Neurourology and Urodynamics 35:349–353 (2016)
Comparison of the Overactive Bladder Symptom Score and the Overactive Bladder Symptom Score Derived From the Bladder Diaries Kat suya Hikita, Masashi Honda,* Shinji Hirano, Bunya Kawamoto, Tsounapi Panagiota, Kuniyasu Muraoka, Takehiro Sejima, and Atsushi Takenaka Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan Aims: The overactive bladder symptom score (OABSS) is a useful tool for assessing the four key symptoms of overactive bladder (OAB), but it sometimes misrepresents a patient’s actual voiding status. To examine whether the patientdetermined OABSS underestimates or overestimates the true status, its results were compared to those of the OABSS derived from a 7-day bladder diary (OABSS-BD). Methods: Records of patients who visited our outpatient clinic with lower urinary tract symptoms were evaluated retrospectively. The patients were asked to complete the OABSS and the 7day bladder diary (BD). The OABSS-BD was created from the 7-day BD. Questions were compared between the OABSS and the OABSS-BD. Results: A total of 44 men and 31 women were evaluated. For daytime frequency, the mean OABSS score was 1.03 0.57 and the OABSS-BD score was 0.69 0.52 (P < 0.01). For nighttime frequency, the mean OABSS score was 2.27 0.84, and the OABSS-BD score was 1.96 1.00 (P ¼ 0.04). For urinary urgency, the mean OABSS score was 2.49 1.83, and the OABSS-BD score was 2.70 1.90 (P ¼ 0.27). For urgency incontinence, the mean OABSS score was 1.67 1.92, and the OABSS-BD score was 1.52 1.87 (P ¼ 0.28). For the total score, the mean OABSS total score was 7.26 3.92, and the OABSS-BD score was 6.98 3.26 (P ¼ 0.23). Conclusions: The OABSS is a very simple and useful tool. However, compared to the results from the 7-day FVC, the present patients overestimated daytime and nighttime frequency. Neurourol. Urodynam. 35:349–353, 2016. # 2015 Wiley Periodicals, Inc. Key words: lower urinary tract symptoms; overactive bladder; overactive bladder symptom score INTRODUCTION
OAB is defined by the International Continence Society (ICS) as a symptom syndrome of urinary urgency, with or without urgency incontinence, usually with urinary frequency and nocturia, in the absence of infection or other obvious pathologic features.1 Nocturia, defined by the ICS as awakening at night to void one or more times, is the most prevalent lower urinary tract symptom.1 The sleep fragmentation and chronic sleep loss attributable to nocturia have a negative impact on quality of life and are associated with increased morbidity and mortality.2 A significant proportion of patients with lower urinary tract symptoms have nocturia as the most bothersome symptom. Fewer than two voids each night may cause no major problem, while two or more give rise to impaired quality of life due to sleep disturbance.3 There is increasing evidence that a bladder diary with a self-reported grading of urinary perception or urgency scale can be a clinically powerful tool for patient selfassessment of urinary sensory function, especially when the bladder diary can provide not only the voided volumes but also the degree of urgency perception at every single void.4–6 Since OAB is diagnosed by symptoms alone, its assessment is very important for physicians. Multiple tools to assess the impact of OAB have been developed, including OAB symptom scores (OABSS) validated by Homma et al. in 2006 and Blaivas et al. in 2007.7,8 Homma’s OABSS was designed to differentiate between OAB and nonOAB by self-report questionnaire. The OABSS was composed of four questions, including daytime frequency, nighttime frequency, the number of episodes of urgency over seven days, and the number of episodes of urgency incontinence over seven days. The OABSS is a very useful tool, but its results sometimes differ from patients’ actual voiding status, because it is reported #
2015 Wiley Periodicals, Inc.
by the patients themselves. It is considered especially susceptible to age, the patient’s character, living environment, and cerebrovascular disease or dementia.9,10,11 To examine whether patients underestimated or overestimated the OABSS, their self-reported OABSS scores were compared with OABSS scores derived from a 7-day bladder diary (OABSS-BD). METHODS Site
The evaluation site was the Division of Urology, Tottori University Hospital, located in Tottori, Japan. The present study was approved by the Tottori University ethics committee. Patients
Between March 2011 and December 2013, 75 patients, ranging in age from 27 to 90 years, who visited our outpatient clinic suffering from lower urinary tract symptoms, were
Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Nothing to disclose. *Correspondence to: Masashi Honda, MD, PhD, Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, 36-1, Yonago, Tottori 638-8504, Japan. E-mail: [email protected] Received 11 August 2014; Accepted 3 November 2014 Published online 16 January 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22719
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Hikita et al.
investigated. Patients were excluded if they had active urinary tract infections or a urinary tract malignancy. All patients completed the OABSS and the 14-day bladder diary (BD). After 2 weeks, the patients visited the outpatient clinic again, and they were then diagnosed and treated. OAB Evaluation
OAB was diagnosed using the OABSS, which was validated by Homma et al. in 2006.7 Patients were instructed to complete the score for their urinary condition during the past week. The overall score was the sum of the four scores. OAB was diagnosed in patients who reported a total OABSS score of three or more and an urgency score of two or more over the 7 days. Creating OABSS-BD
The 7-day BD record was used to create the OABSS-BD. Daytime frequency, nighttime frequency, the number of urgency episodes over seven days, and the number of urgency incontinence episodes over seven days were scored and calculated using the same method as for the OABSS (Fig. 1). Comparison of the OABSS and OABSS-BD Scores
The mean scores for questions 1-4 and the mean total score were compared between the OABSS and OABSS-BD for all patients, male patients and female patients. Statistical Analysis
All data, presented as the means with standard deviation, were evaluated with the Mann–Whitney U-test, and a P-value of less than 0.05 was considered significant. Correlations between the OABSS and OABSS-BD scores were evaluated using Spearman’s correlation co-efficient, with a Pvalue of less than 0.05 considered significant. Statistical analysis was carried out using the Statistical Package for the Social Sciences (version 19 SPSS Japan Inc., Tokyo, Japan) software package. RESULTS
The forms of 178 patients were collected. A total of 103 patients were excluded from the analysis, because they recorded fewer than 7 days. A total of 44 men and 31 women were evaluated. The mean patient age was 68.9 (range 27–90) years. The 75 patients recorded a total of 772 (mean 10.3) days. As underlying diseases, benign prostatic hyperplasia was diagnosed in 24 patients, nocturnal polyuria in 20 patients, and stress urinary incontinence in one patient (Table I). The mean question 1 (daytime frequency) score was 1.03 0.57 on the OABSS and 0.69 0.52 on the OABSS-BD (P < 0.01) (Table II); but there was significant correlation between them (P ¼ 0.03, r ¼ 0.25). The question 1 scores were equal in 39 patients (52.0%); the difference between the question 1 scores ranged from 1.0 to 1.0. For question 2 (nighttime frequency), the mean score was 2.27 0.84 on the OABSS and 1.96 1.00 on the OABSS-BD (P ¼ 0.04) (Table II); there was a significant correlation between them (P < 0.01, r ¼ 0.68). The question 2 scores were equal in 26 patients (34.7%), and the difference between them ranged from 2.0 to 2.0. For question 3 (urinary urgency), the mean score was 2.49 1.83 on the OABSS and 2.70 1.90 on the OABSS-BD (P ¼ 0.27) (Table II); there was a significant correlation Neurourology and Urodynamics DOI 10.1002/nau
between them (P < 0.01, r ¼ 0.54). The question 3 scores were equal in 21 patients (28.0%), and the difference between them ranged from 4.0 to 4.0. For question 4 (urgency incontinence), the mean score was 1.67 1.92 on the OABSS and 1.52 1.87 on the OABSS-BD (P ¼ 0.28) (Table II); there was a significant correlation between them (P < 0.01, r ¼ 0.76). The question 4 scores were equal in 40 patients (53.3%), and the difference between them ranged from 3.0 to 3.0. The mean OABSS total score was 7.26 3.92, and the mean OABSS-BD score was 6.98 3.26 (P ¼ 0.23) (Table II). There was a significant correlation between the OABSS total score and the OABSS-BD total score (P < 0.01, r ¼ 0.68). The OABSS total score equaled the OABSS-BD total score in seven patients (9.3%), and the difference between the total scores ranged from 6.0 to 7.0. For the male participants, the mean question 1 score was 0.91 0.64 on the OABSS and 0.72 0.54 on the OABSS-BD (P ¼ 0.13) (Table III); there was significant correlation between them (P < 0.01, r ¼ 0.38). The question 1 scores were equal in 23 patients (65.7%); the difference between the question 1 scores ranged from 1.0 to 1.0. For question 2 (nighttime frequency), the mean score was 2.39 0.75 on the OABSS and 2.14 1.02 on the OABSS-BD (P ¼ 0.20) (Table III); there was a significant correlation between them (P < 0.01, r ¼ 0.70). The question 2 scores were equal in 26 patients (59.0%), and the difference between them ranged from 2.0 to 1.0. For question 3 (urinary urgency), the mean score was 2.20 1.91 on the OABSS and 2.43 1.96 on the OABSS-BD (P ¼ 0.36) (Table III); there was a significant correlation between them (P < 0.01, r ¼ 0.63). The question 3 scores were equal in 15 patients (34.0%), and the difference between them ranged from 3.0 to 4.0. For question 4 (urgency incontinence), the mean score was 1.13 1.78 on the OABSS and 1.02 1.65 on the OABSS-BD (P ¼ 0.40) (Table III); there was a significant correlation between them (P < 0.01, r ¼ 0.76). The question 4 scores were equal in 29 patients (65.9%), and the difference between them ranged from 4.0 to 3.0. The mean OABSS total score was 6.61 3.91, and the mean OABSS-BD score was 6.34 3.86 (P ¼ 0.36) (Table III). There was a significant correlation between the OABSS total score and the OABSS-BD total score (P < 0.01, r ¼ 0.70). The OABSS total score equaled the OABSS-BD total score in six patients (13.4%), and the difference between the total scores ranged from 6.0 to 7.0. For the female participants, the mean question 1 score was 1.16 0.45 on the OABSS and 0.64 0.49 on the OABSS-BD (P < 0.01) (Table IV); there was no significant correlation between them (P ¼ 0.44). The question 1 scores were equal in 15 patients (48.4%); the difference between the question 1 scores ranged from 2.0 to 1.0. For question 2 (nighttime frequency), the mean score was 2.13 0.96 on the OABSS and 1.71 0.94 on the OABSS-BD (P < 0.05) (Table IV); there was a significant correlation between them (P < 0.01, r ¼ 0.63). The question 2 scores were equal in eight patients (25.8%), and the difference between them ranged from 2.0 to 0.0. For question 3 (urinary urgency), the mean score was 2.90 1.62 on the OABSS and 3.06 1.75 on the OABSS-BD (P ¼ 0.31) (Table IV); there was no significant correlation between them (P ¼ 0.08). The question 3 scores were equal in seven patients (22.6%), and the difference between them ranged from 3.0 to 4.0. For question 4 (urgency incontinence), the mean score was 2.45 1.86 on the OABSS and 2.23 1.96 on the OABSS-BD (P ¼ 0.31) (Table IV); there was a significant correlation between them (P < 0.01, r ¼ 0.74). The question 4 scores were equal in 10 patients (32.3%), and the difference between them ranged from 2.0 to 3.0. The mean OABSS total score was 8.58 3.71, and the mean OABSS-BD score was 7.87 3.72 (P ¼ 0.20) (Table IV). There was a significant correlation between the OABSS total
Comparison of the Overactive Bladder Symptom Time
voiding volume(ml)
urgency?
incontinence?
351
drinks(ml)
daytime
after sleeping
daytime frequency
nighttime frequency
urinary urgency
urgency incontinence
Fig. 1. Bladder diary.
score and the OABSS-BD total score (P < 0.01, r ¼ 0.60). The OABSS total score equaled the OABSS-BD total score in one patient (3.3%), and the difference between the total scores ranged from 5.0 to 5.0. A total of 43 patients (21 men and 22 women) were diagnosed as having OAB based on the OABSS, but four patients were excluded based on the OABSS-BD. Neurourology and Urodynamics DOI 10.1002/nau
DISCUSSION
Overactive bladder (OAB) is defined as a symptom syndrome of urinary urgency, with or without urgency incontinence, usually with urinary frequency and nocturia, in the absence of infection or other obvious pathologic features.1 OAB greatly affects social, mental, and physical functioning, including
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Hikita et al.
TABLE I. Patients’ Characteristics
No. patients Age (meanSD) BPH Nocturnal polyuria Stress incontinence Neurogenicbladder Medical history HT DM Brain infraction Spinal canal stenosis Cerebral hemorrhage
TABLE III. Comparison of the OABSS Score and the OABSS-BD Score in Male Male
Female
Total
44 70.713.1 24 10 0 0
31 66.414.9 0 10 1 2
75 68.913.9 24 20 1 2
20 11 4 2 2
8 2 1 0 1
28 13 5 2 3
Q-1 Q-2 Q-3 Q-4 Total
OABSS
OABSS-BD
P-value
0.91 0.64 2.39 0.75 2.20 1.91 1.13 1.78 6.61 3.91
0.72 0.54 2.14 1.02 2.43 1.96 1.02 1.65 6.34 3.86
0.13 0.20 0.36 0.40 0.36
Data expressed as mean standard deviation.
work, sleep, sexual relationships, and interpersonal relationships.12–14 Even though OAB is diagnosed by symptoms alone, its assessment is very important for physicians and patients. Many tools to assess the impact of OAB have been developed, including two different OABSS tools (developed by Homma et al. and Blaivas et al.) and the OAB questionnaire (OAB-q). Homma’s OABSS is a single symptom score that uses a selfreport questionnaire to quantify OAB symptoms.7 The score is obtained as the simple sum of four symptom scores, which address the number of daytime voiding, nighttime voiding, urgency, and urgency incontinence.7 Homma mentions that the relative weight across the four scores was determined on the basis of the maximal influence rate of that symptom in an epidemiological survey. Other self-assessment questionnaires usually have many questions with minimum and maximum scores. Because Homma’s OABSS is composed of only four questions, it is easy for patients, especially elderly patients, to answer. On the other hand, for physicians, it is also easy to understand the status of the patients. However, since there are few questions, if the patients themselves overestimate the symptoms, physicians cannot get a good understanding of the severity of the patients’ OAB symptoms. Therefore, the OABSS and the OABSS derived from the 7-day bladder diary (OABSSBD) were compared. In this study, in all patients, the question 1 and 2 score was significantly higher on the OABSS than on the OABSS-BD. Divided into men and women there was no significant difference in men, but the scores for question 1 and 2 in women was significantly higher on the OABSS than on the OABSS-BD. For daytime frequency, various reasons can be considered to explain the overestimation of the OABSS compared to the BD. First, many patients were active during the daytime, so that they might not have been able to be correctly recall the number of micturitions. Moreover, when a patient chooses to score OABSS question 1, 0 is scored for 7 or less daytime micturitions, 1 point for 8 to 14, and 2
for 15 times, and these are wide ranges. Stav et al. also reported that women overestimate day time urinary frequency.10 They considered that patients assume physicians will give more attention to the complaints or perhaps it’s a matter of poor recollection. However, in terms of nighttime frequency, Stav et al. reported that there was no overestimation.10 Our study showed women overestimated nighttime frequency. For overestimation of nighttime frequency, there have been some reports of differences between the International Prostate Symptom Score (IPSS) and the frequency volume chart (FVC).11,16 Haarst et al. reported that the IPSS overestimates nocturia as assessed by the FVC, and Abrams et al. reported that patients who are inconvenienced or disturbed by their symptoms might overemphasize the frequency and severity of their complaints.17 Haarst et al. noted, ‘‘A perfect symptom score should reflect the measured symptom exactly as it is. However, due to the inevitable categorizing of scores a perfect match is not always achieved. Moreover, due to the wide inpatient variation of voiding patterns a single normal voiding pattern does not exist.’’ 11 In this study, because of the few cases, no explanation could be given for the overestimation based on patient characteristics. There were no significant differences between the OABSS and OABSS-BD scores for the other questions and for total scores, and there were significant correlations between the OABSS and OABSS-BD. For the other questions, since they were categorized in detail, there may have been less possibility of overestimation, resulting in no significant differences. Traditionally, questionnaires have many items with the same minimum and maximum scores. In contrast, the OABSS has only 4 questions. For the diagnosis of OAB, the OABSS is very simple and very useful for both patients and physicians. On the other hand, because of its few questions, diagnosis may be difficult when patients overestimate or underestimate. Therefore, a combined evaluation of the symptom score and the BD is required. There are various opinions about the duration of the BD. The ICS has defined the FVC as, ‘‘This records the volumes voided as well as the time of each micturition, day and night, for at least 24 hr.’’1 There are also various reports about the duration of the FVC.18 An excessive duration reduces patients’ compliance, but too short a duration may produce
TABLE II. Comparison of the OABSS Score and the OABSS-BD Score in All Patients
TABLE IV. Comparison of the OABSS Score and the OABSS-BD Score in Female
Q-1 Q-2 Q-3 Q-4 Total
OABSS
OABSS-BD
P-value
1.03 0.57 2.27 0.84 2.49 1.83 1.67 1.92 7.26 3.92
0.69 0.52 1.96 1.00 2.70 1.90 1.52 1.87 6.98 3.26
Comparison of the Overactive Bladder Symptom Score and the Overactive Bladder Symptom Score Derived From the Bladder Diaries Kat suya Hikita, Masashi Honda,* Shinji Hirano, Bunya Kawamoto, Tsounapi Panagiota, Kuniyasu Muraoka, Takehiro Sejima, and Atsushi Takenaka Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan Aims: The overactive bladder symptom score (OABSS) is a useful tool for assessing the four key symptoms of overactive bladder (OAB), but it sometimes misrepresents a patient’s actual voiding status. To examine whether the patientdetermined OABSS underestimates or overestimates the true status, its results were compared to those of the OABSS derived from a 7-day bladder diary (OABSS-BD). Methods: Records of patients who visited our outpatient clinic with lower urinary tract symptoms were evaluated retrospectively. The patients were asked to complete the OABSS and the 7day bladder diary (BD). The OABSS-BD was created from the 7-day BD. Questions were compared between the OABSS and the OABSS-BD. Results: A total of 44 men and 31 women were evaluated. For daytime frequency, the mean OABSS score was 1.03 0.57 and the OABSS-BD score was 0.69 0.52 (P < 0.01). For nighttime frequency, the mean OABSS score was 2.27 0.84, and the OABSS-BD score was 1.96 1.00 (P ¼ 0.04). For urinary urgency, the mean OABSS score was 2.49 1.83, and the OABSS-BD score was 2.70 1.90 (P ¼ 0.27). For urgency incontinence, the mean OABSS score was 1.67 1.92, and the OABSS-BD score was 1.52 1.87 (P ¼ 0.28). For the total score, the mean OABSS total score was 7.26 3.92, and the OABSS-BD score was 6.98 3.26 (P ¼ 0.23). Conclusions: The OABSS is a very simple and useful tool. However, compared to the results from the 7-day FVC, the present patients overestimated daytime and nighttime frequency. Neurourol. Urodynam. 35:349–353, 2016. # 2015 Wiley Periodicals, Inc. Key words: lower urinary tract symptoms; overactive bladder; overactive bladder symptom score INTRODUCTION
OAB is defined by the International Continence Society (ICS) as a symptom syndrome of urinary urgency, with or without urgency incontinence, usually with urinary frequency and nocturia, in the absence of infection or other obvious pathologic features.1 Nocturia, defined by the ICS as awakening at night to void one or more times, is the most prevalent lower urinary tract symptom.1 The sleep fragmentation and chronic sleep loss attributable to nocturia have a negative impact on quality of life and are associated with increased morbidity and mortality.2 A significant proportion of patients with lower urinary tract symptoms have nocturia as the most bothersome symptom. Fewer than two voids each night may cause no major problem, while two or more give rise to impaired quality of life due to sleep disturbance.3 There is increasing evidence that a bladder diary with a self-reported grading of urinary perception or urgency scale can be a clinically powerful tool for patient selfassessment of urinary sensory function, especially when the bladder diary can provide not only the voided volumes but also the degree of urgency perception at every single void.4–6 Since OAB is diagnosed by symptoms alone, its assessment is very important for physicians. Multiple tools to assess the impact of OAB have been developed, including OAB symptom scores (OABSS) validated by Homma et al. in 2006 and Blaivas et al. in 2007.7,8 Homma’s OABSS was designed to differentiate between OAB and nonOAB by self-report questionnaire. The OABSS was composed of four questions, including daytime frequency, nighttime frequency, the number of episodes of urgency over seven days, and the number of episodes of urgency incontinence over seven days. The OABSS is a very useful tool, but its results sometimes differ from patients’ actual voiding status, because it is reported #
2015 Wiley Periodicals, Inc.
by the patients themselves. It is considered especially susceptible to age, the patient’s character, living environment, and cerebrovascular disease or dementia.9,10,11 To examine whether patients underestimated or overestimated the OABSS, their self-reported OABSS scores were compared with OABSS scores derived from a 7-day bladder diary (OABSS-BD). METHODS Site
The evaluation site was the Division of Urology, Tottori University Hospital, located in Tottori, Japan. The present study was approved by the Tottori University ethics committee. Patients
Between March 2011 and December 2013, 75 patients, ranging in age from 27 to 90 years, who visited our outpatient clinic suffering from lower urinary tract symptoms, were
Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Nothing to disclose. *Correspondence to: Masashi Honda, MD, PhD, Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, 36-1, Yonago, Tottori 638-8504, Japan. E-mail: [email protected] Received 11 August 2014; Accepted 3 November 2014 Published online 16 January 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22719
350
Hikita et al.
investigated. Patients were excluded if they had active urinary tract infections or a urinary tract malignancy. All patients completed the OABSS and the 14-day bladder diary (BD). After 2 weeks, the patients visited the outpatient clinic again, and they were then diagnosed and treated. OAB Evaluation
OAB was diagnosed using the OABSS, which was validated by Homma et al. in 2006.7 Patients were instructed to complete the score for their urinary condition during the past week. The overall score was the sum of the four scores. OAB was diagnosed in patients who reported a total OABSS score of three or more and an urgency score of two or more over the 7 days. Creating OABSS-BD
The 7-day BD record was used to create the OABSS-BD. Daytime frequency, nighttime frequency, the number of urgency episodes over seven days, and the number of urgency incontinence episodes over seven days were scored and calculated using the same method as for the OABSS (Fig. 1). Comparison of the OABSS and OABSS-BD Scores
The mean scores for questions 1-4 and the mean total score were compared between the OABSS and OABSS-BD for all patients, male patients and female patients. Statistical Analysis
All data, presented as the means with standard deviation, were evaluated with the Mann–Whitney U-test, and a P-value of less than 0.05 was considered significant. Correlations between the OABSS and OABSS-BD scores were evaluated using Spearman’s correlation co-efficient, with a Pvalue of less than 0.05 considered significant. Statistical analysis was carried out using the Statistical Package for the Social Sciences (version 19 SPSS Japan Inc., Tokyo, Japan) software package. RESULTS
The forms of 178 patients were collected. A total of 103 patients were excluded from the analysis, because they recorded fewer than 7 days. A total of 44 men and 31 women were evaluated. The mean patient age was 68.9 (range 27–90) years. The 75 patients recorded a total of 772 (mean 10.3) days. As underlying diseases, benign prostatic hyperplasia was diagnosed in 24 patients, nocturnal polyuria in 20 patients, and stress urinary incontinence in one patient (Table I). The mean question 1 (daytime frequency) score was 1.03 0.57 on the OABSS and 0.69 0.52 on the OABSS-BD (P < 0.01) (Table II); but there was significant correlation between them (P ¼ 0.03, r ¼ 0.25). The question 1 scores were equal in 39 patients (52.0%); the difference between the question 1 scores ranged from 1.0 to 1.0. For question 2 (nighttime frequency), the mean score was 2.27 0.84 on the OABSS and 1.96 1.00 on the OABSS-BD (P ¼ 0.04) (Table II); there was a significant correlation between them (P < 0.01, r ¼ 0.68). The question 2 scores were equal in 26 patients (34.7%), and the difference between them ranged from 2.0 to 2.0. For question 3 (urinary urgency), the mean score was 2.49 1.83 on the OABSS and 2.70 1.90 on the OABSS-BD (P ¼ 0.27) (Table II); there was a significant correlation Neurourology and Urodynamics DOI 10.1002/nau
between them (P < 0.01, r ¼ 0.54). The question 3 scores were equal in 21 patients (28.0%), and the difference between them ranged from 4.0 to 4.0. For question 4 (urgency incontinence), the mean score was 1.67 1.92 on the OABSS and 1.52 1.87 on the OABSS-BD (P ¼ 0.28) (Table II); there was a significant correlation between them (P < 0.01, r ¼ 0.76). The question 4 scores were equal in 40 patients (53.3%), and the difference between them ranged from 3.0 to 3.0. The mean OABSS total score was 7.26 3.92, and the mean OABSS-BD score was 6.98 3.26 (P ¼ 0.23) (Table II). There was a significant correlation between the OABSS total score and the OABSS-BD total score (P < 0.01, r ¼ 0.68). The OABSS total score equaled the OABSS-BD total score in seven patients (9.3%), and the difference between the total scores ranged from 6.0 to 7.0. For the male participants, the mean question 1 score was 0.91 0.64 on the OABSS and 0.72 0.54 on the OABSS-BD (P ¼ 0.13) (Table III); there was significant correlation between them (P < 0.01, r ¼ 0.38). The question 1 scores were equal in 23 patients (65.7%); the difference between the question 1 scores ranged from 1.0 to 1.0. For question 2 (nighttime frequency), the mean score was 2.39 0.75 on the OABSS and 2.14 1.02 on the OABSS-BD (P ¼ 0.20) (Table III); there was a significant correlation between them (P < 0.01, r ¼ 0.70). The question 2 scores were equal in 26 patients (59.0%), and the difference between them ranged from 2.0 to 1.0. For question 3 (urinary urgency), the mean score was 2.20 1.91 on the OABSS and 2.43 1.96 on the OABSS-BD (P ¼ 0.36) (Table III); there was a significant correlation between them (P < 0.01, r ¼ 0.63). The question 3 scores were equal in 15 patients (34.0%), and the difference between them ranged from 3.0 to 4.0. For question 4 (urgency incontinence), the mean score was 1.13 1.78 on the OABSS and 1.02 1.65 on the OABSS-BD (P ¼ 0.40) (Table III); there was a significant correlation between them (P < 0.01, r ¼ 0.76). The question 4 scores were equal in 29 patients (65.9%), and the difference between them ranged from 4.0 to 3.0. The mean OABSS total score was 6.61 3.91, and the mean OABSS-BD score was 6.34 3.86 (P ¼ 0.36) (Table III). There was a significant correlation between the OABSS total score and the OABSS-BD total score (P < 0.01, r ¼ 0.70). The OABSS total score equaled the OABSS-BD total score in six patients (13.4%), and the difference between the total scores ranged from 6.0 to 7.0. For the female participants, the mean question 1 score was 1.16 0.45 on the OABSS and 0.64 0.49 on the OABSS-BD (P < 0.01) (Table IV); there was no significant correlation between them (P ¼ 0.44). The question 1 scores were equal in 15 patients (48.4%); the difference between the question 1 scores ranged from 2.0 to 1.0. For question 2 (nighttime frequency), the mean score was 2.13 0.96 on the OABSS and 1.71 0.94 on the OABSS-BD (P < 0.05) (Table IV); there was a significant correlation between them (P < 0.01, r ¼ 0.63). The question 2 scores were equal in eight patients (25.8%), and the difference between them ranged from 2.0 to 0.0. For question 3 (urinary urgency), the mean score was 2.90 1.62 on the OABSS and 3.06 1.75 on the OABSS-BD (P ¼ 0.31) (Table IV); there was no significant correlation between them (P ¼ 0.08). The question 3 scores were equal in seven patients (22.6%), and the difference between them ranged from 3.0 to 4.0. For question 4 (urgency incontinence), the mean score was 2.45 1.86 on the OABSS and 2.23 1.96 on the OABSS-BD (P ¼ 0.31) (Table IV); there was a significant correlation between them (P < 0.01, r ¼ 0.74). The question 4 scores were equal in 10 patients (32.3%), and the difference between them ranged from 2.0 to 3.0. The mean OABSS total score was 8.58 3.71, and the mean OABSS-BD score was 7.87 3.72 (P ¼ 0.20) (Table IV). There was a significant correlation between the OABSS total
Comparison of the Overactive Bladder Symptom Time
voiding volume(ml)
urgency?
incontinence?
351
drinks(ml)
daytime
after sleeping
daytime frequency
nighttime frequency
urinary urgency
urgency incontinence
Fig. 1. Bladder diary.
score and the OABSS-BD total score (P < 0.01, r ¼ 0.60). The OABSS total score equaled the OABSS-BD total score in one patient (3.3%), and the difference between the total scores ranged from 5.0 to 5.0. A total of 43 patients (21 men and 22 women) were diagnosed as having OAB based on the OABSS, but four patients were excluded based on the OABSS-BD. Neurourology and Urodynamics DOI 10.1002/nau
DISCUSSION
Overactive bladder (OAB) is defined as a symptom syndrome of urinary urgency, with or without urgency incontinence, usually with urinary frequency and nocturia, in the absence of infection or other obvious pathologic features.1 OAB greatly affects social, mental, and physical functioning, including
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TABLE I. Patients’ Characteristics
No. patients Age (meanSD) BPH Nocturnal polyuria Stress incontinence Neurogenicbladder Medical history HT DM Brain infraction Spinal canal stenosis Cerebral hemorrhage
TABLE III. Comparison of the OABSS Score and the OABSS-BD Score in Male Male
Female
Total
44 70.713.1 24 10 0 0
31 66.414.9 0 10 1 2
75 68.913.9 24 20 1 2
20 11 4 2 2
8 2 1 0 1
28 13 5 2 3
Q-1 Q-2 Q-3 Q-4 Total
OABSS
OABSS-BD
P-value
0.91 0.64 2.39 0.75 2.20 1.91 1.13 1.78 6.61 3.91
0.72 0.54 2.14 1.02 2.43 1.96 1.02 1.65 6.34 3.86
0.13 0.20 0.36 0.40 0.36
Data expressed as mean standard deviation.
work, sleep, sexual relationships, and interpersonal relationships.12–14 Even though OAB is diagnosed by symptoms alone, its assessment is very important for physicians and patients. Many tools to assess the impact of OAB have been developed, including two different OABSS tools (developed by Homma et al. and Blaivas et al.) and the OAB questionnaire (OAB-q). Homma’s OABSS is a single symptom score that uses a selfreport questionnaire to quantify OAB symptoms.7 The score is obtained as the simple sum of four symptom scores, which address the number of daytime voiding, nighttime voiding, urgency, and urgency incontinence.7 Homma mentions that the relative weight across the four scores was determined on the basis of the maximal influence rate of that symptom in an epidemiological survey. Other self-assessment questionnaires usually have many questions with minimum and maximum scores. Because Homma’s OABSS is composed of only four questions, it is easy for patients, especially elderly patients, to answer. On the other hand, for physicians, it is also easy to understand the status of the patients. However, since there are few questions, if the patients themselves overestimate the symptoms, physicians cannot get a good understanding of the severity of the patients’ OAB symptoms. Therefore, the OABSS and the OABSS derived from the 7-day bladder diary (OABSSBD) were compared. In this study, in all patients, the question 1 and 2 score was significantly higher on the OABSS than on the OABSS-BD. Divided into men and women there was no significant difference in men, but the scores for question 1 and 2 in women was significantly higher on the OABSS than on the OABSS-BD. For daytime frequency, various reasons can be considered to explain the overestimation of the OABSS compared to the BD. First, many patients were active during the daytime, so that they might not have been able to be correctly recall the number of micturitions. Moreover, when a patient chooses to score OABSS question 1, 0 is scored for 7 or less daytime micturitions, 1 point for 8 to 14, and 2
for 15 times, and these are wide ranges. Stav et al. also reported that women overestimate day time urinary frequency.10 They considered that patients assume physicians will give more attention to the complaints or perhaps it’s a matter of poor recollection. However, in terms of nighttime frequency, Stav et al. reported that there was no overestimation.10 Our study showed women overestimated nighttime frequency. For overestimation of nighttime frequency, there have been some reports of differences between the International Prostate Symptom Score (IPSS) and the frequency volume chart (FVC).11,16 Haarst et al. reported that the IPSS overestimates nocturia as assessed by the FVC, and Abrams et al. reported that patients who are inconvenienced or disturbed by their symptoms might overemphasize the frequency and severity of their complaints.17 Haarst et al. noted, ‘‘A perfect symptom score should reflect the measured symptom exactly as it is. However, due to the inevitable categorizing of scores a perfect match is not always achieved. Moreover, due to the wide inpatient variation of voiding patterns a single normal voiding pattern does not exist.’’ 11 In this study, because of the few cases, no explanation could be given for the overestimation based on patient characteristics. There were no significant differences between the OABSS and OABSS-BD scores for the other questions and for total scores, and there were significant correlations between the OABSS and OABSS-BD. For the other questions, since they were categorized in detail, there may have been less possibility of overestimation, resulting in no significant differences. Traditionally, questionnaires have many items with the same minimum and maximum scores. In contrast, the OABSS has only 4 questions. For the diagnosis of OAB, the OABSS is very simple and very useful for both patients and physicians. On the other hand, because of its few questions, diagnosis may be difficult when patients overestimate or underestimate. Therefore, a combined evaluation of the symptom score and the BD is required. There are various opinions about the duration of the BD. The ICS has defined the FVC as, ‘‘This records the volumes voided as well as the time of each micturition, day and night, for at least 24 hr.’’1 There are also various reports about the duration of the FVC.18 An excessive duration reduces patients’ compliance, but too short a duration may produce
TABLE II. Comparison of the OABSS Score and the OABSS-BD Score in All Patients
TABLE IV. Comparison of the OABSS Score and the OABSS-BD Score in Female
Q-1 Q-2 Q-3 Q-4 Total
OABSS
OABSS-BD
P-value
1.03 0.57 2.27 0.84 2.49 1.83 1.67 1.92 7.26 3.92
0.69 0.52 1.96 1.00 2.70 1.90 1.52 1.87 6.98 3.26
