Pelvic floor symptoms, i.e. lower urinary tract symptoms (LUTS), defecation problems, sexual dysfunction, pelvic pain, and pelvic organ prolapse (POP) in females are common and frequently co-occur, and are associated with a negative impact on an individual’s quality of life. There are several treatment strategies for these symptoms. However, many patients with pelvic floor symptoms do not seek help and therefore do not start any treatment. Most studies assessing help-seeking behaviour are focused on one symptom at the time, predominantly urinary incontinence (1,2). As we are interested in help-seeking behaviour when multiple pelvic floor symptoms occur, the aim of this study is to explore the contributing factors of, and barriers to help-seeking behaviour in both males and females with two or more pelvic floor symptoms.

Males and females aged ≥16 years were invited to fill in a questionnaire on pelvic floor symptoms for a cohort study conducted in a municipality in the Netherlands. Presence of symptoms was defined using the following questionnaires: LUTS: the International Consultation on Incontinence Modular Questionnaire (ICIQ)-male and female (ICIQ-MLUTS/FLUTS). Defecation problems: the combined Wexner score (Wexner incontinence score plus Wexner constipation score, based on the Groningen Defecation and Fecal Continence (DeFeC) questionnaire. Sexual dysfunction males: having erectile and/or ejaculation problems and/or pain during intercourse or ejaculation; females: having orgasmic dysfunction and/or orgasmic problems and/or vaginismus and/or vaginal dryness and/or pain during intercourse (based on the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) and Sexual Health in the Netherlands questionnaire). POP: four out of six items of the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6) answered with yes. Pelvic pain: Presence of pain in the pelvic region (yes).
Participants with two or more pelvic floor symptoms, and willing to take part in sub-studies of the cohort study were pre-selected based on their type of symptoms and age, and invited for this interview study. The local ethical committee approved the study and all participants of this current study provided informed consent for both the questionnaire (cohort) study and the interviews.

Two female interviewers conducted the semi-structured interviews by telephone, using an interview guide compiled based on literature. They had no prior relationship with the participants. Interviews were performed until saturation was reached and no longer new themes were introduced. The audio-recorded telephone interviews were transcribed and analysed thematically.
Two researchers separately encoded the transcripts using Atlas.ti. First, the person who interviewed the participants coded the interviews. Subsequently, the other interviewer continued with the codes of the first researcher. All interviews with males were conducted first, then all interviews with females. Codes from the male interviews were used as a starting point for coding of the female interviews.

In total 13 males (mean age 68.7±12.1 years) and 12 females (mean age 63.4±9.5 years) were interviewed. Most prevalent clusters in males were LUTS and defecation problems (n=7, with or without other symptoms as well), and LUTS and sexual dysfunction (n=6, with or without other symptoms as well). Most prevalent clusters in females were: LUTS and defecation problems (n=8, with or without other symptoms as well), and LUTS and pelvic pain (n=7, with or without other symptoms as well). Four males and five females sought help for all their symptoms, five males and five females did not seek any help and four males and two females sought help for some, but not all of their symptoms. 

Figure 1 illustrates the themes found in this study for seeking help and not seeking help. Since help seeking is a process in which multiple factors play a role, there can be more than one theme or subtheme applicable for one participant. The associations between themes and subthemes are illustrated in the figure. 
Factors that influence help-seeking behaviour (both as a facilitator and as a barrier) are duration, severity and type of the symptoms, and the impact of the symptoms on (activities in) daily life. Other overlapping themes were the influence from someone else in their surroundings, and the role of their doctor (i.e. relation/connection with their health care provider). Themes specific for not seeking help were: the conception that it is useless (nothing to do about it, age-related, and part of life), having a negative earlier experience when looking for help for their symptoms, feelings of shame or embarrassment, finding it difficult to discuss the symptoms, and practising self-help (e.g. using incontinence pads). Facilitators for seeking help were having a specific question for a health care professional, and experiencing emotional distress because of the symptoms.

Differences between males and females 
Although most themes apply for both sexes, we found some specific themes for males and for females. Males generally do not quickly seek help for their symptoms. Furthermore, males specifically mentioned sexual complaints (type of symptom), either as a reason to seek help, or as a barrier to seek help. For females, having pelvic pain or prolapse symptoms were specific reasons to seek help. Furthermore, having no trust in, or having a negative relation with their general practitioner prevented females from seeking help. Furthermore, females do not seek help when they experience their symptoms as being part of the female sex and therefore, in their opinion, nothing can be done about it.

Our results are in agreement with the findings of other studies. However, what makes our study of particular interest is the fact that we included males and females having multiple pelvic floor symptoms, where some patients did seek help for some of their symptoms, but not for all of their symptoms. This adds information to the current knowledge of help-seeking behaviour for pelvic floor symptoms in both males and females.

Although most themes apply for both sexes, showing similarities in help-seeking behaviour when having multiple pelvic floor symptoms, we found some specific themes for males and for females.

Teunissen D, Lagro-Janssen T. Urinary incontinence in community dwelling elderly: are there sex differences in help-seeking behaviour? Scand J Prim Health Care. 2004;22(4):209-216.
Li Y, Cai X, Glance LG, Mukamel DB. Gender Differences in Healthcare-Seeking Behavior for Urinary Incontinence and the Impact of Socioeconomic Status: A Study of the Medicare Managed Care Population. Medical Care. 2007;45(11):1116-1122.

Continence 2S2 (2022) 100427
DOI: 10.1016/j.cont.2022.100427