Troublesome lower urinary tract symptoms in the community: a prevalence study
Carole B Pinnock and Villis R Marshall
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Abstract - Introduction - Method - Population surveyed - Survey questionnaire - Results - Discussion - Key points of study - References - Authors' details
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©MJA1997
However, LUTS measured with the IPSS and related symptom scores may
have a range of aetiologies. Urinary symptoms such as urgency and urge
incontinence may be caused by idiopathic detrusor instability,
changes in muscle contractility, and other non-obstructive causes
related to ageing.8,9 The
IPSS is thus a non-specific measure of LUTS possibly caused by BPH, and
this is reflected by studies that have shown high symptom scores in men
with other lower urinary tract conditions,10 and in women.11-13
In an Australian general practice survey, urological problems were
given as 1.7% of reasons for encounter with a doctor (all ages, both
sexes),14 while in older men
7%-14% of encounters were for urinary problems.15 But the number of people
significantly "bothered" by LUTS appears to be very much greater than
the number seeking medical help for the problem.5,6,15
Symptom prevalence varies between countries, but there is evidence
that similar levels of symptoms have a similar impact on daily
activities of living in different countries.16,17 The prevalence of LUTS has been
measured with the IPSS or related indices in the Netherlands,18 Canada,19 the United Kingdom,5 France,20 Japan,21 Spain,22 New Zealand,23 Scotland and the United States;17 no community-based
surveys of symptom prevalence have been undertaken in Australia.
Because of this, we undertook a community survey to determine the
prevalence of troublesome LUTS in men and women in South Australia.
The symptoms surveyed are described as uncomplicated by the National
Health and Medical Research Council.8 Our objective was not to derive a
severity score, but to determine the presence or absence of
troublesome symptoms, their impact on quality of life, and the
proportion of individuals seeking medical help for such a problem.
Data are weighted by the inverse of the individual's probability of
selection, then reweighted to benchmarks derived from estimated
resident population at 30 June 1993 by age, sex and local government
area from the Australian Bureau of Statistics. The data
analysed and presented have thus been weighted to represent the age
and sex structure of the SA population.
To ensure completeness and accuracy of recording, five per cent of
each interviewer's work was selected at random and the respondent
re-interviewed with selected questions. After data checking, any
missing responses were followed up by telephone.
Statistical analysis was done with SPSS for Windows version 6.1
(SPSS, Chicago, Ill, USA). Statistical significance was calculated
with Pearson chi-squared tests, unless
otherwise indicated.
Only adults aged over 18 years are included in the analysis reported
here (1204 men, 1686 women).
Twenty-six per cent of men (318/1204) and 39% of women (662/1686)
reported one or more troublesome urinary symptoms, with no
differences between rural and metropolitan respondents (men or
women) (Box 1).
The most common symptoms in both men and women were frequency and
nocturia (Box 2). In men, nocturia increased significantly with age
(from 4% in 18- to 24-year-olds to 33% in those over 65 years; P
< 0.00001). Weak stream also increased, from 2% in 18- to
24-year-olds to 12% in men over 65 (P < 0.00001).
Urgency, frequency and mild incontinence were reported more
frequently by women than by men (all, P < 0.001), and, as
stated above, the overall prevalence of troublesome urinary
symptoms (i.e, prevalence of more than one symptom) was also higher in
women (P < 0.00001).
The prevalence of one or more storage (irritative) symptoms (i.e.,
urgency, frequency or nocturia) was 23% in men and 33% in women (P
< 0.0001), with the prevalence of one or more voiding
(obstructive) symptoms (i.e., weak stream and intermittency) being
6.7% and 6.4%, respectively (difference not significant).
Under the category "other", the most common symptom was stress
incontinence (n= 17/44; 38%) in women and medication
side-effects in men (n= 4/16; 25%).
Age-specific symptom prevalence varied between men and women. For
men, there was a clear age dependence, with symptom prevalence
exceeding 20% only after age 45. In women, the age-related increase
was weaker, and symptom prevalence exceeded 30% in all age groups. For
men and women over 65, symptom prevalence was 48% (314/649).
While the percentage of respondents reporting troublesome urinary
symptoms was high (Box 1), only 28% of men (88/318) and 27% of women
(179/662) with troublesome LUTS had visited a doctor about a urinary
problem during the preceding 12 months. Satisfaction with urinary
condition seems to be a better predictor of visits to the doctor than
symptom prevalence (one or more symptoms) -- only 6% (23/397) who were
"pleased" with their urinary condition had visited a doctor for
urinary symptoms, compared with 60% (39/65) who were "unhappy" with
their urinary condition (P < 0.00001).
Most studies show that the prevalence of mild symptoms is high, and
that symptoms which substantially affect quality of life or trigger a
visit to the doctor have a lower prevalence.3 The prevalence of severe or
bothersome symptoms is often as low as 25% to 30% of the total symptom
prevalence,5,29 suggesting
that adaptation to mild symptoms may occur. A review of moderate to
severe symptoms in four community-based studies reported
prevalence rates of 14%-33% for men over 40 years,16 and agrees with the 37% (220/593)
of men over age 45 reporting one or more troublesome urinary symptoms
in our study.
In our study the most common troublesome symptoms for men were
nocturia and frequency. This agrees with studies in France,20 the Netherlands,29 and the United Kingdom,5 but not Scottish studies1,6 or a French study.3 Methodological differences, such
as the wording of questions and framing of population sampling
methods, may account for these differences.
In our study, the prevalence of urinary symptoms associated with
"prostatism" in men was the same for men and women aged 55 and over (Box 2). Other studies in clinical or selected populations have also
reported high symptom scores in women.11-13 However, we found the
prevalence of LUTS in women did not show the same age-specific trend as
for men, and storage symptoms (urgency, frequency and nocturia) were
more prevalent in women (33% [563/1686] for one or more symptoms) than
men (23% [274/1204]), while voiding symptoms were similar in both
groups. In a study of women with voiding symptoms undergoing
urodynamic evaluation, relatively few women had outflow
obstruction.11
While the overall prevalence of LUTS, particularly in those aged 55
and over, was similar in men and women in our study, the symptom profile
(age-specific trend and individual symptom prevalences) differed,
reflecting their potentially different aetiologies.
For both men and women, impact on quality of life (measured by
satisfaction with urinary condition) was strongly correlated with
visits to the doctor, with this correlation being similar in men and
women. This argues against some reports of men's "stoicism" in the
face of urinary symptoms.1
However, the finding also suggests that men and women may be equally
reluctant to seek medical assistance for LUTS. Sixty-three per cent
(65/104) of men and 59% (162/274) of women substantially
dissatisfied with their urinary condition were not visiting a doctor
for the condition, which agrees with the substantial numbers not
seeking help reported in other studies.1,5 Conversely, the small proportion
of our participants who had seen a doctor despite being "delighted"
with their urinary condition may represent preventive activity,
such as checkups, or concern, for example, about prostate cancer.
Other studies report a substantial impact of moderate to severe LUTS
on quality of life. Activities of daily living were affected in 51% of
men with clinically defined BPH,1
and working-age men reported symptoms as more bothersome than
retirement-age men, despite experiencing them less frequently.6
People may be reluctant to seek help for LUTS because these symptoms
are considered a normal part of ageing, because of the perceived
stigma of the symptoms or fear of possible treatments,1 or (in men) because of stoicism.30 These possibilities need
to be addressed in future studies, as does the possibility that rural
men who were dissatisfied with their urinary condition were less
likely than urban men to seek medical help (P = 0.057).
The main reason patients visit doctors about their urinary condition
may be to reduce its effect on their daily activities, and this is
therefore an objective of treatment. Conservative measures such as
bladder training, pelvic muscle exercises, diet and fluid-intake
management as well as attention to functional factors may be helpful
in achieving this when symptoms are mild.
©MJA 1997
<URL: http://www.mja.com.au/>
© 1997 Medical Journal of Australia.
Abstract
Objective: To determine the prevalence of
troublesome lower urinary tract symptoms (LUTS) in men and women in
the community.
Design: Interview-based prevalence survey.
Setting: Metropolitan and rural communities in
South Australia, September, 1995.
Subjects: Probability sample of 1204 men and 1686
women (aged over 18 years) weighted to reflect the age and sex
distribution of the South Australian population.
Data collected: Presence of storage (irritative)
and voiding (obstructive) symptoms, based on the International
Prostate Symptom Score questionnaire; satisfaction with urinary
condition (quality-of-life measure); and visits to a doctor for
urinary symptoms in the preceding 12 months.
Results: The prevalence of one or more troublesome
LUTS was 26% (318/1204) for men and 39% (662/1686) for women (all ages)
and 48% (314/649) for men and women over 65. The most common
troublesome symptoms in men and women were nocturia and frequency.
Symptoms were significantly age-related in men, but less so in women,
in whom symptom prevalence exceeded 30% for all age groups. Ten per
cent of men (123/1204) and 15% of women (249/1686) had visited a doctor
for a urinary problem in the previous 12 months. Nine per cent of men
(104/1204) and 16% of women (274/1686) were substantially
dissatisfied with their urinary condition. Symptom prevalence and
dissatisfaction with urinary condition were significantly
associated with visiting the doctor ( P < 0.0001), but only
28% (88/318) of men and 27% (179/662) of women with troublesome LUTS
saw a doctor, and 63% (65/104) of men and 59% (162/274) of women
dissatisfied with their urinary condition did not seek medical help.
Conclusions: Although the prevalence of
troublesome LUTS in the community is high, the number of people whose
quality of life is substantially affected is much lower. The impact of
these symptoms upon quality of life is a major reason for patients to
see a doctor, yet many who are "bothered" by the symptoms do not do so.
Introduction
As the community ages, conditions affecting the quality of life and
activity of older people become of increasing concern. Lower urinary
tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH)
have been termed "prostatism" and may greatly affect the quality of
life of older men;1-3 the
consequent cost of treatment to the community is high.4 The prevalence of clinically
demonstrated BPH is 20% in men aged 40-49 years and 40%-50% in those
over 65 years.1,5,6 To
document the prevalence of symptoms related to BPH, the
International Prostate Symptom Score (IPSS)7 grades the presence of seven LUTS
(nocturia, intermittency, urgency, weak stream, incomplete
emptying, hesitancy, frequency) on a severity scale of 0-5. It also
includes a disease-specific quality-of-life question.
Method
Population surveyed
The Omnibus survey, a multiple-user household interview survey
undertaken for health organisations in South Australia (SA), was
used for the study. The methodology and results of its use in other
studies have been reported.24-26
The sampling method provides a probability sample of the SA
population: in the metropolitan sample, 10 dwellings are chosen from
each of 320 census collection districts (1991 census) using a random
starting point and selection is then based on every fourth household.
One person aged over 15 years (the person whose birthday was last) is
chosen per household. In the country sample, all cities/towns with a
population of 10 000 or more are chosen, and the balance of the sample is
chosen from centres with a population of 1000 or more, with weighting
proportional to size. The sampling method was the same as for
metropolitan dwellings. Sixty interviewers conducted 3016
interviews from the 4200 households selected.
Survey questionnaire
The questions were derived from the American Urological
Association-7 BPH questionnaire,27 adopted by the World Health
Organization (WHO) as the IPSS,7
and have been validated for test/retest reliability,
validity and clarity. Respondents were asked if, in the previous 12
months, any of the following urinary symptoms were troublesome: a
strong need to urinate (pass water) with little or no warning; needing
to go again less than two hours after finishing urination; needing to
get up twice or more at night to urinate; having a weak urinary stream;
stopping and starting several times when urinating; wetting
underclothes;20 and
whether there were other troublesome urinary symptoms. Respondents
were asked about the presence or absence of "troublesome symptoms" --
they were not asked to grade symptom severity. They were also asked
about quality-of-life7
(level of satisfaction with their urinary condition, in seven
categories: delighted, pleased, mostly satisfied, mixed, mostly
dissatisfied, unhappy, terrible), and whether they had seen a doctor
about any urinary problem in the past 12 months. Questions were
piloted for ease of understanding, internal consistency and
sensitivity in a group of 18 men, and subsequently in 50 further
interviews with men and women.
Results
The initial sample drawn was 4200 houses, of which 4067 were occupied
and defined as "households". Of these, 3016 households
participated, a response rate of 74.2%. Of the 3016 people
interviewed, 1734 were women (57.5%) and 1281, men (42.5%). The major
reasons for non-response were refusal (601; too busy, not
interested) and contact not established after six visits (293);
75.6% of interviews were in the metropolitan area and 24.4% in the
country. Respondents were evenly spread across all age groups.
Discussion
This first study of LUTS in the Australian community shows a high
prevalence of troublesome LUTS, which occurred across all ages, but
particularly in older age groups (48% of men and women over 65 reported
one or more symptoms). Other reports also show a high prevalence of
urinary symptoms for older men, ranging from 35% in a United States
study28 to more than 90% of
men in a Canadian study.19
Specific symptom prevalence can also be high (e.g., 61% for urgency,6 and 51% for hesitancy5 ).
Key points of study
References
(Received 24 June 1996, accepted 17 Feb 1997)
Authors' details
Repatriation General Hospital Daw Park, South Australia
Carole Pinnock, PhD, Principal Research Scientist,
Division of Surgery;
Villis R Marshall, MD, FRACS, Professor
and Head, Department of Surgery, Flinders Medical Centre, and
Division of Surgery, Repatriation General Hospital Daw Park.
Reprints: Dr CB Pinnock, Division of Surgery, Repatriation
General Hospital Daw Park, Daws Road, Daw Park, SA 5041.
E-mail:
spinncb AT rgh.sa.gov.au
Received 20 September 2018, accepted 20 September 2018
- Carole B Pinnock
- Villis R Marshall