BJU International

(2002),

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doi:10.1046/j.1464-4096.2002.02903.x

Blackwell Science, LtdOxford, UKBJUBJU International1464-4096BJU International

902903

METHODS OF TOILET TRAINING TO ACHIEVE BLADDER CONTROLE. BAKKER

et al.10.1046/j.1464-4096.2002.02903.x

Original Article456461BEES SGML

Accepted for publication 14 May 2002

Results of a questionnaire evaluating the effects of different methods of toilet training on achieving bladder control

E. BAKKER, J.D. VAN GOOL, M. VAN SPRUNDEL, C. VAN DER AUWERA and J.J. WYNDAELE

Department Urology, University of Antwerp, Edegem, Belgium

Objective

To analyse if family situation, personal habitsand toilet training methods can influence the achieve-ment of bladder control.

Subjects and methods

A questionnaire with 41 questionswas distributed to 4332 parents of children completingthe last 2 years of normal primary school. The ques-tionnaire had been tested for reproducibility of theanswers in a random subgroup of 80 parents. The aimsof the investigation were explained in an accompany-ing letter and the response rate was 76.7%. Theresult were analysed using the chi-square test (Yatescorrected).

Results

Two groups of children were identified, one withno lower urinary tract symptoms (3404) and one withcomplaints of daytime and night-time wetting, and uri-nary tract infections (928). The groups were termedthe ‘control’ and ‘symptom’ groups, respectively. Therewere no differences in the family situation between thegroups. The symptom group reported more ‘belowaverage’ school results and less independence in home-

work and hygiene. The age at which toilet trainingstarted was significantly higher in the symptom groupand scheduled voiding was used significantly less. Thereaction of the parents when the attempt at voidingwas unsuccessful was significantly different; in the con-trol group most parents just postponed the effort andhad the child try again later, whereas in the symptomgroup more parents asked the child to push, madespecial noises or opened the water tap.

Conclusions

These data show significant differences intoilet training between children with and with no last-ing problems of bladder control. Postponing the onsetof the training after 18 months of age and using certainmethods to provoke voiding (asking to push, openingthe water tap) probably increases the risk of laterproblems with bladder control.

Keywords

toilet training, bladder instability,dysfunctional voiding, urinary infection, incontinence,children

Introduction

For a long time detrusor-sphincter function in newborns,which is the basis of continence, was believed to be a sim-ple reflex, occurring as the bladder fills. Recently, severalauthors noted that newborns already have a well-developed and functional spino-pontospinal micturitionpathway with a micturition threshold, influenced byspinal and/or arousal mechanisms, which suggests moresupraspinal control than was previously thought to bepresent when so young [1,2]. Gladh

et al.

[3] reportedmean (range) voided volumes for newborns of 23 (1–77) mL and median voiding intervals of 49 min. However,the dyssynergic voiding patterns they observed indicatedthat the coordination between detrusor contraction andurinary sphincter relaxation was still incomplete, whichleads in 70% of newborns to a residual volume of

>

10 mL.According to Olbing

et al.

[3] the communication andcoordination of the lower urinary tract are fully developedat 2.5–4 years.

Voiding problems are common in children and lead tosymptoms such as incontinence, UTIs and urgency. Theexact causes of such abnormal development, leading tolasting voiding problems, are yet unknown. Most of thedisorders occur in neurologically normal children andare thought to be functional, i.e. so-called non-neurogenicbladder sphincter dysfunction (NNBSD) [4].

Hellström [5] recently suggested that during the transi-tion to bladder control there might be a risk of developingNNBSD, a risk that probably increases when the transitionperiod is prolonged and when the child starts the transi-tion at a later age. Wiener

et al.

[6] suggested that func-tional voiding disorders might be caused by inadequatetoilet habits and positions. They proposed trainingprogrammes to remedy those dysfunctions, and reportedsome success. In a recent study we were able to show thattoilet-training methods have changed greatly in the last60 years, and hypothesized that this could be one cause ofthe reported high prevalence of voiding dysfunctions inschool-aged children [7].

The purpose of the present study was to evaluate,through a questionnaire, the family situation, personal

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habits and particularly toilet-training methods (time andreasons of onset, method of training) used in a populationof children completing the last 2 years of normal primaryschool. These data were compared in two subgroups of thepopulation, one with and one with no LUTS.

Subjects and methods

A questionnaire (41 questions) was developed [8]: thefirst nine questions evaluated the family situation andthe personal data of the child; the next 14 were aboutthe age at which continence was achieved, micturitionbehaviour at the time of the evaluation and the methodsused for dry training; the last 18 questions were to docu-ment lasting LUTS and signs, day-time wetting with orwithout night-time wetting, monosymptomatic noctur-nal enuresis (MNE), fecal soiling and/or actual or former(recurrent) UTIs, and the applied treatment(s) for thesedisorders.

The questionnaire was distributed to 5646 pupils com-pleting the last 2 years of normal primary school (meanage 11.5 years,

SD

0.56). The schools were contactedthrough six centres of the School Health system, chosenat random and including children of all social classes inthe group. There were no exclusion criteria for participa-tion in the study. The parents were contacted throughthe schoolteachers, who after providing an explanation,agreed to distribute the questionnaires. An accompany-ing letter explained the purpose of the evaluation andintroduced the questionnaire, which was answered bythe parents at home with no help from the investigators,and was collected again at the schools. The reproducibil-ity and validation of the questionnaire was confirmedpreviously [8].

Day-time wetting with or without night-time wetting,independent of the severity and the frequency of the wet-ting, fecal soiling, and a history of UTI were consideredas signs of an abnormal outcome of bladder control,and these children were designated the ‘symptom’ group.When no history of previous or current UTI and/or noday- and/or night time wetting was reported, childrenwere designated as the ‘control’ group. For some evalua-tions children with MNE were evaluated separately.

The results were analysed using nonparametric tests,i.e. the chi-square test (Yates corrected), with

P

<

0.05considered to indicate statistical significance.

Results

In all, 4332 replies were collected from 5646 question-naires and were complete for 2215 boys and 2117 girls(51% and 49%); this represents a response rate of 76.7%.The population was divided into the control group of 3404children (1963 boys and 1541 girls, 57.6% and 45.2%)

and the symptom group of 928 children (352 boys and576 girls, 37.9% and 62.1%). There were no age differ-ences between the groups, but the proportion of girls wassignificantly (

P

<

0.001) higher in the symptom group(Table 1).

There was a small but statistically significant difference(

P

=

0.015) in the familial background between thegroups; 86% of the control and 82% of the symptom groupwere from a stable first marriage. Coming from a one-parent family seemed to have no influence, but theso-called ‘recomposed’ family (second marriage of bothpartners, often with children from their first andsecond union) was more frequent in the symptom group(7% vs 4%). The prevalence of the primary or secondaryform of MNE was independent of the familial situation.

Significantly (

P

<

0.001) more bedwetting in relativeswas reported by the symptom group, at 37% (146 boys,195 girls) vs 25% (494 boys, 381 girls) in the controlgroup. In the small group with MNE (47 boys and 15 girls)61% (boys and girls) reported having had a bedwettingrelative.

Children in the symptom group were reported to havestatistically significantly (

P

=

0.006) more frequent school

Table 1

The distribution of age, and the age at onset of trainingand achievement of continence, in the asymptomatic control andsymptomatic groups, for both boys and girls

Variable

Control, n Symptom, n

M F M F

Age, years

10 23 16 1 811 880 717 165 27512 848 727 161 25813 98 78 22 2714 14 3 3 8Total 1863 1541 352 576

Onset of toilet training, months

<

18 558 537 67 14118–24 873 717 182 31025–30 250 159 67 81

>

30 20 10 11 0Unknown 162 118 25 44

Age (years) at achievement of continence

<

3 day,

<

6 night:Day 1762 1494 307 531Night 1739 1483 248 516

>

3 day,

>

6 night:Day 101 47 42 41Night 124 58 50 42

Still wet:Day 0 0 3 4Night 0 0 54 18

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results below average, at 12% (107) in the symptom and8% (279) in the control group. The ability to managehomework and appointments independently was also sig-nificantly (

P

<

0.001) lower in the symptom group; 73%had to be frequently or systematically reminded of theirobligations, as against 68% of the control group. Therewere similar differences (

P

<

0.001) between the groupsin the capacity to manage normal daily hygiene; in thesymptom group 37% (341) washed themselves only oncommand vs 31% (1046) in the control group. Theparticipation in extra-school activities was equal in bothgroups; most were involved in sports or music.

The age at the onset of the toilet-training (Fig. 1) wassignificantly (

P

<

0.001) different; 32% of the parents ofthe control group started toilet training before 18 months,vs only 22% in the symptom group, where most (53%) ofthe parents started 6 months later. In the symptom group17% started the training after 2.5 years but only 13% inthe control group started so late;

≈

8% in both groupsreported no longer remembering when they had startedtraining (Table 1). Significant differences (

P

<

0.001) werereported in the age at which continence was achieved,both during the day and the night (Table 1).

Age was reported as the main reason for initiating toilettraining, by 62% in the control and 65% in the symptomgroup. School admittance was mentioned significantlymore often (

P

=

0.001) as an incentive for training inthe symptom group (30% vs 36%). Being dry during thechild’s afternoon sleep seemed a little more important forthe parents of the control group (22% vs 20%) but thisdifference was not significant.

There were no significant differences in the choice ofreceptacle used during toilet training, although more par-ents of the symptom group (29% vs 27%) used a normaltoilet without a reducing seat and support for the feet. Sig-

nificantly (

P

<

0.001) more prompting, alone or simulta-neously with other methods, was used by the parents inthe control (68%) than in the symptom group (62%). Thesymptom group adopted a more liberal attitude and imi-tation was far more popular. Rewarding and punishingwere also significantly different (

P

<

0.001); parents in thesymptom group had a tendency to reward and punishmore (53% vs 46%) but in both groups more reward thanpunishment was used.

There was a major difference between the groups inthe reaction of the parents when the child’s attempt tovoid was unsuccessful; most parents of the control group(83%) just encouraged the child to try again later and didnot insist. This was in contrast with the attitude of the par-ents in the symptom group; 13% invited the child to ‘push’to obtain a void, 26% opened a water tap and 43% encour-aged them with special noises. Some of the parents triedtwo or three different ways simultaneously to stimulatevoiding. A similar low percentage of parents in bothgroups no longer remembered their methods in suchcircumstances (Table 2).

There was considerable confusion about the use of theterms ‘continence and incontinence’ by the parents; 459of the 466 parents in the symptom group considered theirchild to be continent, despite severe day-time wetting(upper clothes needed to be changed) several times a day.Very few parents of the symptom group (126 of the 928)consulted a health carer; most of those who sought helpconsulted their GP. Night-time wetting seemed to be farmore alarming for the parents than day-time wetting.

Discussion

As indicated in a previous study [7] we report our data onfamily situation, behaviour and methods of toilet-trainingin a large population of children. From the questionnaireused to gather the data, two subgroups could be defined,i.e. the symptom and control groups. Kyle

et al.

[9] notedin 1991 that a lack of independence and below-averageschool results might be caused by lasting LUTS, rather

Fig. 1.

The child’s age at the onset of the toilet-training for the control(green) and symptom (red stipple) groups (percentage, with bars rep-resenting the 95% CI).

0102030405060708090

100

Per

cen

tag

e

<18monthsn = 1303

18–24monthsn = 2082

>24monthsn = 598

Unknownn = 349

Table 2

The reaction of the parents when an attempt to void wasunsuccessful in control and symptomatic children; there couldbe several answers at the same time

Reaction when no void Control, n (%) Symptom, n (%) P

Try later again 2840 (83) 625 (67)

<

0.001Wait until void 90 (3) 73 (8)

<

0.001Push/strain 185 (5) 122 (13)

<

0.001Make special noises 1267 (37) 396 (43) 0.0024Open tap 719 (21) 238 (26) 0.0032Did not remember 194 (6) 46 (5) 0.3809Total 5101 1564 –

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than these problems being the result of other behaviour.Redsell and Collier [10] confirmed the clinical evidence forincreased behavioural problems in children with night-time wetting. Moreover, they found that behavioural prob-lems increased in older children, which might indicatethat wetting was the primary problem. In the presentstudy, school results ‘below average’ and a low degree ofindependence, for homework and for daily hygiene, weremore prevalent in children with LUTS, which indeed sug-gests a lower self-esteem and self-confidence in this group.

The identical prevalence of primary and secondaryMNE in the present children with a different familial back-ground is in agreement with the findings of Hirasing

et al.

[11], who found no differences in behavioural and emo-tional problems between these forms of MNE. However,the result contrasts with those of von Gontard

et al.

[12],who reported higher total problem scores (Child Behav-iour Check List Achenbach) for secondary MNE. Thepresent findings reinforce previous reports; with very fewexceptions, bedwetting is not caused by psychological fac-tors, but psychological and behavioural problems in chil-dren with bedwetting are a consequence of the wetting.

In the present study, 61% of all children with MNE hadhad a bed-wetter in the family, which agrees with Bakwin[13], who reported in 1973 that in about half of childrenwith MNE at least one parent had experienced night-timewetting. When both parents were bedwetters their off-spring had a 70% chance of having MNE.

The association between NNBSD and the developmentof UTI, and the high prevalence of recurrent UTI in chil-dren with incontinence, has been well documented. Therisks of developing renal scarring from UTI have also beenreported [14,15]. By trying to understand the causes ofthe development of dysfunctional voiding problems, itmight be possible to prevent them and contribute todecreasing renal scarring in children.

We chose an anonymous enquiry for the present study,to obtain a high response rate in a large group of children.We were aware that the study design could make it impos-sible to verify retrospectively any urodynamic abnormali-ties in the symptom group. We reported previously [8]the association between the urodynamic findings and theanswers from the questionnaire in a group of 140 chil-dren; no false-positive urge syndromes were detected, indi-cating that diagnosing NNBSD using a questionnaire isvaluable, as already described by van Gool

et al.

[16].Toilet-training methods have changed considerably

over the last 60 years; the onset of training is significantlypostponed, scheduled voiding progressively abandoned,and the potty-chair often replaced by a normal toilet (evenwith no reducing seat or support for the feet) [7]. Similardifferences in training methods were found and reportedin our previous study comparing two small groups of chil-dren with a different outcome of bladder control [8]. In the

present study, conducted in a large population, we againfound these differences in training methods; significantlymore parents in the control group began the toilet-training before the child was 18 months old, used sched-uled voiding and did not insist when the first attempt tovoid was unsuccessful.

In 1943, Gesell [17] noted that at age 15–18 monthsthe child is particularly receptive to toilet-training; thiscorresponds with the 15–24 month period during whichSchmitt [18] reported a progressive increase of the inter-vals between voids. That more parents in the present con-trol group started training their child before 18 monthsold, as used by parents in the 1940s, might indicate thatGesell’s assumption is right, i.e. initiating training before18 months old is important.

When the child’s attempt to void was unsuccessful moreparents in the symptom group interfered, leaving the childon the toilet/potty until he/she voided, etc. Straininginduces a reflex contraction of the pelvic floor (guardingreflex) and is considered harmful for the normal coordina-tion between detrusor and pelvic floor [6]. The presentfindings indicate that such a danger is especially presentif straining is used regularly during the development ofnormal bladder-sphincter function, eventually leading toNNBSD, as noted recently by Hellström [5].

The major differences between ‘dryness and cleanli-ness’ in the present children and in the studies of Largo

etal.

[19,20] might arise through the different definition of‘continence’; Largo

et al.

defined being continent as hav-ing the capacity to manage independently the whole con-tinence process (go to the potty/toilet, get undressed andinitiate the void). They state that this continence processis largely maturational and not predominantly influencedby training. In their view, training and drill impose paren-tal control. Gesell [17] differentiated between being ‘dry-drilled’ and having complete bowel and bladder control,drawing attention to the fact that being dry and clean wasachieved through close control from the mother ratherthan by the demands of the child. That ‘dryness’ can betrained, as shown here, and that sociocultural factors aremore important determinants of toilet training than iscurrently thought, is suggested by the early (5–6 monthsold) achievement of day and night dryness of the childrenin the study reported by de Vries and de Vries [21]. Thegood results reported with retraining programmes forNNBSD, based amongst others on the imposition of void-ing and drinking schedules, even suggest that the devel-opment of bladder control can be influenced at any time[16,22].

Gesell [17] indicated the importance of using a smallpotty, adapted to the child; the child’s bottom must bewell supported and in a stable position during voiding, toobtain good relaxation of the pelvic floor. This mightexplain the higher prevalence of symptoms in the present

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children who were trained on an adult toilet. Part of thetraining programme proposed for NNBSD is learning anadequate toilet position with support for the feet,giving a stable position to permit relaxation of thepelvic floor and thus to obtain complete physiologicalemptying of the bladder [16,23]. The positive effects oftoilet training have been documented in recent studies.Both Sillen

et al.

[24] and Jansson

et al.

[25] reportedgood results in a longitudinal study in children withdilating reflux trained when young.

Considering all these findings, the hypothesis that nor-mal bladder-sphincter coordination is purely a matura-tional process which cannot be influenced by toilet-training should be reconsidered. The bladder can probablybe trained to be ‘quiet’, by imposing upon the urinary sys-tem a strict filling/emptying schedule. The best time tostart this training seems to be before 18 months old; therewere significantly more symptoms in the present groupwhen training started after that age.

In conclusion, physicians and paediatricians should paymore attention to wetting in children, and initiate discus-sion about toilet behaviour and problems of bladder con-trol with parents and children. Ten years ago, Robson

etal.

[26] advised physicians to start discussions about toilettraining with parents when the child was 12–18 monthsold. We strongly encourage such an attitude, as thepresent results seem to indicate that age and methods usedduring toilet training probably influence the outcome ofbladder control. An over-liberal attitude and a late startmight favour the development of NNBSD. However, it isnot yet possible to recommend one ‘correct’ way of train-ing which might prevent all voiding problems, as mostchildren seem to develop normally despite environmentalconditions and harmful methods. The present results indi-cate the risks when starting training after 18 months old,when using a normal toilet, and especially when advocat-ing straining to initiate voiding.

Acknowledgements

The authors are grateful to the Medical Health Centresand the Vlaams Wetenschappelijke Vereniging voor JeugdGezondheidszorg (VWVJ, Scientific Association of YouthHealth) involved in the distribution and collection of thequestionnaires, and to all school teachers encouragingthe children to participate.

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Authors

E. Bakker, Physiotherapist.J.D. van Gool, MD, PhD, Professor, Paediatric Nephrologist.M. Van Sprundel, MD, PhD, Professor, Epidemiologist.J.C. Van Der Auwera, Statistician.J.J. Wyndaele, MD, PhD, DSc, Professor, Urologist.Correspondence: J.J. Wyndaele, University of Antwerp, Depart-ment of Urology, Wilrijkstraat 10, B-2650 Edegem, Belgium.e-mail: jean-jacques.wyndaele@uza.be

Abbreviations:

NNBSD

, non-neurogenic bladder sphincter dysfunction;

MNE

, monosymptomatic nocturnal enuresis.