Achieving urinary continence in children

Delayed elimination communication is a crucial factor in disposable diaper dependence in Chinese preschool-aged children

PURPOSE

Elimination communication (EC) is considered to be a milestone in a child's development. Nowadays, a trend toward an older age at EC initiation has been observed globally, probably due to the convenience of disposable diaper use in daily life. The study aimed to identify potential risk factors for disposable diaper dependence (DDD) and evaluate whether an early/proper EC can reduce the risk of DDD among children in China.

METHODS

A cross-sectional study was performed on 13,500 children in mainland China from October 2019 to March 2020. An anonymous questionnaire was used to collect information including the sociodemographic characteristics, details about DDD and EC, and the effect of DDD on the quality of life of children. Data were analyzed by SPSS and R software.

RESULTS

The overall prevalence of DDD was 4.17% (4.31% in boys; 4.02% in girls) and decreased with age, from 8.71% at 2 years to 0.73% at 6 years (χ ² _trend  = 210.392, P < 0.001). In univariable analysis, age, location or EC were associated with DDD. Four independent factors-age, location (urban), caregivers with high education levels (junior college or above) and delayed EC (after 12 months of age)-were identified to be significantly associated with DDD risk in logistic regression model. Compared with EC onset after 12 months of age, EC onset before 12 months of age was associated with a 79.6% (model 2) reduction in DDD. Four independent factors were selected to establish the nomogram for DDD based on the results of logistic regression analysis. The C-index (0.770) and the AUC (>0.7) indicated satisfactory discriminative ability of the nomogram. The calibration diagrams showed favorable consistency between the prediction of the nomogram and actual observations.

CONCLUSION

Our findings indicate the joint contribution of age, location, caregivers' education level and EC to DDD in Chinese preschool-aged children. Timely cessation of the use of disposable diapers and early/proper EC may help to reduce the risk of DDD in children.

Improving continence in children and young people with neurodisability: a systematic review and survey

BACKGROUND

Children and young people with neurodisability often need help to achieve socially acceptable bladder and bowel control. Approaches vary depending on whether or not the impairment results from spinal cord pathology that impairs motor control and sensation of the bladder and bowel. Currently, there is uncertainty about which interventions are effective.

OBJECTIVE

The objective was to summarise the available evidence on and current practice for improving continence in children and young people with neurodisability.

DESIGN

A systematic review of the effectiveness, cost-effectiveness and factors that modify intervention implementation, alongside a cross-sectional, online survey of current practice with health professionals, parent carers, school and care staff and young people with neurodisability.

RESULTS

Twelve databases were searched in the review, resulting in 5756 references; 71 studies (72 papers) were included in the analyses. Most of the evidence was for children with spinal cord pathology, which involved evaluations of pharmacological approaches and surgical techniques, whereas the evidence pertaining to those with non-spinal-cord-related pathology tended to be for behavioural interventions. The methodological quality of studies was rated as being moderate to poor. There were three robust qualitative studies about the experience of continence among children with spinal cord pathology. We found substantial heterogeneity across the interventions that we evaluated in terms of quality, study design and outcomes measured. No economic studies were found. The results were synthesised narratively and reported in text and tables. We did not find any eligible studies evaluating interventions using toilet and clothing adaptations in the review, although the survey highlighted that these types of interventions are frequently used and considered. In total, 949 people responded to the survey: 202 health professionals, 605 parent carers, 122 school and social care staff, and 20 young people. The survey results illustrated the different roles that professionals have in improving continence, highlighting the importance of a multidisciplinary approach to supporting children and young people and their families. Clinicians employ a range of assessments and interventions to improve continence or independent toileting, depending on the needs of the child.

LIMITATIONS

Quantitative studies in the review were not methodologically robust. The survey had a risk of response bias.

CONCLUSIONS

Our research found a dearth of good-quality evidence for many of the interventions currently in use, and no evidence of experiences of implementing interventions for children with non-spinal-cord-related pathology. There was also no evidence of cost-effectiveness of any of the interventions.

FUTURE WORK

There is a need to involve young people and families in the design of high-quality evaluative research for interventions that aim to improve continence. This is especially the case for children with autism and learning disability, who have been neglected in previous evaluative and qualitative research. We recommend better training for health, education and care professionals about toileting, informed by evidence and the lived experiences of children and their families. We recommend a joined-up multidisciplinary and holistic approach to improving continence to maximise independence, dignity and comfort. It is vital that children and young people with neurodisability have early access to regular, integrated assessment of their bladder and bowel health, and are fully supported with appropriate personalised treatment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018100572.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 73. See the NIHR Journals Library website for further project information.

Determinants of bedwetting trajectories between 4 and 7 years - A birth cohort analysis

INTRODUCTION

Enuresis is frequent in school-aged children and results from a complex interaction between genetics, biological and psychosocial factors. This study aims to analyze bedwetting trajectories between 4 and 7 years of age and to evaluate the impact of biological and developmental characteristics of the child and sociodemographic factors in those bedwetting trajectories.

METHODS

Data from 5433 children from the Generation XXI population-based birth cohort was analyzed. Four bedwetting trajectories were defined: normative (acquired nighttime bladder control at 4 years and no enuresis at 7 years); delayed (no nighttime bladder control at 4 years and no enuresis at 7 years); enuresis (no nighttime bladder control at 4 years and enuresis at 7 years); and secondary enuresis (acquired nighttime bladder control at 4 years and enuresis at 7 years). Multinomial logistic regression models were fitted to test the association between biological and developmental characteristics of the child and sociodemographic factors with bedwetting trajectories.

RESULTS

At the age of 4 years, 36.5% of children had bedwetting (8.1% infrequently and 28.4% frequently) and at the age of 7 years, 11.0% had enuresis (5.8% infrequently and 5.2% frequently). Of the 4-year-old children who were infrequent bedwetters, 14.0% had enuresis at 7 years, while among frequent bedwetters, 30.2% had enuresis at 7 years. Regarding bedwetting trajectories, 26.8% of children were classified in the delayed trajectory, 9.7% in the enuresis trajectory and 1.3% were in the secondary enuresis trajectory. Children with developmental disorders presented an increased risk of being in enuresis trajectory (OR = 1.47, 95% CI 1.15-1.88) than children without developmental disorders. Living in overcrowded houses (OR = 1.60, 95% CI 1.12-2.30), growing up in families with low household income (OR = 1.27, 95% CI 1.03-1.57) and an orphan of one parent (OR = 3.19, 95% CI 1.18-8.64) presented higher odds of being in the enuresis trajectory than in the normative trajectory. Having a sibling both before the age of 4 years and between the ages of 4 and 7 years was associated with delayed trajectory (OR = 1.55, 95% CI 1.16-2.07) and with enuresis (OR = 1.53, 95% CI 1.01-2.33), when compared with children without siblings born at that time.

CONCLUSION

Both developmental disorders and sociodemographic factors seem to be important determinants of bedwetting trajectories. Further studies are needed to better characterize the impact of biological and environmental determinants, on the nighttime bladder control acquisition, to enable timely medical interventions that improve the quality of life of enuretic children.

Disposable diaper overuse is associated with primary enuresis in children

This research investigated the association between prolonged disposable diaper (DD) wearing in infancy and primary enuresis (PNE). As a case–control study, we collected data from 376 children with enuresis and 379 healthy children who were sex- and age-matched at three tertiary care institutions in mainland China from August 2017 to July 2018. The results of adjusted logistic regression showed the odds ratios (95% confidence intervals) for PNE across the categories of age of daytime DD use cessation were as follows: ≥ 25 months: 1.00, 18–24 months: 0.25 (0.17–0.37), and ≤ 17 months: 0.11 (0.06–0.20), independent of age, mother education, residence, toilet training approach, breastfeeding duration, UTI, constipation, anaphylactic disease and family history. After a similar multivariable adjustment, increased age of daytime DD use (per-month) had a positive correlation with PNE, OR = 1.17, 95% CI 1.13–1.20 and non-linear relationship was detected, whose point was 21 months (the effect sizes and the 95%CI on the left and right sides of inflection point were 1.04 (0.99–1.10), P = 0.131 and 1.25 (1.18–1.31), P < 0.001). Subgroup analysis found that the effect of duration of disposable diaper exposure for each additional month, those children had accepted assisted infant toilet training/elimination communication (AITT/EC) practice had a lower risk of PNE (OR = 1.08, 95% CI 1.04–1.12), compared with those without AITT/EC practice (OR = 1.20, 95% CI 1.14–1.27), P for interaction < 0.001. In conclusion, the children diagnosed with primary enuresis after age 5 stopped using disposable diapers at daytime later than the control group. Association between duration of DD exposure and the risk of childhood enuresis is modified by AITT/EC practice. Timely cessation use of disposable diaper and practice AITT/EC may shorten the time to nocturnal continence, and the prospective cohort studies are needed to verify the discoveries.

Delayed in toilet training association with pediatric lower urinary tract dysfunction: A systematic review and meta-analysis

BACKGROUND

Globally, attitudes and practices towards toilet training have changed several decades ago and children are completing toilet training at a later age compared to previous generations. Concurrently, there has been an increase in the incidence of pediatric bladder bowel dysfunction (BBD), including lower urinary tract dysfunction (LUTD). Whether the fact of delayed toilet training may negatively impact the ability of children to obtain bladder and bowel control and cause LUT dysfunction remains controversial.

OBJECTIVES

To investigate the association between age at initiation of toilet training or approach to toilet training and the risks of lower urinary tract (LUT) dysfunction.

METHODS

A comprehensive search of the CENTRAL, EMBASE and MEDLINE via Ovid SP, and CINAHL via EBSCO databases was conducted to identify RCTs, cohort or case-control studies investigating the association between age at initiation of toilet training, approach used for toilet training, and pediatric LUT dysfunction.

RESULTS

A total of 10 studies with 24,121 participants (aged 5-17) were included for pooled analysis. Overall, the odds ratio (OR) with 95% confidence interval (95%CI) of LUT dysfunction in children who initiated toilet training at a younger age when compared to those who initiated toilet training at an older age, was 0.71 (0.63-0.81), P < 0.001), irrespective of the approach used for toilet training (Table). Subgroup analysis for day-time incontinence (persistent daytime wetting) was 0.77 (0.62-0.95), P = 0.014; although the outcomes for enuresis fluctuated, favorable results were still observed in the earlier training group (OR:0.63, 95%CI:0.43-0.94, P = 0.023). Subgroup analysis for age at initiating toilet training vs LUT dysfunction also showed favorable results in children who were trained earlier, i.e., before 24 months (OR:0.77, 95% CI 0.63-0.94, P = 0.009). Sensitivity analysis confirmed that the results were robust.

DISCUSSION

Although the definition about the age of initial toilet training varied greatly in studies, findings from the current study suggested that the optimal time for initiating toilet training may be prior to the age of 24 months; if toilet training was initiated after 24 months or later, it may result in increased prevalence of LUT dysfunction. Since no RCTs studies were included in the current meta-analysis, well-designed longitudinal studies with larger sample size and from different cultural background are needed to confirm these results.

CONCLUSION

This meta-analysis presents preliminary findings that show the incidence of LUTD may be decreased by initiating toilet training in children at a younger age.

Is the strong desire to void a source of diverted attention in healthy adult volunteers?

AIMS

The strong desire to void (SDV) induces changes in both cognition and gait. This may be due to the sensation of urinary urge acting as a source of diverted attention. This exploratory study examined the influence of SDV and a standardized distracting task on the performance of two measures of cognition, a simple reaction time (SRT) test and the trail making B test (TMT-B).

METHODS

18 volunteers, 8 male and 10 female, without lower urinary tract symptoms (LUTS) (mean age: 20.5, range: 20-47), performed a test of SRT and the TMT-B under three conditions; undistracted with an empty bladder, while experiencing SDV, and when performing a simultaneous distracting task, the auditory n back test.

RESULTS

A statistically significant increase in SRT was found when experiencing SDV and when distracted compared with the undistracted, bladder empty condition. The time taken to compete the TMT-B significantly increased with distraction but was not affected by SDV.

CONCLUSION

SDV induced a similar but smaller change in reaction time when compared with a distracting task, suggesting that SDV may act as a source of diverted attention in continent, healthy volunteers.

Information as a crucial factor for toilet training by parents

BACKGROUND

Toilet training (TT) is a milestone in a child's development. Nowadays, children complete TT later than previous generations. This can have detrimental consequences for the child, the parents, and the environment. TT is experienced as difficult and time-consuming; parents could benefit from guidelines to assist in this process.

METHODS

Focus group discussions (FGDs) were used to explore parents' experiences in an inductive approach applying purposive sampling. The FGDs aimed to explore the type of information parents wanted to receive on TT, from whom and how.

RESULTS

After six FGDs, including 37 participants with personal experience in TT, data saturation was achieved. The findings of this qualitative study show that reputable agencies, family, friends, day-care workers, and nursery school teachers were considered very helpful and trustworthy sources. TT information should be easily understandable and not contain scientific terms or much text. A colourful and illustrated brochure sent by regular mail is preferred.

CONCLUSION

Our study allows to develop a source of correct and wanted information about TT that parents can and want to use, which helps them completing this training more easily and timely.

Lidocaine Gel for Urethral Catheterization in Children: A Meta-Analysis

OBJECTIVE

To compare the efficacy and safety of lidocaine gel vs nonanesthetic gel (NAG) in reducing transurethral bladder catheterization (TUBC) procedural pain in children.

STUDY DESIGN

A systematic literature search was done using electronic medical databases and trial registries up to September 2016 with no language restrictions. Randomized controlled trials (RCTs) that assessed the efficacy and safety of lidocaine gel vs NAG in reducing TUBC-associated pain in children were screened, identified, and appraised. Risks of bias and study quality of the eligible trials were assessed according to the Cochrane Collaboration recommendations. Various pain assessment scales from the included studies were extracted as mean differences and standard deviations for each treatment group. Standardized mean differences (SMDs) were generated with 95% CIs for between-group difference estimation. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed for different age groups.

RESULTS

Five RCTs (with a total of 369 children) were included. Overall pooled effect estimates showed that compared with NAG, lidocaine gel has no significant benefit in decreasing TUBC-associated pain in children (SMD, -0.22; 95% CI, -0.65 to 0.21). Effect estimates from 4 studies revealed no difference in pain reduction between the lidocaine gel and NAG in children aged <4 years (SMD, 0.01; 95% CI, -0.22 to 0.24). No serious adverse events from the lidocaine gel use were reported in any of the studies.

CONCLUSIONS

Lidocaine gel does not appear to reduce TUBC pain compared with NAG, specifically in children aged <4 years.

PROSPERO REGISTRATION NUMBER

CRD42016050018.

The association between lower urinary tract symptoms and falls: Forming a theoretical model for a research agenda

BACKGROUND

There is a well-recognised association between falls and lower urinary tract symptoms (LUTS) in older adults, with estimates of odd ratios for falls in the presence of LUTS ranging between 1.5 and 2.3. Falls and LUTS are both highly prevalent among older people and both are markers of frailty, with significant associated morbidity, mortality, and healthcare resource cost. This association is not well examined or explained in the literature.

AIMS

We aimed to outline current knowledge of the association between falls and lower urinary tract symptoms and suggest a research program to further investigate this.

MATERIALS AND METHODS

A consensus conference of experts in the field was convened to review the current literature and brainstorm potential future investigative avenues.

RESULTS AND DISCUSSION

Despite the recognition of this association, there has been little research to examine its potential causes, and no intervention trial has established if reducing LUTS or urinary incontinence can reduce the risk of falls. The commonly held assumption that urgency causes falls through rushing to the toilet is likely incorrect. Falls and LUTS are both symptoms of frailty and have many common causes. Gait, balance, and continence are all processes requiring cognitive input, and the concept of dual tasking may be a further link.

CONCLUSION

The significant association between lower urinary tract symptoms and falls is currently unexplained, and further research into the potential causes of this association is needed.

Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial

Objective To determine if a simple stimulation method increases the rate of infant voiding for clean catch urine within five minutes.Design Randomised controlled trial.Setting Emergency department of a tertiary paediatric hospital, Australia.Participants 354 infants (aged 1-12 months) requiring urine sample collection as determined by the treating clinician. 10 infants were subsequently excluded.Interventions Infants were randomised to either gentle suprapubic cutaneous stimulation (n=174) using gauze soaked in cold fluid (the Quick-Wee method) or standard clean catch urine with no additional stimulation (n=170), for five minutes.Main outcome measures The primary outcome was voiding of urine within five minutes. Secondary outcomes were successful collection of a urine sample, contamination rate, and parental and clinician satisfaction with the method.Results The Quick-Wee method resulted in a significantly higher rate of voiding within five minutes compared with standard clean catch urine (31% v 12%, P<0.001), difference in proportions 19% favouring Quick-Wee (95% confidence interval for difference 11% to 28%). Quick-Wee had a higher rate of successful urine sample collection (30% v 9%, P<0.001) and greater parental and clinician satisfaction (median 2 v 3 on a 5 point Likert scale, P<0.001). The difference in contamination between Quick-Wee and standard clean catch urine was not significant (27% v 45%, P=0.29). The number needed to treat was 4.7 (95% confidence interval 3.4 to 7.7) to successfully collect one additional urine sample within five minutes using Quick-Wee compared with standard clean catch urine.Conclusions Quick-Wee is a simple cutaneous stimulation method that significantly increases the five minute voiding and success rate of clean catch urine collection.Trial registration Australian New Zealand Clinical Trials Registry ACTRN12615000754549.

The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society

AIM

The impact of the original International Children's Continence Society (ICCS) terminology document on lower urinary tract (LUT) function resulted in the global establishment of uniformity and clarity in the characterization of LUT function and dysfunction in children across multiple healthcare disciplines. The present document serves as a stand-alone terminology update reflecting refinement and current advancement of knowledge on pediatric LUT function.

METHODS

A variety of worldwide experts from multiple disciplines within the ICCS leadership who care for children with LUT dysfunction were assembled as part of the standardization committee. A critical review of the previous ICCS terminology document and the current literature was performed. Additionally, contributions and feedback from the multidisciplinary ICCS membership were solicited.

RESULTS

Following a review of the literature over the last 7 years, the ICCS experts assembled a new terminology document reflecting current understanding of bladder function and LUT dysfunction in children using the resources from the literature review, expert opinion and ICCS member feedback.

CONCLUSIONS

The present ICCS terminology document provides a current and consensus update to the evolving terminology and understanding of LUT function in children. Neurourol. Urodynam. 35:471-481, 2016. © 2015 Wiley Periodicals, Inc.

Best practice in the assessment of bladder function in infants

The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be 'reflexive' or 'uninhibited', with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic 'detrusor sphincter dyssynergy' seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of 'early prophylactic treatment (clean intermittent catheterization and anticholinergics)' versus initial 'watchful waiting and treatment as needed' is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux.

Vietnamese mothers' experiences with potty training procedure for children from birth to 2 years of age

OBJECTIVE

This study addresses mothers' experiences with potty training in a Vietnamese population.

SUBJECTS AND METHODS

Forty-seven mothers were interviewed and followed from the time that their children were newborns until they were 24-months old. The interviews were analyzed using qualitative content analysis.

RESULTS

According to tradition, diapers were used only rarely. The mothers used a whistling sound at certain times to remind their children to eliminate and frequently checked for signs of need. With this process, all children used the potty by the age of 9 months. At the age of 24 months the potty training was completed, and most of the children managed the whole process independent of help.

CONCLUSION

This study shows that it is possible to start potty training with good outcomes very early in life. The process described can be achieved through an ongoing communication between parent and child.

Bladder health across the life course

Influences on bladder health begin during infancy and continue throughout the lifespan. Bladder anatomy and physiology change as individuals age, and the risk and propensity for bladder conditions, including lower urinary tract symptoms, throughout life are related to factors specific to age, sex, and life events. Bladder habits and dysfunctions at one stage of life may affect bladder health in subsequent stages. However, bladder problems are neither a normal part of aging nor inevitable at any stage of life. Many of the factors that negatively impact bladder health at all ages may be modifiable, and healthy bladder habits may prevent or reverse bladder dysfunctions that can occur naturally or in response to life events. There are opportunities to further define and promote healthy bladder habits through focused research and heightened public awareness of the importance of bladder health, which may lead to improvements in overall health and quality of life. It is our hope that this paper will inform and encourage public health initiatives and research programs aimed at this goal.

Can evidence-based medicine change toilet-training practice?

OBJECTIVES

To assess the evidence showing that a specific method of toilet training (TT) is more effective than others, as any method of TT recommended by a physician faces obstacles because parents rarely request advice on TT from physicians, and TT practices vary tremendously across cultures and socioeconomic levels.

METHODS

Reports on the natural course of urinary incontinence in children and different methods of TT, published in English between 1946 and 2012, were reviewed. Specifically investigated were historical recommendations on TT, the prevalence of urinary incontinence during childhood, the outcome of TT methods, and the effect of culture and socioeconomic status on the choice of TT method and timing.

RESULTS

TT now occurs at later ages than it did previously. This progression reflects changing ideas about normal childhood physiology and psychology. The prevalence of urinary incontinence in European countries progressively decreased in children aged between 6-7 years and 16-17 years old. TT methods change with increasing socioeconomic levels to 'child-centred' techniques applied at older ages, but the prevalence of urinary incontinence after 'parent-centred' techniques of TT at younger ages has not been studied. There is currently no evidence that a specific timing or method of TT is more effective or prevents voiding dysfunction.

CONCLUSIONS

Follow-up studies of urinary continence in children toilet trained at 6-12 months of age might provide evidence for whether a given method or timing of TT is beneficial to prevent voiding dysfunction. The recommendations of physicians might be more readily adopted if they fit culturally accepted ideas of good parenting techniques.

Toilet training in daycare centers in Flanders, Belgium

Several changes have occurred in the toilet training (TT) process in recent decades. There has been an increase in the use of daycare as both parents now often work outside the home. Most children attend daycare centers during the period TT usually takes place, and daytime training has shifted from home to daycare. This study is the first to evaluate the way TT is done in daycare centers. A questionnaire was sent to 1,500 daycare centers, of which 429 replied (response rate of 28.6%). The results show that half of the childcare workers base the decision to start TT on readiness signs. The combination of age and readiness signs is used by 44.5%. The majority of the respondents spent more than 1 h per day on TT (81.8%); 79.8% considered that daycare and parents should play an equal role in TT. However, more than a third of the respondents thought that parents pass the responsibility for TT on to daycare and that not enough attention was paid to TT in the home. Most respondents stated that daycare centers had the facilities and means to be able to give the children proper TT (88.5%). Other research indicated that the outcome of TT is not that good overall and that there is room for improvement in the methods used. More research is needed on the role division and on the interaction between daycare and parents and their combined influence on the process and outcome of TT.

The medical care of children with autism

The prevalence of autism spectrum disorder (ASD) has increased considerably in the past decades. The primary care paediatrician plays an important role not only in the early recognition of ASD but also in its chronic management. Paediatricians need to be comfortable with the global care of children with ASD. The diagnostic assessment of children with ASD comprises the medical investigations to identify associated or underlying medical conditions. The most important associated conditions are seizures, feeding and gastrointestinal problems, sleep disturbances and dental abnormalities. The care of ASD patients is very demanding since along with the purely medical issues there are challenging behavioural and psychiatric conditions that need consideration and professional skills.

Readiness signs used to define the proper moment to start toilet training: a review of the literature

Confusion exists about when to start toilet training, which causes stress and anxiety. Another consequence can be the actual postponement of the toilet training process, which has created extra social problems. Therefore, in this review we will focus on the proper moment to start toilet training, more specific on readiness signs. This will clarify on which topics further research is necessary. We searched databases for publications on toilet training. Next, we gathered information about the normal development of healthy children and at which age skills needed for each readiness sign are acquired. Twenty-one readiness signs were found. Our results show that there is no consensus on which or how many readiness signs to use. Depending on the readiness sign, the moment to start toilet training can vary a lot. More studies are needed to define which readiness signs are most important and how to detect them easily.

A healthy bladder: a consensus statement

A panel of experts in urology, urogynecology, nursing, and behavioral therapy convened in 2010 to discuss the importance of a healthy bladder on overall health. They determined that a consensus statement was necessary to raise awareness among the general public, healthcare providers, payors, and policymakers, with the goals of minimizing the impact of poor bladder health and stimulating primary prevention of bladder conditions. In this statement, 'healthy' bladder function is described, as well as internal and external factors that influence bladder health. It is suggested that primary prevention strategies should be aimed at providing education regarding normal lower urinary tract structures and functioning to the public, including patients and healthcare providers. This education may promote the achievement of optimal bladder health by increasing healthy bladder habits and behaviors, awareness of risk factors, healthcare seeking, and clinician engagement and reducing stigma and other barriers to treatment. Promoting optimal bladder health may reduce the personal, societal and economic impact of bladder conditions, including anxiety and depression and costs associated with conditions or diseases and their treatment. While adopting healthy bladder habits and behaviors and behaviors may improve or maintain bladder health, it is important to recognize that certain symptoms may indicate the presence of conditions that require medical attention; many bladder conditions are treatable with a range of options for most bladder conditions. Lastly, the authors propose clinical directives based on persuasive and convergent research to improve and maintain bladder health. The authors hope that this statement will lead to promotion and achievement of optimal bladder health, which may improve overall health and help minimize the effects of bladder conditions on the public, healthcare professionals, educators, employers, and payors. The advisors are in consensus regarding the recommendations for improving and maintaining bladder health presented herein.