Tag Archive for: comorbidity


Article of the week: Cluster analysis of multiple chronic conditions associated with urinary incontinence among women in the USA

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a new residents’ podcast focussing on this article. 

If you only have time to read one article this week, it should be this one.

Cluster analysis of multiple chronic conditions associated with urinary incontinence among women in the USA

Alayne D. Markland*, Camille P. Vaughan§, Ike S. Okosun, Patricia S. Goode*, Kathryn L. Burgio*and Theodore M. Johnson II§


*Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama-Birmingham UAB School of Medicine, Birmingham/Atlanta VA Geriatric Research, Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, Birmingham/Atlanta VA Geriatric Research, Education and Clinical Center, Atlanta VA Medical Center, Decatur, §Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine and Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA, USA




To identify patterns of prevalent chronic medical conditions among women with urinary incontinence (UI).

Materials and Methods

We combined cross‐sectional data from the 2005–2006 to 2011–2012 US National Health and Nutrition Examination Surveys, and identified 3 800 women with UI and data on 12 chronic conditions. Types of UI included stress UI (SUI), urgency UI (UUI), and mixed stress and urgency UI (MUI). We categorized UI as mild, moderate or severe using validated measures. We performed a two‐step cluster analysis to identify patterns between clusters for UI type and severity. We explored associations between clusters by UI subtype and severity, controlling for age, education, race/ethnicity, parity, hysterectomy status and adiposity in weighted regression analyses.


Eleven percent of women with UI had no chronic conditions. Among women with UI who had at least one additional condition, four distinct clusters were identified: (i) cardiovascular disease (CVD) risk‐younger; (ii) asthma‐predominant; (iii) CVD risk‐older; and (iv) multiple chronic conditions (MCC). In comparison to women with UI and no chronic diseases, women in the CVD risk‐younger (age 46.7 ± 15.8 years) cluster reported the highest rate of SUI and mild UI severity. In the asthma‐predominant cluster (age 51.5 ± 10.2 years), women had more SUI and MUI and more moderate UI severity. Women in the CVD risk‐older cluster (age 57.9 ± 13.4 years) had the highest rate of UUI, along with more severe UI. Women in the MCC cluster (age 61.0 ± 14.8 years) had the highest rates of MUI and the highest rate of moderate/severe UI.


Women with UI rarely have no additional chronic conditions. Four patterns of chronic conditions emerged with differences by UI type and severity. Identification of women with mild UI and modifiable conditions may inform future prevention efforts.



Editorial: Urinary incontinence and the causality dilemma

Fundamentally, the aetiology of most female urinary incontinence (UI) remains an enigma. Although we gain comfort in our conceptualisations of anatomical defects and neurological compromise as contributing factors, most of our therapies for UI are directed at symptomatic control instead of a disease prevention or modification. Thus, the principal drivers of female UI symptoms remain elusive. The premise of the series published in this issue by Markland et al. [1], to identify patterns of comorbid conditions in patients with various types of UI, is a valid and intriguing question, and this effort provides an important component of emerging concepts of the pathophysiology of UI development in women. The authors describe the analysis of cross‐sectional data from the National Health and Nutrition Examination Surveys (NHANES) and report on 3800 women with UI. Exploration of associations between UI with patient demographics and medical conditions revealed fascinating relationships and not surprisingly, a high prevalence of comorbid conditions in patients with self‐reported UI. Thus, despite the known limitations of such a cross‐sectional analysis, this study by Markland et al. [1] provides provocative information to achieve actionable mandates.

The novel approach described in the article of developing cluster analysis revealed four distinct patterns between UI and multiple chronic conditions. One of the most dominant relationships that merits intense exploration is the relationship between common conditions of hypertension, hyperlipidaemia, and increased cardiovascular disease (CVD) risk. Indeed, CVD remains a leading cause of death in women in the USA [2]. Population‐based analysis has hinted at possible connections between CVD and UI, although determinative causality has not been established [3, 4]. UI in women may reflect a similar vascular pathology to erectile dysfunction (ED) in men, potentially resultant from a gradual compromise of the delicate neurovascular anatomy required for normal sphincter and detrusor activity. In women, no such prodromal syndrome or symptom such as ED in men has been acknowledged to prompt CVD screening in otherwise asymptomatic patients.

Alternately, one might interpret this cluster data to indicate that multimorbid chronic conditions and increasing age are sufficient in the development of UI, although assigning such risk silos is disposed to misconceptions. The contribution of polypharmacy in these clusters is a decidedly substantial component for careful consideration. However, data extracted from such survey sampling have inherent complexities that limit defining causality, so how do we retrospectively discern understanding viewing the insults of a lifetime resulting in UI? The short answer is, we do not.

We must extract ourselves from the realm of symptom suppression for women with UI and direct resources to a broader view of the life course of the condition. In addition to the expansive phenotyping efforts ongoing from the National Institute of Diabetes and Digestive Kidney Disease (NIDDK) through the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN), no initiative speaks to the endeavor to principally change paradigms about bladder health in women more than the pioneering concept of The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium [5]. The PLUS consortium is dedicated to promoting prevention of LUTS across the woman’s life spectrum, which roots in the appreciation of progression of factors contributing to disease. Without this critical transdisciplinary approach, comprehension of the base aetiology of UI, and our continued attempts to mask symptoms, may propagate further deterioration of systemic manifestations of primary high‐risk diseases in our patients.


  1. Markland AD, Vaughn CP, Okosun IS, Goode PS, Burgio KL, Johnson TM, 2nd. Cluster analysis of multiple chronic conditions associated with urinary incontinence among women in the USA. BJU Int 2018; 122: 1041–8
  2. National Institutes of Health and National Heart, Lung, and Blood Institute. Morbidity & Mortality: 2009 Chart Book on Cardiovascular, Lung, and Blood Diseases. Available at: https://ecopmc.files.wordpress.com/2012/04/2009_chartbook.pdf. Accessed July 2018
  3. Coyne KS, Kaplan SA, Chapple CR et al. Risk factors and comorbid conditions associated with lower urinary tract symptoms: EpiLUTS. BJU Int 2009; 103 (Suppl. 3): 24–32
  4. Andersson KE, Sarawate C, Kahler KH, Stanley EL, Kulkarni AS. Cardiovascular morbidity, heart rates and use of antimuscarinics in patients with overactive bladder. BJU Int 2010; 106: 268–74
  5. Harlow BL, Bavendam TG, Palmer MH et al. The Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium: a transdiciplinary approach toward promoting bladder health and preventing lower urinary tract symptoms in women across the life course. J Womens Health (Larchmt) 2018; 27: 283–9



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