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International Journal of Urology (2014) 21, 1027–1033
doi: 10.1111/iju.12519
Original Article: Clinical Investigation
Prevalence of lower urinary tract symptoms, overactive bladder and urinary incontinence in western Turkey: Results of a population-based survey Ali E Zumrutbas,1 Ali I Bozkurt,2 Erdogan Tas,3 Cenk I Acar,4 Okan Alkis,1 Kazim Coban,2 Bulent Cetinel5 and Zafer Aybek1 Departments of 1Urology and 2Public Health, Pamukkale University School of Medicine, 3Denizli Provincial Health Directory, Denizli, 4Department of Urology, Acibadem University School of Medicine, and 5Department of Urology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
Abbreviations & Acronyms ICIQ-SF = International Consultation on Incontinence Questionnaire Short Form ICS = International Continence Society LUTS = lower urinary tract symptoms OAB = overactive bladder PCP = primary care physicians UI = urinary incontinence Correspondence: Ali E Zumrutbas M.D., Pamukkale Universitesi Tip Fakultesi, Uroloji Anabilim Dali, 20070, Kinikli, Denizli, Turkey. Email: [email protected] Received 1 February 2014; accepted 1 May 2014. Online publication 15 June 2014
Objective: To estimate the prevalence of lower urinary tract symptoms, urinary incontinence and overactive bladder in western Turkey. Method: This cross-sectional, population-based survey was carried out between May and October 2012. A random sample of 2128 women and men aged ≥18 years was selected from the health registries. A questionnaire including sociodemographic data, comorbid conditions, lower urinary tract symptoms, overactive bladder and urinary incontinence symptoms, body mass index, vital signs, and dipstick urinalysis was developed. The questions were answered by the participants, and remaining data were provided by the site staff. International Continence Society definitions were used. Results: A total of 1571 (74%) individuals agreed to participate, and analysis were carried out on 1555 people (636 men [40.9%] and 919 women [59.1%]) after 16 individuals with a nitrite-positive dipstick test were excluded. Lower urinary tract symptoms were reported by 71.0% of the study population. The prevalence of storage, voiding and post-micturition symptoms were 56.1% (44.2% men, 64.1% women), 39.3% (40.9% men, 37.8% women) and 30.7% (38.6% men, 28.7% women), respectively. The most prevalent storage symptom was urgency, which was reported by 29.3% of the study population (20.1% men, 35.6% women). The prevalence of urge, stress and mixed urinary incontinence were: 6.5% (3.9% men, 8.2% women), 14.1% (3.9% men, 21.2% women) and 5.6% (0.8% men, 9.0% women), respectively. Conclusion: The present study is the first and largest population-based survey evaluating the prevalence of lower urinary tract symptoms, urinary incontinence and overactive bladder in Turkey. Our findings show these symptoms are highly prevalent in western Turkey.
Key words:
incontinence, lower urinary tract symptoms, overactive bladder, prevalence.
Introduction LUTS are divided into three groups; storage, voiding and postmicturition symptoms, according to the current ICS definitions.1 OAB is a syndrome that is defined as “urgency, with or without urge incontinence usually with frequency and nocturia” and thus is actually a subset of storage LUTS. LUTS, OAB and UI are highly prevalent conditions that have detrimental effects on health-related QoL.2–5 Although the rates present within a wide range because of the inconsistencies between studies, the prevalence of LUTS, OAB and UI range between 13–67%, 7–26%, and 4–50%, respectively.6 The prevalence of these symptoms increases with age.5–7 LUTS also has economic consequences; particularly OAB, which was estimated to have a total cost of €4.2 billion to the healthcare systems of five European countries in 2000, and this is expected to increase to €5.2 billion by 2020.8 Most of the population-based studies regarding LUTS estimated the prevalence of the subsets of LUTS, such as UI and OAB. In addition, there is a tendency to investigate LUTS in men and UI in women.7,9–11 The ICS definition of OAB has led several prevalence studies to use the current OAB definition with consistent findings. In the literature, however, there are only a few largescale population-based studies evaluating the prevalence of all LUTS, including UI and OAB, using the widely accepted ICS definitions and validated questionnaires.2,7,12,13 These assessments are also valid for Turkey, and there have been a few studies regarding the prevalence of UI only in women.9,14–16 Furthermore, only one study investigated the prevalence of © 2014 The Japanese Urological Association
1027
AE ZUMRUTBAS ET AL.
LUTS in men aged ≥40 years, and no studies were carried out to investigate the prevalence of OAB.17 Therefore, the objective of the present study was to estimate the population-based prevalence of LUTS, OAB and UI among men and women aged ≥18 years in western Turkey using validated questionnaires and current ICS definitions.
Methods The present study was designed as a population-based, crosssectional, prevalence study. Pamukkale University School of Medicine Ethics Committee approved the study protocol.
Study group and sampling technique Denizli is a city in the western part of Turkey with a population of approximately 479 000, and according to the data of the provincial health directorate, approximately 320 000 of that population are aged 18 years or older. By using a sample size calculating table, the minimum sample size was determined as 1064. The final study population was determined as 2128 because of the design effect of the cluster sampling method. Primary healthcare for all citizens is provided by 118 PCP at 46 Family Health Centers in urban and rural districts of Denizli. Of these, 40 were randomly assigned and 54 individuals (27 men and 27 women) were selected to participate in the present cross-sectional study by computer randomization from the health registries of each selected PCP. All the selected PCP and their assistant nurses had been instructed about the study and questionnaires before starting the study. An appointment was arranged for each participant, and during personal interview, the study was explained and a written informed consent was obtained. Questionnaires were completed by participants at family health centers. If the individual was not present or unavailable (due to moving, marriage, vacation etc.), a second attempt was made 1 week later, and if he/she could not be contacted again, the next person of the same sex on the health registry list of the PCP was included in the study. If the selected individual was unwilling to participate in the study, no substitution was made.
Questionnaires and definitions The study questionnaire was developed by the study team and consisted of five parts including: (i) sociodemographic data; (ii) comorbid conditions, dietary habits and risk factors; (iii) LUTS, OAB and UI symptoms; (iv) parity, the number and the type of delivery and menopause age; and (v) height, weight, body mass index, blood pressure, heart rate and dipstick urinalysis to be filled out by the site staff. The questionnaires were explained to the participants in detail by the staff, who were previously trained. The site staff were instructed not to engage with the participants while they were completing the questionnaires unless the participant requested assistance with a specific question that was not understood clearly. The 2002 ICS report for the standardization of terminology of LUTS1 was previously translated into Turkish, and linguistic validation was completed by the Turkish Continence Society Terminology Group.18 The definitions in that report were used for LUTS and OAB symptoms. The response options for voiding symptoms were as yes/no, and for storage symptoms, 1028
Table 1
Demographic data of the study population
Sex Age group 18–29 years 30–39 years 40–49 years 50–59 years ≥60 years Educational level Illiterate Literate (below primary school) Primary school graduate Secondary school graduate High school graduate University graduate or higher
Men (%) n = 636
Women (%) n = 919
Total (%) n = 1555
40.9
59.1
100
18.3 23.8 22.9 18.6 16.4
22.3 28.6 20.8 15.2 13.1
20.7 26.6 21.6 16.6 14.5
2.5 1.9 44.7 11.3 20.4 19.2
9.9 3.2 44.7 9.8 19.3 13.2
6.9 2.6 44.7 10.4 19.8 15.6
the frequency (daytime frequency, nocturnal frequency and a Likert scale [every day, >once a week, once a week, once a week (% of urgency†) Urinary incontinence Urge UI Stress UI Mixed UI Other UI Any UI Voiding symptoms Any voiding symptom Splitting or spraying Slow stream Intermittent stream Hesitancy Straining Terminal dribble Postvoiding symptoms Any postvoiding symptom Incomplete emptying Postmicturition dribble Any LUTS Any LUTS (nocturia ≥1 time/night) Any LUTS (nocturia ≥2 times/night) Any LUTS (nocturia ≥3 times/night)
Table 2
642 (70.2)
650 (71.1)
672 (73.5)
141 (15.5) 190 (20.8)
262 (28.7)
341 (37.8) 142 (15.6) 69 (7.6) 161 (17.6) 66 (7.3) 5 (5.5) 205 (22.5)
75 (8.2) 194 (21.2) 82 (9.0) 24 (2.6) 354 (38.7)
283 (31.0) 170 (18.6) 86 (9.4) 287 (31.6) 325 (35.6) 188 (60.3)
548 (60.0)
559 (61.2)
586 (64.1)
n (%)
Total
0.001
0.0001
0.0001
0.707 0.817
0.74
0.402 0.143 0.0001 0.512 0.74 0.125 0.555
0.002 0.0001 0.0001 0.004 0.0001
0.0001 0.0001 0.0001 0.0001 0.0001 0.02
0.0001
0.0001
0.0001
P*
Prevalence of LUTS, OAB and UI in Turkey
AE ZUMRUTBAS ET AL.
(a)
(b) 100,0
60,0
90,0 50,0
80,0 70,0
40,0
60,0 50,0
30,0
40,0 20,0
30,0 20,0
10,0
10,0 0,0
0,0 18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
(c)
18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
(d) 100,0
100,0
90,0
90,0
80,0
80,0
70,0
70,0
60,0
60,0
50,0
50,0
40,0
40,0
30,0
30,0
20,0
20,0
10,0
10,0
0,0
18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
0,0
18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
The most common storage symptom was urgency in women (35.6%) and nocturia (24.8%) in men. Nocturia was observed to become more prominent in men after the age of 40 years and in women after the age of 60 years. When nocturia was defined as voiding “two or more” times each night, the prevalence of nocturia decreased from 24.8% to 16.1% in men and from 31.0% to 18.6% in women, respectively. Urgency, as the dominating symptom of OAB, was reported by 29.3% of the study population (20% of men, 35.7% of women), and the frequency was more than “once a week” in 62.2% (66.4% of men and 60.5% of women). Among the participants with OAB, 30.7% of men (6.1% of total) and 66.7% of women (23.8% of total) reported UI. In men with OAB and UI, UI was due to urge UI alone in 42.5%, stress UI alone in 27.5%, mixed UI in 12.5% and other UI in 17.5%. In women who reported OAB and UI, UI was due to urge UI alone in 19.8%, stress UI alone in 42.2%, mixed UI in 28.7% and other UI in 9.3%.
Prevalence of voiding and postmicturition LUTS The most prevalent voiding and postvoiding symptoms were terminal dribble and postmicturition dribble in both sexes (Fig. 2). In men, voiding symptoms increased with age, and were more prevalent in men older than 50 years. In women, age did not affect the prevalence of the voiding 1030
Fig. 1 Prevalence (%) of (a) storage symptoms, (b) urinary incontinence, (c) voiding symptoms and (d) , Any storage postvoiding symptoms by age. (a) , Nocturia (≥1 time/ symptom (nocturia ≥1; men); , Frequency (men); , Urgency night; men); , Any storage symptom (nocturia ≥1; (men); , Nocturia (≥1 time/night; women); , women); , Urgency (women); (b) , Frequency (women); , Urge UI (men); , Stress UI Any UI (men); , Mixed UI (men); , Other UI (men); , (men); , Urge UI (women); , Stress Any UI (women); , Mixed UI (women); , Other UI UI (women); , Any voiding symptom (men); , (women); (c) , Intermittency (men); , Slow stream (men); , Straining (men); , Terminal Hesitancy (men); , Any voiding symptom (women); dribble (men); , Slow stream (women); , Intermittency , Hesitancy (women); , Straining (women); , Terminal dribble (women); (d) , (women); , Incomplete Any postvoiding symptom (men); , Postmicturition dribble (men); emptying (men); , Any postvoiding symptom (women); , , Postmicturition Incomplete emptying (women); dribble (women).
symptoms except slow stream, which significantly increased in prevalence after 60 years-of-age (P < 0.001). Age did not affect the prevalence of postmicturition symptoms in both sexes.
Prevalence and bother of UI Any UI was reported by 38.7% of women and 9.9% of men. Stress and urge UI were the most common types in men, and stress UI was the most common type in women. Details about the prevalence of UI are given in Table 2. All types of UI among women increased in prevalence with advancing age. In men, such an increasing trend was not observed in all subtypes of UI; however, “any UI” significantly increased after 60 years-of-age (P < 0.05). The frequency and amount of UI were determined by the relevant questions of ICIQ-SF in the questionnaire. The frequency of UI was “once in a week” or less in 58.3% of men and 54.7% of women, “two or three times a week” in 21.7% of men and 21.1% of women, and “everyday” in 20% of men and 24.2 of women. The amount of urinary leak was significantly larger in women with UI, and 18.2% of women were found to have a moderate to high amount of leakage when compared with 5% of men (P < 0.01). The effects of UI on QoL was assessed according to the fifth question of ICIQ-SF, “Overall, how much does leaking urine interfere with your everyday life?”, and the results are presented in Table 3. © 2014 The Japanese Urological Association
Prevalence of LUTS, OAB and UI in Turkey
*Storage Symptom
(b) 50,0 45,0 Prevalence (%) of UI
40,0 70,0 60,0 50,0 40,0 30,0
35,0 30,0 25,0 20,0 15,0 10,0
20,0 10,0 0,0
5,0 0,0
Any UI Urge UI Stress UI Mixed UI Other UI
An yS
S*
(n o No tim ctu ct e/ ria ur ni ≥ ia gh 1 No ≥ t 1 ct tim ) ur ia e/ ni ≥ gh 2 tim t es /n ig ht Fr eq ue nc y Ur ge nc y
Prevalence (%) of storage symptoms
(a)
Prevalence (%) of post-micturition symptoms
(d)
Table 3
45,0 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0,0 Any postvoiding Incomplete Postmicturition symptom emptying dribble
An
Fig. 2 Prevalence (%) of (a) storage symptoms, (b) urinary incontinence, (c) voiding symptoms and (d) postvoiding symptoms by sex. , Men; , Women.
50,0 45,0 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0,0
yv oi d Sp ing lit tin sym p g or tom sp ra y Sl ow ing In stre te rm am itt en He cy sit an c Te Stra y rm in in in g al dr ib bl e
Prevalence (%) of voiding symptoms
(c)
50,0
Table 4
Impact of UI on the QoL
Bother of UI
ICIQ-SF QoL domain†
Male
Female
Total
ICIQ-SF score (mean ± SE)
0 (Not at all) 1–3 (Mild) 4–6 (Moderate) 7–9 (Severe) 10 (Great extent)
35.7% 48.2% 8.9% 7.1% 0.0%
26.9% 47.8% 17.4% 5.7% 2.2%
28.2% 47.8% 16.1% 5.9% 1.9%
Women
Men
Overall
6.09 ± 2.90* 5.89 ± 3.07** 9.19 ± 4.72*,** 7.00 ± 2.00
5.16 ± 2.87 5.43 ± 2.03 8.00 ± 5.15 6.50 ± 3.93
5.89 ± 2.90* 5.85 ± 2.99** 9.12 ± 4.72*,** 6.64 ± 3.41
†ICIQ-SF, fifth question: “Overall, how much does leaking urine interfere with your everyday life?”
The most bothersome types of UI were mixed UI and other UI in the overall population. The mean ICIQ-SF scores in each subtype of UI are presented in Table 4. The difference was significant for mixed UI compared with urge UI and stress UI (P < 0.001). The frequency and the amount of UI significantly affected ICIQ-SF scores in both sexes (Fig. 3).
Discussion The present study is the first population-based epidemiological study carried out in Turkey using the current ICS definitions of LUTS including OAB and UI. The results of our study showed © 2014 The Japanese Urological Association
Urge UI Stress UI Mixed UI Other UI
*P < 0.001, **P < 0.001.
that LUTS are highly prevalent (44.2% in men and 64.1% in women) in our country, specifically western Turkey. After the ICS definition in 2002, several large-scale population-based trials evaluated the prevalence of OAB all over the world.7,13,20–23 Although higher prevalence rates were reported in the older studies,5,24 recent studies using the current definition reported the prevalence of OAB between 6.5% and 15.8% in men, and 9.3% and 32.6% in women. As the classification of a symptom including the frequency can influence the results, we also added a Likert scale for urgency. If the participants who had symptoms once a week or less frequently were regarded as normal and excluded from the analysis, the OAB 1031
AE ZUMRUTBAS ET AL.
(b)
20
20
16
16
12 P < 0.001 P < 0.001
8
4
ICIQ-SF score
ICIQ-SF score
(a)
P < 0.001 P < 0.001
12
8
4
0
0 ≤ 1 time/week
2-3 times/week
≥ 1 time/week
Small
prevalence decreases to 13.3% in men and 21.6% in women, which is within the limits of the current literature. Using such a classification in a national community prevalence of OAB study by Coyne et al., the prevalence rates of OAB decreased from 27.2% to 15.8% in men, and from 43.1% to 32.6% in women. In addition, the present results confirm those of previous studies, which suggested that the prevalence of OAB increases with age and that OAB is more prevalent in women. In the ICS Standardization Sub-committee report, the current definition of OAB is based on urgency, and the majority of the recent studies determined the prevalence of OAB as the prevalence of “urgency”, which is the dominating symptom of OAB.7,12,13,25 Temml et al. also included UI in the prevalence estimates, and classified OAB as OABdry and OABwet with prevalence rates of 8.4% and 1.8% in men, and 10.3% and 6.5% in women, respectively.23 Although the prevalence rates of OAB are higher in the present study, 30.7% of men and 66.7% of women with OAB had UI (OABwet). As also shown by Temml et al., among people having OAB in the present study, women had higher rates of UI when compared with men. Although the consensual ICS definition adheres to the nocturia cut-off of one void per night, some authors suggest that choosing two voids per night might be more clinically relevant and better correlated to QoL impairment.25 The present results showing the significant decrease in the prevalence of nocturia according to the latter definition support this suggestion. The published prevalence of nocturia using ICS definition ranges from 30% to 53%.7,26 The prevalence rates of nocturia in the present study are close to the lower limits presented in the literature. Our findings are consistent with other epidemiological studies of LUTS that also showed that the prevalence of voiding symptoms increased with age in men, especially those older than 40 years-of-age.7,12,13,17 In women, the prevalence of voiding symptoms was not affected by increasing age. The only exception to this was “slow stream”, which significantly increased in prevalence after 60 years-of-age in women. When compared with recent large-scale epidemiological studies, the prevalence rates of voiding symptoms are slightly higher in our population. The most prevalent voiding symptoms in the present study were terminal dribble (26.8% in men and 22.5% in women) and intermittency (20.5% in men and 17.6% in women), which contributed to the overall high prevalence rate. The findings of the Fourth International Consultation on Incontinence showed prevalence rates for any UI of all types 1032
Moderate
Large
Fig. 3 The effect of the frequency and the amount , Women; , Men. of UI on ICIQ-SF score.
ranging from 7% to 63% in women and 2% to 53% in men.27 Severity and bother of a symptom is also important when considering its significance. As the frequency and amount of UI were determined by the addition of ICIQ-SF, the present study gives an idea about the relative prevalence and bother of UI. The frequency of UI was more than “once in a week” in nearly half of the participants. A similar threshold was included in the EpiLUTS study, and when “often” was considered as the frequency, the prevalence rates of stress UI and urge UI decreased to almost half of the rates of the “sometimes” threshold.12 In addition to the frequency and severity, the bother of UI was also assessed in the present study. A previous study investigating the prevalence, risk factors and impact on QoL in Turkey showed that the bothersome effect of UI remained mostly at the mild or moderate level.9 The present findings were consistent with that study. The bother of UI in women was extensively investigated in previous studies; however, there is a lack of data about the correlation between the amount and the frequency of UI and QoL.9 In the present study, a positive correlation was shown. Despite the advanced studies carried out in women, the epidemiology of UI in men has not been investigated to the same extent. The majority of the studies investigating UI in men mostly included the old population, and a systematic review of 21 studies reported a prevalence of UI in that population ranging from 11% to 34%.28 In the same review, the prevalence of UI in the male population was between 2% and 11%.28,29 The results of the present study have shown the prevalence of UI in men as 9.9%, which is within the limits of that review. Urge and stress UI were the most prevalent subtypes in men. Recent large-scale epidemiological studies on LUTS, however, reported lesser rates ranging from 5.0% to 5.4%.7,30 The methodology of the present study differed from the previously published large-scale trials, which included questionnaires administered by telephone or internet. In the present study, the questionnaires were administered in primary healthcare centers. Although the questions were answered by the participants, the study was briefly explained and informed consents were obtained by trained healthcare professionals. The participants had the opportunity to request explanations to prevent misunderstanding any questions and also to overcome literacy problems. Another advantage of our methodology was the sampling technique, which represented our population exactly, as we determined the participants from equally distributed population records randomly. In previously published studies, telephone numbers or email addresses were selected © 2014 The Japanese Urological Association
Prevalence of LUTS, OAB and UI in Turkey
from official records, which might cause selection bias.2,7,12,13 Because we included dipstick analysis in the present study, the presence of a urinary tract infection was confirmed by a positive nitrite test in 0.9% of men and 1.0% of women who were further excluded from the study. In the EPIC study, approximately 1.4% of men and 1.8% of women had reported symptoms of UTI; however, the results were not clinically confirmed.7 Although designed as a population-based study and carried out in a large sample of people, there were limitations to the present study. The questionnaires were completed by the participants; however, trained physicians and nurses helped illiterate participants (6.9%) to complete the questionnaires. The staff that participated in the present study did not intervene otherwise, unless the participant had any questions or concerns about the questionnaire. The response rate (74%) in our study was higher than the response rates of previous large-scale prevalence studies, which ranged from 22.1% to 66%.2,7,12,13 We suppose that inviting the participants to healthcare centers might contribute to the high response rate in our study. In conclusion, the present study is the first and largest population-based survey evaluating the prevalence of LUTS, UI and OAB in Turkey using the ICS definitions. The results of the present study showed that these symptoms are highly prevalent in our region. Increasing age is an important risk factor for the majority of LUTS. In addition to the population prevalence rates, other risk factors of LUTS, OAB and UI can be investigated in further large-scale population-based studies.
Acknowledgments The authors thank all primary care physicians and their assistant nurses working in the family healthcare centers for their valuable time and devoted effort. This study would not be possible without their dedication and wholehearted collaboration, which motivated us throughout the study period.
Conflict of interest None declared.
References 1 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol. Urodyn. 2002; 21: 167–78. 2 Coyne KS, Sexton CC, Bell JA et al. The prevalence of lower urinary tract symptoms (LUTS) and overactive bladder (OAB) by racial/ethnic group and age: results from OAB-POLL. Neurourol. Urodyn. 2013; 32: 230–7. 3 Coyne KS, Sexton CC, Irwin DE, Kopp ZS, Kelleher CJ, Milsom I. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int. 2008; 101: 1388–95. 4 Milsom I, Kaplan SA, Coyne KS, Sexton CC, Kopp ZS. Effect of bothersome overactive bladder symptoms on health-related quality of life, anxiety, depression, and treatment seeking in the United States: results from EpiLUTS. Urology 2012; 80: 90–6. 5 Stewart WF, Van Rooyen JB, Cundiff GW et al. Prevalence and burden of overactive bladder in the United States. World J. Urol. 2003; 20: 327–36. 6 Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int. 2011; 108: 1132–8.
© 2014 The Japanese Urological Association
7 Irwin DE, Milsom I, Hunskaar 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; discussion 1314–15. 8 Reeves P, Irwin D, Kelleher C et al. The current and future burden and cost of overactive bladder in five European countries. Eur. Urol. 2006; 50: 1050–7. 9 Kocak I, Okyay P, Dundar M, Erol H, Beser E. Female urinary incontinence in the west of Turkey: prevalence, risk factors and impact on quality of life. Eur. Urol. 2005; 48: 634–41. 10 Logie J, Clifford GM, Farmer RD. Incidence, prevalence and management of lower urinary tract symptoms in men in the UK. BJU Int. 2005; 95: 557–62. 11 Ojengbede OA, Morhason-Bello IO, Adedokun BO, Okonkwo NS, Kolade CO. Prevalence and the associated trigger factors of urinary incontinence among 5000 black women in sub-Saharan Africa: findings from a community survey. BJU Int. 2011; 107: 1793–800. 12 Coyne KS, Sexton CC, Thompson CL 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. 13 Lee YS, Lee KS, Jung JH et al. Prevalence of overactive bladder, urinary incontinence, and lower urinary tract symptoms: results of Korean EPIC study. World J. Urol. 2011; 29: 185–90. 14 Cetinel B, Demirkesen O, Tarcan T et al. Hidden female urinary incontinence in urology and obstetrics and gynecology outpatient clinics in Turkey: what are the determinants of bothersome urinary incontinence and help-seeking behavior? Int. Urogynecol. J. Pelvic Floor Dysfunct. 2007; 18: 659–64. 15 Onur R, Deveci SE, Rahman S, Sevindik F, Acik Y. Prevalence and risk factors of female urinary incontinence in eastern Turkey. Int. J. Urol. 2009; 16: 566–9. 16 Tozun M, Ayranci U, Unsal A. Prevalence of urinary incontinence among women and its impact on quality of life in a semirural area of Western Turkey. Gynecol. Obstet. Invest. 2009; 67: 241–9. 17 Tuncay Aki F, Aygun C, Bilir N, Erkan I, Ozen H. Prevalence of lower urinary tract symptoms in a community-based survey of men in Turkey. Int. J. Urol. 2003; 10: 364–70. 18 Arıkan N, Koçak T, Seçkin B, Tarcan T. Kontinans Derneg˘i Terminoloji Standardizasyon Raporu. Kontinans Derneg˘i, Ankara, 2010. 19 Çetinel B, Özkan B, Can G. The validation study of ICIQ-SF Turkish version. Turk. J. Urol. 2004; 30: 332–8. 20 Coyne KS, Sexton CC, Vats V, Thompson C, Kopp ZS, Milsom I. National community prevalence of overactive bladder in the United States stratified by sex and age. Urology 2011; 77: 1081–7. 21 Safarinejad MR. Prevalence of the overactive bladder among Iranian women based on the International Continence Society definition: a population-based study. Int. Urol. Nephrol. 2009; 41: 35–45. 22 Teloken C, Caraver F, Weber FA et al. Overactive bladder: prevalence and implications in Brazil. Eur. Urol. 2006; 49: 1087–92. 23 Temml C, Heidler S, Ponholzer A, Madersbacher S. Prevalence of the overactive bladder syndrome by applying the International Continence Society definition. Eur. Urol. 2005; 48: 622–7. 24 Milsom I, Abrams P, Cardozo L, Roberts RG, Thuroff J, Wein AJ. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001; 87: 760–6. 25 Cornu JN, Abrams P, Chapple CR et al. A contemporary assessment of nocturia: definition, epidemiology, pathophysiology, and management-a systematic review and meta-analysis. Eur. Urol. 2012; 62: 877–90. 26 Bosch JL, Weiss JP. The prevalence and causes of nocturia. J. Urol. 2010; 184: 440–6. 27 Buckley BS, Lapitan MC. Prevalence of urinary incontinence in men, women, and children-current evidence: findings of the Fourth International Consultation on Incontinence. Urology 2010; 76: 265–70. 28 Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J. Am. Geriatr. Soc. 1998; 46: 473–80. 29 Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U, Thom D. Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Abrams P, Cardozo L, Khoury S, Wein A (eds). Incontinence (4th International Consultation on Incontinence), 4th edn. Health Publication Ltd, Paris, France, 2009; 35–112. 30 Herschorn S, Gajewski J, Schulz J, Corcos J. A population-based study of urinary symptoms and incontinence: the Canadian Urinary Bladder Survey. BJU Int. 2008; 101: 52–8.
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International Journal of Urology (2014) 21, 1027–1033
doi: 10.1111/iju.12519
Original Article: Clinical Investigation
Prevalence of lower urinary tract symptoms, overactive bladder and urinary incontinence in western Turkey: Results of a population-based survey Ali E Zumrutbas,1 Ali I Bozkurt,2 Erdogan Tas,3 Cenk I Acar,4 Okan Alkis,1 Kazim Coban,2 Bulent Cetinel5 and Zafer Aybek1 Departments of 1Urology and 2Public Health, Pamukkale University School of Medicine, 3Denizli Provincial Health Directory, Denizli, 4Department of Urology, Acibadem University School of Medicine, and 5Department of Urology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
Abbreviations & Acronyms ICIQ-SF = International Consultation on Incontinence Questionnaire Short Form ICS = International Continence Society LUTS = lower urinary tract symptoms OAB = overactive bladder PCP = primary care physicians UI = urinary incontinence Correspondence: Ali E Zumrutbas M.D., Pamukkale Universitesi Tip Fakultesi, Uroloji Anabilim Dali, 20070, Kinikli, Denizli, Turkey. Email: [email protected] Received 1 February 2014; accepted 1 May 2014. Online publication 15 June 2014
Objective: To estimate the prevalence of lower urinary tract symptoms, urinary incontinence and overactive bladder in western Turkey. Method: This cross-sectional, population-based survey was carried out between May and October 2012. A random sample of 2128 women and men aged ≥18 years was selected from the health registries. A questionnaire including sociodemographic data, comorbid conditions, lower urinary tract symptoms, overactive bladder and urinary incontinence symptoms, body mass index, vital signs, and dipstick urinalysis was developed. The questions were answered by the participants, and remaining data were provided by the site staff. International Continence Society definitions were used. Results: A total of 1571 (74%) individuals agreed to participate, and analysis were carried out on 1555 people (636 men [40.9%] and 919 women [59.1%]) after 16 individuals with a nitrite-positive dipstick test were excluded. Lower urinary tract symptoms were reported by 71.0% of the study population. The prevalence of storage, voiding and post-micturition symptoms were 56.1% (44.2% men, 64.1% women), 39.3% (40.9% men, 37.8% women) and 30.7% (38.6% men, 28.7% women), respectively. The most prevalent storage symptom was urgency, which was reported by 29.3% of the study population (20.1% men, 35.6% women). The prevalence of urge, stress and mixed urinary incontinence were: 6.5% (3.9% men, 8.2% women), 14.1% (3.9% men, 21.2% women) and 5.6% (0.8% men, 9.0% women), respectively. Conclusion: The present study is the first and largest population-based survey evaluating the prevalence of lower urinary tract symptoms, urinary incontinence and overactive bladder in Turkey. Our findings show these symptoms are highly prevalent in western Turkey.
Key words:
incontinence, lower urinary tract symptoms, overactive bladder, prevalence.
Introduction LUTS are divided into three groups; storage, voiding and postmicturition symptoms, according to the current ICS definitions.1 OAB is a syndrome that is defined as “urgency, with or without urge incontinence usually with frequency and nocturia” and thus is actually a subset of storage LUTS. LUTS, OAB and UI are highly prevalent conditions that have detrimental effects on health-related QoL.2–5 Although the rates present within a wide range because of the inconsistencies between studies, the prevalence of LUTS, OAB and UI range between 13–67%, 7–26%, and 4–50%, respectively.6 The prevalence of these symptoms increases with age.5–7 LUTS also has economic consequences; particularly OAB, which was estimated to have a total cost of €4.2 billion to the healthcare systems of five European countries in 2000, and this is expected to increase to €5.2 billion by 2020.8 Most of the population-based studies regarding LUTS estimated the prevalence of the subsets of LUTS, such as UI and OAB. In addition, there is a tendency to investigate LUTS in men and UI in women.7,9–11 The ICS definition of OAB has led several prevalence studies to use the current OAB definition with consistent findings. In the literature, however, there are only a few largescale population-based studies evaluating the prevalence of all LUTS, including UI and OAB, using the widely accepted ICS definitions and validated questionnaires.2,7,12,13 These assessments are also valid for Turkey, and there have been a few studies regarding the prevalence of UI only in women.9,14–16 Furthermore, only one study investigated the prevalence of © 2014 The Japanese Urological Association
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AE ZUMRUTBAS ET AL.
LUTS in men aged ≥40 years, and no studies were carried out to investigate the prevalence of OAB.17 Therefore, the objective of the present study was to estimate the population-based prevalence of LUTS, OAB and UI among men and women aged ≥18 years in western Turkey using validated questionnaires and current ICS definitions.
Methods The present study was designed as a population-based, crosssectional, prevalence study. Pamukkale University School of Medicine Ethics Committee approved the study protocol.
Study group and sampling technique Denizli is a city in the western part of Turkey with a population of approximately 479 000, and according to the data of the provincial health directorate, approximately 320 000 of that population are aged 18 years or older. By using a sample size calculating table, the minimum sample size was determined as 1064. The final study population was determined as 2128 because of the design effect of the cluster sampling method. Primary healthcare for all citizens is provided by 118 PCP at 46 Family Health Centers in urban and rural districts of Denizli. Of these, 40 were randomly assigned and 54 individuals (27 men and 27 women) were selected to participate in the present cross-sectional study by computer randomization from the health registries of each selected PCP. All the selected PCP and their assistant nurses had been instructed about the study and questionnaires before starting the study. An appointment was arranged for each participant, and during personal interview, the study was explained and a written informed consent was obtained. Questionnaires were completed by participants at family health centers. If the individual was not present or unavailable (due to moving, marriage, vacation etc.), a second attempt was made 1 week later, and if he/she could not be contacted again, the next person of the same sex on the health registry list of the PCP was included in the study. If the selected individual was unwilling to participate in the study, no substitution was made.
Questionnaires and definitions The study questionnaire was developed by the study team and consisted of five parts including: (i) sociodemographic data; (ii) comorbid conditions, dietary habits and risk factors; (iii) LUTS, OAB and UI symptoms; (iv) parity, the number and the type of delivery and menopause age; and (v) height, weight, body mass index, blood pressure, heart rate and dipstick urinalysis to be filled out by the site staff. The questionnaires were explained to the participants in detail by the staff, who were previously trained. The site staff were instructed not to engage with the participants while they were completing the questionnaires unless the participant requested assistance with a specific question that was not understood clearly. The 2002 ICS report for the standardization of terminology of LUTS1 was previously translated into Turkish, and linguistic validation was completed by the Turkish Continence Society Terminology Group.18 The definitions in that report were used for LUTS and OAB symptoms. The response options for voiding symptoms were as yes/no, and for storage symptoms, 1028
Table 1
Demographic data of the study population
Sex Age group 18–29 years 30–39 years 40–49 years 50–59 years ≥60 years Educational level Illiterate Literate (below primary school) Primary school graduate Secondary school graduate High school graduate University graduate or higher
Men (%) n = 636
Women (%) n = 919
Total (%) n = 1555
40.9
59.1
100
18.3 23.8 22.9 18.6 16.4
22.3 28.6 20.8 15.2 13.1
20.7 26.6 21.6 16.6 14.5
2.5 1.9 44.7 11.3 20.4 19.2
9.9 3.2 44.7 9.8 19.3 13.2
6.9 2.6 44.7 10.4 19.8 15.6
the frequency (daytime frequency, nocturnal frequency and a Likert scale [every day, >once a week, once a week, once a week (% of urgency†) Urinary incontinence Urge UI Stress UI Mixed UI Other UI Any UI Voiding symptoms Any voiding symptom Splitting or spraying Slow stream Intermittent stream Hesitancy Straining Terminal dribble Postvoiding symptoms Any postvoiding symptom Incomplete emptying Postmicturition dribble Any LUTS Any LUTS (nocturia ≥1 time/night) Any LUTS (nocturia ≥2 times/night) Any LUTS (nocturia ≥3 times/night)
Table 2
642 (70.2)
650 (71.1)
672 (73.5)
141 (15.5) 190 (20.8)
262 (28.7)
341 (37.8) 142 (15.6) 69 (7.6) 161 (17.6) 66 (7.3) 5 (5.5) 205 (22.5)
75 (8.2) 194 (21.2) 82 (9.0) 24 (2.6) 354 (38.7)
283 (31.0) 170 (18.6) 86 (9.4) 287 (31.6) 325 (35.6) 188 (60.3)
548 (60.0)
559 (61.2)
586 (64.1)
n (%)
Total
0.001
0.0001
0.0001
0.707 0.817
0.74
0.402 0.143 0.0001 0.512 0.74 0.125 0.555
0.002 0.0001 0.0001 0.004 0.0001
0.0001 0.0001 0.0001 0.0001 0.0001 0.02
0.0001
0.0001
0.0001
P*
Prevalence of LUTS, OAB and UI in Turkey
AE ZUMRUTBAS ET AL.
(a)
(b) 100,0
60,0
90,0 50,0
80,0 70,0
40,0
60,0 50,0
30,0
40,0 20,0
30,0 20,0
10,0
10,0 0,0
0,0 18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
(c)
18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
(d) 100,0
100,0
90,0
90,0
80,0
80,0
70,0
70,0
60,0
60,0
50,0
50,0
40,0
40,0
30,0
30,0
20,0
20,0
10,0
10,0
0,0
18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
0,0
18-29 y 30-39 y 40-49 y 50-59 y ≥60 y
The most common storage symptom was urgency in women (35.6%) and nocturia (24.8%) in men. Nocturia was observed to become more prominent in men after the age of 40 years and in women after the age of 60 years. When nocturia was defined as voiding “two or more” times each night, the prevalence of nocturia decreased from 24.8% to 16.1% in men and from 31.0% to 18.6% in women, respectively. Urgency, as the dominating symptom of OAB, was reported by 29.3% of the study population (20% of men, 35.7% of women), and the frequency was more than “once a week” in 62.2% (66.4% of men and 60.5% of women). Among the participants with OAB, 30.7% of men (6.1% of total) and 66.7% of women (23.8% of total) reported UI. In men with OAB and UI, UI was due to urge UI alone in 42.5%, stress UI alone in 27.5%, mixed UI in 12.5% and other UI in 17.5%. In women who reported OAB and UI, UI was due to urge UI alone in 19.8%, stress UI alone in 42.2%, mixed UI in 28.7% and other UI in 9.3%.
Prevalence of voiding and postmicturition LUTS The most prevalent voiding and postvoiding symptoms were terminal dribble and postmicturition dribble in both sexes (Fig. 2). In men, voiding symptoms increased with age, and were more prevalent in men older than 50 years. In women, age did not affect the prevalence of the voiding 1030
Fig. 1 Prevalence (%) of (a) storage symptoms, (b) urinary incontinence, (c) voiding symptoms and (d) , Any storage postvoiding symptoms by age. (a) , Nocturia (≥1 time/ symptom (nocturia ≥1; men); , Frequency (men); , Urgency night; men); , Any storage symptom (nocturia ≥1; (men); , Nocturia (≥1 time/night; women); , women); , Urgency (women); (b) , Frequency (women); , Urge UI (men); , Stress UI Any UI (men); , Mixed UI (men); , Other UI (men); , (men); , Urge UI (women); , Stress Any UI (women); , Mixed UI (women); , Other UI UI (women); , Any voiding symptom (men); , (women); (c) , Intermittency (men); , Slow stream (men); , Straining (men); , Terminal Hesitancy (men); , Any voiding symptom (women); dribble (men); , Slow stream (women); , Intermittency , Hesitancy (women); , Straining (women); , Terminal dribble (women); (d) , (women); , Incomplete Any postvoiding symptom (men); , Postmicturition dribble (men); emptying (men); , Any postvoiding symptom (women); , , Postmicturition Incomplete emptying (women); dribble (women).
symptoms except slow stream, which significantly increased in prevalence after 60 years-of-age (P < 0.001). Age did not affect the prevalence of postmicturition symptoms in both sexes.
Prevalence and bother of UI Any UI was reported by 38.7% of women and 9.9% of men. Stress and urge UI were the most common types in men, and stress UI was the most common type in women. Details about the prevalence of UI are given in Table 2. All types of UI among women increased in prevalence with advancing age. In men, such an increasing trend was not observed in all subtypes of UI; however, “any UI” significantly increased after 60 years-of-age (P < 0.05). The frequency and amount of UI were determined by the relevant questions of ICIQ-SF in the questionnaire. The frequency of UI was “once in a week” or less in 58.3% of men and 54.7% of women, “two or three times a week” in 21.7% of men and 21.1% of women, and “everyday” in 20% of men and 24.2 of women. The amount of urinary leak was significantly larger in women with UI, and 18.2% of women were found to have a moderate to high amount of leakage when compared with 5% of men (P < 0.01). The effects of UI on QoL was assessed according to the fifth question of ICIQ-SF, “Overall, how much does leaking urine interfere with your everyday life?”, and the results are presented in Table 3. © 2014 The Japanese Urological Association
Prevalence of LUTS, OAB and UI in Turkey
*Storage Symptom
(b) 50,0 45,0 Prevalence (%) of UI
40,0 70,0 60,0 50,0 40,0 30,0
35,0 30,0 25,0 20,0 15,0 10,0
20,0 10,0 0,0
5,0 0,0
Any UI Urge UI Stress UI Mixed UI Other UI
An yS
S*
(n o No tim ctu ct e/ ria ur ni ≥ ia gh 1 No ≥ t 1 ct tim ) ur ia e/ ni ≥ gh 2 tim t es /n ig ht Fr eq ue nc y Ur ge nc y
Prevalence (%) of storage symptoms
(a)
Prevalence (%) of post-micturition symptoms
(d)
Table 3
45,0 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0,0 Any postvoiding Incomplete Postmicturition symptom emptying dribble
An
Fig. 2 Prevalence (%) of (a) storage symptoms, (b) urinary incontinence, (c) voiding symptoms and (d) postvoiding symptoms by sex. , Men; , Women.
50,0 45,0 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0,0
yv oi d Sp ing lit tin sym p g or tom sp ra y Sl ow ing In stre te rm am itt en He cy sit an c Te Stra y rm in in in g al dr ib bl e
Prevalence (%) of voiding symptoms
(c)
50,0
Table 4
Impact of UI on the QoL
Bother of UI
ICIQ-SF QoL domain†
Male
Female
Total
ICIQ-SF score (mean ± SE)
0 (Not at all) 1–3 (Mild) 4–6 (Moderate) 7–9 (Severe) 10 (Great extent)
35.7% 48.2% 8.9% 7.1% 0.0%
26.9% 47.8% 17.4% 5.7% 2.2%
28.2% 47.8% 16.1% 5.9% 1.9%
Women
Men
Overall
6.09 ± 2.90* 5.89 ± 3.07** 9.19 ± 4.72*,** 7.00 ± 2.00
5.16 ± 2.87 5.43 ± 2.03 8.00 ± 5.15 6.50 ± 3.93
5.89 ± 2.90* 5.85 ± 2.99** 9.12 ± 4.72*,** 6.64 ± 3.41
†ICIQ-SF, fifth question: “Overall, how much does leaking urine interfere with your everyday life?”
The most bothersome types of UI were mixed UI and other UI in the overall population. The mean ICIQ-SF scores in each subtype of UI are presented in Table 4. The difference was significant for mixed UI compared with urge UI and stress UI (P < 0.001). The frequency and the amount of UI significantly affected ICIQ-SF scores in both sexes (Fig. 3).
Discussion The present study is the first population-based epidemiological study carried out in Turkey using the current ICS definitions of LUTS including OAB and UI. The results of our study showed © 2014 The Japanese Urological Association
Urge UI Stress UI Mixed UI Other UI
*P < 0.001, **P < 0.001.
that LUTS are highly prevalent (44.2% in men and 64.1% in women) in our country, specifically western Turkey. After the ICS definition in 2002, several large-scale population-based trials evaluated the prevalence of OAB all over the world.7,13,20–23 Although higher prevalence rates were reported in the older studies,5,24 recent studies using the current definition reported the prevalence of OAB between 6.5% and 15.8% in men, and 9.3% and 32.6% in women. As the classification of a symptom including the frequency can influence the results, we also added a Likert scale for urgency. If the participants who had symptoms once a week or less frequently were regarded as normal and excluded from the analysis, the OAB 1031
AE ZUMRUTBAS ET AL.
(b)
20
20
16
16
12 P < 0.001 P < 0.001
8
4
ICIQ-SF score
ICIQ-SF score
(a)
P < 0.001 P < 0.001
12
8
4
0
0 ≤ 1 time/week
2-3 times/week
≥ 1 time/week
Small
prevalence decreases to 13.3% in men and 21.6% in women, which is within the limits of the current literature. Using such a classification in a national community prevalence of OAB study by Coyne et al., the prevalence rates of OAB decreased from 27.2% to 15.8% in men, and from 43.1% to 32.6% in women. In addition, the present results confirm those of previous studies, which suggested that the prevalence of OAB increases with age and that OAB is more prevalent in women. In the ICS Standardization Sub-committee report, the current definition of OAB is based on urgency, and the majority of the recent studies determined the prevalence of OAB as the prevalence of “urgency”, which is the dominating symptom of OAB.7,12,13,25 Temml et al. also included UI in the prevalence estimates, and classified OAB as OABdry and OABwet with prevalence rates of 8.4% and 1.8% in men, and 10.3% and 6.5% in women, respectively.23 Although the prevalence rates of OAB are higher in the present study, 30.7% of men and 66.7% of women with OAB had UI (OABwet). As also shown by Temml et al., among people having OAB in the present study, women had higher rates of UI when compared with men. Although the consensual ICS definition adheres to the nocturia cut-off of one void per night, some authors suggest that choosing two voids per night might be more clinically relevant and better correlated to QoL impairment.25 The present results showing the significant decrease in the prevalence of nocturia according to the latter definition support this suggestion. The published prevalence of nocturia using ICS definition ranges from 30% to 53%.7,26 The prevalence rates of nocturia in the present study are close to the lower limits presented in the literature. Our findings are consistent with other epidemiological studies of LUTS that also showed that the prevalence of voiding symptoms increased with age in men, especially those older than 40 years-of-age.7,12,13,17 In women, the prevalence of voiding symptoms was not affected by increasing age. The only exception to this was “slow stream”, which significantly increased in prevalence after 60 years-of-age in women. When compared with recent large-scale epidemiological studies, the prevalence rates of voiding symptoms are slightly higher in our population. The most prevalent voiding symptoms in the present study were terminal dribble (26.8% in men and 22.5% in women) and intermittency (20.5% in men and 17.6% in women), which contributed to the overall high prevalence rate. The findings of the Fourth International Consultation on Incontinence showed prevalence rates for any UI of all types 1032
Moderate
Large
Fig. 3 The effect of the frequency and the amount , Women; , Men. of UI on ICIQ-SF score.
ranging from 7% to 63% in women and 2% to 53% in men.27 Severity and bother of a symptom is also important when considering its significance. As the frequency and amount of UI were determined by the addition of ICIQ-SF, the present study gives an idea about the relative prevalence and bother of UI. The frequency of UI was more than “once in a week” in nearly half of the participants. A similar threshold was included in the EpiLUTS study, and when “often” was considered as the frequency, the prevalence rates of stress UI and urge UI decreased to almost half of the rates of the “sometimes” threshold.12 In addition to the frequency and severity, the bother of UI was also assessed in the present study. A previous study investigating the prevalence, risk factors and impact on QoL in Turkey showed that the bothersome effect of UI remained mostly at the mild or moderate level.9 The present findings were consistent with that study. The bother of UI in women was extensively investigated in previous studies; however, there is a lack of data about the correlation between the amount and the frequency of UI and QoL.9 In the present study, a positive correlation was shown. Despite the advanced studies carried out in women, the epidemiology of UI in men has not been investigated to the same extent. The majority of the studies investigating UI in men mostly included the old population, and a systematic review of 21 studies reported a prevalence of UI in that population ranging from 11% to 34%.28 In the same review, the prevalence of UI in the male population was between 2% and 11%.28,29 The results of the present study have shown the prevalence of UI in men as 9.9%, which is within the limits of that review. Urge and stress UI were the most prevalent subtypes in men. Recent large-scale epidemiological studies on LUTS, however, reported lesser rates ranging from 5.0% to 5.4%.7,30 The methodology of the present study differed from the previously published large-scale trials, which included questionnaires administered by telephone or internet. In the present study, the questionnaires were administered in primary healthcare centers. Although the questions were answered by the participants, the study was briefly explained and informed consents were obtained by trained healthcare professionals. The participants had the opportunity to request explanations to prevent misunderstanding any questions and also to overcome literacy problems. Another advantage of our methodology was the sampling technique, which represented our population exactly, as we determined the participants from equally distributed population records randomly. In previously published studies, telephone numbers or email addresses were selected © 2014 The Japanese Urological Association
Prevalence of LUTS, OAB and UI in Turkey
from official records, which might cause selection bias.2,7,12,13 Because we included dipstick analysis in the present study, the presence of a urinary tract infection was confirmed by a positive nitrite test in 0.9% of men and 1.0% of women who were further excluded from the study. In the EPIC study, approximately 1.4% of men and 1.8% of women had reported symptoms of UTI; however, the results were not clinically confirmed.7 Although designed as a population-based study and carried out in a large sample of people, there were limitations to the present study. The questionnaires were completed by the participants; however, trained physicians and nurses helped illiterate participants (6.9%) to complete the questionnaires. The staff that participated in the present study did not intervene otherwise, unless the participant had any questions or concerns about the questionnaire. The response rate (74%) in our study was higher than the response rates of previous large-scale prevalence studies, which ranged from 22.1% to 66%.2,7,12,13 We suppose that inviting the participants to healthcare centers might contribute to the high response rate in our study. In conclusion, the present study is the first and largest population-based survey evaluating the prevalence of LUTS, UI and OAB in Turkey using the ICS definitions. The results of the present study showed that these symptoms are highly prevalent in our region. Increasing age is an important risk factor for the majority of LUTS. In addition to the population prevalence rates, other risk factors of LUTS, OAB and UI can be investigated in further large-scale population-based studies.
Acknowledgments The authors thank all primary care physicians and their assistant nurses working in the family healthcare centers for their valuable time and devoted effort. This study would not be possible without their dedication and wholehearted collaboration, which motivated us throughout the study period.
Conflict of interest None declared.
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