This study is novel as it is the first to report the age of onset of toileting behaviors.  Earlier studies revealed that toileting behaviors, e.g., delayed voiding, are related to lower urinary tract symptoms (LUTS), specifically storage symptoms. LUTS are prevalent across women’s lifecourse, are associated with co-morbidities, and are costly for women, the healthcare system, and society. Recent research has focused on bladder health promotion and LUTS prevention. This perspective encourages investigation of factors outside of the lower urinary tract system that could protect or harm bladder health. 

Toileting behaviors include those behaviors women use prior to and during urination. These include behaviors related to place preference to urinate, premature urination, delayed urination, straining to void, and position preference to urinate, e.g., hovering over a toilet. The purpose of this study is to describe at what ages these toileting behaviors started and when urgency and leakage symptoms of LUTS began.

This is a descriptive study based on the results of an online survey conducted in the Spring of 2020. Participants were members of panels contracted by Qualtrics Research Services to complete questionnaires. Of the 2043 respondents who accessed the survey, 9% did not consent, 1.7% were excluded and 73% were screened out because race or ethnicity quotas had been met. The remaining 16% comprised the sample of 338 women aged 65 and older, unselected for urinary symptoms. 

The Toileting Behaviors-Women’s Elimination Behavior (TB-WEB) is a 22-item Likert-type questionnaire that consists of five domains: place preference (4 items), premature voiding (5 items), delayed voiding (3 items), straining to void (4 items), and position preference to void at home and away from home (6 items). Follow-up questions to each of the TB-WEB items were used to assess participants’ recollections of when in their life course they started using various toileting behaviors. 

The International Consultation on Incontinence Questionnaire Overactive Bladder Short Form (ICIQ OAB-SF) was also administered.  After answering the item related to rushing to the toilet (urgency), participants were asked “How old were you when the need to rush to the toilet to urinate started?”  After answering the item related to leaking, subjects were asked “At what age did urine start to leak before you got to the toilet?” For all age of onset items, the response alternatives were before 11 years, 11-17, 18-25, 26-44, 45-64, and 75+ years. The age questions were skipped when the response to the initial question was “Never.”

The sample consisted of 338 women who completed the survey.  All women resided in the United States and read and spoke English. Their average age was 70.9 years (SD 5.55, range 65-97 years). The women identified their race and ethnicity as follows:  22.5% as Black, 67% as white, 5% as persons of other races, 3% of the sample identified as more than one race, and 2% preferred not to identify their race.  Twelve percent (n = 39) identified their ethnicity as Hispanic.  Twenty-six percent of the sample did not attend college, 34.4% had attended some college, while 39.7% had a bachelor’s degree or above.  Approximately 84% of the sample (n = 285) reported having to rush to the toilet “occasionally” or more often in response to the ICIQ-OAB urgency item.  About 74% of the sample (n = 250) reported leaking before getting to the toilet “occasionally” or “more often.” The number of participants endorsing one or more of the 15 most common toileting behaviors ranged from 140 (41%) to 338 (100%). 

Figure 1 shows the six toileting behaviors that were generally adopted before age 45.  These included 3 place preference and 2 delayed voiding items and 1 position preference item. Each stripe on the bars of the figure shows the percentage of respondents who reported starting the behavior while at specific age ranges, which are represented by different colors. For example, the first stripe of the first bar shows that about 20% of our respondents worried about public toilet cleanliness before they were 11 years old (medium blue stripe), while the first stripe on the second bar shows that 24% began to void before leaving home before 11 years old. The top of the fourth (purple) stripe shows the percentage of respondents who reported beginning a behavior before age 45. The bars are sorted, left to right, by that before-age-45 percentage. The first bar shows that by age 45, over 75% of our respondents had begun worrying about public toilet cleanliness, but only about two-thirds had begun voiding before leaving home. The top (dark navy) stripe on each bar is the percentage of our respondents who reported never adopting the behavior. For example, about a third of our respondents reported never adopting the behavior of hovering when away from home (fifth bar). The onset of hovering over the toilet away from home was spread across the early years; 16.9% reported starting before age 11 years, 12.7% between 11 and 17 years old, and 13.9% between 18 and 25 years old.

Also shown in Figure 1 are the reported ages of onset of the LUTS symptoms of urinary urgency and leak. Approximately 13% of the sample reported onset of urinary urgency prior to age 45 and 71% reported age of onset at or after 45 years. Seven percent of the sample reported onset of leaking prior to age 45 and 67% reported the onset at or after age 45.

Figure 2 shows the timeline for the average age of onset of the earliest toileting behavior in each subscale and for rushing to the toilet and leaking urine. On average, the earliest place preference and position preference behaviors began in the mid to late teens. The earliest delayed voiding behavior occurred in the early twenties. The earliest premature voiding behavior started early in the adult premenopausal years (age 29 years), while the earliest straining began somewhat later in the pre-menopausal period (age 36 years).  The LUTS storage symptoms occurred in peri-menopausal period with feeling the need to rush to the toilet beginning, on average, around age 46 and leaking beginning, on average, around age 53 years.

Because women were asked about the age of onset only if they reported that they currently engage in the behavior, results reveal that some of these behaviors are lifetime habits.  For some women, toileting behaviors such as avoiding public toilets and hovering over the toilet when away from home began in childhood. Delayed voiding tended to increase in early adulthood, while the earliest prevalence of premature voiding occurred before age 30, greater percentages of respondents began premature voiding in middle adulthood.  Straining, if it occurs at all, does so in later adulthood.

Toileting behaviors are related to LUTS and factors external to the urinary tract play a role in toileting behaviors women use. The age of onset data suggest women begin using behaviors related to toileting at different life stages, perhaps in response to family and peer influences, the presence of LUTS, other co-morbidities, and environments women move through throughout their lives. The relationship between toileting behaviors and specific LUTS requires further investigation to develop interventions at different life stages to promote bladder health and prevent urinary incontinence and other LUTS in women.

Continence 7S1 (2023) 100908
DOI: 10.1016/j.cont.2023.100908