Pelvic floor symptoms (PFS) are prevalent and often bothersome in both females and males (1,2). PFS include micturition problems (e.g. urinary incontinence, urgency, voiding dysfunction), defaecation problems (e.g. fecal incontinence, constipation, obstructed defaecation), sexual problems (e.g. erectile dysfunction, ejaculation problems, dyspareunia), and genito-pelvic pain. 
Although the pelvic floor is an anatomical and functional unit, and therefore different PFS may co-occur, the literature on prevalence of concomitant PFS is scarce. Furthermore, PFS is understudied in the male population. We aimed to study the prevalence of concomitant PFS in a general population of men.

A prospective observational population-based cohort study started in May 2019. Eligible participants were invited through general practices in a Dutch municipality. This included all men aged 16 years and older, except those with terminal disease, dementia, cognitive impairment or current psychological condition precluding informed consent, and those not suitable or too ill to participate based on the judgement of the general practitioner. Participants signed informed consent before completion of the study questionnaire. The questionnaire included the International Consultation on Incontinence Questionnaire male Lower Urinary Tract Symptoms (ICIQ-mLUTS); the Groningen Defaecation and Fecal Continence (DeFeC) questionnaire, which includes all items for the Wexner score (incontinence and constipation); item M1 of the ‘Sexual Health in the Netherlands’ questionnaire; the ICIQ-Male Sexual Matters Associated with LUTS Module (ICIQ-MLUTSsex); and items on genito-pelvic pain in the pelvic region (location, duration and severity).
For most of these questionnaires, clear cut-off values are lacking. Therefore, we defined the presence of LUTS based on the upper quartile of ICIQ-mLUTS scores (scores ≥9), and defaecation problems on the upper quartile of the combined Wexner scores (scores ≥6). Having erectile and/or ejaculation problems and/or pain during intercourse or ejaculation was defined as having sexual dysfunction. Presence of pain in the pelvic region was defined as having pelvic pain. 
As a result, no prevalence rates of individual PFS could be calculated for the study population. For men with PFS, the prevalence of concomitant symptoms was calculated. Data were presented as a Sankey diagram for each main symptom. So, each diagram starts with the subgroup of men with the specific PFS. Data were ranked according to the largest overlap between symptoms.

In total 11,723 citizens received a postal invitation including information about the study. 694 males responded by returning informed consent. In total 566 males (mean age 62.1±13.7 years) completed all PFS parts of the questionnaire. Of these, 212 (37.5%) reported no PFS; the other men had one or more PFS. Median ICIQ-mLUTS score was 6.0 (Interquartile range 3.0-10.0); median Wexner score was 3.0 (IQR 2.0-6.0).
202 of the 436 sexually active men reported sexual dysfunction. The Sankey diagram illustrated that 37.1% of men with sexual dysfunction reported no concomitant PFS, and 33.1% reported defaecation problems with or without LUTS, and 41.1% reported concomitant LUTS with or without pain or defaecation problems (Figure 1A). 
The most frequent concomitant PFS in men with LUTS was defaecation problems (Figure 1B): approximately half of all men with LUTS also reported defaecation problems. Likewise, for men who reported defaecation problems, the main concomitant PFS was LUTS (52.2%, Figure 1C).
Pelvic pain was reported by 88 men and showed considerable overlap with both LUTS and sexual dysfunction (Figure 1D), only 15.9% of men with pain reported no other PFS.

This is the first study in the general population aimed at finding concomitant PFS in men, who not necessarily have requested care for their symptoms. The low response rate limits generalization of the outcomes. Since clear cut-off values are lacking, we were unable to assess the prevalence of separate PFS. This was the case especially for LUTS and defaecation problems. As the main goal of this study was to find clusters of symptoms, we feel that this approach is feasible, and the study outcome reflects clinically relevant issues.
We have found a large overlap between the presence of LUTS and defaecation problems. In addition, the presence of sexual dysfunction coincided with the presence of LUTS in 41% and defaecation problems in 33% of cases. These estimates were higher than expected and deserve special attention in clinical practice, i.e. when men present with either LUTS, defaecation problems or sexual dysfunction, health care providers should ask about the other two pelvic floor symptoms.
We found that the vast majority of men with pelvic pain also has another PFS, especially LUTS and sexual dysfunction.
The co-occurrence of different PFS could reflect a common cause, but the cross-sectional nature of this survey limits to draw conclusions on the causal associations. Longitudinal studies are needed to clarify this further.

This study in the general population showed a considerable overlap between PFS in adult men, especially between LUTS and defaecation symptoms, whether or not in combination with sexual dysfunction.

Davis K, and Kumar D. Pelvic floor dysfunction: A conceptual framework for collaborative patient-centred care. J Adv Nurs. 2003;43:555-68.
Pierce H, et al. A systematic review of prevalence and impact of symptoms of pelvic floor dysfunction in identified workforce groups. J Adv Nurs. 2016;72:1718-34.