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Natural History of Prostatism: Impaired Health States in Men With Lower Urinary Tract Symptoms
Val. 157,1711-1717. May 1997 Printed i n U S A .
NATURAL HISTORY OF PROSTATISM: IMPAIRED HEALTH STATES IN MEN WITH LOWER URINARY TRACT SYMPTOMS ROSEBUD 0. ROBERTS, STEVEN J. JACOBSEN,* THOMAS RHODES, CYNTHIA J. GIRMAN, HARRY A. GUESS AND MICHAEL M. LIEBER From the Section of Clinical Epidemiology, and Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and Department of Epidemiology, Merck Research Labomtorie8, Blue Bell, Pennsylvania
ABSTRACT
Purpose: Lower urinary tract symptoms are reported to have a significant impact on quality of life. However, the impact on specific aspects of health status is not clear. We evaluated the association between lower urinary tract symptoms, and physical and mental aspects of health using community based data from a cross-sectional component of a prospective cohort study. Materials and Methods: A total of 2,133 men 41 to 84 years old who were randomly selected from the Olmsted County, Minnesota population completed the 36-item health status questionnaire and a previously validated questionnaire assessing urinary symptoms. Eight domains, measured on a scale of 0 to 100, were used to assess general health status. Men were classified as having an impaired health status if they scored less than 75 points on the scale. Symptom seventy (none, mild, moderate or severe) was measured from responses to the urinary symptom questionnaire. Results: The results demonstrated a cross-sectional decrease in mean health status scores for all 8 domains across levels of increasing urinary symptom severity. The strongest associations between health status scores and urinary symptoms (severe versus none) were observed for role limitation due to physical problems (odds ratio 15.7, 95% confidence interval 6.6 to 37.0), energylfatigue (odds ratio 9.2, 95% confidence interval 4.7 to 18.11, role limitation due to emotional problems (odds ratio 8.7,95% confidence interval 4.1 to 18.2) and general perception of health (odds ratio 7.2,95% confidence interval 3.8 to 13.4). For these 4 dimensions men with mild urinary symptoms were also significantly more likely to have an impaired health status. Adjustment for age and co-morbidity did not alter the results. Conclusions: These findings suggest that urinary symptoms have a multidimensional association with physical and mental aspects of health. Although lower urinary tract symptoms may be the cause of an impaired health status, men with impaired health conditions may be more sensitive to prevalent urinary symptoms and more likely to report them. While the casual nature of this association has not been ascertained, these results may help to identify appropriate health dimensions to assess in patients with lower urinary tract symptoms. KEY WORDS: prostate, prostatic hypertrophy, quality of life
Benign prostatic hyperplasia (BPH) and related lower urinary tract symptoms are significant causes of morbidity in men 55 years old or older. In 1991,l.g million physician office visits were for BPH1 and it has been estimated that 5.5 million men in the United States would meet the Agency for Health Care Policy and Research diagnostic and treatment guidelines for discussing treatment options for BPH.2 Thus, the significant public health impact of lower urinary tract symptoms in elderly men cannot be ignored. The symptoms and signs associated with bladder outlet obstruction, commonly referred to as prostatism, result from varying degrees of enlargement of the prostate gland, increase in the smooth muscle tone of the bladder neck and prostate, changes in bladder contractility and urethral narrowing.3 Several investigators have reported an association between quality of life and prostatism.4-10 In these studies disease specific measures of quality of life, such as bother associated with sympAccepted for publication October 3, 1996. supported by Grant AR30582 fmm the Public Health Service, National Institutes of Health and a grant from Merck Research Laboratories.
* %uests for re rink Lk artment of Health Sciences Research, Section of ClinicalEpidemiofogy, Mayo Clinic, 200 First St., S.W., Rochester, Minnesota 55905.
toms, interference of symptoms with daily living activities, as well as nondisease specific measures (global health related quality of life, mental status, activity and general health indexes, and psychological well-being) have been used to evaluate the association between lower urinary tract symp toms and health related quality of life. However, these measures do not present a comprehensive view of the association between lower urinary tract symptoms and general health status, including physical and mental states.11 The health status questionnaire (HSQ 2.0),12virtually the same as the Medical Outcomes Study 36item Short Form Health Swey,13 was designed primarily as a tool for measuring medical outcomes. It has been tested repeatedly in different populations, and is a reliable and valid multidimensional measure of health status. This tool effectively measures the physical and mental domains of health with 8 multiple item health constructs: l)physical functioning, 2) role limitation due to physical problems, 3) bodily pain, 4) overall evaluation of health, 5) role limitation due to emotional problems, 6 ) mental health, 7) energy and vitality, and 8 ) social functioning. Thus, these concepts present a comprehensive view of the health status of an individual. We investigated the association between lower urinary tract symptoms, and
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mental and physical aspects of health status using crosssectional data from the Olmsted County study of urinary symptoms and health status among men. MATERIALS AND METHODS
Study subjects. The Olmsted County longitudinal study of urinary symptoms and health status among men was initiated in December 1989 to study the natural history of prostatism in a community based cohort. of men. Many of the details of the study design and the selection of subjects have been reported previously.14.16 Briefly, the resources of the Rochester Epidemiology Project were used to construct a sampling frame of Olmsted County, Minnesota residents. A sample of men 40 to 79 years old on January 1, 1990 was randomly selected at a 14% sampling fraction within 5-year age and residence (City of Rochester versus balance of Olmsted County) specific strata.16 ARer exclusion of men with prostate cancer, a history of prostate surgery or other medical conditions that could affect normal urinary function (other than BPH), 3,850 eligible men were invited to participate in the study. Of these men 1,735 refused to participate and 2,115 participated a t baseline for a response rate of 55%. In subsequent evaluations conduded in 1992 and 1994 men who died, had refused to participate further or were lost to followup were replaced with randomly selected eligible men.17 This report is based on data collected during evaluations conducted in 1994, and provided by 2,044 men from the baseline cohort and 89 replacement men. The study protocol was approved by the Mayo Clinic institutional review board. Urinary symptom questionnaire. Men were asked to complete a previously validated self-administered 134-item questionnaire on urinary symptoms, health status and sociodemoizranhic characteristics. The freauencv with which thev ha$ eherienced 12 specific urinary symptoms during th'k previous month was ranked on a 7-point ordinal scale from 0 (do not have the symptom) to 6 (always). As a measure of symptom severity, the 2 highest categories were collapsed for 7 of the symptoms to obtain an approximation of the American Urological Association (AUA) symptom index. The degree of bother associated with each symptom was also ranked on a 7-point ordinal scale from 0 (do not have the symptom) to 6 (extremely bothersome) and a bother score was calculated. In addition the extent to which urinary symptoms interfered with specific daily activities, including drinking fluids before travel or before bed, driving for 2 hours without stopping, getting enough sleep at night, going to places without a toilet, playing outdoor sports and going to the movies, was ranked on a 5-point ordinal scale from 0 (none of the time) to 4 (all of the time). From these data an interference score was calculated. The questionnaire also asked whether participants had ever been told by a physician that they had diabetes, hypertension, heart disease, bronchitis, a serious injury, stroke, arthritis, Parkinson's disease, an enlarged prostate, recurrent prostatitis, urinary stones, emphysema, multiple sclerosis, visual or hearing impairment and any cancer other than prostate cancer. Co-morbidity was assessed in 2 ways based on the responses to these questions. Men were classified as having a co-morbid condition ifthey 1) had a history of diabetes, hypertension or heart disease (3 most important chronic diseases) and 2) if they had any of the diseases listed. Health status questionnaire. In the evaluation conducted during 1994 men were asked to complete the 36-item health status questionnaire that elicited information on multidimensional aspects of physical and mental domains of health. Item responses were recoded, scored and summed to measure 8 multiple item scales or health dimensions, scored on a tramformed scale from 0 to 100.12 A score of 100 suggested no impairment in the health dimension being measured. Physical health was assessed bv _Dhvsical . " functioning (10 1
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u
items), role limitation due to physical problems (4), bodily pain (2) and general health perception (5). Mental health was assessed by social functioning (2 items), role limitation due to emotional problems (3),mental health (5)and energy/fatigue (4). The HSQ 2.0 questionnaire is almost identical in wording of item stems and response categories to the Medical Outcomes Study SF-36 questionnaire.12 The main differences between the 2 questionnaires are in the handling of missing responses, and in the recalibration of responses for bodily pain and health perception scale, which results in an average difference of 4 points in scoring of pain (less pain in HSQ 2.0 test scoring). When the responses to the questionnaire were scored by either method the results were exactly the same for all scales except that the bodily pain dimension was shifted by an average of 4 points when scored by the HSQ 2.0 algorithm. Our results are based on the HSQ 2.0 scoring algorithm. Statistical analysis. Using the full range of outcome and predictor variables, Spearman correlation coefficients were calculated for the association among health status scores for the 8 dimensions and the AUA symptom index, AUA bother score, interference score and age. Men were categorized as having no, mild, moderate or severe urinary symptoms based on the AUA symptom index ( 0 , l to 7, 8 to 19 and 20 to 35, respectively); no, mild, moderate or severe bother based on the bother score ( 0 , l to 3 , 4 to 18 and 19 to 35, respectively), and no, mild, moderate or severe interference with daily activities based on the interference score ( 0 , l to 2 , 3 to 8 and 9 to 28, respectively). Mean and median scores for men in ,each symptom category (no, mild, moderate and severe) were ,calculated. Based on the empirical distribution of health status scores, cutoff points were chosen that would classify approximately a fifth of men as having impaired health status. Dichotomization based on cutoff points less than 65 or more than 75 resulted in too few or too many men being categorized as having impaired health status. Cutoff points of 65 and 75 yielded similar results. The results reported are based on a cutoff point of 75 and on average 26% of men (range 9.9 to 54.2) were classified as having impaired health status. With health status as a dichotomous outcome measure and symptom severity as an ordinal exposure, the association between each health status domain and symptoms was investigated using logistic regression models with 3 dummy variables for symptom severity and with adjustment for the effects of age. A second set of logistic regression models examined the association with adjustment for age and presence of co-morbidity (yes or no). Linear regression models examined the additional benefit of adding bother and interference scores to models using symptoms (AUA symptom index) to predict health status score. To evaluate further the association between lower urinary tract symptoms and health status, the association between health status and individual urinary symptoms was assessed using multiple logistic regression analyses with adjustment for age. Men were categorized as having symptoms more than rarely versus none or rarely. RESULTS
A total of 2,133 men completed both parts of the questionnaire (health status and urinary symptom questionnaires). The men were 41 to 84 years old (mean age plus or minus standard deviation 57 ? 10.71, with almost three-quarters (74%) younger than 65 years. On average the men were reasonably well educated (approximately 90% had a high school diploma or education beyond high school and 9% had no high school diploma) and a marginally greater proportion earned an annual income of more than $45,000 (49%) than those who earned less than $45,000 (47%).Slightly less than two-thirds of the men were employed (64%) and of the 752 who reported a reason for unemployment 89% were retired. Of the men 90% were married o r lihng as married (table 1).
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LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS TABLE 1. Demographic and socioeconomic characteristics according to &heOlrnsted County study of urinary symptoms and health
status among men No. Pts. (%)
Characteristic Age (yrs.1: Less than 65 65 or More Education: Less than high school graduate High school graduate Greater than high school graduate Annual income ($1: Less than 25.000
1,578 (74.0) 555 (26.0) 190 (8.9) 1,492 (69.9) 426 (20.0) 371 (17.3) 624 (29.2) 1,047 (49.0)
2545,000 45,000 or More
Marital status: Not married 195 (9.1) Mamed 1.920 (90.0) Working status: Working 1,375 (64.5) 746 (36.2) Not working Health status score less than 75: Physical functioning 350 (16.6) Health perception 920 (43.5) Role limitation-physical 370 (17.5) Bodily pain 616 (28.9) Energylfatigue 1,149 (54.2) Social functioning 209 (9.9) Mental health 523 (24.7) Role limitation-emotional 335 (15.8) * Numbers may not total 2.133 due to missing responses.
There were sigdicant negative correlations among all health status dimensions and the AUA symptom index, AUA bother score and interference scores (table 2). Physical functioning, general health perception, role limitation due to physical problems and energylfatigue were the most strongly associated with the AUA symptom index, AUA bother score and interference scores (Spearman correlation coefficients -0.2 to -0.3, all p <0.001).Role limitation due to emotional problems had the weakest correlations with the Urinary symptom scores. The range of the correlations did not differ materially across health status dimensions, and was greatest for the association with the AUA symptom index (range = 0.14)and least for the association with interference (range = 0.10).There was little difference in the correlations of the health dimensions with the AUA symptom index, AUA bother score and interference score, and the clinical significance of these differences may be minimal. All dimensions except mental health and energy/fatigue were negatively correlated with age. Age was most strongly correlated with physical functioning and role limitation due to physical pmblems (Spearman correlation Coefficients -0.45 and -0.27, respectively, both p <0.001). There were slight negative correlations between age and bodily pain, mental health and general perception of health, and almost negligible correla-
TABLE2. Correlation among health status, AUA symptom inder, AUA bother scores. interference scores and w e ~~
Health Dimension
AUA Symptom Index
kgr Score
Intefierence
score
Age
-0.45 -0.26 -0.27 Physical fmctioning -0.30 -0.24 -0.17 -0.26 Health perception -0.26 Role limitation-physical -0.24 -0.22 -0.22 -0.27 -0.20 -0.13 -0.21 -0.22 Bodily pain O.OO* -0.22 -0.27 -0.25 Energylfahgue -0.07 -0.20 -0.20 Soeial functioning -0.18 -0.19 0.12 -0.18 Mental health -0.16 Role limitation-emotional -0.16 -0.16 -0.16 -0.07 Spearman correlation coefficient. * Not significant at a = 0.05. All other correlations were significant at a = 0.001.
I
IE
LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
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TABLE4. Associatwn between impaired health status and urinary symptom severity Age Adjusted Odds Ratio for Urinary Symptom Severity (952confidence interval) -0-; '
A
-x-
+ mh - Y -
re
.... b...pt
-v0:
-
None
,
I
I
Mild*
rp
d
I
Mlld Yoderste Swem n=192 n=1141 n=715 n=76 Urinary symptom severity
FIG. 1. Health status score b urinary sym tom severity according to percent of men with healti status score Ess than 75 by health status domain. Ef, energy/fatigue. hp, health perception. bp, bodily iain. rp, role limitation due to physical functioning. mh, mental ealth. re, role limitation due to emotional problems. pf, physical functioning. sf, social functioning.
tions with social functioning, role limitation due to emotional problems and energylfatigue. With men categorized as having no (192 or 9%),mild (1,141 or 53%), moderate (715 or 34%) or severe (76 or 4%) urinary symptoms the mean health status scores decreased with worsening symptom seventy for each health dimension (table 3). For example, for role limitations due to physical problems mean health status scores decreased from 95.6 in men with no, to 87.6 with mild, 80.3 with moderate and 53.3 with severe symptoms, for a 44% difference in mean scores for men with no and severe symptoms. Median scores for all health status dimensions were similar in men with no and mild symptoms, slightly lower in men with moderate symptoms, and much lower in men with severe relative to mild or no symptoms. The results were similar for categories of the bother and interference scores (results not shown). For all 8 domains the proportion of men with a score of less than 75 increased across urinary symptom categories (fig. 1).The Mantel-Haenszel chi-square test for trend was significant for a monotonic decrease in mean health status scores across urinary symptom categories for all 8 dimensions (p <0.0001). The results of the age-adjusted logistic regression also showed that for all dimensions severe urinary symptoms had the strongest association with health status (table 4). The strongest associations between severe urinary symptoms and health status were with role limitation due to physical problems (odds ratio 15.7, 95% confidence interval 6.6 to 37.0), energylfatigue (odds ratio 9.2,95% confidence interval 4.7 to 18.1), role limitation due to emotional problems (odds ratio 8.7,95% confidence interval 4.1 to 18.2) and general perception of health (odds ratio 7.2, 95% confidence interval 3.8 to 13.4). For these dimensions men with mild, moderate or severe urinary symptoms were significantly more likely to have an impaired health status relative to men with no urinary symptoms. For bodily pain, physical functioning, social functioning and mental health, men with moderate and severe urinary symptoms were at increased risk relative to men with no symptoms, and those with mild symptoms were not significantly different from men with no urinary symptoms. The weakest association with severe urinary symptoms was observed for mental health (odds ratio 4.4, 95% confidence interval 2.2 to 7.9). Adjustment for co-morbidity as measured by the presence of self-reported diabetes, hypertension or heart disease (or any condition from the longer list of diseases) did not change the results. Linear regression models showed that AUA symptom score was a significant predictor of health status. Addition of the
Moderate*
Severe'
Severet
Functional domain Role limitation- 2.5 (1.2-5.2) 3.8 (1.8-7.9) 15.7 (6.6-37.0) 6.3 (3.8-10.4) physical 2.1(1.04.5) 2.9(1.4-6.1) 5.3(2.2-12.8) 2.5 (1.54.2) Physical functioning 1.5(1.1-2.2) 2.7 (1.6-3.8) 7.2 (3.8-13.4) 4.6 12.7-8.0) General health perception 1.4(1.0-2.2) 2.2(1.5-3.4) 5.6(3.0-10.2) 3.9 12.4-6.3) Bodilypain 1.9 (1.4-2.6) 3.0(2.143) 9.2(4.7-18.1) 4.9 (2.69.1) EnergyXatigue 2.0(1.1-3.8) 6.6(3.0-14.3) 6.7t3.9-11.5) Social fundion- 1.0(0.~1,8) ing 1.3(0.9-1.9) 2.3(1.5-3.5) 4.4 (2.4-7.9) 3.4 (2.1-5.4) Mental health Role limitation- 1.9 (1.1-3.5) 2.9 (1.6-5.4) 8.7 (4.1-18.2) 4.5 (2.7-7.3) pmnt.innal
* Relative to no urinary symptoms. t Relative to mild symptoms.
interference and bother scores to models with symptoms provided a minimal but statistically significant increase in predictive power for all health status domains (model r-squares increased an additional 1 to 2%). Overall, individual lower urinary tract symptoms were positively associated with an impaired health status for all health domains, adjusted for age. The association was significant between lower urinary tract symptoms and all health domains except physical functioning. The strength of the associations differed with each health statudurinary symptom combination, and the strongest associations for each health status domain were role limitation due to physical problems and repeat urination (odds ratio 2.7, 95% confidence interval 2.0 to 3.61, physical functioning and nocturia (odds ratio 2.0, 95% confidence interval 1.5 to 2.51, social functioning and dysuria (odds ratio 3.0, 95% confidence interval 1.8 to 4.9), bodily pain and dysuria (odds ratio 2.4,95% confidence interval 1.6 to 3.7), general health perception and dysuria (odds ratio 2.5, 95% confidence interval 1.6 to 2.9), role limitation due to emotional problems and dysuria (odds ratio 2.5, 95% confidence interval 1.6 to 3.9), energy/fatigue and urgency (odds ratio 2.1, 95% confidence interval 1.7 to 2.5), and mental health and repeat urination (odds ratio 2.2, 95% confidence interval 1.6 to 2.8, fig. 2). DISCUSSION
Our results suggest that urinary symptoms have a negative association with physical and mental aspects of health, with the strongest associations observed for role limitation due to physical problems, energyifatigue, role limitation due to emotional problems and overall health perception. The mental health dimension has the weakest association with severe urinary symptoms but the association is still strong (odds ratio 4.4). Thus, although urinary symptoms are associated with impairment in physical and mental health, certain aspects of physical and mental health are impaired to a greater extent than others. The results also demonstrate that even mild symptoms are associated with impairment in health status to a degree, and in 4 of the 8 dimensions men with mild urinary symptoms are 1.5 to 2 times as likely to have a score less than 75 compared to those with no urinary symptoms after adjustment for age. This association may be due to the negative impact of lower urinary tract symptoms on health status or, alternatively, men with impaired health status may have an increased sensitivity to prevalent lower urinary tract symptoms. These findings build on and support other reports that urinary symptoms have a significant impact on health related quality of life.4-6.8.9
LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
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)f quality of life in the assessment of medical outcomes, and :ost-benefit analyses of patient management and treatment :valuation. Fowler et a1 noted little improvement in quality if life following prostatectomy in men with mild symptoms, and concluded that this may have been because the symptoms had little effect on daily l i ~ e s . 4An . ~ alternate explanation may be that the measures of quality of life used in their study, that is the activity index, mental health index and general health index, may be insensitive to slight changes in '1 General Health Bodily Pain health related quality of life. Disease specific measures of Perception quality of life, including bother associated with symp3 t0ms,~-10interference of symptoms with daily a c t i v i t i e ~ ~ - ~ ~ . ~ ~ m and the International Prostate Symptom Score quality of life 2 question,7 have been shown to be worse in the presence of 1 increased lower urinary tract symptom severity. However, 0 0 they provide limited insight regarding the impact of lower urinary tract symptoms on specific dimensions of nonurologi51 EnergyiFatigue Social cal general health. Previous studies have also shown this Functioning negative association between lower urinary tract symptoms and more general measures of health.6.9 In our study the modest correlations between the disease specific measures (bother and interference scores) and the 8 health dimensions used to assess general health status suggest that, although disease specific measures capture certain aspects of health, they may not provide adequate depth of '1 Mental Health Role Emotional understanding of the association between urinary symptoms and general health status. Addition of the bother and interference scores to symptoms significantly improved the predictive power of linear regression models for all health status domains. Information from these health status domains may help determine the specific aspects of health that are associated with these disease specific measures. Thus, the health status questionnaire, in conjunction with disease specific measures, may provide a more comprehensive view of the impact of urinary symptoms on global health status or health related quality of life. It may be of value to physicians and FIG.2. Odds of impaired health status (score less than 75) in men patients in determining the impact of symptoms on health, in with urinary symptoms occurring more than rarely (at least few formal decision making processes and as a tool to assess the times) in previous month. *, 95% confidence interval includes 1 (p relative disease burden of urinary symptoms compared to >0.05). men with other diseases. Although this study demonstrates the ability of the health status questionnaire to discriminate between men with and without urinary tract symptoms, the sensitivity of the questionnaire to changes in health status Similar results have been reported in a study of British with changes in urinary symptoms must be explored in fumen with lower urinary tract symptoms.18 As in our study ture studies. Our findings also provide additional insight into health median scores decreased with increasing urinary symptom severity for most dimensions, although energylfatigue did not care seeking behavior for urinary symptoms. It has been vary for British men with moderate or severe symptoms. reported that symptoms alone do not explain health care There were differences in median scores between American seeking behavior for urinary symptoms.15 Factors that have and British men for some dimensions, with scores for Amer- been reported to be associated with health care seeking for ican men higher than those for British men. This finding may urinary symptoms include bother scores greater than can be S , ~ ~ size34 have been due to the British cohort being slightly older (55 predicted from symptom frequency S C O T ~prostate years old or older) than the American cohort (40 to 79 years worry and embarrassment about urinary symptoms,25 and old), or to cultural differences in coping skills that would the extent to which BPH interferes with life-style.22 Our affect how they ranked the responses to questions. The bodily findings suggest that, in addition to these previous findings, pain dimension for men with moderate symptoms and the mild symptoms are associated with a perceived decrease in energylfatigue dimension in men with severe symptoms were energy or increased fatigue, a lower perception of health and the only dimensions in which the median scores in British a limitation in the daily roles associated with the urinary men exceeded those in the American men participating in the symptoms. which in turn may cause men to seek care. These current study. The mean scores for energylfatigue and gen- specific aspects of health may not necessarily be captured by eral perception of health were lower than those for the other the AUA symptom index, disease specific measures, global domains. This finding is similar to that of other studies health status or global health related quality of life. In interpreting these data several potential limitations reporting normative data.18-21 This lower score for these 2 health domains in normal men may partly account for a should be kept in mind. The associations described are crossgreater proportion of men with no lower urinary tract symp- sectional in nature. The temporal order between onset of toms having a health status score of less than 75 for energy/ symptoms and impairment in functional status cannot be fatigue (36%)and general health perception (26%)compared established. There may be some unmeasured confounder responsible for the observed associations. While statistical adto the other domains. Our findings have broad implications in the conceptualiza- justment for age and presence of co-morbid conditions did not tion of lower urinary tract disease, which is particularly alter estimates of the association, residual confounding from important with the increasing recognition of the importance these factors or from unmeasured factors may explain some Role Physical
51
T
1 :I
Physical Functionlng
~
g;
T
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LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
of the observed associations. The association may be due to the choice of cutoff point used to distinguish decreased function. However, in studies reporting normative data in American12.19 and British’R.20.21 men, mean scores decreased slightly with age but were essentially greater than 75 for all dimensions except general health perception and energy/ fatigue, in which mean scores were 60 to 70 (slightly greater in younger men). Furthermore, when a cutoff point of 65 was examined the results remained essentially the same for 5 dimensions (role limitation due to physical problems, general perception of health, bodily pain, social finctioning and energylfatigue) but the odds ratios increased slightly for physical functioning, role limitation due to emotional problems and mental health. Finally, the limitation in generalizability should be addressed. The fact that participants were all white and predominantly of middle class, and the original response rate was 55% may limit the generalizability to other persons and settings. However, mean scores from all 2,133 men for the 8 dimensions (results not shown) were comparable to reference data mean scores for men 35 to 74 years old reported by the developers of the health status questionnaire.12 The greatest decreases in mean scores with age were for the variables measuring physical health, that is physical functioning, role limitation due to physical problems, bodily pain and general health perception, whereas dimensions related to mental health, such as energy/fatigue, social functioning and role limitations due to emotional problems, remained relatively stable across different age groups as found in our study. Although participants were more likely than nonparticipants to have had a urological diagnosis in the p a ~ t , ~ ~there , 2 7 was no difference in the history of general medical examinations in the previous 9 years. CONCLUSIONS
Our findings indicate a negative association between urinary symptoms, and the physical and mental domains of health, which may not necessarily be captured by disease specific measures. While men with lower urinary tract symptoms may have an impaired health status due to the symptoms, those with an impaired health status may be more sensitive to prevalent lower urinary tract symptoms. Because these findings are based on cross-sectional data it is not possible to determine which of these 2 alternatives is most appropriate. Nonetheless, these findings have important implications. They suggest appropriate health dimensions to consider in the treatment of patients with prostatism. These health domains may be captured partly by the health status questionnaire. Cross-sectionally this instrument appears able to detect differences between men with versus those without lower urinary tract symptoms. However, this finding does not necessarily imply that the domains would be responsive to slight changes within individuals followed with time. Nonetheless, the comprehensiveness of the health status questionnaire, coupled with its simplicity and the short period required for completion, may make it desirable to assess health status and quality of life in men with lower urinary tract symptoms. Luanne Schmidt and Karen Hanson assisted with the continuing followup of this cohort. REFERENCES
1. Schappert, S. M.: National Ambulatory Medical Care Survey: 1991 summary. Vital Health Stat., 13 1, 1994. 2. Jacobsen, S. J., Girman, C. J.,Guess, H. A., Oesterling, J . E. and Lieber, M. M.: New diagnostic and treatment guidelines for benign prostatic hyperplasia. Potential impact in the United States. Arch. Intern. Med., 186: 477, 1995. 3. Madsen, F. A. and Bruskewitz, R. C.: Clinical manifestations of benign prostatic hyperplasia. Urol. Clin. N. Amer., 2 2 291, 1995.
4. Fowler, F. J., Jr., Wennberg, J. E., Timothy, R. E., Barry, M. J., Mulley, A. G. Jr. and Hanley, D.: Symptom status and quality of life following prostaktomy. J.A.M.A., 259 3018, 1988. 5. Fowler, F. J., Jr. and Barry, M. J.: Quality of life assessment for evaluating benign prostatic hyperplasia treatments. An examd e of using a condition-specific index. Eur. Urol., suppl., 24: .i 4 , 1993. 6. Girman, C. J., Jacobsen, S. J., Guess, H. A., Oesterling, J. E., Chute, C. G., Panser, L. A. and Lieber, M. M.: Natural history of prostatism: relationship among symptoms, prostate volume and peak urinary flow rate. J. Urol., 153: 1510,1995. 7. Girman, C. J., Epstein, R. S., Jacobsen, S. J., Guess, H. A., Panser, L. A., Oesterling, J. E. and Lieber, M. M.: Natural history of prostatism: impact of urinary symptoms on quality of life in 2115 randomly selected community men. Urology, 44: 825, 1994. 8. Garraway, W. M., Russell, E. B., Lee, R. J., Collins, G. N., McKelvie, G. B., Hehir, M., Rogers, A. C. and Simpson, R. J.: Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly men. Brit. J. Gen. Pract., 43:318, 1993. 9. Tsang, K. K. and Garraway, W. M.: Impact of benign prostatic hyperplasia on general well-being of men. Prostate, 2 3 1, 1993. 10. Sagnier, P-P., MacFarlane, G., Teillac, P., Botto, H., Richard, F. and Boyle, P.: Impact of symptoms of prostatism on level of bother and quality of life of men in the French community. J. Urol., 153: 669, 1995. 11. Bergner, M.: Measurement of health status. Med. Care, 2 3 696, 1985. 12. Radosevich, D. M., Wetzler, H. and Wilson, S. M.: Health Status Questionnaire (HSQ) 2 . 0 Scoring Comparisons and Reference Data, Bloomington, Minnesota: Health Outcomes Institute, 1994. 13. McHorney, C. A., Ware, J. E., Jr. and Raczek, A. E.: The MOS 36-Item Short-Form Health Survey (SF-36). 11. Psychometric and clinical testa of validity in measuring physical and mental health constructs. Med. Care, 31: 247, 1993. 14. Chute, C. G., Panser, L. A., Girman, C. J., Oesterling, J. E., Guess, H. A., Jacobson, S. J. and Lieber, M. M.: The prevalence of prostatism: a population-based survey of urinary symptoms. J. Urol., 1% 85, 1993. 15. Jacobsen, S. J., Guess, H. A., Panser, L., Girman, C. J., Chute, C. G., Oesterling, J. E. and Lieber, M. M.: A population-based study of health careseeking behavior for treatment of urinary symptoms: the Olmsted County study of urinary symptoms and health status among men. Arch. Fam. Med., 2 729,1993. 16. Kurland, L. T. and Molgaard, C. A.: The patient record in epidemiology. Sci. Amer., 246 54, 1981. 17. Jacobsen, S. J., Girman, C. J., Guess, H. A., Rhodes, T., Oesterling, J. E. and Lieber, M. M.: Natural history of prostatism: longitudinal changes in voiding symptoms in community dwelling men. J . Urol., 156 595, 1996. 18. Hunter, D. J., McKee, M., Black, N. A. and Sanderson, C. F.: Health status and quality of life of British men with lower urinary tract symptoms: results from the SF-36. Urology, 45: 962,1995. 19. Ware, J. E., Jr., Snow, K. K., Kosinski, M. and Gandek, B.: SF-36 Health Survey Manual and Interpretation Guide, Boston: Medical Outcomes Trust, 1993. 20. Garratt, A. M., R u b , D. A., Abdalla, M. I., Buckingham, J. K. and Russell, I. T.: The SF 36 health survey questionnaire: a n outcome measure suitable for routine use within the NHS? Brit. Med. J., 306: 1440, 1993. 21. Jenkinson, C., Coulter, A. and Wright, L.: Short form 36 (SF 36) health survey questionnaire: normative data for adults of working age. Brit. Med. J., 306: 1437, 1993. 22. A comparison of quality of life with patient reported symptoms and objective findings in men with benign prostatic hyperplasia. Department of Veterans Affairs Cooperative Study of Transurethral Resection for Benign ProsLtic Hyperplasia. J. Urol., 1 5 0 1696, 1993. 23. Jacobsen, S. J., Girman, C. J., Guess, H. A,, Panser, L. A., Chute, C. G., Oesterling, J. E. and Lieber, M. M.: Natural history of prostatism: factors associated with discordance between frequency and bother of urinary symptoms. Urology, 4 2 663, 1993. 24. Jacobsen, S. J., Girman, C. J., Guess, H. A,, Panser, L. A,, Chute,
LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
c. G.,Oesterling, J. E. and Lieber, M.M.:Do proatate size and
urinary flow rates predict health care-seeking behavior for urinary symptoms in men? Urology, .M:64,1996. 25. &krta, R. O., Rhodes, T., Panser, L. A, Girman, C. J., Chute,
C. G., Oesterhg, J. E., Lieber, M. M. and Jacobaen. S. J.: Natural history of prostatiim: worry and embarrassment from urinary symptoms and health careseeking behavior. Umlogy, 43:621,1994. 26. Panser, L.A.,Chute, C. G., Guess, H.A, Lareon Keller, J. J.,
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G h a n , C. J., Oe.sterliug, J. E., Lieber, M.M and Jambeen, S. J.: The natural hietory of pmstatism: the effects of nonresponea bias. Int. J. Epidemiol., 25.1198. 1994. 27. Paneer, L. A. Chute, C. G., Girman, C. J., Gueee. H. A, Oeakrling, J. E.,Lieber, M. M. and Jaeobaen, S.J.: Effeet of
several recruitmentstrategiea on reeponse ratea at baseline in a prospective cohort investigation: the Olmated County study of urinary symptom and health status among men. Ann. Epidemiol., 4: 321,1994.
NATURAL HISTORY OF PROSTATISM: IMPAIRED HEALTH STATES IN MEN WITH LOWER URINARY TRACT SYMPTOMS ROSEBUD 0. ROBERTS, STEVEN J. JACOBSEN,* THOMAS RHODES, CYNTHIA J. GIRMAN, HARRY A. GUESS AND MICHAEL M. LIEBER From the Section of Clinical Epidemiology, and Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and Department of Epidemiology, Merck Research Labomtorie8, Blue Bell, Pennsylvania
ABSTRACT
Purpose: Lower urinary tract symptoms are reported to have a significant impact on quality of life. However, the impact on specific aspects of health status is not clear. We evaluated the association between lower urinary tract symptoms, and physical and mental aspects of health using community based data from a cross-sectional component of a prospective cohort study. Materials and Methods: A total of 2,133 men 41 to 84 years old who were randomly selected from the Olmsted County, Minnesota population completed the 36-item health status questionnaire and a previously validated questionnaire assessing urinary symptoms. Eight domains, measured on a scale of 0 to 100, were used to assess general health status. Men were classified as having an impaired health status if they scored less than 75 points on the scale. Symptom seventy (none, mild, moderate or severe) was measured from responses to the urinary symptom questionnaire. Results: The results demonstrated a cross-sectional decrease in mean health status scores for all 8 domains across levels of increasing urinary symptom severity. The strongest associations between health status scores and urinary symptoms (severe versus none) were observed for role limitation due to physical problems (odds ratio 15.7, 95% confidence interval 6.6 to 37.0), energylfatigue (odds ratio 9.2, 95% confidence interval 4.7 to 18.11, role limitation due to emotional problems (odds ratio 8.7,95% confidence interval 4.1 to 18.2) and general perception of health (odds ratio 7.2,95% confidence interval 3.8 to 13.4). For these 4 dimensions men with mild urinary symptoms were also significantly more likely to have an impaired health status. Adjustment for age and co-morbidity did not alter the results. Conclusions: These findings suggest that urinary symptoms have a multidimensional association with physical and mental aspects of health. Although lower urinary tract symptoms may be the cause of an impaired health status, men with impaired health conditions may be more sensitive to prevalent urinary symptoms and more likely to report them. While the casual nature of this association has not been ascertained, these results may help to identify appropriate health dimensions to assess in patients with lower urinary tract symptoms. KEY WORDS: prostate, prostatic hypertrophy, quality of life
Benign prostatic hyperplasia (BPH) and related lower urinary tract symptoms are significant causes of morbidity in men 55 years old or older. In 1991,l.g million physician office visits were for BPH1 and it has been estimated that 5.5 million men in the United States would meet the Agency for Health Care Policy and Research diagnostic and treatment guidelines for discussing treatment options for BPH.2 Thus, the significant public health impact of lower urinary tract symptoms in elderly men cannot be ignored. The symptoms and signs associated with bladder outlet obstruction, commonly referred to as prostatism, result from varying degrees of enlargement of the prostate gland, increase in the smooth muscle tone of the bladder neck and prostate, changes in bladder contractility and urethral narrowing.3 Several investigators have reported an association between quality of life and prostatism.4-10 In these studies disease specific measures of quality of life, such as bother associated with sympAccepted for publication October 3, 1996. supported by Grant AR30582 fmm the Public Health Service, National Institutes of Health and a grant from Merck Research Laboratories.
* %uests for re rink Lk artment of Health Sciences Research, Section of ClinicalEpidemiofogy, Mayo Clinic, 200 First St., S.W., Rochester, Minnesota 55905.
toms, interference of symptoms with daily living activities, as well as nondisease specific measures (global health related quality of life, mental status, activity and general health indexes, and psychological well-being) have been used to evaluate the association between lower urinary tract symp toms and health related quality of life. However, these measures do not present a comprehensive view of the association between lower urinary tract symptoms and general health status, including physical and mental states.11 The health status questionnaire (HSQ 2.0),12virtually the same as the Medical Outcomes Study 36item Short Form Health Swey,13 was designed primarily as a tool for measuring medical outcomes. It has been tested repeatedly in different populations, and is a reliable and valid multidimensional measure of health status. This tool effectively measures the physical and mental domains of health with 8 multiple item health constructs: l)physical functioning, 2) role limitation due to physical problems, 3) bodily pain, 4) overall evaluation of health, 5) role limitation due to emotional problems, 6 ) mental health, 7) energy and vitality, and 8 ) social functioning. Thus, these concepts present a comprehensive view of the health status of an individual. We investigated the association between lower urinary tract symptoms, and
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LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
mental and physical aspects of health status using crosssectional data from the Olmsted County study of urinary symptoms and health status among men. MATERIALS AND METHODS
Study subjects. The Olmsted County longitudinal study of urinary symptoms and health status among men was initiated in December 1989 to study the natural history of prostatism in a community based cohort. of men. Many of the details of the study design and the selection of subjects have been reported previously.14.16 Briefly, the resources of the Rochester Epidemiology Project were used to construct a sampling frame of Olmsted County, Minnesota residents. A sample of men 40 to 79 years old on January 1, 1990 was randomly selected at a 14% sampling fraction within 5-year age and residence (City of Rochester versus balance of Olmsted County) specific strata.16 ARer exclusion of men with prostate cancer, a history of prostate surgery or other medical conditions that could affect normal urinary function (other than BPH), 3,850 eligible men were invited to participate in the study. Of these men 1,735 refused to participate and 2,115 participated a t baseline for a response rate of 55%. In subsequent evaluations conduded in 1992 and 1994 men who died, had refused to participate further or were lost to followup were replaced with randomly selected eligible men.17 This report is based on data collected during evaluations conducted in 1994, and provided by 2,044 men from the baseline cohort and 89 replacement men. The study protocol was approved by the Mayo Clinic institutional review board. Urinary symptom questionnaire. Men were asked to complete a previously validated self-administered 134-item questionnaire on urinary symptoms, health status and sociodemoizranhic characteristics. The freauencv with which thev ha$ eherienced 12 specific urinary symptoms during th'k previous month was ranked on a 7-point ordinal scale from 0 (do not have the symptom) to 6 (always). As a measure of symptom severity, the 2 highest categories were collapsed for 7 of the symptoms to obtain an approximation of the American Urological Association (AUA) symptom index. The degree of bother associated with each symptom was also ranked on a 7-point ordinal scale from 0 (do not have the symptom) to 6 (extremely bothersome) and a bother score was calculated. In addition the extent to which urinary symptoms interfered with specific daily activities, including drinking fluids before travel or before bed, driving for 2 hours without stopping, getting enough sleep at night, going to places without a toilet, playing outdoor sports and going to the movies, was ranked on a 5-point ordinal scale from 0 (none of the time) to 4 (all of the time). From these data an interference score was calculated. The questionnaire also asked whether participants had ever been told by a physician that they had diabetes, hypertension, heart disease, bronchitis, a serious injury, stroke, arthritis, Parkinson's disease, an enlarged prostate, recurrent prostatitis, urinary stones, emphysema, multiple sclerosis, visual or hearing impairment and any cancer other than prostate cancer. Co-morbidity was assessed in 2 ways based on the responses to these questions. Men were classified as having a co-morbid condition ifthey 1) had a history of diabetes, hypertension or heart disease (3 most important chronic diseases) and 2) if they had any of the diseases listed. Health status questionnaire. In the evaluation conducted during 1994 men were asked to complete the 36-item health status questionnaire that elicited information on multidimensional aspects of physical and mental domains of health. Item responses were recoded, scored and summed to measure 8 multiple item scales or health dimensions, scored on a tramformed scale from 0 to 100.12 A score of 100 suggested no impairment in the health dimension being measured. Physical health was assessed bv _Dhvsical . " functioning (10 1
-
u
items), role limitation due to physical problems (4), bodily pain (2) and general health perception (5). Mental health was assessed by social functioning (2 items), role limitation due to emotional problems (3),mental health (5)and energy/fatigue (4). The HSQ 2.0 questionnaire is almost identical in wording of item stems and response categories to the Medical Outcomes Study SF-36 questionnaire.12 The main differences between the 2 questionnaires are in the handling of missing responses, and in the recalibration of responses for bodily pain and health perception scale, which results in an average difference of 4 points in scoring of pain (less pain in HSQ 2.0 test scoring). When the responses to the questionnaire were scored by either method the results were exactly the same for all scales except that the bodily pain dimension was shifted by an average of 4 points when scored by the HSQ 2.0 algorithm. Our results are based on the HSQ 2.0 scoring algorithm. Statistical analysis. Using the full range of outcome and predictor variables, Spearman correlation coefficients were calculated for the association among health status scores for the 8 dimensions and the AUA symptom index, AUA bother score, interference score and age. Men were categorized as having no, mild, moderate or severe urinary symptoms based on the AUA symptom index ( 0 , l to 7, 8 to 19 and 20 to 35, respectively); no, mild, moderate or severe bother based on the bother score ( 0 , l to 3 , 4 to 18 and 19 to 35, respectively), and no, mild, moderate or severe interference with daily activities based on the interference score ( 0 , l to 2 , 3 to 8 and 9 to 28, respectively). Mean and median scores for men in ,each symptom category (no, mild, moderate and severe) were ,calculated. Based on the empirical distribution of health status scores, cutoff points were chosen that would classify approximately a fifth of men as having impaired health status. Dichotomization based on cutoff points less than 65 or more than 75 resulted in too few or too many men being categorized as having impaired health status. Cutoff points of 65 and 75 yielded similar results. The results reported are based on a cutoff point of 75 and on average 26% of men (range 9.9 to 54.2) were classified as having impaired health status. With health status as a dichotomous outcome measure and symptom severity as an ordinal exposure, the association between each health status domain and symptoms was investigated using logistic regression models with 3 dummy variables for symptom severity and with adjustment for the effects of age. A second set of logistic regression models examined the association with adjustment for age and presence of co-morbidity (yes or no). Linear regression models examined the additional benefit of adding bother and interference scores to models using symptoms (AUA symptom index) to predict health status score. To evaluate further the association between lower urinary tract symptoms and health status, the association between health status and individual urinary symptoms was assessed using multiple logistic regression analyses with adjustment for age. Men were categorized as having symptoms more than rarely versus none or rarely. RESULTS
A total of 2,133 men completed both parts of the questionnaire (health status and urinary symptom questionnaires). The men were 41 to 84 years old (mean age plus or minus standard deviation 57 ? 10.71, with almost three-quarters (74%) younger than 65 years. On average the men were reasonably well educated (approximately 90% had a high school diploma or education beyond high school and 9% had no high school diploma) and a marginally greater proportion earned an annual income of more than $45,000 (49%) than those who earned less than $45,000 (47%).Slightly less than two-thirds of the men were employed (64%) and of the 752 who reported a reason for unemployment 89% were retired. Of the men 90% were married o r lihng as married (table 1).
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LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS TABLE 1. Demographic and socioeconomic characteristics according to &heOlrnsted County study of urinary symptoms and health
status among men No. Pts. (%)
Characteristic Age (yrs.1: Less than 65 65 or More Education: Less than high school graduate High school graduate Greater than high school graduate Annual income ($1: Less than 25.000
1,578 (74.0) 555 (26.0) 190 (8.9) 1,492 (69.9) 426 (20.0) 371 (17.3) 624 (29.2) 1,047 (49.0)
2545,000 45,000 or More
Marital status: Not married 195 (9.1) Mamed 1.920 (90.0) Working status: Working 1,375 (64.5) 746 (36.2) Not working Health status score less than 75: Physical functioning 350 (16.6) Health perception 920 (43.5) Role limitation-physical 370 (17.5) Bodily pain 616 (28.9) Energylfatigue 1,149 (54.2) Social functioning 209 (9.9) Mental health 523 (24.7) Role limitation-emotional 335 (15.8) * Numbers may not total 2.133 due to missing responses.
There were sigdicant negative correlations among all health status dimensions and the AUA symptom index, AUA bother score and interference scores (table 2). Physical functioning, general health perception, role limitation due to physical problems and energylfatigue were the most strongly associated with the AUA symptom index, AUA bother score and interference scores (Spearman correlation coefficients -0.2 to -0.3, all p <0.001).Role limitation due to emotional problems had the weakest correlations with the Urinary symptom scores. The range of the correlations did not differ materially across health status dimensions, and was greatest for the association with the AUA symptom index (range = 0.14)and least for the association with interference (range = 0.10).There was little difference in the correlations of the health dimensions with the AUA symptom index, AUA bother score and interference score, and the clinical significance of these differences may be minimal. All dimensions except mental health and energy/fatigue were negatively correlated with age. Age was most strongly correlated with physical functioning and role limitation due to physical pmblems (Spearman correlation Coefficients -0.45 and -0.27, respectively, both p <0.001). There were slight negative correlations between age and bodily pain, mental health and general perception of health, and almost negligible correla-
TABLE2. Correlation among health status, AUA symptom inder, AUA bother scores. interference scores and w e ~~
Health Dimension
AUA Symptom Index
kgr Score
Intefierence
score
Age
-0.45 -0.26 -0.27 Physical fmctioning -0.30 -0.24 -0.17 -0.26 Health perception -0.26 Role limitation-physical -0.24 -0.22 -0.22 -0.27 -0.20 -0.13 -0.21 -0.22 Bodily pain O.OO* -0.22 -0.27 -0.25 Energylfahgue -0.07 -0.20 -0.20 Soeial functioning -0.18 -0.19 0.12 -0.18 Mental health -0.16 Role limitation-emotional -0.16 -0.16 -0.16 -0.07 Spearman correlation coefficient. * Not significant at a = 0.05. All other correlations were significant at a = 0.001.
I
IE
LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
1714
TABLE4. Associatwn between impaired health status and urinary symptom severity Age Adjusted Odds Ratio for Urinary Symptom Severity (952confidence interval) -0-; '
A
-x-
+ mh - Y -
re
.... b...pt
-v0:
-
None
,
I
I
Mild*
rp
d
I
Mlld Yoderste Swem n=192 n=1141 n=715 n=76 Urinary symptom severity
FIG. 1. Health status score b urinary sym tom severity according to percent of men with healti status score Ess than 75 by health status domain. Ef, energy/fatigue. hp, health perception. bp, bodily iain. rp, role limitation due to physical functioning. mh, mental ealth. re, role limitation due to emotional problems. pf, physical functioning. sf, social functioning.
tions with social functioning, role limitation due to emotional problems and energylfatigue. With men categorized as having no (192 or 9%),mild (1,141 or 53%), moderate (715 or 34%) or severe (76 or 4%) urinary symptoms the mean health status scores decreased with worsening symptom seventy for each health dimension (table 3). For example, for role limitations due to physical problems mean health status scores decreased from 95.6 in men with no, to 87.6 with mild, 80.3 with moderate and 53.3 with severe symptoms, for a 44% difference in mean scores for men with no and severe symptoms. Median scores for all health status dimensions were similar in men with no and mild symptoms, slightly lower in men with moderate symptoms, and much lower in men with severe relative to mild or no symptoms. The results were similar for categories of the bother and interference scores (results not shown). For all 8 domains the proportion of men with a score of less than 75 increased across urinary symptom categories (fig. 1).The Mantel-Haenszel chi-square test for trend was significant for a monotonic decrease in mean health status scores across urinary symptom categories for all 8 dimensions (p <0.0001). The results of the age-adjusted logistic regression also showed that for all dimensions severe urinary symptoms had the strongest association with health status (table 4). The strongest associations between severe urinary symptoms and health status were with role limitation due to physical problems (odds ratio 15.7, 95% confidence interval 6.6 to 37.0), energylfatigue (odds ratio 9.2,95% confidence interval 4.7 to 18.1), role limitation due to emotional problems (odds ratio 8.7,95% confidence interval 4.1 to 18.2) and general perception of health (odds ratio 7.2, 95% confidence interval 3.8 to 13.4). For these dimensions men with mild, moderate or severe urinary symptoms were significantly more likely to have an impaired health status relative to men with no urinary symptoms. For bodily pain, physical functioning, social functioning and mental health, men with moderate and severe urinary symptoms were at increased risk relative to men with no symptoms, and those with mild symptoms were not significantly different from men with no urinary symptoms. The weakest association with severe urinary symptoms was observed for mental health (odds ratio 4.4, 95% confidence interval 2.2 to 7.9). Adjustment for co-morbidity as measured by the presence of self-reported diabetes, hypertension or heart disease (or any condition from the longer list of diseases) did not change the results. Linear regression models showed that AUA symptom score was a significant predictor of health status. Addition of the
Moderate*
Severe'
Severet
Functional domain Role limitation- 2.5 (1.2-5.2) 3.8 (1.8-7.9) 15.7 (6.6-37.0) 6.3 (3.8-10.4) physical 2.1(1.04.5) 2.9(1.4-6.1) 5.3(2.2-12.8) 2.5 (1.54.2) Physical functioning 1.5(1.1-2.2) 2.7 (1.6-3.8) 7.2 (3.8-13.4) 4.6 12.7-8.0) General health perception 1.4(1.0-2.2) 2.2(1.5-3.4) 5.6(3.0-10.2) 3.9 12.4-6.3) Bodilypain 1.9 (1.4-2.6) 3.0(2.143) 9.2(4.7-18.1) 4.9 (2.69.1) EnergyXatigue 2.0(1.1-3.8) 6.6(3.0-14.3) 6.7t3.9-11.5) Social fundion- 1.0(0.~1,8) ing 1.3(0.9-1.9) 2.3(1.5-3.5) 4.4 (2.4-7.9) 3.4 (2.1-5.4) Mental health Role limitation- 1.9 (1.1-3.5) 2.9 (1.6-5.4) 8.7 (4.1-18.2) 4.5 (2.7-7.3) pmnt.innal
* Relative to no urinary symptoms. t Relative to mild symptoms.
interference and bother scores to models with symptoms provided a minimal but statistically significant increase in predictive power for all health status domains (model r-squares increased an additional 1 to 2%). Overall, individual lower urinary tract symptoms were positively associated with an impaired health status for all health domains, adjusted for age. The association was significant between lower urinary tract symptoms and all health domains except physical functioning. The strength of the associations differed with each health statudurinary symptom combination, and the strongest associations for each health status domain were role limitation due to physical problems and repeat urination (odds ratio 2.7, 95% confidence interval 2.0 to 3.61, physical functioning and nocturia (odds ratio 2.0, 95% confidence interval 1.5 to 2.51, social functioning and dysuria (odds ratio 3.0, 95% confidence interval 1.8 to 4.9), bodily pain and dysuria (odds ratio 2.4,95% confidence interval 1.6 to 3.7), general health perception and dysuria (odds ratio 2.5, 95% confidence interval 1.6 to 2.9), role limitation due to emotional problems and dysuria (odds ratio 2.5, 95% confidence interval 1.6 to 3.9), energy/fatigue and urgency (odds ratio 2.1, 95% confidence interval 1.7 to 2.5), and mental health and repeat urination (odds ratio 2.2, 95% confidence interval 1.6 to 2.8, fig. 2). DISCUSSION
Our results suggest that urinary symptoms have a negative association with physical and mental aspects of health, with the strongest associations observed for role limitation due to physical problems, energyifatigue, role limitation due to emotional problems and overall health perception. The mental health dimension has the weakest association with severe urinary symptoms but the association is still strong (odds ratio 4.4). Thus, although urinary symptoms are associated with impairment in physical and mental health, certain aspects of physical and mental health are impaired to a greater extent than others. The results also demonstrate that even mild symptoms are associated with impairment in health status to a degree, and in 4 of the 8 dimensions men with mild urinary symptoms are 1.5 to 2 times as likely to have a score less than 75 compared to those with no urinary symptoms after adjustment for age. This association may be due to the negative impact of lower urinary tract symptoms on health status or, alternatively, men with impaired health status may have an increased sensitivity to prevalent lower urinary tract symptoms. These findings build on and support other reports that urinary symptoms have a significant impact on health related quality of life.4-6.8.9
LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
1715
)f quality of life in the assessment of medical outcomes, and :ost-benefit analyses of patient management and treatment :valuation. Fowler et a1 noted little improvement in quality if life following prostatectomy in men with mild symptoms, and concluded that this may have been because the symptoms had little effect on daily l i ~ e s . 4An . ~ alternate explanation may be that the measures of quality of life used in their study, that is the activity index, mental health index and general health index, may be insensitive to slight changes in '1 General Health Bodily Pain health related quality of life. Disease specific measures of Perception quality of life, including bother associated with symp3 t0ms,~-10interference of symptoms with daily a c t i v i t i e ~ ~ - ~ ~ . ~ ~ m and the International Prostate Symptom Score quality of life 2 question,7 have been shown to be worse in the presence of 1 increased lower urinary tract symptom severity. However, 0 0 they provide limited insight regarding the impact of lower urinary tract symptoms on specific dimensions of nonurologi51 EnergyiFatigue Social cal general health. Previous studies have also shown this Functioning negative association between lower urinary tract symptoms and more general measures of health.6.9 In our study the modest correlations between the disease specific measures (bother and interference scores) and the 8 health dimensions used to assess general health status suggest that, although disease specific measures capture certain aspects of health, they may not provide adequate depth of '1 Mental Health Role Emotional understanding of the association between urinary symptoms and general health status. Addition of the bother and interference scores to symptoms significantly improved the predictive power of linear regression models for all health status domains. Information from these health status domains may help determine the specific aspects of health that are associated with these disease specific measures. Thus, the health status questionnaire, in conjunction with disease specific measures, may provide a more comprehensive view of the impact of urinary symptoms on global health status or health related quality of life. It may be of value to physicians and FIG.2. Odds of impaired health status (score less than 75) in men patients in determining the impact of symptoms on health, in with urinary symptoms occurring more than rarely (at least few formal decision making processes and as a tool to assess the times) in previous month. *, 95% confidence interval includes 1 (p relative disease burden of urinary symptoms compared to >0.05). men with other diseases. Although this study demonstrates the ability of the health status questionnaire to discriminate between men with and without urinary tract symptoms, the sensitivity of the questionnaire to changes in health status Similar results have been reported in a study of British with changes in urinary symptoms must be explored in fumen with lower urinary tract symptoms.18 As in our study ture studies. Our findings also provide additional insight into health median scores decreased with increasing urinary symptom severity for most dimensions, although energylfatigue did not care seeking behavior for urinary symptoms. It has been vary for British men with moderate or severe symptoms. reported that symptoms alone do not explain health care There were differences in median scores between American seeking behavior for urinary symptoms.15 Factors that have and British men for some dimensions, with scores for Amer- been reported to be associated with health care seeking for ican men higher than those for British men. This finding may urinary symptoms include bother scores greater than can be S , ~ ~ size34 have been due to the British cohort being slightly older (55 predicted from symptom frequency S C O T ~prostate years old or older) than the American cohort (40 to 79 years worry and embarrassment about urinary symptoms,25 and old), or to cultural differences in coping skills that would the extent to which BPH interferes with life-style.22 Our affect how they ranked the responses to questions. The bodily findings suggest that, in addition to these previous findings, pain dimension for men with moderate symptoms and the mild symptoms are associated with a perceived decrease in energylfatigue dimension in men with severe symptoms were energy or increased fatigue, a lower perception of health and the only dimensions in which the median scores in British a limitation in the daily roles associated with the urinary men exceeded those in the American men participating in the symptoms. which in turn may cause men to seek care. These current study. The mean scores for energylfatigue and gen- specific aspects of health may not necessarily be captured by eral perception of health were lower than those for the other the AUA symptom index, disease specific measures, global domains. This finding is similar to that of other studies health status or global health related quality of life. In interpreting these data several potential limitations reporting normative data.18-21 This lower score for these 2 health domains in normal men may partly account for a should be kept in mind. The associations described are crossgreater proportion of men with no lower urinary tract symp- sectional in nature. The temporal order between onset of toms having a health status score of less than 75 for energy/ symptoms and impairment in functional status cannot be fatigue (36%)and general health perception (26%)compared established. There may be some unmeasured confounder responsible for the observed associations. While statistical adto the other domains. Our findings have broad implications in the conceptualiza- justment for age and presence of co-morbid conditions did not tion of lower urinary tract disease, which is particularly alter estimates of the association, residual confounding from important with the increasing recognition of the importance these factors or from unmeasured factors may explain some Role Physical
51
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1 :I
Physical Functionlng
~
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LOWER URINARY TRACT SYMPTOMS AND HEALTH STATUS
of the observed associations. The association may be due to the choice of cutoff point used to distinguish decreased function. However, in studies reporting normative data in American12.19 and British’R.20.21 men, mean scores decreased slightly with age but were essentially greater than 75 for all dimensions except general health perception and energy/ fatigue, in which mean scores were 60 to 70 (slightly greater in younger men). Furthermore, when a cutoff point of 65 was examined the results remained essentially the same for 5 dimensions (role limitation due to physical problems, general perception of health, bodily pain, social finctioning and energylfatigue) but the odds ratios increased slightly for physical functioning, role limitation due to emotional problems and mental health. Finally, the limitation in generalizability should be addressed. The fact that participants were all white and predominantly of middle class, and the original response rate was 55% may limit the generalizability to other persons and settings. However, mean scores from all 2,133 men for the 8 dimensions (results not shown) were comparable to reference data mean scores for men 35 to 74 years old reported by the developers of the health status questionnaire.12 The greatest decreases in mean scores with age were for the variables measuring physical health, that is physical functioning, role limitation due to physical problems, bodily pain and general health perception, whereas dimensions related to mental health, such as energy/fatigue, social functioning and role limitations due to emotional problems, remained relatively stable across different age groups as found in our study. Although participants were more likely than nonparticipants to have had a urological diagnosis in the p a ~ t , ~ ~there , 2 7 was no difference in the history of general medical examinations in the previous 9 years. CONCLUSIONS
Our findings indicate a negative association between urinary symptoms, and the physical and mental domains of health, which may not necessarily be captured by disease specific measures. While men with lower urinary tract symptoms may have an impaired health status due to the symptoms, those with an impaired health status may be more sensitive to prevalent lower urinary tract symptoms. Because these findings are based on cross-sectional data it is not possible to determine which of these 2 alternatives is most appropriate. Nonetheless, these findings have important implications. They suggest appropriate health dimensions to consider in the treatment of patients with prostatism. These health domains may be captured partly by the health status questionnaire. Cross-sectionally this instrument appears able to detect differences between men with versus those without lower urinary tract symptoms. However, this finding does not necessarily imply that the domains would be responsive to slight changes within individuals followed with time. Nonetheless, the comprehensiveness of the health status questionnaire, coupled with its simplicity and the short period required for completion, may make it desirable to assess health status and quality of life in men with lower urinary tract symptoms. Luanne Schmidt and Karen Hanson assisted with the continuing followup of this cohort. REFERENCES
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