People experiencing homelessness (PEH) represent a medically vulnerable population. Social determinants of health such as adequate housing and insurance status significantly impact one’s health and access to healthcare. Living on the streets or in unhygienic conditions can contribute to many urological issues related to lack of access clean bathrooms and appropriate medical care. This study aims to describe prevalence of lower urinary tract symptoms (LUTS) and genitourinary (GU) disorders such as urinary incontinence, benign prostatic hyperplasia (BPH) and urinary tract infections (UTIs) in people experiencing homelessness (PEH). This study also looks at the severity of these disorders while describing voiding and bathroom habits in this population.

Two surveys were administered, titled BPH and LUTS survey. The BPH survey was based on the International Prostate Symptom Score (IPSS) scoring system. For the BPH survey, a score between 0 to 7 is defined as mild, 8 to 19 is moderate and 20 to 35 is severe. The LUTS survey was based on the Urogenital Distress Inventory short form (UDI-6) questionnaire and a score equal to or above 33.33 is defined as severe. Data was collected from IRB-approved, confidential BPH and LUTS surveys conducted among PEH who sought care at a student-led free medical clinic situated in Miami-Dade County. Participation in the survey was contingent on explicit consent of participants 18 or older. Clinical information of patients seen between December 2023 and March 2024 were stored in a HIPAA compliant electronic database, REDCap, and de-identified prior to downloading for statistical analysis in SPSS. Data analysis was conducted using descriptive statistics to examine trends and patterns in participants' responses. Those with missing values were not included in the data analysis.

A total of 17 PEH were surveyed. Of the 17 participants, 70.5% (n=12) had severe urinary symptoms by IPSS or UDI-6. 75 % (n=9) of all participants with severe urinary symptoms did not have any known diagnosis of either BPH or any bladder or lower urinary tract conditions or disorders. Additionally, about 50% of PEH surveyed said these symptoms impact their quality of life whether moderately or severely. 

There were 9 men in total and 2 had a known diagnosis of BPH. Of the 9 men, about 55.5% (n=5) had severe urinary symptoms. Of the 2 men with a known BPH diagnosis: 50% (n=1) had severe BPH symptoms by UDI and the other 50% (n=1) had moderate BPH symptoms by IPSS. Of the 7 men without a known BPH diagnosis, 57% (n=4) had severe symptoms by IPSS and UDI (1 had severe symptoms by UDI), 28.5% had moderate symptoms by IPSS (n=2), 14.3% had mild symptoms (n=1).

There were 8 women in total. However, 1 was missing UDI-6 score and thus excluded from the data analysis. Out of the 7 with UDI-6 scores, 1 did not report whether they had a known diagnosis of LUTS or not and 85.7% (n=6) had severe urinary symptoms. 1 reported having a known diagnosis of LUTS with a severe UDI-6 score of 79. Of the 6 remaining women with no known diagnosis of LUTS, 83.3% (n=5) had severe LUTS by UDI-6 which was defined as a score > 33.33. 

Of the 12 participants with severe urinary symptoms, 1 did not report access to bathroom time or place and subsequently not included in the analysis. 45.4% (n=5) of those with severe symptoms reported having access to a bathroom 24hrs/day. 45.4% (n=5) of those with severe symptoms reported only having access to the bathroom during 7am-7pm. 9% (n=1) reported never using the bathroom. With regards to where they use the bathroom, 40%  (n=4) used public bathrooms, 30% (n=3) used overnight shelter,  20% (n=2) used a day shelter, and 10% (n= 1) used a private location (business). Of patients with access to the bathroom 24/7, mean IPSS scores (23) and mean UDI-6 scores (61.7) were higher compared to the mean IPSS scores (22) and mean UDI-6 scores (57.3) of those with bathroom access only from 7am-7pm. 

We defined overactive bladder (OAB) as IPSS urgency question scores of 4-5 and/or UDI-6 scores of 5-6. Out of the total participants with completed surveys, 71.4% of men and 50% of women experienced OAB symptoms. We defined stress urinary incontinence (SUI) as a UDI-6 stress question score of 2-6. Out of the total participants with completed surveys, 50% of women experienced SUI symptoms.

Severe urinary distress symptoms are highly prevalent in PEH, with nearly half reporting no access to bathrooms overnight. Majority of participants (57% of men and 83% of women) who did not have a known diagnosed GU disorder experienced severe urinary symptoms. 

Those who had access to the bathroom 24/7 had higher IPSS and UDI-6 total scores. It's possible any area that may not be actual physical bathrooms were being used, including sidewalks, bushes, and other semi-public places. Unpredictable and unsanitary bathroom access can worsen urinary symptoms, including incontinence, among PEH, exacerbating their already challenging living conditions and impacting their overall quality of life. The results of the BPH and LUTS surveys also highlight a lack of urological care available to this population through lack of access to primary and specialty urological care.

It is evident that PEH experience severe urinary symptoms that are majorly underdiagnosed. At this stage, the impacts of access to bathrooms, whether the timing or place, with regards to LUTS and BPH are inconclusive. However, there is a need for greater access to urological care among PEH. 

The current statistics are preliminary as we continue to collect data through the student-led free medical clinic. Future directions of this project include implementing interventions to address barriers faced by PEH to increase access to hygienic bathrooms and urological care for this vulnerable population. Future research is needed to explore the efficacy and feasibility of implementing urological treatment interventions tailored to the unique circumstances and challenges faced by PEH.

Continence 12S (2024) 101669
DOI: 10.1016/j.cont.2024.101669