A Randomized Controlled Trial to Compare 2 Scalable Interventions for Lower Urinary Tract Symptom Prevention: Main Outcomes of the TULIP Study

Developing a urinary incontinence primary care pathway: a mixed methods study

BACKGROUND

While nearly 50% of adult women report at least one episode of urinary incontinence (UI), most never receive treatment.

OBJECTIVE

To better integrate primary and specialty UI care, we conducted (i) an environmental scan to assess the availability of key pathway resources in primary care, (ii) interviews with primary care providers to understand barriers to care, and (iii) a pilot UI care pathway intervention.

METHODS

Environmental scan: Clinic managers from all primary care clinics within a Midwestern healthcare system were invited to participate in an interview covering the availability of clinic resources. Provider interviews: Primary care providers were invited to participate in an interview covering current practices and perceived barriers to UI care. Pilot UI care pathway: Patients who screened positive for UI were provided resources for first-line behavioral management. Pilot patients completed questionnaires at baseline, 8 weeks, and 6 months.

RESULTS

While many clinics had point-of-care urinalysis (17/21, 81%), most did not have a working bladder ultrasound (14/21, 67%) or on-site pelvic floor physical therapy (18/21, 86%). Providers (n = 5) described barriers to completing almost every step of diagnosis and treatment for UI. The most persistent barrier was lack of time. Patients (n = 15) reported several self-treatment strategies including avoiding bladder irritants (7/15, 47%) and performing Kegel exercises (4/15, 27%). Five patients (33%) requested follow-up care. At 6 months, patients reported small improvements in UI symptoms.

CONCLUSION

Promising results from a novel UI care pathway pilot indicate that streamlining UI care may assist primary care providers in the first-line treatment of UI.

Bladder Health Knowledge, Attitudes, and Beliefs among US Adolescent Women

STUDY OBJECTIVE

Lower urinary tract symptoms (LUTS) can have a pronounced impact on adolescent women's overall health and quality of life, both during adolescence and across the life course. Little research has examined adolescent women's knowledge, attitudes, and beliefs about bladder health and preventing LUTS.

METHODS

This study combines data from two large multi-site focus group studies of individuals born female who identified as women conducted by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. The first study included data from 8 focus groups conducted in 2018 with 44 adolescents aged 11 through 17 years. The second consisted of data from 20 focus groups conducted in 2020 with 123 adolescents aged 13 through 17 years. We used directed content analysis, including deductive and inductive approaches, to explore textual data and identify emergent insights. We present themes that emerged from analyzing coded data related to knowledge, attitudes, and beliefs.

RESULTS

Themes included: (1) lack of information about bladder function, leading to limited knowledge, (2) hydration as a healthy behavior, (3) distinguishing healthy versus unhealthy voiding, (4) social and environmental barriers to voiding, and (5) shame and stigma of bladder related behaviors.

CONCLUSION

Our data suggests that adolescent women are aware of healthy and unhealthy behaviors related to bladder health, despite little exposure to formal education about the bladder. Social and environmental factors, including stigma, appear to be primary drivers of adolescents' behaviors around bladder health, suggesting that multi-level socio-ecological prevention interventions are needed to prevent LUTS in this population.

Reducing Falls in Older Women with Urinary Incontinence

Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

Preferences for Public Health Messaging Related to Bladder Health in Adolescent and Adult Women

Objective: The purpose of this analysis was to explore adolescent and adult women's preferences for the content and delivery of public health messaging around bladder health. Materials and Methods: This was a directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course. This article reports an analysis of the "Public Health Messaging" code, which includes participants' views on what information is needed about bladder health, attributes of messaging, and preferred locations and delivery methods. Results: Forty-four focus groups were conducted with 360 participants (ages 11-93 years) organized into six age groups. Across age groups, participants wanted messaging on maintaining bladder health and preventing bladder problems. They offered suggestions for a wide variety of methods to deliver bladder health information. Ideas for delivery methods fell into three broad categories: (1) traditional in-person modes of delivery, which included individual communication with providers in clinical settings and group-based methods in schools and other community settings where adolescent and adult women naturally gather; (2) internet-based website and social media delivery methods; and (3) static (noninteractive) modes of delivery such as pamphlets. Participants recommended the development of multiple delivery methods to be tailored for specific audiences. Conclusions: These findings can inform development of broad ranging public health messaging tailored to audiences of all ages with a goal of engaging adolescent and adult women across the bladder health risk spectrum.

Postmenopausal women's adherence to pelvic floor muscle exercises over 2 years

OBJECTIVE

This study aimed to investigate women's adherence patterns to pelvic floor muscle exercises (PFME), their associated factors and within-pattern changes.

METHODS

This was a secondary analysis using data collected from 647 women aged 55 years and older in the USA. Women were randomly assigned to either a 2-h class group or an equivalent content 20-min DVD group to receive PFME complemented with adherence enhancement strategies. Adherence was assessed at 3, 12 and 24 months using three self-reported items matching PFME parameters. The k-mean clustering and multinomial logistic regression were used to investigate adherence patterns and their associated factors, respectively. Descriptive statistics were used for within-pattern changes over time.

RESULTS

Four adherence patterns, A, B, C and D, were identified. Women who displayed optimal adherence to all three aforementioned items, i.e. adherence pattern A, constituted 49.1%, 38.2% and 37.2% of women at 3, 12 and 24 months, respectively. Women with income > US$100,000 were more likely to display adherence pattern A within 12 months. Of women who had adherence pattern A at 3 months, 63.9% and 49.2% continued in this pattern at 12 and 24 months.

CONCLUSIONS

Fewer than half of women displayed adherence pattern A for 2 years. Early optimal adherence predicted women's subsequent optimal adherence.

Reasons Behind Preferences for Community-Based Continence Promotion

OBJECTIVES

This study aimed to understand the potential reach of continence promotion intervention formats among incontinent women.

METHODS

The Survey of the Health of Wisconsin conducts household interviews on a population-based sample. In 2016, 399 adult women were asked about incontinence and likelihood of participation in continence promotion via 3 formats: single lecture, interactive 3-session workshop, or online. Descriptive analyses compared women likely versus unlikely to participate in continence promotion. To understand format preferences, modified grounded theory was used to conduct and analyze telephone interviews.

RESULTS

One hundred eighty-seven (76%) of 246 incontinent women reported being likely to attend continence promotion: 111 (45%) for a single lecture, 43 (17%) for an interactive 3-session workshop, and 156 (64%) for an online program. Obesity, older age, nonwhite race, prior health program participation, and Internet use for health information were associated with reported continence promotion participation. Cited advantages of a single lecture included convenience and ability to ask questions. A workshop offered accountability, hands-on learning, and opportunity to learn from others; online format offered privacy, convenience, and self-directed learning.

CONCLUSIONS

Most incontinent women are willing to participate in continence promotion, especially online.

Vitamin D Intake and Progression of Urinary Incontinence in Women

OBJECTIVE

To determine if vitamin D intake is associated with reduced progression of urgency urinary incontinence (UI) in women.

METHODS

We used the Nurses' Health Study (NHS) I and NHSII cohorts to evaluate the association of vitamin D intake with progression of urgency UI and mixed UI, from mild-moderate to severe symptoms, from 2004 to 2012 (NHS) and 2005-2013 (NHSII). Intake of vitamin D at study baseline was categorized and updated at the start of each 2-4 year follow-up period. Multivariable-adjusted relative risks (RRs) and 95% confidence intervals (95% CI) of progression to severe UI were estimated using Cox proportional hazard models.

RESULTS

At baseline, of the 20,560 older women (age range 58-73 years) in NHS I with mild/moderate urgency or mixed UI, 21% reported oral vitamin D intake of at least 800 IU per day. Among 12,573 middle-aged women (age range 42-59) in NHS II with mild/moderate urgency or mixed UI, 17% reported oral vitamin D intake of at least 800 IU daily. From 2004 to 2012, 4853 incident cases of urgency/mixed UI progression were identified among older women. From 2005 to 2013, 1378 incident cases of urgency/mixed UI progression were identified among middle-aged women. After multivariable adjustment, no significant associations between vitamin D intake and incidence of urgency/mixed UI progression were observed in either cohort (RR = 1.10, 95% CI 0.99-1.23 in older women, RR = 0.88, 95% CI 0.71, 1.10 in middle-aged women).

CONCLUSION

Despite interest in vitamin D as a low-cost strategy to prevent or reduce UI, our findings indicate oral vitamin D may not reduce urgency/mixed UI progression.

Effects of unsupervised behavioral and pelvic floor muscle training programs on nocturia, urinary urgency, and urinary frequency in postmenopausal women: Secondary analysis of a randomized, two-arm, parallel design, superiority trial (TULIP study)

OBJECTIVE

To determine and compare the effects of an unsupervised behavioral and pelvic floor muscle training (B-PFMT) program delivered in two formats on nocturia, urinary urgency, and urinary frequency in postmenopausal women.

STUDY DESIGN

A secondary analysis used data collected from women enrolled in the TULIP study. Women aged 55 years or more with no urinary incontinence were provided the B-PFMT program. Each woman was randomly assigned to a face-to-face class that took about 2 h (2-hrClass) or to a DVD showing essentially the same information as a 20-minute video (20-minVideo). All women were instructed to independently continue the program following their education session. Three urinary outcomes were assessed at baseline, 3, 12, and 24 months.

MAIN OUTCOME MEASURES

Nocturia and urinary urgency were examined with one item each from the questionnaire-based voiding diary, and urinary frequency was assessed with patients' self-documenting 3-day bladder diary.

RESULTS

Women in the 2-hrClass group experienced significantly fewer nocturia episodes and longer average inter-void interval at each follow-up and fewer urinary urgency episodes at 12 months. Women in the 20-minVideo group experienced significantly fewer episodes of nocturia and urinary urgency and longer average inter-void interval at each follow-up time point. No significant between-group differences were found for any outcome, except for nocturia at 24 months, when effectiveness favored women in the 20-minVideo group.

CONCLUSIONS

Unsupervised B-PFMT programs are effective for improving postmenopausal women's urinary outcomes regardless of the format. The optimal format to deliver B-PFMT programs in terms of effectiveness should be explored in future studies.

It's About Time: The Temporal Burden of Lower Urinary Tract Symptoms Among Women

This secondary analysis studied 50 transcripts of women who shared day-to-day experiences of lower urinary tract symptoms (LUTS) and characterized temporal (time-associated) features of living with LUTS. Findings revealed two overarching time-associated themes: The Complexity of LUTS and The Quest for Empowerment over LUTS. Findings suggest that the temporal burden of LUTS is the accumulated impact of symptoms and symptom management on women's daily lives within multiple contexts across the life course. Increasing nurses' knowledge of the temporal context of LUTS may heighten awareness and improve symptom detection and management.

After the Randomized Trial: Implementation of Community-Based Continence Promotion in the Real World

BACKGROUND/OBJECTIVES

Most women aged 65 and older have incontinence, associated with high healthcare costs, institutionalization, and negative quality of life, but few seek care. Mind over Matter: Healthy Bowels, Healthy Bladder (MOM) is a small-group self-management workshop, led by a trained facilitator in a community setting, proven to improve incontinence in older women.

DESIGN

We used mixed methods to gather information on the real-world adoption, maintenance, and implementation of MOM by community agencies following a randomized controlled trial (RCT) that tested intervention effects on incontinence.

SETTING

Community agencies serving older adults in six Wisconsin communities.

PARTICIPANTS

Community agency administrators and facilitators trained to offer MOM for the RCT.

MEASUREMENTS

Investigators tracked rates of adoption (offering MOM in the 12 months following the RCT) and maintenance (offering MOM more than once in the next 18 months) in six communities. Individual interviews and focus groups (N = 17) generated qualitative data about barriers and facilitators related to adoption and maintenance. Trained observers assessed implementation fidelity (alignment with program protocol) at 42 MOM sessions.

RESULTS

A total of 67% of communities (four of six) adopted MOM, and 50% (three of six) maintained MOM. No implementation fidelity lapses occurred. Facilitators of adoption and maintenance included MOM's well-organized protocol and lean time commitment, sharing of implementation efforts between partner organizations, staff specifically assigned to health promotion activities, and high community interest in continence promotion. Other than stigma associated with incontinence, barriers were similar to those seen with other community-based programs for older adults: limited funding/staffing, competing organizational priorities, challenges identifying/training facilitators, and difficulty engaging community partners/participants.

CONCLUSION

Using design for dissemination and community engagement, assessment of implementation outcomes is feasible in conjunction with a clinical RCT. Partner-centered implementation packages can address barriers to adoption and maintenance.

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

AIMS

To determine whether childhood adversity is associated with self-reported lower urinary tract symptoms (LUTS) among older adult women.

METHODS

A convenience sample of women (≥55 years old) who presented to an academic urology practice or who had participated in a previous bladder health prevention study completed questionnaires including the LUTS Tool (on frequency and bother of LUTS), the Adverse Childhood Experiences (ACEs) Questionnaire, the Spielberger State-Trait Anxiety Inventory, and the Center for Epidemiologic Studies Depression Scale.

RESULTS

The average age (SD) of participants (N = 151) was 64.7 (6.9) years. The total number of ACEs predicted the total number of LUTS, β = .39 (95% confidence interval [CI] = 0.14, 0.64), P = .003, as well as LUTS frequency, β = .09 (95% CI = 0.04, 0.13), P < .001. ACEs predicted bother for nocturia, β = 0.12 (95% CI = 0.03, 0.22), P = .008. Negative affect symptoms did not mediate the relationship between the total number of ACEs and the total number of LUTS. Rather, ACEs predicted LUTS and negative affect symptoms through (at least partially) independent pathways. Analyses controlled for tobacco use, number of vaginal deliveries, hypertension, overactive bladder medication use, body mass index, income, and race because these variables were significantly associated with the total number of ACEs or total number of LUTS.

CONCLUSIONS

Childhood adversity has an enduring impact on risk for LUTS in adulthood even when controlling for potential confounds and this relationship cannot be explained by negative affect symptoms.

Small-Group, Community-Member Intervention for Urinary and Bowel Incontinence: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of Mind Over Matter: Healthy Bowels, Healthy Bladder, a small-group intervention, on urinary and bowel incontinence symptoms among older women with incontinence.

METHODS

In this individually randomized group treatment trial, women aged 50 years and older with urinary, bowel incontinence, or both, were randomly allocated at baseline to participate in Mind Over Matter: Healthy Bowels, Healthy Bladder immediately (treatment group) or after final data collection (waitlist control group). The primary outcome was urinary incontinence (UI) improvement on the Patient Global Impression of Improvement at 4 months. Validated instruments assessed incontinence, self-efficacy, depression, and barriers to care-seeking. Intent-to-treat analyses compared differences between groups. Target sample size, based on an anticipated improvement rate of 45% in treated women vs 11% in the control group, 90% power, type I error of 0.05, with anticipated attrition of 25%, was 110.

RESULTS

Among 121 women randomized (62 treatment group; 59 control group), 116 (95%) completed the 4-month assessment. Most participants were non-Hispanic white (97%), with a mean age of 75 years (SD 9.2, range 51-98); 66% had attended some college. There were no significant between-group differences at baseline. At 4 months, 71% of treated women vs 23% of women in the control group reported improved UI on Patient Global Impression of Improvement (P<.001); 39% vs 5% were much improved (P<.001). Regarding bowel incontinence, 55% of treated women vs 27% of women in the control group improved on Patient Global Impression of Improvement (P<.005), with 35% vs 11% reporting much improvement (P<.005). Treated women improved significantly more than women in the control group on all validated instruments of incontinence severity, quality of life, and self-efficacy. Care-seeking rates were similar between groups.

CONCLUSION

Participation in a small-group intervention improves symptoms of both urinary and bowel incontinence in older women. Mind Over Matter is a feasible model with potential to bring effective behavioral solutions to the community.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03140852.

Self-Perceived Improvement in Bladder Health After Viewing a Novel Tutorial on Knack Use: A Randomized Controlled Trial Pilot Study

Purpose: To test a novel bladder health tutorial on use of the Knack for overcoming bladder control challenges. The Knack-tutorial is a self-administered vignette-based instructional program on preempting bladder challenges in daily life (urgency, stress-leakage, or urge-leakage) through anticipatory, well-timed pelvic floor muscle contraction at the moment of challenge. Materials and Methods: This is a randomized controlled trial pilot test of 108 women with stress or mixed urinary incontinence. The Knack-tutorial group saw a 15-minute slide show with 10 vignettes portraying use of the Knack in daily life. The slide show format used inserted narrated videos, dubbed and animation enhanced pictures and cartoons, and automatic slide advancement. A control group saw a similarly constructed slide show on incorporating good diet/exercise habits. Outcomes were self-perceived improvement (yes/no, and as 0%-100%) 1 month after viewing the tutorial. Results: We enrolled 123 women, randomizing 64 to Knack-tutorial group and 59 to diet/exercise tutorial group. Eleven and one participant, respectively, did not return. Three did not fill out the self-perceived improvement report. Significant improvement was reported by 71% in the Knack-tutorial group compared to 25% in the diet/exercise group (p < 0.001). Self-perceived improvement was 21%-22% higher (Model I Est: 21.01, SE: 4.25, p < 0.001) in the Knack-tutorial group. Conclusions: An electronic tutorial viewed independent of a health care provider with vignettes showing Knack application to manage the everyday bladder challenges women face shows benefit of a magnitude that warrants more widespread use and rigorous testing. A professional remake of the intervention is now available (www.myconfidentbladder.com).

Review of the 6th International Consultation on Incontinence: Primary prevention of urinary incontinence

AIMS

To report the state of the science on primary prevention of urinary incontinence (UI) in adults from the 6th International Consultation on Incontinence with an update through January 2019.

METHODS

Online databases PubMed, CINAHL, PsycInfo, and Medline were searched in March 2016 and February 2019 with a focus on literature published after 2010. The International Consultation on Urological Diseases modified Oxford Centre for Evidence-Based Medicine Levels of Evidence and grades of recommendation were used to evaluate the literature.

RESULTS

Grade B recommendations to prevent UI in pregnant and postpartum women are available and promising evidence exists for educational interventions to prevent UI up to 2 years in older women. There is little evidence for adding preoperative pelvic floor muscle exercises to postprostatectomy pelvic floor muscle exercises for men to regain continence. Insufficient evidence exists for the effectiveness of screening for UI in women. The absence of information on primary prevention remains for adolescents, nulliparous and perimenopausal women, and middle-aged and aged men and women.

CONCLUSIONS

Few primary prevention interventions for UI exist for specific populations, especially pregnant and postpartum women. Research interest in developing foundational knowledge to design these interventions is growing.

Feasibility and outcomes: Pilot Randomized Controlled Trial of a home-based integrated physical exercise and bladder-training program vs usual care for community-dwelling older women with urinary incontinence

AIMS

To assess the feasibility of a randomized controlled trial of a home-based integrated physical exercise and bladder-training program vs usual care in community-dwelling women with urinary incontinence (UI).

METHODS

We conducted a parallel arm, nonblinded, pilot randomized controlled trial of a home-based integrated physical exercise and bladder training with urge suppression and fall prevention program (ExerciseUP) vs usual care in women aged 65 and older with UI. Outcomes included feasibility (process, resources, management, and acceptability), urinary symptoms, and falls risk using self-administered questionnaires. Objective physical activity was measured using accelerometry.

RESULTS

A total of 37 of 38 (97%) eligible women were willing to participate in the study. In the ExerciseUP intervention cohort, 17 of 19 (89%) women completed all 6 weeks of intervention and follow-up, and 16 of 18 (89%) women in the usual group completed follow-up. Ten (53%) women in the ExerciseUP group achieved at least 70% adherence to exercise prescription. The improvement in UI severity scores from baseline was greater in the ExerciseUP intervention group than the usual care group (- 6.2 ± 5.8 vs - 2.4 ± 4.2, P = 0.04). Fall-risk score decreased (improved) in both groups. There were no significant between-group differences in change in physical activity or sedentary behavior.

CONCLUSIONS

We determined that it would be feasible to conduct a home-based exercise intervention in older women with UI. Our clinical outcomes were modestly favorable for the ExerciseUP intervention group.

Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women: A Randomized Clinical Trial

IMPORTANCE

Urinary incontinence (UI) guidelines recommend behavioral interventions as first-line treatment using individualized approaches. A one-time, group-administered behavioral treatment (GBT) could enhance access to behavioral treatment.

OBJECTIVE

To compare the effectiveness, cost, and cost-effectiveness of GBT with no treatment for UI in older women.

DESIGN, SETTING, AND PARTICIPANTS

Multisite randomized clinical trial (the Group Learning Achieves Decreased Incidents of Lower Urinary Symptoms [GLADIOLUS] study), conducted from July 7, 2014, to December 31, 2016. The setting was outpatient practices at 3 academic medical centers. Community-dwelling women 55 years or older with UI were recruited by mail and screened for eligibility, including a score of 3 or higher on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), symptoms of at least 3 months' duration, and absence of medical conditions or treatments that could affect continence status. Of 2171 mail respondents, 1125 were invited for clinical screening; 463 were eligible and randomized; 398 completed the 12-month study.

INTERVENTIONS

The GBT group received a one-time 2-hour bladder health class, supported by written materials and an audio CD.

MAIN OUTCOMES AND MEASURES

Outcomes were measured at in-person visits (at 3 and 12 months) and by mail or telephone (at 6 and 9 months). The primary outcome was the change in the ICIQ-SF score. Secondary outcome measures assessed UI severity, quality of life, perceptions of improvement, pelvic floor muscle strength, and costs. Evaluators were masked to group assignment.

RESULTS

Participants (232 in the GBT group and 231 in the control group) were aged 55 to 91 years (mean [SD] age, 64 [7] years), and 46.2% (214 of 463) were African American. In intent-to-treat analyses, the ICIQ-SF scores for GBT were consistently lower than control across all time points but did not achieve the projected 3-point difference. At 3 months, the difference in differences was 0.96 points (95% CI, -1.51 to -0.41 points), which was statistically significant but clinically modest. The mean (SE) treatment effects at 6, 9, and 12 months were 1.36 (0.32), 2.13 (0.33), and 1.77 (0.31), respectively. Significant group differences were found at all time points in favor of GBT on all secondary outcomes except pelvic floor muscle strength. The incremental cost to achieve a treatment success was $723 at 3 months; GBT dominated at 12 months.

CONCLUSIONS AND RELEVANCE

The GLADIOLUS study shows that a novel one-time GBT program is modestly effective and cost-effective for reducing UI frequency, severity, and bother and improving quality of life. Group-administered behavioral treatment is a promising first-line approach to enhancing access to noninvasive behavioral treatment for older women with UI.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02001714.

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.

A Novel Research Definition of Bladder Health in Women and Girls: Implications for Research and Public Health Promotion

BACKGROUND

Bladder health in women and girls is poorly understood, in part, due to absence of a definition for clinical or research purposes. This article describes the process used by a National Institutes of Health funded transdisciplinary research team (The Prevention of Lower Urinary Tract Symptoms [PLUS] Consortium) to develop a definition of bladder health.

METHODS

The PLUS Consortium identified currently accepted lower urinary tract symptoms (LUTS) and outlined elements of storage and emptying functions of the bladder. Consistent with the World Health Organization's definition of health, PLUS concluded that absence of LUTS was insufficient and emphasizes the bladder's ability to adapt to short-term physical, psychosocial, and environmental challenges for the final definition. Definitions for subjective experiences and objective measures of bladder dysfunction and health were drafted. An additional bioregulatory function to protect against infection, neoplasia, chemical, or biologic threats was proposed.

RESULTS

PLUS proposes that bladder health be defined as: "A complete state of physical, mental, and social well-being related to bladder function and not merely the absence of LUTS. Healthy bladder function permits daily activities, adapts to short-term physical or environmental stressors, and allows optimal well-being (e.g., travel, exercise, social, occupational, or other activities)." Definitions for each element of bladder function are reported with suggested subjective and objective measures.

CONCLUSIONS

PLUS used a comprehensive transdisciplinary process to develop a bladder health definition. This will inform instrument development for evaluation of bladder health promotion and prevention of LUTS in research and public health initiatives.

Nonbiologic factors that impact management in women with urinary incontinence: review of the literature and findings from a National Institute of Diabetes and Digestive and Kidney Diseases workshop

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI)-defined as a complaint of involuntary loss of urine-is common in women, with major public health, financial, and quality of life (QoL) implications. Despite the high toll of UI and the availability of effective conservative treatments, many women with UI do not seek care. Those who do often continue to experience symptoms. Improving UI treatment may require a comprehensive approach to urology research, including a broad set of potentially influential factors beyond biologic.

METHODS

To explore the effects of nonbiologic factors (NBF) on UI management and treatment response, the National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop for clinical and psychosocial researchers. Participants proposed a UI treatment pathway: recognizing the problem, willingness to seek treatment, access to care, receiving quality treatment, engaging in self-management, and adhering to chosen treatments; discussed potential NBFs that may affect the pathway; and identified areas for future research. After the meeting, a rapid literature review was conducted to assess the current state of research on NBFs in women with UI.

RESULTS

Participants identified several patient-level NBFs that may influence the UI management pathway, including QoL and perceived bother; stigma, shame, and embarrassment; knowledge and perceptions; social determinants of health; cultural and language characteristics; personal characteristics and skills; and physical abilities. Additionally, participants acknowledged that provider- and system-level factors also play a role and likely interact with patient-level factors.

CONCLUSIONS

NBFs that potentially affect the UI management pathway are not well understood, and a comprehensive, interdisciplinary approach to research is needed to understand and appropriately support effective UI treatment.