LowerUrinaryTractSymptomsin SwedishMalePopulation

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(1)Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 156. Lower Urinary Tract Symptoms in Swedish Male Population Prevalence, Distress and Quality of Life GABRIELLA ENGSTRÖM. ACTA UNIVERSITATIS UPSALIENSIS UPPSALA 2006. ISSN 1651-6206 ISBN 91-554-6590-0 urn:nbn:se:uu:diva-6931.

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(157) List of Papers. This thesis is based on the following papers, referred by their Roman numerals: I. Engström G, Walker-Engström M-L, Lööf L, Leppert J. Prevalence of Three Lower Urinary Tract Symptoms in Men – a Population-Based Study. Family Practice 2003; 20: 7-10. II. Engström G, Henningsohn L, Walker-Engström M-L, Lööf L, Leppert J. Prevalence of Distress and Symptom Severity from Lower Urinary Tract in Men - a Population-Based Study with the DANPSS Questionnaire. Family Practice 2004; 21: 617-22. III. Engström G, Henningsohn L, Walker-Engström M-L, Leppert J. The Impact on Quality of Life Measured by the SF-36 in Men with Different Symptoms from the Lower Urinary Tract. Accepted for publication in Scand J Urol Nephro. IV. Engström G, Henningsohn L, Steineck G, Leppert J. Self-Assessed Health, Sadness and Happiness in Relation to Total Burden of Symptoms from the Lower Urinary Tract. BJU International 2005; 95: 810-15. Papers ȱ, II and IV are reprinted with the permission of the publishers..

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(159) Contents. Introduction.....................................................................................................9 Normal bladder and Lower Urinary Tract Function...................................9 Lower Urinary Tract Symptoms...............................................................11 Assessment of Lower Urinary Tract Symptoms..................................11 Lower Urinary Tract Function of Ageing............................................12 Prevalence of Lower Urinary Tract Symptoms ...................................13 Seeking Help for Lower Urinary Tract Symptoms ..................................20 Quality of Life..........................................................................................20 SF-36 questionnaire and Lower Urinary Tract Symptoms ..................21 Aims..............................................................................................................22 Methods ........................................................................................................23 Study Population ......................................................................................23 Study Design and Data Collection ...........................................................23 Paper ȱ..................................................................................................25 Paper II, III and IV...............................................................................26 DAN-PSS questionnaire ......................................................................26 SF-36 questionnaire .............................................................................27 Statistical Analysis ...................................................................................28 Results...........................................................................................................30 Paper ȱ ......................................................................................................30 Paper II .....................................................................................................33 Symptoms ............................................................................................33 Distress ................................................................................................36 Paper III....................................................................................................40 Storage symptoms and SF-36 measurements ......................................41 Voiding symptoms and post micturition symptoms and SF-36 measurements ......................................................................................45 Paper IV ...................................................................................................48 Methodological Considerations ....................................................................58 Confounding factors .................................................................................58 Misrepresentations ...................................................................................59 Misclassifications .....................................................................................60.

(160) Discussion .....................................................................................................62 Lower Urinary Tract Symptoms...............................................................62 Seeking Help for Lower Urinary Tract Symptoms ..................................63 Quality of Life..........................................................................................65 Conclusions - Remarks .................................................................................69 Implications .................................................................................................70 Swedish summary .........................................................................................71 Acknowledgments.........................................................................................74 References.....................................................................................................76 Appendix.......................................................................................................87 International Continence Society definition of LUTS Frågeformulär 1 DAN-PSS frågeformulär Hälsoenkät (SF-36).

(161) Abbreviations. AHCPR AUA BPH DAN-PSS ICS IQOLA LUTS NHP SBU SD SF-36 SIP WHO. Agency for Health Care Policy and Researc American Urological Association Benign Prostatic Hyperplasia Danish Prostatic Symptom Score International Continence Society International Quality of Life Assessment Lower Urinary Tract Symptoms Nottingham Health Profile Statens Beredning för medicinsk Utvärdering The Swedish Council on Technology Assessment in Health Care Standard Deviation Short Form-36 Sickness Impact Profile World Health Organization.

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(163) Introduction. Lower Urinary Tract Symptoms (LUTS) is a prevalent condition and occurs in men (Table 1-3) and women of all ages (Hellström et al. 1990, Rekers et al. 1992, Samuelsson et al. 1997, Hägglund et al. 1999, Nuotio et al. 2003, Andersson et al. 2004a, Stenzelius et al. 2004, Nørby et al. 2005). Lower urinary tract symptoms increase with age (Hunter et al. 1996, Malmsten et al. 1997, Temml et al. 2000, Haidinger et al. 2000, Bortolotti et al. 2000, Perry et al. 2000, Molander et al. 2002, TuncayAki et al. 2003, Andersson et al. 2004b, Nørby et al. 2005, Logie et al. 2005, Seim et al. 2005, Yukio et al. 2005, Li et al. 2005, Tikkinen et al. 2006) and have become a public health problem with the progressive ageing of the population. The interest in studying the lower urinary tract symptoms has increased substantially in recent years. However, lower urinary tract symptoms in men has not been investigated to the same extent as it has in women. Until recently, urinary leakage was seen as a “women’s problem”. When planning care and treatment strategy for individual male patients it is essential to have knowledge about men’s symptoms, the distress they cause and their impact on perceived quality of life. However, there is little information about the distress caused by the symptoms in the male population. The studies in the present thesis were conducted to increase general knowledge about the prevalence of symptoms from the lower urinary tract in a population-based sample of men, and determine to what extent these symptoms distress the men and affect their quality of life.. Normal bladder and Lower Urinary Tract Function The bladder and lower urinary tract have two functions: storage of the urine and periodic elimination of urine (Getliffe, Dolman 2003). Urine is produced continuously by the kidneys. Each day, approximately 180 liters primary urine is reduced by concentration processes in the kidneys to 1-2 liters of urine. The total urine volume depends on many factors (Brooker 1998, Hayes Engelberg 2000). The urine is transported in the 2 ureters by peristaltic waves to the urinary bladder. The 2 ureters run obliquely through the bladder wall in order to prevent urine reflux through a valve-like mechanism of the intrinsic part of the ureter (lying within the bladder wall). The ureters enter the bladder inferiodorsal landmarking in the 9.

(164) upper corners of the trigonum (together with the internal urethral orifice) at the bladder base, the most sensitive part of the bladder (Chiras 2002, Brooker 1998, Getliffe, Dolman 2003). The bladder acts as a reservoir for urine and lies in the anterior part of the pelvic, behind the symphysis pubis, under the peritoneum and the abdominal cavity resting on the pelvic floor. During filling, the bladder rises into the abdominal cavity. The wall of the highly distensible bladder consists of several muscle layers. The detrusor muscle is mainly controlled by the parasympathetic nervous system. As the bladder fills, the detrusor muscle is relaxed and pressure remains nearly constant. Contraction of the detrusor muscle causes the bladder to reduce in length and diameter so that it is emptied effectively. The bladder neck is mainly controlled by the sympathetic nervous system. In men, there is a circular layer of smooth muscle (internal sphincter) around the bladder neck which extends down into the prostatic capsule. The internal sphincter prevents retrograde ejaculation into the bladder (Chiras 2002, Brooker 1998, Getliffe, Dolman 2003, Edlund et al. 2006). The male urethra has an “S” shaped form and is approximately 18-22 cm long and consists of four parts. The prostatic urethra is attached to the bladder base and passes through the prostate gland. The membranous urethra is surrounded by the external sphincter (controlled by somatomotoric sacral nerves) and passes through the pelvic floor. The bulbar urethra is surrounded by the bulbospongiosus muscle which assists in emptying of the urethra at the end of voiding. The penile (spongy) urethra which passes through the penis to open at the external urethral orifice (Getliffe, Dolman 2003). An awareness of mild desire to void is experienced when urine reach a level at 150-250 ml in the bladder. When urine is present at 400-500 ml, involuntary contractions of the detrusor muscle and bladder neck relaxation force the internal sphincter in the urethra to open, which allows urine into the urethra. The external sphincter in the urethra is controlled until a suitable opportunity for voiding occurs (Gertliffe, Dolman 2003, Brooker 1998, Chiras 2002). The voiding is affected by contraction of the abdominal muscles and by increased intra-abdominal pressure (Brooker 1998). After completed emptying the bladder the external sphincter closes. Any urine above the level of the external sphincter is forced back to the bladder (Gertliffe, Dolman 2003).. 10.

(165) Lower Urinary Tract Symptoms Lower urinary tract symptoms has become the preferred term for urinary symptoms, replacing “symptoms of benign prostatic hyperplasia” and “prostatism” which were previously used to describe lower urinary tract symptoms (Abrams 1994). According to the International Continence Society (ICS), lower urinary tract symptoms denote three things: a symptom, perceived by the patient; a sign, observed by the physician; and a condition, defined by urodynamic observations (Abrams et al. 2003). In the present definition, ICS divides lower urinary tract symptoms into three groups: storage symptoms experienced when urine is stored in the bladder, voiding symptoms experienced during the voiding phase and post micturition symptoms experienced immediately after micturition (Abrams et al. 2003) (see Appendix).. Assessment of Lower Urinary Tract Symptoms For assessment of lower urinary tract symptoms several instruments have been developed. Describing the frequency of the symptoms is a first basic step toward understanding their impact (Barry 2001). The Boyarsky Score (Boyarsky et al. 1977) is the first published questionnaire to assess lower urinary tract symptoms. The questionnaire is designed to be completed by the physician and has never been validated. The symptom scoring system evaluates the severity of nocturia, frequency, hesitancy, intermittency, terminal dribbling, urgency, reduction of the size and force of the stream, dysuria and incomplete voiding. The Madsen-Iversen Score (Madsen, Iversen 1983) is another unvalidated questionnaire, also designed for completion by the physician. The questionnaire assesses urinary stream, straining to void, hesitancy, intermittency, bladder emptying, stress incontinence or post void dribbling, urgency, frequency and nocturia. The importance of the patient’s perception of the symptoms has been recognized and new instruments for assessing severity, frequency and quality of life of lower urinary tract symptoms have been designed. Health measurements or scales can be used to directly inquire about the impact of the symptoms or the distress they cause (Barry 2001). The International Prostate Symptom Score (IPSS) questionnaire (Cockett et al. 1991) is a validated instrument that measures the occurrence of seven symptoms from the lower urinary tract (incomplete emptying, frequency, urgency, nocturia, straining, weak stream, hesitancy). The IPSS questionnaire includes one separate question concerning the quality of life, graded on a scale from 0 to 6.. 11.

(166) The American Urological Association (AUA) symptom index is a validated questionnaire and includes seven questions covering frequency, nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying and urgency and two questions on quality of life (Barry et al. 1992). The ICSmaleSF questionnaire includes 11 questions on lower urinary tract symptoms (hesitancy, straining, decreased stream, intermittency, incomplete emptying, urgency, urge incontinence, stress incontinence, unpredictable incontinence, nocturia, post-void dribbling) and one question on quality of life (Donovan et al. 2000). The Danish Prostatic Symptom Score (DAN-PSS) (Hald et al. 1991) measures the occurrence of 12 symptoms. Moreover, it evaluates the symptoms both quantitatively and qualitatively, using both a symptom score and a distress score. This instrument has a sensitivity of 92% and a specificity of 94% (Hansen et al. 1995, Hansen et al. 1997). The DAN-PSS questionnaire also measures the occurrence of dysuria, post micturition dribbling and urinary incontinence, as well as measuring activities of daily living, none of which are covered by the IPSS questionnaire (Teillac 1998). The DAN-PSS questionnaire is well understood by men 40 years or older (Brasso et al. 1994) and is reliable and valid for the same purposes as the IPSS questionnaire (Hansen et al. 1998). At the ICS conference in Tampere 2000, Koskimäki and co-workers presented data showing that the Spearman correlation coefficient between the prevalence as measured with DAN-PSS and IPSS was 0.75 and that the correlation coefficient between total DANPSS score and total IPSS score was 0.70 (Koskimäki et al. 2000).. Lower Urinary Tract Function of Ageing Age-related changes in the central nervous system and adjacent organs to the bladder increase the risk for lower urinary tract symptoms (Gray 2000, Reilly 2000, Dubeau 2006). Alterations in nervous system e.g. Parkinson’s disease, often associated with aging, places the elderly individuals at risk for develop lower urinary tract symptom (Araki, Kuno et al. 2000, Lemack et al. 2003, Winge et al. 2005, Edlund et al. 2006). Lower urinary tract symptoms is common in elderly individuals with dementia often because memory loss (forget the way to the toilet, forgetting they were on the way to the toilet) (Gray 2000). Enlargement of the prostate through age-associated changes can, due to the prostate position affect the transport of urine through the urethra leading to obstruction of the outflow of urine. The severity of the obstruction symptoms does not correlate with the degree to which the prostate gland is enlarged. For some men, the obstruction remains mild, and the detrusor muscle is able to compensate by increasing the power of contraction. For other men, a more significant obstruction causes decompensation of the 12.

(167) detrusor muscle leading to emptying symptoms e.g. weak stream, dribbling, increase frequency, hesitancy and/or urgency (Heath, Watson 2003). Drug treatment also affects the functional status of the elderly individual. The drug treatment may lead to lower urinary tract symptoms in some individuals with an otherwise health lower urinary tract (Reilly 2000).. Prevalence of Lower Urinary Tract Symptoms The overall prevalence of symptoms from the lower urinary tract varies greatly in published reports (Table 1-3, Chute et al. 1993, Tsukamoto et al. 1995, Hunter et al. 1996, Madersbacher et al. 1998, Lee et al. 1998, Trueman et al. 1999, Haidinger et al. 1999, Berges et al. 2001, Treagust et al. 2001, Okamura et al. 2002, TuncayAki et al. 2003, Masumori et al. 2003, Andersson et al. 2004b, Glover et al. 2004, Nørby et al. 2005, Campbell 2005, Seim et al. 2005, Holden et al. 2005, Li et al. 2005). One explanation for the variation could be that different symptoms are included (Thom 1998). Most of the studies refer to urinary incontinence alone (Table 1), but some studies have taken other lower urinary tract symptoms in account (Table 13). The studies also differ in how they define the symptom itself, as well as its frequency and severity. No standardized clear-cut level has been set for what is or is not regarded as a symptom or how often it needs to occur to be regarded as a symptom. The most commonly used frequency categories found in a review of urinary incontinence were “ever”, “ever in the past year” and “daily” (Thom 1998). Another explanation for the apparent difference in prevalence is the selection of the population. Some surveys have selected their samples from patients listed in general practice, selected from health care district or visiting other than urology clinics (Table 1-3, Glover et al. 2004, Okamura et al. 2002, TuncayAki et al. 2003). Selection of a study population that includes everyone living within a certain geographical area gives a more accurate estimate of prevalence than studies where the population is selected from among patients attending a physician’s office (Minassian et al. 2003). A number of studies excluded men who had undergone various forms of surgery on the lower urinary tract (Garraway et al. 1991, Chute et al. 1993, Jolleys et al. 1994, Sagnier et el. 1994, Bosch et al. 1995, Lee et al. 1998, Eckhardt et al. 2001, Joseph et al. 2003, Glover et al. 2004, Gades et al. 2005, Temml et al. 2005, Seim et al. 2005), prostate obstruction (Irwin et al. 2006) or had been treated for prostate cancer (Chute et al. 1993, Tsukamoto et al. 1995, Lee et al. 1998, Hughes et al. 2000, Eckhardt et al. 2001, Joseph et al. 2003, Glover et al. 2004, Seim et al. 2005, Gades et al. 2005). Age differences among the participants, with no upper age limit (Tabel 1-3, Hunter et al. 1996, Lee et al. 1998, Trueman et al 1999, Nørby et al. 2005, Holden et al. 2005), make comparisons difficult because of the increasing 13.

(168) symptom prevalence with age (Hunter et al. 1996, Malmsten et al. 1997, Temml et al. 2000, Bortolotti et al. 2000, TuncayAki et al. 2003, Andersson et al. 2004b, Nørby et al. 2005, Molander et al. 2002). Reported symptom prevalence also differs between countries (Witjes et al. 1997, Tsukamoto et al. 1995, Scarpa 2001, Li et al. 2005). In studies based on men, with the IPSS questionnaire or AUA symptom index, the prevalence rates for moderate or severe symptoms (score >7), vary between 11 and 72% (Chute et al. 1993, Tsukamoto et al. 1995, Hunter et al. 1996, Madersbacher et al. 1998, Lee et al. 1998, Trueman et al. 1999, Haidinger et al. 1999, Berges et al. 2001, Treagust et al. 2001, Okamura et al. 2002, TuncayAki et al. 2003, Masumori et al. 2003, Andersson et al. 2004b, Glover et al. 2004, Nørby et al. 2005, Campbell 2005, Seim et al. 2005, Holden et al. 2005, Li et al. 2005).. 14.

(169) Table 1. Prevalence of storage symptoms in men; reports published 1993 to 2006 Storage symptoms Reference, Method Study base Definition Country No. men/total No. Symptoms Age Brocklehurst Random sample 1883/4007 Urinary incontinence 1993 Interview at > 30 y -ever Great Britain home -in preceding year -in the preceding 2 months - in preceding week Lagace et al. 1993 USA Norman et al. 1994 Canada. Visited a primary care office Questionnaire Random sample Telephone interview. 922 men/3638 men and women > 20 y 508/19359 telephone calls 50-70+ y. Hunter et al. 1994 Great Britain. Registered within a general practice Questionnaire. 1480/2000 > 55 y. Any urine loss in the last 12 months. Prevalence % 30-49 = 2 50-59 = 5 > 60 = 13 30-49 = 1 50-59 = 2 > 60 = 7 30-49 = 1 50-59 = 2 > 60 = 5 30-49 = 1 50-59 = 2 > 60 = 2 11. Nocturia, once a night In the last week have you…. rarely, sometimes or often experienced Urgency In the past month, how often have you …… Frequency: hardly ever < half half > half always Urgency hardly ever < half half > half always Urinary incontinence. 62. 9 56. Borgen et al. 1997 Sweden Malmsten et al. 1997 Sweden. Selected from health care district Questionnaire Random sample Questionnaire. 219/233 65 y 7763/10458 > 45 y. Urinary incontinence Nocturia. Koskimäki et al. 1998 Finland. All men born 1924, 1934, 1944 in a city Questionnaire. 2128/3143 50, 60, 70 y. Stenzelius et al. 2004 Sweden. Random agestratified sample Questionnaire. 1642 men /8500 men and women >75 y. Reported mild, moderate or severe Urgency Urge incontinence Stress incontinence “Other” incontinence Nocturia > 1/night Repeat voiding within 2-3 hrs Have you had problems controlling urine during the last 3 months? Yes, a little Yes, rater or very much. 18. 34 18 10 5 4 23 9 5 3 5 9. 34 17 9 10 56 47. 75-79 = 26 75-79 = 5. 15.

(170) Table 1 Continued Reference, Country Kay et al. 1999 Denmark. Method Random agestratified sample Questionnaire. Temml et al. 2000 Austria. Free health examination Questionnaire. Bortolotti et al. 2000 Italy. Random sample from general practitioner Telephone interview Random selected Telephone interview Random selected Questionnaire. Sladden et al. 2000 Australia Perry et al. 2000 Great Britain Boyle et al. 2003 Netherlands France Great Britain Korea McGrother et al. 2003 Great Britain. 16. Storage symptoms Study base Definition No. men/total No. Symptoms Age 210/250 In the two preceding 40-89 y weeks had mild, moderate or severe: Urgency Urge incontinence Stress incontinence “Other” incontinence Nocturia 1/night Repeat voiding within 2-3 hrs 1236/Not reported Involuntary loss of urine 20-96 y within the past 4 weeks 2721/Not reported 50 y. 340/523 40-80 y 4682/6941 40 y. Random agestratified sample Questionnaire. 4979/Not reported 40-79 y. Cross-sectional Questionnaire. 42939/74667 40->80 y. At least one episode of urinary incontinence during the year before the interview Urgency Urge incontinence Nocturia 1/night Nocturia 2/night Urinary incontinence several times a month or more often Urgency most of the time Mild to severe urinary incontinence. During the last year: Nocturia 1/night 2/night 3/night 4/night Frequency half-hourly hourly 2-hourly 3-hourly Urgency several times/day several times/week several time/month several time/year Incontinence profound severe moderate minimal. Prevalence %. 58 17 5 4 53 47 40-49 = 4 50-59 = 4 60-69 = 8 > 70 = 11. 3 30 4 54 20 9 5 4-16. 37 13 5 2 1 5 22 35 4 5 3 6 1 4 4 5.

(171) Table 1 Continued Reference, Country Nuotio et al. 2003 Finland. Teunissen et al. 2004 Netherlands Moorthy et al. 2004 Asia Andersson et al. 2004a Sweden. Nørby et al. 2005 Denmark. Method Populationbased crosssectional study. Registered within a general practice Questionnaire Random sample of men visiting other than urology clinics Questionnaire Populationbased study Random selected Questionnaire. Populationbased study Random selected Questionnaire. Storage symptoms Definition Study base Symptoms No. men/total No. Age 171/Not reported Stress incontinence: > 70 y answered Yes to: “Having urinary leakage during exertion, for example coughing or lifting” Urge incontinence: answered Yes to: “Having urinary leakage associated with a strong urge to urinate” 2137men/5278 men Involuntary loss of urine and women twice or more a month > 60 y 2369/Not reported Frequency 8 times/day Urgency: a strong desire 18-70+ y to void Urge incontinence: involuntary loss of urine Not reported/7680 Stress incontinence: 18-79 y answered Yes to: “Do you have involuntary urine loss in relation to physical strain” Urge incontinence: answered Yes to: “Do you have involuntary urine loss in relation to a sense of urgency or a sudden need to urinate” 5350/8700 Nocturia: 2/night > 50 y Frequency: Urgency. Liew et al 2006 Singapore Gourova et al. 2006 Netherlands. Populationbased study Stratified random sample Interview Registered within a general practice Questionnaire. 1139 men/3000 men and women 20-92 y. Nocturia: > 1/night. 2934/3048 55-75 y. Nocturia: 1/night 2/night 3/night 4/night > 5/night. Prevalence %. 2. 17 9 37 34 13 35-49 = 13 50-64 = 11 65-79 = 13. 35-49 = 37 50-64 = 43 65-79 = 59 50-59 = 30 60-69 = 37 70-79 = 51 50-59 = 16 60-69 = 20 70-79 = 27 50-59 = 6 60-69 = 17 70-79 = 21 Total 53 > 70 years 75 46 21 7 2 3. 17.

(172) Table 2. Prevalence of voiding symptoms in men; reports published 1993 to 2005 Voiding symptoms Reference, Method Study base Definition Country No. men/total No. Symptoms Age Norman Population based 508/19359 In the last week have et al. 1994 sample > 50 y you…. rarely, sometimes Canada Telephone or often experienced: interview Weak stream Hesitancy Wolfs et al. 1994 Netherlands. Registered within a general practice Questionnaire. 1692/2734 > 55 y. Prevalence %. 61 13. In the last week have you…. less than half the time, half the time, more than half the time, or always experienced Hesitancy Straining. 27 6 51 35 23. Jolleys et al. 1994 Great Britain. Registered within a general practice Questionnaire. 423/649 > 40 y. Hesitancy Weak stream Straining. Hunter et al. 1994 Great Britain. Registered within a general practice Questionnaire. 1480/2000 > 55 y. Malmsten et al. 1997 Sweden. Random sample Questionnaire. 7763/10458 > 45 y. In the past month, how often have you …… Hesitancy: hardly ever < half half > half always Poor flow hardly ever < half half >half always Hesitancy Weak stream. Roberts et al. 1998 USA. Random sample in the community Questionnaire All men born 1924, 1934, 1944 in a city Questionnaire Random agestratified sample Questionnaire. 775 men /2337 men and women > 50 y. In the last year: slow leakage/ dribbling of urine throughout the day. 24. 2128/3143 50, 60, 70 y. Reported mild, moderate or severe: Hesitancy. 46. In the two previous weeks had mild, moderate or severe: Hesitancy Weak stream Straining Straining. 17 29 19 1. Koskimäki et al. 1998 Finland Kay 1999 Denmark. Perry et al. 2000 Great Britain Nørby et al. 2005 Denmark. 18. 210/250 40-89 y. Random selected Questionnaire. 4682/6941 > 40 y. Populationbased study Random selected Questionnaire. 5350/8700 > 50 y. Weak stream. 15 5 3 1 1 21 10 6 4 4 9 31. 50-59 = 14 60-69 = 25 70-79 = 31.

(173) Table 3. Prevalence of post micturition symptoms in men; reports published from 1993 to 2005 Post micturition symptoms Reference, Country. Method. Wolfs et al. 1994 Netherlands. Registered within a general practice Questionnaire. Norman et al. 1994 Canada. Random sample Telephone interview. 508/19359 50-70+ y. Koskimäki et al. 1998 Finland. All men born 1924, 1934, 1944 in a city Questionnaire Random sample Questionnaire. 2128/3143 50, 60, 70 y. Random agestratified sample Questionnaire. 210/250 40-89 y. Malmsten et al. 1997 Sweden Kay et al. 1999 Denmark. Study base No. men/total No. Age 1692/2734 > 55 y. 7763/10458 > 45 y. Sladden et al. 2000 Australia. Random selected Telephone interview. 340/523 40-80 y. Hughes et al. 2000 Australia. Random selected Telephone interview. 305/425 40-80 y. Nørby et al. 2005 Denmark. Populationbased study Random selected Questionnaire. 5350/8700 > 50 y. Definition Symptoms In the last week have you…. less than half the time, half the time, more than half the time, or always experienced: Dribbling In the past week have you rarely, sometimes or often experienced Incomplete emptying Reported mild, moderate or severe Post micturition dribbling Incomplete emptying Incomplete emptying Dribbling In the two previous weeks had mild, moderate or severe Post micturition dribbling Incomplete empting Sometimes or frequently experienced Terminal dribbling Post micturition dribbling rarely sometimes frequently Incomplete emptying. Prevalence %. 49. 23. 63 30 26 34. 40 21 47. 18 28 7 50-59 = 9 60-69 = 15 70-79 = 20. 19.

(174) Seeking Help for Lower Urinary Tract Symptoms The percentage of men reported to have sought medical help for lower urinary tract symptoms ranges from 5 to 10% (Malmsten et al. 1997, Pinnock, Marshall 1997, Nørby et al. 2005). Among men with self-reported symptoms from the lower urinary tract, 4 to 46% had sought medical care (Lagace et al. 1993, Roberts et al. 1998, Malmsten et al. 1997, Teunissen et al. 2005, Homma et al. 2005). The percentage of men seeking help increases with increasing age (MacFarlane et al. 1995, Wolfs et al. 1994, Homma et al. 2005), with the severity (Andersson et al. 2005) and the frequency (MacFarlane et al. 1995, Andersson et al. 2005) of the symptoms and with the man’s degree of dissatisfaction with the symptoms (MacFarlane et al. 1995, Pinnock, Marshall 1997, Scarpa 2001, Wolters et al. 2002, Boyle et al. 2003). Other reasons why men seek help are that they have read about prostate problems, discussed symptoms of the lower urinary tract with a physician or have been encouraged by their partner to seek help for their symptoms (Scarpa 2001). Social influences such as advice from other people or from the media are also important factors in the decision to seek medical care (Wolters et al. 2002).. Quality of Life The International Consultations on Benign Prostatic Hyperplasia (BPH) and International Continence Society (ICS) have recommended that quality of life should be considered as an important factor in future research (Cockett et al. 1993a, Cockett et al. 1993b, Abrams et al. 2003). Moreover, the Agency for Health Care Policy and Research (AHCPR) guidelines for BPH declare that an examination of quality of life should be incorporated into clinical trials (Agency for Health Care Policy and Research 1994) Data on quality of life can be collected by questionnaires or interviews. Questionnaires are usually used because they are relatively easy to administer to large populations, whereas interviews are time-consuming and expensive. The majority of the quality of life instruments are based on the WHO’s definition of health as a “state of complete physical, mental and social well-being and not merely the absence of disease and infirmity” (World Health Organization 1948). It is important to select an instrument appropriate to a specific group of individuals (Symonds 2003). There are two basic types of quality of life questionnaires, generic and disease-specific quality of life instruments. Generic instruments have been designed to cover the spectrum of function, disability and distress and are not specifically designed for a particular disease. Some of the most widely used generic instruments are the 20.

(175) Sickness Impact Profile (SIP) (Bergner et al. 1981), the Nottingham Health Profile (NHP) (Hunt et al. 1981, Hunt et al. 1985), and the Short-Form 36 health survey questionnaire (SF-36) (Ware, Sherbourne 1992, Ware et al. 1993). The SF-36 questionnaire was designed for use in clinical practice, health policy evaluations, medical research and general population surveys (Ware, Sherbourne 1992). It has been translated and developed for use in more than 60 countries (IQOLA) and permits comparisons with normative populations (Sullivan, Karlsson 1998) and different groups of people with specific diseases or disabilities. The questionnaire has been validated for use in primary health care (Brazier et al. 1992) and it takes about five minutes to complete the 36 questions covering eight dimensions. Despite these advantages, Nordling and co-workers found that little scientific work with generic quality of life instruments had been done in men with lower urinary tract symptoms (Nordling et al. 1998). Disease-specific instruments have been designed to focus on physical problems, functional limitations and emotional consequences of a specific disease. These instruments are useful in clinical studies, especially for evaluating a specific therapeutic intervention and comparing different treatments. During the past decade, the traditional way of measuring lower urinary tract symptoms (frequency, severity) has been supplemented with various instruments including an index or single questions to assess the quality of life (Cockett et al. 1991, Hald et al. 1991, Barry et al. 1992, Donovan et al. 2000).. SF-36 questionnaire and Lower Urinary Tract Symptoms Hunter and co-workers asked men over 55 years, known to have lower urinary tract symptoms (fullness, frequency, intermittency, urgency, poor flow, hesitancy) to fill in the SF-36 questionnaire (Hunter et al. 1995). Increasing symptom severity was significantly associated with decreasing median SF-36 scores for physical role (PR), social functioning (SF), mental health (MH) and general health (GH). Welch and co-workers asked men who 12 months earlier reported lower urinary tract symptoms (Welch et al. 2002). Increased symptom severity (from none/mild symptoms through severe symptoms) decreased the mean score for all eight dimensions. Stewart and co-workers interviewed men over 18 years by telephone (Stewart et al. 2003). Men who had overactive bladder with or without urge incontinence had significantly lower mean scores on all SF-36 dimensions compared with men without overactive bladder. Mozes and co-workers interviewed men 45 to 75 years (Mozes et al. 1999). Men who experienced “very” distressful urinary symptoms scored worse for each of the eight dimensions than men who were “not distressed at all”, or who reported “mild” distress. 21.

(176) Aims. The specific aims were:. 22. I. To investigate the prevalence of three common urinary symptoms (urgency, stress incontinence and post micturition dribbling) and health-care seeking behaviors in men aged 40-80 years in a defined population.. II. To examine symptom severity and different levels of distress using the DAN-PSS questionnaire in men affected by storage, voiding and/or post micturition symptoms.. III. To describe how different symptoms from the lower urinary tract in men affect the quality of life measured with the SF-36 questionnaire.. IV. To evaluate the self-assessed health, sadness and happiness of men with reported symptoms from the lower urinary tract..

(177) Methods. Study Population The study took place in the community of Surahammar, which is situated in the County of Västmanland in Sweden. The County is north of Lake Mälaren and is about 110 km west of Swedish capital, Stockholm. The community covers an area of 345 km2 and had a total population of 11,200 residents in 1996. At the time of the study, there were four acute-care hospitals and 36 primary health care centers in the County of Västmanland. According to the population registry that covers the entire Swedish population, 2571 men aged 40 to 80 were residents in the Surahammar community on 1 January 1996. These men comprised the study population.. Study Design and Data Collection The studies presented in this thesis are based on two different data collections. The general design, response rates and data collection methods are presented in Figure 1.. 23.

(178) Questionnaire sent to all men aged 40-80 years in the community of Surahammar n = 2571. Not responding n = 354. I Total responding n = 2217. Post-micturition dribbling, stress incontinence or urgency n = 536 Moved/died. LUTS. n = 32. n = 504. No symptoms n = 1681 Age-matched Randomly selected n = 504. DAN-PSS SF-36 n = 504. DAN-PSS SF-36 n = 504. Not responding. Not responding. n = 117. n = 143. Responding n = 387. Responding n = 361. Total responding n = 748. Figure 1. Flow chart. 24. II-IV.

(179) Paper ȱ In January 1996, all men 40-80 years old (n=2571) living in the community of Surahammar, Sweden, received a postal questionnaire (see Appendix) with a letter explaining the objectives of the study and an invitation to participate. They were asked to return the questionnaires by mail and a prepaid envelope was provided. Those who did not reply within six weeks were sent two reminders by mail, including new questionnaires. The questionnaire consisted of eight questions. Five of the questions covered urinary tract infection during the preceding 12 months (yes/no), previous consultations for voiding problems (yes/no), present full-time or part-time work (yes/no), physical exercise more than twice a week (yes/no), and current smoking (yes/no). The characteristics of the participating men are presented in Table 4. In order to screen for symptoms from the lower urinary tract, three questions were used. A man was considered to have lower urinary tract symptom if he experienced the presence of one or more of these three symptoms. Urgency: Respondents were asked if they experienced a sudden, violent need to urinate. Stress incontinence: Respondents were asked if they had experienced involuntary loss of urine in association with, e.g., sneezing, lifting or coughing. Post micturition dribbling: Respondents were asked if they experienced dribbling after having completed urination. The questions about urgency and post micturition dribbling were adopted from a previous population study in an urban population in Denmark (BeierHolgersen, Brunn 1990). The question about stress incontinence was developed from a previous population-based study on urinary incontinence among women in the same community (Hägglund et al. 1999). The three questions were chosen in collaboration with an urologist familiar with the condition decribed in the referral letter that is sent to the urology department from the primary health centres. The usual way to measure urine symptoms in the primary health centres at the time of the study was to ask the men if the symptom occurred or not. A pilot study was performed prior to the main study in order to determine if the participants understood the questions.. 25.

(180) Paper II, III and IV Of the 2571 men in the first study, 1008 were invited to take part in the following study after 12 months. Of these 1008 men, 504 had reported one or more of the lower urinary tract symptoms investigated in study 1 and 504 had not reported such symptoms. Men without symptoms were matched by age with men with symptoms from the same community population. All men received a letter of invitation where we explained the objectives of the study. All the 1008 men were asked to complete a questionnaire booklet containing the self-administered questionnaires, DAN-PSS (Hald et al. 1991) (see Appendix) and the Swedish version of the SF-36 questionnaire (Sullivan et al. 1994) (see Appendix). Questions about socioeconomic status, level of education, marital status, smoking habits, physical activity and history of urinary tract infections during the preceding 12 months were also included in the questionnaire booklet. There were four levels of occupation: working, unemployed, retired or on sick leave and there were three levels of education: elementary school, higher secondary school or college/university education. A man was defined as a smoker if he answered “Yes” to the question “Do you smoke?”. The characteristics of the men included in Paper II, III and IV are presented in Table 4. The questionnaires were returned by mail in a prepaid envelope. A postal reminder including a new questionnaire was sent twice to those who did not reply within six weeks.. DAN-PSS questionnaire The DAN-PSS questionnaire (Hald et al. 1991, Hansen et al. 1995) contains 12 questions on symptoms from the lower urinary tract as well as on the perceived distress corresponding to each specific symptom. Each question contains two parts: symptom score and distress score. The first part (symptom score) involves assessing the severity or frequency on a four stage scale (none, mild, moderate, severe) of each symptom separately. The second part (distress score) measured the extent to which a particular symptom distressed the men on a four stage scale (none, small, moderate, major). A total symptom score ranging from 0 to 36 was obtained by adding the symptom scores from the 12 symptom questions. The total distress score was obtained in the same way. The total DAN-PSS score ranging from 0 to 108 was obtained by multiplying the symptom score and the distress score for each of the 12 questions and then adding the results. Urge incontinence, stress incontinence, “other” incontinence, hesitancy, incomplete emptying, straining, dysuria and urgency were classified as mild when the symptom was reported to occur rarely, moderate when the symptom occurred often, and severe when the symptom occurred always. 26.

(181) Weak stream was classified as a mild symptom when the urinary stream was weak, moderate when the urinary stream was very weak and severe when the urinary stream was described as “dribbling”. Daytime frequency symptoms were classified as mild when the interval between two urinations was two to three hours, moderate when the interval was one to two hours and severe when the interval was less than one hour. Nocturia was classified as mild when it occurred once to twice during the night, moderate when it occurred three to four times at night and severe when it occurred more than five times during the night. Post-micturition dribbling was classified as mild when the dribbling was reported only to take place in the lavatory, moderate when the dribbling was reported to occur in small amounts, and severe when it occurred in large amounts in the person’s trousers.. SF-36 questionnaire The SF-36 questionnaire contains 36 questions: 35 questions deal with quality of life distributed among eight dimensions, and one single question measures the changes in reported health over the past year. The eight dimensions were: Physical Functioning (PF): 10 questions about limitations in physical activity because of health problems Role limitations due to Physical problems (RP): four questions about limitations in usual role activities because of physical health problems Role limitations due to Emotional problems (RE): three questions about limitations in usual role activities because of emotional problems Social Functioning (SF): two questions about limitations in social activities because of physical or emotional problems Body Pain (BP): two questions about presence of pain and limitations due to pain Vitality (VT): four questions about energy and fatigue Mental Health (MH): five questions concerning psychological distress and well-being General perception of Health (GH): five questions involving self evaluation of personal health According to the instructions in the Swedish manual (Sullivan et al. 1994) each question was coded, and the responses added together into a scale from 0 to 100, with 0 representing the worst possible perceived quality of life and 100 representing the best possible perceived quality of life.. 27.

(182) Statistical Analysis All the calculations were performed with the Statistical Package for the Social Sciences 12.0 (SPSS). A p-value of <0.05 was considered as significant. In paper ȱ, we calculated the percentage of men with self-reported symptoms. Student’s t test was performed to compare mean age between men with and without symptoms and also between respondents and the total population. Chi-square was used to test for statistical differences between proportions of symptoms. In paper ɉ, Spearman Ranks test was used to study correlations between the total distress score and the total symptom score. Mann-Whitney U-test was performed to test differences between the age groups: 41-50, 51-60, 61-70 and 71-81 years. Values are presented as mean and rSD. In paper ȱII, the SF-36 questionnaire was analyzed according to the instructions of the manual questionnaire (Sullivan et al. 1994). Each of the eight SF-36 dimensions is presented as the mean for storage symptoms, voiding symptoms and post-micturition symptoms combined a total of 12 symptoms. The Mann-Whitney U-test was used to compare the mean SF-36 score for men with no specific lower urinary tract symptoms versus men with mild or moderate/severe symptom severity; men with mild symptoms versus men with moderate/severe symptom severity; and men aged 40-65 years versus 66-80 years, for each of the 12 symptoms from the lower urinary tract. In paper IV, the five and six graded questions measuring health, sadness and happiness were dichotomized. The responses relating to health were classified as low if the answer was “moderate” or “bad”. Sadness was classified as high if the answer was “all of the time”, “most of the time” “some of the time” and “part of the time”. Happiness was classified as high if the answer was “all of the time” and “most of the time”. The four graded symptom scales of the DAN-PSS questionnaire was dichotomized into a no/mild group classified as the “no symptom”- group versus moderate/severe severity as the “symptom”-group. The total symptom burden was then categorized into four levels; no LUTS, 1-4 LUTS, 5-8 LUTS and 9-12 LUTS. In order to evaluate the full spectra of a symptom from the lower urinary tract, all levels of symptom severity were included in the calculations concerning the specific symptom in relation to health, sadness and happiness.. 28.

(183) Another dichotomization was used in the calculation concerning the complex of symptoms from the lower urinary tract, the total LUTS burden. In these calculations the symptoms classified by the men as “mild” were dichotomized into the “no/mild”-group in order to harmonize with our clinical experienced indicating that patients with a mild symptom severity hesitate seeking medical advice. To compare groups, we calculated relative risks (RR): the percentage of men reporting a specific symptom at any level (mild, moderate, severe) from the lower urinary tract divided by the percentage of men who did not report having the same symptom at any level. For specific background factors, the relative risks were calculated as the percentage of men with moderate/severe symptoms from the lower urinary tract reporting a specific background factor divided by the percentage of men with no/mild symptoms from the lower urinary tract who reported the same background factor. Proportions were used to describe the number and percentage of men with specific symptoms from the lower urinary tract. The ethics committee at Uppsala University approved the study.. 29.

(184) Results. Paper ȱ The total response rate was 86% (2217/2571), and in the age groups 40-49, 50-59, 60-69 and 70-80 years the response rate was 88, 86, 89 and 85%, respectively. The characteristics of the study population are shown in Table 4. The mean age (95% CI) among the symptomatic responders was 57.7 (56.8-58.6), which was significantly higher than 55.9 (55.4-56.4) for the asymptomatic respondents. No significant difference in the mean age (95%CI) between respondents and the total population (56.0 CI 55.6-56.4) of the men aged 40-80 years in the community were found. Overall, 24% of the men reported that they had post micturition dribbling, urgency or stress incontinence either individually or in combination (Table 5). The prevalence increased from 20% in the 40-49 years age group to 28% in the group aged 70-80. Post micturition dribbling was the most frequently reported symptom: 21% of the men stated that they experienced post micturition dribbling, 6% reported urgency and 2% reported stress incontinence. The prevalence of urgency and stress incontinence increase with age, but the prevalence of post micturition dribbling was independent of age. In the 12 months preceding the study, 4% (96/2217) of the men had sought health care for voiding difficulties. Of the 96 who had sought help, 49 men reported urgency, stress incontinence or post micturition dribbling. The proportion of the men who seek help increased with an increasing number of reported symptoms. Among men with one, two or three symptoms, 6% (26/433), 19% (15/80) and 35% (8/23) had sought health care, respectively. Men in the age-group of 60-80 years had sought health care significantly more often than men in the age-group 40-59 years (16% and 6%, respectively). The proportion of the men who reported having had urinary tract infection at least once during the preceding year was 2%, 3%, 3%, and 7% in the four age classes. Urinary tract infection was more common among men who reported urgency, stress incontinence or post micturition dribbling than among men without these symptoms. 30.

(185) Table 4. Characteristics of the men in the rural community of Surahammar.. Descriptive statistics Age: Mean (95%CI). Social status: Employed Unemployed Retired On sick leave Missing Education: Primary school Secondary school University studies Missing Marital status: Married/ living together Single/widower Missing Other: Smoker Non-smoker Missing Physical activity, more than twice a week Physical activity, twice a week or less Missing Urinary tract infection t 1 during the last year No urinary tract infection during the last year Missing. Paper ȱ n = 536. Paper ȱ n = 1681. Paper ɉ n = 387. Paper III, IV n = 748. LUTS No. (%). No LUTS No. (%). No. (%). No. (%). 57.7 55.9 (56.8-58.6) (55.4-56.4). 59.6 (58.4-60.6). 59.8 (59.0-60.5). 197 (51) 19 (5) 120 (31) 43 (11) 8 (2). 393 (53) 25 (3) 229 (31) 76 (10) 25 (3). 244 (63) 77 (20) 58 (15). 456 (61) 155 (21) 107 (14). 8 (2). 30 (4). 329 (85). 618 (83). 57 (15) 1 (0). 113 (15) 17 (2). 306 (57). 1009 (60). 113 (21) 423 (79) 306 (57). 420 (25) 1261 (75) 992 (59). 77 (20) 309 (80) 1 (0) 188 (49). 146 (20) 585 (78) 17 (2) 354 (47). 230 (43). 689 (41). 196 (51). 376 (51). 34 (6). 37 (2). 2 (0) 30 (8). 18 (2) 48 (6). 354 (92). 680 (91). 3 (0). 20 (3). 502 (94). 1644 (98). -. -. 31.

(186) Table 5. Prevalence of urinary tract symptoms (urgency, stress incontinence or post micturition dribbling) in different age groups.. Symptom *. 40-49 n=687. 50-59 n=717. 60-69 n=465. 70-80 n=348. All ages n=2217. No. (%). No. (%). No. (%). No. (%). No. (%). 98 (28). 536 (24). 52 (15) 18 (5). 140 (6) 53 (2). 73 (21). 469 (21). Reporting 136 (20) 176 (25) 126 (27) 1 to 3 symptoms 7 (1) 39 (5) 42 (9) Urgency Stress 7 (1) 11 (2) 17 (4) incontinence Post micturition 134 (20) 159 (23) 103 (22) dribbling *Any individual may have reported up to three symptoms.. 32.

(187) Paper II Among the men who had reported stress incontinence, urgency or post micturition dribbling in Paper I, 77 % (387/504) answered the DAN-PSS questionnaire. The response rate increased from 71% among men 41-50 years to 88% among men 71-81 years. The characteristics of the study population are shown in Table 4.. Symptoms Of the 387 participating men, 94% reported at least one of the 12 lower urinary tract symptoms (mild, moderate or severe). The number of selfreported lower urinary tract symptoms among the participants is shown in Figure 2.. 100. Percent. 80 60. 48%. 40 26%. 20%. 20 6%. 0 0. 1-4. 5-8. 9-12. Number of symptoms. Figure 2. Distribution of the number of self-reported lower urinary tract symptoms among the participants (n=387).. The median for the total symptom scores varied between 7 and 10 in the different age groups, with a score of eight for the whole study population. The mean value for the total symptom score was significantly higher in the oldest age group (71-81 years) compared with other age groups (Table 6). Forty-six percent of the men (179/387) had a total symptom score less than 7, and 8% (31/387) had a total symptom score of >15.. 33.

(188) Table 6. Symptoms, distress and DAN-PSS median scores (q1, q3) by age group in men 41-81 years old.. Symptom score (min 0 max 36) Distress score (min 0 max 36) DAN-PSS score (min 0 max 108). 41-50 (n=79) 7 (4,10). Median scores (q1,q3) 51-60 61-70 71-81 (n=123) (n=101) (n=84) 7 (4,10) 8 (5,11) 10 (7,13). All ages (n=387) 8 (5,11). 3 (1,9). 5 (1,9). 5 (1,10). 7 (3,13). 5 (1,10). 5 (2,12). 6 (2,13). 6 (2,12). 8 (4,20). 6 (2,14). The distribution of reported symptoms at different levels of severity during the storage phase, voiding phase or immediately after micturition is shown in Table 7. Post-micturition dribbling was the most common symptom, reported by 86% of the men. Sixty-three percent (209/332) of these men reported a small amounts of urinary leakage in the trousers (score 2) or large amounts of leakage of in the trousers (score 3). Among storage symptoms, urgency was reported by 69% of the men and 34% (91/265) of these men had a score of 2 (daily) or 3 (always). Nocturia, was reported by 60% of the men. Eighty-four percent (194/232) of these men had nocturia once to twice during the night and 16% (38/232) had it more than twice per night. Urge incontinence was reported by 35% of the men. The corresponding figures were 18% for men with “other” incontinence and 15% with stress incontinence. Seventy-three percent (99/134) of the men with urge incontinence, 79% (55/70) of the men with “other” incontinence and 80% (47/59) of the men with stress incontinence reported mild symptoms. None of the 387 men reported severe symptoms of stress or “other” incontinence. Of the symptoms experienced during the voiding phase, hesitancy was most common, reported by 61% of the men. Twenty-six percent (61/237) of the men reported that the symptom hesitancy occurred often or always (score 23). The proportion reporting straining at severity class 2 to 3 was 36% (75/209).. 34.

(189) Table 7. Proportion (%) of the participants reporting no, mild, or moderate to severe lower urinary tract symptoms (n=387).. Symptom. Number of men per score level No. Mild, Moderate, Severe. Mild. Moderate/ Severe. Score 0. Score 1-3. Score 1. Score 2-3. Urgency. 122 (31). 265 (69). 174 (45). 91 (24). Nocturia. 155 (40). 232 (60). 194 (50). 38 (10). Frequency. 172 (44). 215 (56). 160 (42). 55 (14). Urge incontinence. 253 (65). 134 (35). 99 (26). 35 (9). Other incontinence. 317 (82). 70 (18). 55 (14). 15 (4). Stress incontinence. 328 (85). 59 (15). 47 (12). 12 (3). Hesitancy. 150 (39). 237 (61). 176 (46). 61 (15). Straining. 178 (46). 209 (54). 134 (35). 75 (29). Weak stream. 188 (49). 199 (51). 166 (43). 33 (8). Dysuria 298 (77) Post micturition Symptoms Post micturation dribbling 55 (14). 89 (23). 81 (21). 8 (2). 332 (86). 123 (32). 209 (54). 250 (65). 169 (44). 81 (21). Storage symptoms. Voiding symptoms. Incomplete emptying. 137 (35). 35.

(190) Distress Of the men with at least one reported symptom from the lower urinary tract, 80% reported that they experienced some degree of distress (small, moderate, major) related to the symptoms. The total median distress score ranged from three to seven in the different age groups, with a score of five for the whole study population (Table 6). Fifty two percent of the men (201/387) had a total symptom score less than 6, and 5% (19/387) had a total symptom score of >20. The distress scores increased as symptom scores increased (r = 0,85 p<0.001). Men with self reported urge incontinence, “other” incontinence or stress incontinence had the highest mean distress score (1.86, 1.53 and 1.29, respectively) (Table 8). These symptoms also show the highest correlation between symptom severity and the degree of distress among symptoms experienced during the storage phase of the bladder (Table 9). Table 8. Distribution of the mean distress scores (SD) for storage, voiding and post micturition symptoms among the participants.. Symptom. Mean distress score (SD). Storage symptoms Urge incontinence. 1.86 (1.1). Other incontinence. 1.53 (1.0). Stress incontinence. 1.29 (0.9). Urgency. 1.09 (0.9). Frequency. 0.89 (0.9). Nocturia. 0.84 (0.9). Voiding symptoms Dysuria. 1.17 (0.8). Weak stream. 0.85 (0.8). Hesitancy. 0.79 (0.8). Straining Post micturition symptoms Post micturation dribbling Incomplete emptying. 36. 0.74 (0.8). 1.26 (1.0) 0.92 (0.8).

(191) Table 9. Correlation between total symptom score and total distress score for storage, voiding and post micturition symptoms.. Symptom. Correlation. Storage symptoms Urge incontinence. 0.834. Other incontinence. 0.807. Stress incontinence. 0.784. Urgency. 0.737. Nocturia. 0.582. Frequency. 0.503. Voiding symptoms Straining. 0.835. Weak stream. 0.685. Dysuria. 0.661. Hesitancy Post micturition symptoms Post micturation dribbling Incomplete emptying. 0.645. 0.664 0.636. The distribution of different levels of distress for men with mild symptoms (symptom score 1) is shown in Figure 3. Among men with urge incontinence, 88% reported the symptoms to be distressful to some degree. Among men reporting “other” incontinence and stress incontinence, 85.5% and 83%, respectively, reported some degree of distress.. 37.

(192) 33. Urge incontinence 11. Other incontinence. 13. 41. 14,5. 12. 60. 14,5. 4. 17. 62. 17. Dysuria 3. 17. 64. 16. Stress incontinence. Nocturia 3. 11. 37. 49. Day time frequency 1. 13. 38. 48. Incomplete 1 10 emptyning Straining 12 Weak Stream. 8. Urgency. 7. Hesitancy. 7. Post micturition dribbling. 5 0%. 47. 42. 36. 61 47. 45. 55. 38. 38. 55. 48 20% Major. 47 40% Moderate. 60%. 80% Small. 100% No. Figure 3. Percentage of men with symptom score one who reported no, small, moderate or major distress.. The distribution of different levels of distress among men with moderate/severe symptoms (symptom score 2-3) is shown in Figure 4. When affected by moderate or severe “other” incontinence or stress incontinence, all men reported distress (small, moderate, major). Of these men, 67% with “other” incontinence and 42% with stress incontinence reported major distress. Among men with moderate or severe urge incontinence, 63% reported major distress (distress score 3).. 38.

(193) 67. Other incontinence. 33. Nocturia. 26. 34. Urgency. 25. 38. Post micturition dribbling. 24. Day time frequency. 22. Weak Stream. 21. Straining. 0%. 7. 44 18. 36. 21. 58. 16. 45. 32. Major. 10. 52. 28. 20%. 12. 37. 38. 6. 3. 33. 24. 10. Incomplete emptyning. 18. 21. 25. 13. Hesitancy. 33. 25. 42. Stress incontinence. 25. 25. 50. Dysuria. 6. 11. 20. 63. Urge incontinence. 40% Moderate. 60%. 80% Small. 100% No. Figure 4. Percentage of men with symptom score 2 or 3 who reported no, small, moderate or major distress.. 39.

(194) Paper III The response rate was 74% (748/1008). Of these men, 694 men answered both the DAN-PSS and SF-36 questionnaires and 54 men answered only the SF-36 questionnaire. The mean age (95% CI) of all the participants at the time of answering the questionnaire was 59.8 (59.0-60.5) years, range 40-80 years. The demographic characteristics of the men are presented in Table 4. The distribution of the number of men with different levels of lower urinary tract symptoms are shown in Table 10. Table 10. Distribution of the number (%) of men reporting severity divided into no, mild moderate or severe lower urinary tract symptoms among the participants n= 694.. Symptom. Number of men per score level (%) No. Mild. Moderate. Severe. Score 0. Score 1. Score 2. Score 3. Urgency. 313 (45). 270 (39). 106 (15). 5 (1). Nocturia. 307 (44). 338 (49). 47 (7). 2 (-). Frequency. 356 (51). 258 (37). 73 (11). 7 (1). Urge incontinence. 524 (76). 131 (19). 35 (5). 4 (-). Other incontinence. 612 (88). 66 (10). 16 (2). -. Stress incontinence. 617 (89). 64 (9). 13 (2). -. Hesitancy. 330 (48). 272 (39). 75 (11). 17 (2). Straining. 368 (53). 226 (32). 81 (12). 19 (3). Weak stream. 389 (56). 262 (38). 37 (5). 6 (1). 576 (83). 109 (16). 8 (1). 1 (-). 202 (29). 227 (33). 258 (37). 7 (1). 345 (50). 249 (36). 88 (2). 12 (2). Storage symptoms. Voiding symptoms. Dysuria Post micturition symptoms Post micturation dribbling Incomplete emptying. 40.

(195) Storage symptoms and SF-36 measurements The distribution of the mean SF-36 scores in men 40-80 years with mild and moderate/severe and no storage symptoms are shown in Figure 5. When it came to urinary incontinence, the mean SF-36 scores were significantly lower in all the dimensions evaluated among men who experienced mild, moderate, severe urge incontinence, stress incontinence or other incontinence than among men without these symptoms. Furthermore, moderate or severe urge incontinence significantly reduced the mean scores on role physical (RP) and role emotional (RE) scales compared with men with mild urge incontinence. For stress incontinence, the mean SF-36 scores were higher for body pain (BP) in men with moderate or severe symptoms than in men with mild symptoms. Men with moderate or severe (score 2-3) stress incontinence reported almost equal mean SF-36 scores on physical functioning (PF), role physical (RP), role emotional (RE) and general health (GH) scales to those reported by men with mild (score 1) stress incontinence. For “other” incontinence, there were differences in the mean SF-36 scores for role physical (RP) and role emotional (RE) between men with moderate or severe (score 2-3) symptoms and men with mild (score 1) symptoms. Men with nocturia at least once a night (score 1-3) reported lower mean SF36 mean scores for physical functioning (PF), role physical (RP), vitality (VT) and general health (GH) scales then men without nocturia. Men with nocturia at least three times a night (score 2-3) reported lower scores in all the evaluated dimensions than men who have to urinate once or twice per night (score 1). The mean SF-36 scores were significantly lower for role physical (RP) functioning, among the men who reported the interval between each daytime urination to be three hours or less (score 1-3) compared with the mean SF-36 scores of men who had a voiding interval of more than three hours. Men who reported the interval between daytime urinations to be two hours or less (score 2-3) scored lower on role physical (RP), role emotional (RE) and vitality (VT) scales than men who had a voiding interval of two to three hours (score 1). Men with mild, moderate or severe (score 1-3) urgency reported lower mean SF-36 scores for physical functioning (PF), role physical (RP), body pain (BP), vitality (VT) and general health (GH) than men without urgency. Furthermore, moderate or severe (score 2-3) urgency significantly reduced the mean SF-36 scores for physical functioning (PF), role physical (RP), role emotional (RE), body pain (BP), vitality (VT) and general health (GH) compared with men with mild (score 1) urgency.. 41.

(196) Figure 5. Mean SF-36 scores (0-100) in men 40-80 years with mild and moderate/severe and no stress incontinence, urge incontinence, nocturia, other incontinence, daytime frequency and urgency.. 42.

(197) Comparisons of the mean SF-36 scores of men 40-65 years and men 6680 years (Figure 6) showed that among men with mild, moderate or severe (score 1-3) urge incontinence the scores were equal in all evaluated dimensions except physical functioning (PF). For mild, moderate or severe (score 1-3) “other” incontinence, men 66-80 years reported lower scores for all the evaluated dimensions, with the exception of vitality (VT), mental health (MH) and general health (GH) compared with men 40-65 years. A lower mean score for physical functioning (PF) and role physical (RP) was showed in men aged 66-80 years with mild, moderate or severe (score 1-3) stress incontinence compared with men 40-65 years with the same symptom. Furthermore, men 66-80 years with mild, moderate or severe (score 1-3) nocturia, daytime frequency or urgency, reported lower scores for physical functioning (PF) compared with men 40-65 years with the same symptom.. 43.

(198) Figure 6. Mean SF-36 scores (0-100) in men 40-65 years and 66-80 years with the storage symptoms; stress incontinence, urge incontinence, other incontinence nocturia, daytime frequency, urgency. Black-boxes display the mean SF-36 scores in men 40-80 years without the storage symptoms.. 44.

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