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IC/PBS/BPS/HBS European Urology - Impact of LUTS Using Bother Index in DAN-PSS-1 Questionnaire
IC/PBS/BPS/HBS European Urology - Impact of LUTS Using Bother Index in DAN-PSS-1 Questionnaire
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| European Urology - Impact of LUTS Using Bother Index in DAN-PSS-1 Questionnaire |
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Volume 51, Issue 2, Pages 473-478 (February 2007) 1. Introduction A fundamental goal for developing scoring systems for lower urinary tract symptoms (LUTS) has been a need to quantify subjective symptoms of benign prostatic hyperplasia (BPH) and find objective support for the prostatic surgery decision-making. Boyarsky and coworkers [1] published the first symptom score system for urinary symptoms in 1977. Another early published tool for the assessment of LUTS was the Madsen-Iversen point system [2]. Later, in the advent of the medical treatment of BPH and increasing interest in treatment outcomes and epidemiology of LUTS, a need for validated instruments became even more important. In 1991 the World Health Organization (WHO) adopted the American Urologic Association's AUA-7 symptom score as an International Prostate Symptom Score (IPSS) after the addition of one global quality of life (QoL) question to the questionnaire [3]. The Danish Prostatic Symptom Score (DAN-PSS-1) was published by Hansen et al. [4] in 1991 and, at that time, contained a unique feature that not only occurrence but also bother of the symptom was judged at the same time by the subject. This evaluation of the symptom-specific bothersomeness became possible also with the IPSS after publication of the Symptom Problem Index (SPI) in 1995 by the AUA [5]. However, use of IPSS with the one original QoL question is still recommended [6]. Although correlation of symptom score with bother score has been found to be good in both scoring systems, the symptom and bother questions do not collect the same information, and the variability between the two scales has been high [5], [7], [8], [9]. These differences mean that both symptom and bother questions are needed in questionnaires intended for clinical use or for epidemiologic studies considering not only prevalence but also the impact of LUTS in a population. There is also a need for further study of the relationship between objective symptom and subjective bother in symptom-scoring systems. DAN-PSS-1 includes a wide range of symptoms and is suitable for both clinical and research use. Each symptom can be analyzed separately with or without a bother score, or combined into a LUTS score describing the overall impact of the symptoms. The original Danish version has been well validated and used in many epidemiologic surveys and clinical trials [7], [10], [11], [12], [13], [14]. In this analysis our aim was to quantify and evaluate the bothersomeness of urinary symptoms in relation to their severity using a bother index with a simple mathematical approach. 2. Methods and material A postal survey of voiding symptoms and sexual function of 2837 men aged 55 to 75 years was carried out. This study was a part of the Tampere Aging Male Urologic Study (TAMUS), details of which have been described elsewhere [12], [15]. The study cohort comprised all the men born in 1924, 1934, or 1944 who lived in the city of Tampere and 11 neighboring municipalities in Pirkanmaa County, Finland. The Finnish translation of the DAN-PSS-1 questionnaire was used in assessing LUTS in the study population. Questionnaires were mailed in May 1999, and an identical questionnaire was sent 3 months later as a reminder to the nonresponders. The number of responders was 2133 (75%). The age distribution of the men was 46%, 33%, and 21% for ages 55, 65, and 75 years, respectively. Twelve urinary symptoms including typical storage, voiding and postmicturition symptoms, incontinence, and dysuria were evaluated by the subjects. Each symptom was rated with A and B questions, the first one inquiring about frequency or severity and the second one about bother of the symptom. Each question had four response options graded from 0 to 3 with increasing frequency or severity (symptom score) and bother (bother score). In bother scores, zero was considered as no bother, and the other three grades as a perceived small, moderate, or severe problem, respectively. To estimate bother relative to symptom, a descriptive, figure, bother index was produced for each urinary symptom. The BI was calculated by dividing the number of men reporting a bother score higher than a symptom score by the number of men reporting a bother score lower than a symptom score. Each index was derived from a cross-table containing symptom scores in rows and bother scores in columns, and including all the men who responded to both A and B questions. In practice the number of scores above the diagonal cells of the table was divided by that under the diagonal. A low BI was considered to describe a symptom that was tolerable or innocuous, and high BI a symptom that was annoying at any symptom score level. The responses in which symptom and bother scores were equal provided no information for the BI; thus, it was insensitive to the prevalence of the symptom, but it detected the symptoms that were frequently considered strongly annoying (high BI) and also those with low bothersomeness (low BI), compared with the severity or frequency of the symptom. The study (# 99013) was approved by the Tampere University Hospital committee of research ethics. 3. Results Information on both a symptom and its bother was available for 1803 (64%) to 2046 (72%) men, depending on the symptom. The mean age of the study group was 62.5 years, 62.8 in responders and 61.8 in nonresponders. Prevalence of at least mild symptoms (symptom score ≥1) varied from 68% in urgency to 8% in stress incontinence and 8% in overflow or other incontinence (Table 1). Cumulative prevalence of bother was also highest in urgency (46%) and lowest in incontinence symptoms (7%) except urge incontinence (17%; Table 1).
The BI for all reported symptoms together was 0.27, that is, the frequency or severity of the urinary symptom was graded higher than its bother by four of five men in those who graded the symptom score differently from the bother score. The BI ranged from 0.06 in straining to 3.7 in overflow or other incontinence (Table 2). All types of incontinence and also weak stream had high BI scores. Straining, postmicturition dribble, and hesitancy were the most well-tolerated symptoms with a very low BI. The cumulative prevalence of a symptom was higher than that of bother in all individual symptoms (Table 1), and the relative risk (RR) showed much less variation (0.5–0.9) than the BI (0.06–3.70; Fig. 1).
;) Fig. 1. Relative prevalence (relative risk) as a function of the bother index (BI). TAMUS 1999. 4. Discussion The DAN-PPS-1 scoring system is based on the frequency or severity of urinary symptoms and on their influence on daily life: bother. These two components were presented separately and independently in the original paper of Meyhoff et al. [14] as was done in subsequent studies. Total score uses both symptom and bother scores simultaneously but without distinguishing their relative weight. The BI, as constructed in this study, weights the relative importance of bother to symptom simultaneously in the same individual. The BI describes the odds that a person reported a higher bother score than severity or frequency score in relation to the odds of having a bother score less than the symptom score. In fact, the BI equals odds ratio of matched observations. The higher the BI is, the more bothersome the symptom is considered relative to its severity. Because subjective bother and objective frequency (severity) cannot be directly compared, the BI as such has only a limited interpretation. This is true for any indicator comparing bother and symptom including the RR (ratio of prevalences); however, those cannot be used as traditional symptom scores describing the burden of the disease in population or individual patient. The major use of the BI is to compare different urinary symptoms or different populations evaluated with the same scoring system. In the DAN-PSS-1 questionnaire, a good correlation of symptom score with bother score overall, as well as in individual urinary symptoms, has been shown [7], [10]. The SPI utilizing the same urinary symptoms as IPSS was developed to circumvent the IPSS questionnaire's inability to measure the bothersomeness of an individual urinary symptom [5]. Correlation of IPSS with SPI scores is also well established, but its theoretical content is not well defined. These separate scoring systems use the same urinary symptoms, but they have different gradation and are not validated for simultaneous use. The BI cannot overcome any previous method of validating symptom scores, but it includes information not possible to achieve with traditional methods. In the present study we evaluated the perceived bothersomeness of the urinary symptoms included in the DAN-PSS-1 questionnaire in a population-based sample and compared it with the severity of the same symptom by means of the BI. The BI detected receptively the symptoms that were frequently considered strongly annoying (high BI) and also those with low bothersomeness (low BI) in comparison with the severity or frequency of the symptom. Therefore, the odds or the BI is a more informative indicator of bothersomeness than, for example, the prevalence of bother or the ratio of prevalence of bother to that of severity. In the study population, the cumulative prevalence of a symptom was higher than the corresponding prevalence of bother for all symptoms (RR<1), whereas the BI ranged from 0.06 to 3.7. There was a less than 100% and an inverse correlation between the prevalence of the symptom and its bothersomeness, indicating that the BI provides information on LUTS that cannot be described by prevalence or prevalence ratio only. The higher informativeness of the BI over the prevalences is demonstrated by comparing it with RR in Fig. 1. The prevalence of most urinary symptoms in our material was high and comparable with previous cross-sectional DAN-PSS-1 surveys [7], [11], [12]. The higher prevalence, compared with Kay et al. [11], may be due to the older population in our survey and the lower prevalence, compared with Engström et al. [7], is due to their different sampling of the study population. Voiding symptoms, straining, and hesitancy, as well as postmicturition symptoms, postmicturition dribble, and incomplete emptying, had a lower BI than the typical storage symptoms of urgency, nocturia, and daytime frequency. This finding is consistent with previous knowledge: Although voiding symptoms are most prevalent, urinary storage symptoms have been considered more bothersome and as strongly impairing QoL in a population [16]. All types of incontinence had a high BI, which also is easy to understand and strongly affects those with the symptom, but at the population level the overall burden of these symptoms is rather subtle because of their low prevalence. In previous IPSS studies, urgency has been one of the most bothersome symptoms but weak stream has been quite tolerable [8], [9]. Engström et al. [7] found weak stream overall to be rather well tolerated, but all men affected by “very weak” or “dribbling” urinary stream in their study reported major distress. They used the DAN-PSS questionnaire and, against this background, our high BI for weak stream is understandable. Obviously the DAN-PSS-1 questionnaire detects well diminished urinary stream from the population. From the clinical point of view, the bothersome nature of a strongly diminished urinary stream can be interpreted that it is a notable urinary symptom in BPH and that proper removal of the infravesical obstruction should be kept in mind to enhance the patient's QoL. In addition to long voiding time, interrupted stream, need for straining, or dribble, another reason for high bothersomeness of weak stream may be psychologic. Men may have learned to consider weak stream as an indication of an unknown, probably insidious disease like cancer [17]. Weak and diminishing urinary flow has also traditionally been connected with getting older and weaker, and losing one's masculine health. These perceptions may increase perceived symptom bothersomeness, especially in younger men. In addition to weak stream, the BI detected daytime frequency, another annoying symptom; it was considered more bothersome than nocturia and urgency. Nocturia is one off the most bothersome storage symptoms [18]. Its low bother score in the present study may be due to the fact that the DAN-PSS-1 combines one and two nightly voidings into the same, mildest score, and that 90% of the men with nocturia in our population fell into this category. Men with only one nocturia episode probable wake up for voiding during early morning hours and important hours of undisturbed sleep just after falling asleep stay unaffected. According to previous knowledge [7], [11] and also to clinical experience, urge incontinence is experienced as much more bothersome than urgency. This is consistent with our estimates of the BI. In developing the DAN-PSS-1 questionnaire, the motivation for the use of both a symptom score and a bother score was their different distributions [14]. To the best of our knowledge, nowhere has the symptom and the bother been considered simultaneously as a pair in analysis that did not simply combine symptom and bother into a total score. Our comparison of two approaches, RR and BI, demonstrates that they provide supportive and independent information for LUTS. The RR shows less variation than the BI, indicating that the distributions of symptom score and bother score do not fully disclose the role of bother. The RR gives only the overall impression that frequency of the symptom is more important to a man, whereas the BI demonstrates that there are many individual men in the total population who perceive the symptom more bothersome than implied by its frequency. Furthermore, the symptoms have an objective ranking of bothersomeness in the BI that goes above only simple prevalence. Editorial CommentIn BPH patients, generally the most frequently reported symptoms have been associated with voiding, for example weak urinary stream, incomplete emptying, hesitancy and intermittency. However, the most bothersome symptoms have been associated with the storage part such as nocturia, frequency and urgency. Studies of the quality of life in BPH have shown that the severity of the symptoms can have a significant impact on the physical and social functioning, well-being. As described by the international guidelines, therapy for BPH must be initiated according to the degree of bothersomeness. Therefore, appropriate scores quantifying the bothersomeness of LUTS are required to evaluate the need for the outcome of the treatment for BPH from the patient's perspective. I agree with the authors that the bothersomeness is very important as symptom score, especially in the decision making for treatment and/or surgery. As described in the present study, the bother index (BI) might be used as a more objective criterion not only to make such a decision in the management but also pursuing the results of the treatment modalities such as watchful waiting, medical or surgical treatments. There are several different indices in the description of bothersomeness in the literature. Eckhardt et al. [1] evaluated the bothersomness using the symptom problem index (SPI) using IPSS in the present study as bothering (B category) as described by the authors. In the same study, the authors also evaluated the BPH impact index to measure how much the urinary problems affect various domains of health. Similarly, SPI and its correaltion with IPSS has been evaluated by Perrin et al. [2]; the authors have concluded that the joint use of IPSS and SPI seems appropriate. With the results of the present study, the assessment using BI can be a combination of symptoms and bothersomeness. However, future well-organized community-based studies, which will compare the advantages of BI, SPI BII or other bother indices, should focus on the impact of LUTS on QoL among men living a different social life and with a different educational status. Support for this study was provided by the Medical Research Fund of the Tampere University Hospital. References 1. Boyarsky S, Jones G, Paulson DF, Prout GR. A new look at bladder neck obstruction by food administration regulators: guidelines for the investigation of benign prostatic hyperplasia. Trans Am Assoc Genitourin Surg. 1977;68:29–32. 2. Madsen PO, Iversen P. A point system for selecting operative candidates. In: Hinman F editors. Benign Prostatic Hypertrophy. New York: Springer; 1983;p. 763–765. 3. Mebust W, Roizo R, Schröder FH, Villiers A. Correlation between pathology, clinical symptoms and the course of the disease. In: Cockett ATK, Aso Y, Chatelain C, et al. editor. The International Consultation on Benign Prostatic Hyperplasia (BPH). SCI; 1991;p. 53–62. 4. Hald T, Nordling J, Andersen JT, Bilde T, Meyhoff HH, Walter SA. A patient weighted symptom score system in the evaluation of uncomplicated benign prostatic hyperplasia. Scand J Urol Nephrol. 1991;138:59–62. 5. Barry MJ, Fowler FJ, O’Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK. Measuring disease-specific health status in men with benign prostatic hyperplasia. Measurement Committee of The American Urological Association. Med Care. 1995;33:AS145–AS155. 6. Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJMCH. EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines). Eur Urol. 2004;46:547–554. 7. Engström G, Walker-Engström ML, Henningsohn L, Loof L, Leppert J. Prevalence of distress and symptom severity from the lower urinary tract in men: a population-based study with the DAN-PSS questionnaire. Fam Pract. 2004;21:617–622. 8. Eckhardt MD, van Venrooij GE, van Melick HH, Boon TA. Prevalence and bothersomeness of lower urinary tract symptoms in benign prostatic hyperplasia and their impact on well-being. J Urol. 2001;166:563–568. 9. Perrin P, Marionneau N, Cucherat M, Taieb C. Relationship between lower urinary tract symptoms frequency assessed by the IPSS and bothersomeness (SPI) among men older than 50 years old. Eur Urol. 2005;48:601–607. 10. Hansen BJ, Flyger H, Brasso K, et al.. Validation of the self-administered Danish Prostatic Symptom Score (DAN-PSS-1) system for use in benign prostatic hyperplasia. Br J Urol. 1995;76:451–458. 11. Kay L, Stigsby B, Brasso K, Mortensen SO, Munkgaard S. Lower urinary tract symptoms. A population survey using the Danish Prostatic Symptom Score (DAN-PSS) questionnaire. Scand J Urol Nephrol. 1999;33:94–99. 12. Koskimäki J, Hakama M, Huhtala H, Tammela TLJ. Prevalence of lower urinary tract symptoms in Finnish men: a population-based study. Br J Urol. 1998;81:364–369. 13. Hansen BJ, Flyger H, Mortensen SO, Mensink HJA, Meyhoff H-H. Symptomatic outcome of transurethral prostatectomy, alpha-blockade and placebo in the treatment of benign prostatic hyperplasia. Scand J Urol Nephrol. 1995;30:103–107. 14. Meyhoff HH, Hald T, Nordling J, Andersen JT, Bilde T, Walter S. A new patient weighted symptom score system (DAN-PSS-1). Clinical assessment of indications and outcomes of transurethral prostatectomy for uncomplicated benign prostatic hyperplasia. Scand J Urol Nephrol. 1993;27:493–499. 15. Shiri R, Koskimäki J, Hakama M, et al.. Prevalence and severity of erectile dysfunction in 50 to 75-year-old Finnish men. J Urol. 2003;170:2342–2344. 16. Peters TJ, Donovan JL, Kay HE. The International Continence Society ‘BPH’ study: the bothersomeness of urinary symptoms. J Urol. 1997;157:885–889. 17. Brown CT, O’Flynn E, Van Der Meulen J, Newman S, Mundy AR, Emberton M. The fear of prostate cancer in men with lower urinary tract symptoms: should symptomatic men be screened?. BJU Int. 2003;91:30–32. 18. Asplund R. Nocturia: consequences for sleep and daytime activities and associated risks. Eur Urol Suppl. 2005;3(6):24–32.
Jukka T. Häkkinen, Matti Hakama, Heini Huhtala, Rahman Shiri, Anssi Auvinen, Teuvo L.J. Tammela, Juha Koskimäki
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