ORIGINAL ARTICLE
Diversity of Urinary Symptoms in Patients Tentatively Diagnosed with Benign Prostatic Hyperplasia Referred to a Urologic Clinic in Norway J. Haltbakk, B. R. Hanestad and S. Hunskaar From the Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway (Submitted November 25, 2003. Accepted for publication May 19, 2004)
Scand J Urol Nephrol 38: 454–461, 2004 Objective: Lower urinary tract symptoms (LUTS) has become the preferred term used to classify the urinary symptoms of elderly men. This term places more emphasis on clinical appearance rather than being restricted to the functional pathophysiology. The objective of this study was to investigate this new concept in a group of patients who had been tentatively diagnosed with benign prostatic hyperplasia (BPH). The range of urinary symptoms, incontinence, sexual function and impact on daily living were registered. Material and Methods: Data from a group of 480 men awaiting urologic assessment were collected by questionnaire shortly after referral from their general practitioner between 1997 and 2000. The questionnaires used were the International Prostate Symptom Score (IPSS), the Symptom Problem Index, the International Continence Society-BPH, the Sandvik Incontinence Severity Index and the BPH-specific Interference with Activities. Results: The mean age of the subjects was 67.0 years. As assessed by the IPSS, 15%, 54% and 31% of the men had mild, moderate and severe symptoms, respectively. Men who gave positive answers to questions regarding the frequency, amount and type of leakage were considered to have urinary incontinence (UI), which was found in 37% of cases. The majority of men had mild or moderate UI. Influence on daily living varied with the severity of symptoms. However, no significant differences in influence on daily living were found between groups with different degrees of severity of incontinence as all groups reported a relatively high impact. Conclusions: Our results show that UI is fairly common, very bothersome and socially embarrassing in male LUTS patients waiting for urologic evaluation. Although UI is not typically associated with BPH and is not regarded as a crucial component of LUTS, this study indicates that more emphasis should be placed on UI in the terminology of LUTS. UI may also act as an indicator of a need for healthcare. Key words: assessment, daily living impact, lower urinary tract symptoms, men, urinary incontinence. Johannes Haltbakk, Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway. E-mail:
[email protected]
Lower urinary tract symptoms (LUTS) may extensively restrict the daily life of the patient, and assessment of the individual patient should therefore draw on a broad base of knowledge (1, 2). Traditionally, the urinary symptoms of elderly men were called “prostatism” and benign prostatic hyperplasia (BPH) was often diagnosed as the result of, and attributed to, a variety of symptoms. In the recent literature (3), the broader concept of LUTS is used, which calls for the inclusion of a variety of symptoms, together with their impact on daily living. In the assessment of LUTS, the International Prostate Symptom Score (IPSS) represents a useful means for conducting comparative studies (4). However, this universally accepted questionnaire has been criticised for not addressing urinary incontinence (UI) (5). UI is not an isolated symptom in men, but is 2004 Taylor & Francis. ISSN 0036–5599 DOI 10.1080/00365590410018657
associated with LUTS, as are, for example, weak stream, hesitancy and sexual problems. UI in men increases with age (6), similar to other LUTS, and may also develop after invasive treatment (7, 8). UI and LUTS have an impact on both sexual life and daily living (1, 9–14). Although UI is not that common, it is bothersome and socially embarrassing (15). The International Continence Society (ICS) have compiled a LUTS-specific questionnaire (ICS-BPH) which includes questions on UI, sexual function and impact on daily living (16–18). In Norway, general practitioners (GPs) refer LUTS patients to urologists in secondary healthcare by means of a mandatory referral system. This selection process probably yields a group of patients with a higher frequency, severity and impact of symptoms than those in the community or in primary healthcare in general. Scand J Urol Nephrol 38
Urinary symptoms in BPH patients However, the group is still mainly unselected regarding specialist treatment and thus comprises patients with a wide range of symptoms and symptom severities. The aim of this paper is to describe urinary symptoms, UI, sexual function and impact on daily living in patients tentatively diagnosed with BPH awaiting urologic assessment after referral from their GP. The IPSS, ICS-BPH, Incontinence Severity Index and other questionnaires are used to describe the patients and to analyse different aspects of the variety of symptoms. MATERIAL AND METHODS Men awaiting urologic evaluation at St. Olavs Hospital (Trondheim University Hospital), Trondheim, Norway during the years 1997–2000 were eligible for the study. Based on an overall assessment of the GP’s description of the patient in the referral letter, the urologist made a tentative diagnosis of BPH for 612 referred patients, who were subsequently enrolled in the study. The patients were then sent information about the waiting list situation, a request to participate in the study and a questionnaire. Patients agreed to participate by returning the questionnaire and a signed consent form in a reply-paid envelope. One reminder was sent. Ethical approval was obtained from the regional ethics review board. The results of five self-reporting indices concerning symptoms, incontinence, sexual function and impact on daily living are reported herein (Table I). IPSS The IPSS (4) covers the following seven symptoms: sensation of incomplete bladder emptying; voiding frequency; intermittence; urgency; urine stream force; strain to begin urination; and nocturia. Based on the total score, symptoms are categorized as either mild, moderate or severe (Table I). A validation study in
455
which reliability was also tested (4) demonstrated a Cronbach’s alpha value of 0.86, an excellent test–retest reliability, a high correlation with global ratings and good discrimination between BPH patients and control subjects. The scale is responsive and correlates well with other BPH symptom scales, but is not very consistent with urodynamic findings (4, 19). Our study was planned before publication of the official version of the Norwegian IPSS (20), and thus the version of the IPSS used here has a slightly different wording regarding some response categories. Symptom Problem Index The Symptom Problem Index (SPI) (21) assesses the bother of each symptom assessed in the IPSS. A validation study (21) demonstrated a high correlation with subjects’ symptom scores, good discrimination between BPH patients and control subjects and satisfactory responsiveness. Excellent test–retest reliability was demonstrated, together with a Cronbach’s alpha value of 0.88. Scores on the Norwegian version of this scale range from zero to six. Incontinence Severity Index (Sandvik’s Index) and type of UI This index was used to characterize the degree of UI (22) (Table I). Men who stated the presence of UI or who gave positive answers regarding the frequency, amount and type of leakage were considered to have incontinence. The Sandvik Index has been validated against a 48-h pad-weighing test in women. According to this test, slight, moderate, severe and very severe incontinence represent mean leakages (grammes per 24 h) of 6 (95% CI 2–9), 23 (15–30), 52 (38–65) and 122 (84–159), respectively (22). Hanley et al. (23) found a good test–retest reliability and the ability to detect changes after treatment. Cronbach’s alpha was
Table I. The indices used in the study Degree of severity Index IPSS (4)
Content
No. of items Score range
Symptom 7 Total/severity score SPI (20) Bother 7 Sandvik’s Index (23) Frequency 1 Amount of leakage 1 Severity score (frequency amount of leakage) BSIA (25) Activity interference 7 ICS-BPH (21, 22) Symptom (corresponding bothera) 19 (19a) Sexual function (corresponding bothera) 4 (4a) 6 (2a) Lifestyle (corresponding bothera) 5 (1a) Other (corresponding bothera) a b
0–5 0–35 0–6 1–4 1–3 1–12
Mild Moderate
Severe Very severe
0–7
8–19
20–35
–
1–2b
3–6
8–9
12
1–5 0–4 (0–3a) 0–3 (0–3a) Various (0–3a) Various (0–3a)
26 of the 34 questions were immediately followed by a question asking about the degree of problem the particular issue caused. Slight. Scand J Urol Nephrol 38
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not reported in the validation studies. In this study, we found a Cronbach’s alpha value of 0.83. On the basis of the items describing various situations, we classified UI as stress incontinence if leakage was associated with coughing, sneezing, laughing or lifting heavy items, as urge incontinence if associated with a sudden, strong urge to urinate, and as mixed type if both stress and urge symptoms were present. A total of 50 men with unclassifiable incontinence were not included in the analyses of type. One item also asked about the impact of UI. BPH-specific Interference with Activities The BPH-specific Interference with Activities (BSIA) index considers interference with fluid intake, driving a car for 2 h without a stop, sleeping at night, going to places without a toilet, taking part in outdoor sports and going to public areas (24). A validation study (24) demonstrated good discrimination between men with and without BPH and high correlations with symptoms and bother. Furthermore, good test–retest reliability and a Cronbach’s alpha value of >0.81 were found. ICS-BPH This 34-item questionnaire considers symptoms, lifestyle and sexual function. It includes five questions about urination habits, catheterization incidents and flow rate and two open-ended questions. Of the 34 items, 26 are immediately followed by a corresponding bother issue (25, 26). A validation study (25) demonstrated differentiation between community and clinical samples, but a poor relationship between questions assessing strength of stream and uroflowmetry has been revealed. Excellent test–retest reliability has been demonstrated, together with a Cronbach’s alpha value of 0.69–0.85 for the symptom and bother subscales (25). Lifestyle items correlated reasonably with the Short Form-36 and had a Cronbach’s alpha value of
0.59 (26). In the present study we demonstrated a Cronbach’s alpha value of 0.41 for this subscale. For comparison reasons, increased day-time frequency and nocturia were reported in accordance with previous reports of ICS-BPH results (17, 18) as follows: urination every 2 h or more frequently (item 1) and at least nine times a day (item 28), respectively. Owing to a printing error, item 21 (need to change clothes or wear pads) had five response categories and not four as in the original English version of the instrument. The validity and reliability of the Norwegian version of the ICS-BPH have not been published. Statistical analyses Statistical analyses were performed using SPSS 11.0 software. Frequency analyses and simple distributions were obtained. To calculate group mean differences in influence of daily living (BSIA) and global lifestyle (ICS-BPH), ANOVA with Bonferroni adjustment was run for the incontinence severity and symptom severity groups. RESULTS Of the 612 questionnaires sent out, 480 (78%) were returned and analysed. The mean age of the respondents was 67.0 years (SD 10.6 years; median 69 years; range 39–91 years). IPSS and SPI Symptoms were mild in 65 patients (15%), moderate in 235 (54%) and severe in 135 (31%). Each symptom in the IPSS was reported by 55–90% of the patients, the commonest symptoms being weak urinary stream and urinating again within 2 h, both of which were reported in 90% of cases (Table II). Symptom severity increased with age. Bother corresponding to each IPSS symptom is
Table II. Symptoms as measured by the IPSS Frequency (%)
Voiding Sensation of incomplete emptying Voiding Stop and start urinating again Voiding Weak urinary stream Voiding Strain to begin urination Storage Urinate again within
