The association of fecal incontinence, constipation, and pelvic pain with the course of lower urinary tract symptoms in community-dwelling men and women.

BACKGROUND: Fecal incontinence, constipation, and pelvic pain are common pelvic floor symptoms (PFS), and frequently coexist with lower urinary tract symptoms (LUTS). However, their association with the longitudinal trajectory of LUTS have not been well described. Our objective was to investigate the association between PFS and the course of LUTS in community-dwelling men and women. METHODS: Men and women aged ≥16 years were invited to participate in a prospective observational cohort study. At baseline, and after 12 and 24 months, participants filled in the International Consultation on Incontinence Modular Questionnaire (ICIQ-MLUTS and ICIQ-FLUTS) for men and women respectively, the Wexner incontinence and constipation scale, and a questionnaire on pelvic pain. Generalized estimating equations were used to examine the association between change scores in defecation problems and pelvic pain, and LUTS change scores. RESULTS: A total of 694 men and 997 women gave informed consent, with 417 men and 566 women included in the analysis. The mean age was 63.2 ± 12.7 years for men and 58.6 ± 14.8 years for women. The study showed minor changes in LUTS scores over the 0-12 and 12-24-month periods. Generalized estimating equations revealed positive associations between changes in constipation and fecal incontinence and LUTS changes in both sexes. For instance, a one-point increase in Wexner constipation score was associated with 0.376 (0.165, 0.587) points higher LUTS change in men and 0.223 (0.109, 0.336) points in women during the 0-12-month follow-up. However, associations between changes in pain and LUTS scores varied across sexes and time periods. CONCLUSIONS: We observed minor changes in LUTS over time and weak associations between PFS and LUTS that sometimes differed between males and females, emphasizing the need for sex-specific considerations. These insights can provide valuable guidance for the development of targeted prevention trials, ultimately aiming to enhance overall pelvic health and patient well-being.

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.

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.

The test-retest reproducibility of the multiple array probe Leiden in men with lower urinary tract symptoms.

BACKGROUND: We aimed to study the test-retest reliability of the Multiple Array Probe Leiden (MAPLe), a multiple electrode probe designed to acquire and discriminate electromyography signals in the pelvic floor muscles, in men with lower urinary tract symptoms (LUTS). METHODS: Adult male patients with LUTS with sufficient knowledge of Dutch language, but without complications (e.g., urinary tract infection), or previous urologic cancer and/or urologic surgery were enrolled. In the initial study, next to physical examination and uroflowmetry, all men underwent MAPLe assessment at baseline and after 6 weeks. Second, participants were reinvited for a new assessment using a stricter protocol. A time interval of 2 h (M2) and 1 week (M3) after baseline (M1) allowed the calculation of the intraday agreement (M1 vs. M2), and the interday agreement (M1 vs. M3) for all 13 MAPLe variables. RESULTS: The outcomes of the initial study in 21 men suggested a poor test-retest reliability. The second study in 23 men showed a good test-retest reliability with intraclass correlations ranging from 0.61 (0.12-0.86) to 0.91 (0.81-0.96). The agreement was generally higher for the intraday determinations than for the interday determinations. CONCLUSIONS: This study revealed a good test-retest reliability of the MAPLe device in men with LUTS, when using a strict protocol. With a less strict protocol, the test-retest reliability of MAPLe was poor in this sample. To make valid interpretations of this device in a clinical or research setting, a strict protocol is needed.

Comparing male and female pelvic floor muscle function by the number and type of pelvic floor symptoms.

AIMS: Pelvic floor symptoms (PFS), including lower urinary tract symptoms, defecation problems, sexual dysfunction, and pelvic pain, are common in males and females. Comparing pelvic floor musculature (PFM) function between sexes may reveal important differences relevant to clinical care. This study aimed to compare male and female PFM function and to assess the function of both sexes with the number and type of PFS. METHODS: We purposively enrolled males and females aged ≥ 21 years with 0-4 PFS based on questionnaire responses in an observational cohort study. Participants then underwent PFM assessment, and muscle function in the external anal sphincter (EAS) and puborectal muscle (PRM) were compared between sexes. The relationships between muscle function and the number and type of PFS were explored. RESULTS: Of the invited 400 males and 608 females, 199 and 187 underwent PFM assessment, respectively. Compared with females, males more often showed increased EAS and PRM tone during assessments. Compared with males, females more often showed weaker maximum voluntary contraction (MVC) of the EAS and dysfunctional endurance of both muscles; additionally, those with zero or one PFS, sexual dysfunction, and pelvic pain more often showed a weak MVC of the PRM. CONCLUSIONS: Despite a few similarities between males and, females we found differences in muscle tone, MVC, and endurance between male and female PFM function. These findings provide useful insights into the differences in PFM function between males and females.

Exploring pelvic floor muscle function in men with and without pelvic floor symptoms: A population-based study.

BACKGROUND: Pelvic floor symptoms (PFS), such as lower urinary tract symptoms, defecation disorders, sexual problems, and genital-pelvic pain, are prevalent in men. Thorough physical assessments of the external anal sphincter (EAS) and the puborectal muscle (PRM) are the keys to unraveling the role of muscle dysfunction. OBJECTIVES: To explore associations within and between the EAS and PRM and between muscle (dys-) function and the number of male PFS. METHODS: This cross-sectional study purposively enrolled men aged ≥21 years with 0-4 symptoms from a larger study. After extensive external and internal digital pelvic floor assessment, we explored (1) agreement between muscle function of the EAS versus PRM (using cross tabulation), (2) associations within and between the EAS and PRM (using heatmaps), and (3) associations between muscle function and number of PFS (using a visual presentation [heatmaps] and χ2  tests). RESULTS: Overall, 42 out of 199 men (21%) had completely normal muscle function. Sixty-six (33.2%) had no symptoms, of which 53 (80%) had some degree of muscle dysfunction. No clear dose-response relationship existed between muscle (dys-) function and the number of symptoms. The PRM showed both more dysfunction and severer dysfunction than the EAS. CONCLUSIONS: No clear association exists between muscle dysfunction and the number of symptoms, and the absence of PFS does not indicate normal muscle function for all men. Dysfunction levels are highest for the PRM. Further pelvic floor muscle research is warranted in men with PFS.

Exploring concomitant pelvic floor symptoms in community-dwelling females and males.

OBJECTIVES: Researchers and clinicians tend to focus on one pelvic floor symptom (PFS) at the time. However, the pelvic floor acts as one functional unit, increasing the likelihood of concurrent PFS in patients with pelvic floor dysfunction. There is also a paucity of literature on the prevalence of concomitant PFS, especially in males. Therefore, we explored the occurrence of concomitant PFS in community-dwelling males and females. MATERIALS AND METHODS: This prospective observational population-based cohort study included males and females aged ≥16 years from a single Dutch municipality. Participants completed validated questionnaires on lower urinary tract symptoms (LUTS), defecation problems, sexual dysfunction, pelvic pain, and pelvic organ prolapse. Medical general practitioner records were examined. Furthermore, a randomly selected group of non-responders aged <80 years received a short questionnaire, to study response bias. RESULTS: We invited 11 724 people, among which 839 females and 566 males completed the questionnaires. Of the female participants, 286 (34.1%) reported no PFS, and 251 (29.9%) reported two or more PFS. The most prevalent PFS clusters in females were sexual dysfunction and pelvic pain, sexual dysfunction and defecation problems, LUTS and defecation problems, and LUTS, defecation problems, and pelvic pain. Of the male participants, 212 (37.5%) reported no PFS, and 191 (33.7%) reported two or more PFS. The most prevalent clusters in males were sexual dysfunction and LUTS, defecation problems and LUTS, and sexual dysfunction, LUTS, and defecation problems. CONCLUSION: A considerable overlap existed between PFS, with differences in PFS clusters between females and males. Of note, females reported pelvic pain more than males. We conclude that healthcare providers should address all PFS in males and females.

Exploring pelvic floor muscle activity in men with lower urinary tract symptoms.

AIM: We aimed to explore the utility of the Multiple Array Probe Leiden (MAPLe) device to assess pelvic floor muscle activity in men with lower urinary tract symptoms (LUTS). METHODS: This was an observational cohort study performed at the urology outpatient department of a large teaching hospital in the Netherlands between April and October 2018. We recruited male patients referred for the assessment of LUTS, without a history of prostate surgery, if they had an International Prostate Symptom Score greater than or equal to 8. The MAPLe device was then used to assess the puborectalis, pubococcygeus, iliococcygeus, urogenital diaphragm, and the internal and external anal sphincters during three tasks: a rest period (1 minute), five maximum voluntary contractions (held for 3 seconds each), and three maximal endurance contractions (held for 15 seconds each). RESULTS: In total, 57 patients were included, 5 of which had diabetes mellitus. Muscle activity at rest was significantly lower than during either contraction task and did not differ between the muscle groups. By contrast, the external anal sphincter had significantly less activity than any other muscle group during the endurance task, and the internal anal sphincter and puborectalis had significantly less activity during the maximum voluntary contraction task. No association was found between pelvic floor muscle activity and LUTS severity during any task. CONCLUSION: Pelvic floor muscle activity and LUTS severity appear to be unrelated, but this does not completely exclude the possibility of muscle involvement in the development or experience of symptoms. Further research is needed.

Differences in help-seeking behaviour between males and females with multiple pelvic floor symptoms: A qualitative study.

Background: Pelvic floor symptoms (PFS) are common and frequently co-occur, but few patients seek help despite negative effects on their quality of life. Moreover, most studies assessing help-seeking behaviour have only focused on a single PFS. Aim: We aimed to explore the barriers to and facilitators of help-seeking behaviour in males and females with at least two PFS. Design and Setting: This interview-based study included participants by age and symptoms (number and type) from a larger group taking part in a survey on PFS in the general population. Method: Two researchers independently encoded and analyzed the semi-structured interviews, which continued to saturation for both the male and female cohorts. Results: Of the 25 participants (13 male and 12 female), 9 sought help for all PFS, 10 did not seek help for any PFS, and 6 sought help for some PFS. We identified themes in domains related to the patient, healthcare professional, environment, and symptoms. Although most themes applied to both sexes, some had greater sex specificity. Conclusion: Males and females have more similarities than differences in help-seeking behaviour. Healthcare providers should know that patients who seek help for one symptom probably have multiple PFS that the patient has not reported.

Cardiovascular and metabolic effects of a mandibular advancement device and continuous positive airway pressure in moderate obstructive sleep apnea: a randomized controlled trial.

STUDY OBJECTIVES: It has been suggested that treatment for obstructive sleep apnea (OSA) reduces cardiovascular risk. So far, knowledge is limited about the difference in the reduction of this risk between mandibular advancement device (MAD) and continuous positive airway pressure (CPAP) therapy. The aim of this study was to compare the cardiovascular effects of MAD vs CPAP therapy in patients with moderate OSA. METHODS: Patients with an apnea-hypopnea index of 15-30 events/h were randomized to either MAD or CPAP therapy. At baseline and after 12-month follow-up, 24-hour ambulant blood pressure measurements and laboratory measurements were performed. Ambulant blood pressure measurements consisted of 24-hour, daytime and night-time systolic and diastolic blood pressure and heart rate measurements. Laboratory measurements consisted of serum lipid values, creatinine, high-sensitivity C-reactive protein, plasma glucose, hemoglobin A1c glycated hemoglobin, proinflammatory cytokines, soluble receptor for advanced glycation end-products, chemokines, and adhesion molecules. RESULTS: Of the 85 randomized patients with moderate OSA, data were available for 54 patients (n = 24 MAD, n = 30 CPAP) at 12-month follow-up and showed that apnea-hypopnea index significantly decreased with either therapy. In the MAD group, soluble receptor for advanced glycation end-products and glycated hemoglobin were significantly higher after 12 months' follow-up compared to baseline. No significant changes were found between MAD and CPAP treatments for all outcomes. CONCLUSIONS: Treatment of patients with moderate OSA with either MAD or CPAP therapy had no profound effects on major cardiovascular risk factors after 12 months. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Title: MRA Therapy vs CPAP Therapy in Moderate OSAS; Identifier: NCT01588275; URL: https://clinicaltrials.gov/ct2/show/NCT01588275. CITATION: Uniken Venema JAM, Knol-de Vries GE, van Goor H, Westra J, Hoekema A, Wijkstra PJ. Cardiovascular and metabolic effects of a mandibular advancement device and continuous positive airway pressure in moderate obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med. 2022;18(6)1547-1555.