Introduction

Only 20% of what influences health outcomes is related to health care. The remaining 80% is made up of nonmedical influences, or social determinants/drivers of health (SDOH). Every person has SDOH, which are not inherently positive or negative, but can negatively influence health outcomes. Employment is one such SDOH and is multifaceted, including finding/keeping a job, occupation, productivity, schedule, work environment, job physicality, and work-related stress, and influences economic stability. Overall, the workforce is also evolving, especially in the COVID-19 era, toward decentralization, which includes more short-term and remote work. Therefore, the impact of lower urinary tract symptoms (LUTS) on employment and how occupation impacts bladder health and toileting behaviors are fascinating, unique, and important relationships to consider.

LUTS and the Workplace

Urological conditions and worse LUTS are associated with lower employee attendance, decreased productivity, and increased rates of unemployment due to disability.¹ The negative impact on productivity is multifactorial, including days lost to medical absenteeism and restricted functioning, and interference with work life due to LUTS. Additionally, more severe overactive bladder has been associated with difficulty finding and keeping employment and with lack of transportation, which indirectly impacts job availability and choice.² Likewise, LUTS may influence employment decisions, including earlier retirement, and choice of work location and schedule. Certain occupations have been associated with LUTS and adaptive toileting behaviors, which could have negative long-term impacts on bladder health. Nursing and health care professions have a higher prevalence of LUTS.³ Infrequent voiders syndrome (nurse’s bladder) refers to bladder dysfunction due to suppressing the desire to void for long periods of time. This adaptive behavior may develop due to workplace restrictions, such as insufficient breaks, time-pressure demands, and heavy workloads, or due to the social framework in health care of “patient first,” resulting in self-imposed restrictions on personal time, including bathroom breaks. The same applies to other occupations with restricted bathroom breaks and distance to a toilet (teaching, factory work, truck driving, etc). Gatekeepers in the workplace limiting bathroom use can be people (supervisors/managers) or concepts (breaks), but encourage purposeful urine holding, delayed voiding, fluid restriction, defensive voiding, and other unhealthy toileting behaviors. Finally, workplace restrooms are public restrooms, and women who limit restroom use at work due to concerns with cleanliness and lack of privacy are more likely to experience LUTS and poorer perceived bladder health.^4,5

Short-term Work, Long-term Effects

Most existing literature considers the traditional workplace a public space away from home. However, short-term work is becoming increasingly common. Specifically, the gig economy (digital platforms to connect people with short-term, freelance, on-demand jobs) has grown exponentially. The recent rise of the gig economy, particularly during and after the pandemic, expanded opportunities for people to make money. Due to disruption of the workplace and loss of employment during the pandemic, more people pursued gig work for supplemental or primary income. It is now estimated that nearly 60 million Americans work in the gig economy,⁶ which is only anticipated to increase. Gig jobs utilize a performance-based pay scheme to incentivize efficiency and productivity; however, this has also been linked to poorer physical and mental health outcomes.⁷ Additionally, gig jobs require constant travel and lack reliable restroom access. This may encourage negative adaptive behaviors and unhealthy coping mechanisms and toileting habits, and increase job-related stress. In our own evaluation of bladder symptoms in gig workers, those who reported at least some bladder problems were more likely to purposefully limit restroom use while working and delay voiding to the point of strong urgency or even incontinence.⁸ Common coping strategies utilized included carrying a change of clothes, using incontinence products while on the job, and fluid restriction. The long-term implications of these strategies and toileting behaviors are unknown but may lead to increased LUTS as seen in other jobs which promote holding (nurse’s bladder). Additionally, gig workers with LUTS may have a decrease in work productivity, which in a performance-based pay scheme means lower pay and possible economic instability.

Other Impacts of the Covid-19 Pandemic on the Evolving Workforce

The expanding gig economy is only 1 example of the decentralization of the workplace that occurred with the COVID-19 pandemic. Another is remote work, which has markedly increased in the COVID era, with 70% of people now working remotely at least weekly.⁹ Unlike the constant travel of gig jobs, remote work has led to people working from home with consistent access to private home toilets. One could hypothesize this may mitigate some of the negative adaptive behaviors used in the workplace. Anecdotally, we have found not necessarily a decrease in LUTS, but less bother from LUTS when working from home, and therefore less desire to pursue medical or surgical treatment. Conversely, when a person must return to a public work setting after working from home, bother from bladder symptoms may increase and lead to overall poorer perceived bladder health.

In recent times, there has been decreased net demand for lower- and middle-income jobs (such as those in customer service, retail, hospitality, and food service), with increasing use of technology, automation, and globalization. During the pandemic, these lower-income workers were disproportionately affected by job loss. Therefore, job instability more often affected vulnerable populations, such as those with lower socioeconomic status, lower levels of educational attrition, younger people, women, and those of non-White race and/or ethnicity, who may also be more affected by urological conditions, including overactive bladder, incontinence, urinary tract infections, and more severe LUTS.^10,11 Pandemic job instability could thereby exacerbate or augment these associations, potentially worsening bladder symptoms. The pathways here are multifactorial and bidirectional due to barriers to accessing care and increase in chronic stressors and other comorbid conditions, additional unmet social needs, or a greater overall burden of urinary symptoms.

Conclusions

Occupation, employment, and the workplace can have significant impacts on bladder health, urological conditions, and toileting behaviors. The traditional office-based workplace is ill-equipped for the toileting needs of those with urinary conditions or LUTS, due to few toilets per employee and/or restrictions on bathroom access or breaks. This leads to decreased work productivity, higher unemployment rates, and difficulty keeping a job, which affects economic stability. During and following the COVID-19 pandemic, the workforce has experienced dramatic changes with job loss disproportionately impacting those in the lowest income occupations, a shift to a decentralized workplace with more working from home, and growth in short-term employment, including the gig economy. These changes undoubtedly have impacts on overall physical and mental health, which includes LUTS and toileting behaviors. It is still unknown, however, the overall negative impact that adaptive toileting and coping behaviors may have on long-term bladder health. Continuing to investigate these impacts and associations as the workforce continues to evolve will be important to understand and manage urological conditions into the future.