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Troublesome lower urinary tract symptoms in the community: a prevalence study

Carole B Pinnock and Villis R Marshall
Med J Aust 1997; 167 (2): 72-75.
Published online: 21 July 1997

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

- ©MJA1997


 

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.

MJA 1997; 167: 72-75  

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.

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.  

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.

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.  

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.

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.  

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.

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).  

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 ).

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.

  Key points of study

  • High prevalence of troublesome lower urinary tract symptoms (LUTS) in Australian men (26%) and women (39%).
  • Far fewer men and women are substantially dissatisfied with their urinary condition (9% men, 16% women) and seeking treatment (10% men, 15% women).
  • But fewer than half of those who are substantially dissatisfied with their urinary condition seek medical help (38% men, 41% women).
  • LUTS in men and women has different aetiologies and symptom profiles, although the prevalence of one or more symptoms in people over the age of 65 years is the same (48%).
  • The impact on quality of life is the major reason for people to seek medical help. Conservative management strategies may reduce this impact when surgical or medical treatment is not indicated.

 

References

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  2. Abramson ZH, Gofin J, Abramson JH. Obstructive prostatic symptoms: a community survey in Jerusalem. Int J Epidemiol 1994; 23: 797-804.
  3. Sagnier P, MacFarlane G, Teillac P, et al. Impact of symptoms of prostatism on level of bother and quality of life of men in the French community. J Urol 1995; 153: 669-673.
  4. Ahlstrand C, Carlsson P, Jonsson B. Estimated total costs of treating benign prostatic hyperplasia in Sweden. Scand J Urol Nephrol 1995; 29: 57-63.
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  8. National Health and Medical Research Council. Clinical practice guidelines. The managment of uncomplicated lower urinary tract symptoms in men. Canberra: AGPS, 1996.
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(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

©MJA 1997

<URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Received 17 November 2018, accepted 17 November 2018

  • Carole B Pinnock
  • Villis R Marshall


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