The Spectrum of Bladder Health: The Relationship Between Lower Urinary Tract Symptoms and Interference with Activities

Characterizing the spectrum of bladder health and lower urinary tract symptoms among men: Results from the CARDIA study

OBJECTIVES

To operationalize a new definition for bladder health, we examined the distribution and impact of lower urinary tract symptoms (LUTS), along with risk factors, among men in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

METHODS

LUTS were defined by American Urologic Association Symptom Index (AUASI) scores and impact on quality of life (QoL). Separate questions assessed urinary incontinence (UI) and postvoid dribbling. We performed cluster analyses using AUASI scores, with and without urine incontinence and postvoid dribbling, and impact collected in 2010-11. We performed analyses to evaluate sociodemographic and cardiovascular risk factors between clusters.

RESULTS

Among CARDIA men (mean age: 50.0, SD = 3.6; range: 42-56 years) with complete LUTS data (n = 929), we identified and compared four clusters: men who reported no or very mild symptoms and no impact on well-being (bladder health, n = 696, 75%), men with moderate symptoms and moderate impact on well-being (moderate symptoms/impact, n = 84, 9%), men with high symptoms and high impact on well-being (severe symptoms/impact, n = 117, 13%), and a separate group that reported moderate symptoms and UI with a high impact on well-being (UI + moderate symptoms/severe impact, n = 32, 3%). Exploration of the groupings showed a large percentage of postvoid dribbling across groups (overall 69%). Sociodemographic and cardiovascular risk factors were not associated with symptom/impact groups.

CONCLUSIONS

Bladder health clustered into four categories. A majority of middle-aged men in the community showed no or mild bladder symptoms without impact on QoL. Postvoid dribbling is pervasive but did not cluster with a specific LUTS or impact category.

When Did They Start? Age of Onset of Toileting Behaviors and Urinary Cues as Reported by Older Women

Background

Lower urinary tract symptoms (LUTS) are prevalent across women's life course. Evidence shows toileting behaviors (TBs) and urinary urge cues are related to LUTS. It is unknown when women start using these behaviors and responding to urinary cues.

Methods

An online survey was administered to 338 women, 65 years of age and older, to assess the age of onset for 20 TBs from the Toileting Behaviors-Women's Elimination Behavior (TB-WEB) questionnaire, 10 urinary urge cues from the Urinary Cues Questionnaire, and urinary urgency and leakage items from the International Consultation on Incontinence Questionnaire-Overactive Bladder (ICIQ-OAB) Short Form. Descriptive statistics were reported for each TB and urinary cue. A timeline was generated with the average earliest age of onsets for each type of TB, urinary cues, and urinary urgency and leakage symptoms.

Results

Place preference, delayed voiding, and hovering over toilets away from home were reported to have the earliest ages of onset. Urinary urge cues, premature voiding, and straining to void tended to start after 45 years of age, as did the symptoms of urinary urgency and leakage. The timeline indicated that the earliest place preference and position preference TBs started before 20 years of age.

Conclusion

Some TBs begin early in life and persist into old age, while other TBs and urinary cues begin later. Bladder health promotion may depend on intervening at specific times in the life course to alter TBs and responses, and potentially making environmental changes.

Prevalence and influencing factors of lower urinary tract symptoms in female nurses: a cross-sectional study based on TARGET

Background

Even though occupational women have a high incidence of lower urinary tract symptoms (LUTS), which seriously affect their daily work life, few large scale sample studies have provided empirical evidence to support this phenomenon among female nurses in China. Consequently, this article investigated female nurses who was presupposed to have a high prevalence of LUTS, which adversely exposes their health and patient safety to these risks. Additionally, it is considered important to explore the factors associated with LUTS in female nurses for patient care safety and nurse bladder health practice.

Objectives

The purpose of this study was to assess the incidence of LUTS and symptoms-related risk factors among female nurses, to provide evidence for the prevention and control of LUTS.

Methods

An online survey recruiting 23,066 participants was carried out in a multicenter cross-sectional study in 42 hospitals from December 2020 to November 2022. Stepwise multivariate logistic regression analysis and nomogram were used to identify the factors associated with lower urinary tract symptoms. Besides, SPSS version 26.0, R version 4.2.2, and GraphPad Prism Version 8.3 software packages were used for statistical analysis.

Results

Based on the completion rate of the questionnaire which was 84.1% (n = 19,393), it was found that among 19,393 female nurses, the prevalence of LUTS was 67.71% and this rate was influenced by age, Body Mass Index (BMI), marital status, years of working, menstrual status, mode of delivery, history of breastfeeding, history of miscarriage, history of alcohol and coffee or tea consumption (p < 0.05). Interestingly, we also find that in addition to the above mentioned factors, anxiety, depression, and perceived stress were also related to LUTS in female nurses (p < 0.05).

Conclusion

Given the high prevalence of LUTS among female nurses and their potential influencing factors, female nurses should focus on their reproductive health and develop good lifestyle habits. Thus, nursing managers should provide a warm and harmonious work environment and sensitize female nurses to increase their awareness about the importance of drinking clean water and urinating during work in a hygienic environment.

RISE FOR HEALTH: Rationale and protocol for a prospective cohort study of bladder health in women

INTRODUCTION

The spectrum of bladder health and the factors that promote bladder health and prevent lower urinary tract symptoms (LUTS) among women are not well understood. This manuscript describes the rationale, aims, study design, sampling strategy, and data collection for the RISE FOR HEALTH (RISE) study, a novel study of bladder health in women conducted by the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium.

METHODS AND RESULTS

RISE is a population-based, multicenter, prospective longitudinal cohort study of community-dwelling, English- and Spanish-speaking adult women based in the United States. Its goal is to inform the distribution of bladder health and the individual factors (biologic, behavioral, and psychosocial) and multilevel factors (interpersonal, institutional, community, and societal) that promote bladder health and/or prevent LUTS in women across the life course. Key study development activities included the: (1) development of a conceptual framework and philosophy to guide subsequent activities, (2) creation of a study design and sampling strategy, prioritizing diversity, equity, and inclusion, and (3) selection and development of data collection components. Community members and cross-cultural experts shaped and ensured the appropriateness of all study procedures and materials. RISE participants will be selected by simple random sampling of individuals identified by a marketing database who reside in the 50 counties surrounding nine PLUS clinical research centers. Participants will complete self-administered surveys at baseline (mailed paper or electronic) to capture bladder health and LUTS, knowledge about bladder health, and factors hypothesized to promote bladder health and prevent LUTS. A subset of participants will complete an in-person assessment to augment data with objective measures including urogenital microbiome specimens. Initial longitudinal follow-up is planned at 1 year.

DISCUSSION

Findings from RISE will begin to build the necessary evidence base to support much-needed, new bladder health promotion and LUTS prevention interventions in women.

Prevalence of lower urinary tract symptoms in a cohort of Australian servicewomen and female veterans

INTRODUCTION AND HYPOTHESIS

Lower urinary tract symptoms (LUTS) are common in the general female population. It was hypothesised that Australian female military personnel and veterans would experience similar types and prevalence of LUTS as the broader Australian female population.

METHODS

An online cross-sectional survey was utilised to explore the pelvic health of active servicewomen and veterans in the Australian Defence Force (ADF). For the purposes of this report, only the demographic and LUTS data (excluding urinary tract infections) were extracted and descriptively analysed.

RESULTS

A total of 491 complete survey responses were received and analysed. Respondent characteristics were comparable to those documented in a departmental report regarding ADF servicewomen. No LUTS were reported by 38% of respondents. Regular symptoms of urinary incontinence were experienced by 27% of respondents (stress urinary incontinence = 23%, urge urinary incontinence = 16%, mixed urinary incontinence = 13%), bladder storage issues by 20-27%, and various voiding impairments by 9-27%. In addition, 41% reported regularly experiencing two or more LUTS, and for over two thirds of respondents, LUTS were an ongoing issue. Relationships between age, parity, and symptoms of urinary incontinence were also seen.

CONCLUSIONS

Consistent with wider research in Australian female populations, LUTS were commonly experienced during service by ADF female military personnel and veterans. Given the high likelihood of female military personnel experiencing LUTS during their service, and a proportion experiencing ongoing symptoms, tailored monitoring and support for urinary health should be available to enhance occupational health, safety, and performance.

Servicewomen's experiences of managing pelvic health in occupational settings

BACKGROUND

Despite increasing numbers of women serving in defence forces worldwide, little is currently known about how servicewomen manage their pelvic health in the traditionally male environment of the military.

OBJECTIVES

The aim of this study was to explore the impacts of pelvic health issues on Australian Defence Force servicewomen and their experiences of managing their pelvic health in occupational settings.

DESIGN

A qualitative hermeneutic design.

METHODS

Telephone interviews were conducted on six currently serving female members of the Australian Defence Force located Australia-wide. A semi-structured interview guide, based on the study objectives, was used to guide the audio-recorded interviews. Data were analysed thematically.

RESULTS

Nine themes were identified. The first six themes explored the experiences of servicewomen in maintaining their pelvic health, including suppressing the urge to go, adjusting hydration depending on toilet access, managing menstruation, regaining 'full' fitness postpartum, awareness and prevention of pelvic health conditions, and inhibiting conversations about women's health. The last three themes explored how servicewomen coped with pelvic health conditions, including self-managing symptoms, diagnosing and treating pelvic conditions, and support for servicewomen's pelvic health.

CONCLUSION

This study suggests workplace culture, low levels of insight into pelvic health norms, and limited healthcare strategies within the Australian Defence Force to support female pelvic health have contributed to servicewomen self-managing pelvic health issues using approaches that may have had significant impacts on their health and well-being.

Pelvic Floor Mobility measured by Transperineal Ultrasound Imaging in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms

BACKGROUND

Women with urgency/frequency predominant lower urinary tract symptoms (UF-LUTS) may have elevated pelvic floor muscle (PFM) position at rest and limited mobility with PFM contraction and bearing down, but this has not been quantified.

OBJECTIVES

To compare PFM position and mobility using transperineal ultrasound (TPUS) at rest, maximal PFM contraction (perineal elevation), and bearing down (perineal descent) in women with and without UF-LUTS. We hypothesized that women with UF-LUTS would demonstrate elevated resting position and decreased excursion of pelvic landmarks during contraction and bearing down as compared to women without UF-LUTS.

STUDY DESIGN

Case-control study.

METHODS

Women with UF-LUTS were matched 1:1 on age, body mass index and vaginal parity to women without UF-LUTS. TPUS videos were obtained during 3 conditions: rest, PFM contraction, and bearing down. Levator plate angle (LPA) and puborectalis length (PR length), were measured for each condition. Paired t-tests or Wilcoxon signed rank tests compared LPA and PR length between cases and controls.

RESULTS

21 case-control pairs (42 women): Women with UF-LUTS demonstrated greater LPA at rest (66.8 ± 13.2 degrees vs 54.9 ± 9.8 degrees; P=0.006), and less PR lengthening from rest to bearing down (0.2 ± 3.1 mm vs 2.1 ± 2.9 mm; P=.03).

CONCLUSION

Women with UF-LUTS demonstrated more elevated (cranioventral) position of the PFM at rest and less PR muscle lengthening with bearing down. These findings highlight the importance of a comprehensive PFM examination and possible treatment for women with UF-LUTS to include PFM position and mobility.

Characterizing the Spectrum of Bladder Health and Lower Urinary Tract Symptoms (LUTS) Among Women: Results From the CARDIA Study

OBJECTIVES

To operationalize a new definition for bladder health, we examined the distribution of lower urinary tract symptoms (LUTS) and impact, along with associated factors, among women in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

METHODS

We performed cluster analyses using validated LUTS symptom burden and impact scales collected between 2005-2006 and 2010-2011. We performed multinomial logistic regression analyses to evaluate cardiovascular factors (metabolic syndrome, cardiovascular health behaviors, and inflammation) between clusters after adjusting for covariates (demographic, obstetric/gynecologic, co-morbidities).

RESULTS

Among CARDIA women (median age 51, range 42-59) with complete LUTS data (n = 1302), we identified and compared 4 cluster groups: women who reported no or very mild symptoms and no impact on well-being (bladder health, 44%, n = 569), versus women with LUTS and negative impact on well-being ranging from mild (31%, n = 407), moderate (20%, n = 259), to severe (5%, n = 67). With each 1-point lower BMI (kg/m2), odds of membership in mild (OR 0.97, CI 0.95-0.99), moderate (OR 0.95, CI 0.93-0.98), and severe (OR 0.90, CI 0.88-0.94) LUTS cluster groups versus the bladder health group were lower. Compared to women with metabolic syndrome, women without metabolic syndrome had lower odds of membership in mild (OR 0.67, CI 0.45-0.99), moderate (OR 0.51, CI 0.33-0.79), and severe (OR 0.48, CI 0.24-0.94) LUTS cluster groups versus the bladder health group.

CONCLUSION

Two out of 5 midlife women met our definition of bladder health. Bladder health and cardiovascular health among women may share common factors, including lower BMI and the absence of metabolic syndrome.

Hip and Pelvic Floor Muscle Strength in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms

Background

Urgency and frequency are common lower urinary tract symptoms (UF-LUTS) in women. There is limited evidence to guide physical therapist-led treatment.

Objectives

To compare hip and pelvic floor muscle strength between women with and without UF-LUTS. We hypothesized women with UF-LUTS would demonstrate 1) diminished hip external rotator and abductor strength and 2) equivalent pelvic floor strength and diminished endurance compared to controls.

Study Design

A matched case-control study.

Methods

Women with UF-LUTS (cases) and controls were matched on age, body mass index (BMI), vaginal parity. Examiner measured participants' 1) hip external rotator and abductor strength via dynamometry (maximum voluntary effort against fixed resistance) and 2) pelvic floor muscle strength (peak squeeze pressure) and endurance (squeeze pressure over a 10 second hold) via vaginal manometry. Values compared between cases and controls with paired-sample t-tests (hip) or Wilcoxon signed rank tests (pelvic floor).

Results

21 pairs (42 women): Hip external rotation (67.0 ± 19.0 N vs 83.6 ± 21.5 N; P=0.005) and hip abduction strength (163.1 ± 48.1 N vs 190.1 ± 53.1 N; P=0.04) were significantly lower in cases than controls. There was no significant difference in pelvic floor strength (36.8 ± 19.9 cmH₂0 vs 41.8 ± 21.0 cmH₂0; P=0.40) or endurance (234.0 ± 149.6 cmH₂0*seconds vs 273.4 ± 149.1 cmH₂0*seconds; P=0.24).

Conclusion

Women with UF-LUTS had weaker hip external rotator and abductor muscles, but similar pelvic floor strength and endurance compared to controls. Hip strength may be important to assess in patients with UF-LUTS, further research is needed.

It's About Time: The Temporal Burden of Lower Urinary Tract Symptoms Among Women

This secondary analysis studied 50 transcripts of women who shared day-to-day experiences of lower urinary tract symptoms (LUTS) and characterized temporal (time-associated) features of living with LUTS. Findings revealed two overarching time-associated themes: The Complexity of LUTS and The Quest for Empowerment over LUTS. Findings suggest that the temporal burden of LUTS is the accumulated impact of symptoms and symptom management on women's daily lives within multiple contexts across the life course. Increasing nurses' knowledge of the temporal context of LUTS may heighten awareness and improve symptom detection and management.

Revisiting the Spectrum of Bladder Health: Relationships Between Lower Urinary Tract Symptoms and Multiple Measures of Well-Being

Background: Little research to date has investigated the spectrum of bladder health in women, including both bladder function and well-being. Therefore, we expanded our previous baseline analysis of bladder health in the Boston Area Community Health (BACH) Survey to incorporate several additional measures of bladder-related well-being collected at the 5-year follow-up interview, including one developed specifically for women. Methods: At follow-up, participants reported their frequency of 15 lower urinary tract symptoms (LUTS), degree of life impact from and thought related to urinary symptoms or pelvic/bladder pain/discomfort, and perception of their bladder condition. Prevalence ratios were calculated by generalized linear models with robust variance estimation, adjusting for LUTS risk factors and individual LUTS. The BACH Survey was approved by the New England Research Institutes Institutional Review Board and all participants provided written informed consent. Results: Generally similar findings were observed in the 5-year cross-sectional analysis as at baseline, irrespective of how we categorized LUTS or measured bladder-related well-being. Approximately one in five women (16.2%-18.0% of 2527 eligible women) reported no LUTS and no diminished bladder-related well-being, the majority (55.8%-65.7%) reported some LUTS and/or diminished well-being, and a further one in five (16.9%-26.6%) reported the maximum frequency, number, or degree of LUTS and/or diminished well-being. Measures of storage function (urinating again after <2 hours, perceived frequency, nocturia, incontinence, and urgency) and pain were independently associated with bladder-related well-being. Conclusions: Our similar distribution of bladder health and consistent associations between LUTS and bladder-related well-being across multiple measures of well-being, including a female-specific measure, lend confidence to the concept of a bladder health spectrum and reinforce the bothersome nature of storage dysfunction and pain.

Converging on Bladder Health through Design Thinking: From an Ecology of Influence to a Focused Set of Research Questions

Lower urinary tract symptoms affect a substantial number of women in the United States (U.S.) and globally. In 2015, the Prevention of Lower Urinary tract Symptoms in women (PLUS) Research Consortium was funded to establish the scientific basis for prevention efforts by (1) understanding healthy bladder function and (2) identifying risk and protective factors for bladder health in women across the lifecourse. This transdisciplinary consortium generated a list of over 600 candidate risk and protective factors for bladder health in women and girls and refined and prioritized these into 29 focused research questions to inform a national longitudinal observational study in the U.S. This paper describes that process using design thinking, a human-centered set of principles and strategies by which innovations are developed, as a framework. Design thinking is an iterative process consisting of five stages: Empathizing with end-users of innovations, Defining core principles girding the work, Ideation of all possible solutions, and rapid-cycle Prototyping and Testing of solutions. Lessons learned are offered to inform future prevention science research endeavors that might benefit from such an approach.

Is the juice worth the squeeze? Transdisciplinary team science in bladder health

AIMS

Prior research on lower urinary tract symptoms (LUTS) has focused on the treatment and management of these conditions with scant attention to prevention. The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was formed to address the complexities of preventing LUTS and promoting bladder health.

METHODS

Herein, we describe challenges faced and strategies used to develop the PLUS Research Consortium into an engaged and productive transdisciplinary scientific team. We apply four previously defined team science phases (development, conceptualization, implementation, and translation) to frame our progress.

RESULTS

Strategies to progress through the development phase included the generation of a shared mission, and valuing of other disciplinary perspectives. The conceptualization phase included generating a shared language and developing a team transdisciplinary orientation. During the implementation phase, the group developed roles and procedures and focused on conflict management. The translation phase includes continued refinement of the mission and goals, implementation of research protocols, and robust dissemination of the scientific work products related to bladder health.

CONCLUSION

A diverse group has matured into a productive transdisciplinary team science consortium. Achieving this outcome required dedicated effort for each member to engage in activities that often required more time than single discipline research activities. Provision of the necessary time and tools has fostered a transdisciplinary team science culture and rich research agenda that reflects the complexity of the health issue to be addressed. Our experience may be useful for others embarking on team science projects.

Laying the Foundation for Bladder Health Promotion in Women and Girls

Prevention strategies have been effective in many areas of human health, yet have not been utilized for lower urinary tract symptoms (LUTS) or bladder health (BH). This commentary outlines LUTS prevention research initiatives underway within the NIH-sponsored Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). Prevention science involves the systematic study of factors associated with health and health problems, termed protective and risk factors, respectively. PLUS is enhancing traditional prevention science approaches through use of: (1) a transdisciplinary team science approach, (2) both qualitative and quantitative research methodology (mixed methodology), and (3) community engagement. Important foundational work of PLUS includes development of clear definitions of both BH and disease, as well as a BH measurement instrument that will be validated for use in the general population, adolescents, and Latinx and Spanish-speaking women.¹ The BH measurement instrument will be used in an upcoming nationally-representative cohort study that will measure BH and investigate risk and protective factors. PLUS investigators also developed a conceptual framework to guide their research agenda; this framework organizes a broad array of candidate risk and protective factors that can be studied across the life course of girls and women.¹ As PLUS begins to fill existing knowledge gaps with new information, its efforts will undoubtedly be complemented by outside investigators to further advance the science of LUTS prevention and BH across additional populations. Once the BH community has broadened its understanding of modifiable risk and protective factors, intervention studies will be necessary to test LUTS prevention strategies and support public health efforts. LUTS providers may be able to translate this evolving evidence for individual patients under their care and act as BH advocates in their local communities.