Systematic review exploring the relationship between sexual abuse and lower urinary tract symptoms

Introduction and hypothesis Patients presenting with lower urinary tract symptoms (LUTS) may report a history of sexual abuse (SA), and survivors of SA may report LUTS; however, the nature of the relationship is poorly understood. The aim of this review is to systematically evaluate studies that explore LUT dysfunction in survivors of SA. Methods A systematic literature search of six databases, Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO, was performed. The last search date was June 2021 (PROSPERO CRD42019122080). Studies reporting the prevalence and symptoms of LUTS in patients who have experienced SA were included. The literature was appraised according to the PRISMA statement. The quality of the studies was assessed. Results Out of 272 papers retrieved, 18 publications met the inclusion criteria: studies exploring LUTS in SA survivors (n=2), SA in patients attending clinics for their LUTs (n=8), and cross-sectional studies (n=8). SA prevalence ranged between 1.3% and 49.6%. A history of SA was associated with psychosocial stressors, depression, and anxiety. LUTS included urinary storage symptoms, voiding difficulties, voluntary holding of urine and urinary tract infections. Most studies were of moderate quality. Assessment of SA and LUTS lacked standardisation. Conclusions The review highlights the need for a holistic assessment of patients presenting with LUTS. Although most of the studies were rated as being of ‘moderate’ quality, the evidence suggests the need to provide a “safe space” in clinic for patients to share sensitive information about trauma. Any such disclosure should be followed up with further assessment.


Introduction
Attempted or executed sexual abuse (SA) conducted without consent from the victim can involve penetrative or non-penetrative acts and non-contact [1]. The perpetrator of abuse can range from being a complete stranger to someone familiar to the victim [2] and acts can be committed in private or in public spaces. The prevalence of SA is largely underestimated; however, the results of a recent survey suggests that 1 in 5 women and 1 in 59 men have been exposed to an attempted or completed act of rape during their lifetime [2]. Rates of childhood sexual abuse (CSA) can vary: between 2% and 62% of females and between 3% and 16% of males [3]. The reason for underreporting by victims are manifold, and can include feelings of shame, fear and guilt, a risk of retaliation by the perpetrator [4] and a lack of awareness that forced sexual acts constitute SA [5].
Abuse can have a profound impact on victims, ranging from reduced global functioning levels to lengthened trauma-related symptoms and an increased risk of developing substance abuse [6]. Both male and female victims can report increased rates of depression, anxiety, suicidal ideation and post-traumatic stress disorder (PTSD) [7]. Multiple physical and psychological sequelae have been reported, including anxiety, anger, depression, re-victimisation, self-mutilation, sexual difficulties, substance abuse, suicidality, impairment of self-concept, interpersonal problems, obsessions and compulsions, dissociation and post-traumatic stress responses to somatisation characterised by medically unexplained symptoms [7][8][9][10][11].
Somatisation, functional neurological symptoms and other medically unexplained symptoms can lead to repeated consultations and help-seeking behaviour, which can have significant financial implications in terms of use of health care resources and receipt of financial assistance [12]. Abuse occurring in childhood before the age of 17 (CSA) can result in multiple long-term consequences such as depression, anxiety, poor physical health and risky health behaviours [13]. Furthermore, CSA has been found to be significantly associated with poor outcomes when treating conversion disorders/functional neurological disorder [14].
Urological symptoms are likely to be common amongst survivors of SA. A Dutch study suggested that 2.1% of men and 13% of women seeking urological care may report SA [15]. Many of the physical and psychological sequelae of CSA were found to persist into adulthood [16] and up to one-third of patients attending a gynaecology clinic had experienced CSA [17,18]. Victims of CSA younger than 6 years old most commonly reported urinary tract infections, daytime incontinence and nocturnal enuresis [19]. SA is likely to be underreported and in the Dutch study, only 15% of participants with a history of SA had disclosed this to their urologist [15]. In a study across five Nordic countries, most women did not disclose a history of SA to their gynaecologist [17]. Seventy percent of Dutch urologists enquired about SA when taking the medical history [20]; however, enquiry rates may vary across specialities and different health care settings.
A recent systematic review and meta-analysis of 38 studies has demonstrated a significant association between a history of sexual assault and developing different gynaecological disorders such as pelvic pain, dyspareunia, dysmenorrhea, abnormal menstrual bleeding and urinary incontinence later in life [21]; however, lower urinary tract dysfunction was not specifically evaluated.
The relationship between SA and LUT dysfunction, however, has been poorly understood. The purpose of this systematic review was to evaluate the reported prevalence of SA, pattern of lower urinary tract symptoms (LUTS) and explore possible associations between SA and LUT dysfunction.

Materials and methods
The systematic review conformed to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and the protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42019122080). A literature search was performed in December 2018 and updated in June 2021 for studies published in the English language without date restrictions in the following databases: Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO. The same search strategy (i.e. keywords and inclusion and exclusion criteria) was used for all the databases. The following key words were used: "sexual dysfunction" OR "sexual abuse" OR "adult sexual abuse" OR "sexual trauma" OR "childhood sexual abuse" OR "CSA" OR "sexual maltreatment" OR "rape" OR "sexual offences" OR "sexual harassment" OR "sexual harm" OR "urinary tract" OR "urologist" OR "urological dysfunction" OR "urological symptoms" OR "LUTS" OR "lower urinary tract symptoms" OR "lower urinary tract problems" OR "uroneurology" OR "urethral" OR "genitourinary" OR "urinary frequency" OR "urgency" OR "urinary infection" AND "treatment" OR "management" OR "symptoms".
Abstracts were imported into bibliography management software (EndNote X8; Thomson Reuters, PA, USA) and were independently evaluated by two reviewers (NS and SH). Studies relevant to the review reporting the prevalence and symptoms of LUTS in male and female patients who have experienced SA were included, whereas experimental studies in animals and studies primarily assessing interstitial cystitis, bladder pain syndrome and pain were excluded. The results of the two reviewers were compared and consensus was achieved by discussion; unresolved differences were reviewed independently (JNP).
Accepted abstracts were retrieved in full text and assessed by the two reviewers (NS and SH), and the following variables were assessed: setting and nature of cohort, definition of SA, assessment of SA, nature of abuse, other types of abuse, nature of LUTS, assessment of LUTS, diagnostic LUTS test and findings, and other co-morbidities. The quality of the studies and risk of bias were assessed using the assessment tool for quantitative studies by the Effective Public Health Practice Project (EPHPP) [22]. Each section was rated by the two reviewers and any discrepancies between scores were discussed and reconciled.

Discussion
In this review we present a synthesis of 18 studies that explore LUTS in survivors of SA. The wide prevalence of abuse across studies reflects differences in the cohorts   Most studies defined SA broadly as forced or unwanted sexual activity, ranging from the broadest, "unwanted sexual touching" [23] to the narrowest, "complete sexual penetration of the vagina, mouth or rectum without a women's consent, involving the use of force or threat of harm" [24]. Furthermore, only four studies used a validated scale to assess SA [23,29,36,40], which limited the extent to which the nature, length and severity of abuse could be assessed. The wide prevalence range of SA reported in the studies, from 1.3% [40] to 49.6% [28] may not accurately reflect the true prevalence of SA in patients reporting with LUTS; however, it is somewhat in keeping with the prevalence reported in other cohorts without LUTS [41,42]. Because of the sensitive nature of SA, there were limits to the extent to which patients could be approached by health care professionals about possible SA. Only 66% of women with pelvic floor disorders were asked about SA [21], whereas in a study exploring physical and SA in patients with an overactive bladder, only women who were not accompanied by a male were approached because of concerns regarding safety [37]. Clinicians would have been reluctant to enquire about SA owing to assumptions that patients may react negatively when questioned [43], lack of familiarity with how to enquire and/or uncertainty about how to proceed if a patient were to disclose SA [20]. In a survey of survivors, more than 70% of abused respondents favourably considered the idea of screening for SA in urological practice [15]. However, patients may not be readily prepared to engage, and over 20% of participants in a study exploring interpersonal trauma and genitourinary dysfunction did not disclose information about sexual assault, more commonly African American and non-partnered women [33]. In a study of Chinese women, which reported the highest response rate of 96%, only 1.3% reported SA and cultural factors of shame and stigma were possible factors responsible for underreporting [40]. Other reasons could include recall bias, disquiet in a public hospital setting, wording of questions about SA and concerns regarding confidentiality.
Lower urinary tract symptoms were variably assessed and urinary storage problems such as urinary incontinence, frequency and nocturia were reported most often. Some patients were reporting incontinence in the context of holding the urine too long until it became painful [25]. Urodynamics testing was not performed in any of the studies. The cause of urinary incontinence was unclear and inclusion of validated questionnaires and possibly urodynamics in future studies would help to understand whether incontinence was due to overactive bladder, stress incontinence or mixed. Establishing dysfunction such as bladder hypersensitivity and/or detrusor overactivity would be critical when tailoring therapeutic strategies for managing these symptoms [44]. Voiding difficulties were less often reported and symptoms reported were pain with urination, hesitancy, slow stream, dribbling, holding urine until painful, incomplete bladder emptying, weak urinary stream and straining to begin urination [25,33]. Questionnaires such as the UDI-6 do specifically enquire about voiding difficulties; however, only the total score was reported in studies. Urinary retention was not reported and post-void residual volumes were not measured in any of the studies; therefore, the extent of incomplete bladder emptying could not be assessed. Although trauma features in the history of patients presenting with idiopathic urinary retention in men and women [45][46][47], none of the studies in this review specifically explored urinary retention related to sexual trauma.
Sexual trauma may be one of different types of abuses suffered by individuals, and in these studies emotional and physical abuse [23,26], violence [29], physical abuse [27,37], and domestic violence, verbal and physical abuse [40] were reported.  Whether other types of abuse contribute to the occurrence of LUT dysfunction is unclear, as an association between emotional abuse and voiding difficulties [35] and urinary incontinence [33] have been reported. Limitations to study designs precluded any meaningful exploration of the association of these different types of abuse with the occurrence of LUTS. The association between trauma and functional somatic syndromes is well established [48,49] and the stressor response occurring following trauma has been shown to result in physiological changes in body and brain functions that can persist through life and predispose individuals to a range of physical and psychological sequelae. The age at which SA occurs is also significant; SA occurring during critical developmental periods has been shown to result in profound endocrinological and immunological consequences that may have long-term effects on an individual's ability to react and respond to illness [50]. Somatic problems such as musculoskeletal pain, ear, nose, and throat symptoms, abdominal pain and gastrointestinal symptoms, fatigue, and dizziness have been found to be more common in adults with a history of childhood trauma than in nontraumatised counterparts [10]. These subjective, medically unexplained physical health problems often persist and present as functional somatic syndromes such as fibromyalgia, chronic fatigue/pain, and irritable bowel syndrome [51]. A recent study found that complex PTSD symptoms mediate the association between childhood maltreatment and trauma and physical health problems. Complex PTSD is associated with a number of psychological sequelae, including hypervigilance, anxiety, agitation, dissociation [52], anger, aggression, self-harm [53], dysregulation in emotion processing, self-organisation (including bodily integrity), relational functioning [54], and psychological interventions that effectively treat symptoms may additionally reduce the risk of physical health problems [55]. Urological symptoms such as OAB are associated with a number of psychiatric conditions such as depression, anxiety and CSA [56].
It is likely, however, that there are different mechanisms responsible for LUTS in survivors of SA. Physical trauma to the perineum and pelvis [57,58] can result in damage to the regional anatomy. Studies have shown an association between LUTS and anxiety, depression [59][60][61][62] and PTSD [63]. Neurobiological mechanisms implicate corticotrophin-releasing factor and serotonergic and dopaminergic systems in the pathogenesis of mood disorders and PTSD, and possible links with LUTS. There is a possibility that adverse life events may lead to neurobiological and physiological changes that increase the risk of both mood disorders and somatic disorders, but that the risk factors may be different [64]. Somatisation may be an adaptive response to psychological distress [65] and although specific symptoms linked to SA have not been consistently identified [66], it is plausible that LUTS may be associated with complex PTSD and a manifestation of somatisation linked to SA; however, this needs to be further explored. Some clinical teams, acknowledging the challenges, are highlighting the need for a multi-disciplinary approach [67]. Notably, duloxetine, a serotonin and norepinephrine reuptake inhibitor (SNRI), that is well established in the treatment of depression and anxiety, has been used with success in the management of both OAB and stress urinary incontinence (SUI) [68,69].
There were some limitations to this review. Few studies were relevant to the topic, and the overall quality was "moderate". In the absence of an operational definition for SA, the cohorts differed between studies. Furthermore, a standardised assessment was lacking and therefore the extent of details about types of abuse and their frequency, relationship to the perpetrator, time-frame of abuse, age and impact on childhood development were often missing. A challenge for any research in this area is recall bias, and the wording used in the enquiry about SA and also the setting differed between studies. The extent of rapport and trust between health care professionals and the participants was not assessed; however, these would be critical when exploring such a sensitive topic. Bias in sampling resulting from poor response rates amongst participants approached was not addressed in any of the studies. The assessment of LUTS also differed considerably between studies and therefore the true extent and pattern of LUT dysfunction could not be assessed. Nonetheless, it can be concluded that there exists an association between SA and urinary storage and voiding symptoms.
One major limitation of the review is the low quality and low level of evidence of these 18 studies. Also, the EPHPP does not explore characteristics from each study design that other quality tools can do, such as the Newcastle-Ottawa Scale [70]. There is a need for further research to explain the relation between SA and LUTS. Further, as the studies included in this review were too heterogeneous, a metaanalysis was not performed.
Treatment options, which should take a multi-disciplinary approach, were outside the scope of this review, but, drawing on the current published evidence of treatments for PTSD and complex PTSD, we hypothesise that a proportion of these patients may be helped by trauma-focussed cognitive behavioural therapy and/or other psychotherapeutic interventions.

Conclusion
The review highlights the need to provide a holistic assessment of patients presenting with LUTS that includes standardised screening for SA in a "safe space" for patients to share sensitive information, and screening for concurrent inter-related factors such as trauma, affective symptoms and somatisation which can impact LUTS. Well-designed studies are required to explore what impact such an assessment may have on the management of LUTS.