Gender differences of lower urinary tract symptoms in older Chinese Americans

Tsung Mou ＊, Oluwteniol Brown Yingxio Hu ,Meliss Simon , XinQi Dong , Kimerly Kenton C.Emi Bretshneider

a Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

b Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ,USA

c Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine,Chicago, IL, USA

KEYWORDS Chinese American;Lower urinary tract symptom;Gender;Prevalence;Risk factor

Abstract Objective: To describe whether or not there are gender differences in lower urinary tract symptoms (LUTS) prevalence and risk factors in community-dwelling older Chinese Americans.Methods: We performed a secondary analysis of a prospective cross-sectional population-based survey of Chinese Americans aged 60 years and older between January 2011 and December 2013 in English,Mandarin,Cantonese,Taishanese,or Teochew.A clinical review of systems was used to assess LUTS,which included urinary frequency,urgency,burning and/or pain,blood in urine,and urinary incontinence.Results: Of the total 3157 people queried, 42% were men and 58% were women.More men reported LUTS compared to women(32.9%vs.28.6%,p=0.01).In a multivariable analysis,female gender(adjusted odds ratio [aOR] 0.60, 95% confidence interval [CI] 0.49-0.73),being married(aOR 0.79,95%CI 0.65-0.97),and smoking(aOR 0.66,95%CI 0.49-0.88)were found to be protective,while traditional Chinese medicine use(aOR 1.51,95%CI 1.28-1.78),heart disease(aOR 1.54,95%CI 1.24-1.91),and anxiety(aOR 1.69,95%CI 1.25-2.28)were most strongly associated with increased odds of LUTS.When examining genders separately,being married was found to be protective only in women.Meanwhile,unique factors found in men were hypertension,heart disease, and practice of Tai Chi.Conclusion: In this large population-based study, LUTS were more prevalent in older Chinese American men than women.We also found gender-specific factors that influenced the odds of reporting LUTS;however, traditional Chinese medicine use was the only factor that was shared by both genders.Future longitudinal investigations are needed to elucidate these underlying mechanisms to provide evidence-based and culture-specific guidelines for this rapidly growing population.

1.Introduction

Lower urinary tract symptoms (LUTS) are highly prevalent and they can have profound effects on the well-being and life quality in both men and women [1,2].Because of the high prevalence worldwide, there has been an increasing interest in identifying risk factors for LUTS.To investigate associations with LUTS, epidemiology of LUTS (EpiLUTS) is an international landmark study that surveyed nearly seven thousand people in the United States (US) [3]; however,only 2.3% of the EpiLUTS study population were Asian Americans even though they comprise over 5.0%of the total population in the US [4].In other large US-based LUTS studies, there was no information on Asian Americans[5-7].

Asian American population grew significantly from 0.5 million in 1965 to over 20 million in 2015 when they became the largest new immigrants to the US [8].Within this highly heterogeneous and diverse population, those of Chinese descent make up the majority of this population with an estimate number over 5 million in the US[9].From the existing literature, there is a wide range of LUTS rates among men and women living in China.One study reported that Chinese men and women shared similar LUTS prevalence rates at nearly 60% [10], while others reported that men’s prevalence rates ranged from 40%to 70%and women were much higher up to 90% [11-13].It is unclear, however,whether these prevalence rates can be applied to the Chinese American population living in the US.Chinese Americans live in a different environmental and sociocultural milieus from their counterparts in China,which could theoretically impact the manifestation of LUTS in this fast-growing portion of the US.To address the existing knowledge gap, this study aimed to study the prevalence of,risk factors for,and gender-specific differences in LUTS among Chinese Americans of 60 years and older.

2.Materials and methods

2.1.Study population

This study was a secondary analysis using the baseline data of the Population Study of Chinese Elderly (PINE) study collected from January 2011 to December 2013 [14].The PINE study aimed to examine the important determinants of health among the aging Chinese population in the Greater Chicago area.The PINE study included adults who were community-dwelling, self-identified as Chinese, and 60 years or older.With informed consents, study participants were interviewed by multilingual research assistants in English or Chinese,which included Mandarin,Cantonese,Teochew, and Toishanese.The survey response rate was 91.9%.Of those responded,just 1.0%completed the surveys and interviews in English.The original study was approved by the institutional review board of Rush University Medical Center (#10090203-IRB02).

2.2.LUTS

Participants’ symptoms were assessed by a self-reported measure from genitourinary review of system (ROS)recognized by the Centers for Medicare and Medicaid Services, a federal governing body overseeing health services provided in the US.The content validity was assessed by experienced bicultural and bilingual experts.The measure contains a question asking indicative information related to LUTS(“Tell me the medical conditions for which you are being treated or for which you have been treated? Have you had these symptoms in the past?“).Study participants were given the options of “urinary frequency”, “urinary urgency”, “burning or pain with urination”, “blood in urine”, and/or “urinary incontinence”.Of note, types of incontinence were not specified.Affirmative answers to any item were considered as positive LUTS.Of those who responded positive LUTS, we further subcategorized participants with urinary urgency and/or frequency without incontinence to the overactive bladder without incontinence(OAB-dry)group.This group was highlighted because of its particularly high prevalence in the general population [15].

2.3.Determinants of health

Basic sociodemographic information was collected including age(year), gender (male and female),education(year in school),years in the US,marital status(married or not married), income, body mass index (BMI), smoking status (now or not), and current alcohol use frequency.Culturally specific variables such as traditional Chinese medicine (TCM) use (TCM herb use of more than once a month versus less)and practice of Tai Chi(more than once a month versus less) were also collected.Participants’medical histories were relied on their own recalls of common disease processes, including coronary artery disease, stroke, cancer, diabetes, hypertension, and osteoarthritis.Furthermore, psychometric and physical functions were assessed with the Hospital Anxiety and Depression Scale-Anxiety Subscale, Patient Health Questionnaires-9, Mini-Mental Status Exam, activities of daily living score,and NAGI score(a basic physical function assessment tool).Overall health status and quality of life were assessed by asking “In general, how would you rate your health?” and “In general, how would you rate your quality of life?” (with answer options “poor”, “fair”,“good”,and“very good”).These questionnaires have been previously administered among elderly and Chinese populations [16-21].

2.4.Analytical approach

Descriptive statistics were used to summarize group differences by LUTS in relations to sociodemographic,medical comorbidities, and individual health and quality of life perceptions.We deleted all missing data and then used Chi-square tests for categorical variables, t-tests for normally distributed continuous variables, and Mann-Whitney U test for skewed continuous variables.To further evaluate the associations between the various key health determinants and LUTS (and also OAB-dry), we carried out logistic regression models.The regression models contained variables that were clinically meaningful and statistically significant from the bivariate analyses.We used SAS Enterprise Guide, Version 7.15 (SAS Institute, Inc, Cary, NC,USA) to conduct our analyses.

3.Results

Of the total survey participants queried in the study,1328 (42%) were men and 1829 (58%) were women.The mean±standard deviation age was 72.8±8.3 years of all the participants, and 30.4% reported at least one LUTS.Of the individual LUTS, 27.9% of men reported frequency, 16.5%with urgency, 2.9% with burning and/or pain, 1.5% with hematuria, and 2.9% with incontinence (Table 1).In women, 22.4% reported frequency, 12.6% with urgency,2.2%with burning/pain,1.7%with hematuria,and 5.6%with incontinence.There was a higher proportion of men reported any LUTS when compared to women (32.9% vs.28.6%,p=0.01);however,women reported higher rates for incontinence than men (5.6% vs.2.9%, p=0.003) and there were no differences in burning and/or pain and hematuria between the two genders.When comparing participants with OAB-dry,more men met the OAB-dry symptom criteria than women (28.8% vs.21.2%, p<0.001).

Table 2 describes the differences in characteristics and comorbidities between men without LUTS and men with LUTS.Of the included comparisons,there were statistically significant differences between men with and without LUTS, except for alcohol use frequency (p=0.10) and cognitive mental status (p=0.40).Table 3 describes the differences between women without LUTS and women with LUTS.Similar to the comparisons made among men,women without LUTS and with LUTS also demonstrated many statistically significant differences between the two groups.However, there were more characteristics that demonstrated no significant difference, including BMI (p=0.18),education level (p=0.42), smoking status (p=0.23),alcohol use (p=0.18), practice of Tai Chi (p=0.20), or any cancer (p=0.07).When comparing between the two genders, women with LUTS had a poorer general health perception than men with LUTS(p=0.01)and there was no difference in the quality of life responses between men andwomen(Table 4).Similar differences in the characteristics,comorbid conditions, and health perceptions were also noted when examining the OAB-dry subgroup in each gender; however, activities of daily living scores in both genders and men’s marital status, depression, and any cancer histories were no longer significant (Tables 2-4).

Table 1 Demographics and LUTS prevalence.

Table 5 describes the multivariable logistic regression analysis used to evaluate LUTS while controlling for gender,age, BMI, education, marital status, smoking status, NAGI score, TCM use status, the practice of Tai Chi, hypertension, heart disease, anxiety, and depression.Female gender (adjusted odds ratio [aOR] 0.60, 95% confidence interval [CI] 0.49-0.73), being married (aOR 0.79, 95% CI 0.65-0.97),and smoking(aOR 0.66,95%CI 0.49-0.88)were found to be associated with a lower odds for reporting any LUTS; while frequent TCM use (aOR 1.51, 95% CI 1.28-1.78), heart disease (aOR 1.54, 95% CI 1.24-1.91),and anxiety (aOR 1.69, 95% CI 1.25-2.28) were most strongly associated with increased odds of reporting any LUTS in the general population.When applying the same multivariable regression to the OAB-dry subgroup only, female gender (aOR 0.52, 95% CI 0.42-0.63), and smoking(aOR 0.67, 95% CI 0.49-0.90) were again found to be protective, while frequent TCM use (aOR 1.51, 95% CI 1.26-1.80), heart disease (aOR 1.47, 95% CI 1.18-1.84),and anxiety(aOR 1.47,95%CI 1.08-2.01)were again found to be most associated with increased odds of reporting OAB-dry symptom.

Controlling for the same variables,we analyzed the male and female cohorts separately in order to examine whether there are gender differences in those reporting LUTS.Again in Table 5, we found being married was protective only for women with LUTS(aOR 0.75,95%CI 0.59-0.96),but not for men.Depression was also strongly associated with LUTS in women (aOR 1.70, 95% CI 1.28-2.26) while anxiety wasassociated with LUTS in men(aOR 2.74,95%CI 1.54-4.87).Frequent TCM use was the only factor that was significantly associated with an increased odds of LUTS in both men and women (aOR 1.33, 95% CI 1.02-1.73 and aOR 1.62, 95% CI 1.30-2.02, respectively).Other gender-specific factors that were associated with an increased odds of LUTS in men but not women included hypertension (aOR 1.37, 95% CI 1.05-1.78), heart disease (aOR 1.91, 95% CI 1.39-2.61),and practice of Tai Chi(aOR 1.78,95%CI 1.21-2.62).When analyzing the OAB-dry subgroup, most associations were similar to those found in LUTS;however,smoking was found to be protective (aOR 0.72, 95% CI 0.52-0.99) only in men who reported OAB-dry symptoms.

Table 2 Characteristics and comorbidities of men with or without LUTS and OAB-dry symptom.

4.Discussion

This large population-based database study examined factors associated with LUTS in an underrepresented population.LUTS are common among older Chinese Americans with OAB-dry being the most predominant phenotype.Chinese American men had a higher prevalence of reporting any LUTS and OAB-dry than women;however,more women reported incontinence than men.Additionally, there were gender-specific characteristics associated with either increased or decreased odds of reporting any LUTS, but frequent TCM use was the only characteristic common to both genders with an increased odds of reporting LUTS.

Table 3 Characteristics and comorbidities of women with or without LUTS and OAB-dry symptom.

As TCM remains commonly used among the Chinese Americans, the association of LUTS to TCM users is particularly interesting and relevant.While people of Chinese ancestry are not the only ones using TCM,it is still the most prevalent among Asian American communities when compared to other cultures [22].Based on the theoretical framework of TCM, the body can become disharmonious when it is offended by external or internal forces [23].Specifically,in the genitourinary system,the disharmonious forces may originate externally via exposure to coldness and/or internal repression of emotions (such as anger and anxiety) [24].There is a paucity of data on the effect of TCM to the lower urinary tract [25].In our study, we found an association between TCM use and LUTS; however,as we do not know the indication for the TCM use in our study population, we cannot discern whether patients were taking TCM to treat LUTS or if patients who were taking TCMfor treatment of other conditions developed LUTS as a side-effect.More studies dedicated to exploring the relationship between TCM and LUTS are warranted to determine whether TCM use could be a modifiable risk factor to LUTS or whether TCM is a common remedy for the treatment of LUTS among Chinese Americans.

Table 4 Individual perception of health and life quality.

The relationship between depression and/or anxiety and LUTS as demonstrated in this study echoes the current literature [26].It has been established that serotonin has effects over the central nervous system and also influences urinary tract functions [27].Our finding reaffirms the need to address mental health when patients present with LUTS.However, it is unclear why depression but not anxiety was significantly associated with LUTS in women but not men and vice versa.Interestingly,being married was associated with decreased odds of LUTS and OAB-dry in Chinese American women.This finding may be supported by the past findings that marital functioning is consequential for health as it provides social support, thus improves physiological functioning, and subsequently maintains lower urinary tract health[28].The connection between depression and/or anxiety and LUTS appears widely applicable,including among older Chinese Americans based on this study.

For male-specific risk factors, we confirmed the previously identified associations between LUTS and hypertension as well as heart disease.Sugaya et al.[29] had demonstrated that men with hypertension had more significant LUTS than those without hypertension.Given hypertension being a major public health burden and commonly associated with increased risks for heart disease,it is important to address cardiovascular health whenChinese American men report LUTS.On the other hand,our study also found men who reported practicing Tai Chi to have increased odds of reporting LUTS.However, this may be due to Tai Chi being considered as a complementary treatment in Asian communities to reduce sympathetic nervous system input and stress,which are related to LUTS[30,31].Jung et al.[32] found that Tai Chi specifically improved LUTS in older men with benign prostate hyperplasia.Further studies are warranted to determine the possible therapeutic relationships between Tai Chi and LUTS.Lastly, although we noted an association between higher education levels with increased odds of reporting LUTS in men, we did not find an association between education level and OAB-dry symptoms in men.

There are limitations to this study.First, given the design of this study, we cannot determine temporal or causal relationships between LUTS and their associated factors.More research is needed to better understand these factors, including gender differences in health perception that could potentially influence the prevalence of LUTS in this population.Second,the data may be subject to recall bias since responses were based on participants’retrospective memories.Third, the results might not be generalizable to other populations.The prevalence of LUTS in this Chinese American city-dwelling population was half the rate reported in other studies investigating LUTS in people of Asian descent[10].This discrepancy might be due to differences in design across the studies, i.e.different tools used to measure LUTS; however, the difference also might reflect unique environmental and sociocultural factors experienced by the Chinese Americans in our cohort,which could in turn impact their bladder health.Fourth,due to the design of the original study, this secondary analysis relied on a genitourinary ROS question to identify LUTS rather than a validated questionnaire.Therefore, we do not have detailed information on LUTS subtypes,such as nocturia, postmicturition symptoms, and types of incontinence.Moreover,given the heterogeneity of LUTS captured by the ROS question, we performed a sub-analysis of OAB symptoms alone.Although genitourinary ROS does not provide the granular details of lower urinary tract symptomology, the ROS provides an accessible way to evaluate this large population speaking predominately in regional dialects and subsequently portrays preliminary understanding of LUTS among this particular population which could lead to future inclusive and culturally specific research.

Despite the possible limitations, this study is strengthened by its large sample of a minority population.The questionnaires and their responses were rich in details with culturally sensitive data which have been largely understudied in the LUTS research.Finally, ROS here was a practical tool to broadly measure LUTS among this traditionally marginalized US population in medical research.

5.Conclusion

This is the first study that sheds light on LUTS amongst community-dwelling older Chinese Americans.This study provides two significant implications for healthcare professionals caring for older Chinese Americans.First,gender-specific differences were noted in factors associated with LUTS and OAB-dry.By understanding the unique comorbidities associated with LUTS in men and women,healthcare and aging professionals could more precisely treat and/or prevent LUTS.Second, it is important for researchers and care providers to consider how TCM plays a role in LUTS.We found TCM use to be the only common factor associated with LUTS in both genders.Expanded research on LUTS is needed to better comprehend the complexity of lower urinary tract symptomology and etiology in the increasingly diverse populations.

Author contributions

Study concept and design: Tsung Mou, Melissa Simon, Kimberly Kenton, C.Emi Bretschneider.

Data acquisition: Yingxiao Hua, Melissa Simon, XinQi Dong.Data analysis: Yingxiao Hua.

Drafting of manuscript: Tsung Mou, Oluwateniola Brown.Critical revision of the manuscript: Kimberly Kenton, C.Emi Bretschneider.

Conflicts of interest

The authors declare no conflict of interest.

Acknowledgement

Data collection for the Population Study of Chinese Elderly(PINE, R01AG042318, PI: XinQi Dong) was supported by the National Institute on Aging.The funding agent had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.