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Abstract

BACKGROUND

The sudden urge to urinate, also known as overactive bladder (OAB), may reflect higher sympathetic activity and associate with higher blood pressure (BP).

METHODS

This cross-sectional analysis utilized data from sixth follow-up exam (2015–2016) of Multi-Ethnic Study of Atherosclerosis to examine the association of OAB with systolic (SBP) and diastolic blood pressure (DBP) levels, hypertension, and BP control. Information on urinary symptoms was obtained with the International Consultation on Incontinence Questionnaire (ICIQ). Sex-stratified regression models were constructed to examine differences in BP, hypertension prevalence, and BP control while adjusting for demographic factors, comorbidities, and medication use.

RESULTS

Among the 1,446 men and 1,628 women who completed the ICIQ (mean age 73.7 years [SD 8.4]), OAB was present in 31.6% of men and 38.9% of women. With no antihypertensive medication use, OAB was not associated with SBP or DBP in both men and women after adjusting for covariates. However, among the 894 men and 981 women on antihypertensive medication, OAB was associated with higher SBP among men (4.04 mm Hg; 95% confidence interval [CI] 1.02, 7.06) but not among women (−0.67 mm Hg; 95% CI −3.79, 2.46) while DBP did not differ by OAB presence in men or women. In addition, OAB was also associated with lower odds of BP control among men (odds ratio [OR] 0.69; 95% CI 0.49, 0.96) but not women (OR 0.96; 95% CI 0.71, 1.30).

CONCLUSIONS

Among men, OAB is associated with lower odds of BP control which suggests that OAB may impede hypertension management.

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blood pressure, blood pressure control, hypertension, incontinence, Multi-Ethnic Study of Atherosclerosis, overactive bladder, urinary urgency

The patient complaint of sudden urge to urinate with or without involuntary urinary leakage when rushing to the toilet is known as overactive bladder (OAB) syndrome.1 OAB is a common condition and affects approximately 1 in 11 US adults over the age of 50 years and prevalence increases with advancing age.2 OAB, especially when urinary incontinence is present, can lead to social isolation, psychological distress and dysphoria,3,4 and reduced quality of life.5,6 Most men and women with OAB do not discuss their urinary symptoms with their healthcare providers or seek treatment7,8 and most providers do not query patients for lower urinary tract symptoms. Thus, most OAB or other lower urinary tract symptoms are never treated.

Lack of attention to OAB may influence cardiovascular risk because of the connection between bladder function and the autonomic nervous system and blood pressure (BP). Several previous studies have demonstrated that men and women with OAB have higher sympathetic activity relative to parasympathetic activity which then leads to increased sensitivity to bladder filling, urgency, and incontinence.9–11 Higher sympathetic activity relative to parasympathetic activity, especially with bladder filling, can also lead to higher BP. In fact, according to the American Heart Association scientific statement on BP measurement, patients should not have a full bladder when BP is measured.12 However, individuals with OAB may have higher sympathetic activity and higher BP even when their bladder is not full. A few previous studies have demonstrated associations between OAB and hypertension prevalence but data from multi-ethnic community-based cohorts remain limited.13–15

Hypertension is often treated with medications such as diuretics, calcium channel blockers, and beta blockers that can exacerbate OAB symptoms. It is possible that presence of OAB may be associated with lower control of hypertension due to lower compliance with medications,16 psychological stress,3,4 or other factors. The aim of this study is to examine the association of the OAB symptoms with BP levels and BP control. We hypothesize that OAB is associated with higher BP levels and higher prevalence of hypertension overall and with lower prevalence of BP control among men and women on antihypertensive medication.

MATERIALS AND METHODS

Multi-Ethnic Study of Atherosclerosis (MESA) is an observational cohort study which recruited 6,814 men and women, age 45–84 years, from 6 communities in the United States (Baltimore, MD; Chicago, IL; Forsyth County, NC; Los Angeles County, CA; Northern Manhattan, NY; and St. Paul, MN) during years 2000–2002 to examine the characteristics of subclinical cardiovascular disease.17 Follow-up clinical exams have occurred approximately every 2 years and sampling and recruitment procedures have been previously described. All participants were free of clinical cardiovascular disease and heart failure at baseline per study design. The Institutional Review Boards at all participating sites approved the study, and all participants gave informed consent.

A total of 1,536 men and 1,749 women returned for the sixth MESA exam conducted during July 2015–June 2016, and over 93% completed the International Consultation on Incontinence Questionnaire (ICIQ) which queries urinary symptoms. This cross-sectional study included all MESA participants who attended MESA exam 6 and completed the ICIQ (1,446 men and 1,628 women). The analysis of the association of OAB with BP control included only those MESA participants who were on antihypertensive medication and completed the ICIQ at MESA exam 6 (981 women and 896 men).

Overactive bladder

Information on urinary symptoms was obtained with the ICIQ.1,18 This tool has been used internationally with established reliability and validity18 and is recommended by the International Continence Society for assessment of urinary symptoms.1,19 This questionnaire measures an individual’s experience with urinary symptoms (e.g., urgency, pain) over the past 4 weeks. For each question, respondents were queried on frequency of a symptom as “never” (0 points), “occasionally” (1 point), “sometimes” (2 points), “most of the time” (3 points), or “all of the time” (4 points). Presence of OAB was defined by a score of 2 or higher for the questions, “Do you have a sudden need to rush to the toilet to urinate?” and/or “Does urine leak before you can get to the toilet?” The ICIQ also asks questions on presence and frequency of urinary symptoms such as urinary hesitancy, strain, post void dribbling, and incomplete bladder emptying. An overall score for lower urinary tract symptoms is then calculated with a score ranging from 0 (no symptoms) to 21 (greatest symptoms).

Hypertension and BP control

Trained and certified clinic staff obtained BP and anthropometric measurements on all MESA participants during the baseline visit. After a 5-minute rest, BP was measured 3 times at 1-minute intervals using a Dinamap PRO 100 automated oscillometric device (Critikon, Tampa, FL) with the subject in a seated position with the back and arm supported.12 The average of the last 2 BP measurements was used for this analysis. Diagnosis of hypertension was defined as self-reported treatment for hypertension with 1 of 6 common classes of antihypertensive medications (thiazide diuretics, beta blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin-2 receptor blockers, and other (alpha blockers or peripheral vasodilators) or a systolic BP (SBP) ≥140 mm Hg or diastolic BP (DBP) ≥90 mm Hg. All MESA participants completed self-administered questionnaires and were interviewed by trained research staff to collect information pertaining to demographic characteristics, medical history, medication, alcohol, and tobacco use. These self-administered questionnaires were available in English, Spanish, and Chinese. BP control was defined as SBP <140 mm Hg and DBP <90 mm Hg among participants on antihypertensive medication. We also examined BP control as SBP <130 mm Hg and DBP <80 mm Hg.20

Covariates

During the recruitment process, potential participants were asked about their race and ethnicity using questions based on the US 2000 census questionnaire. Potential participants who self-reported their race/ethnicity group as White or Caucasian, Black or African-American, Chinese, or Spanish/Hispanic/Latino were asked to participate. Race and ethnicity variables were then categorized as non-Hispanic White, non-Hispanic Black, Chinese, and Hispanic. Demographic characteristics, body mass index, physical activity, medical history, parity, current smoking and alcohol use, and current medication use at exam 6 and a fasting blood sample were collected during the standardized interview. Age was defined as the age at the 6th follow-up exam interview. Body mass index in kg/m2 was calculated from height and weight measured during the examination. Information on physical activity was collected using the MESA Typical Week Physical Activity Survey, which was adapted from the Cross-Cultural Activity Participation Study21 and designed to identify the time spent in and frequency of various physical activities during a typical week in the past month.22 Diabetes was based on a self-reported physician diagnosis, and/or use of insulin or oral hypoglycemic agents, or a fasting glucose value ≥126 mg/dl. Prostate cancer history was queried at the baseline visit and then participants were contacted every 6–9 months and asked about health status including new cancer diagnoses and cancer type. Information on cancer treatment was not ascertained.

Statistical analysis

All analyses were stratified by sex due to sex differences in OAB etiologies. The characteristics of men and women were compared by OAB status in the full sample of persons who completed the ICIQ. Categorical variables were compared using a Chi-square test and continuous variables were compared using an unpaired t-test. To address the nonparametric distribution of physical activity and parity, values were presented as median (interquartile range) and then log transformed for the unpaired t-test. Adjusted differences in SBP and DBP by presence of OAB among men and women were examined using linear regression after stratifying by use of antihypertensive medication use. Multivariable regression models were used to adjust for potential confounding, particularly from differences in demographic factors, comorbidities, and medication use.19,23,24 We examined 3 separate sequential models stratified by sex to assess the association of OAB with each outcome. Model 1 adjusted for age and race/ethnicity. Model 2 added body mass index, diabetes, current smoking status, current alcohol use, physical activity, parity (women), history of prostate cancer (men), education, and MESA exam site to Model 1. Model 3 added use of medications that have been previously reported to be associated with urinary symptoms.16,25–28 These medications included diuretics, beta blockers, calcium channel blockers, alpha blockers (men), and oral estrogen (women) to Model 2 for the analysis of BP among MESA participants on antihypertensive mediations. For the model of MESA participants not on antihypertensive medications, Model 3 adjusted for oral estrogen use among women only. The same 3 models were used to examine BP control as the dependent variable using logistic regression. Models were repeated with hypertension defined as a SBP ≥130 mm Hg or DBP ≥80 mm Hg and BP control defined as a SBP <130 mm Hg and a DBP <80 mm Hg.

Based on the distribution of urinary scores in participants with OAB, scores were categorized for all participants as <5, 5 to <10, and ≥10. Ordered probit regression with marginal effects was then used to calculate adjusted prevalence of hypertension (among all participants) and BP control (among participants on antihypertensive medication) based on the urinary score categories after adjustment for all covariates. To determine a linear trend of the urinary score categories, we fitted the median value of each urinary score category into the fully adjusted model as a continuous variable.

RESULTS

The 90 men and 121 women who did not complete the ICIQ were older (mean age 81.0 [SD 9.2] and 82.7 [SD 9.0], respectively) compared with the men and women who completed the ICIQ (73.7 [SD 8.4] years for both men and women, respectively) (P < 0.01 for both comparisons) (Supplementary Table S1 online). Table 1 shows the characteristics of the participants by sex and by presence of OAB. Among the 1,446 men and 1,628 women who completed the ICIQ, OAB was present in 31.6% of men and 38.9% of women. Among those with OAB, 50.3% of men and 52.0% of women were ≥ age 75 years. Among those without OAB, 39.6% and 38.7% of men and women, respectively, were ≥ age 75 years. The prevalence of obesity and diabetes mellitus was also higher among the men and women with OAB compared with those without OAB. Table 2 shows the medication use in men and women by presence of OAB. Diuretic and calcium channel blocker use was higher in women with OAB compared with women without OAB while no difference in medication use was noted among men by presence of OAB. The characteristics of MESA participants on antihypertensive medication who completed the ICIQ (981 women and 896 men) and their medication use are shown in Supplementary Table S2 online. Similar to the total sample, older age was associated with presence of OAB, and the prevalence of diabetes and hypertension was higher for men and women with OAB compared with those without OAB. The prevalence of BP control was lower among those with vs. without OAB among men (68.1% vs. 78.4%; P = 0.001) but was similar among women with and without OAB (63.4% vs. 64.9%; P = 0.6).

Table 1.
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Characteristics of the MESA participants who completed exam 6 and the ICIQ by sex and by presence of overactive bladder (OAB)

MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Age, years74.8 (8.3)73.2 (8.4)<0.00175.2 (8.7)72.8 (8.1)<0.001
Age categories<0.001
 55–64 years, %11.917.012.317.0
 65–75 years, %37.943.435.744.4
 75–84 years, %37.528.136.429.2
 85+ years, %12.811.515.69.5
Race/ethnicity<0.001<0.001
 Non-Hispanic White, %35.343.139.039.6
 Non-Hispanic Black, %28.420.430.325.3
 Chinese, %12.115.37.715.6
 Hispanic, %28.421.220.019.5
BMI, kg/m228.7 (5.2)28.0 (4.6)0.0230.0 (6.7)27.8 (6.0)<0.001
aObese, %35.130.0<0.00142.930.9<0.001
bDM %32.723.7<0.00125.919.40.002
cHtn, %66.263.80.474.463.8<0.001
Antihypertensive medicine use, %64.361.00.266.256.8<0.001
SBP, mm Hg127.2 (20.1)123.8 (19.6)0.003131.2 (21.2)128.7 (21.6)0.02
DBP, mm Hg70.5 (9.5)70.5 (10.0)0.966.9 (9.8)67.0 (9.7)0.8
Smoking, %4.46.70.065.74.90.07
Alcohol use, %45.152.30.0133.938.20.08
dParityn/an/a2 (2,3)2 (1,3)0.04
Prostate cancer, %1.81.10.3n/an/a
dPhysical activity (MET/minute/week)3,446 (1,470, 7,065)3,750 (1,755, 7,575)0.052,536 (840, 5,640)3,270 (1,530, 5,985)<0.001
<High school education, %14.110.10.0917.411.70.009
MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Age, years74.8 (8.3)73.2 (8.4)<0.00175.2 (8.7)72.8 (8.1)<0.001
Age categories<0.001
 55–64 years, %11.917.012.317.0
 65–75 years, %37.943.435.744.4
 75–84 years, %37.528.136.429.2
 85+ years, %12.811.515.69.5
Race/ethnicity<0.001<0.001
 Non-Hispanic White, %35.343.139.039.6
 Non-Hispanic Black, %28.420.430.325.3
 Chinese, %12.115.37.715.6
 Hispanic, %28.421.220.019.5
BMI, kg/m228.7 (5.2)28.0 (4.6)0.0230.0 (6.7)27.8 (6.0)<0.001
aObese, %35.130.0<0.00142.930.9<0.001
bDM %32.723.7<0.00125.919.40.002
cHtn, %66.263.80.474.463.8<0.001
Antihypertensive medicine use, %64.361.00.266.256.8<0.001
SBP, mm Hg127.2 (20.1)123.8 (19.6)0.003131.2 (21.2)128.7 (21.6)0.02
DBP, mm Hg70.5 (9.5)70.5 (10.0)0.966.9 (9.8)67.0 (9.7)0.8
Smoking, %4.46.70.065.74.90.07
Alcohol use, %45.152.30.0133.938.20.08
dParityn/an/a2 (2,3)2 (1,3)0.04
Prostate cancer, %1.81.10.3n/an/a
dPhysical activity (MET/minute/week)3,446 (1,470, 7,065)3,750 (1,755, 7,575)0.052,536 (840, 5,640)3,270 (1,530, 5,985)<0.001
<High school education, %14.110.10.0917.411.70.009

Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; ICIQ, International Consultation on Incontinence Questionnaire; MESA, Multi-Ethnic Study of Atherosclerosis; SBP, systolic blood pressure.

aObesity defined as a body mass index ≥30 kg/m2.

bDM = diabetes mellitus defined with 2003 ADA Fasting criteria.

cHtn = hypertension defined as use of blood pressure lowering medication and/or systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg; data shown as mean or frequency.

dData shown as median (interquartile range).

Table 1.
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Characteristics of the MESA participants who completed exam 6 and the ICIQ by sex and by presence of overactive bladder (OAB)

MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Age, years74.8 (8.3)73.2 (8.4)<0.00175.2 (8.7)72.8 (8.1)<0.001
Age categories<0.001
 55–64 years, %11.917.012.317.0
 65–75 years, %37.943.435.744.4
 75–84 years, %37.528.136.429.2
 85+ years, %12.811.515.69.5
Race/ethnicity<0.001<0.001
 Non-Hispanic White, %35.343.139.039.6
 Non-Hispanic Black, %28.420.430.325.3
 Chinese, %12.115.37.715.6
 Hispanic, %28.421.220.019.5
BMI, kg/m228.7 (5.2)28.0 (4.6)0.0230.0 (6.7)27.8 (6.0)<0.001
aObese, %35.130.0<0.00142.930.9<0.001
bDM %32.723.7<0.00125.919.40.002
cHtn, %66.263.80.474.463.8<0.001
Antihypertensive medicine use, %64.361.00.266.256.8<0.001
SBP, mm Hg127.2 (20.1)123.8 (19.6)0.003131.2 (21.2)128.7 (21.6)0.02
DBP, mm Hg70.5 (9.5)70.5 (10.0)0.966.9 (9.8)67.0 (9.7)0.8
Smoking, %4.46.70.065.74.90.07
Alcohol use, %45.152.30.0133.938.20.08
dParityn/an/a2 (2,3)2 (1,3)0.04
Prostate cancer, %1.81.10.3n/an/a
dPhysical activity (MET/minute/week)3,446 (1,470, 7,065)3,750 (1,755, 7,575)0.052,536 (840, 5,640)3,270 (1,530, 5,985)<0.001
<High school education, %14.110.10.0917.411.70.009
MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Age, years74.8 (8.3)73.2 (8.4)<0.00175.2 (8.7)72.8 (8.1)<0.001
Age categories<0.001
 55–64 years, %11.917.012.317.0
 65–75 years, %37.943.435.744.4
 75–84 years, %37.528.136.429.2
 85+ years, %12.811.515.69.5
Race/ethnicity<0.001<0.001
 Non-Hispanic White, %35.343.139.039.6
 Non-Hispanic Black, %28.420.430.325.3
 Chinese, %12.115.37.715.6
 Hispanic, %28.421.220.019.5
BMI, kg/m228.7 (5.2)28.0 (4.6)0.0230.0 (6.7)27.8 (6.0)<0.001
aObese, %35.130.0<0.00142.930.9<0.001
bDM %32.723.7<0.00125.919.40.002
cHtn, %66.263.80.474.463.8<0.001
Antihypertensive medicine use, %64.361.00.266.256.8<0.001
SBP, mm Hg127.2 (20.1)123.8 (19.6)0.003131.2 (21.2)128.7 (21.6)0.02
DBP, mm Hg70.5 (9.5)70.5 (10.0)0.966.9 (9.8)67.0 (9.7)0.8
Smoking, %4.46.70.065.74.90.07
Alcohol use, %45.152.30.0133.938.20.08
dParityn/an/a2 (2,3)2 (1,3)0.04
Prostate cancer, %1.81.10.3n/an/a
dPhysical activity (MET/minute/week)3,446 (1,470, 7,065)3,750 (1,755, 7,575)0.052,536 (840, 5,640)3,270 (1,530, 5,985)<0.001
<High school education, %14.110.10.0917.411.70.009

Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; ICIQ, International Consultation on Incontinence Questionnaire; MESA, Multi-Ethnic Study of Atherosclerosis; SBP, systolic blood pressure.

aObesity defined as a body mass index ≥30 kg/m2.

bDM = diabetes mellitus defined with 2003 ADA Fasting criteria.

cHtn = hypertension defined as use of blood pressure lowering medication and/or systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg; data shown as mean or frequency.

dData shown as median (interquartile range).

Table 2.
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Medication use by presence of overactive bladder (OAB) in men and women

MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Any diuretic, %17.816.30.422.616.40.002
Loop diuretic, %7.50.40.016.33.30.005
Thiazide diuretic without potassium sparing agents, %9.19.40.813.09.80.05
Thiazide diuretic with potassium sparing agent, %0.91.70.23.23.60.6
Calcium channel blockers, %23.921.00.228.118.5<0.001
Beta blockers, %23.622.60.224.122.00.3
Angiotensin-converting enzyme inhibitors, %23.419.40.617.013.60.06
Angiotensin receptor blockers, %15.213.70.0816.713.90.1
aVasodilators, %6.95.30.42.72.10.2
Alpha blockers, %4.33.90.10.20.80.2
Oral estrogen, %n/an/a3.63.20.07
MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Any diuretic, %17.816.30.422.616.40.002
Loop diuretic, %7.50.40.016.33.30.005
Thiazide diuretic without potassium sparing agents, %9.19.40.813.09.80.05
Thiazide diuretic with potassium sparing agent, %0.91.70.23.23.60.6
Calcium channel blockers, %23.921.00.228.118.5<0.001
Beta blockers, %23.622.60.224.122.00.3
Angiotensin-converting enzyme inhibitors, %23.419.40.617.013.60.06
Angiotensin receptor blockers, %15.213.70.0816.713.90.1
aVasodilators, %6.95.30.42.72.10.2
Alpha blockers, %4.33.90.10.20.80.2
Oral estrogen, %n/an/a3.63.20.07

aVasodilators include centrally acting vasodilators and peripheral arterial vasodilators.

Table 2.
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Medication use by presence of overactive bladder (OAB) in men and women

MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Any diuretic, %17.816.30.422.616.40.002
Loop diuretic, %7.50.40.016.33.30.005
Thiazide diuretic without potassium sparing agents, %9.19.40.813.09.80.05
Thiazide diuretic with potassium sparing agent, %0.91.70.23.23.60.6
Calcium channel blockers, %23.921.00.228.118.5<0.001
Beta blockers, %23.622.60.224.122.00.3
Angiotensin-converting enzyme inhibitors, %23.419.40.617.013.60.06
Angiotensin receptor blockers, %15.213.70.0816.713.90.1
aVasodilators, %6.95.30.42.72.10.2
Alpha blockers, %4.33.90.10.20.80.2
Oral estrogen, %n/an/a3.63.20.07
MenWomen
OAB (n = 457)No OAB (n = 989)P valueOAB (n = 634)No OAB (n = 994)P value
Any diuretic, %17.816.30.422.616.40.002
Loop diuretic, %7.50.40.016.33.30.005
Thiazide diuretic without potassium sparing agents, %9.19.40.813.09.80.05
Thiazide diuretic with potassium sparing agent, %0.91.70.23.23.60.6
Calcium channel blockers, %23.921.00.228.118.5<0.001
Beta blockers, %23.622.60.224.122.00.3
Angiotensin-converting enzyme inhibitors, %23.419.40.617.013.60.06
Angiotensin receptor blockers, %15.213.70.0816.713.90.1
aVasodilators, %6.95.30.42.72.10.2
Alpha blockers, %4.33.90.10.20.80.2
Oral estrogen, %n/an/a3.63.20.07

aVasodilators include centrally acting vasodilators and peripheral arterial vasodilators.

Figure 1 shows the unadjusted BP values among men and women not on antihypertensive medications which did not differ by presence of OAB presence. Figure 2 shows the unadjusted SBP and DBP values by presence of OAB among the MESA participants on antihypertensive medication. Among participants on hypertensive medication, presence of OAB was associated with higher SBP among the men (130.2 mm Hg [20.4] vs. 125.3 mm Hg [19.2]; P < 0.001) but not women (134.2 mm Hg [21.0] vs. 133.5 mm Hg [21.0]; P = 0.6). No difference in DBP was noted by presence of OAB among men or women on antihypertensive medication.

Unadjusted blood pressure values among men and women by use of antihypertensive medications and by presence of overactive bladder (OAB). Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.
Figure 1.

Unadjusted blood pressure values among men and women by use of antihypertensive medications and by presence of overactive bladder (OAB). Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.

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Adjusted prevalence of hypertension and blood pressure control by urinary scores among men and women.
Figure 2.

Adjusted prevalence of hypertension and blood pressure control by urinary scores among men and women.

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Table 3 shows the adjusted differences in SBP and DBP in men and women by presence of OAB and by use of antihypertensive medication. Among men and women not on antihypertensive medication, no differences in SBP or DBP were noted by OAB presence in both men and women after adjusting for covariates. However, among men on antihypertensive medication, OAB was associated with a 4.04 mm Hg higher SBP (95% confidence interval [CI] 1.02, 7.06) after adjustment for all covariates. No difference was noted in SBP by presence of OAB among women on antihypertensive medication and no difference in DBP was noted by OAB presence among men or women on antihypertensive medication.

Table 3.
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Linear regression analysis for differences in systolic and diastolic blood pressure by presence of overactive bladder

MESA participants who completed ICIQ on antihypertensive medication (n = 1,875)
Male (n = 894)Female (n = 981)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 13.87 (1.12, 6.61)−0.49 (−3.20, 2.21)
 Model 24.01 (0.9, 7.05)−0.75 (−3.87, 2.37)
 Model 34.04 (1.02, 7.06)−0.67 (−3.79 to 2.46)
Diastolic blood pressure
 Model 10.74 (−0.60, 2.07)−0.49 (−1.75, 0.77)
 Model 21.35 (−0.11, 2.82)−0.32 (−1.81, 1.16)
 Model 31.32 (−0.12, 2.78)−0.31 (−1.80, 1.19)
aMESA participants who completed ICIQ not on antihypertensive medication(n = 1,199)
Male (n = 552)Female (n = 647)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 1−0.25 (−3.86, 3.36)1.35 (−1.79, 4.49)
 Model 2−1.83 (−5.35, 1.70)−0.15 (−6.76, 2.08)
 Model 30.11 (−3.10, 3.32)
Diastolic blood pressure
 Model 1−0.28 (−0.38, −0.18)0.86 (−0.70, 2.42)
 Model 2−0.33 (−2.10, 1.45)0.70 (−0.92, 2.31)
 Model 30.75 (−0.88, 2.38)
MESA participants who completed ICIQ on antihypertensive medication (n = 1,875)
Male (n = 894)Female (n = 981)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 13.87 (1.12, 6.61)−0.49 (−3.20, 2.21)
 Model 24.01 (0.9, 7.05)−0.75 (−3.87, 2.37)
 Model 34.04 (1.02, 7.06)−0.67 (−3.79 to 2.46)
Diastolic blood pressure
 Model 10.74 (−0.60, 2.07)−0.49 (−1.75, 0.77)
 Model 21.35 (−0.11, 2.82)−0.32 (−1.81, 1.16)
 Model 31.32 (−0.12, 2.78)−0.31 (−1.80, 1.19)
aMESA participants who completed ICIQ not on antihypertensive medication(n = 1,199)
Male (n = 552)Female (n = 647)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 1−0.25 (−3.86, 3.36)1.35 (−1.79, 4.49)
 Model 2−1.83 (−5.35, 1.70)−0.15 (−6.76, 2.08)
 Model 30.11 (−3.10, 3.32)
Diastolic blood pressure
 Model 1−0.28 (−0.38, −0.18)0.86 (−0.70, 2.42)
 Model 2−0.33 (−2.10, 1.45)0.70 (−0.92, 2.31)
 Model 30.75 (−0.88, 2.38)

Abbreviations: BMI, body mass index; CI, confidence interval; ICIQ, International Consultation on Incontinence Questionnaire; MESA, Multi-Ethnic Study of Atherosclerosis. Model 1 includes age and race, Model 2 adds BMI, diabetes status, smoking status, physical activity, alcohol use, parity (women) and prostate cancer (men), education, and site to Model 2. Model 3 adds use of diuretics, calcium channel blockers, alpha blockers (men), oral estrogen (women), and beta blockers.

aModel 3 adjusts for oral estrogen use among women only.

Table 3.
Open in new tab

Linear regression analysis for differences in systolic and diastolic blood pressure by presence of overactive bladder

MESA participants who completed ICIQ on antihypertensive medication (n = 1,875)
Male (n = 894)Female (n = 981)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 13.87 (1.12, 6.61)−0.49 (−3.20, 2.21)
 Model 24.01 (0.9, 7.05)−0.75 (−3.87, 2.37)
 Model 34.04 (1.02, 7.06)−0.67 (−3.79 to 2.46)
Diastolic blood pressure
 Model 10.74 (−0.60, 2.07)−0.49 (−1.75, 0.77)
 Model 21.35 (−0.11, 2.82)−0.32 (−1.81, 1.16)
 Model 31.32 (−0.12, 2.78)−0.31 (−1.80, 1.19)
aMESA participants who completed ICIQ not on antihypertensive medication(n = 1,199)
Male (n = 552)Female (n = 647)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 1−0.25 (−3.86, 3.36)1.35 (−1.79, 4.49)
 Model 2−1.83 (−5.35, 1.70)−0.15 (−6.76, 2.08)
 Model 30.11 (−3.10, 3.32)
Diastolic blood pressure
 Model 1−0.28 (−0.38, −0.18)0.86 (−0.70, 2.42)
 Model 2−0.33 (−2.10, 1.45)0.70 (−0.92, 2.31)
 Model 30.75 (−0.88, 2.38)
MESA participants who completed ICIQ on antihypertensive medication (n = 1,875)
Male (n = 894)Female (n = 981)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 13.87 (1.12, 6.61)−0.49 (−3.20, 2.21)
 Model 24.01 (0.9, 7.05)−0.75 (−3.87, 2.37)
 Model 34.04 (1.02, 7.06)−0.67 (−3.79 to 2.46)
Diastolic blood pressure
 Model 10.74 (−0.60, 2.07)−0.49 (−1.75, 0.77)
 Model 21.35 (−0.11, 2.82)−0.32 (−1.81, 1.16)
 Model 31.32 (−0.12, 2.78)−0.31 (−1.80, 1.19)
aMESA participants who completed ICIQ not on antihypertensive medication(n = 1,199)
Male (n = 552)Female (n = 647)
Beta coefficienta (95% CI)Beta coefficienta (95% CI)
Systolic blood pressure
 Model 1−0.25 (−3.86, 3.36)1.35 (−1.79, 4.49)
 Model 2−1.83 (−5.35, 1.70)−0.15 (−6.76, 2.08)
 Model 30.11 (−3.10, 3.32)
Diastolic blood pressure
 Model 1−0.28 (−0.38, −0.18)0.86 (−0.70, 2.42)
 Model 2−0.33 (−2.10, 1.45)0.70 (−0.92, 2.31)
 Model 30.75 (−0.88, 2.38)

Abbreviations: BMI, body mass index; CI, confidence interval; ICIQ, International Consultation on Incontinence Questionnaire; MESA, Multi-Ethnic Study of Atherosclerosis. Model 1 includes age and race, Model 2 adds BMI, diabetes status, smoking status, physical activity, alcohol use, parity (women) and prostate cancer (men), education, and site to Model 2. Model 3 adds use of diuretics, calcium channel blockers, alpha blockers (men), oral estrogen (women), and beta blockers.

aModel 3 adjusts for oral estrogen use among women only.

Table 4 shows the odds ratios (ORs) of hypertension by OAB presence in men and women when hypertension was defined as SBP ≥140 and DBP ≥90 and/or use of antihypertensive medication. After adjusting for all the covariates, OAB was associated with a lower odds of hypertension in men (OR 0.72; 95% CI 0.51, 1.01) and women (OR 0.90; 95% CI 0.67, 1.22) but 95% CIs included 1.0. Findings were similar when hypertension was defined as a SBP ≥130 mm Hg or DBP ≥80 mm Hg (see Supplementary Table S3 online). In contrast, OAB was associated with lower odds of BP control (SBP <140 mm Hg and DBP <90 mm Hg) among men on antihypertensive medication after adjustment for all covariates (OR 0.69; 95% CI 0.49, 0.96). When BP control was defined as a SBP <130 mm Hg and DBP <80 mm Hg, OAB was still associated with lower odds of BP control but the 95% CI included 1.0 (OR 0.76; 95% CI 0.55, 1.05). No association was noted with OAB and BP control among women on antihypertensive medication (OR 0.96; 95% CI 0.71, 1.30). Findings were similar when BP control was defined as a SBP <130 mm Hg and DBP <80 mm Hg (see Supplementary Table S3 online).

Table 4.
Open in new tab

Odds of hypertension and blood pressure control by overactive bladder (OAB) status and by sex in MESA participants overall and in participants on antihypertensive medication

MESA participants who completed ICIQ (n = 3,074)
Men (n = 1,446)Women (n = 1,628)
Hypertension defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg and/or use of antihypertensive medicationsOAB (n = 457)No OAB (n = 989)OAB (n = 634)No OAB (n = 994)
Proportion with hypertension65.6%63.8%74.4%63.8%
Odds ratios (95% CI) of hypertension by OAB status
Model 10.96 (0.75, 1.22)Reference1.26 (1.00, 1.59)Reference
Model 20.74 (0.56, 0.97)Reference0.99 (0.74, 1.31)Reference
Model 30.72 (0.51, 1.01)Reference0.90 (0.67, 1.22)Reference
MESA participants who completed ICIQ on antihypertensive medications (n = 1,875)
Men (n = 894)Women (n = 981)
Blood pressure control defined as SBP <140 mm Hg and DBP <90 mm Hg on antihypertensive medicationOAB (n = 292)No OAB (n = 602)OAB (n = 419)No OAB (n = 562)
Proportion with controlled blood pressure68.2%78.4%63.5%64.9%
Odds ratios (95% CI) of blood pressure control by OAB status
Model 10.68 (0.50, 0.90)Reference1.07 (0.83, 1.38)Reference
Model 20.68 (0.49, 0.95)Reference1.00 (0.75, 1.35)Reference
Model 30.69 (0.49, 0.96)Reference0.96 (0.71, 1.30)Reference
MESA participants who completed ICIQ (n = 3,074)
Men (n = 1,446)Women (n = 1,628)
Hypertension defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg and/or use of antihypertensive medicationsOAB (n = 457)No OAB (n = 989)OAB (n = 634)No OAB (n = 994)
Proportion with hypertension65.6%63.8%74.4%63.8%
Odds ratios (95% CI) of hypertension by OAB status
Model 10.96 (0.75, 1.22)Reference1.26 (1.00, 1.59)Reference
Model 20.74 (0.56, 0.97)Reference0.99 (0.74, 1.31)Reference
Model 30.72 (0.51, 1.01)Reference0.90 (0.67, 1.22)Reference
MESA participants who completed ICIQ on antihypertensive medications (n = 1,875)
Men (n = 894)Women (n = 981)
Blood pressure control defined as SBP <140 mm Hg and DBP <90 mm Hg on antihypertensive medicationOAB (n = 292)No OAB (n = 602)OAB (n = 419)No OAB (n = 562)
Proportion with controlled blood pressure68.2%78.4%63.5%64.9%
Odds ratios (95% CI) of blood pressure control by OAB status
Model 10.68 (0.50, 0.90)Reference1.07 (0.83, 1.38)Reference
Model 20.68 (0.49, 0.95)Reference1.00 (0.75, 1.35)Reference
Model 30.69 (0.49, 0.96)Reference0.96 (0.71, 1.30)Reference

Abbreviations: BMI, body mass index; CI, confidence interval; DBP, diastolic blood pressure; MESA, Multi-Ethnic Study of Atherosclerosis; SBP, systolic blood pressure. Analysis of hypertension by OAB status completed in all MESA participants who completed exam 6 and the International Consultation on Incontinence Questionnaire (ICIQ); analysis of blood pressure control completed in MESA participants who completed exam 6 and ICIQ and on antihypertensive medications at exam 6. Model 1 includes age and race, Model 2 adds BMI, diabetes status, smoking status, physical activity, alcohol use, parity (women) and prostate cancer (men), education, and site to Model 2. Model 3 adds use of diuretics, calcium channel blockers, alpha blockers (men), oral estrogen (women), and beta blockers.

Table 4.
Open in new tab

Odds of hypertension and blood pressure control by overactive bladder (OAB) status and by sex in MESA participants overall and in participants on antihypertensive medication

MESA participants who completed ICIQ (n = 3,074)
Men (n = 1,446)Women (n = 1,628)
Hypertension defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg and/or use of antihypertensive medicationsOAB (n = 457)No OAB (n = 989)OAB (n = 634)No OAB (n = 994)
Proportion with hypertension65.6%63.8%74.4%63.8%
Odds ratios (95% CI) of hypertension by OAB status
Model 10.96 (0.75, 1.22)Reference1.26 (1.00, 1.59)Reference
Model 20.74 (0.56, 0.97)Reference0.99 (0.74, 1.31)Reference
Model 30.72 (0.51, 1.01)Reference0.90 (0.67, 1.22)Reference
MESA participants who completed ICIQ on antihypertensive medications (n = 1,875)
Men (n = 894)Women (n = 981)
Blood pressure control defined as SBP <140 mm Hg and DBP <90 mm Hg on antihypertensive medicationOAB (n = 292)No OAB (n = 602)OAB (n = 419)No OAB (n = 562)
Proportion with controlled blood pressure68.2%78.4%63.5%64.9%
Odds ratios (95% CI) of blood pressure control by OAB status
Model 10.68 (0.50, 0.90)Reference1.07 (0.83, 1.38)Reference
Model 20.68 (0.49, 0.95)Reference1.00 (0.75, 1.35)Reference
Model 30.69 (0.49, 0.96)Reference0.96 (0.71, 1.30)Reference
MESA participants who completed ICIQ (n = 3,074)
Men (n = 1,446)Women (n = 1,628)
Hypertension defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg and/or use of antihypertensive medicationsOAB (n = 457)No OAB (n = 989)OAB (n = 634)No OAB (n = 994)
Proportion with hypertension65.6%63.8%74.4%63.8%
Odds ratios (95% CI) of hypertension by OAB status
Model 10.96 (0.75, 1.22)Reference1.26 (1.00, 1.59)Reference
Model 20.74 (0.56, 0.97)Reference0.99 (0.74, 1.31)Reference
Model 30.72 (0.51, 1.01)Reference0.90 (0.67, 1.22)Reference
MESA participants who completed ICIQ on antihypertensive medications (n = 1,875)
Men (n = 894)Women (n = 981)
Blood pressure control defined as SBP <140 mm Hg and DBP <90 mm Hg on antihypertensive medicationOAB (n = 292)No OAB (n = 602)OAB (n = 419)No OAB (n = 562)
Proportion with controlled blood pressure68.2%78.4%63.5%64.9%
Odds ratios (95% CI) of blood pressure control by OAB status
Model 10.68 (0.50, 0.90)Reference1.07 (0.83, 1.38)Reference
Model 20.68 (0.49, 0.95)Reference1.00 (0.75, 1.35)Reference
Model 30.69 (0.49, 0.96)Reference0.96 (0.71, 1.30)Reference

Abbreviations: BMI, body mass index; CI, confidence interval; DBP, diastolic blood pressure; MESA, Multi-Ethnic Study of Atherosclerosis; SBP, systolic blood pressure. Analysis of hypertension by OAB status completed in all MESA participants who completed exam 6 and the International Consultation on Incontinence Questionnaire (ICIQ); analysis of blood pressure control completed in MESA participants who completed exam 6 and ICIQ and on antihypertensive medications at exam 6. Model 1 includes age and race, Model 2 adds BMI, diabetes status, smoking status, physical activity, alcohol use, parity (women) and prostate cancer (men), education, and site to Model 2. Model 3 adds use of diuretics, calcium channel blockers, alpha blockers (men), oral estrogen (women), and beta blockers.

When urinary scores were examined as categories, no linear trend was noted with urinary score categories and hypertension prevalence in both men (P = 0.3 for linear trend) or women (P = 0.3 for linear trend) after adjustment for covariates. Linear trends in BP control by urinary score categories were noted among men on antihypertensive medication (P = 0.006 for linear trend). Figure 2 shows that the adjusted prevalence of BP control declined from 78.0% (95% CI 74.7, 81.2) in the lowest urinary score category to 59.8% (35.6, 83.9) in the highest urinary score category in men (see Supplementary Table S4 online). No linear trend was noted with urinary score categories and BP control in women (P = 0.1 for linear trend) after adjustment for covariates.

DISCUSSION

This study shows that OAB symptoms are common in this multi-ethnic community-based sample of US adults. Among men on antihypertensive medication, OAB was associated with higher SBP and lower odds of BP control even after adjustment for demographics and comorbidities. Higher urinary scores, indicating worse urinary symptoms, were also associated with lower prevalence of BP control in men on antihypertensive medication. Urinary symptoms may be influenced by exercise and obesity status,19 factors strongly associated with elevated BP.20 Thus, associations of urinary symptoms with elevated BP may simply be due to shared risk factors. Another potential mechanism linking OAB with higher BP values is the higher sympathetic activity relative to parasympathetic activity in OAB9–11 which leads to increased sensitivity to bladder filling. Sympathetic activity normally increases with bladder filling which is why patients should not measure BP if the bladder is full.12

Our findings of higher SBP and lower odds of BP control among men with OAB who were on antihypertensive medication are supported by several previous studies which have shown associations of urinary symptoms with hypertension in men14,15,29–32 but these previous studies did not focus on BP control. Hypertension, especially when BP is poorly controlled, can accelerate prostatic hyperplasia, via vascular damage of prostatic blood vessels which reduces prostatic perfusion and triggers prostatic growth.33–35 While multiple factors such as bladder wall inflammation and aging influence development of OAB,36,37 benign prostatic hyperplasia often incites and/or exacerbates lower urinary tract symptoms via infravesical obstruction in men. The lower odds of BP control in men with OAB could also be due to differences in hypertension management. OAB symptoms may negatively influence medication compliance,16 physical activity, and other disease management behaviors. OAB symptoms may also lead to higher levels of psychological distress3,4 which could heighten BP. One previous study has noted that men with OAB symptoms are less likely to seek treatment than women which suggests that coping skills for these symptoms may differ by sex.7 While our findings are supported by previous studies,14,15,31 future studies are needed to further elucidate factors that may mediate lower rates of BP control among men with OAB.

The strengths of this study include the use of a multi-ethnic study population recruited from 6 US communities across the United States. Urinary symptoms were ascertained using the previously validated ICIQ which asks persons to recall urinary symptoms over the past 4 weeks. Completion of the ICIQ was high, but the men and women who did not complete the ICIQ were older than completers and this nonresponse may have led to under estimation of OAB. Because urinary symptoms are defined by participant response to the ICIQ and not based on urodynamic measurements or urinary diaries, recall bias may be present. However, the ICIQ asks respondents to consider urinary symptoms over a short period of time (past 4 weeks) in order to minimize recall bias and the ICIQ shows strong and significant correlations with urodynamic measurements.38,39 Another limitation of the study is the lack of information on diagnosis of benign prostatic hyperplasia or treatments for prostate cancer. The cross-sectional design of the study also limits the interpretation of the findings and we cannot discern temporal associations.

In conclusion, OAB is associated with higher SBP in both men and women and this association appears largely due to shared risk factors between OAB and hypertension. Among men, OAB is associated with lower rates of BP control even after adjustment for demographics and comorbidities. These findings suggest that OAB may be an important factor to consider when addressing BP control to lower cardiovascular disease risk. More studies are needed to elucidate reasons for reduced BP control in men with OAB symptoms.

FUNDING

NIDDK 1R01DK104842-01 and by contracts 75N92020D00001, HHSN268201500003I, N01-HC-95159, 75N92020D00005, N01-HC-95160, 75N92020D00002, N01-HC-95161, 75N92020D00003, N01-HC-95162, 75N92020D00006, N01-HC-95163, 75N92020D00004, N01-HC-95164, 75N92020D00007, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168, and N01-HC-95169 from the National Heart, Lung, and Blood Institute, and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from the National Center for Advancing Translational Sciences (NCATS) and NIDDK 1R01DK104842-01 from the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK).

DISCLOSURE

L.B.: editorial stipends from Journal of the American Medical Association, Journal of Female Pelvic Medicine and Reconstructive Surgery, and Up to Date. All authors report no conflicts of interest.

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ORIGINAL CONTRIBUTIONS > Epidemiology
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