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RESEARCH ARTICLE
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 95-100
 

Causes of lower urinary tract symptoms (LUTS) in adult Indian males


1 KCP Nephro-Urological Center and Research Foundation, Pinnamaneni Polyclinic, India
2 Department of Biochemistry, Siddhartha Medical College, Vijayawada, India

Correspondence Address:
C Nageswara Rao
KCP Nephro-Urological Center and Research Foundation, Pinnamaneni Poly Clinic, Siddhartha Nagar, Vijayawada - 520 010
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objectives : Evaluation of causes of lower urinary tract symptoms in adult Indian males.
Methods : In this study, 1329 men above the age of 40 years from Krishna District of Andhra Pradesh attending the clinics for lower urinary tract symptoms (LUTS) were subjected to detailed physical examination and were given IPSS questionnaire for evaluating LUTS. Special atten­tion was paid to nocturia, as it behaved differently from other LUTS.
Results : Of the 1329 men, 480 had specific diseases (i.e. 36%) responsible for occurrence of LUTS (stricture urethra 43%, prostatic enlargement 40%, neurogenic blad­der 8.8%, miscellaneous 8.2%). About 14% of the total subjects (192/1329) had benign prostatic enlargement. Among the 849 men who had some degree of LUTS, no specific disease was found responsible for these symptoms. Nocturia was the most predominant among the symptoms in both groups of subjects and it had a significant impact on IPSS. If nocturia is eliminated, IPSS gets drastically lowered for each age group irrespective of the presence or absence of disease.
Conclusions: The study indicated that lower urinary tract symptoms are not just confined to the prostatic en­largement. There could be contribution of several urological and non-urological factors in the etiopatho­genesis of LUTS. The relevance of nocturia in IPSS re­quires careful reconsideration. Thus patients with LUTS need a well-planned assessment of disease process and a clear cut understanding of the relevant pathophysiology and an orderly approach to diagnosis and therapy.


Keywords: Lower urinary tract symptoms, prostatism, IPSS, nocturia.


How to cite this article:
Rao C N, Singh MK, Shekhar T, Venugopal K, Prasad M R, Saleem K L, Satyanarayana U. Causes of lower urinary tract symptoms (LUTS) in adult Indian males. Indian J Urol 2004;20:95-100

How to cite this URL:
Rao C N, Singh MK, Shekhar T, Venugopal K, Prasad M R, Saleem K L, Satyanarayana U. Causes of lower urinary tract symptoms (LUTS) in adult Indian males. Indian J Urol [serial online] 2004 [cited 2019 Jun 18];20:95-100. Available from: http://www.indianjurol.com/text.asp?2004/20/2/95/21520



   Introduction Top


Lower urinary tract symptoms (LUTS) are common in men affecting upto 78% of the elderly population. [1],[2] The most common LUTS are urinary frequency, urgency, hesi­tancy, weak stream and nocturia. Until recently, the con­stellation of obstructive and irritative symptoms, observed in aging men was termed prostatism. [3] However, the pre­ferred usage for these manifestations in recent years is LUTS, rather than to try and make a diagnosis on the ba­sis of a mixture of symptoms. [3]

The pathophysiology of LUTS, being multifactorial, is not well characterized. Traditionally, lower urinary tract symptoms in men were attributed to bladder outlet ob­struction, secondary to prostate enlargement mainly be­nign pro static hyperplasia (BPH). However, recent studies have failed to reveal any significant correlation of LUTS with bladder outlet obstruction. [2],[4] Further, urinary symp­toms can stem from other disease entities and have been shown to be present in women as wells. [5],[6],[7] Thus, the term 'LUTS' or lower urinary tract dysfunction has been pro­posed [3],[8] for use when symptoms are not necessarily spe­cific to the prostate. The severity of LUTS is best quantified by using quantitative symptoms indices, including the American Urological Association (AUA) symptom index and the International Prostate Symptom Score or IPSS. [9] The prevalence of LUTS, mostly measured by IPSS has been reported from United States, [10] United Kingdom, [11] Canada, [12] Australia [13] and several other countries. Recently, the relationship of nocturia with international prostate symptom score in men with lower urinary tract symptoms due to BPH has been reported from Japan. [14] However, there have been no reports on LUTS from India.

We have evaluated the etiology of LUTS in Indian males and data obtained are incorporated in this paper. We also studied the impact of nocturia on the IPSS scores in these patients.


   Patients and Methods Top


Of 5418 urological patients who visited our Urology camps and free clinics, 1684 men had LUTS. Of these, 1329 men who were above the age of 40 years were se­lected for the study. These men were subjected to thor­ough physical examination (including external genitalia and digital rectal examination) and neurological evalua­tion. Routine blood and urine examinations and ultra­sonography were carried out for all these individuals. Each person was subjected to an IPSS questionnaire [15],[16] admin­istered by the interviewer, for recording lower urinary tract symptoms (sense of incomplete emptying, frequency, in­termittency, urgency, weak stream, hesitancy and noctu­ria). At least, two acts of micturition at night by an individual is regarded as nocturia. [17] The subjects were per­sonally and individually interviewed and their response for LUTS was recorded. After screening, uroflowmetry, retrograde urethrography and cystometry were performed in selected patients. The criteria of selection was based on symptomatology, i.e. uroflowmetry for men with com­plaints of slow stream, retrograde urethrogram for men with poor peak flow rates, and cystometry was done in men with poor peak flow rates in absence of enlarged pros­tates and a normal RUG to rule out/confirm neurologic disease. Cystometry was also performed for stress/urge incontinence, and also in diabetic men with BPH. BPH was diagnosed based on symptomatology and a prostate size >25 gms PSA and histological diagnosis were not done.


   Results Top


The subjects were distributed into different groups at an age interval of 10 years. There were 429, 393, 330, 144 and 33 men respectively in the age groups 40-49, 50­59, 60-69, 70-79 and 80-89 years.

Of the 1329 men, 480 had specific diseases responsible for occurrence of LUTS, whereas in the remaining (849 subjects), no specific diseases were identified. Thus, about 36% of the men studied (480/1329) were suffering from LUTS with specific diseases. Further, about 14% of the total subjects (192/1329) had BPH (i.e. prostate size > 25 g on ultrasonography).

The distinct diseases responsible for causing LUTS are given in [Table - 1]. Stricture urethra was responsible for causing LUTS in 207 men (43%), being more prevalent in the age groups of 40-49, 50-59 and 60-69 years. BPH was detected in 192 individuals (40%) and this was most frequently observed in the age group of 60-69 years, fol­lowed by 70-79 years. Neurogenic bladder was held re­sponsible for causing LUTS in 42 subjects (8.8%). In the remaining 39 men (8.2%) urolithiasis, urethritis, prostatic abscess, chronic bacterial prostatitis and interstitial/chronic cystitis contributed to these symptoms.

The distribution of urinary symptoms in 480 patients with specific diseases is given in [Table - 2]. Nocturia was the most predominant symptom in the patients with LUTS in the age groups of 40-49, 70-79 and 80-89 years. Noc­turia (74.4%), weak stream (89.8%) and urgency (84.7%) contributed to a significant percentage in the age group of 50-59 years. Weak stream and nocturia were mainly re­sponsible for causing LUTS in the age group of 60-69 years. However, the remaining LUTS (i.e. frequency, in­termittency, hesitancy and sense of incomplete emptying) also contributed to a certain extent in virtually all age groups.

Eight hundred and forty-nine subjects in our study groups had also shown LUTS [Table - 3], but here we could not arrive at any causative factor, being responsible for their sufferings. Again nocturia (ranging from 75.4 to 100% with an overall average of 80.2%) was a predomi­nant factor for causing these symptoms in almost all age groups. Besides nocturia, weak stream, urgency and hesi­tancy were also responsible for causing LUTS to a lim­ited extent in some of the groups. However, sense of incomplete emptying, frequency and intermittency con­tributed very little to their sufferings.

The prevalence of nocturia in subjects having LUTS with diseases or without diseases in relation to IPSS is given in [Table - 4],[Table - 5] respectively. As is evident from the tables, for each age group nocturia changed the IPSS. If nocturia is eliminated, then IPSS gets substantially low­ered for each age group irrespective of the presence or absence of disease. For instance, in the age group 60-69 years without any disease [Table - 5], 81 subjects are cat­egorized as moderate in conventional IPSS. All these sub­jects will shift to mild IPSS, if nocturia is eliminated. Almost similar results are found for each age group, ei­ther with disease or without disease.


   Discussion Top


The term LUTS was proposed by Paul Abrams. [3] The increase in the prevalence of LUTS with advancement of age is an accepted fact. Population based studies on the age related increase in LUTS in some countries have been reported. The prevalence of LUTS was lowest in France (14%) and Scotland (18%) and highest in USA (38%) and Japan (46%). [1],[14],[17],[18],[19] However, there have been no reports on the prevalence of LUTS from India. The preliminary data reported in this paper indicate that LUTS due to spe­cific diseases in a rural based Indian male population is around 36% (480 out of 1329). About 14% of the total subjects had BPH.

Nocturia has been proposed as "more than two voids per night". It behaves differently from other lower uri­nary tract symptoms in IPSS. It was the most predomi­nant among LUTS ranging from 75% to 100% irrespective of presence or absence of disease. The prevalence of noc­turia based on age-related studies worldwide may vary from 10% in those 40 years old to 80% in those aged 80 years. The percentage of nocturia among Indian patients with LUTS in the age group 40-49 years was much higher (77%) compared to the data reported on general popula­tion from elsewhere. [17],[20] Stricture of the urethra was the commonest etiology in this age group.

Nocturia had a very significant impact on IPSS. If noc­turia was eliminated from IPSS, it was seen that the symp­tom scores shifted from moderate to mild in almost all age groups. Presumably the elimination of nocturia may avoid to a significant level, unnecessary evaluation, intervention and expenses for our already impoverished population.

LUTS are not indicative of BPH and vice-versa, as men and women may have LUTS caused by conditions unre­lated to the prostate. Thus, the pathophysiology of LUTS is multifactorial, which may be due to urological condi­tions (BPH, urethral stricture, prostatitis, cystitis, bladder and prostate cancer, urolithiasis, etc.) or non-urological conditions (neurological conditions such as  Parkinsonism More Details, cerebrovascular accident, diabetes mellitus, etc.).

It is important for the urologist to distinguish irritative (frequency, nocturia urgency, urge incontinence) from obstructive (hesitancy, intermittency, weak stream, etc.) LUTS. This guides the astute clinician to arrive at a proper differential diagnosis.

Age associated urinary disturbances do occur in both men as well as women. Urologists attach more signifi­cance to the urinary tract symptoms of aging men due to their association with BPH. This may not be always jus­tified, since in their over-enthusiasm, there is a possibility of making a wrong diagnosis based on a normal physi­ological age-related processes.


   Conclusions Top


The pathophysiology of LUTS is a multifactorial and not only confined to enlargement of the prostate. There is a contribution of several urological and non-urological factors in the etiopathogenesis of LUTS. The impact of nocturia on IPSS needs careful consideration. The avail­ability and increased use of various treatment modalities have created a greater need to diagnose accurately the etiology of LUTS in men. Thus patients with LUTS need a well-planned assessment and understanding of the rel­evant pathophysiology and an orderly approach to diag­nosis and therapy.

 
   References Top

1.Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic hypertrophy in the community. Lancet 1991; 338: 469­-72.  Back to cited text no. 1  [PUBMED]  
2.Nielsen KK, Nordling J, Hald T. Critical review of the diagnosis of prostatic obstruction. Neurourol Urodyn 1994; 13: 201-8.  Back to cited text no. 2  [PUBMED]  
3.Abrams P. New words for old: Lower urinary tract symptoms for "Prostatism". Br Med J 1994; 308: 929-30.  Back to cited text no. 3    
4.Barry MJ, Cockett AT, Holtgrewe HL et al. Relationship of symp­toms of prostatism to commonly used physiological and anatomi­cal measures of the severity of benign prostatic hyperplasia. J Urol 1993; 150: 351-5.  Back to cited text no. 4    
5.Lepor H, Machi G. Comparison of the AUA symptom index in unselected males and females between 55 and 79 years of age. Urol­ogy 1993; 42: 36-40.  Back to cited text no. 5    
6.Chai TC, Belville WD, McGuire EJ, Nyquist L. Specificity of the American Urological Association voiding symptom index: Com­parison of unselected and selected samples of both sexes. J Urol 1993; 150: 1710-3.  Back to cited text no. 6  [PUBMED]  
7.Chancellar MB, Rivas DA. American Urological Association symp­tom index for women with voiding symptoms: lack of index specificity for benign prostatic hyperplasia. J Urol 1993; 150: 1706­-9.  Back to cited text no. 7    
8.Barry MJ, Boyle P, Fourcroy J et al. Epidemiology and natural his­tory of BPH. In: Proceedings of the 3 rd International consultation on benign prostatic hyperplasia (BPH). Jersey: Scientific Commu­nication International Ltd. 1996.  Back to cited text no. 8    
9.Baily MJ, O'Leary MP. The development and clinical utility of symptom scores. Urol Clin North Am 1995; 22: 229-307.  Back to cited text no. 9    
10.Guess HA, Chute CG, Garraway WM et al. Similar levels of urological symptoms have similar impact on Scottish and Ameri­can men - although Scots report less symptoms. J Urol 1993; 150: 1701-5.  Back to cited text no. 10    
11.Jolleys JV, Donovan JL, Nanchahal K et al. Urinary symptoms in the community: how bothersome are they? Br J Urol 1994; 74: 551-­5.  Back to cited text no. 11    
12.Norman RW, Nickel JC, Fish D, Pickett SN. `Prostate related symp­toms' in Canadian men 50 years of age or older: Prevalence and relationships among symptoms. Br J Urol 1994; 74: 542-50.  Back to cited text no. 12  [PUBMED]  
13.Pinnock CB, Marshall VR. Troublesome lower urinary tract symp­toms in the community: a prevalency study. MJA 1997; 1-9.  Back to cited text no. 13    
14.Tsukamoto T, Kumamoto Y, Masumori N et al. Prevalence of pros­tatism in Japanese men in a community based study with compari­son to a similar American study. J Urol 1995; 154: 391-5.  Back to cited text no. 14    
15.Barry MJ, Fowler F, O'Lerry M et al. The American Urological Association symptom index for BPH. J Urol 1992; 148: 1549-57.  Back to cited text no. 15    
16.Mebrust W, Bosch R, Donovan J et al. Symptom evaluation, qual­ity of life and sexuality. In: Second International Consultation on BPH, Paris: WHO 1993; 131-143.  Back to cited text no. 16    
17.Chute CG, Pancer LA, Girman CJ et al. The prevalence of pros­tatism: a population based survey of urinary symptoms. J Urol 1993; 150: 85-9.  Back to cited text no. 17    
18.Jacobson SJ, Guess HA, Pancer L, German CJ, Dosterling JC, Leiber MM. A population based study of health care-seeking behaviour for treatment of urinary symptoms. Arch Fam Med 1993; 2: 729-­35.  Back to cited text no. 18    
19.Sagnier PP, Girman CJ, Garraway WM et al. International com­parison of the community prevalence of symptoms of prostatism in four countries. Eur Urol 1996; 29: 15-20.  Back to cited text no. 19    
20.Malmsten UGH, Milson I, Molannder U, Norlen LJ. Urinary in­continence and lower urinary tract symptoms: an epidemiological study of men aged 45-99 years. J Urol 1997; 158: 1733-7.  Back to cited text no. 20    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]



 

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusions
    References
    Article Tables

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