Hypothesis / aims of study
Rheumatoid arthritis (RA) is a common inflammatory arthritis in women and may present with extra-articular manifestations. Rarely, RA can cause lower urinary tract disease such as urinary tract infections, urolithiasis, and lower urinary tract symptoms (LUTS) [1]. Both RA and LUTS negatively impact the patient’s quality of life (QoL). Very few studies that have highlighted the frequency of LUTS among patients with RA, Systemic Lupus Erythematosus (SLE) and Sjogrens syndrome showed a high prevalence of voiding dysfunction among such a cohort [2].
The objective of the present study was to evaluate the frequency, severity and nature of LUTS in patients with RA. LUTS (filling, voiding, and incontinence) were explored in detail using the ICIQ-FLUTS questionnaire. RA disease activity was also studied (among other factors) to see which factors may be related to LUTS among RA patients.
Study design, materials and methods
This was a cross-sectional study carried out at a tertiary care teaching hospital in a major metropolitan city between January 2022 and December 2022. One hundred adult (> 18 years) women patients of seropositive RA were recruited. Patients of RA with diabetes mellitus, overlap with SLE or Sjogren’s syndrome, chronic kidney disease, previous urological problems, genito-urinary tract surgery, recent urinary tract infection, chronic liver disease, chronic heart failure, and those taking diuretics or on fluid restriction were excluded.
The following sets of data were collected : 1). demographics and clinical data including age, body mass index (BMI), smoking, tea intake, 2) duration of RA disease (sub-grouped as < 10 years and > 10 years) and disease acitivity of RA using Clinical Disease Activity Index (CDAI) score 3). ICIQ-FLUTS questionnaire, administered in native language by a trained physician.
Data was analysed using the Statistical Package for Social Sciences program (SPSS) version 25. Data was expressed as means ± SD for quantitative variables, median ± IQR for continuous variables, and frequencies and percentages for categorical variables. Kruskal Wallis and Mann Whitney U-tests were used to analyse patients’ characteristics according to ICIQ-FLUTS total score and sub-scores. The significance level was set at a p-value < 0.05.
The study was approved by the Institutional Ethics Committee of the medical college attached with the hospital. All study participants provided written informed consent and full confidentiality was maintained. The study was conducted according to the Declaration of Helsinki.
Results
One hundred women with seropositive RA were included in the study. Mean age of the women was 32.4 ± 12.3 years. Mean disease duration was 5.23 ± 2.89 years. Eighty-eight women had RA disease duration less than 10 years while 12 had had RA for more than 10 years. There were no somkers or coffee drinkers. However, 95 women were regular tea drinkers with an average of 2 cups per day. The mean BMI of the women was 22.78 ± 4.61 kg/sq.m. As per RA disease activity - 8, 12, 58 and 22 patients were in remission, low, moderate, and high disease activity, respectively.
We found that 88% of RA patients had at least one symptom of ICIQ-LUTS questionnaire. The mean total ICIQ-LUTS score was 12.65 ±9.02 (range 0–48). The mean score of filling, voiding and incontinence domains was 6.34 ± 2.23 (range: 0–16), 1.74 ± 0.92 (range 0–12) and 4.69 ±2.23 (range 0–20), respectively. On analysing the ICIQ-FLUTS subdomains, filling symptoms were: nocturia (>1 time) in 48%, urgency in 58%, and frequency in 62%; voiding symptoms were: hesitancy in 4%, straining in 7%, and intermittency in 12%; incontinence was: urge incontinence in 15%, and stress incontinence in 45% women.
BMI was positively and significantly correlated with filling symptoms (r = 0.428, p = 0.02) and to the total ICIQ-LUTS score (r = 0.382, p = 0.023). Age, tea intake or physical activity were not correlated with the ICIQ-LUTS total score or subdomains. The disease activity of RA was not found to be associated with any domains of ICIQ-LUTS (filling, voiding, and incontinence), or total ICIQ-LUTS score (p = 0.27). Further, duration of RA, also was not significantly associated with any domains of ICIQ-LUTS (p = 0.085).
Interpretation of results
This study shows that RA patients frequently complain of LUTS. The most frequent symptoms were frequency, urgency and nocturia, suggesting overactive bladder syndrome. The presence of overactive bladder syndrome in connective tissue diseases has been documented [2]. These LUTS symptoms of overactive bladder are frequently overlooked by the treating rheumatologist whose focus is on the joints. Also, patients do not often complain of these symptoms, either due to embarrassment or lack of knowledge. Thus, a routine assessment of such symptoms is important during the consultation for RA, so that treatment for overactive bladder (behavioural modification or anticholinergics) can be offered.
Incontinence was another frequently encountered problem in our patients of RA. Urinary incontinence can cause great distress to the patient and severey impede her lifestyle. Further studies are required to document the magnitude of the problem of urinary incontinence among RA patients and assess factors that exacerbate such symptoms.
BMI was positively and significantly correlated to storage symptoms and urinary incontinence in RA pateitns in this study. It may be the main factor responsible for LUTS in RA patients. This makes a case for counselling RA patients to control body weight. It is pertinent to note that obesity has been linked to RA disease activity, poor response to treatment, and risk for long-term adverse cardiovascular outcomes.
Disease activity of RA, disease duration or tea intake were not related to LUTS symptoms in our study. Most of the extra-articular manifestations of RA have been found to be correlated with disease duration or activity. This leads us to believe that LUTS may not be related to the inflammation in RA and may have separate patho-mechanisms. In a previous study, the author (SS) has demonstrated significant autonomic neuropathy among patients of RA [3]; it is possible that LUTS are a manifestation of autonomic neuropathy in RA.
Our study had some limitations, namely the absence of a control group (women with no RA) and the small sample size. We did not study if drugs used for RA had any impact on the LUTS. We also did not evaluate these RA patients for autonomic neuropathy.