Abstract
Objective:
To examine relationships between interpersonal trauma exposures and urinary symptoms in community-dwelling midlife and older women.
Methods:
We analyzed cross-sectional data from a multiethnic cohort of women aged 40-80 years enrolled in an integrated health care system in California. Lifetime history of intimate partner violence (IPV) and sexual assault, current posttraumatic stress disorder (PTSD) symptoms, and current urinary symptoms were assessed using structured-item questionnaires. Multivariable-adjusted logistic regression models examined associations between traumatic exposures and PTSD symptoms with any weekly urinary incontinence, stress-type incontinence, urgency-type incontinence, and nocturia ≥2 times per night.
Results:
Of the 1,999 participants analyzed, 21.7% women reported lifetime emotional IPV, 16.2% physical IPV, 19.7% sexual assault , and 22.6% reported clinically significant PTSD symptoms. Overall, 45% reported any weekly incontinence, 23% stress-type incontinence, 23% urgency-type incontinence, and 35% nocturia. Exposure to emotional IPV was associated with any weekly incontinence (OR 1.33, 95% CI 1.04–1.70), stress-type incontinence (OR 1.30, 95% CI 1.00–1.65), urgency-type incontinence (OR 1.30, 95% CI 1.00–1.70), and nocturia (OR 1.73, 95% CI 1.36–2.19). Physical IPV exposure was associated with nocturia (OR 1.35, 95% CI 1.04–1.77), but not incontinence. Sexual assault history was not associated with weekly incontinence of any type or nocturia. PTSD symptoms were associated with all urinary symptoms assessed, including any weekly incontinence (OR 1.46, 95% CI 1.15–1.85), stress-type incontinence (OR 1.70, 95% CI 1.32–2.20), urgency-type incontinence (OR 1.60, 95% CI 1.24–2.06), and nocturia (OR 1.95, 95% CI 1.55–2.45).
Conclusion:
Over 20% of women in this multiethnic, community-based cohort reported a history of IPV, PTSD symptoms, or both, which were associated with symptomatic urinary tract dysfunction. Findings highlight the need to provide trauma-informed care of midlife and older women presenting with urinary symptoms.
Précis
Midlife and older women with a history of interpersonal trauma are more likely to experience symptomatic urinary tract dysfunction.
Introduction
Urinary symptoms are common in midlife and older women, with approximately one in three women over age 40 complaining of urinary incontinence, nocturia, or urgency.1-3 While urinary symptoms can arise from specific defects in the bladder, urethra, or pelvic floor, a growing body of literature has demonstrated associations between chronic urinary symptoms and other psychological and contextual factors.4,5
Exposure to interpersonal trauma, including sexual assault or intimate partner violence (IPV), has the potential to contribute to urinary symptoms.6 However, few studies have examined relationships between interpersonal trauma or trauma-related psychological sequelae and urinary tract dysfunction in women. To date, research on this issue has focused on children and reproductive-aged women or on specialized populations such as women veterans, resulting in a gap in knowledge about midlife and postmenopausal women who are at greatest risk of experiencing urinary symptoms.4,7,6
To provide new insight into this issue, we examined interpersonal trauma exposures and posttraumatic stress disorder (PTSD) symptoms in an ethnically-diverse, community-based cohort of midlife and older women and explored associations between these exposures and common urinary symptoms. We hypothesized that interpersonal trauma and PTSD symptoms would be associated with increased prevalence and perceived bother of urinary symptoms, even after accounting for other demographic and clinical risk factors. Our goal was to examine trauma as a potential marker of risk for symptomatic urinary tract dysfunction in midlife and older women.
Methods
We conducted a cross-sectional analysis of data from the Reproductive Risks of Incontinence Study at Kaiser (RRISK), an observational, community-based cohort study of risk factors for urinary tract dysfunction in midlife and older women. Construction of the original RRISK cohort has been described elsewhere.8 Briefly, participants were long-time female enrollees in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system that serves approximately 30% of the northern California population. To be eligible, women had to be at least 40 years of age, enrolled in KPNC since age 21 years, and report that at least half of any childbirth events had taken place at a KPNC facility. Approximately 20% were recruited from the KPNC Diabetes Registry to ensure robust participation of women with diabetes, but urinary symptoms were not required for participation. Participants were randomly sampled from within 10-year age and race/ethnicity strata (Non-Latina White, African American, Latina, and Asian) to provide robust representation from women across a range of ages and racial/ethnic backgrounds.
The initial RRISK cohort was assembled between 1999–2003, followed by two additional waves of data collection (RRISK2 2003–2008; and RRISK3, 2008–2012). For this report, analyses focused on RRISK3, the only wave to include assessment of traumatic exposures and PTSD symptoms. All data were collected through clinic- or home-based study visits with participants’ informed consent. All procedures were approved by the institutional review boards of the University of California, San Francisco and Kaiser Permanente Division of Research.
Interpersonal trauma exposures were assessed by structured, interviewer-administered questionnaire measures adapted from past epidemiologic studies and described in a previous report.9,10 Briefly, participants were asked about lifetime exposure to physical abuse by an intimate partner, emotional abuse by an intimate partner, and sexual abuse or assault (by anyone). To assess physical IPV, women were asked if they had “ever been physically abused by being hit, slapped, pushed, shoved, punched or threatened with a weapon?” by an intimate partner. To assess emotional/verbal IPV, women were asked if they had “ever been verbally abused by being made fun of, severely criticized, told you were a stupid or worthless person, or threatened with harm to yourself, your possessions, or your pets?” by an intimate partner. To assess sexual abuse or assault, women were asked if “anyone has ever touched sexual parts of your body after you said or showed that you didn’t want them to, or without your consent?” PTSD symptoms were assessed using the self-administered PTSD Checklist for DSM-IV, Civilian Version (PCL-C), a 17-item validated questionnaire designed to assess PTSD symptoms within the last month. A standard threshold score of ≥30 for probable PTSD was used to define clinically significant PTSD symptoms in this sample.11
Urinary symptom outcomes such as incontinence and nocturia were assessed using structured, interviewer-administered questionnaire items previously validated against a detailed bladder diary.12 For incontinence, questions assessed the frequency of incontinence, clinical type of incontinence, as well as perceived bother associated with incontinence (see Appendix 1, available online at http://links.lww.com/xxx). For this report, outcome analyses focused on women reporting either “any weekly” incontinence or “any bothersome” incontinence. Specifically, participants were designated as having “any weekly” incontinence if they reported any urine leakage of any type in the past month occurring an average of at least once a week. Women were further designated as having any weekly stress-type incontinence if they reported stress-type leakage episodes at least 4 times per month and as having any weekly urgency-type incontinence if they reported urgency-type leakage episodes occurring at least 4 times per month. By these definitions, women could have one, both, or neither of the above type-specific weekly incontinence outcomes. Participants were considered to have “any bothersome” incontinence if they reported leakage in the past month that was at least moderately bothersome to them, irrespective of the frequency of incontinence, and further designated as having “any bothersome” stress- or urgency-type incontinence if they reported stress- or urgency-type leakage in the past month that was at least moderately bothersome, irrespective of frequency. By these definitions, women could have any weekly incontinence without having any bothersome incontinence, and vice versa.
Nocturia was also assessed as an outcome by asking participants how often they urinated during the night and how much this nighttime urination bothered them (see Table 1 in Appendix 1, available online at http://links.lww.com/xxx). For this report, nocturia outcome analyses focused on women reporting “any frequent” nocturia or “any bothersome” nocturia. Women were categorized as having “any frequent” nocturia if they reported urinating at least twice per night on a typical night. Women were considered to have “any bothersome” nocturia if they reported being at least moderately bothered by getting up to urinate at night, irrespective of frequency. By these definitions, women could have frequent nocturia without having bothersome nocturia, and vice versa.
Other demographic and clinical characteristics were assessed using questionnaires, medical record review, or physical exam (Table 1). Race/ethnicity, educational attainment, and parity were assessed by self-report. Depression symptoms were also assessed using the depression subscale of the Hospital Depression and Anxiety Scale (HADS), a validated questionnaire in which higher scores indicate greater depression symptom burden.13 Use of medications such as hormone therapy, diuretics, and anticholinergic bladder medications was abstracted from medical records for all participants who reported filling ≥80% of their medications at a KPNC pharmacy and self-reported by participants who reported filling ≥80% at non-KPNC pharmacies. Height and weight were directly measured by trained study staff in order to calculate body mass index (BMI) during study visits.
Table 1.
Characteristics of the Sample
| Characteristic | N = 1,999 |
|---|---|
| Age (mean ± SD) | 60.2 ±9.4 |
| Body mass index* (mean ± SD) | 30.0 ±7.4 |
| Race/ethnicity | |
| Non-Latina White | 712 (35.6) |
| African American | 431 (21.6) |
| Latina | 460 (23.0) |
| Asian | 396 (19.8) |
| Education | |
| High school or less | 369 (18.5) |
| Some college | 871 (43.6) |
| College graduate | 316 (15.8) |
| Graduate or professional school | 443 (22.2) |
| Menopause status | |
| Pre- or perimenopausal | 359 (18.0) |
| Postmenopausal | 1640 (82.0) |
| Hysterectomy | 497 (24.9%) |
| Current medication use | |
| Diuretics | 753 (37.7) |
| Anticholinergic bladder medication | 89 (4.5) |
| Hormone therapy | 338 (16.9) |
| Parity | |
| Nulliparous | 350 (17.5) |
| Primiparous | 261 (13.1) |
| Multiparous | 1384 (69.2) |
Data were missing for 8 women for body mass index, 1 woman for menopausal status, 53 women for current medication use, and 4 women for parity.
Descriptive statistics were used to summarize key characteristics of the participant sample, including frequencies and percentages for categorical data and means and standard deviations for continuous data. Due to the multiethnic composition of the cohort, we examined the prevalence of key traumatic exposures and urinary symptom outcomes within each racial/ethnic group and evaluated differences in the prevalence of these exposures and outcomes across racial/ethnic groups with chi-square analyses. Multivariable logistic regression analyses were conducted in the combined participant sample to examine independent associations between each traumatic exposure (history of emotional IPV, physical IPV, sexual assault, current PTSD symptoms) and each urinary symptom outcome. To address potential confounders, all models were adjusted for age, race/ethnicity, education, body mass index, parity, menopausal status, prior hysterectomy, hormone therapy, and diuretic use, selected a priori due to known associations with urinary tract symptoms.2 Missing data were treated as missing at random.
In additional exploratory analyses, models were also further adjusted for: 1) participant-reported history of depression diagnosis, and 2) current depression symptoms as measured by HADS depression subscale score greater than 8, in order to assess for depression as a potential mediator of relationships between IPV and urinary symptoms. All analyses were conducted using SPSS Version 24.0 (Armonk, NY: IBM Corp., 2016). Reported p values are 2-sided, and statistical significance was defined by a threshold of p < .05.
Results
Of the 4,819 women initially contacted to assess eligibility for RRISK3, 3,438 (71.3%) met eligibility criteria, of which 2,468 (71.7%) of these consented to participate, with 2,016 (81.7%) of these completing a study visit. This report includes data from 1,999 of these participants (99.2%) who provided data to indicate whether they had at least one traumatic exposure and at least one urinary symptom outcome examined in these analyses. In this multi-ethnic sample (35.6% Non-Latina White, 21.6% African American, 23.0% Latina, 19.8% Asian), women were largely postmenopausal (82.0%), overweight or obese (42.7%), and multiparous (69.2%) (Table 1). Over a third (37.7%) reported using diuretics, but only 4.5% reported using anticholinergic bladder medications.
More than one in five (21.2%) women reported lifetime emotional IPV, 15.8% physical IPV, and 19.1% sexual assault. Overall, 22.5% of women met criteria for current clinically significant PTSD symptoms. Lifetime prevalence of IPV and sexual assault varied across racial/ethnic groups (Table 2).
Table 2.
Prevalence of traumatic exposures by race/ethnicity
| Traumatic exposures | Total N (%) | Non-Latina White N (%) |
African American N (%) |
Asian N (%) |
Latina N (%) |
P value |
|---|---|---|---|---|---|---|
| Emotional IPV | 423/1953 (21.7) | 190/696 (27.3) | 103/416 (24.8) | 33/390 (8.5) | 97/451 (21.5) | <.001 |
| Physical IPV | 316/1955 (16.2) | 118/699(16.9) | 98/418 (23.4) | 23/388 (5.9) | 77/450 (17.1) | <.001 |
| Sexual Assault | 382/1939 (19.7) | 176/693 (25.3) | 95/413 (23.0) | 33/386 (8.5) | 78447 (17.4) | <.001 |
| PTSD symptoms* | 450/1983 (22.6) | 163/707 (23.1) | 113/427 (26.4) | 80/393 (20.4) | 94/456 (20.6) | .09 |
Data were missing for 46 women with emotional IPV, 44 women for physical IPV, 60 women for sexual assault, and 16 women for PTSD symptoms
Among non-Latina white women, data were missing for 16 women for emotional IPV, 13 women for physical IPV, 19 women for sexual assault, 5 women for PTSD.
Among African American women, data were missing for 15 women for emotional IPV, 13 women for physical IPV, 18 women for sexual assault, 4 women for PTSD.
Among Latina women, data were missing for 9 women for emotional IPV, 10 women for physical IPV, 13 women for sexual assault, 4 women for PTSD
Among Asian women, data were missing for 6 women for emotional IPV, 8 women for physical IPV, 10 women for sexual assault, 3 women for PTSD
Percentages presented in this table are column percentages
P-values were obtained from Chi-square tests.
Participants were considered to have clinically significant PTSD symptoms if they had a score ≥30 on the PTSD Checklist (PCL)
Forty-five percent of women reported weekly urinary incontinence of any type, including 22.9% reporting weekly stress-type incontinence, and 23.3% reporting weekly urgency-type incontinence. Just over a quarter (25.1%) reported bothersome incontinence of any type in the past month, including 15.9% with bothersome stress-type incontinence and 18.3% with bothersome urgency-type incontinence. Frequent nocturia (occurring at least twice per night) was also reported in 34.5% of participants, while bothersome nocturia was reported by 16.6% (Table 3). Prevalence of incontinence varied across racial/ethnic groups (Table 3).
Table 3.
Prevalence of urinary symptoms by race/ethnicity
| Total N (%) | Non-Latina White N (%) |
African American N (%) |
Asian N (%) |
Latina N (%) |
p-value | |
|---|---|---|---|---|---|---|
| Any-type incontinence | ||||||
| Any weekly incontinence1 | 900 (45.0) | 423 (59.4) | 168 (39.0) | 119 (30.1) | 190 (41.3) | <.001 |
| Any bothersome incontinence2 | 501 (25.1) | 209 (29.4) | 90 (20.9) | 63 (15.9) | 139 (30.2) | .04 |
| Stress incontinence | ||||||
| Any weekly stress incontinence3 | 458 (22.9) | 206 (28.9) | 61 (14.2) | 64 (16.2) | 127 (27.6) | <.001 |
| Any bothersome stress incontinence4 | 318 (15.9) | 142 (19.9) | 42 (9.7) | 37 (9.3) | 97 (21.1) | <.001 |
| Urgency incontinence | ||||||
| Any weekly urgency incontinence5 | 466 (23.3) | 186 (26.1) | 110 (25.5) | 60 (15.2) | 110 (23.9) | <.01 |
| Any bothersome urgency incontinence6 | 365 (18.3) | 140 (19.7) | 78 (18.1) | 43 (10.9) | 104 (22.6) | .02 |
| Nocturia | ||||||
| Nocturia (≥2 times per night)7 | 690 (34.5) | 242 (34.0) | 189 (43.9) | 110 (27.8) | 149 (32.4) | <.001 |
| Any bothersome nocturia8 | 332 (16.6) | 122 (17.1) | 90 (20.9) | 42 (10.6) | 78 (17.0) |
No missing data for urinary symptom outcomes. P-values were obtained from Chi-square tests.
Percentages presented in this table are column percentages
Defined by reporting weekly or daily urine leakage in the past 3 months.
Defined by reporting at least moderate bother associated with any type of urine leakage in the past month.
Defined by reporting leaking urine with an activity like coughing, lifting, sneezing, or exercise at least 4 times per month.
Defined by reporting at least moderate bother associated with leaking urine with coughing, lifting, sneezing, or exercise in the past month.
Defined by reporting leaking urine with an "overwhelming urge to urinate" at least 4 times per month.
Defined by reporting at least moderate bother associated with leaking urine with an overwhelming urge to urinate in the past month.
Defined by reporting urinating at least two times per night on a typical night.
Defined by reporting at least moderate bothered by getting up to urinate at night.
In multivariable adjusted analyses, emotional IPV was associated with an increased odds of all urinary symptoms assessed, including any weekly or bothersome incontinence, any weekly or bothersome stress-type incontinence, any weekly or bothersome urgency-type incontinence, and any frequent or bothersome nocturia. Physical IPV was not associated with any incontinence outcomes, but was associated with an increased odds of frequent nocturia. Sexual assault was associated with an increased odds of any bothersome incontinence, bothersome stress incontinence, and bothersome urge incontinence, but not any nocturia outcomes. Women with a history of PTSD had an increased odds of reporting all urinary symptoms assessed, including any weekly or bothersome incontinence, any weekly or bothersome stress incontinence, any weekly or bothersome urgency incontinence, and any frequent or bothersome nocturia (Table 4). A similar pattern of associations was detected in unadjusted models, with more of the associations between sexual assault and urinary symptoms remaining significant (see Appendix 2, available online at http://links.lww.com/xxx).
Table 4.
Adjusted odds of reporting urinary symptoms with interpersonal violence exposures or PTSD symptoms
| Emotional IPV | Physical IPV | Sexual Assault | PTSD Symptoms | |||||
|---|---|---|---|---|---|---|---|---|
| Any-type incontinence | ||||||||
| Any weekly incontinence1 | 1.33 (1.04-1.70) ¥€ | .02 | 1.05 (.79-1.39) | .74 | 1.16 (.90-1.50) | .25 | 1.46 (1.15-1.85) | <.01 |
| Any bothersome incontinence2 | 1.33 (1.03-1.72) | .03 | 1.05 (.78-1.42) | .74 | 1.39 (1.07-1.81) | .01 | 1.98 (1.55-2.53) | <.001 |
| Stress incontinence | ||||||||
| Any weekly stress incontinence3 | 1.30 (1.00-1.65) | .049 | .99 (.72-1.35) | .93 | .97 (.73-1.28) | .82 | 1.70 (1.32-2.20) | <.001 |
| Any bothersome stress incontinence4 | 1.46 (1.09-1.95) ¥€ | .01 | 1.01 (.71-1.43) | .98 | 1.32 (.97-1.79) | .07 | 1.74 (1.25-2.43) | <.01 |
| Urgency incontinence | ||||||||
| Any weekly urgency incontinence5 | 1.30 (1.00-1.70) | .049 | 1.13 (.84-1.53) | .43 | 1.26 (.96-1.66) | .09 | 1.60 (1.24-2.06) | <.001 |
| Any bothersome urgency incontinence6 | 1.38 (1.04-1.82) | .03 | 1.24 (.90-1.71) | .19 | 1.41 (1.06-1.89) | .02 | 2.07 (1.58-2.70) | <.001 |
| Nocturia | ||||||||
| Nocturia (≥2 times per night)7 | 1.73 (1.36-2.19) | <.001 | 1.35 (1.04-1.77) € | .03 | 1.21 (.94-1.55) | .13 | 1.95 (1.55-2.45) | <.001 |
| Any bothersome nocturia8 | 1.63 (1.23-2.17) | <.01 | 1.32 (.96-1.81) | .09 | 1.27 (.95-1.71) | .11 | 2.57 (1.97-3.34) | <.001 |
Odds ratios and confidence intervals are derived from separate multivariable logistic regression models examining relationships between each traumatic exposure and each urinary symptom outcome, using data from all study participants without missing variable data.
All models were adjusted for age, race/ethnicity, education, body mass index, parity, menopausal status, prior hysterectomy, hormone therapy, and diuretic use, selected a priori due to known associations with urinary tract symptoms
Defined by reporting weekly or daily urine leakage in the past 3 months.
Defined by reporting at least moderate bother associated with any type of urine leakage in the past month.
Defined by reporting leaking urine with an activity like coughing, lifting, sneezing, or exercise at least 4 times per month.
Defined by reporting at least moderate bother associated with leaking urine with coughing, lifting, sneezing, or exercise in the past month.
Defined by reporting leaking urine with an "overwhelming urge to urinate" at least 4 times per month.
Defined by reporting at least moderate bother associated with leaking urine with an overwhelming urge to urinate in the past month.
Defined by reporting urinating at least two times per night on a typical night.
Defined by reporting at least moderate bothered by getting up to urinate at night.
In exploratory analyses, after adjustment for 1) participant-reported history of depression diagnosis, or 2) current self-reported clinically significant depression symptoms (HADS depression subscale score >8), the majority of observed associations between interpersonal trauma exposures and urinary tract symptoms were still significant (Appendixes 3 and 4, available online at http://links.lww.com/xxx). However, associations between emotional IPV and any bothersome urinary incontinence as well as any bothersome urge incontinence were mildly attenuated and no longer significant, as was the association between physical IPV and any frequent nocturia.
Discussion
In this community-based cohort of ethnically-diverse middle-aged and older women, women who reported a history of interpersonal trauma or trauma-related sequelae were more likely to report symptomatic urinary tract dysfunction. The strongest and most consistent associations were seen with emotional IPV and PTSD symptoms, which were associated with all types of urinary symptoms we assessed. These associations persisted even after adjustment for a variety of demographic and clinical factors, including age, race/ethnicity, education, weight, parity, medication use, and history of depression or current depression symptoms. These findings point to interpersonal trauma as a potentially independent marker of risk for urinary tract dysfunction in midlife and older women.
Compared to emotional IPV, physical IPV showed a less robust pattern of associations with urinary symptoms, in that women reporting a history of physical IPV had an increased odds of nocturia only. These data suggest that emotional IPV may be more potent than physical IPV as a marker of risk for urinary tract dysfunction. Given that other studies have also reported a pronounced effect of emotional IPV on other health-related symptoms such as sleep difficulty14,15 and sexual dysfunction,16 our findings highlight the potentially unique importance of this under-recognized form of interpersonal trauma.
This study extends the small existing body of literature pointing to associations between traumatic exposures and urinary dysfunction in midlife and older women. In a prior study of primarily non-Latina white men and women, participants with a history of physical, emotional, or sexual abuse reported more urinary frequency, urgency, and nocturia, but incontinence was not assessed.4 Another study relying upon medical record-based diagnoses demonstrated an association between past-year IPV and urinary tract infections in older women, but did not examine other urinary symptoms.6 Recent research in women veterans has also pointed to an association between PTSD and urinary urgency, frequency, and incontinence.17
In addition to defining urinary symptoms by frequency, we also assessed symptoms based on participants’ perceptions of bother. Not all women with frequent urinary symptoms reported being bothered by them. Nevertheless, the pattern of associations linking emotional IPV and PTSD symptoms with urinary symptoms was similar regardless of whether urinary symptoms were defined by frequency or by bother, while sexual assault was only associated with symptom bother. These findings may pave the way for future investigations to assess whether trauma and its psychological sequelae may play an important role in shaping women’s subjective experience and response to urinary symptoms, such as decreasing their ability to cope with these symptoms.
Although our study is not mechanistic in nature, it may pave the way for future studies that can explore potential mechanisms underlying interpersonal trauma and urinary symptoms in greater detail. Prior studies have demonstrated strong associations between perceived stress and anxiety with urinary symptoms,18 with some researchers hypothesizing that disorders of the genitourinary system and psychiatric conditions may stem from shared dysregulation of common neurochemical pathways.18 This hypothesis is supported by research that has discovered increased levels of corticotropin releasing factor (CRF), a mediator of the stress-induced response, in patients with urinary symptoms.18 In a study of neuroendocrine maladaptations after childhood abuse and its association with adult psychopathology, patients with major depression were found to exhibit CRF hypersecretion, blunted adrenocorticotropic hormone responses to CRF stimulation, and possible stimulatory effects on the bladder.19
This study has multiple strengths, including assessment of multiple types of both traumatic exposures and urinary symptoms in a large, multi-ethnic population. However, these findings should also be interpreted in the setting of several limitations. Participants in RRISK3 did not provide information regarding elapsed time since trauma, duration of traumatic exposures, or severity of these exposures. This limits our ability to characterize women’s experience of abuse, particularly emotional abuse, which arguably may encompass a wide array of experiences ranging from slightly to severely stressful. Assessment of PTSD was based on participant-reported symptoms rather than clinician evaluation, and participants identified as having clinically significant PTSD symptoms may not necessarily have met clinical diagnostic criteria for PTSD. Urinary symptoms were assessed by questionnaire, without further clinician evaluation to evaluate the pathophysiology of their incontinence or nocturia. Our analyses also involved multiple comparisons, increasing the likelihood that some associations observed could result from chance alone. Finally, this was a cross-sectional study, which cannot provide definitive evidence of causality although it can give rise to inferences.
Nevertheless, these findings have potentially important clinical implications. Urinary symptoms in women may be associated with previous exposure to interpersonal trauma, particularly emotional IPV, or with the psychological sequelae of trauma such as PTSD. This should prompt clinicians caring for women with urinary tract symptoms to consider assessing for and exploring all forms of IPV. Our findings suggest the possibility that evaluation and management of urinary tract dysfunction in women may be improved by a trauma-informed approach to care– including an emphasis patient-centered communication, interprofessional collaboration, and promotion of understanding of the health effects of trauma.20,21
Supplementary Material
Acknowledgments
Funding was provided by the National Institute of Health's Office of Research on Women's Health (#P50 DK064538), National Institute of Diabetes and Digestive and Kidney Diseases (#DK5335, #2K24DK080775-06), and VA Health Services Research and Development Service (CDA IK2 HX002402). This research was also supported by the resources and facilities of the University of California San Francisco and Kaiser Permanente Northern California. Database management and analytic support was provided by a UCSF/Kaiser Division of Research Small Grant for Fellows (from 1/2016-1/2017, Carolyn J. Gibson).
Financial Disclosure
Carolyn J. Gibson disclosed that her salary and research efforts are supported by a Career Development Award (CDA IK2 HX002402) from the Department of Veterans Affairs Office of Research and Development, Health Services Research & Delivery. The other authors did not report any potential conflicts of interest.
Footnotes
Presented as an abstract at the American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting, May 3–6, 2019, Nashville, Tennessee, and at the American Urological Association Annual Meeting, May 3–6, 2019, Chicago, Illinois.
Each author has confirmed compliance with the journal’s requirements for authorship.
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