1088) had an IPSS of 8, indicating moderate-to- problem facing the growing number of elderly men in

Transcription

1 BJU International (1999), 83, Prevalence of lower urinary tract symptoms and self-reported diagnosed benign prostatic hyperplasia, and their evect on quality of life in a community-based survey of men in the UK P. TRUEMAN, S.C. HOOD, U.S.L. NAYAK* and M.F. MRAZEK Global Health Outcomes, Glaxo Wellcome plc, Stockley Park, *Centre for Applied Gerontology, University of Birmingham, Birmingham and London School of Economics and Political Science, London, UK Objectives To assess the prevalence of lower urinary status (as measured by the VAS) decreased as urinary tract symptoms (LUTS) in a community-based population symptom severity increased, and the greater the sever- in the UK, to measure the impact of these ity, the more men who reported a problem with symptoms on quality of life and health status in men mobility, self-care, usual activity, pain/discomfort, and with self-reported benign prostatic hyperplasia anxiety/depression (the five domains of the EQ-5D). ( BPH ), and to evaluate health-seeking behaviour in The possibility of symptoms worsening appeared to be this population. the key determinant in the respondents decisions to Subjects and methods A postal survey was distributed consult a medical professional for their LUTS. Less to an age-stratified random sample of 1500 men aged than 11% of the respondents were aware of the 50 years or older from throughout England, Scotland availability of specific prescription drug therapies or and Wales. The self-administered survey included: surgical options for the treatment of BPH. The most demographic questions; the EuroQoL (EQ-5D) instrument, common first treatment strategy for those consulting consisting of a health-status index question- for symptoms was watchful waiting (34%), followed naire and a visual analogue scale (VAS) on which by surgery (30%) and prescription drugs (21%). participants rated their current health status; the Conclusions Moderate-to-severe LUTS were relatively International Prostate Symptom Score (IPSS) questionnaire; common in this UK population of men over the age and a questionnaire assessing the participants of 50, yet relatively few had been diagnosed with health-seeking behaviour and awareness of BPH. BPH. As LUTS adversely acect quality of life, Results Responses to the survey were received from improved treatment options and increased public 1115 (74%) of the 1500 men. Overall, 41% (450/ awareness of BPH and LUTS are needed to combat a 1088) had an IPSS of 8, indicating moderate-to- problem facing the growing number of elderly men in severe LUTS, yet only 196 men (18%) reported that the population. they had been diagnosed with BPH. Both quality of Keywords Benign prostatic hyperplasia, lower urinary life (as measured by the EQ-5D) and general health tract symptoms, quality of life, prevalence, treatment lence of BPH in the community is dibcult to determine, Introduction as it depends both on the diagnostic criteria used and BPH is a histopathological definition for a condition that the population sampled [5,7]. For example, in two comacects both the glandular and the smooth muscle of the munity-based studies of men aged years in prostate in varying proportions; it is often characterized Scotland, which used a urinary symptom questionnaire, by a benign enlargement of the prostate. However, no urinary flow measurements and ultrasonography to single BPH case-definition has gained wide acceptance document BPH, the prevalence varied widely between for use in epidemiological studies, as there is controversy the studies, with an overall rate of 25% in one [4] and about the specific clinical diagnostic criteria [1]. While 77% in the other [6]. In comparison, the prevalence of BPH is recognized as a common condition in men over BPH based on histological evidence from autopsy studies the age of 40 years [2 6], with both autopsy and clinical was >50% in men aged years and nearly 90% retrospective studies agreeing that the prevalence by age 85 [3]. increases with advancing age [3,4,6], the actual prevaably Although the symptomatology of BPH varies consider- amongst men, most diagnosed cases will have some Accepted for publication 3 November 1998 degree of BOO and LUTS. However, LUTS are not BJU International

2 P. TRUEMAN et al. 411 necessarily indicative of BPH, and vice versa, as men (and The EQ-5D is a generic QoL questionnaire that provides women) may have LUTS caused by conditions unrelated a single, global measure of health status [11] and to the prostate. Despite seemingly high rates of prevalence has been shown to have good validity, responsiveness of BPH, several studies have reported that urologists see and reliability in several studies [12,13]. The question- only a fraction of men with clinical symptoms often naire explores five domains of health (mobility, self-care, associated with, although not indicative, of BPH (e.g. usual activity, pain/discomfort, and anxiety/depression). urgency, frequency and nocturia), and that many more Responses to the EQ-5D questions in each of these men may be in need of further assessment and treatment domains are coded as: 1, no problem; 2, some/moderate [4,8]. Drummond et al. [9] further suggested that the problems; and 3, extreme problems. A health-state profile, main burden of BPH is manifested as a reduction in in the form of a five-digit number, is then generated quality of life (QoL) and is not reflected in the consumption for each respondent (e.g represents no problem of healthcare resources. This situation could deteriorate on any of the five domains; indicates extreme in the future as the number of elderly (men in this case) problems with pain/discomfort and no other problems continues to increase in the next decade. in any other domains), and the numbers were then We report the prevalence of LUTS in a large com- converted to an index score, ranging from 0 (death) to munity-based population of men in the UK over the age 1 (best possible health), using valuations of health states of 50 years, and the prevalence of those men who report collected from representative samples of a general population that they had been diagnosed with BPH. The impact of in the UK [11]. The EQ-5D also contains a VAS symptom severity on QoL and perceived health status in on which respondents rate their present health status, men with self-reported BPH was then assessed. As some ranging from 0 to 100, with 0 representing the worst men appear to endure relatively severe LUTS before (or imaginable health state and 100 the best. without) seeking medical advice [10], we also surveyed The IPSS, which consists of the validated seven- health-seeking behaviour and public awareness of BPH question AUA Symptom Index [14,15] plus one BPHspecific in this population. quality-of-life question, has been recommended by an international consensus committee on BPH under the auspices of the WHO as the standard test with which Subjects and methods to assess symptoms of BPH [16]. Each respondent s IPSS Study design yielded a value corresponding to the following severity ratings: 0, no LUTS; 1 but <8, mild LUTS; 8 but This population-based study was conducted using a <19, moderate LUTS; 19, severe LUTS. postal survey distributed through the Centre for Applied All respondents, regardless of whether they had selfreported Gerontology at the University of Birmingham. The Centre BPH or not, were asked to complete a final has a database of #5000 persons aged 50 years section on their knowledge of the condition and the throughout England, Scotland and Wales, who are regularly available treatments. Those with self-reported BPH were contacted to participate in consumer surveys asked to provide further information on diagnosis and relevant to this age group. The study was conducted treatments. collaboratively with the Centre as it allowed access to a suitable population and has recorded high response rates in previous studies. From this database, an age-stratified Statistical analysis sample of 1500 men was randomly selected to receive The demographic and patient-awareness data are presented the survey. using descriptive statistics; anova was used to evaluate the relationship between EQ-5D scores and IPSS Questionnaires severity, adjusted by age. Age adjustments were made using regression analysis with dummy coebcient variables The self-administered survey included several components: for the IPSS scores and age to predict the EQ-5D questions pertaining to the respondents demo- scores. graphic characteristics; the EuroQoL (EQ-5D), consisting of a health-status index questionnaire and a visual analogue scale (VAS) on which participants rated their Results current health status; the IPSS questionnaire; and a Responses to the survey were received from 1115 men questionnaire assessing the participant s awareness of (mean age 73 years, range 50 92, response rate 74%). BPH. Participants were asked to complete all parts of the Overall, 41% (450/1085) of the respondents had moderate-to-severe survey, regardless of whether or not they had been LUTS as measured by the IPSS (i.e. IPSS diagnosed with BPH. 8). Of those completing the entire IPSS questionnaire,

3 412 LUTS AND BPH IN A COMMUNITY-BASED SURVEY OF MEN IN THE UK 196 (18%) reported that they had been diagnosed as why respondents, among those with a reported diagnosis having BPH (Table 1); 56% of those with symptoms of BPH, consulted a medical professional for their had experienced them for 6 12 months and 12% claimed condition (patients were provided response choices with to have had their symptoms for >5 years. space provided for additional responses). The possibility Table 2 shows the EQ-5D and VAS scores by urinary of symptoms worsening appeared to be the key determinant symptom status (i.e. IPSS category) for all respondents, in the decision to consult or not, although fear of and separately for those with a diagnosis of BPH. The cancer and interruption to daily activities were named results in the two groups, which were very similar, second most frequently. showed that QoL (as measured by the EQ-5D) and When asked about their knowledge of treatments for general health status (as measured by a VAS) both BPH, relatively few respondents (4 11%) were aware of decreased as symptom severity increased. the availability of prescription drug therapies (e.g. Figure 1 shows the percentage of patients with some/ a-adrenergic blockers or 5-a reductase inhibitors) or moderate or extreme problems (i.e. a score of 2 or 3) in surgical options (e.g. TURP). Overall, 63% of respondents the QoL domains measured by the EQ-5D by prostatic claimed not to have heard of any of the treatment symptom category (i.e. IPSS). In all respondents, includ- options listed for BPH. Of those consulting for symptoms, ing those with a BPH diagnosis, the greater the severity 34% had watchful-waiting suggested to them as the first of the LUTS, the more men who reported a problem in treatment strategy, 21% had prescription drug therapy each of the EQ-5D domains. anova confirmed that after suggested, 30% had surgery suggested as their first-line adjusting for age, symptom severity continued to have therapy, and the remainder had a combination of watchful-waiting a significant (P<0.005) impact on QoL. with optional drug therapy or surgery. When the self-reported BPH group was asked, By whom was your BPH diagnosed?, 55% responded that it was by a specialist (e.g. urologist, surgeon) and 40% Discussion responded that it was by a GP. Table 3 provides reasons The results of this survey provide an interesting profile of urinary symptomatology in a community-based popu- Table 1 Overall and age-specific prevalence of men with moderate- lation of older men in the UK. The picture presented is to-severe LUTS (IPSS 8) and of reported BPH not unfamiliar in the literature, i.e. moderate-to-severe LUTS (although not necessarily BPH-specific) are rela- Age group Symptomatic Reported BPH tively common, occurring in 29 51% of the present (years) n n (%) n (%) sample, depending on the age group. This finding is All (50 92) (41) 196 (18) consistent with other epidemiological studies [17,18] (29) 0 that have reported the age-specific prevalence of moder (38) 36 (11) ate-to-severe urinary symptoms (IPSS 8) in men in (41) 113 (19) Canada [19], The Netherlands [20], Asia [17], the USA > (51) 37 (25) [21] and Australia [17] as being 15 36% in those years old, 27 41% in those and 31 56% in those years. Table 2 EQ-5D and VAS scores by urinary symptom status In the present study, no clinical procedures were undertaken to detect undiagnosed cases or to confirm Urinary the anatomical presence of BPH. Using only self-reported symptoms (according to IPSS*) All Reported BPH diagnoses of BPH, the overall prevalence of BPH was 19%. However, previous studies have shown that (anatomical) EQ-5D mean score (n) BPH is often underestimated [4,6]. Although None 37 (0.91) the terminology was kept as simple as possible, it is Mild 583 (0.84) 61 (0.87) possible that the present respondents may not have been Moderate 323 (0.78) 75 (0.79) totally familiar with the terms benign prostatic hyper- Severe 113 (0.71) 52 (0.71) plasia or enlarged prostate when they responded to VAS mean score (n) the question of whether or not they had been diagnosed None 38 (80.2) Mild 600 (76.8) 63 (75.6) with BPH. Thus, the prevalence reported is likely to be Moderate 332 (71.5) 78 (70.1) an underestimate of the condition in this population. Severe 118 (67.6) 54 (67.4) The much higher percentage of moderate-to-severe LUTS (41%) than reported for BPH (19%), even when viewed *IPSS of 0, none; >1 but <8, mild; >8 but <19, moderate; conservatively because the IPSS is not specific for BPH 19, severe. (e.g. the IPSS also detects symptoms in women with

4 P. TRUEMAN et al All respondents Percentage of patients with problems Respondents with reported BPH Mobility Self-care Usual activities Pain/ discomfort Anxiety/ depresiion Fig. 1. Percentage of respondents with problems in the QoL domains of the EQ-5D by urinary symptom status (none, dark green; mild, light green; moderate, light red; severe, dark red). Table 3 Reasons for consulting about LUTS measured the impact of these symptoms on men s QoL, particularly in terms other than bothersomeness. In the Reason* Number reporting a diagnosis of BPH present study, using the validated EQ-5D questionnaire, the more severe the LUTS, the lower the QoL and Symptoms may worsen 137 Fear of cancer 97 perceived health status. This was the case even when Interruption to daily activities 97 the results were controlled statistically for age, which is Embarrassment 68 known to be related to symptom scores. The greatest Other 39 number of men with problems in the five domains of the Total 208 EQ-5D were those with the most severe LUTS. Results were similar for all respondents, including those with a *Reasons were not mutually exclusive. self-reported BPH diagnosis. This may reflect that the IPSS questionnaire is not disease-specific and would not urinary tract infections), is likely to be an indication that necessarily be expected to dicerentiate between those a significant number of the men chose not to consult a with or without BPH, or this may indicate that the men physician for their symptoms or they were not referred who did not have a diagnosis of BPH (possibly because to a specialist for a diagnosis. they did not or would not seek medical care) had similar While several studies have investigated the relationship LUTS to those who had received a diagnosis of BPH. between urinary symptoms and the pathophysiolog- Although the present results show a consistent inverse ical processes which contribute to BPH [4,6], few have relationship between symptom severity and QoL,

5 414 LUTS AND BPH IN A COMMUNITY-BASED SURVEY OF MEN IN THE UK controlled trials assessing whether reductions in sympminimally 5 Oesterling JE. Benign prostatic hyperplasia. Medical and tom severity through new pharmaceutical interventions invasive treatment options. N Engl J Med 1995; translate into improvements in health-related QoL are 332: needed to make these data more clinically relevant. 6 Simpson RJ, Fisher W, Lee AJ, Russell EB, Garraway M. Benign prostatic hyperplasia in an unselected community- The present study did not attempt to establish a based population: a survey of urinary symptoms, botherquantitative relationship between QoL scores, symptoms someness and prostatic enlargement. Br J Urol 1996; and health-seeking behaviour. However, the fear of 77: symptoms deteriorating was a major factor in the 7 Bosch JL, Hop WC, Kirkels WJ, Schroder FH. Natural decision to consult a medical professional. From the history of benign prostatic hyperplasia; appropriate case results it is clear that increased education of the public definition and estimation of its prevalence in the com- (and possibly the healthcare professionals informing munity. Urology 1995; 46: them of a diagnosis) about treatments for BPH and LUTS 8 Britton JP, Dowell AC, Whelan P. Prevalence of urinary is needed, as relatively few respondents who sought symptoms in men over 60. Br J Urol 1990; 66: medical help for their symptoms were aware of the 9 Drummond MF, McGuire AJ, Black NA, Petticrew M, various treatment options available. Whether this reflects McPherson CK. Economic burden of treated benign prostatic inadequate patient counselling on the part of the medical hyperplasia in the United Kingdom. Br J Urol 1993; professionals or a lack of understanding on the part of 71: Oesterling JE. Benign prostatic hyperplasia: a review of its the patient unfortunately cannot be determined from histogenesis and natural history. The Prostate (Suppl) 1996; this survey. Nonetheless, increased awareness of the 6: nature and magnitude of the problem of BPH in elderly 11 The EuroQol Group. EuroQol a new facility for the men should be encouraged. measurement of health-related quality of life. Health Policy In summary, the results of this large survey of men 1990; 16: over the age of 50 years showed that urinary tract 12 Brazier J, Jones N, Kind P. Testing the validity of the symptoms are fairly common, but only about half the EuroQol and comparing it with the SF-36 health survey men with moderate-to-severe symptoms had sought questionnaire. Qual Life Res 1993; 2: medical attention for the symptoms and were diagnosed 13 Hurst NP, Kind P, Ruta D, Hunter M, Stubbings A. with BPH. As LUTS adversely acect QoL, improved Measuring health-related quality of life in rheumatoid treatment options and increased public awareness are arthritis: validity, responsiveness and reliability of EuroQol needed to combat a problem facing the growing number (EQ-5D). Br J Rheumatol 1997; 36: of elderly men in the population. 14 Barry MJ, Fowler FJ Jr, O Leary MP et al. The American Urological Association Symptom Index for benign prostatic hyperplasia. J Urol 1992; 148: Acknowledgements 15 Barry MJ, Fowler FJ, O Leary MP et al. Correlation of the American Urological Association Symptom Index with self- We thank Rose Mills of GlaxoWellcome for her assistance administered versions of the Madsen-Iversen, Boyarsky and in reviewing and preparing this manuscript, Guy Nuyts, Maine Medical Assessment Program Indexes. J Urol 1992; formerly of the Lewin Group, for input at the early stages 148: of the questionnaire design and Kate Hodsall of the 16 Cockett AT, Aso Y et al. Recommendation of the Centre for Applied Gerontology for assitance in data International Consensus Committee on prostate symptom entry. score and quality of life assessment. In Cockett ATK, Khoury S, Aso Y et al., eds. Proceedings of the 2nd International Consultation on Benign Prostatic Hyperplasia (BPH) Paris: Scientific Communication International Ltd, References 1994: Guess HA. Epidemiology and natural history of benign 17 Homma Y, Kawabe K, Tsukamoto T et al. Epidemiologic prostatic hyperplasia. Urol Clin North Am 1995; 22: survey of lower urinary tract symptoms in Asia and Australia using the International Prostate Symptom Score. 2 BirkhoC JD, Wiederhorn AR, Hamilton ML, Zinsser HH. Int J Urol 1997; 4: 40 6 Natural history of benign prostatic hypertrophy and acute 18 Sagnier PP, Girman CJ, Garraway M et al. International urinary retention. Urology 1976; 7: comparison of the community prevalence of symptoms of 3 Barry MJ. Epidemiology and natural history of benign prostatism in four countries. Eur Urol 1996; 29: prostatic hyperplasia. Urol Clin North Am 1990; 17: 19 Norman RW, Nickel JC, Fish D, Pickett SN. Prostate related symptoms in Canadian men 50 years of age or 4 Garraway WM, Collins GN, Lee RJ. High prevalence of older; prevalence and relationships among symptoms. Br benign prostatic hypertrophy in the community. Lancet J Urol 1994; 74: ; 338: Bosch JLHR, Hop WCJ, Kirkels WJ, Schroeder FH. The

6 Authors P. TRUEMAN et al. 415 international prostate symptom score in a communitybased sample of men between 55 and 74 years of age: P. Trueman, MA, Health Economist. prevalence and relationships among symptoms. Br J Urol S.C. Hood, MA, currently at SmithKline Beecham, UK. 1994; 74: U.S.L. Nayak, ME, PhD. 21 Chute CG, Panser LA, Girman CJ et al. The prevalence of M.F. Mrazek, MSc. prostatism: a population-based survey of urinary symptoms. Correspondence: Mr P. Trueman, Global Health Outcomes, J Urol 1993; 150: 85 9 Glaxo Wellcome R & D, Greenford, Middlesex UB6 0HE, UK.