Patients' experiences of seeking health care for lower urinary tract symptoms

A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms

BACKGROUND

Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing.

AIM

To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention.

METHODS

Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings.

RESULTS

86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators.

CONCLUSIONS

Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021256956.

A national survey of lower urinary tract symptoms in Jordan

Objective

To determine the prevalence of lower urinary tract symptoms (LUTS) and their severity population in Jordan.

Methods

This cross-sectional survey was conducted using a paper-based survey between August and September in 2019. The study was carried out in the health care centers or hospitals in three different regions of Jordan: North (Irbid and Jarash), Middle (Amman, Madaba, Salt, and Zarqa), and South (Karak and Aqaba).

Results

To estimate the prevalence of LUTS, two definitions were used, including the first definition (presence of any LUTS regardless of the degree of severity) and the second definition (presence of any LUTS that occurs half the time or more). According to the first definition, 1038 (89.9%) reported LUTS (male: 47.3%, female: 52.7%), while 763 (66.1%) reported LUTS according to the second definition (male: 45.6%, female: 54.4%). According to the International Prostate Symptom Score characterization, 73.9% had nocturia and 62.9% reported daytime increased frequency.

Conclusion

LUTS are highly prevalent among the Jordanian population, and more than half of them have nocturia or daytime increased frequency as most frequently reported symptoms.

A meta-ethnography to understand the experience of living with urinary incontinence: 'is it just part and parcel of life?'

BACKGROUND

Urinary incontinence (UI) is highly prevalent and affects the lives of many men and women. We aimed to conduct a qualitative evidence synthesis (QES) to explore the experience of living with UI and to develop a conceptual model that can help us to understand this experience, and the potential barriers to appropriate healthcare.

METHODS

We used the methods of meta-ethnography developed by Noblit and Hare and recently refined for larger studies. Meta-ethnography involves identifying concepts from the studies and abstracting these concepts into a line of argument. We searched for studies that explored the experience of adults with UI. We used the GRADE-CERQual framework to assess confidence in review findings.

RESULTS

We screened 2307 titles, 429 abstracts, 107 full texts and included 41 studies (36 unique samples) in the synthesis. We organised the concepts into 26 conceptual categories, which we further abstracted into 6 themes: (1) Am I ill or is this normal? (2) It effects who I am and how I feel; (3) I feel stigmatised, ashamed and guilty; (4) talking can be difficult but it can help; (5) keeping incontinence under control; (6) have I got to the point that I need help? Our model conceptualises living with UI as navigating antagonists: Is UI normal or am I ill? Do I need help or am I managing? Do I keep UI to myself (and manage alone) or do I tell other people (and get the support that I need)? Do I use control strategies that focus on concealing (avoid risky situations, wear pads) versus, I use strategies that focus on improving the bodily function to improve continence. Our model highlights the experience of stigma, shame and guilt which exert a pull towards concealment.

CONCLUSIONS

The culture of secrecy and profound sense of shame is barrier to seeking help. An environment which reduces the shame and stigma of UI may help people to switch the focus to strategies that will improve continence, rather than conceal incontinence.

The Prevention of Lower Urinary Tract Symptoms (PLUS) in girls and women: Developing a conceptual framework for a prevention research agenda

AIMS

The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was established by the National Institutes of Health in 2015 to expand research beyond the detection and treatment of lower urinary tract symptoms (LUTS) to the promotion and preservation of bladder health and prevention of LUTS in girls and women. While many multi-disciplinary scientific networks focus on pelvic floor dysfunction and LUTS, the PLUS Consortium stands alone in its focus on prevention. This article describes the PLUS approach to developing a conceptual framework to guide the Consortium's initial prevention research agenda.

METHODS

The conceptual framework was informed by traditional social ecological models of public health, biopsychosocial models of health, Glass and McAtee's Society-Behavior-Biology Nexus, and the World Health Organization's conceptual framework for action on the social determinants of health.

RESULTS

The PLUS conceptual framework provides a foundation for developing prevention interventions that have the greatest likelihood of promoting and preserving bladder health among diverse populations.

CONCLUSIONS

PLUS Consortium work is premised on the notion that programs, practices, and policies designed to promote health will have optimal impact if the conceptual foundation upon which efforts are based is comprehensive and informed by multiple disciplines. The PLUS conceptual framework is broadly applicable to domains of health that have historically focused on the treatment of illness and symptoms rather than the promotion of health. It is also applicable to domains of health that have been examined from a predominantly biological or social ecological perspective, without integration of both perspectives.

Exploring the feelings of Iranian women of reproductive age about health care seeking behavior: a qualitative study

Background: Despite the important role of feelings in health care seeking behavior (HCSB), this subject has not yet been adequately investigated. HCSB-related feelings begin with the onset of disease symptoms and persist in different forms after treatment. The aim of current study was to explore the feelings that women of reproductive age experience when they seek health care. Methods: In this deductive, qualitative content analysis, participants were selected by purposeful sampling. Semi-structured, in-depth interviews with 17 women of reproductive age and 5 health care staffs in Qom, Iran were carried out until data saturation was achieved. Qualitative data were concurrently analyzed by deductive content analysis, using the Health Promotion Model (HPM). The MAXQDA10 software was used to manage qualitative data analysis. Results: Three main categories were drawn from data to explain the HCSB-related feelings of participants consisting of (1) feeling of inner satisfaction with the treatment with 2 subcategories including "peace of mind" and "feeling alive", (2) multiple roles of fear with 5 subcategories including "fear about the consequences of delay", "fear of having hidden diseases", "fear of unknown experiences", "fear of hearing bad news" and "fear of medical errors" and (3)uncomfortable feelings with 3 subcategories including "feeling uneasy when attending health facility", "feeling embarrassed" and "feeling worthless due to dealing the doctor". Conclusion: This study revealed that the inner feelings of women varied widely, ranging from positive or motivating feelings to negative or inhibitory ones, given their experiences with the formal health care system and the current situation of medical and health services. Highlighting patients' perceived inner satisfaction and reducing fear and uncomfortable feelings by adopting culture-based practical strategies can enhance women's HCSB.

Adult women's experiences of urinary incontinence: a systematic review of qualitative evidence

BACKGROUND

Women are affected dramatically by urinary incontinence (UI). This disease is currently considered as epidemic.

OBJECTIVE

The objective of this review is to identify, through the best available evidence, how women experience UI worldwide.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review included studies of adult women who had experienced UI.

PHENOMENA OF INTEREST

Women with UI from various social and cultural settings were included in this review.

TYPES OF STUDIES

Qualitative data including, but not limited to, study designs such as phenomenology, grounded theory, ethnography, action research and feminist research were included in this review.

OUTCOMES

All aspects related to the experience of UI endured by women were considered.

SEARCH STRATEGY

An initial search of MEDLINE (PubMed) and CINAHL was done, followed by the exploration of all the databases and all identified studies, published in English, Spanish, French and Portuguese. The databases searched were CINAHL, PubMed, PsycINFO, Lilacs, Scielo, BVS, BVS-Psi, Scopus, Embase, Sociological Abstracts, Dissertation Abstracts International and the University of São Paulo Dissertations and Thesis bank and gray literature.

METHODOLOGICAL QUALITY

Each primary study was assessed by two independent reviewers for methodological quality. The Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI-QARI) data extraction form for interpretive and critical research was used to appraise the methodological quality of all papers.

DATA EXTRACTION

Qualitative data were extracted using the JBI-QARI.

DATA SYNTHESIS

Qualitative research findings were synthesized using the JBI-QARI.

RESULTS

From the 28 studies were included, 189 findings were extracted and they were grouped into 25 categories and eight synthesized findings: (i) cultural and religious backgrounds and personal reluctance contribute to delays in seeking UI treatment; (ii) the inevitable and regrettable problem of UI endured silently and alone affects women's daily activities and their social roles; (iii) poor knowledge and the vague nature of the symptoms mask the fact that UI is a disease; (iv) the experiences provoked by UI and the sense of shame regarding the condition have contributed to impair women's lives; (v) UI has provoked negative effects on women's intimacy and sexual satisfaction and provoked changes in the ways they experience their sexuality and sexual function; (vi) UI is considered a consequence of pregnancy and childbirth, inherent to aging or a religious punishment; (vii) the women affected by UI adopt several strategies to improve their health status; and (viii) women have personal preferences toward care providers and treatments; they confront difficulties through UI treatment and some care needs are not met.

CONCLUSION

Personal and tailored health care should be provided, and preferences and expectations should be taken into consideration in the provision of health care to the people affected by UI.

Future Directions of Research and Care for Urinary Incontinence: Findings from the National Institute of Diabetes and Digestive and Kidney Diseases Summit on Urinary Incontinence Clinical Research in Women

PURPOSE

Female urinary incontinence is prevalent, costly and morbid. Participants in a NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) sponsored summit reviewed findings from NIH (National Institutes of Health) funded clinical research on urinary incontinence in women and discussed the future of urinary incontinence research.

MATERIALS AND METHODS

The NIDDK convened the Summit on Urinary Incontinence Clinical Research in Women on March 14, 2014. Participants representing a broad range of clinical expertise reviewed completed NIH sponsored urinary incontinence related studies, including results from community based epidemiological studies such as the BACH (Boston Area Community Health) Survey and from randomized clinical trials such as PRIDE (Program to Reduce Incontinence by Diet and Exercise), and studies conducted by the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network.

RESULTS

BACH Survey results improved our understanding of precursors, incidence, prevalence and natural history of urinary incontinence in a diverse group of women. The Pelvic Floor Disorders Network study found that anticholinergic medications and onabotulinumtoxinA are efficacious for treating urge urinary incontinence, and Burch colposuspension and retropubic mid urethral polypropylene slings are efficacious for decreasing stress urinary incontinence following pelvic organ prolapse surgery in women with potential stress urinary incontinence. The Urinary Incontinence Treatment Network study found that fascial slings were better than colposuspension, and that retropubic and transobturator mid urethral polypropylene slings were equivalent for stress urinary incontinence. In patients with stress urinary incontinence a preoperative urodynamic study was noninferior to basic office examinations for surgical outcome. The addition of behavioral intervention did not allow female patients to discontinue antimuscarinics for urge urinary incontinence. PRIDE showed that modest weight reductions significantly decreased urinary incontinence.

CONCLUSIONS

Strategies for future research on urinary incontinence should include a focus on early disease, risk factor identification, better phenotyping, incorporation of new technologies, patient centered research and prevention.

Advancing a Comprehensive Approach to the Study of Lower Urinary Tract Symptoms

PURPOSE

Lower urinary tract symptoms are common in the United States population, leading to significant economic, quality of life and public health issues. The burden will increase as the population ages, and risk factors for lower urinary tract symptoms, including diabetes and obesity, remain highly prevalent. Improving clinical management and establishing the knowledge base to prevent lower urinary tract symptoms will require a comprehensive research approach that examines factors beyond the lower urinary tract. While the study of extra-lower urinary tract factors has increased recently, current urological research does not systematically account for the broad set of potential contributing factors spanning biological, behavioral, psychological/executive function and sociocultural factors. A comprehensive assessment of potential contributors to risk, treatment response and progression is necessary to reduce the burden of this condition in the United States.

MATERIALS AND METHODS

We considered challenges to continuing the predominantly lower urinary tract dysfunction centric approach that has dominated previous research of lower urinary tract symptoms.

RESULTS

We developed a new, comprehensive framework for urology research that includes a broader set of potential factors contributing to lower urinary tract symptoms. This framework aims to broaden research to consider a comprehensive set of potential contributing factors and to engage a broad range of researchers in the investigation of as many extra-lower urinary tract factors as possible, with the goal of improving clinical care and prevention.

CONCLUSIONS

We propose a new framework for future urology research, which should help to reduce the medical and economic burden of lower urinary tract symptoms in the United States population.

How Men Manage Bulbar Urethral Stricture by Concealing Urinary Symptoms

In this article, we present findings from research conducted as part of a multi-center surgical trial. Bulbar urethral stricture, a narrowing of the middle urethra, is a common cause of urinary problems in men that can have a profound impact on their lives. Semi-structured interviews were conducted with a sample of 19 men seeking treatment for urethral stricture. The findings reveal how men tend to develop routines and tactics to adapt to their symptoms and hide them from others rather than seek help. We argue that this concealment becomes an inseparable part of how the disease is managed and is an additional hidden practical and emotional burden for these men. In addition, we suggest that the patients only sought curative treatments once practices of social concealment are no longer viable.

Factors associated with treatment-seeking behavior for postpartum urinary incontinence

PURPOSE

To identify the factors associated with treatment-seeking behavior for urinary incontinence (UI) among postpartum women.

DESIGN

This is a cross-sectional study. A total of 142 women with postpartum UI responded a telephone interview between August of 2010 and March of 2011. The association between the treatment-seeking and the predicting variables were measured through odds ratio and 95% confidence interval.

RESULTS

The treatment-seeking percentage was 37.3% and the treatment percentage was 27.5%. The result of multiple logistic regressions indicated that: counseling about UI in pregnancy, postpartum physical exercise, and Spanish nationality predicted 47.8% of the variance in treatment-seeking behavior

CONCLUSIONS

The lack of counseling largely determines the low rates of treatment-seeking among Spanish mothers.

CLINICAL RELEVANCE

Nursing counseling during pregnancy can contribute substantially to increasing the number of women treated for postpartum UI.

Parasexuality in genitourinary investigations: a qualitative study

BACKGROUND

Genitourinary investigations are performed on a large proportion of middle-aged and older men and the majority undergo investigations for prostate issues. The effects that genitourinary disease can have on men depend on the type of problem, investigations required and treatment including impotence, gynaecomastia and urinary incontinence that have lasting devastating physical, social and psychological effects. The aim was to explore older men's experience and views of intimate and intrusive genitourinary investigations and specifically to develop hypotheses and theories concerning gender and sexuality issues in intimate genitourinary investigations.

METHODS

Written informed consent was obtained for this qualitative study. Data were collected through one-off, semi-structured interviews involving 15 men in the first year following patient's last urological procedure. Initially, multiple themes were identified and when analysed further concepts were repeatedly present. As the urological investigations were limited to men, gender and sexuality became prominent issues in the data.

RESULTS

On analysis, the term parasexuality appeared to explain the dynamic of the situation. Parasexuality is a modified form of sexuality which is channelled and limited to maintain propriety. This was not expressed as sexuality in its overt, explicit sense, but instead a type of covert sexuality where professional boundaries are maintained but nonetheless undercurrents remain. This managed version of sexuality created a common currency by which interactions between staff and patients could take place safely. Feeding into parasexuality were gender role stereotypes and for some of the participants this reflected their own experience, context, historical and cultural norms. Intimate contact in the form of exposure and handling of the participants' genitalia during the investigations particularly challenged the boundaries of parasexuality. In order to remain parasexual, many of the participants suppressed their sexuality. Viewing staff as professional was an additional strategy used by participants to limit any sexuality as parasexuality.

CONCLUSION

This study has contributed towards the appeal for more studies to examine privacy perceptions of patients in genitalia-related care, however, it is by no means definitive. Parasexuality goes some way to explain the dynamics of communication between older men and health care professionals during genitourinary investigations.

Expression and function of vascular endothelial growth inhibitor in aged porcine bladder detrusor muscle cells

Aging of the bladder detrusor muscle plays an important role in lower urinary tract symptoms in elderly people. Our previous work demonstrated that elderly patients have increased levels of vascular endothelial growth inhibitor (VEGI) in bladder tissue. Therefore, we hypothesized that VEGI may play a role in aging of the bladder detrusor muscle cells. This study aims to develop and characterize primary cultures of aged porcine bladder detrusor muscle cells in order to explore the expression and function of VEGI. Bladder samples from female pigs were divided into two groups: the aged group (Model) and the young group (Control). We confirmed β-galactosidase expression, a marker for senescence, in aged muscle cells (identified by α-smooth muscle actin (α-SMA) staining), but not in the young group. mRNA levels of VEGI-251 and death receptor 3 (DR3) were up-regulated (P < 0.05) and total cell protein levels of VEGI-251, DR3 and nuclear factor-kappa B [NF-κB (p65)], membrane protein levels of DR3, and nuclear protein levels of NF-κB (p65) were significantly higher (P < 0.01) in the Model cells compared to Control cells. In conclusion, we have established a method to culture aged detrusor muscle cells derived from porcine bladder. Higher levels of VEGI-251, DR3 and NF-κB (p65) were observed in the aged cells. VEGI-251 may function by increasing DR3 on cellular membranes and promoting the transfer of NF-κB into the nucleus. This suggests that VEGI may be a target for reversing the aging process of bladder detrusor muscle cells.

Cohort profile: the Boston Area Community Health (BACH) survey

The Boston Area Community Health (BACH) Survey is a community-based, random sample, epidemiologic cohort of n = 5502 Boston (MA) residents. The baseline BACH Survey (2002-05) was designed to explore the mechanisms conferring increased health risks on minority populations with a particular focus on urologic signs/symptoms and type 2 diabetes. To this end, the cohort was designed to include adequate numbers of US racial/ethnic minorities (Black, Hispanic, White), both men and women, across a broad age of distribution. Follow-up surveys were conducted ∼5 (BACH II, 2008) and 7 (BACH III, 2010) years later, which allows for both within- and between-person comparisons over time. The BACH Survey's measures were designed to cover the following seven broad categories: socio-demographics, health care access/utilization, lifestyles, psychosocial factors, health status, physical measures and biochemical parameters. The breadth of measures has allowed BACH researchers to identify disparities and quantify contributions to social disparities in a number of health conditions including urologic conditions (e.g. nocturia, lower urinary tract symptoms, prostatitis), type 2 diabetes, obesity, bone mineral content and density, and physical function. BACH I data are available through the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Central Repositories (www.niddkrepository.org). Further inquiries can be made through the New England Research Institutes Inc. website (www.neriscience.com/epidemiology).