Burden of Non-Cancerous GU Conditions| Volume 166, P39-49, August 2022

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

Published:September 15, 2021DOI:



      To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.


      The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.


      The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).


      NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.
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        • Markland AD
        • Richter HE
        • Fwu CW
        • Eggers P
        • Kusek JW
        Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008.
        J Urol. 2011; 186: 589-593
        • Irwin DE
        • Kopp ZS
        • Agatep B
        • Milsom I
        • Abrams P
        Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction.
        BJU international. 2011; 108: 1132-1138
        • Hoberman A
        • Charron M
        • Hickey RW
        • Baskin M
        • Kearney DH
        • Wald ER
        Imaging studies after a first febrile urinary tract infection in young children.
        N Eng J Med. 2003; 348: 195-202
        • Stöhrer M
        • Blok B
        • Castro-Diaz D
        • et al.
        EAU guidelines on neurogenic lower urinary tract dysfunction.
        Eur Urol. 2009; 56: 81-88
        • Hernández Hernández D
        • Tesouro RB
        • Castro-Diaz D
        Urinary retention.
        Urologia. 2013; 80: 257-264
        • Bosch JL
        • Weiss JP
        The prevalence and causes of nocturia.
        J Urol. 2010; 184: 440-446
        • Gibson W
        • Hunter KF
        • Camicioli R
        • et al.
        The association between lower urinary tract symptoms and falls: forming a theoretical model for a research agenda.
        Neurourol Urodyn. 2018; 37: 501-509
        • Kalinderi K
        • Delkos D
        • Kalinderis M
        • Athanasiadis A
        • Kalogiannidis I
        Urinary tract infection during pregnancy: current concepts on a common multifaceted problem.
        Journal of obstetrics and gynaecology: the journal of the Institute of Obstetrics and Gynaecology. 2018; 38: 448-453
      1. U.S. Department of Health and Human Services. Multiple chronic conditions: A strategic framework – Optimum health and quality of life for individuals with multiple chronic conditions. Accessed March 15, 2021,

        • Coyne KS
        • Wein A
        • Nicholson S
        • Kvasz M
        • Chen CI
        • Milsom I
        Comorbidities and personal burden of urgency urinary incontinence: a systematic review.
        Int J Clin Pract. 2013; 67: 1015-1033
        • Morris AR
        • Ho MT
        • Lapsley H
        • Walsh J
        • Gonski P
        • Moore KH
        Costs of managing urinary and faecal incontinence in a sub-acute care facility: a "bottom-up" approach.
        Neurourol Urodyn. 2005; 24: 56-62
        • Tellechea L
        • Zuo S
        • Kohn JR
        • et al.
        The effect of social determinants of health on overactive bladder symptom severity.
        J Urol. 2021; 205: 1415-1420
      2. U.S. Department of Health and Human Services National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases. Urologic diseases. Accessed March 15, 2021,

        • National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health
        Paper presented at: Uncovering the Hidden Burden of Benign Genitourinary Conditions.
        Final Meeting Summary. Bethesda, MD2019
        • Brady SS
        • Bavendam TG
        • Berry A
        • et al.
        The Prevention of Lower Urinary Tract Symptoms (PLUS) in girls and women: developing a conceptual framework for a prevention research agenda.
        Neurourol Urodyn. Nov 2018; 37: 2951-2964
        • Golden SD
        • Earp JA
        Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions.
        Health Educ & Behav. Jun 2012; 39: 364-372
        • Kim M
        • Harvey J
        • Gusev A
        • Norton J
        • Miran S
        • Bavendam T
        A scoping review of the economic burden of non-cancerous GU conditions.
        Urology. 2021; (Submitted for publication)
        • Norton JM
        • Dowling-Castronovo A
        • Conroy B
        • et al.
        The Inflection Point Model: A model to explore the hidden burdens of non-cancerous genitourinary conditions.
        Urology. 2021;
        • Glass TA
        • McAtee MJ.
        Behavioral science at the crossroads in public health: extending horizons, envisioning the future.
        Soc Sci Med. 2006; 62: 1650-1671
        • Hackler RH
        A 25-year prospective mortality study in the spinal cord injured patient: comparison with the long-term living paraplegic.
        J Urol. 1977; 117: 486-488
        • Cameron AP
        • Wallner LP
        • Tate DG
        • Sarma AV
        • Rodriguez GM
        • Clemens JQ
        Bladder management after spinal cord injury in the United States 1972 to 2005.
        J Urol. 2010; 184: 213-217
        • Furusawa K
        • Tokuhiro A
        • Sugiyama H
        • et al.
        Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury.
        Spinal Cord. 2011; 49: 49-54
        • Bliwise DL
        • Foley DJ
        • Vitiello MV
        • Ansari FP
        • Ancoli-Israel S
        • Walsh JK
        Nocturia and disturbed sleep in the elderly.
        Sleep Med Rev. 2009; 10: 540-548
        • Mezick EJ
        • Hall M
        • Matthews KA
        Are sleep and depression independent or overlapping risk factors for cardiometabolic disease?.
        Sleep Med Rev. 2011; 15: 51-63
        • Tasali E
        • Leproult R
        • Ehrmann DA
        • Van Cauter E
        Slow-wave sleep and the risk of type 2 diabetes in humans.
        Proc Natl Acad Sci U S A. 2008; 105: 1044-1049
        • Calhoun DA
        • Harding SM.
        Sleep and hypertension.
        Chest. 2010; 138: 434-443
        • Hublin C
        • Partinen M
        • Koskenvuo M
        • Kaprio J
        Sleep and mortality: a population-based 22-year follow-up study.
        Sleep. 2007; 30: 1245-1253
        • Boyé ND
        • Van Lieshout EM
        • Van Beeck EF
        • Hartholt KA
        • Van der Cammen TJ
        • Patka P
        The impact of falls in the elderly.
        Trauma. 2013; 15: 29-35
        • Mody L
        • Juthani-Mehta M
        Urinary tract infections in older women: a clinical review.
        JAMA. 2014; 311: 844-854
        • Hu KK
        • Boyko EJ
        • Scholes D
        • et al.
        Risk factors for urinary tract infections in postmenopausal women.
        Arch Intern Med. 2004; 164: 989-993
        • Collamati A
        • Martone AM
        • Poscia A
        • et al.
        Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence.
        Aging Clin Exp Res. 2016; 28: 25-35
        • American Geriatrics Society 2019
        Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults.
        J Am Geriatr Soc. 2019; 67: 674-694
        • Hirshburg JM
        • Kelsey PA
        • Therrien CA
        • Gavino AC
        • Reichenberg JS
        Adverse effects and safety of 5-alpha reductase inhibitors (Finasteride, Dutasteride): a systematic review.
        J Clin Aesthet Dermatol. 2016; 9: 56-62
        • Lepor H
        Alpha blockers for the treatment of benign prostatic hyperplasia.
        Rev Urol. 2007; 9: 181-190
        • Klein RD
        • Hultgren SJ
        Urinary tract infections: microbial pathogenesis, host-pathogen interactions and new treatment strategies.
        Nat Rev Microbiol. 2020; 18: 211-226
      3. U.S. Department of Health and Human Services Centers for Disease Control.
        Antibiotic resistance threats in the United States. 2019; (Accessed October 7, 2021)
        • Sun F
        • Sun X
        • Shi Q
        • Zhai Y
        Transurethral procedures in the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis of effectiveness and complications.
        Medicine. 2018; 97: e13360
        • Cooper JL
        • François N
        • Sourial MW
        • et al.
        The impact of ureteral access sheath use on the development of abnormal postoperative upper tract imaging after ureteroscopy.
        J Urol. Nov 2020; 204: 976-981
        • Lu C
        • Zhang W
        • Peng Y
        • et al.
        Endoscopic balloon dilatation in the treatment of benign ureteral strictures: a meta-analysis and systematic review.
        J Endourol. 2019; 33: 255-262
        • Shah HN
        • Badlani GH
        Mesh complications in female pelvic floor reconstructive surgery and their management: a systematic review.
        Indian J Urol. 2012; 28: 129-153
        • Ray S
        • Clifton MM
        • Koo K
        Inaccuracies in news media reporting about the 2019 US Food and Drug Administration ban on transvaginal mesh for pelvic organ prolapse repair.
        Urology. 2021; 150: 194-200
        • Unger CA
        • Rizzo AE
        • Ridgeway B
        Indications and risk factors for midurethral sling revision.
        Int Urogynecol J. 2016; 27: 117-122
        • Ugianskiene A
        • Davila GW
        • Su TH
        FIGO review of statements on use of synthetic mesh for pelvic organ prolapse and stress urinary incontinence.
        Int J Gynaecol Obstet. Nov 2019; 147: 147-155
        • Bale TL
        • Epperson CN
        Sex differences and stress across the lifespan.
        Nat Neurosci. 2015; 18: 1413-1420
        • Epperson CN
        • Duffy KA
        • Johnson RL
        • Sammel MD
        • Newman DK
        Enduring impact of childhood adversity on lower urinary tract symptoms in adult women.
        Neurourol Urodyn. 2020; 39: 1472-1481
        • Dmochowski RR
        • Newman DK
        Impact of overactive bladder on women in the United States: results of a national survey.
        Curr Med Res Opin. 2007; 23: 65-76
        • Milsom I
        • Kaplan SA
        • Coyne KS
        • Sexton CC
        • Kopp ZS
        Effect of bothersome overactive bladder symptoms on health-related quality of life, anxiety, depression, and treatment seeking in the United States: results from EpiLUTS.
        Urology. 2012; 80: 90-96
        • Bogner HOD AJ
        • de Vries HF
        • Northington GM
        • Joo JH
        The temporal relationship between anxiety disorders and urinary incontinence among community-dwelling adults.
        J Anxiety Disord. 2011; 25: 203-208
        • Felde G
        • Ebbesen MH
        • Hunskaar S
        Anxiety and depression associated with urinary incontinence. A 10-year follow-up study from the Norwegian HUNT study (EPINCONT).
        Neurourol Urodyn. 2017; 36: 322-328
        • Breyer BN
        • Kenfield SA
        • Blaschko SD
        • Erickson BA
        The association of lower urinary tract symptoms, depression and suicidal ideation: data from the 2005-2006 and 2007-2008 National Health and Nutrition Examination Survey.
        J Urol. May 2014; 191: 1333-1339
        • Welk B
        • McArthur E
        • Ordon M
        • Anderson KK
        • Hayward J
        • Dixon S
        Association of suicidality and depression with 5α-reductase inhibitors.
        JAMA Int Med. 2017; 177: 683-691
        • Yip SO
        • Dick MA
        • McPencow AM
        • Martin DK
        • Ciarleglio MM
        • Erekson EA
        The association between urinary and fecal incontinence and social isolation in older women.
        Amer J Obstet Gynecol. 2013; 208: 146.e1-146.e7
        • Nicholson NR
        A review of social isolation: an important but underassessed condition in older adults.
        J Prim Prev. 2012; 33: 137-152
        • Coyne KS
        • Sexton CC
        • Clemens JQ
        • et al.
        The impact of OAB on physical activity in the United States: results from OAB-POLL.
        Urology. 2013; 82: 799-806
        • Lavie CJ
        • Ozemek C
        • Carbone S
        • Katzmarzyk PT
        • Blair SN
        Sedentary behavior, exercise, and cardiovascular health.
        Circ Res. 2019; 124: 799-815
        • Lean K
        • Nawaz RF
        • Jawad S
        • Vincent C
        Reducing urinary tract infections in care homes by improving hydration.
        BMJ Open Qual. 2019; 8e000563
        • Hwang R
        • Chuan F
        • Peters R
        • Kuys S
        Frequency of urinary incontinence in people with chronic heart failure.
        Heart Lung. 2013; 42: 26-31
        • Patel M
        • Vellanki K
        • Leehey DJ
        • et al.
        Urinary incontinence and diuretic avoidance among adults with chronic kidney disease.
        Int Urol Nephrol. 2016; 48: 1321-1326
        • Richard L
        • Gauvin L
        • Raine K
        Ecological models revisited: their uses and evolution in health promotion over two decades.
        Annu Rev Public Health. 2011; 32: 307-326
        • Bradway C
        • Miller E
        • Heivly A
        • Fleshner I
        Continence care for obese nursing home residents.
        Urol Nurs. 2010; 30: 121-129
        • Hakimi Z
        • Houbiers J
        • Pedersini R
        • Vietri J
        The burden of bladder pain in five european countries: a cross-sectional study.
        Urology. 2017; 99: 84-91
        • Mendes A
        • Hoga L
        • Gonçalves B
        • Silva P
        • Pereira P
        Adult women's experiences of urinary incontinence: a systematic review of qualitative evidence.
        JBI Database System Rev Implement Rep. 2017; 15: 1350-1408
        • Schultheiss D
        Urogenital infections and male sexuality: effects on ejaculation and erection.
        Andrologia. 2008; 40: 125-129
        • Kong EH
        • Deatrick JA
        • Bradway CK
        Men's experiences after prostatectomy: a meta-synthesis.
        Int J Nurs Studies. 2017; 74: 162-171
        • Moriarty HJ
        • Robinson JP
        • Bunting-Perry L
        • Bradway CW
        Cognitive, affective, and behavioral dimensions of the lower urinary tract symptom experience in men with Parkinson's Disease.
        J Wound Ostomy Continence Nurs. 2016; 43: 80-87
      4. Wild DJ, Clayson DJ, Keating K, Gondek K. Validation of a patient-administered questionnaire to measure the activity impairment experienced by women with uncomplicated urinary tract infection: the Activity Impairment Assessment (AIA). Health Qual Life Outcomes.2005;3:42. doi:10.1186/1477-7525-3-42

        • Medina M
        • Castillo-Pino E
        An introduction to the epidemiology and burden of urinary tract infections.
        Health Qual Life Outcomes. 2019; 111756287219832172
        • Vasudevan V
        • Moldwin R
        Addressing quality of life in the patient with interstitial cystitis/bladder pain syndrome.
        Asian J Urol. 2017; 4: 50-54
        • Santini S
        • Andersson G
        • Lamura G
        Impact of incontinence on the quality of life of caregivers of older persons with incontinence: a qualitative study in four European countries.
        Arch Gerontol Geriatr Suppl. 2016; 63: 92-101
        • Moriarty H
        • Bunting-Perry L
        • Robinson JP
        • Bradway CW
        The experience of women who care for spouses with Parkinson's Disease and lower urinary tract symptoms.
        JOGNN-J Obst Gyn Neo. 2016; 45: 737-748
        • Hu TW
        • Wagner TH
        • Bentkover JD
        • Leblanc K
        • Zhou SZ
        • Hunt T
        Costs of urinary incontinence and overactive bladder in the United States: a comparative study.
        Urology. 2004; 63: 461-465
        • McDaniel C
        • Ratnani I
        • Fatima S
        • Abid MH
        • Surani S
        Urinary incontinence in older adults takes collaborative nursing efforts to improve.
        Cureus. 2020; 12: e9161
        • Rogers MA
        • Fries BE
        • Kaufman SR
        • Mody L
        • McMahon Jr., LF
        • Saint S
        Mobility and other predictors of hospitalization for urinary tract infection: a retrospective cohort study.
        BMC Geriatr. 2008; 8: 31
        • Fultz N
        • Girts T
        • Kinchen K
        • Nygaard I
        • Pohl G
        • Sternfeld B
        Prevalence, management and impact of urinary incontinence in the workplace.
        Occup Med. 2005; 55: 552-557
      5. United States Department of Labor Occupational Safety and Health Administration. 1915.88 - Sanitation. Occup Safety and Health Standards for Shipyard Employment. Accessed March 16, 2021.,

        • Pierce HM
        • Perry L
        • Gallagher R
        • Chiarelli P
        Delaying voiding, limiting fluids, urinary symptoms, and work productivity: a survey of female nurses and midwives.
        J Adv Nurs. 2019; 75: 2579-2590
        • Shoham DA
        • Wang Z
        • Lindberg S
        • et al.
        School toileting environment, bullying, and lower urinary tract symptoms in a population of adolescent and young adult girls: Preventing lower urinary tract symptoms consortium analysis of Avon longitudinal study of parents and children.
        Urology. 2021; 151: 86-93
        • Lundblad B
        • Hellström AL
        Perceptions of school toilets as a cause for irregular toilet habits among schoolchildren aged 6 to 16 years.
        J Sch Health. 2005; 75: 125-128
        • Camenga DR
        • Brady SS
        • Hardacker CT
        • et al.
        U.S. Adolescent and adult women’s experiences accessing and using toilets in schools, workplaces, and public spaces: a multi-site focus group study to inform future research in bladder health.
        Int J Environ Res Public Health. 2019; 16: 3338
        • Peake S
        • Manderson L
        The constraints of a normal life: the management of urinary incontinence by middle aged women.
        Women Health. 2003; 37: 37-51
      6. Schneider B. The dirty truth about San Francisco's sidewalks. Is the city really drowning in filth? In: Lab BC, ed2018. Accessed March 16, 2021.

        • Fultz NH
        • Fisher GG
        • Jenkins KR
        Does urinary incontinence affect middle-aged and older women's time use and activity patterns?.
        Obstet Gynecol. 2004; 104: 1327-1334
        • Morin JP
        • King AB
        • Goetz LL
        • Wolfe LG
        • Klausner AP
        Racial disparities in bladder management in veterans with spinal cord injury and disorders.
        Neurourol Urodyn. 2019; 38: 968-974
        • Sosland R
        • Kowalik CA
        • Cohn JA
        • et al.
        Nonclinical barriers to care for neurogenic patients undergoing complex urologic reconstruction.
        Urology. 2019; 124: 271-275
        • Luppa M
        • Luck T
        • Weyerer S
        • König HH
        • Brähler E
        • Riedel-Heller SG
        Prediction of institutionalization in the elderly. A systematic review.
        Age Ageing. 2010; 39: 31-38
      7. Wagner TH MK, Subak LL, de Wachter S, Dudding T. Incontinence. Paper presented at: 6th International Consultation on Incontinence; 2017, 2017; Tokyo.

        • Subak LL
        • Brown JS
        • Kraus SR
        • et al.
        The "costs" of urinary incontinence for women.
        Obstet Gynecol. 2006; 107: 908-916
        • Diokno AC
        • Sand PK
        • Macdiarmid S
        • Shah R
        • Armstrong RB
        Perceptions and behaviours of women with bladder control problems.
        Fam Pract. 2006; 23: 568-577
        • Coyne KS
        • Wein A
        • Nicholson S
        • Kvasz M
        • Chen CI
        • Milsom I
        Economic burden of urgency urinary incontinence in the United States: a systematic review.
        J Manag Care Pharm. 2014; 20: 130-140
        • Antonelli JA
        • Maalouf NM
        • Pearle MS
        • Lotan Y
        Use of the National Health and Nutrition Examination Survey to calculate the impact of obesity and diabetes on cost and prevalence of urolithiasis in 2030.
        Eur Urol. 2014; 66: 724-729
      8. United States Environmental Protection Agency. Facts and Figures About Materials, Waste and Recycling. Guide to the Facts and Figures About Materials, Waste and Recycling. Accessed March 22, 2021.

        • Itsubo N
        • Wada M
        • Imai S
        • Myoga A
        • Makino N
        • Shobatake K
        Life cycle assessment of the closed-loop recycling of used disposable diapers.
        Resources. 2020; 9: 34
        • Willskytt S TA-M
        Resource efficiency of consumables - Life cycle assessment of incontinence products.
        Resour Conserv Recy. 2019; 144: 13-23
        • Younes L
        The future: Energy-producing diapers.
        The EPA Blog. 2021;
        Date accessed: October 7, 2021
        • Feldstein CA
        Nocturia in arterial hypertension: a prevalent, underreported, and sometimes underestimated association.
        J Am Soc Hypertens. 2013; 7: 75-84
        • Tabara Y
        • Matsumoto T
        • Murase K
        • et al.
        Frequent nocturnal urination in older men is associated with arterial stiffness: The Nagahama study.
        Hypertens Res. 2019; 42: 1996-2001
        • Khan SA
        • Rahman EU
        • Chobufo MD
        • et al.
        Nocturia is an independent predictor of abdominal aortic calcification in women: Results from the National Health and Nutrition Examination Survey.
        J Community Health. 2020; 45: 1111-1115
        • Pressman MR
        • Figueroa WG
        • Kendrick-Mohamed J
        • Greenspon LW
        • Peterson DD
        Nocturia. A rarely recognized symptom of sleep apnea and other occult sleep disorders.
        Arch Intern Med. 1996; 156: 545-550
        • Tsai M
        • Khayat R
        Sleep apnea in heart failure.
        Curr Treat Options Cardiovasc Med. 2018; 20: 33
        • Victor RG
        • Li N
        • Blyler CA
        • et al.
        Nocturia as an unrecognized symptom of uncontrolled hypertension in black men aged 35 to 49 years.
        J Am Heart Assoc. 2019; 8e010794
        • Montorsi P
        • Ravagnani PM
        • Galli S
        • et al.
        The artery size hypothesis: a macrovascular link between erectile dysfunction and coronary artery disease.
        Am J Cardiol. 2005; 96: 19m-23m
        • Zhao B
        • Hong Z
        • Wei Y
        • Yu D
        • Xu J
        • Zhang W
        Erectile dysfunction predicts cardiovascular events as an independent risk factor: a systematic review and meta-analysis.
        J Sex Med. 2019; 16: 1005-1017
        • Panicker JN
        • Fowler CJ
        • Kessler TM
        Lower urinary tract dysfunction in the neurological patient: clinical assessment and management.
        Lancet: Neurol. 2015; 14: 720-732
        • Roy HA
        • Nettleton J
        • Blain C
        • et al.
        Assessment of patients with lower urinary tract symptoms where an undiagnosed neurological disease is suspected: a report from an International Continence Society consensus working group.
        Neurourol Urodyn. 2020; 39: 2535-2543
        • Daneshgari F
        • Liu G
        • Birder L
        • Hanna-Mitchell AT
        • Chacko S
        Diabetic bladder dysfunction: current translational knowledge.
        J Urol. 2009; 182 (ppl): S18-526
        • Hardacker CT
        • Baccellieri A
        • Mueller ER
        • et al.
        Bladder health experiences, perceptions and knowledge of sexual and gender minorities.
        Int J Environ Res Public Health. 2019; 16: 3170
        • Hall WJ
        • Chapman MV
        • Lee KM
        • et al.
        Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review.
        Am J Public Health. 2015; 105: e60-e76