatty liver can also affect your bladder, so those are things. [Age Group: 45–64]

How Women Describe the Relationship Between Bladder Function and Health Behaviors

Participants considered how certain health behaviors such as eating healthy foods, staying hydrated, and exercising can affect bladder function.

Food and Nutrition.

Eating healthy foods was typically mentioned in the context of living a balanced lifestyle and engaging in a variety of healthy behaviors. The use of diet supplements such a probiotics was suggested to promote bladder health. In general, while participants acknowledged the importance of a healthy diet, their conversations focused more on certain types of foods or substances that could be harmful to their bladder health, such as bladder irritants, artificial sweeteners, and junk food. Table 2 provides exemplary quotes demonstrating women’s thoughts about the relationship between nutrition and bladder health.

Table 2:

Illustrative Quotes Describing the Role of Food and Nutrition in Bladder Health

• I would say just overall living a balanced lifestyle, umm, because the way that these bodies are set up, I would say one thing can possibly affect the other, so whether it’s eating right, umm, exercise, hygiene. [Age Group: 26–44]

• I kind of think that all health things... Like the better you’re eating, the more exercise you get, the more water you drink, the more sleep you get probably, some indirect effect on that. [Age Group: 18–25]

• I think that well it is a combination of drinking liquids, the food, vegetables, that also, cleans the, the system. [Age Group: 65+]

• I don’t know, I guess certain probiotics that you can put in your body to make your bladder healthier. I’m not exactly sure what you can eat or drink to make it better but. [Age Group: 26–44]

• Maybe there’s foods that can cause irritation and staying away from that. Like I’ve heard of soda... Yeah, or citrus or something like that. [Age Group: 45–64]

• Well, [I] changed from regular sugar to Splenda, and I think that’s what my problem really started. I would only use one pack. [Age Group: 65+]

• So I feel like if everybody’s just like not putting drugs and like garbage into their bodies, like garbage I mean like an awful lot of chips and like I don’t know just you know junk food, I think that it probably stays pretty healthy on its own unless something happens to make it get sick like a UTI or some sort of disease. But you would think that it would just kind of stay like regular, right? Like naturally clean, like the rest of our parts. [Age Group: 26–44]

Hydration.

Participants were universally emphatic about the value of hydration, particularly with respect to drinking water, which was seen as important for facilitating the work of the bladder, avoiding infection, and maintaining bladder health. They described the bladder as needing to be “flushed” to work properly and believed fluids are needed to filter out impurities and/or balance the system for optimal performance. Several participants testified to personal experience with increasing fluids reducing risk for urinary tract infections (UTIs). Drinking cranberry juice to prevent or treat UTIs was endorsed by some participants and challenged by others. Participants identified fluids they believe are bad for bladder health. This includes sugary drinks like soda/pop or sweetened iced tea, acidic juices, alcohol, and coffee. Urine odor and color were mentioned as indicators of hydration and a potential sign of bladder problems; however, participants seemed uncertain about the physiological significance of these aspects. Table 3 provides exemplary quotes expressing women’s notions of how hydration is associated with bladder health.

Table 3:

Illustrative Quotes Describing the Role of Hydration in Bladder Health

Drinking Water

• You got to drink a lot of water. You got to consume a lot of water because if you don’t drink water, that means that you’re going to end up on dialysis, one way or the other. Because you got to take care of your body. [Age Group: age 65+]

• You know to [drink water] to keep things going through your kidneys and from your intestines and your kidneys, your stomach, and your whole digestive tract so that the impurities can go through your urine. [Age Group: 45–64)]

• One of the things that I have done to cleanse my bladder is what I do is slice up cucumbers and steep them in water overnight and then I have the water and it’s supposed to cleanse. It’s supposed to be a natural cleanser for the bladder. [Age Group: 26–44]

• I think that diet really plays a key part, drinking lots of fluids, the correct fluids. To my understanding, coffee and tea that for each one that you drink, you should drink two glasses of water to replace the fluids because they act as a diuretic. Just those kind of like little nuances to make sure that your body’s healthy. [Age Group: 45–64]

Hydration and Urinary Tract Infections

• It’s really necessary to stay hydrated and the like because of bacteria that grows there and the like and that starts you know urinary tract infections and things like that can be precipitated if you aren’t drinking liquids and the like, like you should. [Age Group: 26–44]

• My mother had problems with her kidneys and every once in a while, when she started feeling something coming on like a UTI, she would drink cranberry juice. And I, when I had my problem, I thought I might, I might try that since it’s all related. So I, I drink a lot of cranberry juice. I haven’t had it in two years, but cranberry juice was always. [Age Group: 45–64]

• I’ve read multiple studies that say that cranberry juice literally does nothing for UTIs’.. My understanding was that you can only make it go away by getting medicine. [Age Group: 26–44]

Urine Color and Odor

• I don’t know. I’ve just always heard that if you are drinking enough water, then your pee will be clear. If your pee is more of a yellow color, then you need to drink more water. [Age Group: 18–25]

• I would say that I guess I wonder, if you’re seeing like discoloration in your urine, does that necessarily equate to you’re having an issue with your bladder or is that only a symptom of being dehydrated or not having enough water? And how long does that really have to occur before you’re doing some damage that you would have no idea of otherwise? [Age Group: 26–44]

• Well like they say if you go to the bathroom too many times, that means you’ve probably got too much salt in your system, so I figured that either I wasn’t drinking enough water while you don’t go to the bathroom or I’m eating too much salt, one of the reason I’m going to the bathroom, so it’s between I can’t remember which is correct but I base everything now off of the smell of urine, so if I go and it’s really, really terrible, I increase my water but I decrease it or I just have 64 ounces for the day and it doesn’t have any odor then, so I figure that’s the correct ratio. [Age Group: 45–64]

Physical Activity and Exercise.

Women discussed physical activity as important for overall health. Commonly mentioned activities were health-promoting behaviors including exercise and walking. While much talk of exercise was positive, women also discussed activities or exercises that are potentially harmful or might be associated with bladder damage or involuntary bladder leakage. This included high impact sports, as well as physical activities that can have negative effects if overdone. Some women also mentioned exercises to strengthen the pelvic floor, such as Kegels, using exercise balls, and different kinds of squatting. Multiple participants mentioned learning about Kegel exercises around the time they were having children. Table 4 provides exemplary quotes articulating women’s assumptions about the connection exercise and bladder health.

Table 4:

Illustrative Quotes Describing the Role of Physical Activity and Exercise in Bladder Health

• I think exercise has a lot to do it with it, too. If you’re sedentary, you know I think that contributes to maybe some issues with the bladder. Just get up and get moving. [Age Group: 65+]

• Well it sounds like extreme sports might. Like you were saying you play basketball and, like and obviously, running does, but like snowboarding like. Anything with like a hard hit I guess maybe just like the shock of it or something, it might like, it might just like make you involuntarily pee for whatever reason. [Age Group: 18–25]

• I know a lot of women that love the gym, and they overdo it sometimes, so a lot of like exercise or weight training you know that puts a lot of pressure on your body. So you gotta be careful with that too, cause that can effect. [Age Group: 45–64]

• Even when I exercise now, you know I exercise three or four times a week and I lift weights, but I still watch myself as far as not putting too much pressure on my stomach you know. [Age Group: 65+]

Pelvic Floor Exercise

• I think there’s exercises you can do, too, that kind of umm give you more strength in that area. [Age Group: 45–64]

• Pelvic floor strengthening muscles with like exercise balls and different squatting techniques. [Age Group: 18–25]

• When I had my first child, I took classes and one of the things that I learned in the Lamaze classes is how important is exercise, specifically Kegels. [Age Group: 65+]

Toileting Practices.

Women articulated an understanding of the association between bladder function and toileting practices, particularly the habit of delaying urination (holding). The discourse on holding emerged most frequently among midlife and older adult women who cautioned the harm ensued by delaying urination. In the narrative of holding, consequences ranged from inflammation, irritation, infection, and stones to a generalized sense of problems with urination. Being busy with work and caregiving responsibilities influenced the holding behavior and was perceived as a barrier to bladder health. Table 5 provides exemplary quotes conveying women’s beliefs about the deleterious impact of delayed voiding on bladder health.

Table 5:

Illustrative Quotes Describing the Impact of Delayed Voiding (Holding) on Bladder Health

• I really haven’t heard much about what would be bad for my bladder, except, you know, the holding it in. [Age Group: 45–64)

• When I feel the urge to go, I think we need to go because if you don’t, you can cause problems if you keep building up your bladder. [Age Group: 65+]

• I say that inflammation also comes and all of those problems that start accumulating because one stops oneself a lot from going to the restroom. When one is outside, um, one stops oneself and then it is when they start forcing, one starts forcing the bladder and then come the infections, irritations, inflammation. [Age Group: 65+]

• The bladder, like, gets swollen [from holding] and afterwards you want to go to the bathroom, and you cannot longer go [pee] well. [Age Group: 45–64]

• Stones are formed in the bladder when one holds it in a lot, it is not good to hold it in, because, um, of the stones, and another thing, also because of the infections. The bladder gets infected if one doesn’t, doesn’t discard the, the, the urine. [Age Group: age 65+]

• I’ve also been told that women tend to hold urine for a long time, because they’re busy doing things – they’re taking care of kids or whatever and that we should be emptying our bladder more often than we do. [Age Group: 65+]

• Another also is the stress at work, that, um, well, they don’t let you go to the restroom frequently, so, well, that is one of the, of the things for which, and the, the, well what one eats. … then, suddenly, they have people that are not given permission and stress begins, and from there, even the bladder infections come as a consequence, first of all, of the stress, and the second, well stopping, holding it in, um, because a doctor did tell me that. Um, holding going to the restroom, he said, ‘You will do a lot of damage to your bladder. [Age Group: 65+]

Hygiene.

The role of hygienic toileting habits, including wiping, contact with toilet seats, and voiding after sex seemed to be familiar topics for many participants across the age groups. Participants agreed bodily cleanliness and hygienic toileting practices play an important role in protecting bladder health and preventing UTIs and bladder infections. Practices for vaginal hygiene also surfaced, although it wasn’t always clear if participants were referring to vaginal or bladder infections, reflecting the tendency for women to sometimes conflate vaginal symptoms with UTI symptoms. They recommended keeping the vaginal area clean and dry with nonirritating cleansing products and avoiding tight clothing, undergarments and pads that don’t allow for ventilation or promote bacteria.

Participants stressed the need for cleaning oneself after toileting and the importance of wiping properly to prevent UTIs. Some participants believed sitting on a toilet seat in a public restroom should be avoided because of the risk of acquiring disease from bacteria left on the seat or from splashing from the toilet bowl. Younger women also speculated about the relationship between sexual behavior and bladder health, having heard that it is important to urinate after having sex to “flush” bacteria away and prevent bacteria from causing urinary tract infections. Table 6 provides exemplary quotes representing women’s understanding of how personal hygiene contributes to bladder health.

Table 6:

Illustrative Quotes Describing the Role of Hygiene in Bladder Health

Good hygiene and cleanliness

• I began to think, like, wow, I just, I didn’t realize like, you know, a person’s hygiene can affect, you know, the way that they’re, umm, their bladder health is. Like it can cause infections and things of that nature. [Age Group: 26–44]

• I want to say as well that it is very important…that part of the body because if there is not cleanliness, ah, infections come. [Age Group: 65+]

Wearing breathable clothing

• They say to wear like clothing that’s not super tight or clothing that’s more like breathable. I think I’ve heard that before. I’ve heard that, too. It stops you from getting all sweaty and bacteria building up down there with nowhere for it to go. [Age Group: 18–25]

Care in using public restrooms

• When one goes to the restroom, to be very careful because it is so easy, very easy for one as an older person, and for children, any kind of person, any woman…to pick up the, a microbe. [Age Group: 65+]

• They also say that when you go to the bathroom, public, or something, you don’t have to sit down because you get infection. [Age Group: 45–64]

Using Non-irritating Products

• You really shouldn’t put hot water down there because you don’t wanna dry out your vaginal area. [Age Group: 26–44]

• The cleansing products that you’re using could be irritants. [Age Group: 26–44]

• Don’t use scented soaps. [Age Group: 18–25]

• I’ve been told recently like you shouldn’t even use soap, it should be water, but you know for me I use mild and make sure that it’s completely dry and use cotton underwear versus like the nice comfy, no panty line type of underwear. [Age Group: 45–64]

• You have to like change your underwear more, maybe you have, maybe you’re wearing them for like, you know, 12 hours throughout the day. I’m like yeah, I am, but it’s stuff like that. Or like wearing a wet bathing suit I’ve heard you should not do - wearing, wearing, like, thongs, you should be wearing cotton underwear and not the type of underwear, not silk. [Age Group: 18–25]

Wiping Correctly

• Also in schools, since an early age, they teach you how to clean yourself when you go to the restroom. The women, as one of our characteristics, we have a very small urethra and if you do not have adequate cleanliness, you will contaminate yourself, you will get infected, right? So, part of your personal hygiene is teaching you how to do it, right? [Age Group: 45–64]

• They tell you to clean when you’re going to wipe yourself that make sure that you do not go from your buttocks to your (front) because you can umm with fecus matter, so it’s very important how you wipe yourself also to avoid any type of urinary infection. [Age Group: 45–64]

Voiding After Sex

• I feel like I’ve read this so many times in like those Cosmo type of magazines that it’s related to like right after, before and after you have sex, you should pee. … Especially after, so that bacteria is, like flushed away and then you don’t get a UTI. The only times I’ve gotten UTIs were literally like the day after I’ve had sex. [Age Group: 18–25]

• I heard the same thing that you’re supposed to you know go to the bathroom after you finish with intercourse, however, there was plenty of times that I didn’t go to the bathroom after intercourse, and I didn’t get a UTI. So I can’t say it’s not true, but I can’t say it’s not – not true, cause it’s happened to other people, it’s just never happened to me personally. [Age Group: 26–44]

Discussion

Our findings demonstrate that woman will openly engage in discussions about the bladder but readily admit to having little actual knowledge on the topic. Participants described bladder health in terms of its interaction with other bodily organs and considered bladder health as an interrelated component of overall health, without being certain of the pathways linking the two. These findings are consistent with previous qualitative research which provided evidence that women have some limited understanding of the underlying physiological and behavioral factors that could compromise bladder health.¹⁴ Our analysis reveals that women are concerned about the potential impact of toileting habits, such as holding and cleanliness, on bladder health. The literature documents that toileting practices, including delayed voiding and management of hygiene issues in shared bathrooms and public restrooms are on the minds of women.^1,3,4

Younger participants shared a belief in a relationship between sexual behavior and bladder health, with sexual intercourse being in the causal pathway for UTIs. This supposition appears to be grounded in women’s lived experience and in anecdotal accounts from friends and family. It also may represent assumptions about the association between urological and genital organs in women. Some research suggests delayed postcoital voiding should be considered as a risk factor for recurrent UTIs.¹⁵ Participants also cautioned that undergarment type and fabric could impact bladder health and cautioned against wearing items that could promote bacterial growth or irritate sensitive pelvic areas. Hamlin and colleague recommend medical providers should discuss sexual practices and underwear fabric with patients concerned with urogenital infection.¹⁶

There was strong and consistent endorsement of hydration, particularly water, as beneficial for bladder health. Participants expressed the opinion that drinks like soda/pop or sweetened iced tea, acidic juices, and alcohol could be irritating to the bladder. A review investigating the association between bladder irritants and LUTS concluded that data supporting these associations are meager and mostly observational.¹⁷ However, a randomized controlled trial currently is testing the benefit of treating overactive bladder by eliminating caffeinated, artificially sweetened, citrus, or alcoholic beverages.¹⁸ The topic of cranberry juice for UTI prevention or treatment generated anecdotal accounts of its efficacy. Though cranberry juice has long been used as a homeopathic remedy for UTIs, ¹⁹ there remains a need for rigorous clinical trials examining the possible benefits of cranberries for urinary tract health.²⁰ There is, however, emerging scientific evidence of the mechanism and efficacy of cranberry supplements for UTI prevention.²¹

Participants hypothesized a general benefit from physical activity and expressed awareness of publicized benefits of pelvic floor muscle exercises. However, many also believed high impact activities such as running, basketball, and weightlifting were detrimental to bladder health and function and should be limited. Studies of elite high impact athletes found no increase in UI 15–20 years after competing, supporting evidence that most physical activity is beneficial to women’s health without harming the pelvic floor.^22–23

What appears to be missing in the current literature, however, are insights regarding the tentativeness with which some women articulated their knowledge of what contributes to bladder health and function. While many of the reported beliefs about bladder health have some basis in the scientific literature, there was significant uncertainty about the validity of these beliefs amongst the participants. It is important to recognize that participants’ focus group discourse includes both factual information and misinformation couched within a context of limited confidence in the accuracy of their knowledge and beliefs about bladder health. Despite the speculative nature of their observations, women described engaging in bladder practices without knowing if or why they were effective. While this process may be a function of the focus group dynamic, where individuals may not be confident about their assumptions and defer to others’ opinions or knowledge,²⁴ it most certainly represents a need for improved bladder health education for woman. This appears to be part of a larger health literacy discussion.

Bladder health education can be delivered in healthcare settings or as part of health promotion programs for individuals, families, friendship networks, and communities. A limited number of studies have begun to examine effects of bladder health education in the US. For example, a short-term school-based health educational intervention for female adolescents yielded significant improvement over time in knowledge about pelvic anatomy, bladder function, and pelvic hygiene.²⁵ Community-engaged public health messaging can inform women’s assumptions and beliefs about bladder health/function, starting early in the lifecourse to educate women about bladder health and empowering them to engage in practices for preserving bladder function in young adulthood to middle and older age.

Conclusions

Among the women in this study, there was agreement on the importance of healthy bladder habits even in the face of uncertainty about what constitutes appropriate bladder health practices. Women’s knowledge, assumptions and beliefs about bladder health, like many other health behaviors, often are based on personal experience, what they observe from family members, glean from their inner circle of acquaintances, and learn from the larger social discourse on bladder function.³ In the absence of established educational programming, woman can lack certitude about the accuracy of the information guiding their bladder practices, which at best may mute their use of positive behaviors or, at worst, allow them to engage in harmful behaviors. However, as our research revealed, women believe that bladder function and health behaviors are interrelated with potential for bidirectional impact. This provides a foundation upon which to build. Although the evidence base is still developing about the relationship between bladder health and some hydration, exercise, toileting, and intimate hygiene practices, women’s assumptions and beliefs about bladder health can be a starting point for clinicians to begin the bladder health conversation with their patients. Across the life course, women’s understanding of bladder health and function could benefit from input from healthcare professionals, in both preventive and treatment settings where women could be informed about bladder health, encouraged to engage in conversations about their concerns and empowered to engage in healthy bladder behaviors and to seek treatment when symptoms emerge. In addition to guidance from health care professionals, systematic programs for educating young women about bladder health and function can inform lifelong toileting practices, provide a sense of self-efficacy about bladder function, and empower women to be proactive about bladder health.