As the medical and public health research communities have increasingly adopted a more holistic view of health, a growing number of fields have developed or revised their definitions of organ-specific health to include not only the absence of disease, but also the presence of well-being and the absence of disease risk factors. Consistent with this trend, the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium developed the following holistic, working research definition of bladder health: “A complete state of physical, mental, and social well-being related to bladder function and not merely the absence of lower urinary tract symptoms (LUTS). Healthy bladder function permits daily activities, adapts to short-term physical or environmental stressors, and allows optimal well-being (e.g., travel, exercise, social, occupational, or other activities)” [1]. 

To begin to inform and quantify the spectrum of bladder health, we recently performed a secondary analysis of existing data from the Boston Area Community Health (BACH) Survey. This analysis took advantage of the BACH Survey’s extensive collection of information on LUTS and its rare, universal collection of information on interference with activities from urinary experiences in adult women. Although these two sets of measures – LUTS and interference from urinary experiences – do not capture all constructs described in our working bladder health definition, we used these two measures to begin to approximate the spectrum of bladder health. At baseline, we found that: approximately one in five women might be considered to have optimal bladder health (no LUTS or interference), three in five to have good to intermediate health (intermediate frequencies of LUTS or interference), and the remaining one in five to have worse or poor bladder health (LUTS or interference all the time), supporting a spectrum of bladder health in women [2]. However, no studies to date have explored the stability of this spectrum or changes in LUTS and interference over time. Therefore, we used data from the baseline and follow-up visits of the BACH Survey to describe changes in our surrogate measure of bladder health over the five-year BACH Survey follow-up.

At the baseline and five-year follow-up interviews, participants reported their frequency of 15 LUTS, including storage, voiding, and incontinence symptoms, and lower urinary tract pain. Information on interference from urinary experiences, pain, or discomfort in the pubic area with seven activities in the past month was also collected, using an adapted version of the validated interference with activities domain of the Epstein Quality of life questionnaire. Activities assessed were drinking fluids before travel; driving for two hours without stopping; going to places that may not have a toilet; playing sports outdoors; going to movies, shows, and church; drinking fluids before bed; and getting enough sleep at night. Self-reported urologic disorders and associated medications and procedures (LUTS medications, incontinence or bladder surgery, chronic indwelling catheterization, and bladder cancer) were also collected at baseline and follow-up. 
We used these data to create the following categories of LUTS and interference at the baseline and five-year follow-up interviews: 1) no LUTS or interference; 2) mild LUTS (rarely) or interference (a little); 3) moderate LUTS (a few times) or interference (some of the time); 4) severe LUTS (fairly often or usually) or interference (most of the time); and 5) very severe LUTS (almost always) or interference (all of the time). These analyses used the maximum LUTS and interference frequency reported at each time point. Women with self-reported histories of urological disorders or associated medications or procedures were included in the highest category (very severe LUTS or interference). Prevalence, odds ratio (OR) and relative risk (RR) estimates accounted for the weights from the BACH sampling design and were adjusted for known LUTS risk factors through use of ordinal logistic regression and generalized linear models. With a sample size of 2,269-2,509 participants, our study had at least 80% power to detect minimum detectable ORs/RRs ranging from 1.21-1.30, assuming baseline prevalence estimates between 15 to 25%, and using two-sided tests and an α-level of 0.05.

2,509 women provided complete information on LUTS and interference at baseline and follow-up. At baseline, 16.9% of participants reported no LUTS or interference, 15.4% mild LUTS or interference, 22.0% moderate, 23.6% severe, and 22.3% very severe LUTS or interference (Figure 1). Five years later, a similar joint distribution of LUTS and interference was observed, although only 37.9% remained in their initial LUTS/interference category. The remaining women either worsened (i.e., increased in category of LUTS or interference, 33.6%) or improved (i.e., decreased in category of LUTS or interference, 28.7%) in approximately equal proportions. Worsening and improvement were observed in almost all baseline categories of LUTS and interference, although worsening was most likely in women with no or minimal LUTS or interference at baseline and improvement was most likely in women with worse baseline LUTS or interference. Nevertheless, women with LUTS or interference at baseline were still more likely to have LUTS or interference at the 5-year follow-up interview and to be in a higher LUTS/interference category, including severe or very severe LUTS or interference (Table 1).

Our findings suggest considerable variability in bladder health over time, with the potential for improvement, maintenance, and worsening in almost all categories of baseline LUTS/interference. Improvement and maintenance were observed even in the absence of LUTS therapy, supporting the potential for secondary prevention of LUTS and interference. In addition, although worsening of LUTS and interference was observed more commonly in women with no or lesser frequencies of LUTS or interference at baseline and improvement was observed more commonly in women with greater frequencies, the finding that women with LUTS or interference at baseline were still more likely to have higher frequencies of LUTS or interference at follow-up, including severe or very severe LUTS/interference, suggests that primary and secondary prevention efforts to promote good bladder health and prevent the development and progression of LUTS and interference are warranted.

Findings from our large secondary analysis of BACH Survey data describe changes in the spectrum of bladder health over time and associations between bladder health at baseline and five years later. In addition to a considerable amount of improvement in bladder health, we also found that women with higher initial frequencies of LUTS/interference were still more likely to have higher frequencies five years later, supporting primary and secondary prevention interventions to promote good bladder health and prevent the onset and progression of LUTS and interference.

Lukacz, E.S., et al., A Novel Research Definition of Bladder Health in Women and Girls: Implications for Research and Public Health Promotion. J Womens Health (Larchmt), 2018. 27(8): p. 974-981.
Sutcliffe, S., et al., The Spectrum of Bladder Health: The Relationship between Lower Urinary Tract Symptoms and Interference with Activities. J Womens Health (Larchmt), In press.