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Abstract
Background Paediatric lower urinary tract symptoms (LUTS) are common experiences among school-aged children, with prevalence rates reaching as high as 20%. Paediatricians are often first-line stakeholders in providing treatment for these bothersome symptoms, yet there is no formal resource to support them with the treatment of LUTS. Evaluating paediatricians’ experiences is an important step in informing health promotion efforts to improve health outcomes in children. This study aims to explore paediatricians’ knowledge, beliefs, practice patterns, and perceived barriers and facilitators in providing LUTS care.
Methods In this qualitative study, we conducted semistructured focus groups of paediatricians within California. Focus groups were conducted via Zoom, and participants were enrolled until thematic saturation was reached. Participants were asked about their current practices, knowledge and beliefs, barriers and facilitators to care, training and education, and responsibility for behaviour and action. Thematic analysis was performed using deductive and inductive approaches; themes were mapped through an iterative, team-based process.
Results 15 paediatricians, aged 30–69 years, with 13 (86.7%) women, were interviewed. Most (11, 73.3%) practised in general outpatient settings. Interviewed paediatricians recognised paediatric LUTS as a common problem that can significantly impact children’s well-being. In practice, paediatricians did not actively screen for LUTS beyond the potty-training milestone due to short visit duration and competing healthcare demands. Lack of guidelines, parental mistrust and inadequate clinical education were barriers identified by paediatricians.
Conclusions Paediatricians expressed a willingness to help patients but indicated several limitations to providing adequate LUTS care. Future professional development work can emphasise guideline development, early screening strategies to support timely intervention and better education for clinicians.
- Enuresis
- Qualitative research
Data availability statement
Data are available on reasonable request. Unpublished data are stored in a passport-protected university computer. They include the original transcripts. Data are available from the corresponding author at http://orcid.org/0000-0001-9508-2763 on reasonable request. The data are not publicly available due to privacy and ethical restrictions.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Paediatric lower urinary tract symptoms (LUTS) can significantly impact a child’s physical, emotional and social well-being. Although paediatricians have a central role in promoting LUTS health, there is limited knowledge about the barriers they face in providing treatment for their patients. To best assist clinicians in providing optimal care to children with LUTS, it is important to understand their unique viewpoints.
WHAT THIS STUDY ADDS
It provides an in-depth exploration of paediatricians’ experiences, identifying gaps in training and a need for national-level resources for paediatricians in practice.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
These perspectives are essential for developing tools to assist clinicians and ultimately improve children’s health outcomes.
Introduction
Lower urinary tract symptoms (LUTSs), such as daytime urinary incontinence, urge incontinence and nocturnal enuresis, are common childhood experiences, with prevalence rates reaching 20%.1–3 Symptom onset can typically begin around age 5 and increases around ages 7–8, likely due to modifiable behavioural factors, such as holding of urine and bathroom fear.2–4 These bothersome symptoms can significantly impact a child’s emotional and social well-being and increase family stress.5–7 Children with LUTS are at a higher risk of urinary tract infection (UTI),8 9 which may require emergency room care. Each year, an estimated 37–128 million US dollars is spent on paediatric incontinence.10
The first-line treatment for functional causes of LUTS (ie, non-neurogenic) is urotherapy. Urotherapy includes education on lower urinary tract function with targeted recommendations on behavioural and lifestyle modifications, such as regular voiding habits, adequate hydration and proper voiding postures.11 This non-surgical and non-pharmacological approach has been shown to enhance symptom resolution significantly, however, it has been primarily studied among specialty healthcare professionals, such as paediatric urologists.12
Paediatricians, who are the first to see young patients in the medical system, may be best positioned to identify and provide this type of treatment. However, only one-fourth of urologists and nephrologists indicated they followed standard guidelines,13 and even less is known about paediatricians. Questionnaire-based assessments of healthcare providers worldwide have demonstrated insufficient knowledge to meet guideline-recommended care.14 15
Evaluating paediatricians’ perspectives towards delivering LUTS care is an important step in informing health promotion efforts to improve children’s health outcomes. Thus, this study aims to explore paediatricians’ knowledge, beliefs, practice patterns and perceived barriers and facilitators in providing LUTS care.
Methods
Study design
In this qualitative study, we conducted key informant focus groups of paediatricians. All participants provided informed consent and received a US$50 Amazon gift card.
Moderator guide development
Interview questions were informed by the social-ecological model,16 17 academic literature,18 19 and feedback from paediatricians and urology practitioners. Participants were asked about their current practice, knowledge and beliefs about LUTS, barriers and facilitators to care, their training and education, and responsibility for behaviour and action (online supplemental appendix 1).
Supplemental material
Sampling and recruitment
We employed purposive sampling to incorporate regionally specific, information-rich perspectives. To capture diverse viewpoints of paediatricians across various practice types, a recruitment flyer was sent to a range of communication channels, including clinics across 13 California counties, the Stanford-affiliated primary care and Stanford Medicine newsletters, and the American Academy of Pediatrics (AAP) California Association newsletter. Eligibility criteria included English-speaking paediatricians from Northern and Central California currently providing care for children. The screening, consent and demographic forms were collected and managed using REDCap electronic capture tools hosted at Stanford.20 21
Data from the focus groups were concurrently gathered and examined; once thematic saturation was reached (ie, no new themes, ideas or patterns were identified), no further focus groups were conducted. Out of 21 eligible participants, 15 paediatricians (71%) participated in 1 of 5 focus groups (5 were not scheduled due to time conflicts and 1 did not attend their session).
Data collection and analysis
Focus groups were conducted via Zoom by three research team members (GA, SS and AS) trained in qualitative methods. Each focus group was limited to 3–4 participants for online practicality, lasted approximately 50 min, was audio and video recorded, and professionally transcribed.
Analysis was conducted by a multidisciplinary team: a paediatric urologist (KMK), three social science researchers (PV, AS and GA), a master’s trained community health and prevention researcher (SS) and a qualitative method expert (CB-J). The research team met weekly to discuss the analysis. After each focus group, summary notes were shared with the group to get context, perspective and feedback. We applied thematic analysis, incorporating deductive and inductive approaches.22–24 Using Dedoose, we (1) open-coded one transcript to create the codebook, (2) independently coded a second transcript and (3) established inter-rater reliability between coders (SS and KMK) with eight excerpts from a third transcript (100% agreement, Cohen’s kappa of 1.0).25 Data interpretation occurred over multiple weekly team conversations, where we looked within and across codes to identify key patterns and connections in the data. Shared meanings were further merged, moved and identified using a mapping technique modified for virtual context (ie, themes and excerpts were sorted in synchronous sessions).23 26
Results
Study participants
15 paediatricians within Northern California were interviewed (August 2021–July 2022). Participants were aged 30–69 years, 13 were women (86.7%) and 11 (73.3%) practiced in a general outpatient setting (table 1).
Paediatrician characteristics across all focus groups
Thematic analysis results
We identified five themes, which are described below. See box 1 for theme summaries and illustrative quotes.
Themes and quotes related to bladder health identified by paediatricians
Theme 1: Paediatric bladder health impacts the social/emotional lives of parents and children
So I think it affects both the physical health and eventually the mental health, not just on the patient but also the parents. The parents want the kids to be potty-trained as they hit the developmental milestone at a particular age. And if that’s not happening, the patient is affected, and the parent is affected. (FG3, P8)
Theme 2: A range of paediatrician beliefs drive variation in counselling that is focused on early childhood
Our population that’s just entering early elementary school age, I think about them the most because of the social impact if you have incontinence as well as I think about the challenges of needing to come into either the urgent care or the pediatric office if they’re getting recurrent infections. (FG5, P14)
Theme 3: Lack of educational support in training drives a need for self-education in practice
Moderator: Where do you get those guidelines right now? […] (FG5, moderator)
P15: I don’t. I don’t get them. [laughter] I just make them up. (FG5, P15)
I feel pretty confident about knowing how to make a diagnosis and the treatment, but what’s challenging at times is getting the family to implement some of the behavioral interventions that are necessary to solving this problem. (FG2, P7)
Theme 4: Paediatricians do not actively screen for LUTS
I think the challenge is time, right? And so, if the parents have other things that they really want to talk about and it’s not on the screening questionnaire and gets circled in the section of concern, then probably it’s not going to get addressed. (FG5, P14)
Theme 5: Referrals to bladder health specialists are driven by parent expectations and mistrust
So I think parents’ pressure is a factor. I don’t have any problem with the referring…it’s very open-ended in my practice. It’s like I have to use it judiciously…but a lot of times it’s like, ‘ah, it’s really too early,’ but the parents are very pushy, ‘I want to see a specialist. (FG3, P9)
I would say that some [parents] don’t really believe their kid’s constipated. They’ll say they poop several times a day, so they’re not constipated, but they really are. So oftentimes, I refer them just because they don’t really believe me. (FG5, P15)
FG, focus group; P, participant; LUTS, lower urinary tract symptoms.
Theme 1: paediatric bladder health impacts the social/emotional lives of parents and children
Paediatricians believe that LUTS is ‘a major problem’ due to the frequent presentations of enuresis, UTI, and voiding frequency and their overall impact on a clinician. All participants saw LUTS frequently. Beyond disease prevalence, the bothersome symptoms drive negative changes to a child’s and parent’s social and emotional well-being. For children, ‘it (bedwetting/LUTS) prevents them from joining camps, sleepover at their friend’s house’. LUTS can ‘bother the parents more than the kids when the kids are younger’, due to concern for disease aetiology and restrictions in social activities.
Theme 2: a range of paediatrician beliefs drive variation in counselling that is focused on early childhood
Beliefs in LUTS aetiology are reflected in diagnosis and treatment counselling with a general focus on early childhood presentations. When prompted, paediatricians stated that LUTS follows a bimodal structure: early childhood and early adolescence. However, the majority of the participants focused responses on early childhood when describing disease aetiology and treatment recommendations. In practice, history-taking and treatment recommendations did not follow a standardised method, and answers varied among participants. Key beliefs include night-time presentations of LUTS will generally self-resolve, daytime presentations are shaped by structures (e.g., bathroom access) and girls are disproportionately affected as a result of gender-related hygiene practices. Paediatricians express the belief that bedwetting (enuresis) is a self-resolving condition that requires reassurance and for some clinicians, night-time alarms. Paediatricians highlight developmental physiology principles in their decision process: ‘It’s a small bladder combined with deep sleep and low antidiuretic hormone. So I just try to buy time with them.’ Factors such as infrequent potty breaks, family and environmental stressors, constipation, and incorrect hygiene were cited as common causes of daytime LUTS. Treatment goals target modifiable aspects within a structural environment: education on increasing the frequency of potty breaks, softening stool, correcting hygiene practices and managing stressors such as starting school. Hygiene discussions primarily focused on correcting inadequate wiping techniques in young girls in order to avoid UTIs. One clinician proposed education: ‘We need to teach the parents to teach the children how to wipe from front to back.’
Theme 3: lack of educational support in training drives a need for self-education in practice
Paediatricians believe that it is their responsibility to provide parents with bladder health information. However, residency training is described as inadequate to meet their current clinical practice needs and clinicians independently seek knowledge to address this gap.
Current residency education that focuses on inpatient diagnosis and treatment management is insufficient at preparing trainees for real-world practice. Since participants consider LUTS to be an outpatient diagnosis, ‘the bladder kind of gets forgotten’. Knowledge-seeking is driven by feelings of inadequate preparation to meet the large volume and expectations of LUTS patients. This effort is individualised without a central resource, as one clinician noted, ‘I’m sort of learning out of residency and trying to educate myself, and as patients come up, how I can help them.’
Clinicians recognise the absence of a resource and voice needs for standardised LUTS education. In paediatric residency, trainees should have LUTS education ‘from the first year, every year; when you’re doing rotations or on the floors, this has to be taught.’ Paediatricians especially wish they had more training on behavioural change instruction. In outpatient practice, clinicians should have treatment guidelines or algorithms to support their practice.
Theme 4: paediatricians do not actively screen for LUTS
Paediatricians do not actively screen for LUTS beyond the potty-training milestone and provide direct recommendations only if prompted by parents. While paediatricians typically ask about bladder health during potty-training, there is no formal screening practice in place for initiating conversations about bladder health outside of that context. For example, one clinician noted, ‘Once they say their child’s potty-trained, I stop talking about it.’ In the majority of practices described, the responsibility of initiating a conversation about post-potty-training bladder health lies with parents.
Paediatricians identify limited clinic visit time and competing healthcare demands as barriers to routinely asking about LUTS. One paediatrician summarised a barrier expressed among almost all participants: ‘I barely have enough time to address the concerns they have already. I’m not going to be…fishing for more issues.’
Theme 5: referrals to bladder health specialists are driven by parent expectations and mistrust
A sense of parental mistrust and expectations plays a major role in clinical decision-making concerning referral patterns. Paediatricians describe three common parent responses to LUTS counselling: (1) there is an underlying anatomical problem, (2) bladder and constipation are not related and (3) an expectation that the problem will be immediately resolved.
In response to counselling on modifiable behaviour factors, families express beliefs that disease aetiology is more likely anatomical. This drives referrals: ‘I’m not able to convince them that this is not something structural…they need to hear it from a specialist.’ In response to counselling on techniques to soften stools and the interrelation of bladder-bowel health, parents do not accept these concepts to be true: ‘Let’s say it’s constipation that’s leading to incontinence…And I think a lot of families just don’t want to believe that. They can’t put the two together.’
Regardless of counselling practices, if parents do not see immediate improvement, some will ask for additional specialist care. Paediatricians think this expectation stems from parent distress. One clinician shared, ‘I think parents also are so frustrated and overwhelmed when they come… So they want it to be fixed then and there.’ Paediatrician and parental concern for additional specialty advice is not equal; parental pressure can influence clinical decision-making for specialist referrals: ‘sometimes I yield a little bit if a parent is very pushy.’
Discussion
In this novel qualitative study of paediatrician perspectives on LUTS, we characterise key gaps in paediatric LUTS care. Our data showed (1) variation in practice, (2) mistrust in the patient–clinician relationship and (3) a need for education support. These factors can be addressed in practice by the addition of clinical guidelines, early and often screening, and medical education.
Our data demonstrate wide variations in LUTS treatment by paediatricians. Similar to other chronic paediatric conditions that involve behavioural change counselling, such as obesity,27 we found inconsistently implemented practices driven by a lack of knowledge, adequate training and/or parental motivation. No clinician referenced existing guidelines, previously published algorithms on urotherapy or their own stepwise treatment approach. Urotherapy is guideline recommended by international and European organisations11 28; however, there is a lack of easily identifiable guidelines or published consensus aimed specifically at US paediatricians. To address this, formal guidelines from a broad regulatory organisation such as the AAP could help fill real-world gaps in clinical practices. Additionally, continuing education interventions for paediatricians in other areas, such as antibiotic prescription recommendations, have been proven effective.29 30 Providing similar education for LUTS can help individualised learning, and our focus groups demonstrated a readiness for such a resource.
A sense of parental expectations and mistrust influence clinical decision-making regarding specialty referrals. Paediatricians expect families to take the initiative to bring forward bladder health concerns. However, when families do disclose their concerns, they often do so after exhibiting a high degree of emotional and symptomatic burdens. Further, paediatricians perceive that parents expect a medical correction of an underlying anatomical problem, leading to a request for additional subspecialty care. In reality, most children referred to paediatric urology do not have an anatomical problem that requires subspecialty care.31
Implementing bladder health screening practices may mitigate this interaction by detecting bladder symptoms earlier, at a lesser degree of bother. This proactive approach may alleviate the emotional distress experienced during initial presentations and help parents accept the timeline and behavioural change concepts of urotherapy. Currently, the AAP ‘checklist’, a commonly employed resource for US clinicians, screens for bladder problems until age 6, with items such as ‘Is dry day and night’.32 33 This may create the misguided perception that bladder health is unique to the early childhood population (12 months to 4 years) when, in fact, there can be an increase in prevalence around middle childhood at 7–8 years.4 At a minimum, adding a screening practice would allow early education and familiarity with lower urinary tract habits.
Finally, our participants perceived the addition of LUTS-focused residency education to benefit future trainees. Paediatricians viewed their residency training as inadequate for preparing them for treating LUTS in an outpatient setting, especially given the requirement for behavioural change counselling that makes up the majority of urotherapy. Current clinical knowledge among practising paediatricians is an accumulation of repeat clinical exposure, self-directed learning, and conversations with specialty healthcare professionals. Specific content for paediatric trainees that focuses on outpatient diagnoses could be developed locally or nationally (eg, formal training standards for residency)34 35 to increase familiarity with existing literature and confidence.
The addition of clinical guidelines, screening practices or educational resources may help improve patient–clinician relationships and overall treatment outcomes. However, structural barriers may influence the extent of improvement. Many participants cited that while they see LUTS frequently and acknowledge its key role in childhood development, short clinic times and competing clinical needs deprioritise these issues. Higher diagnosis rates and increased knowledge may improve paediatricians’ quality of care; still, they may face environmental-level constraints. Including community health workers and members of childcare centres and schools in bladder health programmes may be key to reducing the overall disease burden in the community.
Strengths and limitations
This qualitative study presents an in-depth exploration of paediatricians’ perspectives on LUTS and was guided by a theoretical framework. To ensure validity, rigorous methods were applied, including an inter-rater reliability test and achieving thematic saturation.
The study has several limitations. It only included paediatricians from one region, limiting the generalisability of our findings. We purposely limited our scope to elucidate regionally specific perspectives. Future work could use our methodology as a framework in other regions. Further, our study gathered the perspectives of only 15 paediatricians, potentially limiting the diversity of viewpoints. Nonetheless, our focus groups included paediatricians from various clinical settings and with a broad range of experience, and we believe that many of the themes will resonate with clinicians in other regions.
Conclusion
Paediatricians revealed a willingness to help patients but expressed several limitations to providing adequate LUTS care. Lack of guidelines, parental mistrust and lack of clinical education were all barriers identified by paediatricians. Future work can emphasise guideline development at the national level, screening to support earlier intervention and parent–clinician trust, and better education for clinicians.
Data availability statement
Data are available on reasonable request. Unpublished data are stored in a passport-protected university computer. They include the original transcripts. Data are available from the corresponding author at http://orcid.org/0000-0001-9508-2763 on reasonable request. The data are not publicly available due to privacy and ethical restrictions.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Stanford University Institutional Review Board 56174. Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @pvpuram
Contributors KMK is the guarantor, had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: GA, KMK, SS and CB-J. Acquisition, analysis or interpretation of data: SS, KMK, GA, AS and PV. Drafting of the manuscript: SS, KMK and CB-J. Critical revision of the manuscript for important intellectual content: all authors. Administrative, technical or material support: KS. Supervision: KMK and CB-J.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.