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ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 132-134  

Lower urinary tract symptoms and feeling of incomplete emptying in Saudi Arabian men and its correlation with postvoid residual urine


Department of Urology, University of Dammam, Dammam, Saudi Arabia

Date of Submission19-Sep-2018
Date of Acceptance05-Nov-2018
Date of Web Publication4-Apr-2019

Correspondence Address:
Dr. Reem Aldamanhori
Department of Urology, University of Dammam, Dammam
Saudi Arabia
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DOI: 10.4103/UA.UA_133_18

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   Abstract 

Purpose: This study was conducted to assess the clinical value of postvoid residual (PVR) urine measurement and associate it with the feeling of incomplete emptying in men with lower urinary tract symptoms.
Methods: Two hundred men were surveyed in the King Fahd Hospital of the University. Patients who had previous urological surgery and patients who are currently on urology treatment were excluded. Information from the remaining 181 patients was analyzed. International Prostate Symptom Score (IPSS) sheets were filed, and then, the PVR was measured.
Results: Data from IPSS sheets were evaluated: 45 patients (24.8%) were characterized as experiencing no symptoms (Score: 0 and 1), 87 (48%) as mild-to-moderate symptoms (Score: 2 and 3), and 49 (27%) as severe symptoms (Score: 4 and 5). The PVR measurement showed no statistical difference in all three categories (being 10, 13, and 12, respectively). Feeling of incomplete emptying despite little PVR was frequently observed.
Conclusion: The study concluded that the feeling of incomplete emptying was poorly correlated with PVR urine volume measurement. This feeling was significantly associated with worsening of both voiding and storage symptoms.

Keywords: International prostate symptom score, lower urinary tract symptoms, postvoid residual urine measurement


How to cite this article:
Aldamanhori R. Lower urinary tract symptoms and feeling of incomplete emptying in Saudi Arabian men and its correlation with postvoid residual urine. Urol Ann 2019;11:132-4

How to cite this URL:
Aldamanhori R. Lower urinary tract symptoms and feeling of incomplete emptying in Saudi Arabian men and its correlation with postvoid residual urine. Urol Ann [serial online] 2019 [cited 2019 Apr 23];11:132-4. Available from: http://www.urologyannals.com/text.asp?2019/11/2/132/254266




   Introduction Top


Lower urinary tract symptoms (LUTSs) are highly prevalent among men and women and destructively affect their quality of life (QoL).[1] Thorough history and physical examination are performed to diagnose and manage LUTS. Evaluation of LUTS includes using questionnaires, such as the International Prostate Symptom Score (IPSS) to establish the impact of these symptoms on a patient's regimen. Patients who are troubled by LUTS feel imprisoned by their symptoms. They rearrange their calendar and their movements based on the availability of a toilet. Some may retain from attending social events and/or visits that require a long drive. The impact of LUTS on patients should not be taken lightly or overlooked.

LUTSs are divided into three categories by the International Continence Society: storage, voiding, and postmicturition symptoms.[2] LUTSs, though affect both men and women, commonly affect middle-aged men. The European Prospective Investigation into Cancer and Nutrition study has estimated that LUTS is present in 62.5% of middle-aged men (voiding symptoms 25.7% and storage symptoms 51.3%).[3] To date, most studies on LUTS have mainly focused on voiding or storage symptoms, whereas postmicturition symptoms (a feeling of incomplete emptying following urination and/or postmicturition dribble) have been relatively unnoticed despite their damaging impact on QoL.[4]

Objective studies including postvoid residual (PVR) urine are also recommended in LUTS patients.[5] PVR can be measured by transabdominal ultrasound, which is a simple, accurate, and noninvasive method.[6] However, a feeling of incomplete emptying does not always strongly correlate with measured PVR volume.[7] Urologists occasionally encounter men with LUTS complaining of a feeling of incomplete emptying despite no or little PVR. In this study, we assess the clinical importance of PVR measurement in men with LUTS and associate that with the feeling of incomplete emptying on the IPSS questionnaire.


   Methods Top


The study used data from a university hospital outpatient interview survey. The survey directed at male participants who gave oral consents to the survey and voluntarily expressed their intention to participate. The university hospital outpatient survey was carried out in the King Fahd Hospital of the University in a urology booth at the hospital reception. IPSS questionnaire survey was performed in 200 male outpatients, visitors, and staff of the university hospital. People with previous urological surgery and people who are already taking treatment for urological conditions were excluded. The number went down to 186 after applying exclusion criteria. After the questionnaire was filled, patients were asked to empty their bladder fully, and then, a PVR measurement was done using a standard bladder scan. Five patients did not attend for bladder scan PVR measurement after filling up the questionnaire, hence their exclusion from the study. Ultimately, 181 patients were eligible for analysis. The mean age of the patients was 51 years (range from 24 to 71).

The severity of LUTS was measured by IPSS based on the American Urological Association symptom index, with one additional question on QoL.[8] IPSS questionnaire has been translated into many different world languages and adapted based on the circumstances of each country. IPSS questionnaire is now widely used for objective assessment of LUTS. The Arabic version of the IPSS was verified by Hammad and Kaya in 2010.[9] In terms of relevance and reliability, it is now the most typical analytical instrument for LUTS evaluation in Saudi Arabia.

The IPSS questionnaire consisted of eight items, which included seven 6-point scale questions on symptoms (feeling of incomplete emptying, urinary frequency, interrupted stream, urinary urgency, weak urinary stream, urinary hesitancy, and nocturia) and one 7-point scale question on patients' satisfaction with their urinary condition. Based on the criteria, symptom severity was divided into three groups: mild (a symptom score of 0–7), moderate (8–19), and severe (20–35).[8] The QoL or level of satisfaction of LUTS patients was represented by seven grades: “No problem” (0 point = very satisfied), “I'm all right” (1 point), “Somewhat satisfied” (2 points), “Half-satisfied, half-dissatisfied” (3 points), “Somewhat dissatisfied” (4 points), “Distressed” (5 points), and “I can't stand it” (6 points = very dissatisfied).

After the patients filled the questionnaire survey, they were asked to empty their bladder in a private bathroom and a PVR was measured. The PVR was measured three times using a noninvasive ultrasound-operated bladder scanner, and the average of the three readings was taken as the PVR.

To enhance the validity of IPSS, we excluded patients who had received any treatment for benign prostatic hyperplasia or prostate cancer; those who had evidence of apparent neurological condition; those with a history of urinary tract infection within the last 3 months; and finally, those who had undergone urological surgery, which might affect their IPSS score.

This is a cross-sectional study to evaluate the clinical importance of PVR measurement in Saudi men with LUTS. The reliability of the questionnaire used in this study was estimated to be similar to that in previous studies. This suggested that we used the same method as previous studies. Well-trained professional doctors conducted the university hospital outpatients' survey. The same group of doctors measured the PVR. This study enrolled hospital outpatients through a formal procedure in compliance with the applicable laws and regulations, good clinical practices, and ethical principles.


   Results Top


On the IPSS questionnaire (range from 0 to 5), 45 patients (24.8%) were characterized as experiencing no symptoms (Score: 0 and 1), 87 (48%) as mild-to-moderate symptoms (Score: 2 and 3), and 49 (27%) as severe symptoms (Score: 4 and 5) [Table 1]. The age was similar among those groups. The PVR measurement showed no statistical difference in all three categories. A feeling of incomplete emptying despite little PVR was frequently observed. This was significantly associated with worsening of voiding symptoms, storage symptoms, total IPSS score, and QoL symptom score. The voiding symptoms mean score was 1.8 in the no symptom group, 2.6 in the mild-to-moderate group, and 3.9 in the severe symptom group. The storage symptoms were significantly related as well showing a mean score of 1.9, 2.4, and 3.7 in no symptom, moderate symptom, and severe symptoms, respectively. The QoL score was 4.8 in the severe group and 3.7 and 2.9 in the moderate group and no symptom group, respectively.
Table 1: Study data that show number of patients and different symptom scores

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   Discussion Top


The feeling of incomplete emptying was poorly correlated with PVR urine volume seen in this population study. A substantial number of patients complained of a feeling of incomplete emptying with little PVR, and this feeling was significantly associated with worsening of both voiding and storage symptoms. Feeling of incomplete emptying is a self-explanatory term for a feeling experienced by the individual after passing urine. There may be several hypotheses that might explain the development of a feeling of incomplete emptying. A prostatic protrusion in the bladder might cause a sense of incomplete emptying as the prostate grows. The feeling of incomplete emptying with little PVR may be closely associated with sensory changes of the bladder.[10] Alterations in the finely tuned neurogenic pathway can be responsible for significant alterations in lower urinary tract function. Several studies have tackled the subject of sensory dysfunction of the bladder trying to explain the pathophysiology of an overactive bladder, which might be accountable for the development of residual urine sense despite little PVR.[11],[12] This also explains the worsening of voiding symptoms, storage symptoms, total IPSS score, and QoL symptom score. Nevertheless, it still remains indeterminate why patients suffer from a feeling of incomplete emptying despite no or little PVR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Coyne KS, Sexton CC, Thompson CL, Milsom I, Irwin D, Kopp ZS, et al. The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: Results from the epidemiology of LUTS (EpiLUTS) study. BJU Int 2009;104:352-60.  Back to cited text no. 1
    
2.
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology in lower urinary tract function: Report from the standardisation sub-committee of the International Continence Society. Urology 2003;61:37-49.  Back to cited text no. 2
    
3.
Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: Results of the EPIC study. Eur Urol 2006;50:1306-14.  Back to cited text no. 3
    
4.
Maserejian NN, Kupelian V, McVary KT, Doshi M, Link CL, McKinlay JB, et al. Prevalence of post-micturition symptoms in association with lower urinary tract symptoms and health-related quality of life in men and women. BJU Int 2011;108:1452-8.  Back to cited text no. 4
    
5.
Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJ, et al. 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;46:547-54.  Back to cited text no. 5
    
6.
Abdelwahab HA, Abdalla HM, Sherief MH, Ibrahim MB, Shamaa MA. The reliability and reproducibility of ultrasonography for measuring the residual urine volume in men with lower urinary tract symptoms. Arab J Urol 2014;12:285-9.  Back to cited text no. 6
    
7.
Lee JY, Lee DH, Lee H, Bang WJ, Hah YS, Cho KS, et al. Clinical implications of a feeling of incomplete emptying with little post-void residue in men with lower urinary tract symptoms. Neurourol Urodyn 2014;33:1123-7.  Back to cited text no. 7
    
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.  Back to cited text no. 8
    
9.
Hammad FT, Kaya MA. Development and validation of an arabic version of the international prostate symptom score. BJU Int 2010;105:1434-8.  Back to cited text no. 9
    
10.
Jung HB, Kim HJ, Cho ST. A current perspective on geriatric lower urinary tract dysfunction. Korean J Urol 2015;56:266-75.  Back to cited text no. 10
    
11.
Roosen A, Chapple CR, Dmochowski RR, Fowler CJ, Gratzke C, Roehrborn CG, et al. Arefocus on the bladder as the originator of storage lower urinary tract symptoms: A systematic review of the latest literature. Eur Urol 2009;56:810-9.  Back to cited text no. 11
    
12.
Lee SR, Kim HJ, Kim A, Kim JH. Overactive bladder is not only overactive but also hypersensitive. Urology 2010;75:1053-9.  Back to cited text no. 12
    



 
 
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