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1 Occupational distribution of Patients with LUTS Single tertiary center experience. Part -4 (Medical Science) Chapter-III August/Vol.4.0/Issue-II ISSN NO : ISSN CODE: (Online) (ICV-MDS /Impact Value): 2.31 (GIF) Impact Factor: Copyright@IJF2016 Journal Code: ARJMD/MDS/V-4.0/I-2/C-3/AUG-2016 Website: Received: Accepted: Date of Publication: Page: Name of the Authors: Anurudda Udaya Bandara Pethiyagoda 1 Kalyani Pethiyagoda 2 1 Consultant Urology Surgeon, Senior Lecturer, Department of surgery, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka. 2 Senior Lecturer, Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka. Citation of the Article Pethiyagoda ADB,, Pethiyagoda K, Occupational Distribution of Patients with LUTS Single tertiary center experience. Advance Research Journal of Multidisciplinary Discoveries. Part-4,Vol. 4.0(2), C3, pp , 31 st August, 2016.ISSN ABSTRACT Lower urinary tract symptoms (LUTS) are a common presentation encountered in urology clinics which affects the quality of life of elderly people considerably. The International Prostate Symptom Score (IPSS) and Uroflowmetry are routine investigations used by urologists in the assessment of LUTS. The main objective of this study was to evaluate the pattern of occupational distribution of patients presenting with LUTS. Specific objectives were to assess severity of LUTS using IPSS and Uroflowmetry (UF) and to identify their association with occupation. This was a descriptive cross sectional study. The patients who have done same occupations for more than two years were enrolled in this study. The sample size was 400. Both male and female patients was studied under the age group of 25 to 65(mean age 61.55±13.56) during a ten month period. The association between the percentages of LUTS and the occupational category was calculated. Then it was compared with the occupational distribution of general Sri Lankan population. Population of patients with LUTS, there were 60.25% patients who did sedentary occupations whereas in general population the percentage was 32.9%. It indicates there is excess percentage of employers who are doing sedentary occupations present with LUTS. In conclusion, people who do sedentary type occupations present in excess percentage of LUTS whereas people do non sedentary type occupations present in less percentage but significantly higher IPSS. But patients who do sedentary type occupations presents with significantly low stage of the disease while patients do non sedentary type occupations show tolerance towards LUTS. KEY WORDS: Lower urinary tract symptoms (LUTS), International Prostate Symptom Score (IPSS), Uroflowmetry, Sedentary occupations, Non- sedentary occupations. A unit of International Journal Foundation Page I 96

2 I. INTRODUCTION Lower urinary tract symptoms (LUTS) are a common presentation encountered in urology clinics which affects the quality of life of elderly people considerably. (1) The leading recognized symptoms can be categorized into two types such as storage or irritative symptoms and voiding or obstructive symptoms. Storage or irritative symptoms such as increased frequency of urination, urgency of urination, painful urination and excessive passage of urine at night (nocuria). Voiding or obstructive symptoms such as poor stream (unimproved by straining), hesitancy (worsened if bladder is very full), terminal dribbling, incomplete voiding, overflow incontinence (occurs in chronic retention) and episodes of near retention.(2) The leading recognized causes such as benign prostatic hyperplasia(bph) with obstruction, detrusor muscle weakness and/or instability, Urinary Tract Infection (UTI), chronic prostatitis, urethral stricture, urinary stones, Malignancy: prostate or bladder, neurological disease( e.g. multiple sclerosis, spinal cord injury, cauda equina syndrome) and IgG4-related prostatitis.(3) The International Prostate Symptom Score (IPSS) and Uroflowmetry are routine investigations used by urologists in the assessment of LUTS. IPSS is an internationally used interview based questionnaire to assess severity of LUTS. (4) The scale for each symptom ranges from zero (symptom never present) to five (symptom always present). The seven symptoms are incomplete emptying, frequency, intermittency, urgency, weak stream, hesitancy and nocturia. (8) Uroflowmetry has become a universal investigation that affords urologists a simple and non-invasive way of measuring and recording the urinary flow rate throughout micturition.(5) According to the literature the association of LUTS and its significant impact of quality of life shows that higher the education level and higher the physical activities the prevalence of LUTS is lower.(6)the Long-term physical activity such as an occupation of an individual has a major influence on risk factors of lower urinary tract symptoms.(7)as an example; a cross-sectional representative sample of 30,377 men 45 to 79 years old in Central Sweden who completed a self-administered life-style questionnaire, including International Prostate Symptom Score questions, physical activity currently and recalled at age 30 years (work/occupation, walking, inactivity and exercise) and demographic data. A total of 6,905 men (23%) who scored 8 or more points on International Prostate Symptom Score questions were considered to have moderate or severe lower urinary tract symptoms. The results suggest that physical activity in young and late adulthood may be associated with a lower risk of moderate and severe lower urinary tract symptoms.(8) Hence there should be a relationship between the pattern of occupation and LUTS. The main objective of this study was to evaluate the pattern of occupational distribution of patients presenting with LUTS. Specific objectives were to assess severity of LUTS using IPSS and uroflowmetry (UF) and to identify their association with occupation. II. METHODOLOGY This was a descriptive cross sectional study. The study population consisted of patients who were referred to the Department of Surgery, Faculty of Medicine, University of Peradeniya, Sri Lanka. The sample size was 400. Both male and female patients was studied under the age group of 25 to 65(mean age 61.55±13.56) during a ten month period ( to ) by using systematic random sampling method. The patients who have done same occupations for more than two years were enrolled in this study. While these patients were clinically evaluated, the standardized questionnaires for IPSS of the patients were also obtained by trained doctors. The severity of LUTS of these patients were assessed by IPSS and further objectively evaluated by Uroflowmetry study. Patients demographic details, IPSS and Uroflowmetry data were entered and evaluated using the statistical package for social sciences (SPSS) with one way ANOVA. The occupation of each individual was categorized according to standard international classification of occupations. The employed population by occupation category in general Sri Lankan population was obtained by annual publication of 'Sri Lanka - Labour Force Survey Annual Report ' by Census and Statistics Department of Sri Lanka. Table 01- Occupational categories in general Sri Lankan population and their percentages Sl. No Occupational category % in general population 1 Managers, senior officials and legislators Professionals Technicians and associate professionals Clerks and clerical support workers Service and sales workers Skilled agricultural, forestry and Craft and related trade workers Plant and machine operators, and assemblers Elementary occupations Armed forces occupations 0.4 Total 100 A unit of International Journal Foundation Page I 97

3 The association between the percentages of LUTS and the occupational category was calculated. Then it was compared with the occupational distribution of general Sri Lankan population. The total IPSS value of each occupational category was analyzed to find the severity of LUTS of each occupational category and the urinary symptoms were also analyzed individually to find their severity. III. RESULTS Table 02- The association between the occupational category, percentages in general population and percentages in LUTS population. Sl.No. Occupational category % in general Population % in LUTS Population 1 Managers, senior officials and legislators Professionals Technicians and associate professionals Clerks and clerical support workers Service and sales workers Skilled agricultural, forestry and fishery workers Craft and related trade workers Plant and machine operators, and assemblers Elementary occupations Armed forces occupations Non occupational Total Sedentary Non Sedentary Population of patients with LUTS, there were 60.25% patients who did sedentary occupations whereas in general population the percentage was 32.9%. It indicates there is excess percentage of employers who are doing sedentary occupations present with LUTS. Figure (01) The graph of percentage in LUTS population vs. occupational category A unit of International Journal Foundation Page I 98

4 Table 03 Mean and Standard Deviation of total IPSS values with different occupational categories. Occupational Mean of Total Std. category IPSS Deviation Table (04) Calculated mean and standard deviation of IPSS for sedentary and non-sedentary occupations with respect to the individual urinary symptoms of LUTS. Urinary symptoms of LUTS Sedentary occupations Non sedentary occupations Sample mean Stand. Dev. Sample mean Stand. Dev. Incomplete empting Frequency Intermittency Urgency Weak stream Straining Nocturia Figure (02) - The comparison of mean values vs. symptoms of LUTS between sedentary (SD) and non-sedentary (NSD) occupations. A unit of International Journal Foundation Page I 99

5 Figure (03) - The graph of mean values of IPSS for sedentary occupations vs. urinary symptoms Figure (04) - The graph of mean values of IPSS for non-sedentary occupations vs. urinary symptoms IV. DISCUSSION According to previous studies it was found that urinary symptoms are prevalent among employers and sizable percentage of employed women with moderate to very severe symptoms report a negative impact on aspects of work.(9) Behaviors such as frequent visits to the toilet or lapses in concentration might be misattributed to poor work habits or insufficient commitment to the organization. From the employee's perspective, this could limit opportunities for advancement and diminish job satisfaction. From the employer's perspective, presenteeism that is, the problem of employees being at the workplace but performing sub optimally due to health issues may be a greater drain on productivity.(9) A unit of International Journal Foundation Page I 100

6 Both the prevalence and incidence of LUTS increases with the age, thus this has become an important medical concern in both adult and elderly population. In the same this condition has acquired a broad medical concern as LUTS has a significant impact of quality of life. Because of these reasons LUTS have been subjected to many studies to assess its various aspects including epidemiology etiology clinical evaluation and treatments. According to the observed results, employers who are doing sedentary type occupations present in higher percentage with LUTS compared to the employers who are doing non sedentary type occupations. According to the table (02), Population of patients with LUTS, there were 60.25% patients who did sedentary occupations whereas in general population the percentage was 32.9%. The figure (01) indicates that there is excess percentage of employers who are doing sedentary occupations present with LUTS. Studies done to assess the association of LUTS and life style shows that higher the physical activities the prevalence of LUTS is lower.(9) According to the table (03), the workers whose occupation involve hard training and lot of physical activity presents with moderate to severe LUTS. As an example army soldiers present with mean IPSS of and manual laborers present with mean IPSS of In contrast to this, workers who have less physical activity present with mild to moderate IPSS. As an example unemployed patients present with mean total IPSS of and professionals presents with mean IPSS of It also clearly visualized in figure (01). Patients who do sedentary type white collar occupations involving minimal physical activity and higher stress levels presents with significantly low stage of the disease whereas there prevalence is higher towards the LUTS. While patients do non sedentary type occupations show tolerance towards LUTS so that present in higher stage of urinary symptoms (Figure02). It may be due to the knowledge and higher education level of sedentary employees tends to attend to the clinic for treatments though they have low stage of the disease. But most of the non sedentary type employees are often reluctant to seek medical care for their symptoms due to lack of knowledge about the symptoms and heavy work load. V. CONCLUSION In conclusion people who do sedentary type occupations present in excess percentage of LUTS whereas people do non sedentary type occupations present in less percentage but significantly higher IPSS. REFERENCES : [1] Roehrborn CG and McConnell JD. Etiology, pathophysiology, epidemiology, and natural history of benign prostatic hyperplasia. Campell's Urology. 2002; 38:1309. [2] Masu S. A Prevalence Study of Lower Urinary Tract Symptoms (LUTS) in Males. International Journal of Medical Science and Public Health. 2014; 3 (8): [3] Rodolfo M, Marina S, Cheng L, et al. Immunoglobulin G4-related disease in genitourinary organs: An emerging fibro inflammatory entity often misdiagnosed preoperatively as cancer. European Urology. 2013; 64(1): [4] Lee JH, Kwon H. and Park YW. Association of lower urinary tract symptom/benign prostatic hyperplasia measures with international index of erectile function 5 in middle-aged policemen of Korea and the role of metabolic syndrome and testosterone in their relationship. Urology. 2013; 82(5): [5] Jarvis TR, Chan L,Tse V. Practical uroflowmetry. BJU Int. 2012; 110(4): [6] Kim TH, Han DH, Lee KS. The prevalence of lower urinary tract symptoms in Korean men aged 40 years or older: a population-based survey. International neuro urology journal. 2014;18(3): [7] Prasad VK, Hakkinen JT, Shiri RA, Al Ansari A. Prevalence and determinants of lower urinary tract symptoms among expatriate male workers in Qatar. Indian Journal of Urology. 2006; 22(1): [8] Barry MJ, Fowler FJ, O'Leary MP, Bruskewitz RC, Holtgrewe HL, et al. (1992) The American Urological Association symptom index for benign prostatic hyperplasia.the Measurement Committee of the American Urological Association J Uro 148: [9] Fultz NH, Burgio K, Diokno AC, Kinchen KS, Obenchain R, Bump RC. Burden of stress urinary incontinence for community-dwelling women. Am J Obstet Gynecol 2003; 189: ***** patients who do sedentary type occupations presents with significantly low stage of the disease while patients do non sedentary type occupations show tolerance towards LUTS so that present in higher stage of the disease. This may be due to the fact that non sedentary type occupants are mostly outdoor workers such as farmers and armed forces who may not use a proper wash room but for sedentary occupants will need proper wash rooms which will involve them leaving their work place. A unit of International Journal Foundation Page I 101