The Overlooked Link Between School Bathrooms and Children’s Health

Up to one in five school-aged children struggle with lower urinary tract symptoms (LUTS) - problems such as daytime incontinence, urinary urgency, frequency, and painful urination. These issues are rarely discussed outside of clinics, yet their impact is profound: children experience embarrassment and distress, parents feel added stress and worry, and families often find themselves navigating recurrent urinary tract infections or enduring symptoms that persist for far too long.

The solution, in many cases, can be surprisingly simple. Research shows that regular bladder emptying -  once every three hours - dramatically improves symptoms. Yet in practice, many children avoid or delay using the bathroom during the school day. The reasons are complex: limited knowledge about healthy bladder habits, negative perceptions of bathrooms, classroom policies that restrict use, and bathroom environments that are often unclean or unsafe. Despite the fact that children spend most of their day at school, the role of school environments in shaping bladder health has never been systematically studied in the United States. At Stanford Urology, researchers are now stepping into this gap.

How a Pediatric Urologist Saw the Gap

The effort is led by Kathleen “Katie” Kan, MD, Assistant Professor of Urology, who was recently awarded an NIH K23 Career Development Award to pursue this work. Kan’s path to the problem started in her pediatric urology clinic, where she frequently meets school-aged children who arrive after months on waitlists. “Seventy percent of kids get better with healthy bladder habits,” she explained. “To both treat and prevent this, you have to change daily behaviors, and school isa key opportunity to intervene where children spend a signicant portion of their day.”

Kan began to notice a pattern. Children came in with accidents, infections, and persistent symptoms - not because they needed surgery, but because their daily environments didn’t support healthy bladder practices. For a surgeon, she noted, the reality was striking: “It is a little weird that somebody who should be operating all day spends 30 percent of their time in clinic managing something that could often be prevented. After speaking extensively with community members, there is a clear call to action for improvement in school bathrooms. Parents themselves highlighted this: “My kids are in school all day, and they don’t use the bathroom,” they would say. That insight shaped the foundation of her research career.

Building the Foundation: Bladder Basics

Before moving into schools, Kan and her team developed Bladder Basics, an evidence-based educational program for children ages 5–10 years and their parents. Delivered through short, engaging videos, the program covers healthy bladder habits in a fun and accessible format. In pilot testing, families reported that they not only learned but enjoyed the resource, making it far more likely they would adopt it into daily routines.

With support from early funding, the program is now being expanded for delivery through pediatric practices, translated into Spanish to improve access for the large Spanish-speaking population in California, and adapted for broader reach through social media platforms such as Instagram and YouTube. For Kan, the pilot showed what was possible - but also underlined the next step: translating awareness into real change in the school environment.

The K23 Award

Kan’s NIH K23 project, Promoting Bladder Health in Elementary Schools: A Community-Engaged Approach, is designed to do just that. The study will investigate both the individual and environmental factors that influence bathroom use during the school day and develop a school-based intervention to promote healthy habits.

The project has three main aims:

• Document school environments through structured observation, focusing on bathroom conditions and classroom practices that affect use.
• Capture children’s real-time behaviors and barriers with ecological momentary assessment, offering the first insight on how young children think about bathroom use
• Co-create and pilot-test an intervention in partnership with schools, combining education with practical changes to encourage school day bathroom use.
   

The study will focus on grades K–5, where LUTS burden is highest and habits are most malleable. Support from county education partners has opened the door for research in Santa Clara County, with the goal of expanding into other Bay Area districts. Teachers and nurses already confirm the scope: they report that 10–20 percent of younger students have accidents at some point each year - a strikingly high number that illustrates how urgently solutions are needed.

Rather than imposing a top-down fix, Kan’s approach emphasizes collaboration. The intervention will not be a one-size-fits-all prescription but instead designed with input from students, teachers, and staff to ensure that it works in real-world classrooms. “Everything before this has mostly been self-report,” Kan said. “We’re going into schools to see what’s actually happening - then working with teachers, nurses, parents, and students to decide what will truly increase bathroom use.”

Normalizing Healthy Bathroom Use for Every Child

The ultimate goal is ambitious: generate the evidence necessary for a fully powered randomized controlled trial that can inform school health policy nationwide. If successful, the work could shift bladder health from a reactive model of treatment - where children arrive at clinics after years of problems - to a proactive culture of prevention embedded in schools.

Kan sees the opportunity not just as a research project, but as a chance to normalize an issue that has long been neglected in public health. “If we can normalize healthy bathroom use at school, we shift from reactive treatment to proactive prevention - improving children’s well-being today and reducing LUTS burden for years to come.”