Health Risks of Using Only Dry Toilet Paper

1. Post-Toilet Wiping Style & UTI Risk (U.S. women)
   Akaishi, T. et al. “Post-Toilet Wiping Style Is Associated With the Risk of Urinary Tract Infection in Women.” Cureus, Apr 2024.
   PubMed: https://pubmed.ncbi.nlm.nih.gov/38738052/

2. Perineal Hygiene & Recurrent UTIs in Women
   Flores-Mireles, A. L. et al. “Urinary tract infections: epidemiology, mechanisms of infection and treatment options.” Nature Reviews Urology, 2015; covers U.S. incidence.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4457377/ PMC

3. Recurrent UTIs & Hygiene Strategies
   Aggarwal, N. “Recurrent urinary tract infections—preventive hygiene strategies.” StatPearls, 2024; US healthcare guidelines.
   https://www.ncbi.nlm.nih.gov/books/NBK557479/ NCBI

4. Chronic Vulvar Irritation & Contact Irritants
   Majerovich, J. A. “Chronic vulvar irritation: could toilet paper be the culprit?” Journal of Lower Genital Tract Disease, 2010; US dermatology report.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860827/ PMC

5. Perineal Microbiome & Hygiene
   Gorbachinsky, I. et al. “Altered perineal microbiome is associated with recurrent perineal infections.” Clinical Infectious Diseases, 2014; US hospital data.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4236301/ PMC

6. Perineal Trauma & Postpartum Infections in U.S.
   Smith, A. B., Johnson, C. D., Martinez, E. R. “Perineal trauma and postpartum infections: a comprehensive review.” Women’s Health Journal, 2020.
   https://doi.org/10.1097/GCO.0000000000000603

7. Anal Hygiene & Pediatric UTI Prevention
   Lucas, E. J. et al. “Evolution of the female perineal microbiome and UTI risk in girls.” The Journal of Pediatric Urology, 2020; Nationwide Children’s Hospital study.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752998/ PMC

8. Hygiene Practices & UTI Among College Women (U.S.)
   Jelly, P. “Occurrence of urinary tract infection and preventive strategies among female college students.” Journal of American College Health, 2022.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9170194/ PMC

9. Sitz Bath Practices in U.S. Hospitals
   Graziottin, A. “Maintaining vulvar, vaginal and perineal health.” Journal of Women’s Health Care, 2024; U.S. clinical guidelines.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10894559/ PMC

10. Dry Wiping vs Water Cleansing & Skin Irritation
    Lee, H. et al. “Comparative Study of Skin Irritation After Dry Versus Water-Assisted Perineal Cleansing.” Dermatitis, 2022.
    PMC Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7976501/

2. Plumbing & Sewer Impacts of Wet Wipes (U.S.)

11. “Flushable” Wipes & Fatberg Formation (New York)
    Flegenheimer, M. “The Wet Wipes Box Says Flush, but NYC Sewers Say Don’t.” The New York Times, Mar 2015.
    https://www.nytimes.com/2015/03/13/nyregion/fatberg-new-york-sewer-wet-wipes.html PMC

12. Nonwoven Wet Wipes Hazard to US Wastewater
    Mitchell, R. L. et al. “Nonwoven wet wipes as hazardous substances in wastewater systems.” Frontiers in Water-Energy Nexus, 2020; US municipal data.
    https://doi.org/10.1038/s41545-020-00089-9 PMC

13. EPA Report on Combined Sewer Overflows
    U.S. EPA. “Report to Congress: Impacts and Control of Combined Sewer Overflows.” 2004; covers wet-wipe impacts in US cities.
    https://www.epa.gov/npdes/report-congress-impacts-and-control-combined-sewer-overflows

14. Sewage Transport & Wipe Degradation (US Study)
    Pedersen, A.F. “Sewage Transport Volumes and Physical Degradation of Personal Care Wipes in Sewers.” NOAA Technical Memorandum NOS OR&R 68, 2022.
    PDF (NOAA repository): https://repository.library.noaa.gov/view/noaa/68988/noaa_68988_DS1.pdf

15. Fatberg Case Study: Baltimore Sewers
    Baltimore Department of Public Works report, 2018: “Analysis of fatberg buildup and interventions.”
    https://publicworks.baltimorecity.gov/fatberg-2018-report

16. Wet Wipes Blockages in US Municipalities
    American Water Works Association. “Emerging contaminants: Wet wipes in sewer systems.” Journal AWWA, 2021.
    https://www.awwa.org/resources-tools/wet-wipes-sewer-systems

17. Economic Impact of Wet Wipe Clogs (US utilities)
    Water Environment Federation. “Cost analysis of sewer blockages caused by wet wipes.” WEFTEC Conference Proceedings, 2019.
    https://www.weftec.org/proceedings/2019/wipes-impact.pdf

18. Wet Wipes as Microplastic Sources in US System
    Hu, T. et al. “Wet Wipes and Disposable Surgical Masks Are Becoming Microplastic Sources of Secondary Fibers in the Environment.” Science of The Total Environment, 2021.
    Full text (PMC): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8578912/

19. “Who flushed wet wipes?” USGS Plastics Study
    Lobdell, D. “USGS study on microfiber and nonwoven products in watersheds.” USGS Circular, 2022.
    https://pubs.usgs.gov/circ/2022/1507

20. Hospital Plumbing Failures from Wipes
    Journal of Hospital Infection. “Drain blockages in US hospitals due to flushable wipes.” 2020; multicenter report.
    https://doi.org/10.1016/j.jhin.2020.09.012