Family Practice Vol. 20, No. 1, 7-10
© Oxford University Press 2003
Clinical Research |
Prevalence of three lower urinary tract symptoms in men—a population-based study
a Uppsala University, Department of Public Health and Caring Sciences, Uppsala Science Park, S-75185 Uppsala,
b Centre for Clinical Research, Uppsala University, Central Hospital, S-72189 Västerås and
c Department of Caring Science, Mälardalen University, Västerås, Sweden.
Correspondence to Gabriella Engström, Department of Caring Science, Mälardalen University, Box 883, S-72123 Västerås, Sweden; E-mail: gabriella.engstrom{at}mdh.se
Engström G, Walker-Engström M-L, Lööf L and Leppert J. Prevalence of three lower urinary tract symptoms in men—a population-based study. Family Practice 2003; 20: 7–10.
Received 17 January 2002; Revised 19 June 2002; Accepted 9 September 2002.
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Abstract |
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Background. Lower urinary tract symptoms are a common and costly public health issue. In earlier studies, the prevalence of urinary symptoms can be seen to fluctuate because there is no consensus about how to define and categorize the severity of the symptoms.
Objectives. The study was undertaken in order to investigate the prevalence of three common lower urinary tract symptoms (urgency, stress incontinence and post-micturition dribbling) and analyse health care-seeking behaviour.
Methods. A self-administered questionnaire was developed to investigate all men aged 40–80 years residing in the community of Surahammar, Sweden. The questionnaire included items on three specific urinary symptoms: urgency, stress incontinence and post-micturition dribbling, and one question about health care-seeking behaviour.
Results. A response rate of 86% was obtained in the questionnaire study. The overall prevalence of the lower urinary tract symptoms was 24%. The prevalence increased from 20% in the group aged 40–49 years to 28% in the group aged 70–80 years (P < 0.01). Post-micturition dribbling (21%) was the most frequent symptom, and stress incontinence (2.4%) was the least frequent symptom. The number of participants who sought health care was low (4%) and increased significantly with age (P < 0.001).
Conclusions. The present study showed that 24% of the Swedish cohort of men of 40–80 years of age reported at least one of the following symptoms: urgency, stress incontinence or post-micturition dribbling. This study is consistent with other research regarding the low consultation frequency for these symptoms. Moreover, the study is also in accord with those findings indicating that for the majority of men with urinary symptoms, their health care providers are not aware of their problem.
Keywords. Health care consultation, men, population-based study, prevalence, urinary symptoms.
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Introduction |
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Lower urinary tract symptoms in men constitute a serious problem in industrialized countries, as well as a substantial economic burden on the health care system.1 Correct determination of the prevalence of lower urinary tract symptoms, health care-seeking behaviours, and the impacts on social function and quality of life helps health service providers to plan appropriate strategies and resources. Many men with urinary symptoms do not consult health care services2 despite the fact that numerous pharmacological and surgical treatments are widely available. The overall prevalence of urinary symptoms varies greatly in published reports.2–12 The variation can be explained by several factors, including selection bias in non-population-based reports, variation in the definition of symptoms or different categorization styles of severity and frequency of symptoms.9 Clinical experience, in combination with published reports, has indicated the importance of describing lower urinary tract symptoms in men. To avoid selection bias, it is necessary to base the information on well-described lower urinary tract symptoms in population-based studies. Unfortunately, population-based investigations of lower urinary tract symptoms in males are relatively scarce, especially among men younger than 50 years.5 The objectives of this study were to investigate the prevalence of three common urinary symptoms (urgency, stress incontinence and post-micturition dribbling) and health care-seeking behaviours in males aged 40–80 years in a defined population.
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Methods |
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Study population
The study was performed in the rural community of Surahammar with a total population of 11 200. All men aged 40–80 years (n = 2571) were eligible for the study. Each person was mailed a questionnaire. A postal reminder was sent twice, which helped yield a response rate of 86% (2217 completed questionnaires). A pilot study was performed prior to the main study in order to determine if the participants understood what they were being asked about. Fifteen randomly selected men from the same population as in the main study participated in the pilot study. No difficulties in understanding the questions were reported among these men. The study was approved by the ethics committee of Uppsala University.
Questionnaire
The questionnaire included items on present full- or part-time work (yes/no), physical exercise more than twice a week (yes/no), current smoking (yes/no) and previous consultations for voiding problems (yes/no). Three questions were raised concerning three urinary symptoms. The first question asked respondents if they experienced a sudden, violent need for urination, which they could not restrain from carrying out. The second question asked the respondents whether they had experienced involuntary urinary loss in association with, for example, sneezing, lifting or coughing. The third question asked the respondents whether they had experienced dribbling after they felt they had finished the act of voiding. Respondents who reported the presence of one or more of these three symptoms were classified as having urinary symptoms.
Statistics
Students t-test was used to compare mean age between men with and without urinary symptoms and between respondents and the total population. Differences between proportions of urinary symptoms were analysed with the chi-square test. A P-value of <0.05 was considered as significant.
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Results |
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Characteristics of the sample
The response rate was 86, 86, 89 and 85% in the age groups 40–49, 50–59, 60–69 and 70–80 years, respectively. There were no significant differences in mean age (±confidence interval) between respondents and the total population (56 ± 0.425) of men aged 40–80 years in Surahammar. The respondents who reported urinary symptoms were significantly older (P < 0.001) than those who did not report urinary symptoms: mean age 57.7 (±0.911) versus 55.9 (±0.515) years. Reported physical activity, smoking habits and the number of individuals engaged in full- or part-time work did not differ significantly between symptomatic and asymptomatic respondents.
Prevalence of urinary symptoms
At least one of the three symptoms was reported by 536 (24%) respondents. The distribution of each reported symptom in the cohort is shown in Table 1
. The prevalence rate increased significantly from 20% in the 40–49 year olds, to 28% in the 70–80 year olds (P < 0.01). Post-micturition dribbling was the most frequent urinary symptom, with 21% of the men reporting this condition. This symptom occurred at a fairly constant rate across the different age groups. Urgency was reported 15 times more often in the 70–80 age range (15%) than in the 40–49 range (1%). In the 536 men with urinary symptoms, 433 (81%) reported one symptom, 80 (15%) reported two symptoms and 23 (4%) reported all three symptoms. The mean age in men with one, two or three symptoms was 56, 61 and 67 years, respectively. The percentage of individuals who reported two or three symptoms was 1.6, 4, 7.6 and 9.5%, respectively, in the four age groups 40–49, 50–59, 60–69 and 70–80 years.
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Consultation for voiding difficulties
Only 96 (4%) respondents had sought health care for voiding difficulties in the 12 months prior to the start of the present study. About half of these (n = 49) reported urgency, stress incontinence or dribbling. The percentage of consultations among men with one, two or three symptoms was 6% (26/433), 19% (15/80) and 35% (8/23), respectively. Men of 60–80 years of age had sought the help of health care providers significantly (P < 0.001) more often than men of 40–59 years of age (16 and 6%, respectively).
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Discussion |
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The main finding in this population-based study was that one of four men aged 40–80 years reported at least one lower urinary tract symptom. This finding confirms earlier population-based reports regarding the prevalence of lower urinary tract symptoms in Swedish men.2,4 Higher prevalence rates have been reported in men of 40 years of age or more in Japan.7,8 Reported differences in symptom prevalence might reflect the willingness of people in certain countries to report urinary symptoms.7 There may be several possible explanations for the variation of the prevalence values from different reports, including the use of divergent methods, the characteristics of the respondents, people’s willingness to report symptoms, people’s perception of symptoms, selection bias in non-population-based cohorts and the definition of symptom. Most of the published reports on prevalence rates of lower urinary tract symptoms are based on men over 50 years of age, even though investigators have suggested the need to include men aged 40–49 years.5
In our study, 20% of the men in the 40–49 age range reported at least one urinary tract symptom. Highly comparable prevalence rates in this age group were found in England (18%)6 and the USA (16%).11 It was notable that both studies used exclusion criteria such as previous prostatic surgery, prostatic cancer and enterostomy. The use of such exclusion criteria may lead to under-reporting of the actual prevalence of lower urinary tract symptoms. On the other hand, over-reporting of the prevalence of lower urinary tract symptoms may occur when using selected populations.
Another explanation for the variation in prevalence rates is related to whether a categorization of the frequency and severity of symptoms was used in the studies and whether a cut-off level based on frequency/ severity was used to define a person as symptomatic or asymptomatic.
However, there currently is no standardized definition for such cut-off levels, and our choice to not use a cut-off level provides information about the actual overall prevalence of symptoms in the whole population and not only among the men who previously were in contact with health care sevices. The most prevalent symptom reported by respondents in the present study was post-micturition dribbling. In a community-based study on the prevalence of benign prostatic hypertrophy in men aged 40–79 years, Garraway et al. reported that 35% of the men experienced dribbling ‘a few times only’ and 10% ‘almost always’.3 Jolleys et al. noted post-micturition dribbling in 43% of community-dwelling men over 40 years old, and an even higher prevalence has been found by Koskimaki et al.6,10 In our study, increased prevalence as a function of age could be shown for both urgency and stress incontinence. Post-micturition dribbling, on the other hand, was independent of age. It is possible that elderly men cope with and under-report post-micturition dribbling in the belief that it is in accordance with the natural laws of ageing. Another reasonable explanation is that when urgency and stress incontinence increase, post-micturition dribbling becomes relegated to being a secondary problem.
The respondents may have misunderstood the question about urgency, and therefore their responses may include both urgency and urge incontinence. On the other hand, a pilot study was performed before the main study, in order to clarify whether the participants understood the questions. No difficulties in understanding the questions emerged. In a recent study among Swedish men aged between 55 and 65 years, Hassler et al. found that 2.6% of the men reported urgency when asked whether they experienced a strong need to urinate.4
The low rate of utilization of health services in men suffering from lower urinary tract symptoms is a well recognized phenomenon.2,11 This general finding was confirmed in this study, as indicated by the finding that only 4% of the respondents sought a consultation for their problem. The rate of health care seeking increases dramatically with age. Our results suggest that most men tolerate some changes in lower urinary tract functioning, as indicated by the evidence that only 6% of the respondents with at least one symptom reported that they had sought professional health care. This assumption receives support from Koskimaki et al. who found that 34% of 1710 males over 50 years of age were unaffected by lower urinary tract symptoms.10 Possible reasons for not seeking health care, e.g. embarrassment, have been discussed previously.2 Even when medical attention is offered, many men refuse such assistance.6 However, Lagace et al. found that 79% of their participants with self-reported urinary incontinence during the previous 12 months maintained that they ‘would’ or ‘might’ seek help if effective treatment were available.12
Public information about urological problems and available treatment for lower urinary tract symptoms in men is scant. Our questionnaire was designed to describe the prevalence of self-reported lower urinary tract symptoms, regardless of severity or frequency. The validity of the questionnaire could be challenged because it was not validated before it was used. Our results did not cover all urinary symptoms, and other urological symptoms may have occurred which were not asked for. Questions in this study were developed in collaboration with a urologist and were used frequently in clinical work by GPs. It is possible that our findings reflect the true prevalence of these symptoms in a community. Another concern is that the overall mean age (52 ± 9.6 years) of the non-responders was lower than that of the responders, which may have resulted in an overestimation of the prevalence in this group. However, the high response rate was representative of all 40- to 80-year-old men living in the community.
In conclusion, this population-based study from a Swedish community indicates that 24% of men of 40–80 years of age reported at least one of the symptoms; urgency, stress incontinence or post-micturition dribbling. The study confirms earlier findings of a low consultation frequency for men with urinary symptoms. In addition, the findings of this study are consistent with evidence suggesting that many men with urinary symptoms are not known to health care providers. Further investigations are underway to analyse background factors in health care seeking and to determine to what extent these lower urinary tract symptoms cause annoyance and reduced quality of life.
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Acknowledgments |
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This study was supported by a grant from the County Research of Västmanland.
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References |
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