This article is based on a panel discussion at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) 2025 Winter Meeting celebrating the 75th anniversary of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). For additional articles related to the SUFU conference, see the May 2025 issue of AUANews.

The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium is in its 10th year of funding from the NIDDK. At the 2025 SUFU annual meeting in Palm Springs, California, the major accomplishments of the consortium, including its more than 61 peer-reviewed publications, were presented to share the breadth of data collected that will be available to the scientific community for secondary analyses.

At inception in 2015, PLUS had a vision to improve bladder health among women and girls. Early work of the consortium included developing and publishing a definition of bladder health¹ (“A complete state of physical, mental, and social well-being related to bladder function, and not merely the absence of lower urinary tract symptoms [LUTS].” Healthy bladder function “permits daily activities, adapts to short-term physical and environmental stressors, and allows optimal well-being [eg, travel, exercise, social, occupational, or other activities].”) Next, the consortium developed and published a conceptual framework to guide bladder health research.² This framework integrates a life course perspective acknowledging that different factors impact the bladder at differ times in life, a social ecological perspective with the understanding that health behaviors are determined by multiple social factors outside of the individual, and biological considerations.

Using the conceptual framework, the consortium developed a comprehensive list of potential risk factors influencing the bladder. There were more than 600 factors generated that were clustered into the 8 broad research themes (Figure 1). Across the 8 themes, 27 research questions were prioritized for study. To answer these questions, the consortium used rigorous psychometric principles to develop and validate a self-reported measure of bladder health, the Bladder Health Scales and Bladder Function Indices³ (Table). Each scale measures an individual’s perception of their bladder and how well it works in various situations. The Bladder Function Indices measure how well the bladder performs. The instrument also captures adaptive/coping behaviors related to the bladder creating a score of 0 to 100, with 100 indicating perfect bladder health. Consortium content experts developed additional instruments to measure novel factors such as toileting environment, bladder knowledge and beliefs, and self-care practices.

Much of the work of the PLUS Consortium was going on in parallel to prepare to launch RISE FOR HEALTH, an observational cohort study. The transdisciplinary nature of the consortium provided expertise in a variety of scientific methods (eg, qualitative, survey, experimental, secondary analyses, and community-based participatory research). The consortium built an organizational structure (Figure 2) to support study development, valuing scientific rigor, feasibility, and inclusion. With community engagement at the foundation (advising on outreach, messaging, content development), cores were developed to focus on novel and innovative sampling strategies, to optimize response and retention of participants, to develop survey content and streamline participant survey experience, to develop the protocol for physical measures and collection protocols for urine, vaginal, and rectal swabs, and to adapt and translate materials for use in Hispanic and Spanish-speaking participants.

RISE FOR HEALTH was launched in 2022 to (1) identify factors associated with bladder health and LUTS in US women and (2) determine the distribution of bladder health and bladder health knowledge in US women using the new measure.⁴ Stratified random sampling was used to recruit a sample of participants who were ethnically and racially similar to the US population across a wide range of ages (18-100 years). Data were collected via mailed or emailed surveys and in-person assessment and specimen collection took place in a subset of participants. Baseline assessments began in May 2022 and cohort enrollment completed in December 2023, the third assessment in the field now.

A total of 50,367 invitations were sent with a 7.9% (n = 3422) response rate; mean age of the cohort was 49.8 years. LUTS were measured using the Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-10. At least 1 mild lower urinary tract symptom was present in 79.2% of participants and 36.5% experienced at least 1 moderate or severe symptom.⁵ Urgency was the most prevalent lower urinary tract symptom in more than 55% of participants, while urgency urinary incontinence occurred in 32.3%. Of participants 37.5% were bothered by urinary symptoms and 37.9% discussed concerns about urinary symptoms with others, yet only 7.1% reported LUTS treatment. This finding highlights the large number of women who are experiencing bothersome urinary symptoms without seeking treatment.

The distributions of bladder health using the new instrument revealed a median global perception of bladder health score of 72 out of 100 before adjustment for adaptive/coping behaviors and 55 after adjustment.⁶ A downward adjustment in score was made when participants were using adaptive/coping behaviors such as carrying or wearing incontinence pads, toilet mapping, or staying close to the toilet. When looking at participants without LUTS (to determine what the new measure captured in those without LUTS), scores were higher across all scales and indices, indicating better health as you would expect, yet scores were not perfect demonstrating a range of bladder health even among those without LUTS. A notable finding was that 68% of participants in RISE reported using adaptive/coping behaviors related to the bladder, including 40% who reported using pads, liners, and/or absorbent underwear, 58% finding the bathrooms everywhere they went (ie, toilet mapping), and 3% staying as close to a bathroom as possible when away from home. Despite best bladder health, 38% of participants in the subset without LUTS also reported using adaptive/coping behaviors, including 11% who reported using pads, 30% toilet mapping, and 2% staying as close to a bathroom as possible when away from home.

RISE FOR HEALTH taught us (1) there is a broad spectrum of bladder health ranging from poor to optimal in US women, (2) there is high utilization of adaptive/coping behaviors (using pads/toilet mapping) even among women without LUTS, and (3) there is a higher range of bladder health scores in those without LUTS, not perfect scores. These findings support the concept of that there is more to bladder health than just LUTS and a novel subclinical population may exist that is optimal for LUTS prevention.

The planned impact of the work of the PLUS Consortium is to lay the foundation for evidenced-based LUTS prevention, promoting the overall well-being of girls and women.