I read with interest the recent article by Linder et al. examining the association between overactive bladder (OAB) and fall risk in a nationally representative sample of US adults aged 20–69 years 1. Given the substantial morbidity associated with falls and the high prevalence of OAB, this study addresses a clinically relevant and timely question. The use of contemporary NHANES data to explore this relationship adds valuable insight into a potentially underrecognized contributor to fall risk. In this cross-sectional analysis of 4118 participants, OAB was defined using a composite symptom score incorporating urge urinary incontinence and nocturia, and fall history was based on self-reported events within the preceding 12 months. The authors reported a higher prevalence of falls among individuals with OAB (39.7% vs. 25.7%), with a graded increase according to symptom severity. After adjustment for sociodemographic and clinical variables, OAB remained independently associated with increased odds of recent falls (adjusted OR 1.42; 95% CI 1.10–1.83), leading the authors to suggest that OAB may represent a potentially modifiable risk factor 1. An important issue to consider is the potential influence of residual confounding, particularly related to pharmacologic exposure and underlying patient vulnerability. A growing body of evidence suggests that anticholinergic burden is likely a major contributor to fall risk in patients with OAB. Longitudinal data demonstrate a dose–response relationship between cumulative anticholinergic exposure and falls and fractures, while prospective studies report more than a twofold increase in fall risk among users of OAB anticholinergic medications, even after adjustment for comorbidities 2, 3. These findings raise the possibility that the observed association between OAB and falls may, at least in part, reflect treatment-related effects rather than disease-specific mechanisms. Furthermore, anticholinergic burden is highly prevalent across populations, increases with age, and arises from multiple medication classes rather than OAB-specific therapies alone, further supporting the likelihood that medication-related factors contribute meaningfully to the observed association 4. In addition, OAB itself may act as a marker of frailty, multimorbidity, and functional impairment—well-established determinants of falls that may not be fully captured in survey-based datasets. The cross-sectional design further limits causal inference. Because OAB symptoms and fall history were assessed contemporaneously, temporal relationships cannot be established and reverse causation remains plausible. Individuals with impaired mobility, neurologic conditions, or functional decline—recognized risk factors for falls—may also be more likely to report OAB symptoms. Moreover, the relationship between urinary symptoms and falls is inherently multifactorial, involving behavioral (e.g., urgency-driven rushing), physical, cognitive, and environmental factors 5, 6. Taken together, these considerations suggest that the reported association should be interpreted cautiously and may reflect shared underlying vulnerability rather than a direct causal effect. Additional methodological limitations relate to potential misclassification of both exposure and outcome, which may have substantially influenced the observed association. The definition of OAB relied on a simplified symptom composite that does not align with established diagnostic frameworks recommended in current international guidelines 7, 8. Importantly, urgency—the defining feature of OAB—was not directly assessed using validated instruments, raising uncertainty as to whether the study population accurately represents individuals with clinically meaningful OAB. Similarly, fall history was based on 12-month self-report without differentiation between single and recurrent events or assessment of severity. This approach introduces considerable heterogeneity in outcome definition and may capture a broad spectrum of events with varying clinical relevance. As a result, the relationship between urinary symptoms and falls may be difficult to interpret within a coherent clinical framework. Taken together, these limitations raise the possibility that the reported association reflects imprecision in both exposure and outcome definitions rather than a robust underlying causal relationship. Importantly, this distinction has meaningful clinical implications. Interpreting OAB as a direct and modifiable cause of falls, rather than as a marker of underlying vulnerability or treatment exposure, may lead to inappropriate management strategies, including escalation of pharmacotherapy without adequate consideration of medication-related risks. A more nuanced interpretation that incorporates anticholinergic burden, functional status, and behavioral factors may better inform fall risk assessment and patient-centered management. In conclusion, this study highlights an important and clinically relevant association using nationally representative data. However, the findings should be interpreted with caution given the potential for residual confounding, measurement limitations, and the inherent constraints of cross-sectional design. Future prospective studies incorporating detailed pharmacologic data and standardized assessment of both OAB and fall outcomes are needed to clarify the nature of this relationship and guide clinical decision-making. Ali Furkan Batur: conception and design, manuscript writing, drafting the manuscript. During the preparation of this manuscript, an artificial intelligence–based language tool (ChatGPT) was used to assist with language refinement and stylistic editing. The authors reviewed and revised the text as needed and take full responsibility for the content and interpretation presented in this letter. The author has nothing to report. Institutional Review Board approval was not required because this paper is based on publicly available databases. The author declares no conflicts of interest.
Ali Furkan Batur (Thu,) studied this question.