Ariana Smith: Thank you for having me, Alan. I'm really excited to tell you about some of the accomplishments of the PLUS research consortium. So the vision for PLUS was to improve bladder health among women and girls. The consortium developed a mission and strategies to get there, such as creating infrastructure for community engagement in our research and for the inclusivity of populations traditionally underrepresented in research. The consortium has accomplished a great deal. With over 70 peer review publications, we developed a definition of bladder health and a conceptual framework to guide bladder health research. We performed qualitative research to hear women and girls' voices about their bladders, and we developed and validated an instrument to measure bladder health called the bladder health scales and bladder function indices. We launched a longitudinal cohort study called Rise for Health and developed a bladder symptom-tracking app called "Where I Go".
This is our PLUS conceptual framework. It integrates a life course perspective, acknowledging that different factors impact the bladder at different times in life, such as childbirth and menopause. A social ecological perspective with the understanding that health behaviors are determined by multiple social factors outside of the individual, such as where public restrooms are built and policies around bathroom use during work or school, and biological considerations such as how hormonal milieu or the microbiome impact the bladder. Our conceptual model guided the development of a variety of novel measures, including the bladder health scales and instruments to measure toileting environment, bladder knowledge and beliefs and self-care practices. And these new measures made up our toolbox for our foundational study on bladder health. Rise for Health was launched in 2022 to determine the distribution of bladder health and bladder health knowledge in U.S. women and to identify risk factors associated with bladder health and LUTS in women.
It was a population-based cohort study centered around our PLUS clinical research centers. It used stratified random sampling to recruit a sample of participants that were ethnically and racially similar to the U.S. population across a wide range of age. Data collection occurred via mailed or emailed surveys, and we had an in-person assessment as well as specimen collection in a subset of our participants. To optimize the scientific rigor, the study feasibility, and the inclusion of our study, we developed this organizational structure to support Rise study development. Community engagement was at the foundation. We had a participant sampling and monitoring core with a focus on novel and innovative sampling strategies, a recruitment and retention core, data cores, and a cross-cultural adaptation and Spanish language translation core. The study was launched in May of 2022 and we enrolled 3,422 participants. The first follow-up was completed in the summer of 2024, and the second follow-up was completed in the summer of 2025 with retention of 2,273 participants.
So what did we find? Well, the mean age of our cohort was 49.8 years. We did a great job achieving a representative sample with 15.3% of participants identifying as Hispanic, 5.9% as non-Hispanic Asians, 12.3% as non-Hispanic Blacks, 62.9% as non-Hispanic white, and 2.6% identifying with multiple racial identities. There was a nice distribution of BMI and menopausal status. We measured LUTS using the LEARN SI-10 questionnaire. The distribution of LUTS is shown in the various shades of purple with the lightest across the bottom, representing the proportion of the sample without LUTS, medium purple indicating the presence of mild LUTS and dark purple on top, indicating the presence of moderate to significant LUTS. And taken together 79.2% of participants experienced at least one mild LUT. While 36.5% experienced at least one moderate or severe symptom. Urgency was the most prevalent LUT in more than 55% of participants while urgency incontinence occurred in 32.3%.
37.5% of our participants were bothered by their urinary symptoms, and they had discussed concerns about their urinary symptoms with others. Yet only 7.1% reported LUTS treatment, highlighting the large number of women in society who are experiencing bothersome urinary symptoms without seeking treatment. The distribution of bladder health using our new instrument is shown here, the unadjusted score in the left column and the adjusted score in the right column. A downward adjustment in score was made if participants were using adaptive or coping behaviors such as carrying or wearing incontinence pads, toilet mapping, or staying close to a toilet when they were out of the house. The median global perception of bladder health score was 72 out of a possible a hundred points before adjustment for adaptive and coping behaviors and 55 after adjustment. When looking at participants without LUTS, essentially determining what the new bladder health measures captures in those people without LUTS, scores were higher across all bladder health scales indicating better bladder health as you would expect yet the scores were not perfect.
The median global bladder health score was 88 before adjustment and 82 after adjustment demonstrating a range of bladder health, even among those who have no complaints of LUTS. What was really interesting is that 68% of participants in Rise reported using adaptive and coping behaviors related to their bladder, including 40% who reported using pads, liners, absorbent underwear, 58% finding the bathroom everywhere they went, or what we call toilet mapping and 3% staying as close to a bathroom as possible when they were away from home. And despite good bladder function, 38% of participants in the subset without LUTS also reported adaptive and coping behaviors.
So what Rise for Health taught us is that there is a broad spectrum of bladder health ranging from poor to optimal in U.S. women. There's high utilization of adaptive and coping behaviors even among women without LUTS, there are higher bladder health scores in those without LUTS yet the scores are not perfect. And this supports the concept that there is more to bladder health than just LUTS, and it may in fact identify a novel subclinical population that may be ripe for prevention efforts. So what I showed you is just the beginning. We continue to publish our data in a wide range of journals, and we're also producing common language summaries for the lay public. The planned impact of the work of the PLUS consortium is to lay the foundation for evidenced-based LUTS prevention studies, thus promoting the overall well-being of girls and women.
Alan Wein: That was terrific. So two questions. One is, can you provide a lay definition for bladder health? I mean, obviously it's more than just LUTS.
Ariana Smith: Yeah, and you're absolutely right. I mean, bladder health includes more than just LUTS. It includes the physical, the mental, and the social well-being related to the bladder, resistance to infection and cancer and resilience to short-term stressors. For an example, if an individual stays close to the toilet and uses it frequently because of fear of leakage, they may tell you that they never leak. Similarly, if someone restricts their fluid intake to avoid frequency, they may have a normal voiding interval, but both of these behaviors are indicative of unhealthy bladder despite the absence of a symptom or complaint.
Alan Wein: Got it. Are there any hints about preventative measures that individuals in various age groups could take to prevent the deterioration of bladder health in the future, either even in childhood or adolescence or whatever, middle ages, the elderly, et cetera? Any hints about that so far?
Ariana Smith: There are some hints. I think this is the exact direction we want to take our study and use the data available to really launch into some of these more in-depth prevention studies, but we have seen some hints. So in one of our early PLUS studies using data from the Avon Longitudinal Study of Parents and Children called ALSPAC, we found that girls, young girls who engaged in sexual activity prior to age 17 and those who used contraceptives prior to age 17 were actually at higher risk of LUTS than girls who waited until after 17. And interestingly, these associations were stronger if the young girls had three or more sexual partners earlier in life versus one or two partners. And using our Rise for Health data, we've been able to look closely at perimenopause, which can encompass several years of women's middle-aged life. And we found much higher rates of LUTS in peri and postmenopausal women compared to premenopausal women.
And during perimenopause, urgency was the most common symptom that these women were experiencing. Now, hormone use was infrequently reported in our cohort, but in those who were using menopausal hormonal therapy, their bladder health scores were actually worse. So I'm not suggesting that hormones cause or worsen LUTS, it's probably more a reflection of the degree of menopausal symptoms those women were enduring that led to their use of hormones and that may potentially have an association with LUTS. But certainly further studies are needed to really understand and investigate whether hormones may have any benefit or risk in worsening a LUTS profile.
Alan Wein: Great. Last question, I promise. Next steps.
Ariana Smith: Next steps. So we are working hard right now. My group is really busy looking at the longitudinal data from Rise for Health. Health specifically change in LUTS prevalence over time and risk factors for incident or worsening LUTS. And one analysis I'm particularly excited about has to do with participant's level and type of physical activity at baseline and their risk for worsening or incident LUTS over time. We're also looking at sedentary behavior as alongside physical activity and how this may also impact incident LUTS or worsening LUTS over time.
Alan Wein: Super. Listen, thank you so much for this. I think that it's really interesting and I wish your group and you success in the future in telling us more about how to prevent poor bladder health in the future. Thanks.
Ariana Smith: Thank you, Alan.