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Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 154-157

Prevalence of lower urinary tract symptoms in patients of benign prostatic hyperplasia attending Tertiary Care Hospital in the State of Andhra Pradesh

1 Department of Medical and Surgical Nursing, College of Nursing, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Biochemistry, School of Life Sciences, University of Hyderabad, Hyderabad, Telangana, India

Date of Web Publication25-Sep-2017

Correspondence Address:
S. A. A. Latheef
School of Life Sciences, University of Hyderabad, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-8632.215533

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Background: There are only few studies available on the prevalence of lower urinary tract symptoms (LUTS) evaluated by the international prostate symptom score tool (IPSS), and it has not been validated in the Indian population.
Aim: The purpose of the present study was to determine the prevalence of lower urinary tract symptoms in patients of benign prostatic hyperplasia (BPH) and to validate the IPSS tool in our studied population.
Materials and Methods: One hundred BPH aged >51 years attending the outpatient department of Urology were recruited for the study. LUTS were evaluated using the international IPSS. The IPSS was validated for reliability and reproducibility by Cronbach's alpha and intraclass correlation coefficient (ICC).
Results: The coefficients of Cronbach's alpha and ICC were 0.80 and 0.86, respectively. The majority of patients had moderate symptoms (72%) followed by severe symptoms (17%). Severity of symptoms increased with age (P < 0.01). The total score was associated with age (P < 0.01). The majority of patients (12%) with the severity of symptoms had reported that symptoms bother them to some extent.
Conclusion: The results of the study showed that IPSS could serve as a good instrument to assess LUTS in this population.

Keywords: Benign prostatic hyperplasia, IPSS, lower urinary tract symptoms

How to cite this article:
Nagarathnam M, Latheef S. Prevalence of lower urinary tract symptoms in patients of benign prostatic hyperplasia attending Tertiary Care Hospital in the State of Andhra Pradesh. J NTR Univ Health Sci 2017;6:154-7

How to cite this URL:
Nagarathnam M, Latheef S. Prevalence of lower urinary tract symptoms in patients of benign prostatic hyperplasia attending Tertiary Care Hospital in the State of Andhra Pradesh. J NTR Univ Health Sci [serial online] 2017 [cited 2021 Jun 15];6:154-7. Available from: https://www.jdrntruhs.org/text.asp?2017/6/3/154/215533

  Introduction Top

Histologically, benign prostatic hyperplasia (BPH) may be defined as the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.[1] The prevalence of BPH was shown to increase from 25% in the age group of 40–49 to 80% in 70–79 years age group.[2] It was proposed that BPH may due to a reawakening of embryonic induction process in adulthood. The enlarged gland was reported to cause lower urinary tract symptoms (LUTS) by direct bladder outlet obstruction from enlarged tissue (static component) and increased smooth muscle tone and resistance within the enlarged gland (dynamic component).[1] The LUTS were further categorized as obstructive voiding (urinary hesitancy, delay in initiating micturition, intermittency, involuntary interruption of voiding, weak urinary stream, straining to void, a sensation of incomplete emptying, and terminal dribbling) and storage (urinary frequency, nocturia, urgency, incontinence, and bladder pain or dysuria) symptoms.[2] In 14% of men with LUTS, clinical progression in terms of worsening LUTS, acute urinary retention, urinary incontinence, renal insufficiency, or recurrent urinary tract infection were observed over a period of 5 years.[2] The progression was shown to result in the severity of LUTS, increased prostate size, and elevated levels of prostate specific antigen, as well as lowered rate of urinary flow.[2],[3],[4] Although pathophysiology was not known, several risk factors such as age, geography, genetics (non-modifiable) and sex steroid hormones, metabolic syndrome, obesity, diabetes, physical activity, diet, and inflammation (modifiable) were observed to be associated with BPH.[5] In India, 6.7–14% prevalence of BPH was reported in hospital and community studies.[6],[7],[8] Barry et al.[9] have reported a symptom index to evaluate the severity of LUTS. Studies conducted in India have used the international prostate symptom score tool (IPSS) to report the symptoms severity but not validated in Indian populations.[6],[7],[8],[9],[10] In this study, we made an attempt to validate the IPSS and report LUTS in the population belonging to the state of Andhra Pradesh.

  Patients and Methods Top

One hundred BPH patients aged >51 years attending an outpatient department of Urology were recruited for the study. BPH was diagnosed by the urologist based on clinical criteria such as medical history and physical and digital rectal examinations. Patients who had LUTS suggesting BPH were recruited in the study. Patients who were suffering from other associated diseases such as prostate cancer, diabetes mellitus, neurological and psychological disorders, prostatitis, cystitis, urinary infection, pelvis trauma or surgery; had undergone surgical procedure for BPH; were under a regimen of drugs affecting bladder function; had permanent bladder catheter, stricture urethra, and urinary flow obstruction disorders such as calculi, etc., were excluded from the study. The study was approved by the Institute Ethics committee and written consent was obtained from the patients before participation in the study. LUTS in BPH patients was evaluated using IPSS tool including bother index.[9] The IPSS tool contains eight items; seven items assess the symptoms such as incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia preceding last month.[10] The eighth question assess bothersome. The seven items are assessed on a 5-point Likert scale, ranging from 0 (not at all), 1 (less than 1 time in 5), 2 (less than half the time), 3 (about half the time), 4 (more than half the time) to 5 (almost always) for a maximum of 35 points. The score of these seven items is summed up to categorize patients into three categories: mild (0–7), moderate (8–19), and severe (20–35). The bothersome is assessed on a 4-point Likert scale, ranging from 0 (not at all), 1 (bothers me little), 2 (bothers me some), and 3 (bothers me a lot).

The IPSS tool was translated into the Telugu language and backtranslated into English by bilingual experts: two investigators (M.N. and G.H.). Purposive sampling technique was used for the recruitment of the patients and were administered the Telugu version of the tool by M.N. and G.S. Data on demographic and social variables were collected using a structured questionnaire.

Statistical analysis

The quantitative data are shown and mean and standard deviation and the qualitative data as proportions. Means were compared by one way analysis of variance (ANOVA) and proportions with Chi-square test. The instrument was evaluated by test and retest method using intracorrelation coefficient (ICC) and reliability by Cronbach's alpha.[10] Assuming reliability of 0.8 acceptable and interobserver reliability to be 0.9, α =0.05 and β =0.2, the calculated sample size was for two raters was 46.[11] We recruited 100 patients for the present study.

  Results Top

The test-rest reliability was 0.86 for the instrument and the reliability was 0.809. The mean of the total score was 14.83 ± 6.18 (1–34). The highest mean score was observed for item 7 followed by items 5, 2, and 4. The mean score of bothersome was 1.71 ± 0.67 [Table 1]. The majority of the patients had moderate (72%) LUTS symptoms. Only 17% of the patients had severe LUTS symptoms. Severity of symptoms increased with increase in age. A greater percentage of severity of symptoms was observed with primary education, agriculture, heavy work, and nonvegetarian diet, but this was not statistically significant. Higher percentage of severity of symptoms in Hindu religion may reflect population trends [Table 2]. Most of the patients with severe symptoms (12%) had reported symptoms bothering them to some extent [Table 3].
Table 1: Mean and Standard Deviation of Items

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Table 2: Sociodemographic and Clinical Characteristics According to the International Prostate Symptom Score Tool Score

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Table 3: Association Between Symptoms and Botherization Index Observed in Patients of Benign Prostatic Hyperplasia

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  Discussion Top

Cronbach's alpha of ≥0.7 and ICC of ≥0.7 were considered as adequate internal consistency and good reproducibility of the instrument.[10] Previous studies have shown Cronbach's alpha of 0.7–0.85.[10],[12],[13],[14],[15] and intracorrelation coefficient of 0.59–0.92.[10],[12],[14],[15] Cronbach's alpha (0.809) and ICC (0.86) for IPSS tool in the present study is within range of coefficients reported in earlier studies,[10],[12],[13],[14],[15] and demonstrated good internal consistency and reproducibility.

Patients with BPH are diagnosed by digital rectal examination, ultrasound, and cystourethroscopy. These procedures are reported to be invasive, inconvenient, cost-intensive, and not feasible in rural areas.[8] IPSS was considered to be a sensible, reliable, and valid instrument for identification of severity of symptoms in patients with BPH; it can also be used for assessing the treatment outcomes in these patients.[1],[8],[9]

Correlation analysis between total score and demographic and social variables revealed a statistically significant correlation between age and total score (0.259) (P < 0.01). The total score increased with age. Statistically significant difference in total scores between age groups was observed (P < 0.05). This study also confirms that age is one of the non-modifiable risk factor for BPH.[2],[5]

A study from coastal Andhra Pradesh had reported a higher number of patients with moderate symptoms in the age group of 70–79 years.[6] Higher percentage of BPH patients with severity of symptoms was observed in a study reported from Kolkata.[16] In a rural community-based study, a greater percentage of BPH patients were identified with mild symptoms.[8] In our study, a majority of patients (72%) had moderate symptoms. Severity of symptoms increased with age. Higher percentage of patients with severity of symptoms had reported that symptoms bother them to some extent. The results of the study can be generalized to the BPH patients in this state. The results of the study suggest that validation of the IPSS tool needs to be established in different populations of India for its wider use for evaluating LUTS in BPH patients.


We are thankful to the Head, Department of Urology, SVIMS, Tirupati, for permitting us to carry out the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnel RF, et al. American Urological Association Guideline: Management of Benign Prostatic Hyperplasia. American Urological Association. 2010. Available at http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph-management/chap_1_GuidelineManagementof (BPH).pdf. [Last Accessed on 2016 May 18].  Back to cited text no. 1
Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med 2012;367:248-57.  Back to cited text no. 2
McConnell JD, Roehrborn CG, Bautista OM, Andriole GL Jr, Dixon CM, Kusek JW, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003;349:2387-98.  Back to cited text no. 3
Crawford ED, Wilson SS, McConnell JD, Slawin KM, Lieber MC, Smith JA, et al. Baseline factors as predictors of clinical progression of benign prostatic hyperplasia in men treated with placebo. J Urol 2006;175:1422-7.  Back to cited text no. 4
Patel ND, Parsons JK. Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction. Indian J Urol 2014;30:170-6.  Back to cited text no. 5
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Rao CN, Singh MK, Shekhar T, Venugopal K, Prasad MR, Saleem KL, Satyanarayana U. Causes of lower urinary tract symptoms (LUTS) in adult Indian males. Indian J Urol 2004;20:95-100.  Back to cited text no. 6
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Kumar V, Acanfora M, Hennessy CH, Kalache A. Health status of the rural elderly. J Rural Health 2001;17:328-31.  Back to cited text no. 7
Patel SP, Srivastava VK. AUA symptom score—A simple tool for assessment of benign prostatic hyperplasia in a rural setting. Indian J Commun Health 2013;25:147-52.  Back to cited text no. 8
Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992;148:1549-57; discussion 1564.  Back to cited text no. 9
Choi EP, Lam CL, Chin WY. Validation of the International Prostate Symptom Score in Chinese males and females with lower urinary tract symptoms. Health Qual Life Outcomes 2014;12:1.  Back to cited text no. 10
Walter SD, Eliasziw M, Donner A. Sample size and optimal designs for reliability studies. Stat Med 1998;17:101-10.  Back to cited text no. 11
Badia X, García-Losa M, Dal-Ré R, Carballido J, Serra M. Validation of a harmonized Spanish version of the IPSS: Evidence of equivalence with the original American scale. International Prostate Symptom Score. Urology 1998;52:614-20.  Back to cited text no. 12
Panahi A, Bidaki R, Mehraban D, Rezahosseini O. Validity and reliability of Persian Version of International Prostate Symptom Score. GMJ 2013;2:18-21.  Back to cited text no. 13
Quek KF, Low WY, Razack AH, Loh CS. Reliability and validity of the International Prostate Symptom Score in a Malaysian population. BJU Int 2001;88: 21-5.  Back to cited text no. 14
Hammad FT, Kaya MA. Development and validation of an Arabic version of the International Prostate Symptom Score. BJU Int 2010;105:1434-38.  Back to cited text no. 15
Jindal T, Sinha RK, Mukherjee S, Mandal SN, Karmakar D. Misinterpretation of the international prostate symptom score questionnaire by Indian patients. Indian J Urol 2014;30:252-5.  Back to cited text no. 16
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  [Table 1], [Table 2], [Table 3]


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