Reviewer’s report
Title: 
Association of decreased grip strength with lower urinary tract symptoms
in women: A cross-sectional study from Korea
Version: 
1 
Date: 
06 Dec 2020
Reviewer's report:
The authors' study provides important data that is potentially applicable across
multiple clinical specialties, primary care, and importantly epidemiology studies
on potential risk factors for LUTS. 
I would encourage the authors to reframe the article to reflect important
considerations beyond using decreased grip strength as an opener for dialogue
with a patient about whether they have LUTS. 
The authors' current framing is that grip strength should be done because women
hesitate to self-identify as having LUTS and clinicians don't inquire, so a grip
strength can help start the conversation in those found to have generalized
muscle weakness. The abstract, introduction and conclusion seem to suggest that
grip strength should serve as a screening tool for asking a woman about "urinary
disease", with a data cut point on grip strength that in this sample means 13% of
women should be asked. I think this framing sets the readers up to dismiss the
broader importance of the data. 
I'd like to see the authors do important yet simple reframing, so that readers of
BMC Women's Health can much more readily see the broader potential impact
of their work. For the authors' consideration, I provide a couple examples. 
Include a discussion of both primary and secondary prevention of LUTS
instigated by a non-LUTS specialist, for instance a primary care provider or
musculo-specialist treating someone for generalized muscle loss/sarcopenia. In
that example, the LUTS discussion could be framed as: "since LUTS is a logical
outcome (associated with) generalized muscle weakness, let's talk about that,
how an intervention for muscle preservation may be important to retaining or
improving continence (could be a pretty powerful motivator), and
appropriateness of a referral to LUTS specialist due to the risk factor. 
The authors do hint at "primary prevention" on page 8, lines 183-185. But this
could be bolstered as "we can speculate that preventing sarcopenia may also
serve to prevent LUTS".
Include a discussion of the importance of this report's data as an important
indicator of the need for more research on mechanistic investigation that
specifically explains the physiology/pathophysiology of why general muscle
weakness and LUTS are connected. In the discussion, page 8, line 175, it starts
to set this up by saying "many studies have reported the association..." 
but
doesn't detail the study findings or provide the references. Instead, the next
sentence is aging issues. Lines 186-197 are also a start, but no real data is
provided, and the point of this reads as a listing of potential linkages (which is
o.k., but say so), not as data-based (need for data remains). For instance, the
comment: "Makes is impossible for the urethra…" is speculation. There's a lot
we don't know about maintenance of urethral pressure, for instance the role of
the vascular mucosal layer. 
In lines 179-185: Why the heavy focus on aging? Seems out of place to the
overall focus, aside from the covariate analysis, which included many factors
beyond age that are not discussed. It's true that aging affects muscle and aging
affects LUTS, but I find this paragraph distracting to the main message in the
manuscript. 
In Discussion, pg 9, lines 198 - 203, this whole paragraph is what I was looking
for in the intro and leads right to why your study is important. Why not place it
there? 
It seems very important at this stage in the state of the science to suggest that
grip strength and in inquiry about LUTS both be included in large epidemiology
studies, to further substantiate the relationship that this manuscript's results
support. 
In Discussion: pg 9, line 208 - 212: there is an emphasis on primary care
screening for sarcopenia with grip strength, but to imply that this is part and
parcel of screening for LUTS is a bit of a stretch in terms of believability within
the primary care setting. 
Please take a look in the abstract and conclusion, where the emphasis is on "few
women receive accurate diagnosis …. " and 
"therefore, clinicians may consider
additional consultation…" . Background: The entirety of paragraph 2: lines 52-
59, "Diagnosing urologic diseases…" 
These are places where I think a reframing
could help readers with believability and draw them towards higher levels of
impact from this reports findings. 
Terminology: I'd suggest consistently use LUTS, and the list of LUTS noted as
"frequency, nocturia, urgency, and incontinence" - and (with the addition in the
methods) of "OAB" under its very specific definition described there. Avoid
straying into additional vague terms such as "urinary disease", "urinary
symptoms", "urological disease", etc. I suggest that the authors search the
manuscript for other such terms that are distracting and undefined and replace
with LUTS for consistency and clarity. 
I'd like to see this work published in BMC Women's Health, if it can be reframed
to have the importance that will better catch readers' attention. The data is great!
And represents a lot of hard work. 
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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from apparent manipulation?
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