Enduring impact of childhood adversity on lower urinary tract symptoms in adult women

Applying natural language processing to understand symptoms among older adult home healthcare patients with urinary incontinence

INTRODUCTION

Little is known about the range and frequency of symptoms among older adult home healthcare patients with urinary incontinence, as this information is predominantly contained in clinical notes. Natural language processing can uncover symptom information among older adults with urinary incontinence to promote holistic, equitable care.

DESIGN

We conducted a secondary analysis of cross-sectional data collected between January 1, 2015, and December 31, 2017, from the largest HHC agency in the Northeastern United States. We aimed to develop and test a natural language processing algorithm to extract symptom information from clinical notes for older adults with urinary incontinence and analyze differences in symptom documentation by race or ethnicity.

METHODS

Symptoms were identified through expert clinician-driven Delphi survey rounds. We developed a natural language processing algorithm for symptom identification in clinical notes, examined symptom documentation frequencies, and analyzed differences in symptom documentation by race or ethnicity using chi-squared tests and logistic regression models.

RESULTS

In total, 39,179 home healthcare episodes containing 1,098,419 clinical notes for 29,981 distinct patients were included. Nearly 40% of the sample represented racially or ethnically minoritized groups (i.e., 18% Black, 14% Hispanic, 7% Asian/Pacific Islander, 0.3% multi-racial, and 0.2% Native American). Based on expert clinician-driven Delphi survey rounds, the following symptoms were identified: anxiety, dizziness, constipation, syncope, tachycardia, urinary frequency/urgency, urinary hesitancy/retention, and vision impairment/blurred vision. The natural language processing algorithm achieved excellent performance (average precision of 0.92). Approximately 29% of home healthcare episodes had symptom information documented. Compared to home healthcare episodes for White patients, home healthcare episodes for Asian/Pacific Islander (odds ratio = 0.74, 95% confidence interval [0.67-0.80], p < 0.001), Black (odds ratio = 0.69, 95% confidence interval [0.64-0.73], p < 0.001), and Hispanic (odds ratio = 0.91, 95% confidence interval [0.85-0.97], p < 0.01) patients were less likely to have any symptoms documented in clinical notes.

CONCLUSION

We found multidimensional symptoms and differences in symptom documentation among a diverse cohort of older adults with urinary incontinence, underscoring the need for comprehensive assessments by clinicians. Future research should apply natural language processing to other data sources and investigate symptom clusters to inform holistic care strategies for diverse populations.

CLINICAL RELEVANCE

Knowledge of symptoms of older adult home healthcare patients with urinary incontinence can facilitate comprehensive assessments, health equity, and improved outcomes.

Can apparently transient life events trigger long-term lower urinary tract symptoms?

INTRODUCTION

One-time life events such as neurological injury can result in lifelong lower urinary tract symptoms (LUTS). However, it is unclear whether an apparently transient life event can also trigger long-term LUTS. This review examines the possibility of an association and hypothesizes the pathogenesis.

METHODS

A pubmed search was conducted using the MeSH words "life change events," "child abuse," or "stress disorders, Posttraumatic", and LUTS. Additional manuscripts were identified by a hand and citation search.

RESULTS

Long-term LUTS was noted following temporally remote childhood sexual abuse, adverse childhood experiences, and stressful experiences in adults. There was evidence for an association of childhood sexual abuse and adverse childhood events with both storage as well as voiding LUTS. There was limited evidence that the number of adverse childhood events might increase the risk and severity of LUTS. There was evidence of an association between post-traumatic stress disorder in adults and LUTS. The finding of mental health disorders in such patients could explain some but not all of the observed association suggesting that other factors might also be important.

CONCLUSIONS

There is an association noted between apparently transient lifetime events and the subsequent reporting of LUTS. The timing of these adverse experiences might be important in determining the propensity for clinical manifestation. There is a need to explore this association, establish causality, and determine the underlying etiopathogenesis.

Sex differences in the association between (sexual) abuse and lower urinary tract symptoms

OBJECTIVES

To study the possible association between (sexual) abuse and lower urinary tract symptoms (LUTS) in men and women. To study the differences in this association between men and women, and between the timing of the abuse.

SUBJECTS AND METHODS

A Dutch observational population-based cross-sectional study was used, based on self-administered questionnaires. Respondents were included if they had answered all questions about abuse and LUTS. Logistic regression was used to analyse the data.

RESULTS

Included were 558 men and 790 women, of whom 29% and 37%, respectively, reported a history of one of more types of abuse. Abuse was significantly associated with LUTS in both men (odds ratio [OR] 1.7; 1.2-2.5) and women (OR 1.4; 1.1-2.1). This association, testing by two-way interaction, was significantly stronger in men. No association was found between childhood abuse or adulthood abuse and LUTS, in men or women. The association of sexual abuse with LUTS was significant in both men (2.7; 1.4-5.2) and in women (1.5; 1.1-2.2), and this association (testing by two-way interaction) was significantly much stronger in men.

CONCLUSION

In men more than in women, a history of any type of abuse is associated with LUTS, regardless of whether the abuse occurred during childhood or adulthood. In both sexes, a history of sexual abuse is also associated with experiencing LUTS, with a much stronger association in men than in women. Patients, in particular male patients, presenting with LUTS should therefore be asked about sexual abuse in the past.

Depressive feelings as mediator in the relation between adverse childhood events and lower urinary tract symptoms in males and females

BACKGROUND

Adverse childhood events (ACEs) are prevalent and lead to well-established adverse health sequelae in adulthood. Recent literature has claimed that exposure to trauma in early life may worsen lower urinary tract symptoms (LUTS) because emotion can alter the perception of bodily distress in the brain. Specifically, depressive symptoms might influence the association between ACEs and LUTS. We aimed to describe the associations between ACEs and LUTS among males and females and to determine whether depressive symptoms mediated these associations.

METHODS

This study was a secondary analysis of the Coevorden observational cohort study (n = 1691, age ≥16 years). For this observational study participants filled in the male or female modules of the International Consultation on Incontinence Questionnaire for LUTS (ICIQ-MLUTS and ICIQ-FLUTS, respectively), the NEMESIS Childhood Trauma Questionnaire (emotional neglect, psychological abuse, physical abuse, and sexual abuse within the family), and the Patient Health Questionnaire (PHQ-9) for depression.

RESULTS

Overall, 564 males and 811 females answered all required items related to LUTS and ACEs. A series of regression models were then estimated to test for mediation: LUTS on ACEs, depression on ACEs, and LUTS on both ACEs and depression. The models were also adjusted for the following covariates: age, body mass index, diabetes mellitus, current smokers, educational level, and vaginal delivery (if female). Depressive symptoms were shown to mediate the association between ACEs and LUTS in both males and females.

CONCLUSION

Childhood adversity and depression are areas of interest during the clinical assessment of patients with LUTS. Early detection of these conditions might help to manage risk, aid in the prevention of LUTS, and facilitate trauma-informed care.

The brain, gut, and bladder health nexus: A conceptual model linking stress and mental health disorders to overactive bladder in women

OBJECTIVE

A small, but growing literature links stressors and mental health disorders (MHDs) across the life course to overactive bladder (OAB) and urinary incontinence symptoms. Mechanisms by which stressors and MHDs may impact bladder health are not fully understood, limiting novel prevention and treatment efforts. Moreover, potential biopsychosocial mechanisms involving the brain and gut have not been considered in an integrated, comprehensive fashion.

METHODS

Members of the prevention of lower urinary tract symptoms Research Consortium developed conceptual models to inform research on biopsychosocial mechanisms through which stress and MDHs may impact bladder health among girls and women, focusing on brain and gut physiology.

RESULTS

Two conceptual models were developed-one to explain central (brain-based) and peripheral (gut-based) mechanisms linking stressors and MHDs to OAB and bladder health, and one to highlight bidirectional communication between the brain, gut, and bladder. Traumatic events, chronic stressors, and MHDs may lead to a maladaptive stress response, including dysregulated communication and signaling between the brain, gut, and bladder. Gut bacteria produce molecules and metabolites that alter production of neurotransmitters, amino acids, short-chain fatty acids, and inflammatory immune response molecules that mediate communication between the gut and brain. Microbiota signal neurogenesis, microglia maturation, and synaptic pruning; they also calibrate brain-gut-bladder axis communication through neurotransmission and synaptogenesis, potentially influencing bladder symptom development. Life course trajectories of risk may be prevented or interrupted by central and peripheral resources for neuropsychological resilience.

CONCLUSIONS

Depicted pathways, including brain-gut-bladder communication, have implications for research and development of novel prevention and treatment approaches.

Comorbidities of community-dwelling older adults with urinary incontinence: A scoping review

BACKGROUND

Identifying comorbidities is a critical first step to building clinical phenotypes to improve assessment, management, and outcomes.

OBJECTIVES

1) Identify relevant comorbidities of community-dwelling older adults with urinary incontinence, 2) provide insights about relationships between conditions.

METHODS

PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched. Eligible studies had quantitative designs that analyzed urinary incontinence as the exposure or outcome variable. Critical appraisal was performed using the Joanna Briggs Institute Critical Appraisal Checklists.

RESULTS

Ten studies were included. Most studies had methodological weaknesses in the measurement of conditions. Comorbidities affecting the neurologic, cardiovascular, psychologic, respiratory, endocrine, genitourinary, and musculoskeletal systems were found to be associated with urinary incontinence.

CONCLUSION

Existing literature suggests that comorbidities and urinary incontinence are interrelated. Further research is needed to examine symptoms, shared mechanisms, and directionality of relationships to generate clinical phenotypes, evidence-based holistic care guidelines, and improve outcomes.

Lower Urinary Tract Symptoms in Depression: A Review

Lower Urinary Tract Symptoms (LUTS) are frequently present in the general population as patients age with approximately a third of individuals experiencing LUTS during their lifetime. LUTS can be further defined as having any of the following symptoms: urinary hesitancy, straining, nocturia, increased urination frequency, and dysuria. LUTS has the potential for patients to contribute their symptoms to what can normally occur as we age. This can lead to a decrease in patients seeking care and could negatively impact patients' health-related quality of life (HRQL). In conjunction with LUTS, we obtained from our analysis that LUTS and depression are closely related and worsening depressive symptoms may increase the severity of LUTS. We also discerned three categories of factors that can yield major depression namely adversity, internalizing, and externalizing factors. Within these categories, trauma, social support, genetic factors, and minimal education appeared to increase the risk of depression in patients. With the recent increase in mental health awareness and more access to mental health care amid the COVID-19 Pandemic, further screening, and collaboration between providers to treat both urological and psychiatric symptoms could improve patient outcomes. It is important for providers to have an increased understanding of the mental and physical impact both LUTS and depression can have on patients' wellbeing. This has the potential to help patients be more open about their symptoms with the aim of better addressing LUTS and depression to positively impact their HRQL.

Systematic review exploring the relationship between sexual abuse and lower urinary tract symptoms

INTRODUCTION AND HYPOTHESIS

Patients presenting with lower urinary tract symptoms (LUTS) may report a history of sexual abuse (SA), and survivors of SA may report LUTS; however, the nature of the relationship is poorly understood. The aim of this review is to systematically evaluate studies that explore LUT dysfunction in survivors of SA.

METHODS

A systematic literature search of six databases, Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO, was performed. The last search date was June 2021 (PROSPERO CRD42019122080). Studies reporting the prevalence and symptoms of LUTS in patients who have experienced SA were included. The literature was appraised according to the PRISMA statement. The quality of the studies was assessed.

RESULTS

Out of 272 papers retrieved, 18 publications met the inclusion criteria: studies exploring LUTS in SA survivors (n=2), SA in patients attending clinics for their LUTs (n=8), and cross-sectional studies (n=8). SA prevalence ranged between 1.3% and 49.6%. A history of SA was associated with psychosocial stressors, depression, and anxiety. LUTS included urinary storage symptoms, voiding difficulties, voluntary holding of urine and urinary tract infections. Most studies were of moderate quality. Assessment of SA and LUTS lacked standardisation.

CONCLUSIONS

The review highlights the need for a holistic assessment of patients presenting with LUTS. Although most of the studies were rated as being of 'moderate' quality, the evidence suggests the need to provide a "safe space" in clinic for patients to share sensitive information about trauma. Any such disclosure should be followed up with further assessment.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Interpersonal violence and painful bladder symptoms in community-dwelling midlife to older women

BACKGROUND

Women are more likely to present with genitourinary complaints immediately after exposure to interpersonal violence, but little is known about the long-term effects of violence on women's urologic health, including their susceptibility to bladder pain and infections.

OBJECTIVE

To determine whether lifetime interpersonal violence exposure and current posttraumatic stress disorder (PTSD) symptoms are associated with the prevalence or severity of painful bladder symptoms and a greater lifetime history of antibiotic-treated urinary tract infections in community-dwelling midlife and older women.

STUDY DESIGN

We examined the cross-sectional data from a multiethnic cohort of community-dwelling women aged 40 to 80 years enrolled in a northern California integrated healthcare system. Women completed structured self-report questionnaires about their past exposure to physical and verbal/emotional intimate partner violence and sexual assault. The symptoms of PTSD were assessed using the PTSD checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Civilian version. Additional structured self-report measures assessed the current bladder pain, other lower urinary tract symptoms, and the history of antibiotic-treated urinary tract infections. Multivariable logistic regression models examined self-reported interpersonal violence exposure history and current PTSD symptoms in relation to current bladder pain and antibiotic-treated urinary tract infection history.

RESULTS

Among 1974 women (39% non-Latina White, 21% Black, 20% Latina, and 19% Asian), 22% reported lifetime interpersonal violence exposure, 22% reported bladder pain, and 60% reported a history of ever having an antibiotic-treated urinary tract infection. Lifetime experiences of sexual assault (odds ratio, 1.39; [95% confidence interval, 1.02-1.88]) and current PTSD symptoms (odds ratio, 1.96; [95% confidence interval, 1.45-2.65]) were associated with current bladder pain. A lifetime experience of physical intimate partner violence was associated with having a urinary tract infection at any time in life previously (odds ratio, 1.38; [95% confidence interval, 1.00-1.86]), as was emotional intimate partner violence (odds ratio, 1.88; [95% confidence interval, 1.43-2.48]), sexual assault (odds ratio, 1.44; [95% confidence interval, 1.09-1.91]), and current PTSD symptoms (odds ratio, 1.54; [95% confidence interval, 1.16-2.03]).

CONCLUSION

In this ethnically diverse, community-based cohort, lifetime interpersonal violence exposures and current PTSD symptoms were independently associated with current bladder pain and the lifetime history of antibiotic-treated urinary tract infections in midlife to older women. The findings suggest that interpersonal violence and PTSD symptoms may be underrecognized markers of risk for urologic pain and infections in women, highlighting a need for trauma-informed care of these issues.