Authors: Vishrut Bharti, Rajesh K. Tiwari, Sanjay Gupta, Rohit Upadhyay, Manoj K. Singh, Deelip K. Singh
Categories: Special Topic - Advances in Female Urology, Original Article, Etiology, Female urology, Lower urinary tract symptoms, Postmenopausal health
Source: Current Urology
Although the prevalence of lower urinary tract symptoms (LUTS) is high in the female population, it is even higher in postmenopausal females. The frequency, severity, and etiology of LUTS vary among populations and individuals. This study aimed to define the characteristics of LUTS in postmenopausal women and their underlying etiologies.
Overall, 74 postmenopausal patients presenting with LUTS in the urological outpatient department were included in the study. A detailed evaluation of LUTS and their underlying etiologies was performed. Patients were divided into 2 groups based on age (<65 and ≥65 years), and the variation in different factors was compared across the groups. Variables were compared using the t test and 1-way analysis of variance.
Nocturia was the most common symptom (89.2%) followed by frequency (83.8%). Among voiding LUTS, the most common was a weak stream (63.5%). Frequency, nocturia, urgency, urge urinary incontinence (UI), stress UI, and nocturnal enuresis were more common in patients older than 65 years. Urgency and urge UI were recognized to be the most bothersome symptoms by 37% of the study population followed by straining (32%). The mean storage scores, incontinence scores, and quality of life (QoL) scores for patients younger than 65 years and 65 years or older were 6.9 and 8.5 (p < 0.01), 1.8 and 4.1 (p ≤ 0.01), 4.9 and 6.1, respectively. The most common diagnosis was bladder outlet obstruction due to urethral/meatal stenosis (40.5%) followed by an overactive bladder (32.4%), urinary tract infection (10.8%), cystocele (8.1%), urethral prolapse (4.1%), and urethral caruncle (4.1%).
Storage LUTS were the most common and increased in both frequency and severity with age. The QoL was also more severely affected in older postmenopausal women. Bladder outlet obstruction due to meatal with or without distal urethral stenosis was the most common underlying cause of LUTS followed by an overactive bladder. Overactive bladder had the most severe impact on patients’ QoL among all the etiologies.
Keywords: Female urology, Lower urinary tract symptoms, Postmenopausal health, Etiology
Females have a high prevalence of lower urinary tract symptoms (LUTS) (64%–76%).^[1,2]^ However, its prevalence and severity are even higher in postmenopausal women because of the effects of low estrogen levels on genitourinary tissue.^[3,4]^ Lower urinary tract symptoms also significantly affect quality of life (QoL); patients report anxiety and depression, making LUTS a major source of morbidity for women.^[5]^ Current trends indicate that by 2030, 76% of postmenopausal females will live in developing countries, such as India.^[6]^ The average menopausal age of Indian women is 46 years, while their updated life expectancy as of 2019 is 72.2 years,^[7,8]^ which highlight the ever-growing susceptible population and its burden on the nation’s health resources.
Lower urinary tract symptoms, as defined by the International Continence Society, comprise storage, voiding, and postmicturition symptoms that may occur in varying frequencies and severity in different populations and among different individuals.
Nonneurogenic LUTS in females can be caused by various etiologies. Conditions, including an overactive bladder (OAB) and bladder outlet obstruction (BOO) due to cystocele, urethral stricture disease, meatal stenosis, dysfunctional voiding, primary bladder neck obstruction, pelvic organ prolapse, and overactive detrusor, are the most common underlying causes of LUTS in various studies.
A comprehensive study of LUTS in postmenopausal women simultaneously dealing with symptom characteristics and their underlying etiologies has not been conducted. A thorough knowledge of these aspects will help prepare the healthcare system for the increasing prevalence of LUTS and educate patients to promote health-seeking behaviors. This study aimed to define the symptom characteristics of postmenopausal patients with LUTS presenting to a tertiary care center and to study its underlying etiologies.
The study was conducted between January 2019 and November 2020 at the Department of Urology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar. Ethical approval was obtained from the institutional ethics committee. Postmenopausal women presenting with LUTS in the urology outpatient department (OPD) and those willing to participate in the study were included. Patients with preexisting conditions, such as diabetes mellitus, hypothyroidism/hyperthyroidism, neurogenic bladder (with H/O cardiovascular accident, Parkinsonism, spinal cord injury, and transverse myelitis), impaired cognitive function, bladder or urethral surgery, and those on anticholinergics, β blockers, calcium channel blockers, cholinergics, and hormone replacement therapy were excluded. Finally, data of 74 eligible patients were analyzed.
A detailed history (including BRISTOL female LUTS questionnaire-SF) and examination (including digital rectal examination and P/V) were performed. Patients underwent hematogram/renal biochemistry/blood sugar, urine routine examination and culture and sensitivity, kidney-ureter-bladder ultrasound with postvoiding residual urine, uroflowmetry, and micturating cystourethrography (MCU). Urodynamic evaluation was also performed in cases wherein there was diagnostic uncertainty or when the condition had the potential to affect the treatment strategy.
Underlying etiologies were defined based on predefined criteria. Urethral/meatal stenosis was defined as symptomatic anatomical narrowing of the urethra based on urethral calibration, visual inspection, endoscopy and/or radiographic evaluation.^[9]^ Thus, we diagnosed urethral/meatal stenosis based on obstructive flow on uroflowmetry, narrowing of the MCU, failure of the urethra to accommodate a 14-Fr catheter, and endoscopic examination. Overactive bladder was diagnosed based on the standard International Continence Society definition.^[10]^ Urinary tract infection (UTI) was diagnosed based on a positive urine culture report after ruling out any other underlying pathology. A cystocele was diagnosed based on obstructive symptoms and obstructive flow patterns along with bladder distention on MCU and confirmed by a per-speculum examination. Urethral mucosal prolapse and caruncle were diagnosed by vaginal examination.
The patient population was divided into 2 groups, A (aged <65 years) and B (aged ≥65 years). Groups A and B had a mean age of 58.2 and 70.1 years, respectively. Data on the prevalence of each component of LUTS and its etiology were noted and compared across the 2 groups. As a secondary end point, the BRISTOL score was used to assess the severity of each component of LUTS and their variation across the groups and etiologies.
Overall, 74 patients were included in the final analysis. Nocturia, defined as 2 or more voids per night, was the most common symptom (89.2%) followed by frequency (83.8%). The prevalence of urgency, urge incontinence (UUI), stress UI (SUI), and nocturnal enuresis was 66.2%, 33.8%, 27%, 9.5%, respectively (Table 1). The most common obstructive symptom was a weak stream (63.5%), followed by intermittency (62.2%), straining (55.4%), hesitancy (21.6%), dysuria (41%), and dribbling (10.8%) (Table 1). Postmicturition symptoms of sensation of incomplete voiding and dribbling were present in 39.2% and 14.9%, respectively (Table 1).
The components of LUTS were then compared between the 2 groups. Frequency, nocturia, urgency, UUI, SUI, and nocturnal enuresis were more common in patients older than 65 years than in younger women (92.9% vs. 78.3%, 96.4% vs. 84.85, 78.6% vs. 58.7%, 57.6% vs. 19.6%, 50% vs. 13%, and 14.3% vs. 6.5%, respectively). However, the difference was significant only for UUI, SUI, and nocturnal enuresis.
Meanwhile, voiding LUTS, including weak stream, intermittency, straining, dribbling of urine, and dysuria, were more common in patients younger than 65 years than in older women (69.5% vs. 53.6%, 63% vs. 60.7%, 63% vs. 42%, 13% vs. 7%, and 52% vs. 25%, respectively), while hesitancy was more common in older patients (25% vs. 19.6%). However, except for dysuria, the difference in all symptoms was not significant.
Each patient was asked about their most bothersome symptoms. Urgency and UUI were recognized as the most bothersome symptoms by 37% followed by straining (32%), dysuria (14.2%), frequency (10.9%), and nocturnal enuresis (2.2%) (Table 2).
In addition, we objectively quantified LUTS using the BRISTOL female LUTS scores and analyzed the following 4 storage score (FS), voiding score (VS), incontinence score (IS), and QoL score.
For the study population, the mean FS (mFS), VS (mVS), IS (mIS), and QoL (mQoL) were 7.4, 4.6, 2.6, and 5.3, respectively. When stratified by age, the mFS, mVS, mIS, and mQoL of groups A and B were 6.9 versus 8.5 (p < 0.01), 5 versus 4.3 (p > 0.05), 1.8 versus 4.1 (p < 0.01), and 4.9 versus 6.1 (p < 0.05), respectively (Table 3).
The most common diagnosis in our study was BOO due to urethral/meatal stenosis (40.5%) followed by OAB (32.4%). Other less common etiologies were UTI (10.8%), BOO due to cystocele (8.1%), urethral prolapse (4.1%), and urethral caruncle (4.1%; Table 4).
Regarding the etiologies, urethral and meatal stenosis, UTI, cystocele, urethral prolapse, and urethral caruncle were more common in group A (43.5% vs. 35.7%, 13% vs. 7%, 8.7 vs 7.1%, 6.5% vs. 0%, and 4.3% vs. 3.6%, respectively), but the differences were not statistically significant. Meanwhile, OAB was significantly more common in patients older than 65 years (46.4% vs. 23.9%).
Analysis of LUTS severity across etiologies revealed that storage LUTS were most severe in patients with OAB followed by UTI, while voiding symptoms were most severe in those with cystocele and distal urethral stenosis. Symptoms of incontinence were most severe in patients with OAB (Table 5).
The QoL score was highest in patients with OAB (6.8) followed by patients with urethral and meatal stenosis (4.9).
In contrast to males, LUTS in females have recently attracted the attention of urologists because of the increasing lifespan of women and the effect of LUTS on QoL. Previously, urinary symptoms in postmenopausal females were ascribed to estrogen deficiency, but several studies have identified functional and anatomical causes based on imaging and urodynamic evaluation.
Many epidemiological studies have evaluated LUTS among the Western population. The EPIC study found that nocturia was the most prevalent symptom, affecting 54.5% of women, while terminal dribbling was the most common voiding LUTS.^[1]^ Another large epidemiological study reported that urgency (35.7%) was the most common symptom followed by nocturia (33.7%).^[2]^ The findings of these studies are similar to ours, although the differences in the absolute values of prevalence can be attributed to the different base populations between the studies. While this study was conducted among postmenopausal patients in the OPD, the above studies were conducted in the general population. The prevalence of LUTS in the studies of Espuña Pons and Puig Clota^[^^12]^ and Malla et al.,^[11]^ wherein the subjects were patients with LUTS presenting to the OPD, was closer to our study. Espuña Pons and Puig Clota^[12]^ reported frequency as the most common symptom (90.8%) followed by urgency (83.4%) and nocturia (80.6%),^[12]^ while Malla et al.^[11]^ reported frequency to be the most common symptom (99%) followed by nocturia (91%).
Broadly, storage LUTS were more common than the other symptoms. Storage symptoms were also more prevalent as noted by the EPIC study and by Heidler et al.^[1,13]^
Analysis of data from this study population revealed a trend suggesting that storage symptoms, including SUI, UUI, and nocturnal enuresis, increase in severity and frequency with age. This finding is supported by other studies, including that of Møller et al.^[4]^ in 2000 who found that the severity and frequency of irritative symptoms and UUI escalated in an almost linear fashion with increasing age. Homma et al.^[14]^ also reported that the frequency of storage LUTS and OAB increase with age. Although voiding symptoms were not statistically different in both age groups, a trend toward obstructive symptoms being more common in relatively younger postmenopausal women is evident.
We also assessed the severity of LUTS and their impact on the patients’ QoL. The EpiLUTS study found that nocturnal enuresis, urgency, and UUI were the most bothersome followed by dysuria.^[2]^ Coyne et al.^[5]^ reported that storage LUTS have a greater impact on bladder function. These studies showed the impact of storage LUTS and incontinence and reported that voiding LUTS were less bothersome. Our study also reported urgency and UUI as the most bothersome symptoms, but straining was also bothersome for many patients.
When the BFLUTS-SF (BRISTOL Female LUTS Questionnaire–Short Form) of the groups were compared, storage LUTS and incontinence were more frequent and more severe in older women. Maserejian et al.^[15]^ noted that the incidence of moderate-to-severe storage LUTS increased with age. Sandvik et al.^[16]^ found that the severity of incontinence increased with age, peaking around menopause and then steadily rising thereafter. In addition, the QoL of older women was more profoundly impacted in this study population. Espuña Pons and Puig Clota^[12]^ assessed the impact of LUTS on QoL and showed that increasing age was a significant factor on QoL.
Previously, the distribution of specific etiologies in the patient population has been understudied, especially in the Indian population. Most studies regarding LUTS have categorized the etiology under broad conditions such as BOO and detrusor underactivity. Cho et al.^[17]^ evaluated female LUTS using a urodynamic study and found BOO in 42% of the patients followed by detrusor underactivity in 38% and detrusor overactivity in 8% of the patients. The prevalence of OAB has varied widely in the literature, with Lapitan et al.^[18]^ reporting a prevalence 51%, whereas the EPIC study reported a prevalence of 11.8%.^[9]^ Bladder outlet obstruction is an underdiagnosed condition in females that has reported rates of 2.7% to 29% in the general population.^[19]^ Groutz et al.^[20]^ reported that anti-incontinence surgery and severe genital prolapse were the most common etiologies for female BOO followed by urethral stricture/stenosis (13%), primary bladder neck obstruction (8%), detrusor sphincter dyssynergia (5%), and learned voiding dysfunction (5%). In a review of female urethral stricture disease, Hoag et al.^[21]^ noted that it accounts for 4% to 18% of females presenting with BOO.^[22]^ In our study population, OAB was noted to affect 32.4% of the subjects, but the most common etiology was meatal stenosis with or without narrowing of the distal urethra, which is not very common in previously published literature and emphasizes the need to investigate this etiology in postmenopausal patients with LUTS. Defreitas et al.^[23]^ also showed that in patients with BOO, 47.8% of the patients had urethral fibrosis/stricture, 28% had a history of previous incontinence surgery, and 26.8% had a cystocele. A low estrogen level in postmenopausal women along with atrophic vaginitis involving the lower urinary tract could be the underlying cause of BOO. While a gynecologist may regard LUTS in postmenopausal women as a component of genitourinary syndrome due to estrogen deficiency, a urologist must address this problem in a more comprehensive way, ruling out functional and anatomical etiologies, such as meatal stenosis and urethral stricture, that may require surgical correction.
Our study included postmenopausal women presenting to a tertiary care center from urban, semiurban, and mostly rural populations of Bihar, which is very different from these previous studies, which explains, to a certain extent, the difference in etiological factors. The absence of a common etiology from Western studies, that is, patients with a history of anti-incontinence procedures, was due to the lack of awareness about stress incontinence as a disease and its possible treatment options, especially in the rural population. This has led to lower rates of anti-incontinence procedures and therefore it's complication in our patient population. Another etiology that was not observed in our study population was functional BOO (dysfunctional voiding, primary bladder neck obstruction), which occurs in relatively younger women. Carlson et al.^[24]^ reported a mean age of 39.2 years in patients with dysfunctional voiding. Thus, a higher average age and small sample size could be the reason for the absence of patients with functional BOO in our study population. Another finding that must be highlighted in the above data is that the most common symptom was storage LUTS, whereas the most common etiology was voiding dysfunction. This highlights the fact that symptoms may not always correlate with the underlying etiology; therefore, there is a need for a holistic approach to these patients.
In this study, OAB was more common in older females. Homma et al.^[14]^ showed that the prevalence of OAB was 11% in women and increased with age. Analysis of the QoL component also showed that compared with all etiologies, OAB was associated with the most severe decline in QoL.
The present study revealed that storage LUTS were more common than voiding LUTS and increased in both frequency and severity with increasing age. In addition, storage LUTS and QoL were also more severe in older postmenopausal women. Bladder outlet obstruction due to meatal with or without distal urethral stenosis was the most common underlying cause followed by OAB. Moreover, OAB had the most severe impact on patients’ QoL among all the etiologies.
Drawing inferences from these findings, sensitizing primary physicians along with treating urologists about the common etiologies and educating patients about the importance of storage LUTS and its impact on QoL are helpful in the comprehensive treatment of such patients.
Limitation of the study were small sample size and bias in the recruitment of study subjects as the patients were those attending the OPD of the institution.
None.
The study protocol was approved by the Indira Gandhi Institute of Medical Sciences institutional review board (Approval letter 832/IEC/IGIMS/2019). All the included patients provided signed informed consent for their participation and the publication of this study. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
The authors declare that they have no conflicts of interest.
None.
RT, VB: Conception and design of research;
VB, MKS, DKS: Acquisition of data;
VB: Analysis and interpretation of data, drafting of the manuscript, statistical analysis;
RT: Critical revision of the manuscript for intellectual content;
RU, SG: Supervision.
Rajesh K. Tiwari, Email: drrtiwariuro@gmail.com.
Sanjay Gupta, Email: sanjayssgtamkuhi@yahoo.co.in.
Rohit Upadhyay, Email: urorohit@yahoo.com.
Manoj K. Singh, Email: drmanojksingh394@gmail.com.
Deelip K. Singh, Email: drdeelip8@gmail.com.