Voiding habits tied to bladder health in women
Voiding behaviour is associated with bladder problems in women, an exploratory analysis shows.
Of the 6,695 women (mean age 41.4 years) who completed the ICIQ-FLUTS* questionnaire, 46.9 percent reported no bladder problems while 53.1 percent had self-perceived bladder issues (ie, voiding, incontinence, overactive bladder). [J Urol 2019;201:129-134]
A majority of the women practiced convenience voiding (ie, emptying the bladder even without a sensation to void), opting to void before leaving home (93.8 percent). This strategy may be an adaptive behaviour to prevent bladder symptoms on the presumption that frequent voiding would avoid incontinence episodes or urgency, said the researchers.
Nearly 90 percent of the women reported concern over public toilet cleanliness, hence the high incidence of delayed voiding (ie, waiting to void despite an urge), with 61.1 percent avoiding public toilets and 55.3 percent waiting to void until they returned home.
Delayed voiding increases the rate of urinary urgency/leakage and is postulated to be a risk factor for lower urinary tract symptoms (LUTS). [Neurourol Urodyn 2018;37:735-743; Int J Nurs Stud 2016;65:1-7] “Encouraging women to avoid delayed voiding to the point of severe urgency or incontinence may help improve symptoms as well as the overall perception of bladder problems.”
To sit or not?
Almost all participants (99.4 percent) reported sitting to void at home, while 76.2 percent reported sitting sometimes when using public toilets. About 12 percent never sat in public toilets.
When voiding away from home, women with and without bladder issues employed nonsitting voiding positions such as hovering (60.0 percent and 54.5 percent, respectively) or squatting (10.1 percent vs 8.4 percent, respectively).
However, certain nonsitting voiding alternatives alter urodynamic parameters which consequently affect bladder function. [Br J Obstet Gynaecol 1991;98:569-572] Hovering during voiding is associated with decreased urine flow rate and increased residual urine volume, which could be attributed to poor pelvic floor relaxation, said the researchers.
Squatting to void may facilitate better bladder emptying due to increased intra-abdominal pressure and levator hiatus relaxation. [Int Urogynecol J 2010;21:1371-1376; Int Urogynecol J 2014;25:1015-1021] However, the inability to fully squat could be a potential constraint in women who are not accustomed to squatting. [J Obstet Gynaecol 2008;28:317-319]
Therefore, it is essential to reiterate in women the importance of employing a comfortable voiding position. [Neurourol Urodyn 2010;29:413-417] “[A] relaxed position during voiding is recommended … to promote and maintain bladder health … Suggestions to sit on the toilet rather than use alternative positions, and to avoid delayed voiding and straining may improve overall bladder health,” said the researchers.
“After women have been encouraged to promptly attend to the urge to void and to use a relaxed voiding position, behaviour changes and symptoms should be monitored,” said Dr Mary Palmer from the University of North Carolina at Chapel Hill in Chapel Hill, North Carolina, US, in an editorial. All women should be asked about toileting behaviours that they typically use at and away from home given the growing evidence linking delayed voiding and straining to female LUTS, Palmer added.
Exploring the association between perception of bladder problems and usual toileting behaviours of women may guide counselling sessions and help implement behaviour-based interventions ie, fluid intake modifications and pelvic floor exercises, said the researchers.
Despite the large sample size, the population represented a limited patient group hence the nongeneralizability of the findings, they noted. Further investigation is warranted to establish temporal or causal relationships between long-standing toileting behaviours and bladder conditions.