Title : Does IPSS Questionnaire Used for LUTS Screening Need Explanation?

 Does IPSS Questionnaire Used for

 LUTS Screening Need Explanation?



In advanced age, manifestation of Lower Urinary Tract Symptoms (LUTS) can be bothersome and also seriously affect the day-to-day activities leading to benign prostatic hyperplasia (BPH). In this descriptive study, 150 subjects with symptoms for more than six months were assessed using International Prostate Symptom Score (IPSS) questionnaire for their severity of symptoms. Data was collected using IPSS questionnaire before and after explanation in their own lan-guages for literate population. The description on additional explanation of IPSS tool was as-sessed. Descriptive statistics and paired t test were used for statistical analysis. The study showed that 12 percent of the subjects had mild symptoms, 52 percent with moderate and 36 percent with severe symptoms. Storage symptoms were more severe than voiding symptoms. There was a significant difference in explanation of symptoms such as frequency, urgency and quality of life. Identifying LUTS is the most important challenge for the health care personnel. A simple screening can provide adequate information to determine further steps in assessment. Hence it is necessary to explain the tool for proper assessment in subjects with LUTS thereby preventing errors in judging their treatment modality.

Staying healthy is the ultimate aim of an individual. Hence every individual strives to achieve contentment in their physical and mental health. A major concern of health for men is the diseases of the prostate and urinary tract that are often clinically silent.

Men very often do not approach health care facilities for such bothersome symptoms as it is a sensitive issue for many. This research is the highlight for the hidden areas of care in the health care setting (Fukuta et al, 2012).


It is suggested that primary prevention strategies should be aimed at providing education regarding normal lower urinary tract structures and functioning to the public, including patients and healthcare providers. Such education may promote the achievement of optimal bladder health by increasing healthy bladder habits and behaviours, awareness of risk factors, seeking healthcare, reducing stigma and other barriers to treatment (Jo-seph et al, 2003). Promoting optimal bladder health may reduce the personal, societal and economic impact of bladder conditions, including anxiety and depression and costs associated with conditions or diseases and their treatment (Ganpute et al, 2004).

The nurse can relatively do a better assessment, diagnostic work-up and stratify the patient who present with LUTS. This assessment includes a complete patient history, a focused physical exami-nation, the IPSS questionnaire, and a urinalysis and prostate specific antigen (Barry et al, 1992). Nurses have better skills in assessing patients with urinary symptoms and manage based on those symptoms. It is the primary duty of urology nurses to take care of patients with LUTS. It is more of a preventive measure creating an awareness among the nursing personnel in evaluating LUTS.

Hypothesis: There will be a significant difference in ability to use the study instrument by under-standing symptoms, severity with explanations among patients with lower urinary tract symptoms suggestive of benign prostrate hyperplasia (BPH).

The aim was to compare the adequacy of data collected on symptoms severity without and with explanations of the tool used by the investigator.

Review of Literature

The manifestations of BPH (known as lower urinary tract symptoms) affect 40 – 50 percent of men over the age of 70. The disorders of the prostate are a major source of discomfort and disease in middle aged men. LUTS are rarely life threaten-ing but in few men, if not treated, it can lead to most serious conditions such as acute urinary re-tention, urinary tract infections, bladder stones and bladder decompensation. Patients with mild to moderate LUTS may find relief from their symp-toms by modifying their behaviour and lifestyles such as avoiding caffeine and alcohol, fluid man-agement, double voiding and bladder retraining. Nurses can assess men with LUTS and provide reassurance by promoting fluid management, caf-feine avoidance and preventing constipation be-fore starting medical therapy or referring from pri-mary to secondary care. Nurses role is to carry out an comprehensive, effective and holistic as-sessment of men with LUTS (Jessica & Green wood, 2003).

A study in Netherlands (Wolters & Wensing, 2004) on shared care and management of LUTS helped in improving public awareness and in-creases the life expectancy by identifying it ear-lier. It also supports that general practitioners can manage the uncomplicated LUTS.

A study published in The Nursing Journal of In-dia (Malathi, 2009) revealed that the knowledge level on management of BPH among patients was inadequate. The author recommended for health education programmes in those patients and had tested their knowledge after a structured teaching programme which showed the significance of the study .

Storage symptoms: Storage symptoms include uri-nary frequency, urgency, nocturia. According to the NICE guidelines (2010), men with storage LUTS need supervised bladder training, advice on fluid intake, lifestyle advice and containment products if needed. The guidelines recommend supervised pelvic floor muscle training.


A descriptive study design was undertaken to as-sess the symptom severity and Quality of Life among Urology patients with lower urinary tract symptoms suggestive of benign prostatic hyperpla-sia in a tertiary level multi-speciality hospital. The instrument used to assess the severity of symp-toms was International Prostate Symptom Score Questionnaire created by American Urological As-sociation which is a six-point Likert scale, con-sists of seven questions on symptom assessment such as incomplete emptying, frequency, inter-mittency, urgency, weak stream, straining and nocturia which is related to symptoms of BPH in terms of mild, moderate and severe symptoms as scoring response and one question on quality of life is a 7-point Likert scale in terms of delighted, pleased, mostly satisfied, mixed, mostly dissatis-fied, unhappy and terrible (Greenwood (2003). In-strument reliability for IPSS scale is of good sta-bility (0.95).

Setting of the study: The study was conducted in the Department of Urology which caters to the health needs of patients all around the world. The average of 7,500 patients with urological problems are seen in the outpatient department everyday or hospitalised for various treatments.

Study population: The study included all Urology patients with lower urinary tract symptoms sug-gestive of BPH pre-operatively from hospitalised pa-tients and those visiting urology OPD in tertiary level hospital.

Study instrument: The instrument used to assess LUTS suggestive of BPH was International Prostate Symptom Score (IPSS) given by American Urologi-cal Association (AUA) as recommended by Interna-tional Scientific Committee (SCI). It is a 6-point Likert scale with 7 questions on symptom assess-ment such as incomplete emptying, frequency, in-termittency, urgency, weak stream, straining and nocturia, related to symptoms of BPH in terms of mild (0-7), moderate (8-19) and severe (20-25) symp-toms as scoring response and one question on qual-ity of life is a 7-point Likert scale in terms of de-lighted, pleased, mostly satisfied, mixed, mostly dis-satisfied, unhappy and terrible.

Sample: The samples consisted of Urological pa-tients with lower urinary tract symptoms for more than six months. A sample of 150 subjects with LUTS participated in the study. Sample size was calculated based on the pilot study. Data was col-lected over a period of six weeks in June 2013. The investigator regularly visited Inpatients and Out-patients as per the schedule and data was collected from the subjects after getting their written in-formed consent. For patients who speak in Hindi and Bengali, services of translator were used for collecting data.

Data analysis was done using statistical pack-age SPSS 17.0 version. The level of significance was set at 0.05 for the study. Descriptive statistics were used to summarise the demographic and clinical data. Paired t test was used to describe the pre- and post-explanation score of symptom severity.

The study was conducted after approval by the College of Nursing Research Committee. Permis-sion to conduct the study was obtained from Head of the Urology Department, the Nursing Superin-tendent and Head of Medical Surgical Nursing Speciality Department. Written consent was ob-tained from participants in their respective lan-guage after explaining the purpose of the study. Confidentiality was maintained throughout the study.

Results and Discussion

In the present study, analysis of the severity of symptoms was based on IPSS, which included the components such as incomplete emptying, fre-quency, intermittency, urgency, weak stream, straining and nocturia. Thirty-four percent of the subjects were with incomplete emptying and in-creased frequency symptoms; 32.7 percent of the subjects were with intermittent urination, symp-toms of urgency (22%), weak stream urination (26.7% ) and straining while urination was seen in 20 percent of the subjects in most of the days  in a month who were above 50 years of age (Table). The overall symptom severity showed that 12 percent had mild symptoms, 52 percent had mod-erate symptoms and 36 percent had severe symp-toms.

 The severity of symptoms using IPSS especially storage symptoms such as frequency and urgency needs more explanation for the subjects (Fig 1). Also, there is a necessity for explanation about Quality of Life item in IPSS questionnaire. The edu-cational status of the subjects was: 18.1 percent primary, 39.3 percent secondary, 29.3 percent graduate and 13.3 percent post-graduate.


The subjects were assessed without and with explanation of the entire tool to identify whether explanation significantly gives a higher or lower score. This emphasises that explanation is man-datory. The subjects were finding difficult to an-swer certain questions such as weak stream and incomplete emptying (Table 2). The score difference on the overall scoring were decreased from mild 15.3 percent to 12 percent, moderate symptoms from 58 percent to 52 percent whereas with proper expla-nation in their own lan-guages helped the subjects to have an increase in se-vere symptoms from 26 per-cent to 36 percent. Hence explanation is required in order to understand their severity of symptoms and intervene based on the symptoms better (Fig 2).

 The IPSS was compared in each component to identify whether explanation of those concepts to subjects made a difference in the score (Table 2). It was certainly a change in scores in symptoms such as frequency and urgency. There is a need for explanation in these aspects. Also the Qual-ity of Life perception after explanation in IPSS scor-ing made a significant difference.

It is imperative that the health care person-nel need to make a proper assessment of their urinary symptoms. It is also been suggested that the IPSS scores along with their quality of life answers provide comprehensive assessment (Stacy, 2002).

A similar study done in Brazil to identify the in-fluence of patient education level on the IPSS with self administered or administered by professional medical personnel suggested that illiterate sub-jects were unable to answer the questionnaire but with the help of professional medical personnel (Netto Jr & Lima, 1995). The literates did not show statistical significance with explanation.

Inference: The severity symptoms scoring done by the subject themselves reveals that 23 subjects (15.3% ) with mild symptoms and 87 (58% ) of them with moderate symptoms and 39 (26%)  of them with severe symptoms. One of them (0.7%) left unanswered. 

After explanation: The score 18(12% ) differs with mild symptoms and 78(52%) with moderate symptoms and 54(36.0%) with severe Lower Uri-nary Tract Symptoms. There was a difference in the score of mild symptoms from 15.3% to 12% and reduc-tion in subjects with moderate symptoms from 87 (58% ) to 78 (52%) and severe symptoms from 39 (26%) to 54 (36%).

Quality of life based on the subjects’ perception in IPSS Questionnaire were analysed (Fig 2). Majority 72 (48% ) were unhappy about their quality of life. Few 28 (18.7%) and 22 (14.7%) of them perceived that their symptoms affect quality of life terribly and mostly dissatisfied irrespectively. Very few 3 (2%) and 2 (1.3% ) perceived that they were mostly satisfied and pleased with symptoms. None (0% ) had delighted perception about their quality of life.

The severity of symptoms in subjects with in-crease in symptoms for almost all the days in a month such as incomplete emptying 51 (34%), frequency 53 (35.3%), intermittency 49 (32.7% ) and nocturia 19 (12.7% ). The other symptoms were not experienced by subjects for a month such as urgency 70 (46.7% ), weak stream of urine 51 (34% ), and straining while passing urine 80 (53.3%).



Subjects with lower urinary tract symptoms need more explanation on their symptom assessment in their own language. IPSS can be worded differently to make it more understand-able by patients, and even have cul-tural elements to enable patients describe their symptoms better.

Hence IPSS can be modified to make it more understandable for the Indian men with LUTS. The study highlights that there were statistical significance in ability to use the study instrument by understanding symptom severity with explanations among patients with LUTS suggestive of BPH and thus the hypothesis is accepted.


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Author: Angeline Jeya Rani1, Beulah Premkumar2, Emily Daniel2, Chandrasingh3


The authors are: Junior Lecturer, Community Health Nursing Depart-ment, College of Nursing, Christian Medical College, Vellore (TN).

Source: TNAI Journal