e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 4 7 3 – 4 7 8

Voiding Dysfunction

Impact of LUTS Using Bother Index in DAN-PSS-1Questionnaire

Jukka T. Hakkinen a,*, Matti Hakama b, Heini Huhtala b, Rahman Shiri b,Anssi Auvinen b, Teuvo L.J. Tammela a,c, Juha Koskimaki a

aDepartment of Urology, Tampere University Hospital, Tampere, Finlandb School of Public Health, University of Tampere, Tampere, FinlandcMedical School, University of Tampere, Tampere, Finland

avai lab le at www.sciencedi rect .com

journa l homepage: www.europeanurology.com

Article info

Article history:Accepted June 7, 2006Published online ahead ofprint on June 23, 2006

Keywords:Benign prostatic hyperplasiaLower urinary tractsymptomsQuality of lifeQuestionnairesDAN-PSS-1

Abstract

Objectives: To quantify the bothersomeness of urinary symptoms inmales with lower urinary tract symptoms (LUTS).Methods: A population-based postal survey of urinary symptoms among2837 men aged 55, 65, or 75 years was conducted. The response rate was75%, and data of both symptom and bother questions were eligible for1803–2046 men, depending on the question. Bothersomeness of eachurinary symptom was measured with a bother index (BI) as a ratio of thenumber of men with a bother score higher than a symptom score to thatwith a bother score lower than a symptom score. The BI was comparedwith the relative risk (RR), the prevalence of men with bother to thosewith symptom.Results: Urgency (46%) and postmicturition dribble (42%) were the mostcommon symptoms. Any type of incontinence was considered highlybothersome (BI: 1.79–3.70). In light of the BI, most voiding and postmic-turition symptoms except weak stream (BI: 1.14) were well tolerated. Thevariation of the BI (0.06–3.70) was substantially larger than that of RR(0.53–0.89) of the urinary symptoms.Conclusions: Bothersomeness of a symptom is an independent contribu-tion in the assessment of LUTS. The BI may be a useful indicator ofbothersomeness of urinary symptoms. The greater variation of the BIthan that of RR indicates that the BI provides information on LUTS thatcannot be described by prevalence or prevalence ratio only.# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Department of Urology, Tampere University Hospital, PO Box 2000,FIN-33521 Tampere, Finland. Tel. +358 40 570 5786; Fax: +358 3 3116 4358.E-mail address: jukka.hakkinen@sarment.fi (J.T. Hakkinen).

0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2006.06.011

e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 4 7 3 – 4 7 8474

1. Introduction

A fundamental goal for developing scoring systemsfor lower urinary tract symptoms (LUTS) has been aneed to quantify subjective symptoms of benignprostatic hyperplasia (BPH) and find objectivesupport for the prostatic surgery decision-making.Boyarsky and coworkers [1] published the firstsymptom score system for urinary symptoms in1977. Another early published tool for the assess-ment of LUTS was the Madsen-Iversen pointsystem [2]. Later, in the advent of the medicaltreatment of BPH and increasing interest in treat-ment outcomes and epidemiology of LUTS, a needfor validated instruments became even moreimportant. In 1991 the World Health Organization(WHO) adopted the American Urologic Associa-tion’s AUA-7 symptom score as an InternationalProstate Symptom Score (IPSS) after the addition ofone global quality of life (QoL) question to thequestionnaire [3]. The Danish Prostatic SymptomScore (DAN-PSS-1) was published by Hansen et al.[4] in 1991 and, at that time, contained a uniquefeature that not only occurrence but also bother ofthe symptom was judged at the same time by thesubject. This evaluation of the symptom-specificbothersomeness became possible also with theIPSS after publication of the Symptom ProblemIndex (SPI) in 1995 by the AUA [5]. However, use ofIPSS with the one original QoL question is stillrecommended [6]. Although correlation of symp-tom score with bother score has been found to begood in both scoring systems, the symptom andbother questions do not collect the same informa-tion, and the variability between the two scales hasbeen high [5,7–9]. These differences mean that bothsymptom and bother questions are needed inquestionnaires intended for clinical use or forepidemiologic studies considering not only pre-valence but also the impact of LUTS in a population.There is also a need for further study of therelationship between objective symptom and sub-jective bother in symptom-scoring systems.

DAN-PSS-1 includes a wide range of symptomsand is suitable for both clinical and research use.Each symptom can be analyzed separately with orwithout a bother score, or combined into a LUTSscore describing the overall impact of the symp-toms. The original Danish version has been wellvalidated and used in many epidemiologic surveysand clinical trials [7,10–14]. In this analysis our aimwas to quantify and evaluate the bothersomenessof urinary symptoms in relation to their severityusing a bother index with a simple mathematicalapproach.

2. Methods and material

A postal survey of voiding symptoms and sexual function of

2837 men aged 55 to 75 years was carried out. This study was a

part of the Tampere Aging Male Urologic Study (TAMUS),

details of which have been described elsewhere [12,15]. The

study cohort comprised all the men born in 1924, 1934, or 1944

who lived in the city of Tampere and 11 neighboring

municipalities in Pirkanmaa County, Finland. The Finnish

translation of the DAN-PSS-1 questionnaire was used in

assessing LUTS in the study population. Questionnaires were

mailed in May 1999, and an identical questionnaire was sent 3

months later as a reminder to the nonresponders. The number

of responders was 2133 (75%). The age distribution of the men

was 46%, 33%, and 21% for ages 55, 65, and 75 years,

respectively.

Twelve urinary symptoms including typical storage, void-

ing and postmicturition symptoms, incontinence, and dysuria

were evaluated by the subjects. Each symptom was rated with

A and B questions, the first one inquiring about frequency or

severity and the second one about bother of the symptom.

Each question had four response options graded from 0 to 3

with increasing frequency or severity (symptom score) and

bother (bother score). In bother scores, zero was considered as

no bother, and the other three grades as a perceived small,

moderate, or severe problem, respectively.

To estimate bother relative to symptom, a descriptive,

figure, bother index was produced for each urinary symptom.

The BI was calculated by dividing the number of men reporting

a bother score higher than a symptom score by the number of

men reporting a bother score lower than a symptom score.

Each index was derived from a cross-table containing

symptom scores in rows and bother scores in columns, and

including all the men who responded to both A and B

questions. In practice the number of scores above the diagonal

cells of the table was divided by that under the diagonal.

A low BI was considered to describe a symptom that was

tolerable or innocuous, and high BI a symptom that was

annoying at any symptom score level. The responses in which

symptom and bother scores were equal provided no informa-

tion for the BI; thus, it was insensitive to the prevalence of the

symptom, but it detected the symptoms that were frequently

considered strongly annoying (high BI) and also those with low

bothersomeness (low BI), compared with the severity or

frequency of the symptom.

The study (# 99013) was approved by the Tampere

University Hospital committee of research ethics.

3. Results

Information on both a symptom and its bother wasavailable for 1803 (64%) to 2046 (72%) men, depend-ing on the symptom. The mean age of the studygroup was 62.5 years, 62.8 in responders and 61.8 innonresponders.

Prevalence of at least mild symptoms (symptomscore �1) varied from 68% in urgency to 8% instress incontinence and 8% in overflow or other

e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 4 7 3 – 4 7 8 475

Table 1 – Cumulative prevalence of symptom and botherscores (men with score > 0 in total men) by urinarysymptoms (TAMUS 1999)

Symptom Cumulative prevalence(%)

Symptom Bother

Overflow or other incontinence 7.6 6.8

Urge incontinence 19.9 17.4

Stress incontinence 8.4 7.3

Weak stream 25.9 20.8

Daytime frequency 34.9 23.1

Dysuria 18.3 12.1

Nocturia 57.3 36.0

Urgency 68.0 46.2

Incomplete emptying 43.3 27.6

Hesitancy 46.9 23.9

Postmicturition dribble 60.0 42.0

Straining 46.4 24.6

All symptoms 35.9 23.7

Fig. 1 – Relative prevalence (relative risk) as a function of

the bother index (BI). TAMUS 1999.

incontinence (Table 1). Cumulative prevalence ofbother was also highest in urgency (46%) and lowestin incontinence symptoms (7%) except urge incon-tinence (17%; Table 1).

The BI for all reported symptoms together was0.27, that is, the frequency or severity of the urinarysymptom was graded higher than its bother by fourof five men in those who graded the symptom scoredifferently from the bother score. The BI rangedfrom 0.06 in straining to 3.7 in overflow or otherincontinence (Table 2). All types of incontinence andalso weak stream had high BI scores. Straining,postmicturition dribble, and hesitancy were themost well-tolerated symptoms with a very low BI.The cumulative prevalence of a symptom washigher than that of bother in all individual symp-toms (Table 1), and the relative risk (RR) showed

Table 2 – BI and RR by urinary symptoms (TAMUS 1999)

Symptom BI RR

Overflow or other incontinence 3.70 0.89

Urge incontinence 2.44 0.87

Stress incontinence 1.79 0.87

Weak stream 1.14 0.80

Daytime frequency 0.72 0.66

Dysuria 0.34 0.66

Nocturia 0.33 0.63

Urgency 0.18 0.68

Incomplete emptying 0.13 0.64

Hesitancy 0.06 0.51

Postmicturition dribble 0.06 0.70

Straining 0.06 0.53

All symptoms 0.27 0.66

BI: bother index; RR: relative risk.

much less variation (0.5–0.9) than the BI (0.06–3.70;Fig. 1).

4. Discussion

The DAN-PPS-1 scoring system is based on thefrequency or severity of urinary symptoms and ontheir influence on daily life: bother. These twocomponents were presented separately and inde-pendently in the original paper of Meyhoff et al. [14]as was done in subsequent studies. Total score usesboth symptom and bother scores simultaneouslybut without distinguishing their relative weight. TheBI, as constructed in this study, weights the relativeimportance of bother to symptom simultaneously inthe same individual. The BI describes the odds that aperson reported a higher bother score than severityor frequency score in relation to the odds of having abother score less than the symptom score. In fact,the BI equals odds ratio of matched observations.The higher the BI is, the more bothersome thesymptom is considered relative to its severity.Because subjective bother and objective frequency(severity) cannot be directly compared, the BI assuch has only a limited interpretation. This is truefor any indicator comparing bother and symptomincluding the RR (ratio of prevalences); however,those cannot be used as traditional symptom scoresdescribing the burden of the disease in population orindividual patient. The major use of the BI is tocompare different urinary symptoms or differentpopulations evaluated with the same scoring sys-tem.

In the DAN-PSS-1 questionnaire, a good correla-tion of symptom score with bother score overall, aswell as in individual urinary symptoms, has beenshown [7,10]. The SPI utilizing the same urinary

e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 4 7 3 – 4 7 8476

symptoms as IPSS was developed to circumvent theIPSS questionnaire’s inability to measure the both-ersomeness of an individual urinary symptom [5].Correlation of IPSS with SPI scores is also wellestablished, but its theoretical content is not welldefined. These separate scoring systems use thesame urinary symptoms, but they have differentgradation and are not validated for simultaneoususe. The BI cannot overcome any previous methodof validating symptom scores, but it includesinformation not possible to achieve with traditionalmethods. In the present study we evaluated theperceived bothersomeness of the urinary symptomsincluded in the DAN-PSS-1 questionnaire in apopulation-based sample and compared it withthe severity of the same symptom by means ofthe BI. The BI detected receptively the symptomsthat were frequently considered strongly annoying(high BI) and also those with low bothersomeness(low BI) in comparison with the severity orfrequency of the symptom. Therefore, the odds orthe BI is a more informative indicator of bother-someness than, for example, the prevalence ofbother or the ratio of prevalence of bother to thatof severity. In the study population, the cumulativeprevalence of a symptom was higher than thecorresponding prevalence of bother for all symp-toms (RR < 1), whereas the BI ranged from 0.06 to 3.7.There was a less than 100% and an inversecorrelation between the prevalence of the symptomand its bothersomeness, indicating that the BIprovides information on LUTS that cannot bedescribed by prevalence or prevalence ratio only.The higher informativeness of the BI over theprevalences is demonstrated by comparing it withRR in Fig. 1.

The prevalence of most urinary symptoms in ourmaterial was high and comparable with previouscross-sectional DAN-PSS-1 surveys [7,11,12]. Thehigher prevalence, compared with Kay et al. [11],may be due to the older population in our surveyand the lower prevalence, compared with Engstromet al. [7], is due to their different sampling of thestudy population. Voiding symptoms, straining,and hesitancy, as well as postmicturition symp-toms, postmicturition dribble, and incompleteemptying, had a lower BI than the typical storagesymptoms of urgency, nocturia, and daytimefrequency. This finding is consistent with previousknowledge: Although voiding symptoms are mostprevalent, urinary storage symptoms have beenconsidered more bothersome and as stronglyimpairing QoL in a population [16]. All types ofincontinence had a high BI, which also is easy tounderstand and strongly affects those with the

symptom, but at the population level the overallburden of these symptoms is rather subtle becauseof their low prevalence. In previous IPSS studies,urgency has been one of the most bothersomesymptoms but weak stream has been quite toler-able [8,9]. Engstrom et al. [7] found weak streamoverall to be rather well tolerated, but all menaffected by ‘‘very weak’’ or ‘‘dribbling’’ urinarystream in their study reported major distress. Theyused the DAN-PSS questionnaire and, against thisbackground, our high BI for weak stream is under-standable. Obviously the DAN-PSS-1 questionnairedetects well diminished urinary stream from thepopulation. From the clinical point of view, thebothersome nature of a strongly diminished uri-nary stream can be interpreted that it is a notableurinary symptom in BPH and that proper removal ofthe infravesical obstruction should be kept in mindto enhance the patient’s QoL. In addition to longvoiding time, interrupted stream, need for strain-ing, or dribble, another reason for high bother-someness of weak stream may be psychologic. Menmay have learned to consider weak stream as anindication of an unknown, probably insidiousdisease like cancer [17]. Weak and diminishingurinary flow has also traditionally been connectedwith getting older and weaker, and losing one’smasculine health. These perceptions may increaseperceived symptom bothersomeness, especially inyounger men.

In addition to weak stream, the BI detecteddaytime frequency, another annoying symptom; itwas considered more bothersome than nocturia andurgency. Nocturia is one off the most bothersomestorage symptoms [18]. Its low bother score in thepresent study may be due to the fact that the DAN-PSS-1 combines one and two nightly voidings intothe same, mildest score, and that 90% of the menwith nocturia in our population fell into thiscategory. Men with only one nocturia episodeprobable wake up for voiding during early morninghours and important hours of undisturbed sleep justafter falling asleep stay unaffected. According toprevious knowledge [7,11] and also to clinicalexperience, urge incontinence is experienced asmuch more bothersome than urgency. This isconsistent with our estimates of the BI.

In developing the DAN-PSS-1 questionnaire, themotivation for the use of both a symptom score anda bother score was their different distributions [14].To the best of our knowledge, nowhere has thesymptom and the bother been considered simulta-neously as a pair in analysis that did not simplycombine symptom and bother into a total score.Our comparison of two approaches, RR and BI,

e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 4 7 3 – 4 7 8 477

demonstrates that they provide supportive andindependent information for LUTS. The RR showsless variation than the BI, indicating that thedistributions of symptom score and bother scoredo not fully disclose the role of bother. The RR givesonly the overall impression that frequency of thesymptom is more important to a man, whereas theBI demonstrates that there are many individual menin the total population who perceive the symptommore bothersome than implied by its frequency.Furthermore, the symptoms have an objectiveranking of bothersomeness in the BI that goes aboveonly simple prevalence.

Acknowledgements

Support for this study was provided by the MedicalResearch Fund of the Tampere University Hospital.

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voiding, for example weak urinary stream, incom-plete emptying, hesitancy and intermittency. How-ever, the most bothersome symptoms have beenassociated with the storage part such as nocturia,frequency and urgency. Studies of the quality of lifein BPH have shown that the severity of the symp-toms can have a significant impact on the physical

e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 4 7 3 – 4 7 8478

and social functioning, well-being. As described bythe international guidelines, therapy for BPH mustbe initiated according to the degree of bothersome-ness. Therefore, appropriate scores quantifying thebothersomeness of LUTS are required to evaluatethe need for the outcome of the treatment for BPHfrom the patient’s perspective. I agree with theauthors that the bothersomeness is very importantas symptom score, especially in the decision mak-ing for treatment and/or surgery. As described inthe present study, the bother index (BI) might beused as a more objective criterion not only to makesuch a decision in the management but also pursu-ing the results of the treatment modalities such aswatchful waiting, medical or surgical treatments.

There are several different indices in the descrip-tion of bothersomeness in the literature. Eckhardtet al. [1] evaluated the bothersomness using thesymptom problem index (SPI) using IPSS in thepresent study as bothering (B category) as describedby the authors. In the same study, the authors alsoevaluated the BPH impact index to measure howmuch the urinary problems affect various domains

of health. Similarly, SPI and its correaltion with IPSShas been evaluated by Perrin et al. [2]; the authorshave concluded that the joint use of IPSS and SPIseems appropriate. With the results of the presentstudy, the assessment using BI can be a combina-tion of symptoms and bothersomeness. However,future well-organized community-based studies,which will compare the advantages of BI, SPI BIIor other bother indices, should focus on the impactof LUTS on QoL among men living a different sociallife and with a different educational status.

References

[1] Eckhardt MD, van Venrooij GE, van Melick HH, Boon TA.

Prevalence and bothersomeness of lower urinary tract

symptoms in benign prostatic hyperplasia and their

impact on well-being. J Urol 2001;166:563–8.

[2] Perrin P, Marionneau N, Cucherat M, Taieb C. Relation-

ship between lower urinary tract symptoms frequency

assessed by the IPSS and bothersomeness (SPI) among

men older than 50 years old. Eur Urol 2005;48:601–7.