This scoping review explores the state of science regarding women’s toileting behaviors, gaps in knowledge, and areas for future research. Online databases were searched to identify papers published in English between January 2010 through July 2019; the search identified 25 articles. The Toileting Behaviors–Women’s Elimination Behaviors scale has been published in four validated language versions and used in 17 of the 25 studies. The most frequent behaviors include concern about public toilet cleanliness, delaying urination when busy or away from home, and using different toileting postures at and away from home. Determinants of toileting behaviors include environmental factors, chronic health conditions, and cognitive/psychological factors. Associations were found between toileting behaviors and lower urinary tract symptoms and between toileting postures and uroflowmetric parameters and post-void residual volume. Strategies that address modifiable determinants of toileting behaviors should be developed and tested in future research. Furthermore, little is known about the toileting behaviors and bladder health in older women and women from developing countries. Rigorous studies are needed to better understand the underlying mechanisms of toileting behaviors, the nature of associations between toileting behaviors and lower urinary tract symptoms, and effects of the environment on women’s toileting behaviors.

This article provides important information about school toilet experiences in a relatively under-studied group, adolescent boys and girls between 16 to 18 years old. Understanding these experiences is important to mitigate risks of developing lower urinary tract symptoms, promote bladder and bowel health, and understand factors that influence toileting and other behaviors. These observations may lead to development of conceptual models for future research questions and provide information to public policy analysis and development. In this study, 21 (6 boys and 15 girls) students between 16-18 years old attending two public and two private high schools in Sweden participated in interviews with researchers. These interviews, approximately 10 to 25 minutes long, addressed school toilet accessibility, school toilet conditions, and toileting habits. Students provided informed consent. Using content analysis techniques, the researchers identified three categories: assessing the toilet environment, coping with the situation and feeling exposed. Both boys and girls agreed that toileting was easier for boys than girls due to boys voiding posture, i.e. standing. Cleanliness of toilets was an important issue as well as cleanliness of the floors and sinks to wash hands and odors in the environment. Having separate toilets with doors locking on the inside and school toilet rules were considered important by students. Students used multiple strategies to address urgent needs to use the toilet during the school day. These included: 1) using toilets during class time (less risk of exposure to others in the toilet environment and exposing one’s sounds and odors from elimination to others); 2) holding one’s breath to avoid smelling bad odors while using the toilet; 3) half standing or crouching over toilets rather than sitting on toilet seats or using toilets after someone familiar to them to avoid infections; 4) using secluded toilets, like staff toilets, and engaging in activities (not drinking fluids) to avoid using toilets at school. Students reported fears about being exposed while using toilets. Fears of being filmed on cell phones or others hearing noises from elimination. These feelings were more attenuated during their first year of high shool. Sex differences were revealed in students’ beliefs about toilet experiences with girls believing boys were less affected about exposing themselves and less concerned about the cleanliness of toilet environment. Boys believed it was difficult for girls to use toilets with others close by and that the toilet environment was more shameful for girls than boys. This study raises three important issues about school toilet environments: 1) sanitation (i.e., cleanliness and odor); 2) security for girls while using toilets; and 3) girls are perceived to be more vulnerable to unpleasant school toilet environments than boys. Existing evidence indicates that school toilets may be one factor influencing students’, especially girls, educational achievement via the pathway of interferring with their school attendance {1-2}. In addition, multiple strategies addressing sanitation and security of school toilets, and girls’ vulnerability should be developed and tested. Potential strategies to enhance sanitation include: 1) resource allocation, e.g., adequate toilet paper and paper towel supplies and 2) toilet environment maintenance, e.g., provision of running water, waste bins, well-developed ventilation system, and timely replacement of automatic toilet bowl cleaner. Providing supervision in school toilet areas {3}, and innovative toilet designs specifically for girls, e.g., discrete disposal facilities for menstrual soiled materials, private spaces where girls can manage menstrual hygiene {4} are potentially useful strategies for solving issues of security and girls’ vulnerability when using school toilets. Finally, holding classes or educational sessions related to toilet use or toileting is a worthwhile endeavor for future studies because sometimes, the biggest solution to problems is beginning and continuing to talk about them.

This paper provides novel information about the acceptability of an app-based pelvic floor muscle training (PFMT) program for women to treat stress urinary incontinence (SUI). The findings may not only increase researchers’ and clinicians’ interest in using app-based PFMT programs but also be beneficial for optimizing future app-based PFMT programs. The authors conducted telephone interviews with 15 women (average age 47 years; range 27-72 years) who received an app-based PFMT intervention and completed the 3-month follow up. Semi-structured interviews (average length was 34 minutes) were used to collect women’s perspectives about using the app-based intervention and performing PFMT independently, their relationship and interaction with the app, and their expectations about using the intervention for self-managing SUI. The authors used constant comparison techniques to provide an informative and rich description of the qualitative data, and identified one core category, i.e. “Enabling my independence”, which referred to the wish to be independent while needing some external support to make it possible, and three underlying categories: “Something new!”; “Keeping motivation up!”; and “Good enough?”. This study found both positive and negative perceptions under each category. Of importance, the app-based intervention was perceived as a convenient and easily accessible intervention and it helped women bypass time-consuming and potentially embarrassing appointments in conventional health care settings. Individualized reminders had not been permanent motivation boosters; women said that after 3 months the reminders became annoying or neglectable. Lack of reassurance, an inherent weakness of many self-management programs, was identified by some women as a source of insecurity about doing PFMT correctly. Women found graphics that showed the magnitude of contractions helpful; some women continued to watch these graphics throughout the intervention to remain focused. Some women wondered if better outcomes would have resulted had they tried harder doing the intervention. Women viewed this app-based intervention as one that promoted their independence in SUI management. Multiple motivation-promoting strategies are likely to be beneficial for women to continue the intervention post-study. Behavioral change techniques related to feedback on behaviors and on outcomes and goal setting {1} integrated into app-based intervention may help minimize women’s uncertainty or insecurity about performing PFMT. As women continue to want programs to self-manage their symptoms, strategies targeting improved user experiences could help women feel comfortable engaging in self-management, remain focused on specific goals, and continue the program. Proactive engagement of women’s input into the design of app-based interventions for SUI could improve both performance and outcomes.