Common in both men and women, lower urinary tract symptoms (LUTS) include urinary incontinence (UI), daytime and nocturnal frequency with or without urgency, difficulty urinating or emptying the bladder, and pain associated with bladder filling and emptying. Unfortunately, the social stigma and misperceptions surrounding LUTS prevent many people from seeking treatment, creating a significant but underacknowledged public health burden. This article reviews LUTS as a public health problem and discusses how nurses can work within the healthcare system and with community health educators to improve care and outcomes.

Beyond their impact on quality of life, LUTS may have important public health consequences. People with LUTS tend to be less physically active than those with normal bladder function. Many women describe their symptoms as a barrier to physical activity and thus a cause of weight gain. Decreased physical activity helps explain the strong association between UI and obesity and diabetes in women. Also, diuretics exacerbate LUTS and may decrease adherence to commonly prescribed cardiovascular medications. In addition, in older adults, nocturia and urgency are linked to increased risk for falls and fractures. LUTS also may contribute to social isolation.

Underacknowledged and undertreated

Although treatable, LUTS may go untreated largely because payers, policy makers, and other key healthcare players don’t recognize the symptoms, even when individuals present for care. Many people with symptoms don’t even seek care, creating another barrier to treatment. Several studies of patients with LUTS across multiple cultures show that no more than one-third seek treatment. Those with multiple symptoms are the most likely to seek treatment, but even among people with three or more symptoms, fewer than one-third seek treatment.

Lack of care-seeking may lead to negative coping behaviors, such as restricting fluids, avoiding physical activity, and not adhering to diuretic medications. Although more pronounced LUTS severity and inconvenience are associated with greater care-seeking, they don’t fully explain individual choices to seek or not seek treatment.

Misperceptions about LUTS—such as believing the symptoms are normal, temporary, an unavoidable consequence of aging or childbirth, not a medical problem, or not treatable—are common across diverse countries and cultures. Other barriers to seeking care include embarrassment and certain social determinants of health (such as low socioeconomic status and limited healthcare access).

Despite the high prevalence of LUTS, many sufferers—especially those with UI—experience considerable social stigma. In a study of 150 healthy Austrian adults, most considered UI to be taboo and more embarrassing than depression or cancer. The stigma may stem from societal norms around toileting—including punishment for wetting accidents in children and association of LUTS with uncleanliness, lack of self-control, childishness, and frailty. (See Did you know? )

Treatment

A positive treatment response is based on reduction of the disruptive symptoms (for example, frequent urination or UI) as well as maintenance or restoration of physical and social activities. First-line treatment for most patients with LUTS includes self-directed behavioral strategies, such as altering the quantity and types of fluids they consume, avoiding acidic and spicy foods, urinating on a schedule (timed voiding) rather than waiting for a strong desire, gradually increasing the time interval between urinations (bladder training), and strengthening the pelvic-floor muscles (Kegel exercises) to help maintain continence.

When these behavioral strategies aren’t adequate, a nurse specialist can provide education, coaching, and enhanced pelvic-floor rehabilitation, which may include biofeedback to improve the patient’s ability to contract the correct muscles or electrical stimulation to passively enhance muscle contractions. These behavioral strategies can be effective for management of most LUTS.

In addition to behavioral strategies, and primarily for overactive bladder (OAB) syndrome (urgency with or without urgency incontinence, usually with frequency and nocturia), antimuscarinic medications are prescribed. Also for treatment of OAB syndrome, posterior tibial nerve stimulation can be performed in the provider’s office. In postmenopausal women, topical estrogens are commonly used to treat LUTS associated with genitourinary syndrome of menopause.

For patients who haven’t met their treatment goals with behavioral strategies and medications, in-office intravesical injection of botulinum toxin A is an option. Also, sacral neuromodulation can be used to treat refractory OAB syndrome.

Outpatient surgical options for treating stress UI (leakage with coughing, sneezing, bending, lifting), such as a urethral sling, can restore support to and compress the urethra.

While the goal of all LUTS treatments is to resolve the problem, this may not be realistic given the multiple causes and contributing factors. Realistic expectations on the part of the patient, family, and provider are important. For example, although a provider would hope to clinically resolve a patient’s problem, the patient and her family might be pleased that simply by wearing a  pad, she’s gained the confidence to enjoy socializing again.

Nurse’s role

Over the past two decades, significant efforts have been made to increase LUTS management in the primary care setting. However, the need to manage chronic conditions, such as hypertension, coronary disease, and diabetes in short appointment times leaves no time to identify and manage LUTS, especially when patients may be too embarrassed to admit they have bladder problems.

As a nurse, you can help fill this gap in care by remaining sensitive to and vigilant for potential bladder problems in patients, providing a comfortable environment for them to acknowledge their symptoms, and encouraging them to seek treatment. Letting patients know there are treatment options that don’t involve medications or surgery can be helpful. The holistic perspective of nursing practice can help nurses recognize a bladder problem that’s limiting a patient’s physical or social activities or medication compliance. (See Case study: Nursing actions aid a patient with bladder problems.)

Educate patients about ways to reduce LUTS, including pelvic-floor muscle training for UI, timed voiding to reduce urgency, and limited fluids before bedtime to decrease nocturia. Also encourage them to discuss their symptoms with their primary care provider or a urology specialist and help them advocate on their own behalf.

Community-level intervention

Reaching patients with LUTS may require public health interventions at the community level. Local, interpersonal networks—including faith organizations, barber shops, yoga studios, and other community-based settings—provide a unique opportunity to overcome barriers to seeking treatment. Such networks help normalize LUTS as a common health issue, correct misperceptions by disseminating evidence-based information, and reduce social stigma.

Participation in faith organizations has been linked to improved health. Such organizations increase resilience within communities and may reduce mistrust of the healthcare system. Implementing community-based public health interventions can be challenging, but when well researched and planned, these interventions are effective in addressing stigma and are especially important for populations with poor access to health care.

Efforts to bring LUTS information to the community include those by health ministers. This largely untapped resource has been the focus of recent efforts by the Department of Health and Human Services’ (HHS) Center for Faith-based and Neighborhood Partnerships (Partnership Center) to raise awareness about important health issues. In partnership with the Wesley Theological Seminary in Washington, DC, and several other federal health agencies, the HHS Partnership Center is developing a series of educational documents on a variety of healthcare issues. These health minister guides (including one on bladder health) will fill a void in community health and seminary education. By educating and equipping health ministers—including ordained, certified, and lay health ministers—HHS is building a cadre of public health workers. (See What’s a health minister? )

Nurses in the community

Through organizations like Chi Eta Phi Sorority and One Nurse At A Time, nurses have a long tradition of engaging with their communities to promote public health. The community-based role of nursing is exemplified by the emergence and growth of the faith community nurse, a licensed RN who engages in personal, communal, and multi-sector faith and health interactions. (See Understanding faith community nursing.)

As respected sources of health information, all nurses can play a role in increasing LUTS awareness by emphasizing it at local public health events, such as community health fairs, organized health ministries trainings, and local community centers. You also can advocate for making safe, clean, and accessible bathrooms available in community spaces. And in your day-today life, you have opportunities to identify bladder problems in members of your community by staying alert for potential signs of bladder dysfunction, such as avoidance of physical activity or withdrawal from regular community events.

It takes a community

To help achieve optimal care for patients with LUTS, you can enhance your own and your patients’ awareness of the problem, work for greater recognition of LUTS within the health system, provide patient education, and reduce stigma at the community level. Through both clinical and community roles, nurses have the opportunity to improve LUTS awareness, education, and outcomes. (See Case study: Helping a patient with LUTS in the community.)

Jenna M. Norton and Tamara G. Bavendam work at the National Institute of Diabetes and Digestive and Kidney Disease at the National Institutes of Health in Bethesda, Maryland; Norton is a program manager in the Kidney and Urologic Science Division and Bavendam is program director in the Division of Kidney, Urologic, and Hematologic Diseases. Tom Pruski and Sam Marullo work at Wesley Theological Seminary in Washington, DC; Pruski is associate director of the Heal the Sick Program in the Institute for Community Engagement and Marullo is a professor of sociology, director of research in the Institute for Community Engagement, and director of the Missional Church Program. Kimberly Konkel is associate director for health at the Center for Faith-based and Neighborhood Partnerships, Department of Health and Human Services, in Washington, DC.

Selected references

Blaivas JG, Purohit RS, Benedon MS, et al. Safety considerations for synthetic sling surgery. Nat Rev Urol. 2015:12(9);481-509.

Center for Faith-based and Neighborhood Partnerships and the National Institute of Diabetes and Digestive and Kidney Diseases. Bladder health: What health ministers need to know. Health Ministers Guide.

Cipullo LM, Cosimato C, Filippelli A, et al. Pharmacological approach to overactive bladder and urge urinary incontinence in women: An overview. Eur J Obstet Gynecol Reprod Biol. 2014;174:27-34.

Coyne KS, Sexton CC, Clemens JQ, et al. The impact of OAB on physical activity in the United States: Results from OAB-POLL.Urology. 2013;82(4):799-806.

Coyne KS, Wein A, Nicholson S, Kvasz M, Chen CI, Milsom I. Economic burden of urgency urinary incontinence in the United States: A systematic review. J Manag Care Pharm. 2014;20(2):130-40.

Dein S, Cook CC, Koenig H. Religion, spirituality, and mental health: Current controversies and future directions. J Nerv Ment Dis. 2012;200(10):852-5.

Elstad EA, Taubenberger SP, Botelho EM, Tennstedt SL. Beyond incontinence: The stigma of other urinary symptoms. J Adv Nurs. 2010;66(11):2460-70.

Fritel X, Panjo H, Varnoux N, Ringa V. The individual determinants of care-seeking among middle-aged women reporting urinary incontinence: Analysis of a 2273- woman cohort. Neurourol Urodyn. 2014; 33(7):1116-22.

Goffman E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice-Hall; 1963.

Jirschele K, Ross R, Goldberg R, Botros S. Physician attitudes toward urinary incontinence identification. Female Pelvic Med Reconstr Surg. 2015;21(5):273-6.

Lee A, Lee KW, Khang P. Preventing falls in the geriatric population. Perm J. 2013;17(4):37-9. Litman HJ, McKinlay JB. The future magnitude of urological symptoms in the USA: Projections using the Boston Area Community Health survey. BJU Int. 2007;100(4):820-5.

Losada L, Amundsen CL, Ashton-Miller J, et al. Expert panel recommendations on lower urinary tract health of women across their life span. J Womens Health (Larchmt). 2016; 25(11):1086-96.

Maserejian NN, Minassian VA, Chen S, Hall SA, McKinlay JB, Tennstedt SL. Treatment status and risk factors for incidence and persistence of urinary incontinence in women. Int Urogynecol J. 2014;25(6):775-82.

Olivera CK, Meriwether K, El-Nashar S, et al. Nonantimuscarinic treatment for overactive bladder: A systematic review. Am J Obstet Gynecol. 2016;215(1):34-57.

Pakgohar M, Sabetghadam S, Vasegh Rahimparvar SF, Kazemnejad A. Quality of life (QoL) and help-seeking in postmenopausal women with urinary incontinence (UI): A population based study. Arch Gerontol Geriatr. 2014;59(2):403-7.

Patel M, Vellanki K, Leehey DJ, et al. Urinary incontinence and diuretic avoidance among adults with chronic kidney disease. Int Urol Nephrol. 2016;48(8):1321-6.

Perera J, Kirthinanda DS, Wijeratne S, Wickramarachchi TK. Descriptive cross sectional study on prevalence, perceptions, predisposing factors and health seeking behaviour of women with stress urinary incontinence. BMC Womens Health. 2014;14:78.

Reavley N, Jorm A. Community and population-based interventions to reduce stigma associated with depression, anxiety and suicide: A rapid review. Ultimo, New South Wales: The Sax Institute; 2013.

Rubin EB, Buehler AE, Halpern SD. States worse than death among hospitalized patients with serious illnesses. JAMA Intern Med. 2016;176(10):1557-9.

Siddiqui NY, Levin PJ, Phadtare A, Pietrobon R, Ammarell N. Perceptions about female urinary incontinence: A systematic review. Int Urogynecol J. 2014;25(7):863-71.

Tannenbaum C, van den Heuvel E, Fritel X, et al. Continence Across Continents To Upend Stigma and Dependency (CACTUS-D): Study protocol for a cluster randomized controlled trial. Trials. 2015;16:565.

Wang C, Li J, Wan X, Wang X, Kane RL, Wang K. Effects of stigma on Chinese women’s attitudes towards seeking treatment for urinary incontinence. J Clin Nurs. 2015;24(7-8):1112-21.

Wang R, Lefevre R, Hacker MR, Golen TH. Diabetes, glycemic control, and urinary incontinence in women. Female Pelvic Med Reconstr Surg. 2015;21(5):293-7.

Wyman JF, Burgio KL, Newman DK. Practical aspects of lifestyle modifications and behavioral interventions in the treatment of overactive bladder and urgency urinary incontinence. Int J Clin Pract. 2009;63(8):1177-91.