BMJ 2000;320:1418-1419 ( 27 May )

Editorials

Fluctuations in lower urinary tract symptoms in women

Reassurance and watchful waiting can prevent overtreatment

Urinary symptoms are common in both men and women. Traditionally "prostatism" has been used to describe the symptoms in men, while urinary incontinence and dysuria were used for women.1 For some years the term lower urinary tract symptoms (LUTS) has been used to describe any constellation of symptoms occurring in patients of either sex at any age. The symptoms are not disease specific and the term does not suggest any cause for the symptoms. It has been shown that instruments developed to score symptoms in men (for example, the international prostate symptom score scale) are not sex specific, as the symptoms are as prevalent in women as in men. 2 3

Lower urinary tract symptoms may come and go
In this issue Møller et al (p 1429) present data on the incidence and rates of remission at one year of lower urinary tract symptoms in 2284 Danish women aged 40-60.4 The prevalence was 29%, the incidence 10%, and the rate of remission was 28%. The authors state that lower urinary tract symptoms are common and they may come and go. These findings may have important clinical implications. But the magnitude of the results may be biased by the design of the study and the definitions used.

Several validated questionnaires have been used in similar studies but they emphasise different aspects of the disorder. For example, in this study women were not asked about dysuria and the popular concept of overactive bladder, but incontinence is extensively covered. Incidence was defined rather unusually as the proportion of women who either developed symptoms or whose symptoms increased from sometimes to weekly or more than weekly. Similarly, remission was defined not only as the disappearance of symptoms but also as a fall in the frequency of symptoms to less than weekly.

Research into incontinence has shown that estimates of prevalence and incidence can change dramatically when different thresholds and definitions are used and that remission rates are high. 5 6 Caution should therefore be used in applying epidemiological data to a clinical context: there is a large transitional zone between healthy and diseased, hence there is a risk of medicalisation and overtreatment.6

Most people with urinary incontinence and LUTS do not seek help from health professionals.6 Many suffer with their illness, despite the availability of good symptomatic treatment. However, for many people with mild or occasional symptoms it is probably reasonable not to seek help. Møller et al's study introduces another factor into this debate: symptoms fluctuate, and there is a good chance that people will have fewer symptoms or even stop having them within a reasonable time.

When a patient consults it is the responsibility of the doctor to make a proper working diagnosis and suggest treatment options. But it is also the practitioner's responsibility to protect patients from unnecessary investigations and treatments. The general practitioner usually knows if the patient has other illnesses and is already taking medication. LUTS is particularly suitable for management in primary care: patients with urinary incontinence and overactive bladders have been shown to be well cared for in general practice. 7 8 Patients should, however, be referred when there is suspicion of organic disease. Patients whose symptoms have changed significantly should be seen urgently by a specialist.

The patient's view of the problem is important
The decision not to treat patients should be based largely on how much their symptoms interfere with daily activities and how willing they are to wait and see if they need medication. Individuals' opinions of what symptoms are bothersome vary considerably; the patient's overall view of the problem is therefore as important as clinical scores.

The decision to actively treat should rarely be made quickly. When patients are provided with information about the waxing and waning of the clinical course of symptoms and the advantages and risks of the full range of treatment options, they are likely to choose differently than if just offered prescriptions.

Reassurance and watchful waiting can help many patients. However, a recent study found that typical patterns of reassurance, which aim at allaying fears and anxieties by minimising complaints, were not interpreted as reassuring. Reassurance was successful only when patients felt that their symptoms and difficulties had been accepted and acknowledged.9 Watchful waiting may be carried out in general practice by having patients visit their practitioners once or twice a year to report changes in symptoms, preferably by using symptom scores in addition to the patient's history.

Steinar Hunskaar, professor in general practice. 

Department of Public Health and Primary Health Care, University of Bergen, Ulriksdal 8c, 5009 Bergen, Norway (steinar.hunskar{at}isf.uib.no)

Acknowledgments

SH has been reimbursed by Pharmacia and Upjohn for attending conferences and has also been paid for speaking at symposiums.


1. Abrams P. New words for old: lower urinary tract symptoms for "prostatism". BMJ 1994; 308: 929-930[Free Full Text].
2. Lepor H, Machi G. Comparison of AUA symptom index in unselected males and females between fifty-five and seventy-nine years of age. Urology 1993; 42: 36-40[CrossRef][Medline].
3. Pinnock C, Marshall VR. Troublesome lower urinary tract symptoms in the community: a prevalence study. Med J Aust 1997; 167: 72-75[Medline].
4. Møller LA, Lose G, Jørgensen T. Incidence and remission rates of lower urinary tract symptoms at one year in women aged 40-60: longitudinal study. BMJ 2000; 320: 1429-1432[Abstract/Free Full Text].
5. Sandvik H, Hunskaar S, Seim A, Hermstad R, Vanvik A, Bratt H. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health 1993; 47: 497-499[Abstract].
6. Hunskaar S, Arnold EP, Burgio K, Diokno AC, Herzog AR, Mallett VT. Epidemiology and natural history of urinary incontinence. In: Abrams P, Khoury S, Wein A, eds. Incontinence. Plymouth: Scientific International, 1999:197-226.
7. Seim A, Sivertsen B, Eriksen BC, Hunskaar S. Treatment of urinary incontinence in women in general practice: observational study. BMJ 1996; 312: 1459-1462[Abstract/Free Full Text].
8. Wein AJ, Rovner ES. The overactive bladder: an overview for primary care health providers. Int J Fertil Wom Med 1999; 44: 56-66.
9. Donovan JL, Blake DR. Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: "just a touch of arthritis, doctor?" BMJ 2000; 320: 541-544[Abstract/Free Full Text].

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Relevant Article

Incidence and remission rates of lower urinary tract symptoms at one year in women aged 40-60: longitudinal study
Lars Alling Møller, Gunnar Lose, and Torben Jørgensen
BMJ 2000 320: 1429-1432. [Abstract] [Full Text] [PDF]

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