Bidet toilets for older adults?

BIDET TOILETS FOR OLDER ADULTS?
Ying-Jyun Shih, BS, MS., PhD candidate, Asia University
Yung-Jen Yang, Taiwanese Society of Geriatric Psychiatry

Key highlights:

• Bidet toilets are increasingly used across the world and in the aging population.
• There have been substantial improvements in bidet toilets and more ergonomic technologies have been integrated into them.
• Despite fair acceptance in the general population, there are still disputes about the benefits and harms of the bidet toilet.
• For the senior population, scientific evidence about bidet toilets is lacking, and no matter its applications, efficacies, benefits, and even harms, additional multidisciplinary studies are encouraged.

Bidets are restroom fixtures commonly used in Europe and in European-style restrooms. A bidet is a separate fixture with a standard faucet typically installed next to the toilet, and, by definition in the Cambridge Dictionary, is a small, low bath in which a person washes the lower part of their body. There is basic information about its history, applications, variants and types in Wikipedia¹. Bidets have long been used in clinical care especially for anorectal and urogenital diseases despite limited evidence for efficacy. In the technological corner of this issue, we will focus on another member of the bidet family, the bidet toilet, or more commonly known as the Washlet toilet.

Tracing its history, the bidet toilet was developed by the Japanese company TOTO in 1980 and was given the name Washlet. Bidet toilets integrate the functions of both toileting and showering, and are mounted on the existent toilet bowl. Current models automatically clean the anal and genital area (for females) after the passage of stool and urine. Since TOTO has updated different models, the number of sales has also bloomed steadily. In part due to the prosperous tourism industry in Japan, the global sales of TOTO bidet toilets has surpassed more than 50 million². First time visitors to Japan are usually astonished by bidet toilets in restrooms and are impressed by the experience³. As technology progresses, more and more engineering improvements have been integrated into recent models, such as instant seat warming, precise aiming, efficient cleaning, deodorization, built-in sterile water production, and automatic self-cleaning.

Bidet toilets are generally well accepted with a high rate of user satisfaction. Although there are pros and cons of bidet toilets⁴, it is generally thought that bidet toilets can ameliorate pain related to haemorrhoids or constipation, improve personal hygiene, and even promote a sense of wellbeing, in addition to being presumed eco-friendly.  Despite a lack of consensus by medical professionals about the use of bidet toilets in regard to urogenital infections, the benefits of use in older adult populations deserves further exploration.

Based on our preliminary search of the medical literature, there is a lack of research on bidet toilet use, and hence there is very limited evidence at the present time. To our knowledge, only two reports are relevant, and the earliest clinical study can be traced back to 2005 by Cohen-Mansfield and Biddison⁵, in which they tested the applicability of bidet use among older residents in a nursing home. Although the findings by Cohen-Mansfield and Biddison were positive indicating an improved toileting experience, unfortunately follow-up investigations have not occurred. The other study by King and colleagues evaluated the use of bidet toilet for the care of frail seniors, which found an approximate 32% reduction in care time; however, the participants were personal support workers rather than the elderly⁶. Unfortunately, the strength of evidence is limited by small sample sizes, inadequacies in research methodology, older technological background (for Cohen-Mansfield and Biddison) and indirectness (for King et al).

Although bidet toilets are more widely used across the world, there are still numerous unanswered questions in terms of the applicability, efficacy, potential benefits and risks in the aging population. For example, whether bidets can ameliorate constipation, improve incontinence, or promote wellbeing deserves further exploration. However, potential risks should also be evaluated including anal irritation/injury and urogenital infections (i.e., urinary tract infection and vaginitis) before using in older adult populations.

In conclusion, despite being well received and popular in some regions, bidet toilets should be used with caution in aging populations due the possibility of infection. We encourage further research by academic institutions as well as industry support for further investigations.

REFERENCES:

1. Bidet. Weblink: https://en.wikipedia.org/wiki/Bidet
2. TOTO WASHLET™ 50 Million Sold Worldwide. Weblink: https://th.toto.com/en/news_promotions/toto-washlet-50-million-sold-worldwide/
3. Have a little happiness in Japan. Weblink: https://www.toto.com/en/wtjapan/exp/index.htm 
4. Washlet or Bidet? How They Work and Which One is For You. Weblink: https://www.qualitybath.com/discover/post/15276/qb-faqs-washlet-bidet
5. Cohen-Mansfield J, Biddison JR. The potential of wash-and-dry toilets to improve the toileting experience for nursing home residents. Gerontologist. 2005;45(5):694-9.
6. King EC, Boscart VM, Weiss BM, Dutta T, Callaghan JP, Fernie GR. Assisting Frail Seniors With Toileting in a Home Bathroom: Approaches Used by Home Care Providers. Journal of Applied Gerontology. 2019;38(5):717-49.

Dr. Yung-Jen Yang is an experienced senior geriatric psychiatrist at the Tsaotun Psychiatric Center in Middle Taiwan. Currently he is a member of Board of Director of the Taiwanese Society of Geriatric Psychiatry and a lifetime member of the IPA. He has special interests in long-term care and new technology.

Excerpted from the IPA Bulletin, Volume 38, Number 1.