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Keywords:

  • health;
  • sadness;
  • happiness;
  • DAN-PSS;
  • lower urinary tract symptoms;
  • SF-36

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  9. Appendix

OBJECTIVES

To evaluate the effect of lower urinary tract symptoms (LUTS) on self-assessed health, sadness and happiness of men.

SUBJECTS AND METHODS

The study included 504 men (aged 40–80 years) in the rural community of Surahammar, Sweden, who a year earlier had reported stress incontinence, urgency or postvoid dribbling in answer to a postal questionnaire, and 504 age-matched control men from the same community. The occurrence of 12 specific LUTS was rated using the Danish Prostatic Symptom Score. Health, sadness and happiness were measured by three questions from the Medical Outcomes Study Short-Form 36 health survey questionnaire.

RESULTS

Completed questionnaires were returned by 74.2% of men (748/1008). A low score for health was reported by 34% of men with one to four LUTS, by 67% with five to eight, and by 75% with nine or more LUTS. The total LUTS burden correlated with lower scores for happiness and with higher scores for sadness. For each of the 12 specific LUTS, men with the symptom had lower scores for health and happiness, and higher scores for sadness, than men without the symptom. Comparing men with the symptom of ‘other incontinence’ to men with no ‘other incontinence’, the relative risk (95% confidence interval) of impaired health was 2.2 (1.8–2.8), while that of a high score for happiness was 0.5 (0.3–0.7) and that of greater sadness was 2.3 (1.7–3.3). Social status, marital status, education, smoking, physical activity and urinary tract infection all affected the impact of LUTS.

CONCLUSIONS

The total burden of LUTS is related to self-assessed health, sadness and happiness.


Abbreviations
DAN-PSS

Danish Prostatic Symptom Score

SF-36

Medical Outcomes Study Short-Form 36 health survey

RR

relative risk

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  9. Appendix

LUTS affect self-assessed quality of life (QoL); in the last decade, the traditional way of measuring urinary symptoms (frequency, severity) has been supplemented by questions relating to the symptom of individual distress [1], as well as a sense of well-being and self-assessed QoL [2–6]. A quick evaluation of the discomfort caused by LUTS and improvements in QoL is an important goal [7], as different treatment strategies depend on symptom quality and distress, and one major therapeutic goal is to improve the QoL of affected men. To our knowledge, no published study has reported the effect on QoL in relation to the number of LUTS in men. In the present study, we evaluated factors related to QoL, and the LUTS burden in correlation with self-assessed health, sadness and happiness. This information could be useful for more effective therapeutic decisions.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  9. Appendix

The study was conducted in the rural community of Surahammar, Sweden, where, in 1997, the 11 200 inhabitants included 2571 men aged 40–80 years. All of the men invited to take part had participated a year earlier in a self-administered questionnaire study (‘yes’ or ‘no’) investigating the prevalence of three common LUTS, i.e. stress incontinence, urgency and post micturition dribbling [1]. All 504 men who had reported one or more LUTS were invited to take part in the present study. As a control group, 504 randomly selected men from the same community who had reported no LUTS in the previous study were matched by age to the group that had reported LUTS, and they were also invited to participate (Fig. 1). These 1008 men were all sent a letter of invitation explaining the objectives of the study, and a postal reminder was sent twice to those who did not reply within 4 and 6 weeks.

image

Figure 1. Flow chart. Men with LUTS (post micturition dribbling, stress incontinence or urgency) who participated in a previous study [1] (indicated with 1) were investigated in the present study with the DAN-PSS questionnaire and three questions from the SF-36 (indicated with 2).

Download figure to PowerPoint

The respondents completed a self-administered questionnaire, the Danish Prostatic Symptom Score (DAN-PSS [8], comprising 12 questions relating to LUTS), and three general questions about health, sadness and happiness, from the Swedish version of the Medical Outcomes Study Short-Form 36 health survey (SF-36) [9]. Information was also collected about potential confounding and effect-modifying factors, e.g. social status, education, marital status, smoking, physical activity and UTI during the preceding year.

In the DAN-PSS, the severity or frequency of specific symptoms of LUTS were assessed on a four-category scale (no, mild, moderate, much). ‘Urge incontinence’, ‘stress incontinence’, ‘other’ incontinence, hesitancy, incomplete emptying, straining, dysuria and urgency were classed as ‘mild’ when the symptom was reported to occur rarely, ‘moderate’ when the symptom occurred often and ‘much’ when the symptom occurred always. ‘Weak stream’ was classed as ‘mild’ when the urinary stream was weak, ‘moderate’ when very weak, and ‘much’ when classified as dribbling. ‘Daytime frequency’ was classed as ‘mild’ when the interval between voids was 2–3 h, ‘moderate’ when 1–2 h, and ‘much’ when <1 h. ‘Nocturia’ was classed as ‘mild’ when it occurred once or twice at night, ‘moderate’ when three to four times, and ‘much’ when five or more times. ‘Post micturition dribbling was classed as ‘mild’ when dribbling was reported only to take place in the lavatory, ‘moderate’ when a small amount of dribbling occurred in the trousers, and ‘much’ when a large amount of dribbling occurred in the trousers.

The questions that were used from the general SF-36 questionnaire [9] related to self-assessed health, sadness and happiness (Appendix 1). Outcome variables for the self-assessed health, sadness and happiness questions were dichotomised. The response relating to the health question was classed as ‘low’ if the answer was ‘moderate’ or ‘bad’. Sadness was classed as ‘high’ if the answer was ‘all of the time’, ‘most of the time’‘some of the time’ or ‘part of the time’. Happiness was classed as ‘high’, if the answer was ‘all of the time’ or ‘most of the time’ (Appendix 1). For dichotomised symptom characteristics, the variables were classified as ‘no symptom’ or ‘symptom’. To calculate relative risks (RRs), the percentage of men reporting a specific symptom was divided by the percentage of men reporting no levels of the same symptom. The RRs for background characteristics were calculated as the percentage of men with LUTS reporting the outcome divided by the percentage of men with no LUTS who reported the same outcome. The RR and 95% CI were calculated and proportions used to describe the number and percentage of men with specific LUTS. The ethics committee at Uppsala University approved the study.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  9. Appendix

In all, 748 (74.2%) men returned the questionnaire; a year earlier 411 of these men (55%) had reported stress incontinence, urgency or post micturition dribbling, and 337 (45%) had none of these symptoms. The mean (sd, range) age of the participants at the time of answering the questionnaire was 60 (10.7, 40–80) years. The characteristics of the cohort are shown in Table 1.

Table 1.  Characteristics of the studied men (n = 748) in the rural community of Surahammar
Descriptive statisticsN (%)
Age in years
mean 60
range 40–80
Social status
Employed393 (53)
Unemployed 25 (3)
Retired229 (31)
On sick leave 76 (10)
Missing 25 (3)
Education
Primary school456 (61)
Secondary school155 (21)
University studies107 (14)
Missing 30 (4)
Marital status
Married/living together618 (83)
Single/widower 113 (15)
Missing 17 (2)
Other
Smoker146 (20)
Non-smoker585 (78)
Missing 17 (2)
Physical activity, > twice/week354 (47)
Physical activity, ≤ twice/week376 (51)
Missing 18 (2)
UTI ≥ 1 during the last year 48 (6)
No urinary tract infection680 (91)
Missing 20 (3)

SELF-ASSESSED HEALTH

The risk of obtaining a low score for health was significantly higher in men with LUTS than in men with no LUTS for all the evaluated characteristics, except for unemployed men, men on sick leave and men with self-reported UTI. Employed men with LUTS had lower scores for health than employed men with no LUTS. For men who went to secondary school, the risk of a low health score was 10 times higher for those with LUTS than for men with no LUTS. Single or widowed men with LUTS reported the same effect on health as those with no LUTS (Table 2).

Table 2.  The relative risk of moderate or bad health, with 95% confidence intervals for social status, education, marital status, smoking, physical activity and urinary tract infection (UTI) in men with lower urinary tract symptoms vs. no lower urinary tract symptoms
CharacteristicN/total (%)
LUTSNo LUTSRR (95% CI)
Social status
Employed 45/198 (23)14/172 (8)2.8 (1.6–4.9)
Retired 64/135 (47)21/81 (26)1.8 (1.2–2.7)
Unemployed  8/17 (47) 0/6 (0) 
On sick leave 35/45 (78)16/27 (59)1.3 (0.9–1.9)
Education
Primary school 110/256 (43)45/131 (26)1.6 (1.3–2.2)
Secondary school 24/79 (30) 2/65 (3)9.9 (2.4–40.2)
University studies 16/58 (28) 4/42 (10)2.9 (1.0–8.0)
Marital status
Single/widower 31/64 (48) 8/40 (20)2.4 (1.2–4.7)
Married/living together125/336 (37)44/249 (17)2.1 (1.5–2.8)
Other
Smoker 38/81 (47)12/58 (21)2.2 (1.3–3.9)
Non-smoker 17/319 (37)40/231 (17)2.1 (1.5–2.9)
No physical activity 93/218 (43)31/142 (22)1.9 (1.4–2.8)
Physical activity 62/181 (34)21/147 (14)2.4 (1.5–3.7)
UTI 27/41 (66) 2/7 (29)2.3 (0.7–7.5)
No UTI128/358 (36)49/281 (17)2.1 (1.5–2.7)

When each of the 12 specific LUTS were considered, the risk of a low score for health was higher for men with the symptom than for men without the symptom (Table 3). In particular, of men who experienced leakage of urine with no urge or physical activity (‘other incontinence’), 59% reported a low score for health, compared with 26% of men who experienced no ‘other incontinence’. The RR of a low score for health was 2.1 (1.7–2.6) for men with urge incontinence compared to men with no urge incontinence.

Table 3.  The RR of moderate/bad health for men with a specific LUTS vs men without that specific symptom.
DAN-PSS itemN/total (%)RR (95% CI)
SymptomNo symptom
  • *

    Urinary leakage without urge or physical activity.

Other incontinence* 48/82 (59)159/606 (26)2.2 (1.8–2.8)
Stress incontinence 38/77 (49)169/610 (27)1.8 (1.4–2.4)
Urge incontinence 85/170 (50)123/519 (24)2.1 (1.7–2.6)
Urgency148/380 (39) 59/309 (19)2.0 (1.6–2.7)
Nocturia149/385 (39) 60/305 (20)2.0 (1.5–2.6)
Weak stream122/203 (40) 85/386 (22)1.8 (1.4–2.3)
Daytime frequency 112/337 (36) 68/327 (21)1.7 (1.4–2.3)
Hesitancy137/363 (38) 72/328 (22)1.7 (1.3–2.2)
Incomplete emptying131/348 (38) 75/336 (22)1.7 (1.3–2.1)
Dysuria 51/117 (44)156/571 (27)1.6 (1.3–2.0)
Postvoid dribbling166/491 (34) 42/199 (21)1.6 (1.2–2.2)
Straining 119/324 (37) 89/367 (24)1.5 (1.2–1.9)

SELF-ASSESSED SADNESS

Of men who had studied at university, a high score for sadness was reported by 29% of men with LUTS, compared with 10% of men with no LUTS. Smokers with LUTS had a greater risk of obtaining a high score for sadness than smokers with no LUTS. Of men living as single/widowers, or married/living together, the RR of a high score for sadness in men with LUTS was higher than in men with no LUTS (Table 4).

Table 4.  The RR of sadness (‘all the time’ or ‘part of the time’) and happiness (‘all the time’ or ‘most of the time’) for men with LUTS vs men with no LUTS
CharacteristicSadness, N/total (%)RR (95% CI)Happiness, N/total (%)RR (95% CI)
LUTSNo LUTSLUTSNo LUTS
Social status:
Employed35/196 (18)19/170 (11)1.6 (0.9–2.7) 93/196 (47) 113/170 (66)0.7 (0.6–0.8)
Retired28/122 (23) 9/71 (13)1.8 (0.9–3.6) 48/123 (39) 50/74 (68)0.6 (0.4–0.7)
Unemployed9/17 (53) 1/6 (17)3.1 (0.5–20.1) 13/16 (19)  5/6 (83)0.2 (0.1–0.6)
On sick leave20/46 (43) 5/25 (20)2.2 (0.9–5.1)  9/45 (20)  8/25 (32)0.6 (0.3–1.4)
Education:
Primary school63/246 (26)24/164 (15)1.7 (1.1–2.7)105/245 (43)109/166 (66)0.6 (0.5–0.8)
Secondary school 11/76 (14) 5/65 (8)1.8 (0.7–5.1) 31/77 (40) 43/65 (66)0.6 (0.4–0.8)
University studies16/56 (29) 4/41 (10)2.9 (1.1–8.1) 18/56 (32) 23/41 (56)0.6 (0.3–0.9)
Marital status:
Single/widower26/62 (42) 6/38 (16)2.6 (1.2-5-8) 16/63 (25) 24/39 (61)0.4 (0.2–0.7)
Married/living together66/323 (20)28/237 (12)1.7 (1.1-2-6)138/322 (43)154/239 (64)0.7 (0.6–0.8)
Other:
Smoker27/77 (35) 6/58 (10)3.5 (1.5–7.7) 32/76 (42) 13/20 (65)0.6 (0.5–0.9)
Non-smoker66/308 (21)28/217 (13)1.6 (1.1–2.5)122/309 (39)140/220 (64)0.6 (0.5–0.7)
Physical activity, ≤ twice/week50/209 (24)20/137 (15)1.6 (1.0–2.6) 75/208 (36) 82/138 (59)0.6 (0.5–0.7)
Physical activity, > twice/week41/175 (23)14/138 (10)2.3 (1.3–4.0) 79/176 (45) 96/140 (69)0.6 (0.5–0.8)
UTI13/38 (34) 0/6  7/38 (18)  4/7 (57)0.3 (0.1–0.8)
No UTI80/346 (23)34/269 (13)1.8 (1.3–2.6)147/346 (42)174/271 (64)0.7 (0.6–0.8)

The risk of a high score for sadness was significantly higher in men with each of 12 specific LUTS. ‘Other incontinence’ significantly increased the risk of feeling sad ‘part of the time’ or ‘all the time’ in men with ‘mild’, ‘moderate’ or ‘much’ effect from this symptom, compared with men unaffected by ‘other incontinence’. The RR of a high score for sadness in men with stress or urge incontinence was 2.1 and 1.9, respectively. The risk of a high score for sadness was higher in men with ‘mild’, ‘moderate’ or ‘much’ effect from the symptom of post-micturition dribbling than in men unaffected by this symptom (Table 5).

Table 5.  The RR of sadness and happiness for men for men with a specific LUTS vs men without that specific symptom
DAN-PSS itemSadness, N/total (%)RR (95% CI)Happiness, N/total (%)RR (95% CI)
SymptomNo symptomSymptomNo symptom
  • *

    Urinary leakage without urge or physical activity.

Other incontinence* 29/75 (39) 96/583 (17)2.3 (1.7–3.3) 20/77 (26) 311/584 (53) 0.5 (0.3–0.7)
Stress incontinence 26/71 (37) 101/587 (17)2.1 (1.5–3.0) 18/72 (25)314/589 (53) 0.5 (0.3–0.7)
Urge incontinence 48/159 (30) 78/500 (16)1.9 (1.4–2.7) 50/160 (31)282/502 (56) 0.6 (0.4–0.7)
Urgency 90/364 (25) 37/295 (13)1.9 (1.4–2.8)145/365 (40)186/297 (63) 0.6 (0.5–0.7)
Nocturia 82/365 (23) 46/295 (16)1.4 (1.0–2.0)153/366 (42)178/297 (60) 0.7 (0.6–0.8)
Weak stream 64/286 (22) 64/375 (17)1.3 (1.0–1.8)121/286 (42)209/377 (55) 0.8 (0.7–0.9)
Daytime frequency 68/320 (21) 51/316 (16)1.3 (1.0–1.8)139/321 (43)187/318 (59) 0.7 (0.6–0.9)
Hesitancy 86/343 (25) 42/318 (13)1.9 (1.4–2.7)135/345 (39)197/319 (62) 0.6 (0.5–0.7)
Incomplete emptying 77/330 (23) 46/325 (14)1.7 (1.2–2.3)132/330 (40)196/328 (60) 0.7 (0.6–0.8)
Dysuria 37/110 (34) 90/548 (16)2.0 (1.5–2.8) 32/109 (29)299/552 (54) 0.5 (0.4–0.7)
Post micturition dribbling107/471 (23) 21/189 (11)2.0 (1.3–3.2)199/472 (42)132/192 (69) 0.6 (0.5–0.8)
Straining 70/308 (23) 58/353 (16)1.4 (1.0–1.9)120/309 (39)212/355 (60) 0.7 (0.6–0.8)

SELF-ASSESSED HAPPINESS

All men apart from those on sick leave reported a significant effect on their happiness score if they had LUTS, compared with men with no LUTS (Table 4). All 12 LUTS significantly reduced the happiness score among men affected mildly, moderately or much compared with men with no LUTS. The proportion of men with a high score for happiness was lower among those who rarely, often, or always had leakage of urine without urge or physical activity than among those men who never had ‘other’ incontinence (Table 5). Stress incontinence significantly reduced the score for happiness in men with ‘mild’, ‘moderate’ or ‘much’ effect from this symptom compared with men unaffected by stress incontinence. The relative prevalence of high scores for happiness was 0.6 for men with ‘mild’, ‘moderate’ or ‘much’ urge incontinence compared with men without urge incontinence (Table 5).

SELF-ASSESSED HEALTH AND SYMPTOM BURDEN

A low score for health was reported by 30% (209 of 692) of the men (Table 6). The self-assessed health correlated with the total LUTS burden; 39% (157 of 402) of men with at least one LUTS reported a low score for health, compared with 18% (52 of 290) of men unaffected by LUTS (RR 2.2, CI 1.7–2.9). Overall, 19% (128 of 662) of the men felt sadness ‘all of the time’ or ‘part of the time’. Among men unaffected by LUTS, 12% reported sadness, vs 43% of men with 5–8 LUTS. There was no further significant increase in reported sadness in men with 9–12 LUTS (Table 6). The RR of a high score for sadness in men with one or more LUTS was 2.0 (1.4–2.8).

Table 6.  The prevalence of tested scores, as n/N (%) and RR (95% CI) in men with different numbers of reported LUTS
GroupNumber of symptoms
01–45–89–12
Low score for health 52/290 (18) 117/343 (34)34/51 (67)6/8 (75)
RR  1  1.9 (1.4–2.5) 3.7 (2.7–5.1)4.2 (2.6–6.7)
High score for sadness 34/275 (12) 73/335 (22)20/47 (43)1/5
RR  1  1.8 (1.2–2.6) 3.4 (2.2–5.4)1.6 (0.3–9.6)
High score for happiness178/278 (64)144/335 (43) 9/46 (20)1/6
RR  1  0.7 (0.6–0.8) 0.3 (0.2–0.6)0.3 (0.0–1.6)

A feeling of happiness ‘all of the time’ or ‘most of the time’ was reported by half (332 of 665) of the men. The happiness score was correlated with the total LUTS burden. The prevalence of a high score for happiness was higher in men unaffected by LUTS than in men affected by LUTS (64% vs 40%; RR 1.6, CI 1.4–1.9).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  9. Appendix

The symptom burden from LUTS determines self-assessed health, sadness and happiness. Most LUTS that were measured in the present study by the DAN-PSS (12 symptoms) had a negative effect on these factors, and there was a strong correlation between the number of LUTS reported and self-assessed health and happiness. A significant difference was already apparent in men affected by one LUTS (RR 1.5), and the prevalence of a low score for health continued to increase with up to eight LUTS. The prevalence of a high score for happiness decreased and that of a high score for sadness increased in the same way, associated with increased LUTS burden. These data are supported by studies of self-assessed variables of well-being. Henningsohn et al.[10] reported that the number of chronic symptoms after treatment for urinary bladder cancer determines the risk of a lower self-assessed well-being, while Koskimaki et al.[5] reported that reduced health was associated with an increased LUTS impact, as measured using the DAN-PSS questionnaire. Correlations have also been found when the impact of LUTS was measured by other methods, e.g. the IPSS [11,12].

In the present study, symptom severity was associated with negative effects on self-assessed health, sadness and happiness. Other studies have also shown negative effects of increasing symptom severity on different QoL domains (SF-36 and King's Health Questionnaire) [4,6,13], thus it appears that the same effect can be measured by extracting key questions from the more extensive QoL questionnaires that are often used.

Different LUTS affect self-assessed health, sadness and happiness in different ways. ‘Other’ incontinence and urge incontinence appear to have a greater impact on health than stress incontinence. In another population-based Swedish study by Hägglund et al.[14], urge incontinence had a greater effect on QoL than stress incontinence in women. It is reasonable to assume that unavoidable urge incontinence that appears suddenly is more distressing than an avoidable symptom such as stress incontinence. The avoidability of this symptom could be one explanation for the results of another study by our group [15], which shows that ‘high-severity’ stress incontinence causes moderate/much distress among a much higher proportion of affected men (67%) than in men with a ‘low-severity’ level of the symptom (21%). Thus, when it occurs, it causes high levels of distress, but because it is avoidable, the affected person avoids risky situations and thereby prevents negative effects on QoL.

Although ‘other’ incontinence was not the most prevalent LUTS, it had a considerable effect on self-assessed health, sadness and happiness. It is therefore important to assess not only highly prevalent LUTS but also symptoms with a low prevalence and which affect QoL in the clinical situation. The findings by Peters et al.[16], that nocturia influences ‘everyday life’, supports the present finding that this symptom has negative effects on perceived health, sadness and happiness. ‘Weak stream’ was also significantly correlated with a lower level of self-assessed health and happiness, and to a higher level of sadness. This has also been discussed previously [17], and could reflect fear of prostate cancer.

The differences between men with LUTS and men with no LUTS with respect to social status, education, marital status, smoking, physical activity and UTI indicate that LUTS have a particular impact on self-assessed health and happiness. Koskimäki et al.[5] found that the RR of a reduction in QoL after adjusting for age and different diseases was higher in men with LUTS than in with men with no LUTS. Unfortunately, in the present study, no specific questions were asked about other diseases.

LUTS were self-reported and the classification based on a questionnaire answered in the home environment. No clinical investigations were undertaken to validate the reported LUTS. The use of a questionnaire in the home environment probably results in fewer investigator errors than, for example, a personal interview [18,19]. As a result, the misclassifications that might have occurred using this method are difficult to assess objectively, but the risk should be low, as the DAN-PSS is a validated questionnaire designed for self-assessment [20]. The Swedish population register provides information on all residents in the country, the present study is based on a large population, and we see no indications that men in this community differed from men in the rest of the country. It is always risky to generalize results from one study population to others, but the prevalence of LUTS is commonly described as being about the same in other countries of the world.

It is difficult to define when symptoms do not merely constitute a normal physical condition or behaviour; LUTS should be evaluated individually, together with the patient's discomfort level from the same symptom. In the present study, we included all LUTS, irrespective of discomfort level, and included the symptom if it was reported at any level in the DAN-PSS. For some LUTS the reported symptom level might represent a ‘normal’ condition, rather than a pathological condition for that individual. Counting these low-grade symptoms together with high-grade symptoms might dilute the results obtained. Self-assessments of LUTS have previously shown limitations; Malmsten et al.[21] found that self-reported urinary incontinence could not be verified objectively in 4.6% of the participants. In the present study, self-assessed health, sadness and happiness were evaluated by three questions from a disease-independent questionnaire, the SF-36; we consider that the most reliable evaluation of LUTS, as well as quality factors, is the self-assessment of specific questions and not a summarized score from many different questions.

Bias could have been introduced during the selection of the study base (Fig. 1). The cohort in the present study consisted of 1008 men, i.e. 504 who 12 months earlier reported the occurrence of one or more of three LUTS [1], and 504 age-matched men from the same community. To minimize misrepresentation, two postal reminders were sent to those not responding, but more men who had reported LUTS answered the questionnaire than men with no earlier reported LUTS. Consequently, nothing indicates that the differences between men with LUTS and the controls are large enough to jeopardise the study results, but we cannot exclude the possibility that the 26% who did not respond biased the results. Even if the present results confirmed the need to assess QoL questions, most men with LUTS are still unknown to the healthcare system [1]. Therefore, the aim of a future study would be to focus on the reasons for health-care seeking, which have been poorly documented and analysed.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  9. Appendix

Appendix

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  9. Appendix

APPENDIX 1

In general, would you say your health is?

a) Excellent; b) Very good; c) Good; d) Moderate; e) Bad

Have you felt sadness?

a) All of the time; b) Most of the time; c) Some of the time; d) Part of the time; e) A little of the time; f) None of the time

Have you been happy?

a) All of the time; b) Most of the time; c) Some of the time; d) Part of the time; e) A little of the time; f) None of the time