Gender-Affirming Testosterone Treatment and Lower Urinary Tract Symptoms

Objectives: In the United States alone, 1.6 million people identify as transgender and gender diverse. Although transgender individuals commonly report lower urinary tract symptoms (LUTS), factors underlying these symptoms are poorly understood. Our primary aim was to compare the severity and impact of LUTS in transgender men/transmasculine individuals on testosterone therapy with those who are not on testosterone. We hypothesize that patients who have access to gender affirming testosterone treatment have less severe LUTS compared to those who are not receiving such treatment.

Methods: We conducted a cross-sectional study of transgender individuals assigned female at birth (including transmen, transmasculine individuals, non-binary or other gender diverse individuals) over age 18 receiving care with OB/GYN and Family Practice within a single tertiary care hospital system. Following informed consent, participants completed an online survey of demographic data, current testosterone use, and LUTS questionnaires. Additional demographic information and medical comorbidities were collected from the electronic medical records. Our primary outcome was LUTS as measured by the Patient Perception of Bladder Condition (PPBC), a validated single-item questionnaire that queries if participants have bladder symptoms that cause problems on a scale from 0 (no problems) to 6 (many severe problems). Secondary outcomes included the Urinary Distress Inventory – Short Form (UDI-6) and International Consultation on Incontinence Questionnaire – Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) scores. UDI-6 scores range from 0 to 75; higher scores indicating greater severity. Although the ICIQ-FLUTS was intended for use in cisgender females, there is no mention of anatomy or gender in the questions. The ICIQ-FLUTS has three subscales, scores of which range 0-16 for symptoms of filling, 0-12 for voiding symptoms, and 0-20 for incontinence symptoms. Higher score indicates worse symptoms. Associations between LUTS and testosterone use were estimated using univariable and multivariable correlations.

Results: 131 respondents were included in the analysis: 106 currently on testosterone and 25 not on testosterone. Demographics between the two groups are shown in Table 1. Individuals not on testosterone were five times more likely to report moderate-severe bladder problems compared to those on testosterone: 6.6% (7/106) v 36% (9/25), p< 0.001 (Table 2). Those on testosterone also had lower (better) UDI-6 scores compared to those not on testosterone (16.5±15.3 v 24.3±18.5, p=0.03). ICIQ subscale scores were not significantly different between the two groups. After controlling for parity and vaginal estrogen prescription, those on testosterone were persistently significantly less likely to report moderate-severe bladder problems than those not on testosterone (unadjusted OR 0.13, 95% CI 0.04-0.39; adjusted OR 0.09, 95% CI 0.02-0.33).

Conclusions: Gender affirming therapy with testosterone use was associated with less bothersome LUTS in our population of transgender men/transmasculine individuals. Further research will be necessary to elucidate the nature of and underlying reason for this relationship.