Inspired by the World Health Organization’s definition of health, the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium recently developed the following working framework for studying 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 and environmental stressors, and allows optimal well-being (e.g., travel, exercise, social, occupational, or other activities) [1].” While much is known about the prevalence of LUTS in women, little is known about the distribution of bladder health. To address this gap, the PLUS Research Consortium recently developed and validated a comprehensive bladder health instrument, the Bladder Health Scales (BHS)/Bladder Function Indices (BFI) [2], to measure multiple dimensions of bladder health in women. The Consortium also incorporated this instrument into the RISE FOR HEALTH (RISE) Study, an ongoing population-based cohort study, to estimate the distributions of multiple dimensions of bladder health in community-dwelling American women. The goal of this analysis is to describe these distributions among RISE participants. A secondary goal is to describe the distributions of bladder health among women without LUTS, as we hypothesize that sub-optimal bladder health characteristics captured by the BHS/BFI may place women at greater risk of developing LUTS. Therefore, a first step is to determine whether variation in bladder health exists in this subset of women.

RISE is a large, regionally-representative cohort study of US women aged 18 and older. Potential participants were selected randomly from a marketing database and were required to reside in one of 50 counties including and surrounding the nine PLUS recruitment sites. Invitations to complete two 30-minute baseline surveys (on a web portal or on paper) were mailed to potential participants between May 2022 and May 2023. The baseline surveys included the BHS/BFI, the 10-item Symptoms of Lower Urinary Tract Dysfunction Symptom Index (LURN SI-10) [3], and multiple additional study items. The BHS/BFI is a comprehensive instrument that assesses bladder well-being across 10 domains (global, holding, perceived efficacy, social-occupation, physical activity, intimacy, travel, emotion, perception, and freedom), and bladder function across six functions (biosis/urinary tract infection, frequency, sensation, continence, comfort, and emptying). Scores for the BHS and BFI range from 0 (poor well-being/function) to 100 (optimal well-being/function). BHS scores are additionally adjusted for adaptive/coping behaviors (e.g., wearing/carrying pads, staying close to a toilet), as these behaviors may potentially minimize the perceived impact of LUTS on well-being [2]. The LURN SI-10 assesses the frequency of 10 lower urinary tract signs or symptoms, including daytime urinary frequency, nighttime urinary frequency, urgency, urgency and stress urinary incontinence, hesitancy, slow urinary stream, terminal dribbling, and pain or discomfort with bladder filling. We used this index to identify participants without self-reported LUTS, which we defined as an average daytime voiding frequency of <8 times/day, nighttime voiding frequency of <2 times/night, and a report of “never” in the past seven days for all other symptoms. We calculated medians and interquartile ranges (IQRs) for each BHS (with and without adaptive behavior adjustment) and BFI in the full study population and the subset of women without self-reported LUTS.

The mean age of the 3,017 eligible participants was 49.8 years (standard deviation = 17.9). Self-identified ethnicity/race was 15.3% Hispanic (any race), 5.9% non-Hispanic Asian, 12.3% non-Hispanic Black, and 62.9% non-Hispanic White. The median global BHS score was 72 (IQR: 56, 84) before adjustment for adaptive/coping behaviors and 55 (IQR: 34, 78) after adjustment (Table 1; difference in medians before and after adaptive behavior adjustment = 17). Median domain-specific BHS scores ranged from 75-100 before adjustment and from 61-72 after adjustment (difference in medians = 14-29). 68% of participants reported using adaptive/coping behaviors. The median overall BFI was 77 (IQR: 63, 89). Median individual BFI scores varied, ranging from 63-68 for frequency, sensation, continence, and emptying indices to 100 for biosis/urinary tract infection and comfort indices. When the analysis was limited to participants without self-reported LUTS (n=700), scores were higher across all BHS and BFI, indicating better health. However, even in this group of women without LUTS, variability in bladder health was observed, as well as utilization of adaptive/coping behaviors (employed by 38% of participants).

Overall, we observed a wide range of bladder health in RISE participants and high utilization of adaptive/coping behaviors, such as carrying pads and staying close to a toilet. These behaviors may potentially lessen women’s bother from LUTS and improve their perceived bladder health. Variability in bladder health and utilization of adaptive/coping behaviors was also observed in women without self-reported LUTS, highlighting dimensions of bladder health not captured by traditional LUTS tools and potentially identifying a group of women with “subclinical” or “pre-LUTS” who may be at greater risk of developing LUTS in the future.

Our findings in the full RISE study population speak to the need for interventions not only to prevent LUTS but also to promote bladder health in women. In addition, our findings among women without LUTS point to a group of women who may be at greater risk of developing LUTS. Future prospective analyses should investigate these findings further to determine whether women with sub-optimal bladder health, but without LUTS, are indeed at higher risk of LUTS and thus may be excellent candidates for targeted LUTS preventive interventions.

Lukacz ES, Bavendam TG, Berry A, et al. A Novel Research Definition of Bladder Health in Women and Girls: Implications for Research and Public Health Promotion. J Womens Health (Larchmt). Aug 2018;27(8):974-981.
Constantine ML, Rockwood TH, Rickey LM, et al. Validation of bladder health scales and function indices for women's research. Am J Obstet Gynecol. 2023;228(5):566.e561-566.e514.
Cella D, Smith AR, Griffith JW, et al; LURN Study Group. A New Brief Clinical Assessment of Lower Urinary Tract Symptoms for Women and Men: LURN SI-10. J Urol. 2020 Jan;203(1):164-170.

Continence 12S (2024) 101583
DOI: 10.1016/j.cont.2024.101583