HIV / AIDS is a worldwide pandemic and has been an ongoing global public health issue since 1981. However, data on lower urinary tract symptoms (LUTS) in males living with HIV (MLWH) are lacking. The aim of this study is to assess whether HIV status has an impact on LUTS.

After Institutional Review Board approval, MLWH and HIV-negative males (control group) who were referred to Urology between August 2022 and February 2023 after their initial presentation to Infectious Diseases and Clinical Microbiology Clinic were included. Males who were receiving treatment due to LUTS and those who underwent urological surgery were excluded. Demographical (age, comorbidities) and clinical laboratory results (CD4 T lymphocyte count, HIV RNA level, anti-retroviral therapy type –bictegravir/ tenofovir alafenamide fumarate/embtristabine,dolutegravir/lamivudine or elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide fumarate-, serology results regarding other  sexually transmitted diseases) data were recorded. 

MLWH and control groups were asked to complete the following questionnaires: International Consultation on Incontinence Questionnaire – Male Lower Urinary Tract Symptoms (ICIQ-MLUTS), ICIQ-Short Form (ICIQ-SF), International Prostate Symptom Score (IPSS), King’s Healthcare Questionnaire (KHQ), 8-item Overactive Bladder Questionnaire (OAB-V8), Urogenital Distress Inventory 6 and 7 (UDI 6 and UDI 7). 

ICIQ-SF score ranges for OAB severity were 1-5 (mild), 6-12 (moderate), 13-21 (severe and very severe). The responses to the first item of KHQ were analyzed under two categories: very good and good versus fair, poor, and very poor. The cut-off value indicating high likelihood of OAB was 9 in OAB V8. Symptom severity on IPSS was recorded as mild (0-7), moderate (8-19) and severe (20-35). Higher scores on UDI 6 and 7 indicated greater disability related to LUTS. 

Separately, presence/absence of LUTS (hesitancy, intermittency, slow urinary stream, feeling of incomplete bladder emptying, urgency, urinary incontinence (urge or stress), terminal dribbling, increased daytime urinary frequency and nocturia) was questioned according to their definitions in International Continence Society Glossary. 

Sample calculation was performed with MedCalc Statistical Software version 19.1 (MedCalc Software bv, Ostend, Belgium; https://www.medcalc.org; 2019), finding a number of 39 males per group. Statistical calculations were done with Student’s t test or Mann-Whitney U test for continuous variables and chi-squared test or Fisher’s exact test for categorical variables. p value of <0.05 was considered statistically significant.

A total of 81 males (40 MLWH and 41 HIV-negative controls) were included. The mean ages of MLWH and HIV-negative males were 41.6 ± 8.8 and 39.2 ± 10 years, respectively (p>0.05). There was no difference between groups regarding presence of comorbidities. All MLWH had CD4 T lymphocyte counts above 200 and non-detectable HIV RNA levels. Eleven of 40 (27.5%) MLWH had positive treponemal chemiluminescent microparticle immunoassay result. 62.5 % of MLWH were receiving anti-retroviral treatment with bictegravir based treatment.

In MLWH group, anti-retroviral type and treponemal positivity had no statistically significant impact on the presence of LUTS and questionnaire scores. 

Table 1 shows the comparative prevalence of LUTS in MLWH and control groups. All LUTS types were more frequent in MLWH group. The difference between MLWH and control group reached statistical significance in hesitancy and feeling of incomplete bladder emptying.

Comparative assessment of questionnaire scores is summarized in Table 2. General health perception was similar between groups whereas OAB V8 scores were significantly lower in the control group.

Our results revealed significantly higher frequency of hesitancy and feeling of incomplete bladder emptying in MLWH with non-detectable HIV RNA’s and CD4 counts over 200 compared to HIV-negative controls. Breyer et al. reported HIV status as an independent risk factor for reporting LUTS in 2011 based on IPSS [1]. Similarly, our data shows moderate to severe IPSS scores being significantly higher in MLWH. 

To the best of our knowledge, our study became the first to question OAB symptoms of MLWH in a case-control fashion. Significantly more patients in MLWH group scored ≥ 11 on OAB V8 (45 % vs 14.6 %), indicating high likelihood of OAB. Supporting this finding, urodynamic evidence of overactive bladder has already been demonstrated in HIV-positive individuals [2]. 

Moreover, we found insignificantly higher ICIQ-MLUTS, ICIQ-SF, UDI 6 and UDI 7 scores in MLWH. Total scores recorded on these questionnaires were very low in both groups, hence, differences remained marginal and potentially subclinical. 

Risk factors for LUTS in HIV-positive individuals might be chronic urinary tract inflammation, history of opportunistic infections, direct effects of virus on central and peripheric nervous system and toxicity of antiretroviral therapy [1, 3].

LUTS is more prevalent in MLWH compared to HIV-negative controls. Significantly more MLWH complained of emptying phase symptoms of hesitancy and feeling of incomplete bladder emptying and storage phase symptoms as reflected by higher OAB V8 scores. Further investigating this association in larger cohorts with invasive urodynamic studies will shed light to pathophysiological basis, improve patient counseling and management.

Breyer, B.N., et al., HIV status is an independent risk factor for reporting lower urinary tract symptoms. J Urol, 2011. 185(5): p. 1710-5.
Hermieu, J.F., V. Delmas, and L. Boccon-Gibod, Micturition disturbances and human immunodeficiency virus infection. J Urol, 1996. 156(1): p. 157-9
Larouche, M., et al., Urinary symptoms and quality of life in women living with HIV: a cross-sectional study. Int Urogynecol J, 2021. 32(2): p. 353-358.

Continence 7S1 (2023) 100833
DOI: 10.1016/j.cont.2023.100833