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In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)?

In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)? Background: The prevalence of lower urinary tract symptoms (LUTS) varies among different populations but the rate of seeking medical advice is consistently low. Little is known about the reasons for this low rate. In the city of Macau, China, primary healthcare is free and easily accessible to all citizens. We aim to study the patients’ rate of consulting for LUTS and their reasons for not consulting under a free healthcare system. Method: A convenience sample of 549 male patients aged 40-85 years in a government health centre filled in the International Prostate Symptoms Scale (IPSS) questionnaire. They were also asked if they had consulted doctors for LUTS, and if not, why not. Result: Of the whole sample, 64 men (11.7%) had ever consulted doctors for LUTS. Of 145 with moderate to severe LUTS, 35 (24.1%) consulted. Of 73 who were dissatisfied with their quality of life, 22 (30.1%) consulted. Regarding the symptoms as normal or not problematic was the main reason for not consulting. Advancing age and duration of symptoms were the significant factors for consulting. Conclusion: Primary care doctors could help many of LUTS patients by sensitively initiating the discussion when these patients consult for other problems. Keywords: LUTS, IPSS, help-seeking behaviour, primary care, free healthcare Introduction differs among different populations, more data are Lower urinary tract symptoms (LUTS) are common in required to see if the rates differ even within the same men aged 40 years or above [1,2]. The reported prevalence ethnic population. of LUTS varies widely among different age groups and Though commonly affected, not many men with ethnic populations. For men aged 40 or above, the preva- LUTS consult their doctors for these symptoms. The lence of moderate to severe LUTS was reported to be: reported rates vary also widely: 4.4% (US) [8], 9.2% 16.2% (Korea) [3], 19.2% (France) [3], 20.7% (Netherlands) (Denmark) [5], 11.3% (Scotland) [9], 18% (UK) [7], [3], 25.1% (UK) [3], 38% (USA) [4], 56% (Japan) [4]. 22.2% (African-American) [10], 38.2% (Spain) [11]. This For men aged 50 or above, the reported rates were: 28% help-seeking behaviour is known to be affected by the (Denmark) [5], 14% (Singapore) [6], 34% (Malaysia) [6], severity of LUTS and how bothered the patients are 39% (Thailand) [6], 41% (UK) [7], 48% (Hong Kong) [6], [7,10,11]. Reports in the literature are mainly on the rea- 59% (Philippines) [6]. These reports used the International sons for men to consult doctors for LUTS [10-12] and Prostate Symptom Score (IPSS) that was validated in dif- not on Asian populations. We are not aware of similar studies on the reasons for not consulting although it ferent languages to assess thepresenceand severity of LUTS, and the recruits were from the community-popula- was suggested that regarding the symptoms as a normal tion. Some of them were done concurrently in different aging process and embarrassment might deter men countries [3,4,6]. Given that the prevalence of LUTS from seeking help [13]. Cultural background, accessibil- ity of the healthcare, and financial restraints might affect men’s decision to seek medical advice for LUTS. Would * Correspondence: ytwun@hotmail.com more men from a free healthcare system consult doctors Department of Family Medicine and Primary Care, University of Hong Kong, for their LUTS? Hong Kong, China Full list of author information is available at the end of the article © 2011 lai et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 2 of 5 http://www.apfmj.com/content/10/1/7 The Macau Special Administrative Region is a city on Of the whole sample, 363 (66.1%) were of mild (IPSS the southern coast of China with a population of score 1-7), 116 (21.1%) of moderate (IPSS score 8-19), 549,500 (Year 2010). The government runs seven public and 29 (5.3%) of severe symptoms (IPSS score ≥20). outpatient clinics, each on average with 15 doctors, and Only 64 men (11.7%) had consulted doctors for LUTS the service is free to all citizens. Medical consultation is and one of them did not receive any subsequent either walk-in or by appointment. Specialist treatment treatment. in public hospital is also free to patients aged 65 or above or with low income. In such free and easily acces- Age siblesetting,weaimed to study(a) theprevalenceof The severity of LUTS increased with age (Table 1, ordi- LUTS in the Chinese residents of this locality, and (b) nal regression Wald = 20.41, p < 0.001; the odds ratio how many men with LUTS had sought advice from for each increase in year being 1.043 (95% confidence their doctors and, if not, why not. interval, CI: 1.024, 1.062)). The older age-group was more likely to consult doc- Method tors for their symptoms (Table 1, c = 25.03, p < 0.001). This is a prospective cross-section survey of patients The men who had consulted doctors got LUTS for attending the Hac Sa Wan Health Centre, Macau. As much more longer time than those who had not other studies we used the IPSS questionnaire to assess (the mean month ± standard deviation were respectively LUTS and the effect on the patient’squalityof life.In 14.1 ± 16.75 and 4.7 ± 8.87, t-test -4.438, p < 0.001). addition we asked whether the patient had ever discussed the symptoms with his doctor, how long had the symp- IPSS toms been, and the reasons for not seeking help (fear Each IPSS item was significantly associated with medical treatment, fear being diagnosed to have prostatic disease, consultation when tested separately (Table 2, all c tests embarrassed to ask, symptoms being normal, or other gave p < 0.01). Taking all the items together, logistic reasons). To encourage response, the questionnaire was regression showed that only nocturia (p = 0.045) and anonymous. straining (p = 0.007) were significantly associated. The From October 5 to November 11, 2010, a nurse was odds ratio of consulting for nocturia was 1.30 (95% CI: delegated to explain the aim of the questionnaire to the 1.005, 1.678), and for straining 1.43 (95% CI: 1.104, male patients aged 40 years or above in the waiting room 1.845). of the adult clinic (after registration and before seeing The men with more severe symptoms were more the doctors). The patients were then invited to fill the likely to consult doctors (Table 3, c = 45.10, p < 0.001). questionnaires according to their opinions. The patients who had difficulty with the questionnaire could ask help Quality of life (QoL) from the nurse who later collected all the distributed Of the sample, 354 (64.5%) men were in the satisfied questionnaires. The collection of data stopped when the range while 73 (13.3%) in the dissatisfied range (Table 4) desired sample size had been reached. if the symptoms persisted. Only one man was very dissa- For the estimated sample size (n), we presumed 50% of tisfied; for analysis we grouped this man into the group our recruits would give either a positive or negative of “Dissatisfied”. answer to the questionnaire items. Taking the confidence The probability of consulting doctors increased with level of 95%, margin of error of ± 5%, and p = 0.05 as sig- dissatisfaction in QoL (logit c = 32.10, p < 0.001); the nificant, n is 385. As we anticipated much fewer men in “slightly dissatisfied” were 13.50 times more likely than the older group aged 70 or above, we aimed to recruit the “mixed feeling” to consult a doctor, and the “dissa- around 550 men so that the sample in the older group tisfied” were 27.6 times more likely than the “slightly would not be less than 50 or 10% of the total sample. We dissatisfied”. used chi-squared test, logistic regression and ordinal When QoL and the total IPSS score were put into the regression for any significant association or estimation logistic regression model for consulting doctor or not, among the categorical data. QoL became insignificant (logit c = 4.19, p = 0.523) The study was approved by the Health Bureau, Macau while IPSS was still significant (logit c = 16.09, government. p < 0.001). Result Combined effect In total 549 men completed the questionnaire. The age When age, duration of symptoms, severity of symptoms, ranged from 40 to 85 years (mean 57.2 ± 9.38 years). QoL were put into the logistic regression model, only There were 41 men (7.5%) who had none of the LUTS age and duration were significantly associated with con- symptoms, giving the prevalence of any LUTS of 92.5%. sulting doctors (p = 0.002, p = 0.035 respectively). lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 3 of 5 http://www.apfmj.com/content/10/1/7 Table 1 Distribution of age-groups with LUTS severity and consulting doctors Age group (years) Total 40-49 50-59 60-69 ≥70 LUTS severity Nil 12 (9.8%) 22 (10.4%) 6 (4.1%) 1 (1.5%) 41 (7.5%) Mild 84 (68.3%) 144 (67.9%) 97 (66.4%) 38 (55.9%) 363 (66.1%) Moderate 23 (18.7%) 43 (20.3%) 31 (21.2%) 19 (27.9%) 116 (21.1%) Severe 4 (3.3%) 3 (1.4%) 12 (8.2%) 10 (14.7%) 29 (5.3%) Total 123 (100.1%) 212 (100.0%) 146 (99.9%) 68 (100.0%) 549 (100.0%) Consult doctor No 113 (91.9%) 195 (92.0%) 129 (88.4%) 48 (70.6%) 485 (88.3%) Yes 10 (8.1%) 17 (8.0%) 17 (11.6%) 20 (29.4%) 64 (11.7%) Total 123 (100.0%) 212 (100.0%) 146 (100.0%) 68 (100.0%) 549 (100.0%) Reasons for not consulting doctors only 11.7% consulted their doctors. While age, total The most common reason for not consulting doctor was IPSS score, quality of life, and duration of symptoms regarding LUTS as normal (Table 5). The “other rea- were each significantly associated with consulting doc- sons” given by the patients included: 87 “nothing tors, only age and duration were statistically significant wrong”,5 “not a problem”,5 “not necessary”,9 “never if these factors were considered together. The main rea- think of it”,1 “no time”,1 “dislike the idea”.The con- son for not consulting was regarding the symptoms as cept of “normal features” hadnosignificantassociation normal or not problematic. Among the IPSS items, noc- with severity of LUTS (logit c = 6.41, p = 0.093), QoL turia and straining were the important symptoms asso- 2 2 ((logit c = 10.74, p = 0.057), or age-group (logit c = ciated with consulting doctors or not. 3.07, p = 0.38). Similarly, “feeling embarrassed” was not Theprevalenceof IPSS≥1 in our sample is high com- associated with age-group (logit c = 3.91, p = 0.272). pared with the 72.3% observed in the study of men aged ≥40 from UK, USA and Sweden [14]. The prevalence of Discussion moderate to severe LUTS (IPSS > 7, 145/549 = 26.4%, This study on 549 male patients (aged 40 years and Table 1) is within the wide range reported by other stu- above) at a government outpatient clinic in Macau dies but much lower than those reported by two studies shows a high prevalence of any LUTS (IPSS≥1, 92.5%). on Chinese. For men aged 50 or above, a study of com- Most of them (87.2%) were of mild or moderate severity, munity residents in Wuhan, Mainland China [15], 13.3% were not satisfied with their quality of life, and reported a prevalence of 40.3% for moderate to severe LUTS in 1023 men, and another involving 201 men in Hong Kong was 46% [6]. The equivalent rate in this Table 2 IPSS and whether to consult doctor or not study was 27.7% (Table 1). It is specially notable that IPSS Consult doctor IPSS score Macau and Hong Kong are two neighbouring cities with 01 2 3 4 5 over 90% of the population being ethnic Chinese. Incomplete emptying No 336 61 38 18 10 22 Although the sampling methods of the three studies Yes 27 12 10 5 2 8 were different, the LUTS prevalence might still vary Frequency No 282 84 54 39 9 17 within the same ethnic population. Yes 21 13 13 9 2 6 As regard to men’s help-seeking behaviour for LUTS, Intermittency No 350 53 37 27 8 10 our findings differ from others in several points. Firstly, Yes 27 10 7 10 3 7 nocturia and straining were significantly associated with Urgency No 372 44 31 21 10 7 Yes 28 11 13 2 4 6 Table 3 Association between severity of LUTS and Weak stream No 368 48 22 24 7 16 consulting doctor Yes 25 9 10 8 5 7 Consult doctor LUTS Straining No 396 37 26 16 4 6 No LUTS Mild Moderate Severe Yes 29 8 10 5 4 8 No 39 (95.1%) 336 (92.6%) 94 (81.0%) 16 (55.2%) Nocturia No 66 221 122 58 11 7 Yes 2 (4.9%) 27 (7.4%) 22 (19.0%) 13 (44.8%) Yes 4 19 17 12 7 5 Total 41 (100.0%) 363 (100.0%) 116 (100.0%) 29 (100.0%) lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 4 of 5 http://www.apfmj.com/content/10/1/7 Table 4 Association between quality of life and consulting doctor Consult Quality of life if symptoms persist Very satisfied Satisfied Slightly satisfied Mixed feeling Slightly dissatisfied Dissatisfied Very dissatisfied No 69 169 91 105 46 4 1 (97.2%) (93.4%) (89.2%) (86.1%) (71.9%) (50.0%) (100.0%) Yes 2 12 11 17 18 4 0 (2.7%) (6.6%) (10.8%) (13.9%) (28.1%) (50.0%) Total 71 181 102 122 64 8 1 (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) consulting doctor in this study. The former was and 30.1% of men who rated their QoL as dissatisfied the most while the latter the least frequent symptom (Table 4) consulted their doctors. These rates could be (Table 2). Many studies found that nocturia was most considered low as medical treatment for LUTS was free to significant in the association of seeking help [10,16]. our patients. The most common reason for not seeking This study however found that straining (an obstructive treatment was taking the symptoms as “normal” or not symptom) was more likely than nocturia to associate regarding them as problematic. (Even the “other reasons” with seeking help. The statistical significance for noc- for not consulting were in fact regarding LUTS as normal.) turia was marginal at p = 0.045. The next frequent reason was embarrassment on disclo- Secondly, being bothered by LUTS was shown to be sure. This study supports the speculation that regarding significantly associated with consulting doctors [10,11], the symptoms as normal and embarrassment deterred our study shows that this association was through the men from seeking help [13]. Whether and how much severity of LUTS rather than the bother itself. Thus, these low rates of help-seeking and patients’ perception were due to the Oriental culture need further research. assessing the bother of LUTS might not be necessary It is notable in this study that only 30.0% men dissa- for every population. Thirdly. it is well known that LUTS is more frequent tisfied with their QoL due to LUTS consulted their doc- with advancing age; indeed LUTS incidence was shown tors; the majority were going to tolerate their to increase linearly with age in one study [17]. But age dissatisfaction some more months. Furthermore, about was seldom reported as an associated factor with seek- 10% of those who did not consult were due to perceived ing medical advice, and one study even showed that age embarrassment (Table 5). Primary care doctors could was not associated [10]. In this study, age was the most help these patients by initiating sensitively the discus- significant determinant for consulting doctors. The asso- sion on LUTS when they consult for other problems. ciation with symptom severity and bother became insig- Limitations nificant on adjusting for age. This study was on a sample from a health centre rather Apart from age, duration of symptoms was the other than on a general population. However, the Hac Sa significant association with consulting doctors. It was Wan Health Centre serves an area with 39.9% of the likely that men tolerated the symptoms (or tried to Macau population that is typical of the city, and there is “adjust their life to self manage their symptoms” [18]) likely no large deviation between the study sample and for some months before they decided to seek treatment. the general population. Another explanation was that LUTS started mildly with- Most of our recruits were of mild to moderate LUTS out disturbing daily life. As LUTS progressed with time, severity; only 5.3% were severe. This might explain the and age, the men found them much less tolerable and small proportion of patients who were bothered by then consulted their doctors. LUTS and the low rate of seeking medical advice. It is Only 11.7% of men in this study consulted their doctors uncertain how much these observation were affected by for LUTS. Just 44.8% of men with severe LUTS (Table 3) the sampling method of this study. We took a consecu- tive convenience sample rather than a randomized one. Table 5 Reasons for not consulting doctors for LUTS Due to the busy routines, the nurse did not document Reason Frequency the exact number of men who refused the questionnaire Embarrassed 64 (11.7%*) but noted from memory to be less than 10%. Normal features 289 (52.6%) Fear treatment 22 (4.0%) Conclusion Fear diagnosis of prostatic diseases 14 (2.6%) The prevalence of LUTS in ethnic Chinese may vary Others 108 (19.7%) among different cities. About 10% would seek medical advice even in a free healthcare system. Although the * Percentage of the total sample lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 5 of 5 http://www.apfmj.com/content/10/1/7 Prostate Research on Behaviour and Education (PROBE) Survey. Int J Clin severity of LUTS, the duration of symptoms, the degree Pract 2008, 62(1):18-26. of bother and age each had significant association with 13. Garraway WM, Russell EB, Lee RJ, Collins GN, McKelvie GB, Hehir M, help-seeking behaviour, only age and duration remain Rogers AC, Simpson RJ: Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly significant in the logistic regression model. The main men. Br J Gen Pract 1993, 43(373):318-21. reason for not seeking help was the perception of the 14. Coyne KS, Sexton CC, Thompson CL, Milsom I, Irwin D, Kopp ZS, symptoms as being normal aging process. The next Chapple CR, Kaplan S, Tubaro A, Aiyer LP, Wein AJ: The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: important reason was the embarrassment with discus- results from the Epidemiology of LUTS (EpiLUTS) study. BJU Int 2009, sion for which primary care doctors could help with 104(3):352-60. tactful approach. 15. Wan S-p, Hu L-q, Liu Y, et al: Survey of lower urinary tract symptoms in 2811 men in Wuhan City. Chinese Journal of Urology 2004, 9:585-87. 16. Hamzah AA, Rahman MNG, Daud MAM, Mahamood Z: A survey on lower urinary tract symptoms (LUTS) among patients with benign prostatic Author details hyperplasia (BPH) in hospital universiti sains malaysia (HUSM). Malaysian Hac Sa Wan Health Centre, Health Bureau, Macau Special Administrative Journal of Medical Sciences 2007, 14:67-71. Region, China. Department of Family Medicine and Primary Care, University 17. Verhamme KM, Dieleman JP, Bleumink GS, van der Lei J, Sturkenboom MC, of Hong Kong, Hong Kong, China. Artibani W, Begaud B, Berges R, Borkowski A, Chappel CR, Costello A, Dobronski P, Farmer RD, Jimenez Cruz F, Jonas U, MacRae K, Pientka L, Authors’ contributions Rutten FF, van Schayck CP, Speakman MJ, Tiellac P, Tubaro A, Vallencien G, All the authors planned the study and read as well as approved the Vela Navarrete R: Incidence and prevalence of lower urinary tract manuscript. Lai UC initiated the study question, supervised the data symptoms suggestive of benign prostatic hyperplasia in primary care– collection, and helped the preparation of the manuscript. Wun YT analyzed the Triumph project. Eur Urol 2002, 42(4):323-8. the data, and prepared the manuscript. Luo TC and Pang SM supervised the 18. Scarpa RM: Lower urinary tract symptoms: what are the implications for study and commented the manuscript. the patients? Eur Urol 2001, 40(Suppl 4):12-20. Competing interests doi:10.1186/1447-056X-10-7 The authors declare that they have no competing interests. Cite this article as: lai et al.: In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)? Asia Pacific Family Received: 27 March 2011 Accepted: 8 June 2011 Published: 8 June 2011 Medicine 2011 10:7. References 1. Garraway WM, Collins GN, Lee RJ: High prevalence of benign prostatic hypertrophy in the community. Lancet 1991, 338(8765):469-71. 2. Simpson RJ, Fisher W, Lee AJ, Russell EB, Garraway M: Benign prostatic hyperplasia in an unselected community-based population: a survey of urinary symptoms, bothersomeness and prostatic enlargement. Br J Urol 1996, 77(2):186-91. 3. Boyle P, Robertson C, Mazzetta C, Keech M, Hobbs FD, Fourcade R, Kiemeney L, Lee C: The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study. BJU Int 2003, 92(4):409-14. 4. Sagnier PP, Girman CJ, Garraway M, Kumamoto Y, Lieber MM, Richard F, MacFarlane G, Guess HA, Jacobsen SJ, Tsukamoto T, Boyle P: International comparison of the community prevalence of symptoms of prostatism in four countries. Eur Urol 1996, 29(1):15-20. 5. Norby B, Nordling J, Mortensen S: Lower urinary tract symptoms in the danish population: a population-based study of symptom prevalence, health-care seeking behavior and prevalence of treatment in elderly males and females. Eur Urol 2005, 47(6):817-23. 6. Li MK, Garcia LA, Rosen R: Lower urinary tract symptoms and male sexual dysfunction in Asia: a survey of ageing men from five Asian countries. BJU Int 2005, 96(9):1339-54. 7. Trueman P, Hood SC, Nayak US, Mrazek MF: Prevalence of lower urinary tract symptoms and self-reported diagnosed ‘benign prostatic hyperplasia’, and their effect on quality of life in a community-based survey of men in the UK. BJU Int 1999, 83(4):410-5. 8. Jacobsen SJ, Girman CJ, Guess HA, Panser LA, Chute CG, Oesterling JE, Submit your next manuscript to BioMed Central Lieber MM: Do prostate size and urinary flow rates predict health care- and take full advantage of: seeking behavior for urinary symptoms in men? Urology 1995, 45(1):64-9. 9. Simpson RJ, Lee RJ, Garraway WM, King D, McIntosh I: Consultation patterns in a community survey of men with benign prostatic • Convenient online submission hyperplasia. Br J Gen Pract 1994, 44(388):499-502. • Thorough peer review 10. Sarma AV, Wallner L, Jacobsen SJ, Dunn RL, Wei JT: Health seeking • No space constraints or color figure charges behavior for lower urinary tract symptoms in black men. J Urol 2008, 180(1):227-32. • Immediate publication on acceptance 11. Hunter DJ, Berra-Unamuno A: Treatment-seeking behaviour and stated • Inclusion in PubMed, CAS, Scopus and Google Scholar preferences for prostatectomy in Spanish men with lower urinary tract symptoms. Br J Urol 1997, 79(5):742-8. • Research which is freely available for redistribution 12. Emberton M, Marberger M, de la Rosette J: Understanding patient and physician perceptions of benign prostatic hyperplasia in Europe: The Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)?

Asia Pacific Family Medicine , Volume 10 (1) – Jun 8, 2011

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Abstract

Background: The prevalence of lower urinary tract symptoms (LUTS) varies among different populations but the rate of seeking medical advice is consistently low. Little is known about the reasons for this low rate. In the city of Macau, China, primary healthcare is free and easily accessible to all citizens. We aim to study the patients’ rate of consulting for LUTS and their reasons for not consulting under a free healthcare system. Method: A convenience sample of 549 male patients aged 40-85 years in a government health centre filled in the International Prostate Symptoms Scale (IPSS) questionnaire. They were also asked if they had consulted doctors for LUTS, and if not, why not. Result: Of the whole sample, 64 men (11.7%) had ever consulted doctors for LUTS. Of 145 with moderate to severe LUTS, 35 (24.1%) consulted. Of 73 who were dissatisfied with their quality of life, 22 (30.1%) consulted. Regarding the symptoms as normal or not problematic was the main reason for not consulting. Advancing age and duration of symptoms were the significant factors for consulting. Conclusion: Primary care doctors could help many of LUTS patients by sensitively initiating the discussion when these patients consult for other problems. Keywords: LUTS, IPSS, help-seeking behaviour, primary care, free healthcare Introduction differs among different populations, more data are Lower urinary tract symptoms (LUTS) are common in required to see if the rates differ even within the same men aged 40 years or above [1,2]. The reported prevalence ethnic population. of LUTS varies widely among different age groups and Though commonly affected, not many men with ethnic populations. For men aged 40 or above, the preva- LUTS consult their doctors for these symptoms. The lence of moderate to severe LUTS was reported to be: reported rates vary also widely: 4.4% (US) [8], 9.2% 16.2% (Korea) [3], 19.2% (France) [3], 20.7% (Netherlands) (Denmark) [5], 11.3% (Scotland) [9], 18% (UK) [7], [3], 25.1% (UK) [3], 38% (USA) [4], 56% (Japan) [4]. 22.2% (African-American) [10], 38.2% (Spain) [11]. This For men aged 50 or above, the reported rates were: 28% help-seeking behaviour is known to be affected by the (Denmark) [5], 14% (Singapore) [6], 34% (Malaysia) [6], severity of LUTS and how bothered the patients are 39% (Thailand) [6], 41% (UK) [7], 48% (Hong Kong) [6], [7,10,11]. Reports in the literature are mainly on the rea- 59% (Philippines) [6]. These reports used the International sons for men to consult doctors for LUTS [10-12] and Prostate Symptom Score (IPSS) that was validated in dif- not on Asian populations. We are not aware of similar studies on the reasons for not consulting although it ferent languages to assess thepresenceand severity of LUTS, and the recruits were from the community-popula- was suggested that regarding the symptoms as a normal tion. Some of them were done concurrently in different aging process and embarrassment might deter men countries [3,4,6]. Given that the prevalence of LUTS from seeking help [13]. Cultural background, accessibil- ity of the healthcare, and financial restraints might affect men’s decision to seek medical advice for LUTS. Would * Correspondence: ytwun@hotmail.com more men from a free healthcare system consult doctors Department of Family Medicine and Primary Care, University of Hong Kong, for their LUTS? Hong Kong, China Full list of author information is available at the end of the article © 2011 lai et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 2 of 5 http://www.apfmj.com/content/10/1/7 The Macau Special Administrative Region is a city on Of the whole sample, 363 (66.1%) were of mild (IPSS the southern coast of China with a population of score 1-7), 116 (21.1%) of moderate (IPSS score 8-19), 549,500 (Year 2010). The government runs seven public and 29 (5.3%) of severe symptoms (IPSS score ≥20). outpatient clinics, each on average with 15 doctors, and Only 64 men (11.7%) had consulted doctors for LUTS the service is free to all citizens. Medical consultation is and one of them did not receive any subsequent either walk-in or by appointment. Specialist treatment treatment. in public hospital is also free to patients aged 65 or above or with low income. In such free and easily acces- Age siblesetting,weaimed to study(a) theprevalenceof The severity of LUTS increased with age (Table 1, ordi- LUTS in the Chinese residents of this locality, and (b) nal regression Wald = 20.41, p < 0.001; the odds ratio how many men with LUTS had sought advice from for each increase in year being 1.043 (95% confidence their doctors and, if not, why not. interval, CI: 1.024, 1.062)). The older age-group was more likely to consult doc- Method tors for their symptoms (Table 1, c = 25.03, p < 0.001). This is a prospective cross-section survey of patients The men who had consulted doctors got LUTS for attending the Hac Sa Wan Health Centre, Macau. As much more longer time than those who had not other studies we used the IPSS questionnaire to assess (the mean month ± standard deviation were respectively LUTS and the effect on the patient’squalityof life.In 14.1 ± 16.75 and 4.7 ± 8.87, t-test -4.438, p < 0.001). addition we asked whether the patient had ever discussed the symptoms with his doctor, how long had the symp- IPSS toms been, and the reasons for not seeking help (fear Each IPSS item was significantly associated with medical treatment, fear being diagnosed to have prostatic disease, consultation when tested separately (Table 2, all c tests embarrassed to ask, symptoms being normal, or other gave p < 0.01). Taking all the items together, logistic reasons). To encourage response, the questionnaire was regression showed that only nocturia (p = 0.045) and anonymous. straining (p = 0.007) were significantly associated. The From October 5 to November 11, 2010, a nurse was odds ratio of consulting for nocturia was 1.30 (95% CI: delegated to explain the aim of the questionnaire to the 1.005, 1.678), and for straining 1.43 (95% CI: 1.104, male patients aged 40 years or above in the waiting room 1.845). of the adult clinic (after registration and before seeing The men with more severe symptoms were more the doctors). The patients were then invited to fill the likely to consult doctors (Table 3, c = 45.10, p < 0.001). questionnaires according to their opinions. The patients who had difficulty with the questionnaire could ask help Quality of life (QoL) from the nurse who later collected all the distributed Of the sample, 354 (64.5%) men were in the satisfied questionnaires. The collection of data stopped when the range while 73 (13.3%) in the dissatisfied range (Table 4) desired sample size had been reached. if the symptoms persisted. Only one man was very dissa- For the estimated sample size (n), we presumed 50% of tisfied; for analysis we grouped this man into the group our recruits would give either a positive or negative of “Dissatisfied”. answer to the questionnaire items. Taking the confidence The probability of consulting doctors increased with level of 95%, margin of error of ± 5%, and p = 0.05 as sig- dissatisfaction in QoL (logit c = 32.10, p < 0.001); the nificant, n is 385. As we anticipated much fewer men in “slightly dissatisfied” were 13.50 times more likely than the older group aged 70 or above, we aimed to recruit the “mixed feeling” to consult a doctor, and the “dissa- around 550 men so that the sample in the older group tisfied” were 27.6 times more likely than the “slightly would not be less than 50 or 10% of the total sample. We dissatisfied”. used chi-squared test, logistic regression and ordinal When QoL and the total IPSS score were put into the regression for any significant association or estimation logistic regression model for consulting doctor or not, among the categorical data. QoL became insignificant (logit c = 4.19, p = 0.523) The study was approved by the Health Bureau, Macau while IPSS was still significant (logit c = 16.09, government. p < 0.001). Result Combined effect In total 549 men completed the questionnaire. The age When age, duration of symptoms, severity of symptoms, ranged from 40 to 85 years (mean 57.2 ± 9.38 years). QoL were put into the logistic regression model, only There were 41 men (7.5%) who had none of the LUTS age and duration were significantly associated with con- symptoms, giving the prevalence of any LUTS of 92.5%. sulting doctors (p = 0.002, p = 0.035 respectively). lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 3 of 5 http://www.apfmj.com/content/10/1/7 Table 1 Distribution of age-groups with LUTS severity and consulting doctors Age group (years) Total 40-49 50-59 60-69 ≥70 LUTS severity Nil 12 (9.8%) 22 (10.4%) 6 (4.1%) 1 (1.5%) 41 (7.5%) Mild 84 (68.3%) 144 (67.9%) 97 (66.4%) 38 (55.9%) 363 (66.1%) Moderate 23 (18.7%) 43 (20.3%) 31 (21.2%) 19 (27.9%) 116 (21.1%) Severe 4 (3.3%) 3 (1.4%) 12 (8.2%) 10 (14.7%) 29 (5.3%) Total 123 (100.1%) 212 (100.0%) 146 (99.9%) 68 (100.0%) 549 (100.0%) Consult doctor No 113 (91.9%) 195 (92.0%) 129 (88.4%) 48 (70.6%) 485 (88.3%) Yes 10 (8.1%) 17 (8.0%) 17 (11.6%) 20 (29.4%) 64 (11.7%) Total 123 (100.0%) 212 (100.0%) 146 (100.0%) 68 (100.0%) 549 (100.0%) Reasons for not consulting doctors only 11.7% consulted their doctors. While age, total The most common reason for not consulting doctor was IPSS score, quality of life, and duration of symptoms regarding LUTS as normal (Table 5). The “other rea- were each significantly associated with consulting doc- sons” given by the patients included: 87 “nothing tors, only age and duration were statistically significant wrong”,5 “not a problem”,5 “not necessary”,9 “never if these factors were considered together. The main rea- think of it”,1 “no time”,1 “dislike the idea”.The con- son for not consulting was regarding the symptoms as cept of “normal features” hadnosignificantassociation normal or not problematic. Among the IPSS items, noc- with severity of LUTS (logit c = 6.41, p = 0.093), QoL turia and straining were the important symptoms asso- 2 2 ((logit c = 10.74, p = 0.057), or age-group (logit c = ciated with consulting doctors or not. 3.07, p = 0.38). Similarly, “feeling embarrassed” was not Theprevalenceof IPSS≥1 in our sample is high com- associated with age-group (logit c = 3.91, p = 0.272). pared with the 72.3% observed in the study of men aged ≥40 from UK, USA and Sweden [14]. The prevalence of Discussion moderate to severe LUTS (IPSS > 7, 145/549 = 26.4%, This study on 549 male patients (aged 40 years and Table 1) is within the wide range reported by other stu- above) at a government outpatient clinic in Macau dies but much lower than those reported by two studies shows a high prevalence of any LUTS (IPSS≥1, 92.5%). on Chinese. For men aged 50 or above, a study of com- Most of them (87.2%) were of mild or moderate severity, munity residents in Wuhan, Mainland China [15], 13.3% were not satisfied with their quality of life, and reported a prevalence of 40.3% for moderate to severe LUTS in 1023 men, and another involving 201 men in Hong Kong was 46% [6]. The equivalent rate in this Table 2 IPSS and whether to consult doctor or not study was 27.7% (Table 1). It is specially notable that IPSS Consult doctor IPSS score Macau and Hong Kong are two neighbouring cities with 01 2 3 4 5 over 90% of the population being ethnic Chinese. Incomplete emptying No 336 61 38 18 10 22 Although the sampling methods of the three studies Yes 27 12 10 5 2 8 were different, the LUTS prevalence might still vary Frequency No 282 84 54 39 9 17 within the same ethnic population. Yes 21 13 13 9 2 6 As regard to men’s help-seeking behaviour for LUTS, Intermittency No 350 53 37 27 8 10 our findings differ from others in several points. Firstly, Yes 27 10 7 10 3 7 nocturia and straining were significantly associated with Urgency No 372 44 31 21 10 7 Yes 28 11 13 2 4 6 Table 3 Association between severity of LUTS and Weak stream No 368 48 22 24 7 16 consulting doctor Yes 25 9 10 8 5 7 Consult doctor LUTS Straining No 396 37 26 16 4 6 No LUTS Mild Moderate Severe Yes 29 8 10 5 4 8 No 39 (95.1%) 336 (92.6%) 94 (81.0%) 16 (55.2%) Nocturia No 66 221 122 58 11 7 Yes 2 (4.9%) 27 (7.4%) 22 (19.0%) 13 (44.8%) Yes 4 19 17 12 7 5 Total 41 (100.0%) 363 (100.0%) 116 (100.0%) 29 (100.0%) lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 4 of 5 http://www.apfmj.com/content/10/1/7 Table 4 Association between quality of life and consulting doctor Consult Quality of life if symptoms persist Very satisfied Satisfied Slightly satisfied Mixed feeling Slightly dissatisfied Dissatisfied Very dissatisfied No 69 169 91 105 46 4 1 (97.2%) (93.4%) (89.2%) (86.1%) (71.9%) (50.0%) (100.0%) Yes 2 12 11 17 18 4 0 (2.7%) (6.6%) (10.8%) (13.9%) (28.1%) (50.0%) Total 71 181 102 122 64 8 1 (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) consulting doctor in this study. The former was and 30.1% of men who rated their QoL as dissatisfied the most while the latter the least frequent symptom (Table 4) consulted their doctors. These rates could be (Table 2). Many studies found that nocturia was most considered low as medical treatment for LUTS was free to significant in the association of seeking help [10,16]. our patients. The most common reason for not seeking This study however found that straining (an obstructive treatment was taking the symptoms as “normal” or not symptom) was more likely than nocturia to associate regarding them as problematic. (Even the “other reasons” with seeking help. The statistical significance for noc- for not consulting were in fact regarding LUTS as normal.) turia was marginal at p = 0.045. The next frequent reason was embarrassment on disclo- Secondly, being bothered by LUTS was shown to be sure. This study supports the speculation that regarding significantly associated with consulting doctors [10,11], the symptoms as normal and embarrassment deterred our study shows that this association was through the men from seeking help [13]. Whether and how much severity of LUTS rather than the bother itself. Thus, these low rates of help-seeking and patients’ perception were due to the Oriental culture need further research. assessing the bother of LUTS might not be necessary It is notable in this study that only 30.0% men dissa- for every population. Thirdly. it is well known that LUTS is more frequent tisfied with their QoL due to LUTS consulted their doc- with advancing age; indeed LUTS incidence was shown tors; the majority were going to tolerate their to increase linearly with age in one study [17]. But age dissatisfaction some more months. Furthermore, about was seldom reported as an associated factor with seek- 10% of those who did not consult were due to perceived ing medical advice, and one study even showed that age embarrassment (Table 5). Primary care doctors could was not associated [10]. In this study, age was the most help these patients by initiating sensitively the discus- significant determinant for consulting doctors. The asso- sion on LUTS when they consult for other problems. ciation with symptom severity and bother became insig- Limitations nificant on adjusting for age. This study was on a sample from a health centre rather Apart from age, duration of symptoms was the other than on a general population. However, the Hac Sa significant association with consulting doctors. It was Wan Health Centre serves an area with 39.9% of the likely that men tolerated the symptoms (or tried to Macau population that is typical of the city, and there is “adjust their life to self manage their symptoms” [18]) likely no large deviation between the study sample and for some months before they decided to seek treatment. the general population. Another explanation was that LUTS started mildly with- Most of our recruits were of mild to moderate LUTS out disturbing daily life. As LUTS progressed with time, severity; only 5.3% were severe. This might explain the and age, the men found them much less tolerable and small proportion of patients who were bothered by then consulted their doctors. LUTS and the low rate of seeking medical advice. It is Only 11.7% of men in this study consulted their doctors uncertain how much these observation were affected by for LUTS. Just 44.8% of men with severe LUTS (Table 3) the sampling method of this study. We took a consecu- tive convenience sample rather than a randomized one. Table 5 Reasons for not consulting doctors for LUTS Due to the busy routines, the nurse did not document Reason Frequency the exact number of men who refused the questionnaire Embarrassed 64 (11.7%*) but noted from memory to be less than 10%. Normal features 289 (52.6%) Fear treatment 22 (4.0%) Conclusion Fear diagnosis of prostatic diseases 14 (2.6%) The prevalence of LUTS in ethnic Chinese may vary Others 108 (19.7%) among different cities. About 10% would seek medical advice even in a free healthcare system. Although the * Percentage of the total sample lai et al. Asia Pacific Family Medicine 2011, 10:7 Page 5 of 5 http://www.apfmj.com/content/10/1/7 Prostate Research on Behaviour and Education (PROBE) Survey. Int J Clin severity of LUTS, the duration of symptoms, the degree Pract 2008, 62(1):18-26. of bother and age each had significant association with 13. Garraway WM, Russell EB, Lee RJ, Collins GN, McKelvie GB, Hehir M, help-seeking behaviour, only age and duration remain Rogers AC, Simpson RJ: Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly significant in the logistic regression model. The main men. Br J Gen Pract 1993, 43(373):318-21. reason for not seeking help was the perception of the 14. Coyne KS, Sexton CC, Thompson CL, Milsom I, Irwin D, Kopp ZS, symptoms as being normal aging process. The next Chapple CR, Kaplan S, Tubaro A, Aiyer LP, Wein AJ: The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: important reason was the embarrassment with discus- results from the Epidemiology of LUTS (EpiLUTS) study. BJU Int 2009, sion for which primary care doctors could help with 104(3):352-60. tactful approach. 15. Wan S-p, Hu L-q, Liu Y, et al: Survey of lower urinary tract symptoms in 2811 men in Wuhan City. Chinese Journal of Urology 2004, 9:585-87. 16. Hamzah AA, Rahman MNG, Daud MAM, Mahamood Z: A survey on lower urinary tract symptoms (LUTS) among patients with benign prostatic Author details hyperplasia (BPH) in hospital universiti sains malaysia (HUSM). Malaysian Hac Sa Wan Health Centre, Health Bureau, Macau Special Administrative Journal of Medical Sciences 2007, 14:67-71. Region, China. Department of Family Medicine and Primary Care, University 17. Verhamme KM, Dieleman JP, Bleumink GS, van der Lei J, Sturkenboom MC, of Hong Kong, Hong Kong, China. Artibani W, Begaud B, Berges R, Borkowski A, Chappel CR, Costello A, Dobronski P, Farmer RD, Jimenez Cruz F, Jonas U, MacRae K, Pientka L, Authors’ contributions Rutten FF, van Schayck CP, Speakman MJ, Tiellac P, Tubaro A, Vallencien G, All the authors planned the study and read as well as approved the Vela Navarrete R: Incidence and prevalence of lower urinary tract manuscript. Lai UC initiated the study question, supervised the data symptoms suggestive of benign prostatic hyperplasia in primary care– collection, and helped the preparation of the manuscript. Wun YT analyzed the Triumph project. Eur Urol 2002, 42(4):323-8. the data, and prepared the manuscript. Luo TC and Pang SM supervised the 18. Scarpa RM: Lower urinary tract symptoms: what are the implications for study and commented the manuscript. the patients? Eur Urol 2001, 40(Suppl 4):12-20. Competing interests doi:10.1186/1447-056X-10-7 The authors declare that they have no competing interests. Cite this article as: lai et al.: In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)? Asia Pacific Family Received: 27 March 2011 Accepted: 8 June 2011 Published: 8 June 2011 Medicine 2011 10:7. References 1. Garraway WM, Collins GN, Lee RJ: High prevalence of benign prostatic hypertrophy in the community. Lancet 1991, 338(8765):469-71. 2. Simpson RJ, Fisher W, Lee AJ, Russell EB, Garraway M: Benign prostatic hyperplasia in an unselected community-based population: a survey of urinary symptoms, bothersomeness and prostatic enlargement. Br J Urol 1996, 77(2):186-91. 3. Boyle P, Robertson C, Mazzetta C, Keech M, Hobbs FD, Fourcade R, Kiemeney L, Lee C: The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study. BJU Int 2003, 92(4):409-14. 4. 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Jacobsen SJ, Girman CJ, Guess HA, Panser LA, Chute CG, Oesterling JE, Submit your next manuscript to BioMed Central Lieber MM: Do prostate size and urinary flow rates predict health care- and take full advantage of: seeking behavior for urinary symptoms in men? Urology 1995, 45(1):64-9. 9. Simpson RJ, Lee RJ, Garraway WM, King D, McIntosh I: Consultation patterns in a community survey of men with benign prostatic • Convenient online submission hyperplasia. Br J Gen Pract 1994, 44(388):499-502. • Thorough peer review 10. Sarma AV, Wallner L, Jacobsen SJ, Dunn RL, Wei JT: Health seeking • No space constraints or color figure charges behavior for lower urinary tract symptoms in black men. J Urol 2008, 180(1):227-32. • Immediate publication on acceptance 11. Hunter DJ, Berra-Unamuno A: Treatment-seeking behaviour and stated • Inclusion in PubMed, CAS, Scopus and Google Scholar preferences for prostatectomy in Spanish men with lower urinary tract symptoms. Br J Urol 1997, 79(5):742-8. • Research which is freely available for redistribution 12. Emberton M, Marberger M, de la Rosette J: Understanding patient and physician perceptions of benign prostatic hyperplasia in Europe: The Submit your manuscript at www.biomedcentral.com/submit

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Asia Pacific Family MedicineSpringer Journals

Published: Jun 8, 2011

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