Questioning questions about symptoms of benign prostatic hyperplasia

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1 Family Practice Vol. 18, No. 3 Oxford University Press 2001 Printed in Great Britain Questioning questions about symptoms of benign prostatic hyperplasia Ejda Hassler, Ingvar Krakau, Lars Häggarth, Lars Norlén and Peter Ekman Hassler E, Krakau I, Häggarth L, Norlén L and Ekman P. Questioning questions about symptoms of benign prostatic hyperplasia. Family Practice 2001; 18: Objectives. Our aim was to conduct a survey about urinary symptoms and to find out if questioning patients about symptoms is helpful for the GP to make medical decisions concerning prostate problems among middle-aged men. Methods. Twelve hundred randomly chosen men aged years from the general population in north-west Stockholm, Sweden were sent a questionnaire consisting of symptom questions focusing on prostate problems based on the International Prostate Symptom Score (I-PSS). A subset of 120 respondents were asked to answer the same questions again and to participate in a urological examination including urodynamics and ultrasonography. The main outcome measures were the prevalence of urinary symptoms and the relationship between the symptom score and objective measures. Results. A response rate of 86% was obtained in the questionnaire study. Twenty-one per cent of the respondents stated that they had general problems related to urination. Among individual symptoms, post-void dribbling and a weak stream were most common. Among the men examined at the Urological Department, the average prostatic volume was found to be 40 cm 3. Three out of four were assessed to have infravesical obstruction. No correlation between subjective symptoms and objective measurements of either a statistical or clinical significance was found. Conclusions. Urinary symptoms are common among middle-aged men. Further, an enlarged prostate and/or infravesical obstruction is often found in the ageing man. Information obtained by asking prostate-specific symptom questions cannot, however, serve as the foundation for the GP to find those men whose problems would be solved by actions directed at the prostate. Keywords. Benign prostatic hyperplasia, epidemiology, questionnaire. Introduction Lower urinary tract symptoms affecting older men are loosely termed prostatism. 1,2 The symptom complex includes voiding symptoms such as weak urinary stream, abdominal straining, hesitancy, intermittency, feeling of incomplete bladder emptying and post-void dribble. In addition, storage symptoms such as frequency, nocturia, urgency, urge incontinence and, possibly, dysuria may be noted. Serious complications considered to be associated Received 28 January 2000; Revised 13 September 2000; Accepted 8 January Department of Internal Medicine and Department of Urology, Karolinska Hospital, Stockholm, Sweden. Correspondence to Dr E Hassler, Research Center of General Medicine, Karolinska Hospital, Borgmästarvillan, S Stockholm, Sweden. with bladder outlet obstruction are acute or chronic urinary tract infection, acute or chronic urinary retention with or without overflow incontinence, and acute or chronic renal failure. 2,3 Today, apart from surgery, pharmacological treatment alternatives to alleviate complaints caused by an enlarged prostate are widely available. Thus, it has become a major challenge to the GP to select those older men who would benefit from treatment. However, unlike patients usually treated in urological wards, men visiting their GP can be supposed to have less pronounced signs and symptoms. The foundation for a decision is fragile and the consequences for the patient of the introduction of unnecessary and possibly harmful diagnostic procedures or of taking medicines have to be taken into account. The aim of this study was to survey urinary symptoms among middle-aged men in the general population and relate these symptoms to urological findings. 328

2 Methods Questioning questions about symptoms of benign prostatic hyperplasia 329 The study was approved by the Karolinska Institute Ethics Committee. Epidemiological study A total of 1200 men, aged years, were chosen randomly from the population in the north-west part of Greater Stockholm, exclusively for this study. The men received an introductory letter in April 1996 and were asked to complete a questionnaire and return it in an enclosed pre-paid envelope. If no reply was received, two follow-up letters were sent after 3 and 5 weeks, respectively. The symptom questions (Table 1) were based on the International Prostate Symptom Score (I-PSS). 4 The wording of the items was elaborated to fit the general population and the questions were arranged so as to be easy to answer by a symptom-free man. 5 Apart from the 10 symptom questions about storage and voiding and one question about general problems due to urination, five more questions were asked. One of Question no. TABLE 1 Questions asked Wording of question and answer 1 Do you have urinary problems? Yes;; No (2) (If Yes, do you know why?) 3 How many times do you have to urinate during the day? Maximum 4 times; 5 8 times;; At least 9 times 4 How many times do you have to urinate during the night? 0 1 time; 2 3 times;; At least 4 times 5 Do you experience a strong need to urinate? 6 Does a dripping faucet give you a strong impulse to urinate? 7 Is your need to urinate so urgent that you cannot withhold it until you reach the toilet? 8 Do you experience dribbling when you thought urination had ended? 9 Do you experience having a weak urinary stream? 10 Do you feel that you do not empty your bladder completely when urinating? 11 Does it happen that you have to urinate again within 15 minutes? 12 Do you have to push and strain to begin urination? The dividing line between the answers indicating health and those indicating problems is shown by two bold semicolons. them was included as number 2 in the questionnaire and was directed at men admitting urinary complaints. They were asked for their own opinion about the causes of the problems experienced. Four other questions dealt with any previous medical contacts due to all urological symptoms. Clinical study As a postscript to the questionnaire, the respondent was asked to give all his telephone numbers if he was willing to accept a possible invitation to participate in a clinical study. A total of 940 declared a willingness to participate. The exclusion of men with uncompleted questionnaires and men suffering from insulin-treated diabetes, prostatic carcinoma, surgery of the prostate or neurological disorders left 890 subjects eligible. One hundred and twenty men, sampled to represent the entire continuum of scores, were invited for a urological examination at Karolinska Hospital. An algorithm assigning greater weight to questions on obstruction than to those on irritation was used to select subjects for the clinical investigation. The reason for weighting was that obstructive symptoms imply the risk of urinary retention. Thirty men scoring high and 30 scoring low on this algorithm, and answering the general question as expected, were chosen. Two other groups of 30 men each scoring high and low, respectively, but with contradictory answers to the symptom questions in relation to the introductory question: Do you have urinary problems? Yes; No, were also included since patients uncertain of the impact on their health of a body sensation are frequents visitors to their GP. A urodynamic examination (including residual volume measurement, cystometry and pressure flow measurements) was carried out and evaluated jointly by two of the authors (LH and LN). The equipment used was a Synectics PolyUro System with a double-lumen 8 French catheter introduced into the bladder through the urethra and a pressure meter in the rectum. The subject also had trans-rectal ultrasonography ( Leopard with probe type 8538 from B&K medical equipment). In cases of pathological findings, a referral to the routine medical service was made promptly. Ten symptom questions as well as a general question about urinary problems, with the same wording and in the same order as in the previous questionnaire, were included in a new questionnaire of 19 questions as items 5 and The other questions, not to be discussed in the present paper, dealt with possible medication and any difficulties caused by urinary problems in the respondent s personal life. Only one of the authors (EH, who did not participate in the urological examinations) knew the subjects scores on the two questionnaires. Statistical methods The software package SAS was used for the statistical analysis.

3 330 Family Practice an international journal Before the computations, the answers to the questions with three alternatives were transformed to four alternatives by replacing the middle alternative with a score of 2.5. Thus, the minimum total score on the symptom questions was zero and the maximum 30. Spearman rank correlation was used to describe the relationship between scores on the one hand and prostatic size and average urine flow on the other. The Kruskal Wallis test was used to compare average scores from those men with and without an obstruction. 6 Results The response rate to the epidemiological study was 86%. A total of 1001 men answered all 10 items about symptoms as well as the general question about urinary problems. A straightforward inspection of dichotomized data showed that post-void dribbling and a weak stream were the main symptoms. Analyses of dichotomized answers from men expressing concern about urinary symptoms and those neglecting general urinary problems, respectively, gave a similar outcome (Table 2). The correlation coefficient between total score and the answer to the question about general concern was Eighty-five men with no previous urological contacts or extra-urological conditions interfering with voiding came to the Urological Department. The median age of the subjects was 60 years. Their total score was , median The examinations took place between November and August , the time between answering the first and second questionnaire thus varying by between 6 and 13 months. The median time between filling in questionnaires was 10 months. All the men, apart from three, changed their answer to one or more questions. The answer to the question about post-void dribble was changed by 40 men; the other questions were more stable over time. The mean difference between the first and the second total score was zero. Nineteen men changed their opinion as to whether the symptoms were problematic or not. The median average urine flow for the subjects was 3.7 ml/second, ranging from 0.7 to 13 ml/second. The examining urologists assessed 64 men as having an obstruction from the urodynamic findings. Information on prostatic size was missing for one subject. The median volume of the prostate for the other 84 men was 40 cm 3, ranging from 11 to 103 cm 3. The correlation coefficients between the total score (according to the first questionnaire given) on the one hand, and prostatic volume and average urine flow on the other, were 0.14 and 0.18, respectively. No statistically significant difference in the total score for men judged as having an obstruction compared with those without was found (P = 0.87). Similar results were obtained when the second questionnaire was used. Discussion No clinically important relationships between the total score, prostate size, average urine flow and obstruction could be demonstrated. Thus, asking presumed prostatespecific questions such as those in the I-PSS is not a very selective way to identify older men in the general population suffering from significant prostate enlargement and/or infravesical obstruction. There is hardly any reason to believe that questions put verbally by the doctor would have been more selective. Probably there are no TABLE 2 Answers indicating urinary problems as a percentage and numbers of men with problems, distributed in accordance with their answer to the general question Item number and content Percentage of answers No. of men with problems, distributed indicating problems in accordance with their answer to the n = 1001 general question about urinary problems 1 General urinary problems 20.8 Yes (n = 208) No (n = 793) 8 Post-void dribbling Weak urinary stream Incomplete emptying Hesitancy Easily induced impulse Day-time frequency Urgency Rapidly repeated need Nocturia Urge incontinence

4 Questioning questions about symptoms of benign prostatic hyperplasia 331 specific prostate questions to be asked, since it has been shown that elderly women answer such questions in the same way as men do and obtain similar scores. 7 Other authors 4 8 have used receiver operating characteristic (ROC) curves to achieve a sense of confidence in the tests discriminative capacity. ROC curves describe cut off points as trade offs between sensitivity and specificity. A gold standard is needed when a cut off point has to be chosen. However, unfortunately, no gold standard for so-called clinically benign prostatic hyperplasia exists. Instead, a treatment decision can be the subject of negotiations between the doctor and the patient. We base this supposition on the report by Isaacs 9 which showed that the number of men with subjective problems and the number who were treated surgically was almost identical. The reported good outcomes of different actions on the prostate may be ascribed to placebo effects, which seem to be very common in prostatic treatment. 2,9 As shown in several studies, e.g , the type and frequency of individual symptoms change with ageing. Other studies have included participants from ~40 years of age with no upper limit. This makes comparisons of total scores and/or separate questions difficult, since the age spread in other studies means that the number of men of comparable age is very small. We chose men between 55 and 65 years of age for two reasons: (i) men younger than 55 years are seldom suspected of having prostate-associated lower urinary tract symptoms; and (ii) confounders to prostatic symptoms such as ageing mucous membranes and muscles, impaired nervous control of the bladder, etc. are more frequent among men over 65 years. Examining a sample of men from encounters at clinics or other places of care as in the study by Chute et al. 12 or Chai et al. 7 may underestimate the number of men without problems, the reverse of the healthy-worker effect. The exclusion of men with known problems may cut off the scores from the other end of the range. We used the census of all the inhabitants in the area, thus giving every man the same probability of being chosen, and we did not make any exclusions. In most studies, using symptom questions such as the I-PSS 4, the response rates reported were low. For example, a Dutch study 11 reported response rates of 33 35% for different age groups, and a French study conducted by Sagnier 14 showed similar figures. Given the high response rate for our questionnaire, the data can be claimed to be representative of the general population of urban middle-aged men. In this study, almost every second man had a prostate larger than 40 g, twice the size suggested by Garraway 13 as a lower boundary for prostatic enlargement, while three-quarters of all the men studied were judged to have an obstruction. Almost every second man thus fulfilled two of the three requirements for clinical action. 16 The subjective symptoms therefore seem to be decisive. However, since the subject s own perception of whether he is troubled by his symptoms varies considerably with time, medical decisions could not be based on the outcome of temporary questionnaires or questions. Watchful waiting instead of hasty prescribing of drugs based on the patient s complaints, and close co-operation between GPs and urologists would be a prudent strategy and, as Humphrey Bogart says at the end of the movie Casablanca This could be the beginning of a beautiful friendship. Conclusion Urinary symptoms are common among middle-aged men. Further, an enlarged prostate and/or infravesical obstruction is often found in the ageing man. Information obtained through a questionnaire similar to the I-PSS cannot, however, serve as the foundation for the GP to identify those men whose problems would be solved by actions directed at the prostate. Acknowledgements We want to thank Mrs Kerstin Cronwall RN, who skilfully took care of the urodynamic examinations at the Urological Department. Funding for this project was provided by Merck, Sharpe & Dohme. References 1 Abrams P. New words for old: lower urinary tract symptoms for prostatism. Br Med J 1994; 308: Nordling J, Hald T. BPH versus LUTS: reflections on lower urinary tract symptoms in search of a definition of clinical benign prostatic hyperplasia. Eur Urol Update Ser 1997; 6: Riehmann M, Hansen BJ, Polishuk PV, Nordling J, Hald T. Symptom scores in benign prostatic hyperplasia. Urology 1997; 49: Barry MJ, Fowler FJ, O Leary MP et al. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 1992; 148: Kirshner B, Guyatt G. A methodological framework for assessing health indices. J Chron Dis 1985; 38: Dawson-Saunders B, Trapp RG. Basic & Clinical Biostatistics. Norwalk, CT: Appleton & Lange, Chai TC, Belville WD, McGuire EJ, Nyquist L. Specificity of the AUA voiding symptom index: comparisons of unselected and selected samples of both sexes. J Urol 1993; 150: Hansen BJ, Flyger H, Brasso K et al. Validation of the selfadministered Danish Prostatic Symptom Score (DAN-PSS-1) system for use in benign prostatic hyperplasia. Br J Urol 1995; 76: Isaacs JT. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. Prostate Suppl 1990; 3: Sommer P, Nielsen KK, Bauer T et al. Voiding patterns in men evaluated by a questionnaire survey. Br J Urol 1990; 55: Bosch JL, Hop WC, Kirkels WJ, Schroeder FH. The International Prostate Symptom Score in a community-based sample of men

5 332 Family Practice an international journal between 55 and 74 years of age: prevalence and correlation of symptoms with age, prostate volume, flow rate and residual urine volume. Br J Urol 1995; 75: Chute CG, Panser LA, Girman CJ et al. The prevalence of prostatism: a population-based survey of urinary symptoms. J Urol 1993; 150: Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic hypertrophy in the community. Lancet 1991; 338: Sagnier PP, MacFarlane G, Richard F, Botto H, Teillac P, Boyle P. Results of an epidemiological survey using a modified American Urological Association symptom index for benign prostatic hyperplasia in France. J Urol 1994; 151: Malmsten U, Milsom I, Molander U, Norlén L. Urinary incontinence and lower urinary tract symptoms; an epidemiological study of men aged 45 to 99 years. J Urol 1997; 158: Roehrborn CG. Objective and subjective response criteria to diagnose benign prostatic hyperplasia. Eur Urol 1993; 24 (Suppl 1): 2 11.

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