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

C Nageswara Rao; Mithilesh K Singh; T Shekhar; K Venugopal; M Rama Prasad; K Lily Saleem; U Satyanarayana

Users online:108

Home

Current Issue

Ahead of print

Editorial Board

Archives

Symposia

Guidelines

Subscriptions


RESEARCH ARTICLE

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

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

C Nageswara Rao¹, Mithilesh K Singh¹, T Shekhar¹, K Venugopal¹, M Rama Prasad¹, K Lily Saleem¹, U Satyanarayana²
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

Source of Support: None, Conflict of Interest: None

Check

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 2020 Oct 22];20:95-100. Available from: https://www.indianjurol.com/text.asp?2004/20/2/95/21520

Introduction

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

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

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

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

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

1.	Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic hypertrophy in the community. Lancet 1991; 338: 469-72. [PUBMED]
2.	Nielsen KK, Nordling J, Hald T. Critical review of the diagnosis of prostatic obstruction. Neurourol Urodyn 1994; 13: 201-8. [PUBMED]
3.	Abrams P. New words for old: Lower urinary tract symptoms for "Prostatism". Br Med J 1994; 308: 929-30.
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.
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.
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. [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.
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.
9.	Baily MJ, O'Leary MP. The development and clinical utility of symptom scores. Urol Clin North Am 1995; 22: 229-307.
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.
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.
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. [PUBMED]
13.	Pinnock CB, Marshall VR. Troublesome lower urinary tract symptoms in the community: a prevalency study. MJA 1997; 1-9.
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.
15.	Barry MJ, Fowler F, O'Lerry M et al. The American Urological Association symptom index for BPH. J Urol 1992; 148: 1549-57.
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.
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.
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.
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.
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.