Pelvic Floor Dysfunction Is Not a Risk Factor for Febrile Urinary Tract Infection in Adults Nieuwkoop, C

Pelvic floor dysfunction is not a risk factor for febrile urinary tract infection in adults Nieuwkoop, C. van; Voorham-van der Zalm, P.J.; Laar, A.M. van; Elzevier, H.W.; Blom, J.W.; Dekkers, O.M.; ... ; Dissel, J.T. van

Citation Nieuwkoop, C. van, Voorham-van der Zalm, P. J., Laar, A. M. van, Elzevier, H. W., Blom, J. W., Dekkers, O. M., … Dissel, J. T. van. (2010). Pelvic floor dysfunction is not a risk factor for febrile urinary tract infection in adults. Bju International, 105(12), 1689-1695. Retrieved from https://hdl.handle.net/1887/117640

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2009 THE AUTHORS . JOURNAL COMPILATION 2009 BJU INTERNATIONAL Lower Urinary Tract PELVIC FLOOR DYSFUNCTION IS NOT A RISK FACTOR FOR FEBRILE UTI IN ADULTS VAN NIEUWKOOP

ET AL.

Pelvic ﬂoor dysfunction is not a risk factor for febrile urinary tract infection in adults BJUIBJU INTERNATIONAL Cees van Nieuwkoop, Petra J. Voorham-van der Zalm*, Anne-Marike van Laar, Henk W. Elzevier*, Jeanet W. Blom†, Olaf M. Dekkers‡, Rob C.M. Pelger*, A. Mieke van Aartrijk-van Dalen, Marjanne C. van Tol and Jaap T. van Dissel Department of Infectious Diseases, *Urology, †Public Health and Primary Care and ‡Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands Accepted for publication 12 August 2009

UTI. Controls were randomly selected ratio 4.9, 95% CI 2.2–11.1) and a history of Study Type – Therapy (case control) subjects who visited their general UTI (odds ratio 2.5, 95% CI 1.0–6.1) were Level of Evidence 3b practitioner for reasons other than UTI or independent significant risk factors for fever. A validated pelvic floor questionnaire febrile UTI, whereas PFD was not (odds ratio OBJECTIVE (the Pelvic Floor Inventories Leiden, PelFIs) 1.0, 0.5–2.2). Within the group of cases, PFD was used to assess pelvic floor function. was not associated with bacteriuria during To determine whether pelvic floor assessment of PelFIs (odds ratio 1.1, 95% CI dysfunction (PFD) might be a risk factor for RESULTS 0.4–3.5) and inversely related to a history of or consequence of febrile urinary tract UTI within the previous year (odds ratio 0.2, infection (UTI), as UTI in adults is a common Between October 2006 and December 2007, 0.1–0.9). infection in which an underlying urological 153 cases were included; of these, the abnormality is often considered, and as in completed questionnaires of 102 (response children, PFD is also thought to have a rate 67%) were compared to those of 100 of CONCLUSIONS pathophysiological role in adults with UTI. 110 (response rate 91%) controls. The median age of cases and controls was 65 and PFD is common among adults but it does not PATIENTS AND METHODS 58 years, respectively; 40% of cases and seem to be a risk factor for febrile UTI. controls were men. The percentage of PelFIs A multicentre case-control study was outcomes consistent with PFD were conducted at 26 primary-care centres and at comparable between cases and controls, at KEYWORDS six Emergency Departments of regional 21% vs 23%, respectively (odds ratio 0.9, hospitals. Cases were consecutive patients 95% confidence interval, CI, 0.4–1.78). In the pelvic floor dysfunction, acute aged ≥18 years, who presented with febrile multivariate analysis, comorbidity (odds pyelonephritis, adults, urinary tract infection

INTRODUCTION unclear, and purposeful integration into syndrome, is widely accepted as a major clinical practice guidelines has not been contributor to the development of UTIs, and UTIs are among the most common bacterial straightforward. In clinical practice, a pelvic muscle floor rehabilitation is the infections in humans and there is ample diagnostic urological evaluation is considered standard of treatment for many young knowledge about its management. Fever after complicated or recurrent UTIs and patients [17]. It has been suggested that in UTI suggests the presence of acute strongly recommended if underlying PFD might also explain the occurrence of pyelonephritis that causes substantial urological disorders are suspected, especially complicated UTIs in cases with a normal morbidity and mortality, with estimated direct in men and postmenopausal women [10–13]. urinary tract [18]. However, in adults the role and indirect costs of $2.14 billion in the USA In general, a urological evaluation relies on a of PFD in UTIs has only been described in in 2000 [1–3]. thorough search for anatomical or functional selected subgroups, predominantly young disorders but the yield for detecting new women with recurrent UTIs [19–22]. To our For the pathophysiology of UTIs, in the past abnormalities is rather low [14,15]. knowledge there have been no comparative decades there has been successful molecular studies that assessed the question of research that has unravelled the main Pelvic floor dysfunction (PFD) is a general whether PFD is a risk factor in adults with determinants of bacterial virulence and term for functional clinical problems affecting complicated UTI. overall host resistance [4–9]. However, the urinary, rectal and/or sexual function [16]. In significance of these molecular findings for children, PFD, also termed dysfunctional For this reason, we conducted a case-control individual patient management remains voiding or dysfunctional elimination study of community-acquired febrile UTI in an

VAN NIEUWKOOP ET AL.

unselected population. The aim of the study certified research nurses or the clinical of 0.41–0.60 corresponds to fair agreement, was to determine whether PFD might be a risk investigators (C.v.N., A.v.L.) who visited 0.61–0.80 to good agreement, 0.81–0.92 to factor for or consequence of febrile UTI. A all primary-care patients directly after very good agreement and 0.93–1.00 to validated questionnaire, the Pelvic Floor notification. Data from patients included at excellent agreement [25]. For comparison of Inventories Leiden (PelFIs), including the emergency departments were collected cases and controls, we used multivariable questions about micturition, defecation and from the medical record, completed with an logistic regression to calculate the odds ratios sexual function, was used to evaluate PFD interview by telephone or at the bedside. (ORs) with their 95% CIs for categorical [23]. variables. In addition to age and sex we Blood and urine cultures were taken before adjusted for comorbidity and a history of UTIs starting antimicrobial therapy within 2 h as potential confounders. This included the PATIENTS AND METHODS of notification, and were assessed using evaluation of potential interaction terms standard microbiological methods. Cases between these factors. Finally, within the We conducted a multicentre case-control were treated for 10–14 days with group of cases, those with suspected PFD study; cases were recruited at six emergency antimicrobials for febrile UTI. Cases were were compared to those without using departments of regional hospitals and 26 visited 28–32 days after presentation with chi-square tests to assess univariable neighbouring primary healthcare centres. febrile UTI to assess the clinical and associations. Multivariable analysis for this Consecutive patients (men and women) microbiological outcome. A midstream urine subgroup analysis was not done because of presenting with a presumptive diagnosis of specimen was cultured and all cases were the small sample size. For all statistical tests, febrile UTI, and those who met the following asked to complete the PelFIs. Controls were a two-tailed P < 0.05 was considered to entry criteria and provided written informed visited once after notification to collect indicate statistical significance. consent, were included. demographic and microbiological data, including urine cultures, and to complete the Inclusion criteria for cases were age PelFIs. RESULTS ≥18 years, fever (rectal/ear temperature of ≥38.2 °C) and/or a history of fever and chills All questionnaires were evaluated Between October 2006 and October 2007, 178 within 24 h before presentation, at least one independently by two urologists (H.W.E., patients with febrile UTI were enrolled in the symptom of UTI (dysuria, frequency, urgency R.C.M.P.) who were unaware of all other data study and 153 met the criteria for case and suprapubic, perineal or flank pain) and except for gender. They dichotomized the definition. Of these 153 cases, 51 could not be leukocyturia defined as a positive leukocyte outcomes of the questionnaires to either evaluated because they were lost to follow- esterase dipstick test or the presence of more suspected presence or absence of PFD. The up, died, refused or for other reasons (Fig. 1). than five leukocytes per high-power field in a cases with interobserver disagreement were The remaining 102 cases (response rate 67%) centrifuged sediment. re-evaluated and discussed by these two were compared to the 51 excluded cases; urologists, who adjudicated the final outcome there were no differences with respect to Controls were consecutive patients aged based on their consensus. Examples of gender, diabetes mellitus or history of UTIs, ≥18 years who consulted their primary questions of the PelFIs are listed in the but the excluded cases were older (median healthcare physician for reasons other than Appendix. age 75 vs 65 years, P = 0.002) and they had fever or UTI. They were recruited at random an underlying urinary tract disorder more selected dates at primary healthcare centres Comorbidity was defined as the presence of often (39% vs 18%, P = 0.013). The PelFIs within the same region as recruitment of any urinary tract disorder, heart failure, questionnaires were analysed and compared cases. cerebrovascular disease, renal insufficiency, to those of the 100 controls of 110 asked diabetes mellitus, malignancy or chronic (response rate 91%). Most controls consulted Exclusion criteria at presentation with febrile obstructive pulmonary disease for which the their primary healthcare physician because UTI were polycystic kidney disease, haemo- patient is prescribed medication and/or of cardiovascular risk management or or peritoneal dialysis, a history of kidney consults a hospital-based medical specialist. musculoskeletal symptoms. The median age transplantation or an expected inability to of cases and controls was 66 and 58 years, obtain follow-up (e.g. language barrier). As for Urinary tract disorder was defined as any respectively; 60% were women. Cases were cases, the PelFIs was obtained 28–32 days history of anatomical urological abnormality more likely to have comorbidity, urological after presentation with a febrile UTI, and the (e.g. BPH, nephrectomy, re-implantation of disorders, a history of UTIs and bacteriuria following exclusion criteria were applied: ureter, VUR, bladder carcinoma, urethral during completion of the questionnaire patients with indwelling urinary catheter, stricture) except nephrolithiasis. Significant (Table 1). urostomy, recent pelvic surgery, spinal cord bacteriuria was defined as a monoculture of lesions or those who developed cognitive ≥103 colony-forming units/mL of urine [24]. Besides fever and symptoms of UTI at dysfunction or became pregnant. For controls, presentation with febrile UTI, 62% of cases all of the above exclusion criteria also applied. Descriptive analysis included means or noticed flank pain, 66% had shaking chills and The study was approved by the local ethics percentages with 95% CIs, or the median 28% were pre-treated for UTI. Cases were committees (protocol number P06.061). (range), as appropriate. Inter-observer empirically treated with oral ciprofloxacin as agreement for the accurate determination of outpatients in 39%, while the remaining 61% Baseline demographic, clinical and the presence or absence of PFD was assessed were admitted and received a β-lactam ± microbiological data were collected by by using the Cohen κ-test, in which a κ-value aminoglycoside i.v.

PELVIC FLOOR DYSFUNCTION IS NOT A RISK FACTOR FOR FEBRILE UTI IN ADULTS

FIG. 1. 178 Consecutive patients with febrile UTI cases than controls but this was not Enrolment of participants in the 79 men statistically signiﬁcant, at 21% vs 23%, study. 99 women respectively (OR 0.9, 95% CI 0.4–1.7). This OR 25 Had an exclusion criterion was the same after adjusting for age and sex. 11 indwelling urinary catheter As this could be different for men and women 8 cognitive dysfunction we compared the 62 women with the 62 3 spinal cord injury women controls; the OR for PFD associated 1 urostomy with febrile UTI, was 0.7 (95% CI 0.3–1.6). 1 underwent urological surgery 1 pregnancy Other risk factors for the presence of febrile 153 Cases did meet inclusion 110 Controls included UTI were comorbidity, urinary tract disorders criteria for PelFIs assessment for PelFIs assessment and previous UTIs (Table 2). Independent signiﬁcant risk factors for febrile UTI in the 51 Excluded 10 Excluded multivariable analysis were comorbidity (OR 4.9, 95% CI 2.2–11.1), a history of UTI (OR 2.5, 30 PelFIs assessment 10 no response 95% CI 1.0–6.1) and a history of UTI the not possible previous year (OR 3.0, 95% CI 1.1–8.2). 7 died 15 lost to follow-up 8 reason unknown Among the 102 cases, a history of urinary 21 Other reasons tract disorder, which was present 10 refused participation predominantly in men, was associated with 6 no response the presence of PFD (OR 3.7, 95% CI 1.1–12.1, 5 incomplete questionnaire adjusted for age and sex). Age >75 years and a history of UTI within the previous year were 102 Cases 100 Controls 40 men 39 men both inversely associated (0.3, 0.06–1.2; and 62 women 61 women 0.2, 0.1–0.9, respectively). The presence of bacteriuria during assessment of the PelFIs (OR 1.1, 95% CI 0.4–3.5) was not associated with the presence of PFD.

TABLE 1 The baseline characteristics of the 102 cases and 100 controls DISCUSSION

Characteristic Cases Controls To our knowledge, the present study is the Median (interquartile range) age, years 65 (44–75) 58 (48–67) ﬁrst to investigate the relationship between Men 40 (40) 39 (39) PFD and febrile UTI in adults which, in this Mean (SD) body mass index, kg/m2 25 (4) 26 (4) study setting, might also be interpreted as Smoking 17 (17) 14 (14) acute pyelonephritis [2,3]. We found that PFD Comorbidity: is common but seems to be neither a risk Diabetes mellitus 19 (19) 8 (8) factor for nor a consequence of febrile UTI in Urinary tract disorder 18 (18) 10 (10) adults. In patients who recovered from febrile History of UTIs 51 (50) 21 (21) UTI, 21% were suspected to have PFD, Bacteriuria during PelFIs 23/98* (24) 4 (4) compared to 23% in a general adult population seeking primary healthcare. As this *In four cases no urine sample was cultured. Data are n (%) unless otherwise indicated. was assessed shortly after recovery from a febrile UTI, we conclude that PFD also does not seem to be a consequence of febrile UTI.

Urine samples, cultured at presentation with 28–32 days after the initial presentation with To assess the presence of PFD we used a febrile UTI, were available in 98 cases; 66 febrile UTI. Of these, 22 (22%) revealed previously validated questionnaire, the PelFIs, (67%) had significant bacteriuria (80% significant bacteriuria (68% E. coli). One of which is not the reference standard to detect Escherichia coli). Of the remaining 32 cases these 22 cases had recurrent UTI symptoms; PFD [23]. However, if there were any standard without significant bacteriuria, 17 could be the remaining 21 with bacteriuria were to assess PFD, the diagnostics used would be explained by antimicrobial pretreatment. considered asymptomatic. complex and often require multiple, difficult Blood cultures were available in 98 cases; 17 to interpret, confirmatory tests [26]. In our (17%) had bacteraemia, of which 88% were The interobserver agreement between the experience, based on this questionnaire, E. coli. two urologists for interpreting the PelFIs patients can be stratified into those suspected questionnaires was good (κ = 0.62, not suspected to have PFD. Suspected cases After recovery of febrile UTI, in 98 cases P < 0.001). The presence of PFD, as assessed are subjected to further analysis of the pelvic a repeat urinary culture was available by the PelFIs questionnaire, was lower among floor and PFD can thus be confirmed in 77%

VAN NIEUWKOOP ET AL.

TABLE 2 Selected risk factors for febrile UTI

OR (95% CI); P Cases Controls Unadjusted Adjusted for Adjusted for age, sex, Factor (102) (100) univariable age and sex comorbidity and history of UTI PFD 21 (21) 23 (23) 0.9 (0.4–1.7) 0.8 (0.4–1.6) 1.0 (0.5–2.2); 0.95 Demographic Age ≥50 years 72 (71) 69 (69) 1.1 (0.6–2.0) 1.1 (0.6–2.0)* 0.8 (0.4–1.7); 0.58 Men 40 (39) 39 (39) 1.0 (0.6–1.8) 0.9 (0.5–1.7)† 1.5 (0.7–3.2); 0.25 Comorbidity Any comorbidity 48 (47) 19 (19) 3.8 (2.0–7.1) 4.1 (2.0–8.1) 4.9 (2.2–11.1); <0.001 Urinary tract disorder 18 (18) 10 (10) 1.9 (0.8–4.4) 1.9 (0.8–4.5) 0.6 (0.2–1.8); 0.39 Diabetes mellitus 19 (19) 8 (8) 2.6 (1.1–6.3) 2.4 (0.9–5.9) 1.9 (0.7–5.2); 0.20 History of UTI Any previous UTI 51 (50) 21 (21) 3.8 (2.0–7.0) 5.0 (2.5–10.1) 2.5 (1.0–6.1); 0.04 History of UTI previous year 35 (35)‡ 11 (11) 4.4 (2.1–9.2) 5.4 (2.4–12.1) 3.0 (1.1–8.2); 0.04

Data are presented as n (%). *adjusted for sex; †adjusted for age; ‡two missing values.

of these cases [27]. We therefore conclude the assessment. The response rate in the group of general healthy population, but the reasons PelFIs is a useful tool for such a case-control cases was lower than in the control group for seeking medical care were unlikely to be study, as is also illustrated by the high degree (67% vs 91%) and cases excluded on pre-set associated with PFD. Moreover, based on of interobserver agreement in the present exclusion criteria were older and more often symptoms assessed by interviews, as in our study. had an underlying urinary tract disorder. This study, a large recent population study in raises concern that selection bias in the group women estimated the prevalence of PFD to be The strengths of our study are the inclusion of of cases might have skewed the findings. We 24%, which is similar to our estimate of 28% cases reflecting daily practice within the therefore evaluated the group on risk factors in women [28]. community setting of patients presenting for PFD and found a positive association with with febrile UTI or acute pyelonephritis, and underlying urinary tract disorder and a The risk factors we identified for febrile UTI controls reflecting the same community of negative association with older age (point or pyelonephritis were remarkably similar people seeking medical attention, reflecting estimate of the OR 3.6 and 0.3, respectively). to previous reports of risk factors for daily primary healthcare practice. The net outcome of these contradictory pyelonephritis and UTIs [11,29–31]. Furthermore, all subjects were clinically and associations is uncertain, but it is reasonable Underlying comorbidity, especially urinary microbiologically well documented, with to consider these effects as balanced. Hence, tract disorders and diabetes mellitus, and a almost no missing data. The combination of it is unlikely that we selectively excluded cases history of UTI were associated with febrile pelvic floor assessment and urine cultures with PFD, as described in Fig. 1. However, UTI. Known risk factors like recent sexual especially created robust data to support the residual selection bias cannot be excluded intercourse, new sexual partner or use of above conclusions. with certainty. spermicide, could not be assessed because these data were not collected [29]. Urinary The limitations of our study are its relatively We used a case-control study design and this incontinence or difficulty holding urine are small sample size and the possibility of approach holds a risk of recall bias. In our associated with febrile UTI but, as this was selection and recall bias. For sample size, it setting, cases completed the PelFIs after a part of the PelFIs questionnaire, these risk could therefore not be excluded that in diagnosis of febrile UTI, which might have factors were not analysed separately [11,29]. specific subgroups there might indeed be a enhanced the sensitivity in reporting relationship between febrile UTI and PFD. symptoms of PFD. However, the severity of Risk factors for the presence of PFD in adults However, the data are consistent with febrile UTI and the fact that cases were could not be addressed by this study because previous reports on other risk factors for slightly older and more frequently had there were too few cases with suspected pyelonephritis and UTIs in general. In this underlying comorbidity, might have clouded PFD. Nevertheless, our results suggest a respect, selection bias is unlikely. We selected their memory, leading to reduced sensitivity in relationship with an underlying urinary cases with febrile UTI for assessment of pelvic detecting PFD; again, the net effect is unclear tract disorder. In this study population, floor function only if this would have made but presumably neutral. an underlying urinary tract disorder sense clinically. Therefore patients with, for predominantly occurred in men, in particular instance, an indwelling urinary catheter, were Controls were individuals seeking primary BPH. A possible explanation for the excluded, as was also done in the control healthcare and 23% (28% in women and 18% relationship between PFD and urinary tract group. In daily practice a similar selection in men) of them were suspected to have PFD. disorder might therefore be that the LUTS would occur before considering a pelvic floor This might also be a biased selection of the associated with BPH are correlated with

PELVIC FLOOR DYSFUNCTION IS NOT A RISK FACTOR FOR FEBRILE UTI IN ADULTS

autonomic nervous system overactivity, and specific subgroups of patients with isolates from women with acute similar symptoms are listed in the PelFIs underlying urinary tract disorder, and the pyelonephritis, with or without questionnaire that particularly predicts PFD in development of guidelines for urological bacteremia. Clin Infect Dis 1993; 17: 448– terms of overactive rest tone [27,32]. diagnostics in unexplained complicated UTIs. 56 7 Lundstedt AC, Leijonhufvud I, Furthermore there was an inverse relationship ACKNOWLEDGEMENTS Ragnarsdottir B, Karpman D, Andersson between a history of UTI and PFD, whereas B, Svanborg C. Inherited susceptibility to there was no association with asymptomatic We acknowledge the patients for their acute pyelonephritis: a family study of bacteriuria. This strongly suggests that there participation, the primary-care physicians urinary tract infection. J Infect Dis 2007; is either no or an inverse relationship between and their staff for enrolment of patients 195: 1227–34 UTIs and PFD in adults. This finding is rather and the co-investigators of the following 8 Chowdhury P, Sacks SH, Sheerin NS. counterintuitive because UTIs are one of the participating hospitals: Groene Hart Hospital, Toll-like receptors TLR2 and TLR4 initiate key features of dysfunctional voiding in Gouda: T. Koster, MD, PhD; Rijnland Hospital, the innate immune response of the renal children and so far, reports suggest that this is Leiderdorp: N.M. Delfos, MD; Diaconessenhuis tubular epithelium to bacterial products. also true for adults [17,21,22]. Probably, as the Leiden, Leiden: H.C. Ablij, MD; Medical Center Clin Exp Immunol 2006; 145: 346–56 PelFIs questionnaire addresses three different Haaglanden, the Hague; E.M. Leyten, MD, PhD; 9 Chromek M, Brauner A. Antimicrobial domains of the pelvic floor, related to Spaarne Hospital, Hoofddorp: G.H. Wattel- mechanisms of the urinary tract. J Mol micturition, defecation and sexual function, Louis, MD. These data were presented in part Med 2008; 86: 37–47 the PFD noted in this cohort could have relied at the 48th Interscience Conference on 10 Lipsky BA. Urinary tract infections in upon problems concerning defecation and Antimicrobial Agents and Chemotherapy/46th men. Epidemiology, pathophysiology, sexual function, of which the latter might lead Infectious Disease Society of America Annual diagnosis, and treatment. Ann Intern Med to sexual abstinence and thus a lower chance Meeting, Washington, DC, 25–28 October, 1989; 110: 138–50 of developing UTIs [29]. Future studies are 2008, Abstract 1874. 11 Raz R, Gennesin Y, Wasser J et al. needed to address this issue further. Another Recurrent urinary tract infections in explanation for the apparent discrepancy CONFLICT OF INTEREST postmenopausal women. Clin Infect Dis between children and adults for UTIs and PFD 2000; 30: 152–6 is that the studies in children are biased by None declared. 12 Nicolle LE. A practical guide to selection, by which only children with antimicrobial management of recurrent UTI were referred to paediatric REFERENCES complicated urinary tract infection. Drugs urologists and thus included in the studies on Aging 2001; 18: 243–54 dysfunctional voiding. This issue is illustrated 1 Brown P, Ki M, Foxman B. Acute 13 Grabe M, Bishop MC, Bjerklund- by the fact that in a general paediatric pyelonephritis among adults: cost of Johansen TE et al. Guidelines on population with UTI there was no relation illness and considerations for the urological infections. European with the dysfunctional elimination syndrome economic evaluation of therapy. Association of Urology. Available at: [33]. 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female anatomy. Lancet Infect Dis 2004; 30 Hu KK, Boyko EJ, Scholes D et al. Risk How often do you feel the need to urinate? 4: 631–5 factors for urinary tract infections in continually; every half hour; every hour; 19 Carlson KV, Rome S, Nitti VW. postmenopausal women. Arch Intern Med longer than 1 h; 2–4 h; Longer Dysfunctional voiding in women. J Urol 2004; 164: 989–93 2001; 165: 143–7 31 Ulleryd P. Febrile urinary tract infection Can you put off urinating if you are sitting 20 Groutz A, Blaivas JG, Pies C, Sassone in men. Int J Antimicrob Agents 2003; 22 quietly? AM. Learned voiding dysfunction (non- (Suppl. 2): 89–93 must run directly; for a few minutes; have neurogenic, neurogenic bladder) among 32 McVary KT, Rademaker A, Lloyd GL, good control; other. Please indicate: adults. Neurourol Urodyn 2001; 20: 259– Gann P. Autonomic nervous system 68 overactivity in men with lower urinary Does the urine come in one spurt? 21 Akkad T, Pelzer AE, Mitterberger M tract symptoms secondary to benign never; seldom; sometimes; regularly; always; et al. Influence of intravesical potassium prostatic hyperplasia. J Urol 2005; 174: other. Please indicate: on pelvic floor activity in women with 1327–433 recurrent urinary tract infections: 33 Shaikh N, Hoberman A, Wise B et al. Do you have to push when you urinate? comparative urodynamics might lead to Dysfunctional elimination syndrome: is it never; seldom; sometimes; regularly; always; enhanced detection of dysfunctional related to urinary tract infection or other. Please indicate: voiding. BJU Int 2007; 100: 1071–4 vesicoureteral reflux diagnosed early in 22 Minardi D, Parri G, d’Anzeo G, Fabiani life? Pediatrics 2003; 112: 1134–7 Domain urinary continence A, El AZ, Muzzonigro G. Perineal 34 Chen JJ, Mao W, Homayoon K, ultrasound evaluation of dysfunctional Steinhardt GF. A multivariate analysis Are you ever incontinent? voiding in women with recurrent urinary of dysfunctional elimination syndrome, yes; no tract infections. J Urol 2008; 179: 947–51 and its relationships with gender, urinary 23 Voorham-van der Zalm PJ, Stiggelbout tract infection and vesicoureteral reflux How much urine leaks? AM, Aardoom I et al. Development and in children. J Urol 2004; 171: 1907–10 drops; a small burst; a whole bladderful; validation of the pelvic floor inventories 35 Feldman AS, Bauer SB. Diagnosis and other. Please indicate: ; not applicable Leiden (PelFIs). Neurourol Urodyn 2008; management of dysfunctional voiding. 27: 301–5 Curr Opin Pediatr 2006; 18: 139–47 Do you have more leakage: 24 Rubin RH, Shapiro ED, Andriole VT, in the cold, yes, no; if a tap is running, yes, no; Davis RJ, Stamm WE. Evaluation of new Correspondence: Cees van Nieuwkoop, Leiden if you are nervous, yes, no; in the shower, anti-infective drugs for the treatment of University Medical Center, Department of yes, no urinary tract infection. Infectious Diseases Infectious Diseases, C5-P, PO Box 9600, 2300 Society of America and the Food and Drug RC Leiden, the Netherlands. Administration. Clin Infect Dis 1992; 15 e-mail: [email protected] Domain obstructive micturition (Suppl. 1): S216–27 25 Byrt T. How good is that agreement? Abbreviations: PelFIs, Pelvic Floor Inventories Do you have the feeling after urinating that Epidemiology 1996; 7: 561 Leiden; PFD, pelvic floor dysfunction. the bladder is completely empty? 26 Messelink B, Benson T, Berghmans B never; seldom; sometimes; regularly; always; et al. Standardization of terminology APPENDIX other. Please indicate: of pelvic floor muscle function and dysfunction: report from the pelvic The PelFIs is a validated questionnaire Is urinating itself painful? floor clinical assessment group of the developed to evaluate whether pelvic floor never; seldom; sometimes; regularly; always; International Continence Society. dysfunction should be suspected. The other. Please indicate: Neurourol Urodyn 2005; 24: 374–80 contents of this questionnaire can be divided 27 Voorham-van der Zalm PJ. Lycklama à into several domains regarding pelvic floor When you have finished urinating and stand Nijeholt GAB, Elzevier HW, Putter H, function that is micturition, defecation and up, does it still dribble? Pelger RC. Diagnostic investigation of sexual function. Within the following out of never; seldom; sometimes; regularly; always; the pelvic floor: a helpful tool in the each specific domain sample questions of the other. Please indicate: approach in patients with complaints PelFIs are listed. of micturition, defecation, and/or sexual Domain defecation dysfunction. J Sex Med 2008; 5: 864–71 Domain micturition 28 Nygaard I, Barber MD, Burgio KL et al. How often on average per week do you have Prevalence of symptomatic pelvic floor How often on average do you urinate during bowel movement in the daytime? disorders in US women. JAMA 2008; 300: the day? <1 × per week; 1–2 × per week; 3–7 × per 1311–6 2–4 × per day; 5–7 × per day; 8–10 × per day; week; >7 × per week; never; other. Please 29 Scholes D, Hooton TM, Roberts PL, more than 10 × per day indicate: Gupta K, Stapleton AE, Stamm WE. Risk factors associated with acute How often on average do you urinate at night? What is the consistency of the stool? pyelonephritis in healthy women. Ann never; 1–2 × per night; 3–4 × per night; thin, watery; mushy; soft; hard; varying Intern Med 2005; 142: 20–7 >4 × per night consistency; other. Please indicate:

Do you ever have bright red bleeding during Have you ever had itch around the anus? Do you have pain around the anus after a the bowel movement? never; seldom; sometimes; regularly; always; bowel movement? never; seldom; sometimes; regularly; always; other. Please indicate: never; seldom; sometimes; regularly; always; other. Please indicate: other. Please indicate:

Domain fecal incontinence Domain constipation Domain sexual function Do you ever have bowel incontinence? Whenever you go to the toilet to move your yes; no bowels, do you need more than 15 min for Do you have sexual intercourse? this? yes; no Can you put off the urge to empty your bowel never; seldom; sometimes; regularly; always; for 15 min? other. Please indicate: Do you have pain during intercourse? never; seldom; sometimes; regularly; always; pain on penetration, yes, no, not applicable; other. Please indicate: Do you feel that the bowel is completely pain deep inside; yes, no, not applicable empty after the bowel movement? Do you feel that faeces is leaking? never; seldom; sometimes; regularly; always; In addition to the above listed sample yes; no; sometimes; not applicable other. Please indicate: questions the PelFIs includes speciﬁc questions for men and women. For men there Have you ever had skin irritation around the Do you feel that the stool is coming in pieces are additional questions about erectile anus? (several times consecutively)? function and for women questions related to never; seldom; sometimes; regularly; always; never; seldom; sometimes; regularly; always; vaginal prolapse, menstrual cycle and history other. Please indicate: other. Please indicate: of pregnancies and deliveries.

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