UI is a prevalent cross-cultural condition. Future studies should rely on universally accepted standardized definitions to produce meaningful evidence-based conclusions, as well as project the costs of this global healthcare problem.

Objective To estimate prevalence of urinary incontinence (UI) health care utilization in women from the population to specialty care. Method The General Longitudinal Overactive Bladder Evaluation – UI (GLOBE-UI) is a population-based study on the natural history of UI in women ≥ 40 years of age. Prevalence of UI was estimated by using the bladder health survey (BHS). Survey data were linked with electronic health records to build the different steps of the iceberg of disease. Descriptive statistics were used to estimate the prevalence estimates at all levels of the iceberg. Results A total sample of 7,059 women received the BHS. Of those, 3,316 (47%) responded. Prevalence of UI was 1,366 (41%). Women with or without UI did not differ by age or marital status. However, women with versus without UI were more parous (91% vs 87%), significantly more overweight or obese (74% vs 61%), and more likely to have a college education or higher (54% vs 46%), P<0.01. Nine-hundred fifty eight (73%) women with UI reported duration of more than two years and 72% reported moderate to severe UI symptoms. Of all 1,366 women with BHS UI diagnosis, only 339 (25%) sought care, 313 (23%) received some care, and 164 (12%) received subspecialty care. Conclusion UI is a highly prevalent disease. Only a minority with UI appears to seek care and a fraction sees a pelvic floor specialist. It is important not only to educate women, but also primary care providers about this highly prevalent yet treatable condition.

Future epidemiological strategies using longitudinal study designs could play a pivotal role in better elucidating the controversies in UI natural history and the pathophysiology of its subtypes leading to improved clinical care.

Objective To estimate how symptom severity, extent of bother, and quality of life differ across urinary incontinence (UI) subtypes. Methods We evaluated prevalent UI cases from the Nurses' Health Studies, including women aged 41–83 years. Women with UI (leaking more than once a month) were subclassified according to reported symptoms as stress (leakage with activity), urgency (leakage with urgency), or mixed UI (stress and urgency co-occurring equally). UI severity was assessed in 102,418 women, based on the Sandvik severity index. In a subset of older women with weekly UI, we asked about bother (n=1,697) and quality of life (Incontinence Impact Questionnaire; n=1,748). UI severity, bother, and quality of life were compared across subtypes using polytomous logistic regression, adjusting for other characteristics. Results The distribution of UI subtypes was 51% stress, 27% urgency, and 22% mixed UI. About half had slight UI, 26% had moderate, and 23% had severe UI. Severe UI was more common in women reporting mixed (37%), than urgency (27%) or stress UI symptoms (15%) (P<0.001). More women with severe mixed (21%, P=0.02) and urgency UI symptoms (13%, P=0.1) reported being “greatly” bothered by their UI, compared with stress UI (10%). Women with severe mixed (mean 18.0, P<0.001) and urgency UI symptoms (mean 13.4, P=0.004) had higher mean Incontinence Impact scores compared with stress UI (mean 9.8). Conclusion Women reporting mixed UI symptoms describe more severe and bothersome incontinence, with higher effect on quality of life.

III.

Urinary incontinence (UI) is a burdensome condition with high prevalence in middle-aged to older women and an unclear etiology. Advances in our understanding of host-microbe interactions in the urogenital tract have stimulated interest in the urinary microbiome. DNA sequencing and enhanced urine culture suggest that similarly to other mucosal sites, the urinary bladder of healthy individuals harbors resident microbial communities that may play distinct roles in bladder function. This review focused on the urobiome (expanded quantitative urine culture-based or genomic sequencing-based urinary microbiome) associated with different subtypes of UI, including stress, urgency and mixed urinary incontinence, and related syndromes, such as interstitial cystitis and overactive bladder in women, contrasted to urinary tract infections. Furthermore, we examined clinical evidence for the association of the urinary microbiome with responses to pharmacotherapy for amelioration of UI symptoms. Although published studies are still relatively limited in number, study design and sample size, cumulative evidence suggests that certain Lactobacillus species may play a role in maintaining a healthy bladder milieu. Higher bacterial diversity in the absence of Lactobacillus dominance was associated with urgency UI and resistance to anticholinergic treatment for this condition. UI may also facilitate the persistence of uropathogens following antibiotic treatment, which in turn can alter the commensal/potentially beneficial microbial communities. Risk factors of UI, including age, menopausal status, sex steroid hormones, and body mass index may also impact the urinary microbiome. However, it is yet unclear whether the effects of these risks factors on UI are mediated by urinary host-microbe interactions and a mechanistic link with the female urogenital microbiome is still to be established. Strategies for future research are suggested.

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