BACKGROUND/RATIONALE:
Urogenital symptoms, including urinary incontinence and frequency, commonly affect women of reproductive age and negatively impact quality of life. Such urinary symptoms are among the top 10 problems reported to primary care providers by women.

In a cross-sectional study of 1000 reproductive-aged women veterans, we found 25% reported at least weekly stress urinary incontinence and 10% weekly urgency urinary incontinence, higher rates than expected from studies of similar aged women in the general population. Depression and post-traumatic stress disorder (PTSD) were also common, and women veterans who reported urgency urinary incontinence were more likely to have depression and PTSD compared to women with no urinary incontinence.

Similar to these findings, overactive bladder (OAB) (urinary frequency, urgency and/or urgency urinary incontinence) has been associated with depression and anxiety in non-veteran populations, but an association between urinary and mental health symptoms may be particularly relevant in women veterans, who have high rates of mental health disorders.

We hypothesized that the high prevalence of urgency urinary incontinence and other urinary symptoms in women veterans in our preliminary study was related to their high rates of depression and PTSD.

OBJECTIVE(S):
1. Define the prevalence and 1-year incidence and remission rates of urogenital symptoms, especially overactive bladder (urgency urinary incontinence and/or urinary frequency), in a representative population of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) women veterans.

2. Identify the impact of depression, anxiety and PTSD symptoms, a history of sexual assault, and deployment-related factors on the prevalence and 1-year incidence of urogenital symptoms, especially overactive bladder (urgency urinary incontinence and/or urinary frequency).

METHODS:
This was a 1-year prospective, longitudinal study in OEF/OIF/OND women veterans from diverse racial/ethnic backgrounds and geographic areas. Participants included women veterans who completed regular military or Reserve/National Guard service including an Iraq or Afghanistan deployment within the past 2 years and then separated from the military. Women veterans meeting these criteria were identified using the Defense Manpower Data Center (DMDC) and recruited by mail and telephone. Telephone screening confirmed participants were ambulatory, community-dwelling veterans who returned from deployment in the past 24 months. Veterans reporting a history of genital fistula, congenital urinary tract abnormality, pelvic radiation, lower urinary tract cancer, spinal cord injury, multiple sclerosis, Parkinson's disease or stroke and those with current or recent pregnancy were excluded.

Enrollment occurred between July 2010 and July 2012. Data collection included computer-assisted telephone interviews performed at enrollment and 1 year later. The interview included a detailed assessment of urogenital symptoms, depression, anxiety and PTSD symptoms, socio-demographic variables, sexual trauma and deployment-related factors. Urogenital and mental health outcomes were identified using validated, diagnostic questionnaires based on current symptoms. OAB was identified if at least moderately bothersome urgency urinary incontinence and/or urinary frequency symptoms were reported. Statistical analyses included descriptive statistics, bivariate comparisons and adjusted analyses (using propensity scores).

FINDINGS/RESULTS:
The DMDC identified 7759 women as potentially eligible during the enrollment period. 3550 were reached by mail or telephone, confirmed as eligible and asked to participate. Of these, 1773 (50%) were enrolled and baseline interviews completed in 1702 women. 1102 1-year interviews were completed.

The 1702 participants had mean age of 31 years and were racially/ethnically diverse (59% white, 21% black, 11% Hispanic, and 5% Asian). 52% were nulliparous. Most had served in the army (73%). 88% were deployed from the active component military and 12% from Reserve/Guard. 17% were officers. PTSD, depression and anxiety were identified in 19%, 10% and 21%, respectively. 27% reported prior completed sexual assault, including 12.9% and 1.6% who reported prior military sexual assault and sexual assault during the recent deployment, respectively. Fewer than half (42%) reported receiving VA care in the past year.

Aim 1:
At baseline, 375 (22.0%; 95% CI (20.1%, 24.1%)) reported OAB. 18.6% reported bothersome stress incontinence and 6.1% bladder pain symptoms. Bowel symptoms were also reported, including fecal incontinence (10.7%), constipation (9.2%) and irritable bowel syndrome (8.2%) symptoms. At 1 year, the prevalence of OAB remained 22%, however OAB symptom status changed over time for some women. The 1-year incidence of OAB was 10.5% and the remission rate 36.9%.

Aim 2:
At baseline, PTSD, anxiety, depression and prior sexual assault were all more common in those with OAB, compared to women without OAB (adjusted OR (95%CI) = 2.7 (2.0, 3.6), 2.7 (2.0, 3.5), 2.5 (1.5, 4.3) and 1.4 (1.1, 1.9) respectively). Urinary symptom bother and functional impact were also increased in those with mental health symptoms and prior sexual assault. At 1 year, new OAB symptoms were more likely to occur in women with PTSD, anxiety and prior sexual assault at baseline (p<0.01 for all).

IMPACT:
This longitudinal, epidemiologic study finds that urogenital symptoms are common in recently-deployed women veterans. 1 in 3 younger women veterans reports OAB, stress urinary incontinence and/or painful bladder symptoms. Twenty percent report OAB symptoms, and these symptoms are more common in women veterans with PTSD, depression, anxiety and prior sexual assault. Women veterans with PTSD, anxiety and prior sexual assault also have a greater risk of developing new OAB symptoms after 1 year.

These results are important to VA and non-VA clinicians, especially urologists, gynecologists and others who commonly provide care for reproductive-age women veterans. By educating clinicians to prevalent and bothersome urogenital symptoms and the impact of deployment- and military-related risk factors including mental health symptoms and sexual trauma, we aim to increase screening and treatment of both urogynecologic and mental health problems in OEF/OIF/OND women veterans.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Bradley CS, Nygaard IE, Hillis SL, Torner JC, Sadler AG. Longitudinal associations between mental health conditions and overactive bladder in women veterans. American journal of obstetrics and gynecology. 2017 Oct 1; 217(4):430.e1-430.e8. [view]
2. Bradley CS, Nygaard IE, Torner JC, Hillis SL, Johnson S, Sadler AG. Overactive bladder and mental health symptoms in recently deployed female veterans. The Journal of urology. 2014 May 1; 191(5):1327-32. [view]

HSR&D or QUERI Articles

1. Sadler AG. Women and Post-Deployment Health. HSR&D FORUM: Translating Research into Quality Health Care for Veterans. 2011 May 1; 6. [view]

Conference Presentations

1. Bradley CS, Nygaard J, Torner J, Hillis SL, Johnson SR. Overactive Bladder and Mental Health Symptoms in Recently Deployed Women Veterans. Poster session presented at: American Congress of Obstetricians and Gynecologists Annual Conference; 2013 May 7; New Orleans, LA. [view]
2. Bradley CS. Panel Presentation: Women's Health Breakout Session. Presented at: VA Office of Rural Health / Veterans Rural Health Central Region Biannual Meeting; 2011 Sep 13; Iowa City, IA. [view]
3. Burgio KL, Goode PS, Daigle SG, Markland AD, Bradley CS, Patel TH, Makarov DV, Newman DK, Moore EE, Feibus KB, Zephyrin L. Partnership to Enhance Care for Women Veterans with Pelvic Floor Disorders. Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA. [view]
4. Bradley CS, Nygaard IE, Torner J, Hillis SL, Johnson SR, Sadler AG. Prevalence and Overlap of Urinary and Bowel Disorders in Younger Women Veterans. Poster session presented at: American Urogynecologic Society Annual Scientific Meeting; 2012 Oct 5; Chicago, IL. [view]
5. Bradley CS, Nygaard IE, Hillis SL, Torner J, Lu X, Sadler AG. The Impact of Mental Health Conditions on Incidence and Remission of Overactive Bladder. Paper presented at: American Urogynecologic Society Annual Scientific Meeting; 2014 Jul 23; Washington, DC. [view]
6. Bradley CS, Nygaard IE, Hillis SL, Torner J, Lu X, Sadler AG. The Impact of Mental Health Conditions on Incidence and Remission of Overactive Bladder in Recently Deployed Women Veterans. Paper presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Other Conditions
DRE: Epidemiology, Etiology, Diagnosis
Keywords: Deployment Related, PTSD, Women - or gender differences
MeSH Terms: none