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

Abstract

MJA 1997; 167: 72-75  

Introduction

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

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

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

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

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 studies^1,6 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.

• 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.

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