Patients attending for pressure-flow studies in our department have often undergone heterogenous clinical assessment prior to urodynamics. Description of patient symptoms vary greatly between referrers, and therefore objective and validated patient questionnaires provide a more standardised view. The most commonly used symptom score for male patients has been the International Prostate Symptom Score (IPSS), which assesses 7 core lower urinary tract symptoms (LUTS) as follows: incomplete emptying, increased frequency, intermittency, urgency, weak stream, straining and nocturia. In addition, it asks patients to describe how they would feel to live with their current LUTS for the rest of their life (0 = delighted to 6 = terrible). The International Consultation on Incontinence Questionnaire (ICIQ) group have developed a series of robust modular questionnaires for assessing lower urinary tract dysfunction. The ICIQ-MLUTS (male LUTS) questionnaire contains 23 symptom questions with their own bother score. The aim of this study was to compare both IPSS and ICIQ-MLUTS in a typical cohort of older men with voiding LUTS referred with likely benign prostatic enlargement (BPE).

As part of an ongoing service evaluation, we invited consecutive men with voiding LUTS referred for urodynamics to prospectively complete both IPSS and ICIQ-MLUTS questionnaires before their investigation. This was registered with our institution’s Clinical Governance department. The scores were anonymised then collated and analysed using SPSS software.

45 consecutive men between the ages of 37 and 84 years (mean age 66 years) completed both an IPSS and ICIQ-MLUTS questionnaire when attending for pressure-flow studies from 1st September 2018 to 4th March 2019. 100% of men fully completed both questionnaires. 

Symptom scores
Mean IPSS score (35 total) was 20.4 + 6.6 (range 6-31), with a mean ICIQ-MLUTS score (84 total) of 33.7 + 10.2 (range 17-57). With both questionnaires, the more symptomatic the patient is the higher the score. The mean percentage of total score was 58.3% for IPSS and 40.1% for ICIQ. There was a strong positive correlation between the two with a Spearman co-efficient of 0.624 which was statistically significant (p value 0.000005). Table 1 shows the mean scores for each and the correlation observed between domains in both questionnaires (with associated p values). All exhibit either a moderate or strong positive correlation. Frequency shows the lowest correlation, and whilst this result is statistically significant (p=0.014), it is not as strong as for the other 6 symptoms, which are all significant at a p value of <0.01.  

The IPSS questionnaire assesses voiding (intermittency, weak stream and straining) versus storage LUTS (frequency, urgency and nocturia). There is one post-micturition question for incomplete emptying. In addition to the voiding and storage symptoms assessed in IPSS, the ICIQ-MLUTS also assesses leakage (both stress and urge), enuresis, hesitancy, terminal dribbling, double voiding, and episodes of retention (amongst other symptoms). Table 1 also demonstrates the prevalence of these symptoms in our cohort. 36 patients had not previously had urinary retention (80%). Out of the remaining 20%, 3 had once (7%), 1 twice (2%), and 5 more than twice (11%). 

Table 2 compares groups of voiding, storage and post micturition symptoms between the two questionnaires. The 3 storage questions in IPSS relate to frequency, urgency and nocturia, with 5 in ICIQ – frequency, nocturia, urgency, urge leakage and enuresis. There was a strong correlation between the two questionnaires (Spearman’s r= 0.522 p=0.0002). The 3 voiding symptoms assessed by IPSS are intermittency, weak stream and straining, compared to 6 in ICIQ; hesitancy, straining to start flow, straining to continue flow, 2 questions on strength of flow (1 pictorial) and intermittency. There was a strong correlation (r= 0.763 p= 1.1x10-9). ICIQ-MLUTS assesses post micturition symptoms with 3 questions regarding post micturition dribble, wetting after re-dressing, sensation of incomplete emptying and need to return to void within 15 minutes, whereas IPSS asks solely about sensation of incomplete emptying. Only a moderate correlation was observed (r=0.487 p=0.001).

Quality of life measures
Mean response to the quality of life score on the IPSS (0 = delighted to 6 = terrible) was 4.7 + 1.2 (range 2-6). Total bother score on the ICIQ-MLUTS is out of a total score of 200 (0 = not at all to 10 = a great deal for 20 domains). The mean score was 95.8 + 44.9 (range 0-191). Spearman’s r=0.564 (p = 0.00005), indicating a moderate to strong correlation between the two scores. Total symptom score for IPSS correlated strongly with its QOL score, Spearman’s r=0.679 (p =2.9x10-7). Total symptom score for ICIQ also had a strong correlation with its total bother score, Spearman’s r=0.829 (p = 2.0x10-12).

There is a strong correlation between both the symptoms and bother/QOL scores of the IPSS and ICIQ-MLUTS patient questionnaires. This suggests that the more symptomatic the man is, the greater their level of bother and the worse the negative effect on their quality of life. The mean percentage of maximum score achieved is higher in the IPSS than ICIQ-MLUTS questionnaire (58.3% vs 40.1%). For our cohort of patients this may reflect the fact that IPSS is specifically designed for men with BPE, which is the presumed diagnosis for this group from clinical assessment, whereas the ICIQ-MLUTS provides a more general assessment of urinary symptoms for all men with LUTS. The maximum percentage achieved within the groups of symptoms remains disparate for storage and post-micturition symptoms (IPSS vs. ICIQ) – storage 54.7% to 40.5%, voiding 56.3% to 58.7% and post micturition 68% to 49.4%, but is much closer for voiding symptoms 58.7% to 56.3%. The difference for post-micturition symptoms will likely be due to just one question being used in IPSS versus 4 in ICIQ. The corresponding questions between the two questionnaires show moderate to strong correlation. Frequency shows the lowest correlation between the two questionnaires, and this may be due to the phrasing used for the questions themselves. IPSS asks “How often have you had to urinate less than every two hours?” from 0 = not at all to 5 = almost always. ICIQ however asks “during the day, how many times do you urinate, on average?” and categorises this into frequencies (1-6, 7-8, 9-10, 11-12 and 13+). This invites the responder to think in two different concepts (time in hours versus number of voids), which could account for the difference seen. The IPSS questionnaire does not record leakage symptoms, and analysis of our results shows that over half of patients experience some degree of urge leakage. Hesitancy is another extremely common symptom in this group (88.9%) which does not get identified by the IPSS.

There are some very prevalent symptoms in this cohort which are missed by the IPSS questionnaire. There is however a trade-off between the clinical priority of completeness of assessment, versus the important factor for patients – ease of completion. There is no current gold standard questionnaire recommended, but given these missed symptoms, we would suggest that ICIQ-MLUTS is a better tool for evaluation of men with LUTS. The broader range of questions can then guide urodynamic assessment, objectively investigating specific symptoms patients are self-reporting. The availability of bother scores per symptom means that following clinical assessment and urodynamic evaluation, we can focus on symptoms which are clinically significant and causing bother to patients, allowing for a patient-centred, individualised treatment plan.