A major weakness of symptom scores for lower urinary tract symptoms (LUTS) such as the IPSS is that all LUTS are treated as though they have an equal impact on patient bother and quality of life. For the vast majority of men and women being treated for LUTS, it is this bother that is most crucial, as it will be a major factor driving the shared decision by the patient and clinician as to whether to commence medical therapy.

The umbrella term LUTS includes a range of different symptoms. The storage symptoms comprise urgency of micturition, with or without urgency urinary incontinence, urinary frequency, and nocturia. Voiding symptoms include slow flow, hesitancy, intermittency and terminal dribble, while the post-micturition symptoms are a sensation of incomplete emptying and post-micturition dribble.

This study, from Finland, aimed to compare the impact of different LUTS in order to answer the question ‘what is the most bothersome lower urinary tract symptom?’ both at a population level (i.e. the symptom with the greatest burden is the most prevalent bothersome symptom), and also on an individual basis (i.e. the symptom most likely to be rated as bothersome among the patients affected).

Questionnaires were mailed to 6,000 individuals aged 18-79 years, randomly identified from the Finnish population register. Of these, 3,727 (62.4%) took part in the study, just over half (53.7%) were women. Respondents completed a urological symptom score, the Danish Prostatic Symptom Score (DAN-PSS) which assessed frequency and bother of 12 LUTS, and answered additional questions on quality of life, medical conditions, medication etc. Bother of LUTS was measured on a four-point scale: none, small, moderate or major.

From the population perspective, the most frequent at least moderately bothersome symptom was urinary urgency – seen in 7.9% of respondents, followed by stress urinary incontinence (6.5%), nocturia (6.0%), post-micturition dribble (5.8%) and urgency urinary incontinence (5.0%).

The burden of both urgency and stress urinary incontinence was higher in women than in men.

The population prevalence of bothersome stress urinary incontinence was higher in women 12% (95% CI:10.0-13.9%) than in men 0.8% (95% CI:0.3-1.3%).

The population prevalence of bother from voiding symptoms i.e. hesitancy, weak stream and straining (and also post-micturition dribble) was higher in men than in women, unsurprisingly as this is a common feature of LUTS secondary to benign prostatic enlargement.

On an individual level, urgency urinary incontinence was the most likely to be rated as bothersome by both men and women, with 30.7% reporting at least moderate bother as a result of this symptom.

The amount of bother recorded from the other symptoms was rated as none or small for at least 80% of individuals with symptoms.

Generally age did not have an effect on perceived bother and neither did gender at the individual level.

‘These findings suggest strongly that although the aetiology of LUTS may be different between genders, the bother impact on individuals is similar,’ the study authors comment.

This study highlights two important points for GPs when assessing the patient with LUTS. First, that it is not the presence of symptoms, but the bother they cause the patient that is vital to understand when assessing and managing LUTS. Second, that different LUTS are typically associated with different degrees of bother – voiding symptoms, as a rule, are less likely to cause bother, whereas storage symptoms, particularly urgency and urgency urinary incontinence are the most likely to cause significant impairment of quality of life.