Background
Women are more likely to present with genitourinary complaints immediately after exposure to interpersonal violence, but little is known about the long-term effects of violence on women’s urologic health, including their susceptibility to bladder pain and infections.
Objective
To determine whether lifetime interpersonal violence exposure and current posttraumatic stress disorder (PTSD) symptoms are associated with the prevalence or severity of painful bladder symptoms and a greater lifetime history of antibiotic-treated urinary tract infections in community-dwelling midlife and older women.
Study Design
We examined the cross-sectional data from a multiethnic cohort of community-dwelling women aged 40 to 80 years enrolled in a northern California integrated healthcare system. Women completed structured self-report questionnaires about their past exposure to physical and verbal/emotional intimate partner violence and sexual assault. The symptoms of PTSD were assessed using the PTSD checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Civilian version. Additional structured self-report measures assessed the current bladder pain, other lower urinary tract symptoms, and the history of antibiotic-treated urinary tract infections. Multivariable logistic regression models examined self-reported interpersonal violence exposure history and current PTSD symptoms in relation to current bladder pain and antibiotic-treated urinary tract infection history.
Results
Among 1974 women (39% non-Latina White, 21% Black, 20% Latina, and 19% Asian), 22% reported lifetime interpersonal violence exposure, 22% reported bladder pain, and 60% reported a history of ever having an antibiotic-treated urinary tract infection. Lifetime experiences of sexual assault (odds ratio, 1.39; [95% confidence interval, 1.02–1.88]) and current PTSD symptoms (odds ratio, 1.96; [95% confidence interval, 1.45–2.65]) were associated with current bladder pain. A lifetime experience of physical intimate partner violence was associated with having a urinary tract infection at any time in life previously (odds ratio, 1.38; [95% confidence interval, 1.00–1.86]), as was emotional intimate partner violence (odds ratio, 1.88; [95% confidence interval, 1.43–2.48]), sexual assault (odds ratio, 1.44; [95% confidence interval, 1.09–1.91]), and current PTSD symptoms (odds ratio, 1.54; [95% confidence interval, 1.16–2.03]).
Conclusion
In this ethnically diverse, community-based cohort, lifetime interpersonal violence exposures and current PTSD symptoms were independently associated with current bladder pain and the lifetime history of antibiotic-treated urinary tract infections in midlife to older women. The findings suggest that interpersonal violence and PTSD symptoms may be underrecognized markers of risk for urologic pain and infections in women, highlighting a need for trauma-informed care of these issues.
Introduction
Bladder pain syndrome (BPS), defined as chronic pain, pressure, or discomfort associated with the bladder, is one of the most common reasons for invasive urological or gynecologic procedures. , Despite research linking BPS to depression, inflammatory syndromes, and other chronic pain conditions, the epidemiologic factors influencing its development and persistence are poorly understood. One potentially under-recognized risk factor for chronic bladder pain in women is exposure to interpersonal violence, including intimate partner violence (IPV). The Centers for Disease Control and Prevention estimates that half of the US women have experienced psychological IPV and a quarter have experienced physical IPV in their lifetime.
Why was this study conducted?
Prior studies conducted in reproductive-age women have pointed to higher rates of urinary tract infections and genitourinary symptoms in the immediate aftermath of an interpersonal violence exposure. This study addresses whether the lifetime interpersonal violence experiences are associated with a greater risk of urinary symptoms later in life.
Key findings
Lifetime interpersonal violence exposure and current posttraumatic stress disorder symptoms were independently associated with current bladder pain symptoms and with ever having an antibiotic-treated urinary tract infection in multiethnic, community-based midlife to older women.
What does this add to what is known?
Interpersonal violence and posttraumatic stress disorder may be underrecognized markers of risk for urologic pain and infections, highlighting a need for trauma-informed care of these issues.
Prior studies conducted primarily in reproductive-age women have pointed to higher rates of urinary tract infections (UTIs) and genitourinary symptoms in the immediate aftermath of an interpersonal violence exposure. , However, few studies have addressed whether lifetime interpersonal violence experiences are associated with a greater risk of urinary symptoms over the lifespan. ,
To address these gaps, we examined the associations between interpersonal violence exposures and painful bladder symptoms and UTI in a large, multiethnic cohort of midlife and older community-dwelling women. We hypothesized that lifetime interpersonal violence exposure would be associated with an increased prevalence of painful bladder symptoms and a greater lifetime history of UTI. Our goal was to guide potential future strategies for identifying women at a high risk of urologic pain and infections related to trauma exposure to promote trauma-informed care of these conditions.
Materials and Methods
Study population
We analyzed the cross-sectional data from the Reproductive Risks of Incontinence Study at Kaiser (RRISK). It is a community-based cohort study of midlife and older women enrolled in Kaiser Permanente Northern California (KPNC), which is an integrated healthcare delivery system. The inclusion criteria comprised being at least 40 years old, enrolled in KPNC since age 21, and reporting at least half of any childbirth events within KPNC facilities. The participants were randomly sampled from within age and race or ethnicity strata for a robust representation across age and racial and ethnic groups that are underrepresented in prior US research, particularly African-American, Asian-American, and Hispanic or Latina women. Approximately 20% were recruited from the KPNC Diabetes Registry to ensure an adequate representation of women with diabetes, but women were not selected on the basis of urinary symptoms or of interpersonal trauma history. This report focused on the third data collection wave of the RRISK study (RRISK3) from 2008 to 2012, which included an assessment of interpersonal violence experiences. The RRISK3 visits included interviews, questionnaires, and exams conducted by research assistants in the participants’ homes. Written informed consent was obtained from the participants at the time of data collection. The study procedures were approved by the institutional review boards of the University of California San Francisco and KPNC.
Exposure and outcome measures
Prior exposure to IPV and sexual assault were assessed during RRISK3 visits using structured-item questionnaire measures adapted from prior studies ( Table 1 ). Given the community-based context, the questions were designed to be easily understood by a diverse population. For IPV, the participants were asked to distinguish between physical violence (being hit, slapped, pushed, shoved, punched, or threatened with a weapon) and emotional abuse (being severely criticized, told that they were a stupid or worthless person, or threatened with harm) by an intimate partner. Sexual assault was assessed by asking about being touched in the sexual areas of the body without consent. Posttraumatic stress disorder (PTSD) symptoms were assessed using the self-administered PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition—Civilian version, which is a 17-item questionnaire previously validated to assess the PTSD symptoms within the last month related to past traumatic exposures. For this measure, a score of 30 has been shown to indicate probable PTSD symptoms in primary care populations.
| Exposures | Questions |
|---|---|
| Physical interpersonal violence | Have you ever been physically abused by being hit, slapped, pushed, shoved, punched, or by being threatened with a weapon by a current or former spouse or intimate partner? |
| Has this occurred in the past 12 mo? | |
| Emotional interpersonal violence | Have you 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 a current or former spouse or intimate partner? |
| Has this occurred in the past 12 mo? | |
| Sexual interpersonal violence | Has anyone ever touched sexual parts of your body after you said or showed that you did not want them to, or without your consent (for example being groped, fondled or raped)? |
| How old were you the first time this happened? | |
| How old were you the last time this happened? |
| Outcomes | Questions |
|---|---|
| Bladder pain (any≥1, moderate-to-severe≥6) | During the past 3 mo, on a scale from 0 to 9, how would you rate the pain or discomfort associated with your bladder? |
| Ever having a UTI | Have you ever taken antibiotics for a bladder infection (also called UTIs or cystitis)? |
| UTIs in the past 12 mo | How many times in the last 12 mo have you been treated with antibiotics for a bladder infection? |
| Urinary urgency | During the past month, how often have you found it difficult to postpone urination? |
| Urinary frequency | During the past month, how often have you had to urinate again <2 h after you finished urinating? |
The presence and severity of the bladder pain were assessed using the questions adapted from validated measures, including the American Urological Association Symptom Index (AUA-SI) and the Urogenital Distress Inventory ( Table 1 ). The participants were asked to describe the severity of the pain or discomfort associated with their bladder over the past 3 months, and the severity fell in the following ranges: no pain (0); mild pain, which is defined by awareness without having to suspend usual activities (3); moderate pain, defined by enough pain/discomfort to interfere with usual activities (6); and severe pain that abruptly stops all activity or tasks (9). The analyses focused on bladder pain identified as being (1) at least mild, or (2) at least moderate in severity.
The self-reported lifetime history of clinician-diagnosed UTI was assessed by asking women if they had ever received antibiotics for a UTI and antibiotic UTI treatment in the past 12 months ( Table 1 ). The symptoms commonly associated with bladder pain such as urgency, frequency, and inability to postpone urination were assessed using AUA-SI items.
The sociodemographic and general clinical characteristics were assessed by self-report, including age, race and ethnicity, immigration status, employment, educational attainment, parity, relationship status, general health status, and sexual activity status. The menopausal status was defined by self-reported cessation of menses for 12 months or bilateral oophorectomy. Diabetes and depression were defined by self-reported clinician diagnoses of these conditions. Pelvic surgical history was based on self-reported surgery to the bladder, uterus, ovaries, colon, or rectum. The height and weight were directly measured by trained study staff to calculate the body mass index (BMI).
Statistical analyses
Descriptive statistics including the frequencies and percentages for the categorical data and the mean values with standard deviations for the continuous data were used to summarize the key exposure and outcomes variables and covariables. The differences in the prevalence of exposure and outcomes variables across racial and ethnic groups were examined with chi-square analyses. In multivariable logistic regression analyses, each type of interpersonal violence (physical IPV, emotional IPV, and sexual assault) was separately modeled as an exposure associated with each type of urologic problem (any bladder pain, moderate-to-severe bladder pain, a lifetime history of antibiotic-treated UTI, and antibiotic-treated UTI in the last 12 months) as outcomes. Similarly, separate multivariable logistic regression models were conducted to examine the association of clinically significant PTSD symptoms to each type of urologic problem. The models were adjusted for age, self-reported race and ethnicity, immigration status, overall health, sexual activity, menopausal status, prior pelvic surgery, diabetes, and obesity (BMI>30 kg/m 2 ) as the factors identified a priori from the literature as being likely to confound the association between interpersonal violence or trauma experiences and bladder pain or UTI history. Additional exploratory models further adjusted for depression as a potential confounder of the relationships between interpersonal violence experience and bladder pain. All analyses were conducted using SAS version 9.4. A formal correction for multiple comparisons was not conducted.
Results
Characteristics of the sample
Of the 4819 women notified about the opportunity to participate in the RRISK3 study, 3438 (72%) met the eligibility criteria based on a 10-year age strata and race and ethnicity. Of these potentially eligible women, 2016 (59%) agreed to enroll in the study and completed a study visit. Of these, 1974 (98%) provided data about interpersonal violence exposure and either bladder pain or UTI history. Within this analytical sample, 39% were non-Latina White, 21% were Black, 20% Latina/Hispanic, and 19% Asian or Pacific Islander. The mean (standard deviation [SD]) age was 60.2 (9.5) years, and most women were born in the United States (70%) and were college-educated (86%), married or living as married (65%) and were sexually active (58%) ( Table 2 ). Few reported fair or poor overall health (14%), but 20% reported having any pelvic surgery. The majority were postmenopausal (90%) and overweight or obese (73%). Almost a fifth reported prior diagnosis with depression (18%).
| Characteristics | Women, N (%) N=1974 |
|---|---|
| Mean age (SD) | 60.2 (±9.5) |
| Race or ethnicity | |
| White, European, or Middle Eastern | 778 (39) |
| Black or African-American | 416 (21) |
| Latina or Hispanic | 394 (20) |
| Asian or Pacific Islander | 381 (19) |
| Immigration status | |
| Born in the United States | 1389 (70) |
| Employment | |
| Full time | 636 (33) |
| Part time | 210 (11) |
| Retired | 1002 (52) |
| None of the above | 88 (5) |
| Household income | |
| <$30,000 | 229 (12) |
| $30,000–$59,999 | 509 (26) |
| $60,000–$89,999 | 429 (23) |
| $90,000–$119,999 | 295 (15) |
| $120,000+ | 443 (23) |
| Education | |
| Did not complete high school | 38 (2) |
| Completed high school | 262 (14) |
| Some or completed college | 1100 (57) |
| Some or completed graduate or professional school | 542 (29) |
| Relationship and sexual activity status | |
| Single | 184 (9) |
| Married, living as married, or involved in a significant relationship | 1252 (65) |
| Separated, divorced, or widowed | 506 (26) |
| Sexual activity in the past 3 mo | 1103 (58) |
| Health history | |
| Poor or fair overall health | 250 (14) |
| Diabetes mellitus | 469 (24) |
| Depression | 346 (18) |
| Number of births mean (SD) | 2.1 (±1.4) |
| Any pelvic surgery history | 397 (20) |
| Hysterectomy | 80 (4) |
| Oophorectomy | 84 (4) |
| Appendectomy | 30 (2) |
| Uterine procedure (D&C, abortion) | 102 (5) |
| Surgical management of urinary incontinence | 34 (2) |
| Surgical management for pelvic organ prolapse | 40 (2) |
| Surgery on anus | 12 (1) |
| Surgery on colon | 24 (1) |
| Postmenopausal | 1736 (90) |
| Taking hormone replacement therapy | 177 (9) |
| BMI | |
| Underweight or normal weight (BMI<25.0) | 523 (26) |
| Overweight (BMI 25.0–29.9) | 582 (29) |
| Obese (BMI≥30.0) | 869 (44) |
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