What Is the Most Bothersome Lower Urinary Tract Symptom? Individual- and Population-level Perspectives for Both Men and Women

Background

No study has compared the bothersomeness of all lower urinary tract symptoms (LUTS) using a population-based sample of adults. Despite this lack of evidence, investigators have often cited their LUTS of interest as the “most bothersome” or “one of the most bothersome.”

Objective

To compare the population- and individual-level burden of LUTS in men and women.

Design, setting, and participants

In this population-based cross-sectional study, questionnaires were mailed to 6000 individuals (18–79 yr of age) randomly identified from the Finnish Population Register.

Outcome measurements and statistical analysis

The validated Danish Prostatic Symptom Score questionnaire was used for assessment of bother of 12 different LUTS. The age-standardized prevalence of at least moderate bother was calculated for each symptom (population-level burden). Among symptomatic individuals, the proportion of affected individuals with at least moderate bother was calculated for each symptom (individual-level bother).

Results and limitations

A total of 3727 individuals (62.4%) participated (53.7% female). The LUTS with the greatest population-level burden were urgency (7.9% with at least moderate bother), stress urinary incontinence (SUI) (6.5%), nocturia (6.0%), postmicturition dribble (5.8%), and urgency urinary incontinence (UUI) (5.0%). Burden from incontinence symptoms was higher in women than men, and the opposite was true for voiding and postmicturition symptoms. At the individual level, UUI was the most bothersome for both genders. Although the response proportion was high, approximately a third did not participate.

Conclusions

Both men and women with UUI report moderate or major bother more frequently than individuals with other LUTS. At the population level, the most prevalent bothersome symptoms are urgency, SUI, and nocturia.

Patient summary

Urinary urgency was the most common troubling symptom in a large population-based study; however, for individuals, urgency incontinence was the most likely to be rated as bothersome.     

A Population-based survey of lower urinary tract symptoms (LUTS) and symptom-specific bother: results from the Brazilian LUTS epidemiology study (BLUES)

Purpose

To examine the prevalence of lower urinary tract symptoms (LUTS) and the bother they impose in a population-based sample of adults in Brazil.

Methods

A cross-sectional population-based survey was conducted between September 2006 and January 2007 in the city of Salvador, Brazil. Cluster samples of representative households were randomly selected for interviews. A structured questionnaire was administered to men and women aged 30 years or older by trained interviewers. Participants were asked about the presence of individual LUTS using current International Continence Society (ICS) definitions and rated their symptom bother. Those with overactive bladder (OAB) also responded the OAB-Validated 8 and the Patient Perception of Bladder Condition questionnaires.

Results

Of 3,616 eligible subjects, 3,000 (83 %) participated (1,500 men and 1,500 women). OAB was present in 5.1 % of men and in 10 % of the women, while the prevalence of any LUTS was 81.5 and 84.1 %, respectively. The majority of subjects with OAB, 80 % of men and 78 % of women, reported some bother associated with their urgency symptoms. Overall, storage symptoms were more common than voiding or postmicturition symptoms. Women reported storage symptoms (76.4 %) more frequently than men (67.7 %), while the opposite was true for voiding (men 39.7 %, women 33.7 %) and postmicturition (men 30.9 %, women 12.8 %).

Conclusions

This is the largest population-based survey of LUTS in Brazil, using the 2002 ICS definitions. LUTS prevalence was high and increased with age among both genders in Brazil, whereas the rates of OAB were somewhat lower than previously reported. The high prevalence of urinary symptoms and the bother commonly associated with them highlight their importance to overall well-being.     

Understanding the elements of overactive bladder: questions raised by the EPIC study

OBJECTIVES

To compare the prevalence of frequency and nocturia and the bother they impose in a population‐based sample of men and women using current International Continence Society (ICS) definitions of lower urinary tract symptoms (LUTS) and commonly used alternative definitions of these LUTS to emphasize the importance of standardizing the definitions when evaluating overactive bladder (OAB) syndrome; we also describe the spectrum of LUTS and bother they impose in this population with OAB.

SUBJECTS AND METHODS

Several validated disease‐specific measures were used in a population‐based, cross‐sectional telephone survey of adults aged ≥18 years in five countries. The population with OAB was defined as those participants who answered ‘yes’ to questions about urgency or urgency urinary incontinence according to ICS standards. The prevalence of daytime frequency and nocturia within the OAB population was examined using two different criteria for each symptom. Frequency was defined using the current ICS definition (i.e. subject’s perception of whether they urinated too often during the day) or more than eight daytime voids. Nocturia was defined according to the ICS definition of having to wake once or more per night to void and using the threshold of waking twice or more per night to urinate. Urinary symptom bother within the OAB population was compared using the different criteria for frequency and nocturia.

RESULTS

In all, 1434 participants (502 men and 932 women) were classified as having OAB; 31% of men and 25% of women with OAB had daytime frequency consistent with the ICS definition. The ICS‐defined frequency identified a population with a varied distribution of reported daytime voiding frequencies; most respondents reported frequencies below the threshold of nine daytime voids. The ICS‐defined daytime frequency was reported as bothersome by more than half of the OAB population (46% of men, 66% of women). Of the OAB population, ≈75% reported one or more nocturia episodes per night, and ≈40% reported two or more per night. The proportion of the OAB population that was bothered by nocturia increased markedly as the number of nocturia episodes increased. Among those with OAB, the most prevalent combination of OAB symptoms was urgency and nocturia. More than half of those with OAB reported urgency combined with three or more other LUTS (including voiding and postmicturition symptoms), and the number of LUTS reported increased with age. The proportion of the population reporting symptom bother increased as the number of reported LUTS in that population increased.

CONCLUSIONS

The ICS definitions for daytime frequency as ‘the subject’s perception of urinating too often’ and for nocturia as ‘one or more episodes per night’ adequately described bladder symptoms within the OAB population when assessed by the level of symptom bother. Urgency was uncommon in isolation and did not alone impose as high a level of bother as when combined with other LUTS. In this population, the most predominant manifestation of OAB was a combination of urgency with one or more other OAB symptoms. Symptom bother became more common as the number of symptoms reported increased. LUTS other than the defining symptoms of OAB were also highly prevalent within the OAB population.     

Gender and Age Differences in the Perception of Bother and Health Care Seeking for Lower Urinary Tract Symptoms: Results from the Hospitalised and Outpatients’ Profile and Expectations Study

Background

Few comparisons have been made of health care seeking behaviour for lower urinary tract symptoms (LUTS) between men and women, as well as trends across age groups.

Objective

To investigate the bother from LUTS and effect on health care seeking in both men and women of different age groups and in comparison between the two genders.

Design, setting, and participants

A representative cross section of each of 13 clinics of a general academic hospital, with equal numbers of subjects recruited in each of six design cells that were defined by age (18–40, 41–60, 61–80 yr) and gender.

Intervention

A 2-h in-person interview, conducted by a trained psychologist/interviewer in a clinic office.

Measurements

Severity of LUTS was measured by the International Prostate Symptom Score (IPSS). Treatment seeking was measured by a single item. A bother question was modified to assess overall bother. Impact on quality of life (QoL) was measured by the IPSS QoL question.

Results and limitations

The final study sample comprised 415 patients. More women than men reported the presence of LUTS (85.5% vs 75.2%; p = 0.01). LUTS were more bothersome in women (25.4% of women vs 17.6% of men with bother “some” or “a lot”; p = 0.02). Severity of LUTS increased with age in both genders (men: p < 0.001; women: p = 0.03). Bother from LUTS increased as severity of symptoms increased in both genders (p < 0.001) but was associated with age only in men (p < 0.001). QoL showed similar results as bother. Although men and women had equal prevalence of treatment seeking (27.9% vs 23.7%; p = 0.40), men, but not women, were more likely to seek treatment as age (p < 0.01) and severity of LUTS (p < 0.001) increased. In multivariate logistic regressions, only bother from LUTS was associated with treatment seeking in women, compared with bother, age, and the presence of voiding symptoms in men.

Conclusions

In our hospital-based sample, differences in LUTS frequency, bother, and health care seeking profiles between men and women suggest a different perception and response to LUTS between the two genders.     

The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study

OBJECTIVES

To examine the effect overactive bladder (OAB) and other lower urinary tract symptoms (LUTS) on health‐related quality of life (HRQoL) in a population sample, as OAB often occurs in conjunction with many other LUTS.

SUBJECTS AND METHODS

A nested case‐control analysis was performed on men and women with (cases) and without (controls) OAB, from the EPIC study. OAB was assessed using 2002 International Continence Society definitions. Based on their responses to questions about LUTS, cases were classified into five groups; continent OAB, OAB with incontinence, OAB + postmicturition, OAB + voiding, and OAB + postmicturition + voiding. Both cases and controls were asked questions about symptom bother (OAB‐q), generic QoL (EQ‐5D), work productivity (Work Productivity and Activity Impairment, WPAI), depressive symptoms (Center for Epidemiologic Studies Depression Scale), sexual satisfaction, and erectile dysfunction (men only) using the Massachusetts Male Aging Study. Cases answered additional condition‐specific questions HRQoL (OAB‐q short form), Patient Perception of Bladder Condition and work productivity related to a specific health problem (WPAI‐SHP). General linear models were used to evaluate group differences.

RESULTS

Of the EPIC participants, 1434 identified OAB cases were matched by age, gender and country, with 1434 participants designated as controls. Cases and controls were primarily Caucasian (96.2% and 96.7%, respectively), and most (65%) were female; the mean age was 53.8 and 53.7 years, respectively. Comorbid conditions differed significantly by case/control status, with cases reporting significantly greater rates of chronic constipation, asthma, diabetes, high blood pressure, bladder or prostate cancer, neurological conditions and depression. There were significant differences between the cases and controls in all reported LUTS. The OAB + postmicturition + voiding group reported significantly greater symptom bother, worse HRQoL, higher rates of depression and decreased enjoyment of sexual activity, than the other subgroups.

CONCLUSION

OAB has a substantial, multidimensional impact on patients; OAB with additional LUTS has a greater impact. The diagnosis and treatment of OAB should be considered in conjunction with other LUTS, to maximize treatment options and optimize patient outcomes.     

The prevalence of clinically meaningful overactive bladder: bother and quality of life results from the population-based FINNO study

Background

Wide variation exists in prevalence estimates of overactive bladder (OAB) syndrome.

Objective

To determine how the frequency of urinary urgency or urgency urinary incontinence (UUI)—the cornerstone symptoms of OAB—affects symptom-related bother, health-related quality of life (HRQL), and ultimately clinically meaningful prevalence.

Design, setting, and participants

Questionnaires were mailed to 6000 subjects (18–79 yr of age) randomly identified from the Finnish Population Register in 2003–2004.

Measurements

The frequency (scale: never, rarely, often, always) and bother (scale: none, small, moderate, major) of urgency and UUI were assessed using the Danish Prostatic Symptom Score (DAN-PSS). HRQL was measured with the generic 15D instrument. For HRQL analyses, respondents were classified according to six symptom categories by frequency of urgency and UUI.

Results and limitations

Of those subjects queried, 62.4% responded to the survey (53.7% female). Any urgency was reported by more than half of all respondents (54.2% [95% confidence interval (CI), 51.6–56.7] of men; 56.9% [95% CI, 52.9–61.0] of women), whereas any UUI was reported by one in nine men (10.7% [95% CI, 8.9–12.4]) and one in four women (25.7% [95% CI, 22.8–28.7]). However, only one in seven of all respondents with urgency and less than one in three with UUI reported at least moderate bother. With increasing OAB severity, statistically significant decreases were found in the total 15D score and on all 15D dimensions (p < 0.001 for all). Reporting often urgency without UUI or rare urgency with rare UUI is associated with a clinically important decrease in HRQL. Although the response proportion was high, approximately one-third of those contacted did not participate.

Conclusions

Increased severity of urgency and UUI is associated with a statistically significant and clinically important decrease in HRQL. Assessing bother associated with OAB drastically modifies the measured OAB prevalence and accounts for variation among studies.     

Efficacy and Safety of Solifenacin Plus Tamsulosin OCAS in Men with Voiding and Storage Lower Urinary Tract Symptoms: Results from a Phase 2, Dose-finding Study (SATURN)

Background

Storage symptoms are often undertreated in men with lower urinary tract symptoms (LUTS).

Objective

To evaluate the combination of an antimuscarinic (solifenacin) with an α-blocker (tamsulosin) versus tamsulosin alone in the treatment of men with LUTS.

Design, setting, and participants

A double-blind, 12-wk, phase 2 study in 937 men with LUTS (≥3 mo, total International Prostate Symptom Score [IPSS] ≥13, and maximum urinary flow rate 4.0–15.0 ml/s).

Intervention

Eight treatment groups: tamsulosin oral controlled absorption system (OCAS) 0.4 mg; solifenacin 3, 6, or 9 mg; solifenacin 3, 6 or 9 mg plus tamsulosin OCAS 0.4 mg; or placebo.

Outcome measurements and statistical analysis

The primary efficacy end point was change from baseline in total IPSS. Secondary end points included micturition diary and quality-of-life (QoL) parameters. Post hoc subgroup analyses were performed by severity of baseline storage symptoms, with statistical comparisons presented only for tamsulosin OCAS alone versus combination therapy, due to the small sample size of the solifenacin monotherapy and placebo subgroups.

Results and limitations

Combination therapy was associated with significant improvements in micturition frequency and voided volume versus tamsulosin OCAS alone in the total study population; improvements in total IPSS were not significant. Statistically significant improvements in urgency episodes, micturition frequency, total urgency score, voided volume, IPSS storage subscore, IPSS-QoL index, and Patient Perception of Bladder Condition were observed in a subpopulation of men with two or more urgency episodes per 24 h (Patient Perception of Intensity of Urgency Scale grade 3 or 4) and eight or more micturitions per 24 h at baseline (storage symptoms subgroup) with combination therapy versus tamsulosin OCAS alone (p ≤ 0.05 for the dose–response slope, all variables). Combination therapy was well tolerated, and adverse events were consistent with the safety profiles of both compounds.

Conclusions

Solifenacin plus tamsulosin OCAS did not significantly improve IPSS in the total study population but offered significant efficacy and QoL benefits over tamsulosin OCAS monotherapy in men with both voiding and storage symptoms at baseline. Combination therapy was well tolerated.

ClinicalTrials.gov identifier

NCT00510406     

Urinary Incontinence,Overactive Bladder,and Other Lower Urinary Tract Symptoms: A Longitudinal Population-Based Survey in Men Aged 45–103 Years

Background

Lower urinary tract symptoms (LUTS) such as urinary incontinence (UI) and overactive bladder (OAB) are highly prevalent conditions, but there are few studies describing progression and remission of LUTS in men, especially over the long term.

Objective

To describe the prevalence of UI, OAB, and LUTS using current International Continence Society definitions in the same men studied longitudinally over time.

Design

Prospective, population-based, longitudinal study.

Setting and participants

In 1992, 10 458 men aged 45–99 yr, resident in the city of Gothenburg, were selected at random from the Population Register.

Measurements

The men received a postal questionnaire about the presence of LUTS, as well as questions on social, medical, health-related quality of life (HRQoL), and demographic data. Responders in 1992 were reassessed 11 yr later in 2003 using a similar questionnaire.

Results and limitations

In 2003, 4072 of the 7763 men who responded in 1992 were still available in the Population Register and 3257 men (80%) aged 56–103 yr, responded. Prevalence of UI and OAB had increased (p < 0.01) in the same men assessed in 1992 (4.5% and 15.6%, respectively) and 2003 (10.5% and 44.4%, respectively). The prevalence of nocturia, urgency, slow stream, hesitancy, incomplete emptying, postmicturition dribble, and the number of daytime micturitions had also increased (p < 0.01). Only a minority reported regression of symptoms. Men with UI or OAB reported a poorer (p < 0.001) HRQoL compared with men without UI or OAB.

Conclusions

There was a marked increase in the prevalence of UI, OAB, and other LUTS in the same men assessed longitudinally over this 11-yr period. UI and OAB had a negative influence on HRQoL, and men who developed UI or OAB had a greater deterioration in HRQoL than men who had no change in their UI/OAB status over time.     

Prevalence of overactive bladder, urinary incontinence, and lower urinary tract symptoms: results of Korean EPIC study

Objective

Despite growing interest in overactive bladder (OAB), urinary incontinence (UI), and lower urinary tract symptoms (LUTS), there is no epidemiologic study on the prevalence in general population of Korea. This survey was aimed at estimating the prevalence of OAB, UI, and other LUTS among Korean men and women.

Methods

Population-based cross-sectional telephone survey was conducted between May and September 2006 using questionnaire regarding demographics and the prevalence. A geographically stratified random sample of men and women aged????18?years were selected. Current International Continence Society definitions were used for individual LUTS and OAB.

Results

Of a total of 9,067 individuals contacted, 2,000 (888 men, 1,112 women) agreed to participate. Overall prevalence of LUTS was 61.4% (53.7% of men, 68.9% of women) and the prevalence increased with age. Storage LUTS was more prevalent than voiding or post-micturition LUTS in both men (storage; 44.6%, voiding; 28.5%, post-micturition; 15.9%) and women (storage; 64.4%, voiding; 25.9%, post-micturition; 13.9%). Nocturia was the most frequently reported symptom (36.6% of men, 48.2% of women). Overall prevalence of OAB was 12.2% (10.0% of men, 14.3% of women). UI was reported by 2.9% of men and 28.4% of women. The most prevalent type was other UI in men and stress urinary incontinence in women.

Conclusions

Lower urinary tract symptoms and OAB are prevalent among Korean men and women and the prevalence increases with age. Storage LUTS is more prevalent than voiding or post-micturition LUTS and nocturia is the most common symptom.     

Extended-release tolterodine with or without tamsulosin in men with lower urinary tract symptoms and overactive bladder: effects on urinary symptoms assessed by the International Prostate Symptom Score

OBJECTIVE

To evaluate the efficacy of tolterodine extended‐release (ER) plus tamsulosin on lower urinary tract symptoms (LUTS) as assessed by changes in the International Prostate Symptom Score (IPSS) in men who met symptom entry criteria for both overactive bladder (OAB) and benign prostatic hyperplasia (BPH) trials.

PATIENTS AND METHODS

Men aged ≥40 years with an IPSS of ≥12 and diary‐documented OAB symptoms (≥8 voids/24 h and ≥3 urgency episodes/24 h, with or without urgency urinary incontinence) who reported at least moderate problems related to their bladder condition were randomized to receive placebo, tolterodine ER (4 mg), tamsulosin (0.4 mg), or tolterodine ER (4 mg) + tamsulosin (0.4 mg) once daily for 12 weeks. Patients completed the IPSS at baseline and at 1, 6 and 12 weeks.

RESULTS

Patients receiving tolterodine ER + tamsulosin had significantly greater improvements than those taking placebo on IPSS storage subscale scores and scores for all three individual storage items included on the IPSS (urinary frequency, urgency, and nocturnal micturitions) by 12 weeks. Storage subscale and urgency scores were significantly improved vs placebo at 1 and 6 weeks, whereas frequency scores were significantly improved at 6 weeks. Changes in IPSS storage subscale and individual storage item scores in the tolterodine ER and tamsulosin monotherapy groups were not significantly different from placebo at most time points. IPSS voiding subscale scores and scores for three of four individual voiding items (sensation of incomplete emptying, intermittency, and weak stream) were significantly improved by 12 weeks for patients receiving tamsulosin monotherapy vs placebo. Voiding subscale and intermittency scores were significantly improved vs placebo at 1 week; weak stream scores were significantly improved at 1 and 6 weeks. The IPSS voiding subscale and individual voiding item scores in the tolterodine ER + tamsulosin and tolterodine ER groups were not significantly different from placebo at most time points.

CONCLUSIONS

In this distinct clinical research population of men who met traditional symptom entry criteria for both OAB and BPH trials, tolterodine ER + tamsulosin was significantly more effective than placebo in treating storage LUTS, including OAB symptoms. Tamsulosin monotherapy produced significant improvements in voiding LUTS.     

The impact of overactive bladder on mental health, work productivity and health-related quality of life in the UK and Sweden: results from EpiLUTS

Study Type – Symptom prevalence (prospective cohort) Level of Evidence 1b

OBJECTIVE

? To examine the prevalence and burden of overactive bladder (OAB) with bother in the UK and Sweden compared to OAB without bother and no/minimal OAB/lower urinary tract (LUTS) symptoms, respectively.

PATIENTS AND METHODS

? A cross‐sectional population‐representative survey was conducted via the Internet in the UK, Sweden and USA. ? Participants rated the frequency and bother of OAB and LUTS. Patient outcomes included the Overactive Bladder Questionnaire Short Form, Patient Perception of Bladder Condition, Short Form‐12, Hospital Anxiety and Depression Scale–Anxiety and Hospital Anxiety and Depression Scale–Depression, as well as questions about treatment seeking and work productivity. ? OAB was defined as urgency at least sometimes or the presence of urinary urgency incontinence. Three subgroups were compared: no/minimal symptoms, OAB without bother and OAB with bother. ? Analyses were conducted by gender and country using general linear and logistic regression models to examine bothersome OAB and treatment seeking.

RESULTS

? Survey response was 59.2%; 10 000 people (4724 men and 5276 women) participated. ? The prevalence of OAB with bother at least ‘somewhat’ was 10.9% and 14.6% for men in the UK and Sweden, and 22.5% and 33.7% for women in the UK and Sweden, respectively. ? Men and women with bothersome OAB were significantly more likely to seek treatment, report the lowest levels of health‐related quality of life and work productivity and the highest levels of anxiety and depression compared to those with no/minimal symptoms and OAB without bother. ? Greater symptom severity of urgency, urgency urinary incontinence, frequency, nocturia, and increasing levels of anxiety were strongly predictive of OAB bother in both men and women. ? Predictors of treatment seeking included frequency, bother as a result of urgency, and lower levels of depressive symptoms in men, and frequency, nocturia and urgency in women.

CONCLUSIONS

? OAB is common in the UK and Sweden, and women are more likely to be affected then men. ? The impact of OAB is evident across generic and condition‐specific domains of health‐related quality of life.     

Dietary macronutrients, cholesterol, and sodium and lower urinary tract symptoms in men

Background

Little is known about dietary correlates of lower urinary tract symptoms (LUTS).

Objective

To examine associations between dietary intakes of total energy, carbohydrates, protein, fats, cholesterol, and sodium and LUTS in men.

Design, setting, and participants

Cross-sectional study of 1545 men aged 30–79 yr in the Boston Area Community Health survey (2002–2005), a random population-based sample. Dietary data were assessed by validated self-administered food frequency questionnaire. LUTS and covariate data were collected during in-person interviews. Primary analyses used multivariate logistic regression.

Measurements

Outcomes were moderate to severe LUTS, storage symptoms, and voiding symptoms as measured by the American Urological Association Symptom Index.

Results and limitations

Greater total energy intake was associated with higher LUTS symptom score (p_trend < 0.01) and increased likelihood of storage symptoms. No associations were observed with total, saturated, or monounsaturated fat intake or carbohydrates. Men who consumed more protein were less likely to report LUTS, particularly voiding symptoms (quintile 5 vs quintile 1 OR = 0.35; 95% CI, 0.17–0.74; p = 0.006). Sodium intake had positive linear associations with LUTS (p_trend = 0.01) and storage symptom score (p_trend = 0.004); this finding should be confirmed by studies using biomarkers of sodium exposure. Storage symptoms increased slightly with greater polyunsaturated fat intake (p_trend = 0.006). Data on specific polyunsaturated fats were unavailable.

Conclusions

This community-based study of men found that total energy and sodium intake were positively associated with LUTS, whereas greater protein intake was inversely associated with LUTS.     

Tolterodine Treatment Improves Storage Symptoms Suggestive of Overactive Bladder in Men Treated With α-Blockers

Background

Some men receiving α-blocker therapy for lower urinary tract symptoms report persistent storage symptoms suggestive of overactive bladder (OAB).

Objective

To evaluate the efficacy of tolterodine extended release (ER) in men on α-blocker therapy.

Design, setting, and participants

This double-blind trial included men aged ≥40 yr with frequency, urgency, and at least moderate problems reported on the Patient Perception of Bladder Condition (PPBC), despite being on a stable dose of α-blocker for ≥1 mo.

Interventions

Subjects were randomized to tolterodine ER 4 mg per day or placebo for 12 wk while continuing their prescribed α-blocker therapy.

Measurements

At baseline and week 12, subjects completed the PPBC, International Prostate Symptom Score (IPSS), Overactive Bladder Questionnaire (OAB-q), and 5-d bladder diaries using the five-point Urinary Sensation Scale (USS). Frequency–urgency sum was defined as the sum of USS ratings for all micturitions.

Results and limitations

PPBC improvement from baseline to week 12 was reported by 63.6% and 61.6% of subjects receiving tolterodine ER plus α-blocker and placebo plus α-blocker, respectively; this treatment difference, which was the primary end point, was not statistically significant (p > 0.6699). At week 12, subjects receiving tolterodine ER plus α-blocker had significantly greater improvements versus placebo plus α-blocker in 24-h micturitions (−1.8 vs −1.2; p = 0.0079) and daytime micturitions (−1.3 vs −0.8; p = 0.0123); 24-h urgency episodes (−2.9 vs −1.8; p = 0.0010), daytime urgency episodes (−2.2 vs −1.4; p = 0.0017), and nocturnal urgency episodes (−0.5 vs −0.3; p = 0.0378); frequency–urgency sum (−7.8 vs −5.1; p = 0.0065); IPSS storage subscale (−2.6 vs −2.1; p = 0.0370); and OAB-q symptom bother scale (−17.9 vs −14.4; p = 0.0086) and coping domain (15.4 vs 12.4; p = 0.0491). Acute urinary retention requiring catheterization occurred in <1% of either group. There were no clinically meaningful changes in postvoid residual volume or maximum urinary flow rate.

Conclusions

Men with bothersome OAB symptoms despite continued α-blocker therapy showed significantly greater improvements in diary variables, IPSS Storage scores, and symptom bother when receiving additional tolterodine ER versus placebo plus α-blocker.     

International prostate symptom score for assessing lower urinary tract dysfunction in women

Introduction and hypothesis

Some lower urinary tract dysfunction (LUTD) subtypes may have similar symptoms. This study aimed to investigate the feasibility of using the International Prostate Symptom Score (IPSS) to evaluate lower urinary tract symptoms (LUTS) in women.

Methods

All consecutive women with non-stress urinary incontinence LUTS who visited the urologic clinics for treatment were prospectively enrolled. LUTS include urinary storage, voiding, and post-micturition symptoms. All enrolled patients were requested to complete the Overactive Bladder Symptom Score (OABSS) and the modified Indevus Urgency Severity Scale (IUSS) questionnaires as well undergo uroflowmetry and post-void residual testing. A videourodynamic study was also performed, if indicated, for LUTD.

Results

A total of 222 women were enrolled, including 60 with overactive bladder (OAB) dry, 42 with OAB wet, 78 with bladder oversensitivity, and 42 with voiding dysfunction. A significantly higher IPSS voiding to storage subscore ratio (IPSS-V/S) and IPSS voiding score were found in the voiding dysfunction group. IPSS-V/S was found to have the highest area under the receiver-operating characteristic curve for predicting voiding LUTD than other noninvasive methods, and an IPSS-V/S of ≥1.33 had the best predictive value for female voiding LUTD with a high negative predictive value (97.4 %). In addition, significantly higher IPSS storage subscore (IPSS-S) values were found in the OAB wet subgroup, and the IPSS-S was well correlated with the OABSS and IUSS.

Conclusions

The IPSS can be used to evaluate female LUTD. IPSS-V/S may provide an initial guide for the treatment of voiding dysfunction in women. In addition, IPSS-S may be used for evaluating storage LUTD in women.

     

Lower urinary tract symptoms revisited: a broader clinical perspective

Context

The term “lower urinary tract symptoms” (LUTS) was introduced to dissociate male urinary symptoms from any implied site of symptom origin, such as the prostate.

Objective

To consider a more expansive view of LUTS, moving beyond an organocentric focus.

Evidence acquisition

Review of the available literature by a consensus panel.

Evidence synthesis

A consensus group reviewed the literature and developed a conceptual framework to facilitate research and clinical practice in patients with LUTS, following steps outlined in the Delphi procedure. Committee discussion, with presentations and review of existing literature and knowledge at four separate occasions, and extensive review and discussion of draft documents encapsulating group views followed. Consensus group findings included evidence that LUTS increase with age and are prevalent in both male and female patients, with differences in the prevalence of individual storage, voiding, and postmicturition symptoms representing underlying pathophysiologic factors between the sexes. Additionally, it was recognised that patients often have underlying and overlapping pathophysiologic mechanisms that may be related to the expression of LUTS and that this global approach to LUTS reflects our contemporary recognition of the lower urinary tract as an integrated functional unit. To improve the current management of patients, education and awareness regarding LUTS, its causes, and associated comorbidities are needed. Major limitations of this work are the potential interpretive bias introduced by prior perceptions and the nature of the study populations drawn conventionally from secondary care.

Conclusions

In conclusion, it is misleading to attribute individual symptoms to sex differences or to a specific underlying organ. LUTS are a non–sex-specific, non–organ-specific group of symptoms, which are sometimes age-related and progressive. A need exists to increase education and awareness regarding LUTS, its causes, and associated comorbidities, and to assess and treat men and women for all LUTS, not just selected symptoms.     

The prevalence of lower urinary tract symptoms (LUTS) in Brazil: Results from the epidemiology of LUTS (Brazil LUTS) study

Aims

We performed the first large population‐based study to evaluate lower urinary tract symptoms (LUTS) in Brazil. The study objective was to assess the prevalence and bother of LUTS in the population aged ≥40 years in five major cities of Brazil.

Methods

This study was conducted as a telephone survey with assessment of LUTS using a standardized protocol, which included the International Prostate Symptom Score (IPSS) and, for overactive bladder (OAB), the OAB‐V8 questionnaire. Participants were asked to rate how often they experienced individual LUTS and the degree of associated bother.

Results

Of the 5184 participants, 53% were women, and the age group with most participants (34%) was 50‐59 years. The prevalence of LUTS (symptoms occurring less than half the time or more) was 75%: 69% in men and 82% in women. There was a statistically significant association between the frequency and bother intensity of each symptom (P < 0.001). The prevalence of OAB was similar in men and women (25% and 24%, respectively). According to the IPSS questionnaire, moderate‐to‐severe symptoms were present in 21% of men and 24% of women. LUTS detrimentally affected quality of life in many individuals: 39% would be “mostly dissatisfied,” “unhappy,” or consider it “terrible” to spend the rest of their life with their urinary condition as it is currently.

Conclusions

This was the first nationwide, population‐based epidemiological study of LUTS to be performed in Brazil. LUTS are highly prevalent and often bothersome among men and women aged ≥40 years.     

A Cross-Sectional,Population-Based,Multinational Study of the Prevalence of Overactive Bladder and Lower Urinary Tract Symptoms: Results from the EPIC Study

The EPIC study was the first large-scale, multinational, population-based, cross-sectional survey to estimate the prevalence of lower urinary tract symptoms (LUTS) using current (2002) International Continence Society (ICS) definitions, with a focus on LUTS subtypes, overactive bladder (OAB), and urinary incontinence (UI). This study was conducted between April and December 2005 using randomly selected men and women ≥18 yr of age living in Canada, Germany, Italy, Sweden, and the United Kingdom. The results of the EPIC study are fairly consistent with the literature, showing that LUTS are highly prevalent; 64.3% of the 19,165 respondents reported experiencing at least one LUTS. Storage LUTS were considerably more prevalent than were voiding and postmicturition LUTS in both men and women. The prevalence of OAB was comparable in men (10.8%) and women (12.8%) and increased with age in both sexes. Nocturia was the most prevalent symptom in both men (48.6%) and women (54.5%). UI was more prevalent among women (13.1%) than men (5.4%). Among women, stress UI and other UI were the most prevalent types of UI; among men, other UI and urgency UI were most prevalent. Rates of physician-diagnosed depression were significantly higher in respondents with OAB, with or without UI, than in respondents without OAB. Further analyses of EPIC data will be available soon and should yield information about OAB regarding bother and impact on quality of life; risk factors and comorbidities; coping and health care-seeking behaviours; and impact on sexuality, mental health, and work productivity.     

Intakes of vitamins and minerals in relation to urinary incontinence, voiding, and storage symptoms in women: a cross-sectional analysis from the Boston Area Community Health survey

Background

Whether lower urinary tract symptoms (LUTS), including voiding, storage, and urinary incontinence, are affected by dietary micronutrients is uncertain.

Objective

To test the hypothesis that carotenoid, vitamin C, zinc, and calcium intakes are associated with LUTS and urinary incontinence in women.

Design, setting, and participants

During an observational, cross-sectional, population-based epidemiologic study of 2060 women (30–79 yr of age) in the Boston Area Community Health (BACH) survey (2002–2005), data were collected by validated food frequency questionnaire and in-person interviews and analyzed using multivariate regression.

Measurements

LUTS, storage, and voiding symptoms were assessed using the American Urological Association Symptom Index (AUASI) and a validated severity index for urinary incontinence.

Results and limitations

Women who consumed high-dose vitamin C from diet and supplements were more likely to report storage symptoms, especially combined frequency and urgency (≥500 vs <50 mg/d; odds ratio [OR]: 3.42; 95% confidence interval [CI], 1.44–8.12). However, greater consumption of dietary vitamin C or β-cryptoxanthin was inversely associated with voiding symptoms (p_trend ≤ 0.01). Both dietary and supplemental calcium were positively associated with storage symptoms (eg, supplement ≥1000 mg/d vs none; OR: 2.04; 95% CI, 1.35–3.09; p_trend = 0.0002). No consistent associations were observed for β-carotene, lycopene, or other carotenoids, although smokers using β-carotene supplements were more likely to report storage problems. Whether the observed associations represent direct causes of diet on LUTS is uncertain.

Conclusions

High-dose intakes of vitamin C and calcium were positively associated with urinary storage or incontinence, whereas vitamin C and β-cryptoxanthin from foods and beverages were inversely associated with voiding symptoms. Results indicate that micronutrient intakes may contribute to LUTS in dose-dependent and symptom-specific ways. Further study is needed to confirm these findings and their relevance to clinical treatment decisions.     

Dynamic Progression of Overactive Bladder and Urinary Incontinence Symptoms: A Systematic Review

Context

Overactive bladder (OAB) and urinary incontinence (UI) are worldwide public health problems. Longitudinal epidemiologic studies that assess the natural history of OAB and UI are valuable in making accurate prognoses, determining causes and consequences, and predicting resource utilization.

Objective

Our aim was to assess whether the severity of OAB and UI symptoms progress dynamically over time, with the secondary aim of assessing factors that may be associated with symptom progression and regression.

Evidence acquisition

A systematic review of English articles published between January 1, 1990, and September 20, 2009, was conducted using PubMed and Embase. Search terms included longitudinal, natural history, overactive bladder, incontinence, progression, remission, and regression. Eligibility was assessed by Dr. Irwin with editorial assistance. Studies were required to be longitudinal and population based; meeting abstracts and conference proceedings were excluded. Results were assessed qualitatively.

Evidence synthesis

Overall, the 7 longitudinal studies of OAB and 14 longitudinal studies of UI reviewed reported an increase in the incidence and remission/regression of both OAB and UI symptoms over time that varied across studies (eg, OAB incidence, 3.7–8.8%; UI incidence, 0.8–19%). The studies provide evidence for a dynamic progression of OAB and UI symptoms (eg, among women with OAB without urge urinary incontinence [UUI], 28% reported OAB with UUI 16 yr later) and also show that although symptom severity progresses dynamically, for many individuals symptoms also persist over long time periods.

Conclusions

The results support the hypothesis that OAB and UI symptom severity progress dynamically and are also sustained over time. However, the variations in symptom definitions and methods used across studies prevent statistical determinations of overall incidence rates. The recognition of OAB and UI as progressive conditions allows for a shift from the current treatment paradigm of symptom control alone to one of symptom management.