Target Physiotherapy Versus Exercise Support Intervention for Bladder-bowel Dysfunction in Adolescents With Obesity

Obesity in adolescence is a major public health challenge and is associated with a broad spectrum of metabolic, psychological, and functional complications. While considerable attention has focused on cardiometabolic consequences, bladder-bowel dysfunction (BBD) remains an underrecognized comorbidity in adolescents with obesity. BBD is characterized by the coexistence of lower urinary tract symptoms and bowel dysfunction, particularly functional constipation, in the absence of neurological or anatomical abnormalities. Symptoms may include urinary urgency, daytime urinary incontinence, nocturnal enuresis, infrequent voiding, constipation, and fecal incontinence, all of which can substantially impair health-related quality of life, psychosocial functioning, and participation in school and social activities.

Current evidence suggests that obesity may contribute to the development and persistence of BBD through multiple interacting mechanisms. Increased intra-abdominal pressure may impair pelvic floor and bladder function, while sedentary behavior, inadequate dietary habits, insufficient hydration, and reduced physical activity may contribute to functional constipation and altered bowel habits. Obesity is also associated with chronic low-grade inflammation, sleep disturbances, and psychosocial stress, factors that may further influence bladder and bowel function. Despite growing evidence supporting an association between obesity and BBD, most available studies are observational, and prospective intervention studies targeting both conditions simultaneously are lacking.

Current international recommendations identify standard urotherapy and bowel management as first-line conservative treatment for non-neurogenic bladder-bowel dysfunction in children and adolescents. These interventions aim to modify voiding and bowel habits, optimize hydration, improve toileting posture, reduce dysfunctional elimination behaviors, and restore normal pelvic floor function. Physiotherapy techniques, including pelvic floor muscle training, breathing exercises, lumbo-pelvic mobility exercises, and behavioral education, are increasingly incorporated into multidisciplinary continence management. However, the effectiveness of these approaches has not been specifically evaluated in adolescents with obesity.

Physical exercise may also represent a clinically relevant intervention for BBD. Besides its established role in obesity management, regular physical activity has been associated with lower rates of constipation and may improve several obesity-related mechanisms potentially involved in bladder and bowel dysfunction, including sedentary behavior, sleep quality, systemic inflammation, psychological health, and body composition. Nevertheless, no randomized controlled trials have prospectively evaluated whether structured exercise programs improve bladder-bowel dysfunction in adolescents with obesity.

The OBE-BBD trial was designed to address this important evidence gap. The study is a single-center, parallel-group, three-arm randomized controlled trial conducted at the Pediatric Outpatient Clinic of the Department of Pediatrics, Hospital de Santa Maria, Unidade Local de Saúde de Santa Maria, Lisbon, Portugal.