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Diane Newman: Welcome to UroToday. I am Diane Newman, medical director of the website and also a continence nurse practitioner. With me today is a colleague of mine, Dr. Ariana Smith. She's a urologist at the University of Pennsylvania, and I asked her to present some really cutting-edge and recent data on bladder health that was presented to the International Continence Society. Welcome, Ariana.

Ariana Smith: Thank you, Diane. It's such a pleasure to be back with you on UroToday. This is such a fabulous website. I know I've learned so much from my colleagues on this website, so I'd like to give back and teach everyone a little bit about what we've learned about bladder health through the PLUS Consortium.

So what I'm going to do is share with you today the slides that were presented at the International Continence Society meeting. These were recently presented in Madrid this year. And it's really exciting work. So the title of our work is "Bladder Health in US Women: Population-Based Estimates from RISE FOR HEALTH." And this study describes the distribution of bladder health using a new tool. And this new tool was specifically designed for this purpose—to measure bladder health in the population. And you'll notice there are 24 authors on this study. And that's because it takes a multidisciplinary village to do this work well. And I really do want to thank all 24 of those authors—including yourself, Diane—for their valuable contributions to this work.

Our study was funded by the NIDDK as part of the Prevention of Lower Urinary Tract Symptoms Research Consortium, which we refer to as the PLUS Consortium.

So, by way of background, I just want to review the definition of bladder health since this is really, really getting out there to the public. Bladder health is a complete state of physical, mental, and social well-being related to bladder function, and it's not merely the absence of lower urinary tract symptoms. Healthy bladder function permits daily activities, adapts to short-term physical and environmental stressors, and allows optimal well-being so that one can accommodate travel, exercise, social events, occupational activities, as well as other activities in daily life.

So our PLUS Research Consortium developed and validated a tool to measure bladder health. It's called the Bladder Health Scales and Bladder Function Indices. And this tool has 10 scales shown in the first column. And each scale is made up of a few questions to measure an individual's perception of their bladder and how well it works in various situations, like on their job, during physical activity, during intimacy and travel, and how the bladder impacts their life. The tool also has six bladder function indices listed in the center column that measure how well the bladder functions—essentially, how well it holds urine without leaking and how well it empties urine and gets it all out. The tool also captures adaptive or coping behaviors that an individual engages in that may be improving their perception of bladder health—things like wearing or carrying incontinence pads, toilet mapping, and staying close to the toilet.

So RISE FOR HEALTH is a population-based cohort study of adult women, and this study was designed to measure bladder health. Specifically, the goals were to better understand the risk factors for bladder health and to estimate the range or the distribution of bladder health in the US population. The study was designed around the nine research centers that are part of the PLUS Consortium, and these are throughout the United States, as shown on the map in the upper right-hand corner. And this includes our site, the University of Pennsylvania.

So we used random probability-based sampling with the goals of enrolling a regionally representative sample of women that mimic the racial and ethnic distribution of women in the United States to make our study more applicable to all women in the US. So women then enrolled by completing questionnaires—either online or on paper—and baseline data was collected between May of 2022 and May of 2023. But this study is ongoing, and new data is being collected all the time.

So the aim of this analysis that I'm going to share with you today is to describe the distribution of multiple dimensions of bladder health and bladder function in US women. So first, I want to describe this overall in our whole population that we were able to recruit. And as a secondary goal, I want to describe the distribution of bladder health among women who do not report urinary symptoms. So essentially, I want to look at the higher end of the bladder health spectrum.

And we chose to do this because several studies have looked at the lower end of bladder health, essentially women with lower urinary tract symptoms. But really, no studies have looked at preclinical LUTS or suboptimal bladder health. And we hypothesized that suboptimal bladder health characteristics captured by our new bladder health tool would identify women at greater risk of developing LUTS in the future. So to fall into the category of women without LUTS, you had to void less than eight times a day and less than two times per night, deny urgency, deny incontinence, and deny poor emptying of the bladder, and report no history of recurrent urinary tract infections or bladder cancer.

So what did we find? 50,367 invitations were mailed using our targeted random sampling around our nine research centers. 3,422 participants responded, for a 7.9% response rate, and 3,017 were eligible for this analysis, meaning they met the inclusion criteria, and they completed their bladder health scales and bladder function indices questionnaires. The mean age of our sample was 49.8 years, and 97.8% lived in urban areas, consistent with the sampling frame that we'd used for this study.

So with respect to ethnicity and race, 15.3% of our participants self-identified as Hispanic of any race, 5.9% as non-Hispanic Asian, 12.3% as non-Hispanic Black, 62.9% as non-Hispanic white, and 2.6% as non-Hispanic with multiple racial identities. So, as you can see, we did a really great job achieving racial and ethnic diversity in this study. With respect to BMI, 36.2% were healthy weight, 26.9% were overweight, and 34.9% were obese. 43.2% reported they were premenopausal, 8.7% perimenopausal, and 48.1% postmenopausal.

So the distributions of the first five of the 10 bladder health scales are shown here on this slide. The unadjusted score is in the left column, and the adjusted for adaptive behavior score is shown in the right column. A downward adjustment in score was made if participants were carrying or wearing incontinence pads, if they were toilet mapping, or if they were staying close to the toilet. So the mean global perception of bladder health score in the top row was 72 out of a possible 100 points, and this was before adjustment for adaptive or coping behaviors, and it was 55 points after adjustment.

The domain-specific bladder health scores below this tended to be higher than the global score, and higher scores were observed for social-occupational bladder health and physical activity-related bladder health. Higher scores were also seen for the intimacy scale, shown here on the top row, the emotional scale, and the perception scale, which measured perceived impact of the bladder on daily life. These all had unadjusted scores with medians of 90 to 100 points. The adjusted scores in the right column were more distributed with lower median scores, and this adjustment in score took into account that participants were using some type of adaptive behavior that may be lessening the impact of bladder symptoms on their day-to-day life.

The distribution of the total average bladder function indices and the six individual bladder function indices are shown here. The median total bladder function index was 77 points out of 100, and scores for the six individual bladder function indices were variable, with median scores ranging from 63 for urinary frequency, urinary sensation, and urinary continence indices to 68 for emptying indices, up to 100 for urinary tract infection and biosis indices. And a bimodal distribution was commonly seen among these functional indices, with a predominance favoring healthy function—that is, scores approaching 100—and a smaller rise around 50 to 60 points, indicating a little bit less healthy function.

When we focus specifically on the 23% of participants without lower urinary tract symptoms in our studies—these are in the right two columns on this slide—mean and median scores were higher across all bladder health scales, indicating better bladder health, as you would expect. However, even in participants who reported they did not experience lower urinary tract symptoms, the bladder health scores—they weren't perfect. The median global bladder health score was 88 points before adjustment and 82 points after adjustment. Scores were higher for all the domain-specific scales, with medians ranging from 91 to 100 points before adjustment and 86 to 100 after, demonstrating a range of bladder health, even among those without reports of lower urinary tract symptoms.

Scores were also higher for the bladder function indices in participants without LUTS, with median overall scores of about 93 points. Interestingly, 68% of participants in RISE FOR HEALTH reported using adaptive or coping behaviors related to the bladder, including 40% who reported using pads, liners, or absorbent underwear. 58% reported finding the bathroom everywhere they went, or something we've termed toilet mapping, and 3% reported staying as close to a bathroom as possible when they're away from home. Now, despite their lack of LUTS and really overall good bladder function, 38% of the participants in the subset without LUTS also reported using adaptive or coping behaviors, including 11% who reported using pads, 30% were toilet mapping, and 2% were staying as close to the bathroom as possible when they were away from home.

So in conclusion, the RISE FOR HEALTH study demonstrated a broad spectrum of bladder health, ranging from poor or low scores to optimal, close-to-100-point scores in US women. We demonstrated high utilization of adaptive and coping behaviors—that is, using pads and toilet mapping—even among women without LUTS. The higher bladder health scores and bladder function indices and those without LUTS was a good sign that we were capturing a healthier population. Yet, we even found that these were not perfect scores. And this supports a concept that bladder health exists on a continuum, and there is a range of bladder health. And we can start shifting focus away from just lower urinary tract symptoms and start to focus on women with subclinical bladder experiences or behaviors where we may be able to intervene and maybe even prevent. And this would be a novel population that is ripe for prevention efforts.

Now, we do need more prospective studies to determine if, in fact, this suboptimal bladder health is a risk factor for future LUTS, but we've laid the foundation with the work we've presented here today. So thank you, Diane. Here are the acknowledgments of my co-investigators throughout the PLUS Consortium. And I want to thank you for having me on today to talk about this.

Diane Newman: Thank you very much. That was real. I mean, of course, I find this very fascinating. I'm just still struck by the fact of the number of women without LUTS who are still wearing pads. That's 1 out of 10. I mean, we all say, well, they maybe use them just in case because they had a previous accident. But I don't think that's the case. I think women are just using pads, and I just, I don't know, I don't quite understand why it would be that high really. That's one of the things that I really found fascinating about this.

Ariana Smith: I think all of the adaptive behaviors that we studied in RISE FOR HEALTH are really fascinating and really add to the existing literature. There's very little about what women are doing every day. But not only are they wearing and carrying these pads, but they're looking for toilets everywhere they go. And it's a small percentage, but nonetheless, 2% to 3% of women were not going places. They were staying close to a toilet all the time because of their bladder. These are things we need to improve. These are things we have to make better for women so that they can leave the house, and they can work, and they can live.

Diane Newman: Do you agree with the fact of us adding in that adaptive behavior looking at the data with and without? I mean, that was a big discussion within our group for, I think, over a year or two.

Ariana Smith: Yeah, I mean, I think this is a really tough concept. I mean, you certainly could figure a way to measure it as part of the primary instrument, but I think, at the end of the day, the results would be very much the same. So either you're calculating it into the original score of 0 to 100, or you're using it to decrease the score afterwards. And either way, if people are engaging in these types of behaviors, their bladder health is compromised. It's certainly not as good as it was looking without taking into account these factors.

So I think we did a good thing in the consortium by measuring these. And whether we refine the scoring over time or not, I think we're still committed to understanding why women are adapting and coping, and what it is about their bladder that is leading them to do that, so we can improve these factors for women.

Diane Newman: Yeah, and I think the real big strength of our study is the fact that we have women across the lifespan. I think that's so very important. So I'm sure that we're going to have much more that will come out of this data, as far as looking at the different areas that we surveyed them on.

Ariana Smith: Yeah, I'm so glad you said that because, remember, our primary goal for RISE FOR HEALTH was to study risk and protective factors for bladder health and LUTS. So there's so much more work that's going to come out of the PLUS Consortium. I mean, I hope we get to 100 manuscripts because we certainly have that many things we were interested in writing about. And I think that the data will really help to lay the foundation for future prevention studies—things that really we can intervene on to make bladder health better.

Diane Newman: Yeah, I agree. Thank you so much. This was so informative, and I know our viewers are going to love this, so thanks.

Ariana Smith: Thank you, Diane.