Toileting behavior and urinary tract symptoms among younger women

The hypothesis in our study was corroborated, as there were significant relations between toileting behavior and LUTS among younger women. This is an interesting finding and could have important clinical implications. For example, Moore et al. found that residual urine increased by 149% in those who hovered over the toilet instead of sitting in a relaxed position [22]. However, the population in that study were older (25–81 years). In our study, most women usually sat on the toilet. The most frequent behaviors were within the factors place preferences (i.e., avoiding toilets) and different strategies to delay voiding. Most study participants were students or worked and thus could avoid public toilets, even though a majority were worried about the cleanliness of public toilets in, e.g., shopping centers, petrol stations, restaurants, or pubs.

There seems to be a lack of knowledge among young and middle-aged women about a normal way of emptying the bladder; for instance, avoiding straining when voiding [23]. It is not clear what impact straining has on voiding dysfunction [23‐25]. However, symptoms connected to the emptying phase often coexist with symptoms correlated to the storage phase. Behavior when emptying the bladder could be important for understanding symptom origin and choosing the appropriate intervention for the LUTS patient. An easy intervention is to teach the patient a relaxed, optimal way of emptying the bladder. Symptoms due to a dysfunctional emptying pattern may be reduced with correction of the pattern. Therefore, this study may indicate the need to investigate a patient’s voiding pattern to obtain an accurate picture and manage symptoms that may be due to dysfunctional toileting behavior.

Surprisingly, many young women reported urinary symptoms when using the definition of having symptoms at least sometimes or more often. However, there is a lack of definition for response alternatives, which can be confusing both for the responder and interpreter. On the other hand, they also reported having symptoms more frequently than occasionally. Our interpretation, therefore, is that they actually have symptoms, which is why data are summarized in this way. According to the definition of the ICS, for instance, urinary incontinence is “any urinary leakage,” with no definition of how frequent it is [26]. Urinating nine times or more during the day, urgency, hesitancy, and straining were the most common symptoms. Van Breda et al. performed a study using ICIQ-FLUTS assessing 159 presumably healthy medical students aged 18–30 years [20]. They also summarized the alternatives in that way. Comparing our results showed that our group had more symptoms in all the investigated parameters. For example, urgency at least sometimes was reported by 34.2% of our group compared with 14.5% in their group. Pauwels et al. also found that middle-aged women had large bladder capacity and high bladder compliance, indicating that women tended to postpone toileting as long as possible [27]. Bladder pain was also quite common (21%), but it is not clear what sort of pain. One explanation could be that cystitis problems in this age group are common, or irritative symptoms are from genitalia after sexual activity. Generally, our results showed higher prevalence rates compared with other studies, indicating that responders were women with more problems.

Higher scores in ICIQ-FLUTS subscales suggest a greater impact of separate symptoms for the patient, but there is no further information about how to interpret the summarized scores, as in the International Prostate Symptom Score (IPSS), in which symptom scores are classified as mild (0–7), moderate (8–19), and severe (20–35) for comparing symptom progression and severity and determining treatment [28].

The significant difference in all dimensions of urinary symptoms, not only incontinence, in the parity group with higher scores is interesting and to our knowledge not reported previously. However, the parity group was small, and this result must be viewed with caution. Parous women with LUTS often have increased laxity in passive-support structures, a deficit in the onset of the pelvic floor and strength to support the bladder neck when intra-abdominal pressure increases. Women with LUTS are also more likely to use straining voiding and for a longer time than healthy women with no symptoms [17]. The way straining is performed and whether LUTS is or is not present seem to be important. Structural changes due to childbirth might alter lower-urinary-tract function and behavior—or the impact of a behavior. More studies are needed in this regard.

Construct validity and reliability of the translated Swedish version of the TB scale showed similar results to the original. However, no other aspects of validity were tested, e.g., comparing results objective measures, which is difficult in a postal questionnaire survey. The TB scale was easy to use and questions well understood, as the internal dropout rate was low; > 95% answered all questions. Factors in the questionnaire’s subscales assessing toileting behavior made it possible to use to analyze relationships, in this case with ICIQ-FLUTS, even though this was not in the aim of instrument validation. Furthermore, it is feasible to assume that the translated version of the TB scale would be an aid in clinical practice to evaluate and modify toileting behavior, thus promoting good bladder health. To strengthen its generalizability, further testing is needed in community-dwelling and hospitalized populations.

Attaining the sample of young women seemed to be difficult, as the response rate was low. This must be taken into consideration when interpreting the results. Also, many questionnaires were returned as address unknown. One can assume that those who answered may have more problems than those who did not. However, that issue remains unknown. Dropout analysis showed a tendency of lower response rate among those living in the cities compared with those living in the country, but it is unclear what consequences that issue may have on results. Using e-mail instead of the postal system may have reached more women, but such data is not available in the population register in Sweden. Another option was to use Facebook or other social media, but a representative sample would not have been reached in that case either. Even though the intention was to have a representative sample from the population in this age group, we obtained a rather large sample and can therefore make some conclusions about young women and their urinary symptoms relative to toileting behavior. Studies among women in this age group are few, usually among selected groups only, but are not representative of the general population. However, the strength in this study was the finding of a relation between urinary symptoms and toileting behavior among younger women. To our knowledge, this has not yet been described in the literature.