Women with Overactive Bladder Exhibit More Unhealthy Toileting Behaviors: a Cross-Sectional Study - Beyond the Abstract

It is a common joke about the difficulty of using a public bathroom- lines, cleanliness, availability, etc.… Now imagine the 17% of women with overactive bladder.1 These ideas led us to work on determining whether there are any specific toileting behaviors associated with overactive bladder (OAB) and if so, which ones? Participants completed validated questionnaires on toileting behaviors and lower urinary tract symptoms using the Toileting Behavior: Women’s Elimination Behavior Scale and International Consultation on Incontinence Questionnaire- Female Lower Urinary Tract Symptoms. Based on our results, the toileting behaviors of convenience voiding (voiding in the absence of a desire), delayed voiding, straining to void, and position preference are associated with OAB symptoms. The strongest association was between OAB and convenience voiding and furthermore, OAB was associated with each individual convenience voiding question (i.e. voiding without desire at home, away from home, at someone else’s house, and “just in case”).

The majority of women reported preferring a sitting position, but when using a toilet away from home, women with OAB were more likely to hover, or squat, over the toilet seat. Based on prior work, we know that a hovering position prevents the relaxation of the pelvic floor muscles during voiding.2 So, based on this, we suggest that women void in a position that is relaxed and comfortable corresponding with recommendations from the Prevention Lower Urinary Symptoms (PLUS) Consortium.3 That women adopt alternative voiding positions when using restrooms also highlights the negative attitudes towards public restrooms with 98.8% of women indicating a preference for home toilets. Further exploration into this concept is the genesis for future publications.

As a population-based study, causal relationships between toileting habits and lower urinary tract symptoms cannot be determined from this data. This left us with more questions: Does convenience voiding predispose to OAB symptoms or are women with OAB symptoms more likely to convenience void in an attempt to avoid symptoms at inopportune times or locations? Do women strain to void out of necessity in order to empty their bladders completely or is straining to void an adopted behavior to decrease voiding time and minimize their time in the bathroom? In conclusion, there were several associations identified between unhealthy toileting behaviors and OAB symptoms. This study was hypothesis-generating with future studies focusing on whether a causal relationship exists. If a causal relationship is determined, this will result in high yield behavioral modification recommendations given the wide prevalence of OAB symptoms in women.  

Written by: Casey Kowalik, MD, Associate Program Director, Assistant Professor in Urology, University of Kansas Health System, Kansas City, Kansas, USA.


  1. Stewart, W., J. Van Rooyen, G. Cundiff, Paul Abrams, A. Herzog, R. Corey, T. Hunt, and A. Wein. "Prevalence and burden of overactive bladder in the United States." World journal of urology 20, no. 6 (2003): 327-336.
  2. Moore, K. H., D. H. Richmond, J. R. Sutherst, A. H. Imrie, and J. L. Hutton. "Crouching over the toilet seat: prevalence among British gynaecological outpatients and its effect upon micturition." BJOG: An International Journal of Obstetrics & Gynaecology 98, no. 6 (1991): 569-572.
  3. Lukacz, E. S., C. Sampselle, M. Gray, S. Macdiarmid, M. Rosenberg, P. Ellsworth, and M. H. Palmer. "A healthy bladder: a consensus statement." International journal of clinical practice 65, no. 10 (2011): 1026-1036.
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