INTRODUCTION  

Benign  prostatic  hyperplasia  (BPH)  is  a clinical diagnosis and may be associated with  a  collection  of  urinary  symptoms, known  as  lower  urinary  tract  symptoms (LUTS).  LUTS  may  be  divided  into  void-ing  (obstructive)  and  storage  (irritative) symptoms.  These  symptoms  experi- enced  by  patients  can  be  assessed through  the  International  Prostate Symptom  Score  (IPSS).  The  IPSS questionnaire  has  been  validated  in Malaysia  (Quek  et  al.  2001). Nevertheless,  LUTS  are  not  specific  for BPH alone  as there  are  other conditions which may also be associated with LUTS such  as  urinary  tract  infections,  prostate carcinoma,  ureteric  stones  and  chronic prostatitis (Cheah et al. 2003). 

The Ministry of Health of Malaysia cited that BPH affects about 50% of men aged 60  years  and  above  (Ministry  of  Health Malaysia 2002). In Kuala Lumpur, 18.9% and 39.6%  of the men were found to be severely  and  moderately  symptomatic, respectively. The prevalence of moderate to  severe  LUTS  in  Malays,  Chinese  and Indians  were  70%,  59%  and 50%  re- spectively (Teh 2001). In Penang, 80% of men reported some degree of LUTS, but the  prevalence  of  moderate  to severe LUTS was only 6.2% (Mariappan & Wooi 2006). 

From  this  study,  we  aim  to  determine the  prevalence  of  LUTS  among  male outpatients  in  Universiti  Kebangsaan Malaysia  Medical  Center  (UKMMC),  be- sides  assessing  their  level  of  awareness towards BPH. 

MATERIALS AND METHODS 

This  cross-sectional  study  was  con- ducted in the surgical and medical clinics of UKMMC, from 20th October, 2009 until 20th  May,  2010.  Male  outpatients  were selected  through  convenient  sampling. Inclusion criteria include patients of age ≥ 40  years  in  stable  clinical  condition  with subject  literacy  (able  to  understand  and respond to questions). 

The  questionnaire  used  in  this  study consists  of  demographic  data,  questions related  to  knowledge,  attitude  and prac- tice  on BPH  and  the International  Pros- tate Symptom Score (IPSS). The aware- ness  (knowledge,  attitude  and practice) of  the outpatients  were  assessed  in this study  via  questionnaire  (Table  1).  They were classified into low (n=146) and high (n=74)  education  levels,  with  low  educa- tion  defined  as  SPM  qualification  and below  while  high  education  was  defined as STPM qualification and above.

A  Medtronic©  Uroflow  Recorder  was used  to  evaluate  the  function  of  the  uri- nary  tract  and  determine  the  severity  of BPH.  BladderScan®  BVI  3000  was  used to determine the post-void urine volume in the  bladder.  Mid-stream  urine  samples were collected for analysis on haematuria, proteinuria  and  nitrite  for  urinary  tract infections using Combur10 Test® dipsticks.

For the uroflowmetry results to be valid, the voided urine volume must be 150 mL or greater (Ezz el Din et al. 1996). Based on  this  criterion,  118  respondents  were excluded.

The  statistical  analyses  of  the  study were  done using  Statistical Package for the  Social  Sciences  (SPSS)  version 17.0.  The  association  between  IPSS score  and  age  group  as  well  as  age group  and  uroflowmetry  were  analyzed by  repeated  measures  analysis  of variance  (ANOVA).  The  level  of significance  was  set  at  0.05.  This  study was  approved  by  the  Ethics  Committee of  Universiti  Kebangsaan  Malaysia Medical Centre (FF-303-2009). 

RESULTS 

Demographic Profile 

A total of 220 male outpatients were sur- veyed in the Medical and Surgical Clinics of  UKMMC,  all  of  whom  were  40  years old and above with a mean age of 61±10 years.  A  total  of  51.8%  of  the  respon- dents  were  Chinese;  followed  by  36.8% Malays,  9.1%  Indians  and  2.3%  other races.  The  baseline  characteristics  are given in Table 2. 

Prevalence  of  Lower  Urinary  Tract Symptoms (LUTS) 

Among  men  aged  40  and  above,  the prevalence of significant LUTS (including moderately  symptomatic  and  severely symptomatic)  is  42.7%.  According  to ethnicity, 45.4% of Malays, 43.0% of Chi- nese and 40.0% of Indians were found to have significant LUTS (Table 3).         The  severity  of  LUTS  was  analyzed  in relation  to  their  age  group.  The  mean IPSS  score  increased  with  age,  from 5.32±5.78  in  the  40  to  49  years  age group to 10.89±8.98 in the more than 70 years  age  group.  This  increase  in  mean IPSS  score  with  age  was  found  to  be significant  by  ANOVA,  in  which  p=0.005 at 95% confidence level (Table 4).

The prevalence of individual symptoms of  IPSS  (scores  1–5)  are  determined from the study sample, whereby the three most commonly found LUTS are nocturia (78.2%),  re-voiding  within  two  hours (58.2%)  and  incomplete  emptying  of bladder (44.6%) (Figure 1).

The  quality  of  life  reported  by  the re- spondents  is  classified  according  to  the severity  of  symptoms  based  on IPSS. The level of satisfaction with their urinary condition  is  generally  higher  among  the mildly  symptomatic  compared  to  the  se- verely  symptomatic  respondents  (Table 5).  Uroflowmetry Results  The mean voided urine volume for all the subjects (n=102) are 278±122 mL with a mean  Qmax  of  19.8±11.5  mL/s  and mean Qave of 10.8±5.2 mL/s. The mean residual  urine  volume  as  determined  by bladder scan was 41±14 mL. 

The  mean  values  for  both  Qmax  and Qave  decreased  with  every  10 years  in- crease  in  age,  and  these  were  found  to be  statistically  significant  associations (p=0.039 and 0.001 respectively). On the other  hand,  the  postvoid  residual  urine volume  rises  significantly  with  age, with p=0.037 (Table 6).

Urinalysis Results 

The  prevalence  of  urine  abnormalities such  as  glycosuria,  proteinuria  and haematuria  were  determined  by  urine dipstick  analysis.  The  most  common  uri- nary  findings  among  male  outpatients  of UKMMC  were  glycosuria  (23.6%),  fol- lowed  by  proteinuria  (11.4%).  The prevalence  of  haematuria  was  found  to be only 1.8% (Figure 2).  Knowledge,  Attitude  &  Practice  (KAP)  In Relation To BPH  More  than  half  (59.5%)  of  the  respondents have  not  heard  of  benign  prostatic  hyper- plasia before. Most of the respondents were able to answer only five questions correctly (34.1%). 

From  Figure  3, the  majority  of  the re- spondents  were  able  to  answer  five questions  correctly;  however,  the  per- centage of respondents with high educa- tion level (39.19%) was much higher than those  with  lower  education  level (31.51%).  Conversely,  the percentage  of respondents who were unable to answer at  least  three  questions  correctly  were found  to be greater  in the lower education  group  compared  to the  higher education group.

Over  78.2%  of  the  respondents  would seek medical attention if they had LUTS. The  reasons  commonly  given  by  those who do not want to seek treatment were that LUTS was a part of the normal age- ing process and that LUTS did not affect their quality of life. In addition, there were 15.9%  of  respondents  who  would  also seek traditional treatment for LUTS. 

DISCUSSION 

Our  study  population  consists  of  three major  ethnic  groups  in  our  country,  i.e. Malays,  Chinese  and  Indians,  as  well  as other minority races. The Chinese (51.8%) made  up  the  highest  proportion  of  our study  population,  followed  by  Malays (36.8%) and Indians (9.1%). This could be due  to  the  relatively  higher  proportion  of Chinese population in the study area. The prevalence  of  symptomatic  LUTS  based on  a  symptom  ind≥ ex  8  (including moderately  symptomatic  and  severely symptomatic)  in  our  study  was  42.7% among  men  of  all  races.  In  comparison with the study conducted in Hospital Kuala Lumpur  (Ministry  of  Health  Malaysia 2002),  our  results  showed  a  lower prevalence  among  all  the  races,  with Malays  at  45.4%,  Chinese  43.0%,  and Indians 40.0%. This could be explained by the  younger  age  range  in  our  study population,  with  a  minimum  age  which was ten years lower than their study. 

The most  important  risk factor  for  BPH is age, being significantly associated with a  higher  IPSS  score  (more  severe LUTS),  lower  maximum  urine  flow  rate (Qmax) and higher post-void residual urine volume.  Similar  findings  have  been  reported  by  Homma  et  al.  (1997).  This study involving Asian men showed a pro- gressing  trend  of  18%,  29%,  40%,  and 56%  BPH  prevalence  in  the  age  groups of 40 to 49, 50 to 59, 60 to 69, and 70 to 79  years,  respectively.  Our  results showed  a  significant  increasing  trend  for the mean IPSS score with every 10 year increase  in  age  (p=0.005),  which  is  also consistent  with  another  study  in  Taiwan (sample  size=100;  p=0.02)  (Liu  et  al. 2004).  However,  a  study  in  Singapore showed  contrasting  results  with  a decreasing  trend  of  median  IPSS  score with  age.  This  is  probably  due  to  the difficulty  in  quantifying  symptoms  and cultural  differences  among  the  older patients in Singapore (Loh et al. 2009). Our  respondents’  urodynamics  were  also assessed  by  uroflowmetry.  The  mean maximum  urine  flow  rate  (Qmax)  was 19.8±11.5 mL/s. Both Qmax and Qave have been shown to progressively decline with advancing  age,  which  was  consistent  with the increase in severity of LUTS with age.  The  residual  urine  volume  showed an  increasing  trend  in  relation  to  age  as this  indicated  an  increase  in  urinary  re- tention  as  a  result  of  bladder  outlet  obstruction.

Aside  from  BPH,  there  are  many urological  as  well  as  non-urological  dis- eases  that  present  with  LUTS  including prostate  cancer,  prostatitis,  bladder  can- cer,  bladder  stones,  overactive  bladder, urinary  tract  infections,  cystitis,  primary bladder  neck  hypertrophy,  urethritis  and diabetes  mellitus.  From  our  study,  the two  most  commonly  reported  LUTS  are nocturia  and  frequency.  However,  they are non-specific and can also be caused by  other  diseases  as  well,  for  example urinary tract infections and diabetes mel- litus.  The  presence  of  glycosuria  in  our study  (23.6%)  is  suggestive  of  diabetes mellitus  while  haematuria  (1.8%)  and nitrites  (6.8%)  are  indicative  of  urinary tract infection. Although these symptoms are  non-specific,  the detection  and  man- agement  of  these  secondary  causes  of LUTS  provide  us  with  another  approach towards  reducing  the  high  prevalence  of LUTS among the population. 

We also found that those whose quality of  life  was  adversely  affected  by  LUTS (67.5%),  mostly  presented  with  significant  urinary  symptoms,  as  compared to those (87.4%) who presented with mild symptoms or were asymptomatic. This is consistent  with  a study  done by  Teh (2001),  which found that there  is a good correlation between the severity of LUTS with  the  quality  of  life  (r=0.69,  p<0.001). Calais  Da  Silva  et  al.  (1997)  found  that the  areas  of  life  most  affected  by  BPH were daily activities due to frequency and sleep interrupted by nocturia. 

A  total  of  34.1%  of  respondents  were able  to  answer  five  out  of  six  questions correctly. Since our study was conducted in  the  surgical  and  medical  clinics  of UKMMC,  our  respondents  have  either been  made  aware  of  BPH  by  their  doc- tors  or  have  read  about  it  from  the  bro- chures or posters in the clinic. Hence, we recommend  that  a  study  should  be  car- ried out in the general population so that the data generated can better reflect the level of awareness in our community. 

Comparing the level of knowledge about BPH between the higher education group and  lower  education  group,  as  expected, the  higher  education  group  had  a  higher level  of  knowledge  of  the  disease, whereas the lower education group had a lower  level  of  knowledge.  However, among those  who answered all six ques- tions correctly, the results  showed  a con- trasting higher proportion of lower educa- tion group. This might be explained by the fact  that  these  subjects  are  afflicted  with BPH  and  hence,  understood  the  disease after being educated by their doctors. 

The  last  part  of  the  assessment  was about  the  health-seeking  behaviour among  those  who  had  LUTS.  We  found that  most  (78.2%)  patients  with  LUTS would  seek  medical  attention  and  treat- ment.  In  addition,  traditional  medication was  still  regarded  as  an  alternative treatment  for  LUTS  by  a  small  group  of people  (15.9%),  especially  among  the elderly, as they still place enormous faith in traditional medicine as part and parcel of  their  culture  and  belief.  In  order  to promote  appropriate  health-seeking  be- haviour, awareness campaigns should be carried out in order to better educate the public  on  BPH,  including  its  prevalence, signs  and  symptoms,  treatment  options, as  well  as  its  complications  if  left  untreated. 

CONCLUSION

 There  is  a  high  prevalence  of  LUTS among male outpatient attendees in Uni- versiti  Kebangsaan  Malaysia  Medical Centre.  The  level  of  awareness  is  satis- factory. However, a more concerted effort is  needed  to  screen  patients  in  the  hos- pital for this problem and provide the op- timal care for them, targeting mainly men above  the  age  of  forty.  However,  lower urinary  tract  symptoms  are  not  synony- mous  with  BPH  and  men  only.  Further studies are also needed to look into lower urinary tract symptoms among women. 

ACKNOWLEDGEMENTS

 We  would  like  to  thank  the  Faculty  of Medicine,  UKMMC  for  allowing  us  to conduct  this  research.  In  addition,  the cooperation  and  help  given  by  Dr.  S. Selvalingam,  nurses  of  UKMMC, volunteers  and  friends  are  highly appreciated.  We  would  also  like  to extend  our  gratitude  to  those  who  are directly  or  indirectly  involved  in  this research.