Applied Nursing Research 28 (2015) 274–280

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Health-related quality of life, psychological well-being, and sexual

function in patients with benign prostatic hyperplasia after
prostatic surgery
Pierre W.C. Yim, BSc (Hons), RN a, Wenru Wang, MScN, PhD, RN a,⁎, Ying Jiang, BA, RMN, RN a,
Hussain Abdul Salam Zakir, MBBS, MS a, Poh Choo Toh, BSN, RN b, Violeta Lopez, PhD, RN a, Hong-Gu He, PhD, RN a
a
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
b
Department of Urology, University Surgical Cluster, National University of Hospital, Singapore

a r t i c l e i n f o a b s t r a c t

Article history: Aims and background: Patients with benign prostatic hyperplasia (BPH) may receive prostatic surgery due to se-
Received 25 August 2014 vere lower urinary tract symptoms (LUTS). This study aimed to investigate the health-related quality of life
Revised 7 January 2015 (HRQoL), psychological well-being, and sexual function of patients with BPH after prostatic surgery and identify
Accepted 21 February 2015 the predictors of HRQoL among this group of patients.
Methods: This was a cross-sectional, descriptive, correlational study. A convenience sample of 94 participants was
Keywords:
recruited from a urology center in a tertiary public hospital in Singapore. The 12-item Short Form Health Survey
Benign prostatic hyperplasia
Prostatic surgery
version 2 (SF-12v2), International Prostate Symptom Score (IPSS), Hospital Anxiety and Depression Scale
Health-related quality of life (HADS), and 5-item International Index of Erectile Function (IIEF-5) were used to measure the study variables.
Anxiety Results: Compared to the general population norms and the findings of similar studies conducted in western
Depression countries, this group of patients reported poorer physical health but better mental health as assessed by SF-
Sexual function 12v2. Despite the prostatic surgery, over a quarter of the patients experienced moderate LUTS, and 13.8%
experienced severe erectile dysfunction. Multiple linear regression analysis identified that LUTS (B = –0.51,
p = 0.02) and maximum flow rate (B = –0.23, p = 0.02) predicted poor physical health, accounting for 45.9%
of variance, while HADS-Anxiety (B = –1.07, p b 0.01) and LUTS (B = –0.32, p = 0.03) predicted poor mental
health, accounting for 57.2% of variance.
Conclusion: The physical health of BPH patients with prostatic surgery was poor, with many suffering moderate
LUTS and sexual dysfunction. Special attention should be given to those patients with severe LUTS who have a
low maximum flow rate or have anxiety symptoms.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction of minimally invasive therapies (MISTs) have resulted in a drop in the

Benign prostatic hyperplasia (BPH) is an increasingly prevalent
medical condition in aging societies, including Singapore. It is often as-
sociated with lower urinary tract symptoms (LUTS), poor health-
related quality of life (HRQoL), and sexual dysfunction (Roehrborn,
2011). Although pharmacological interventions are used as a first-line
treatment, prostatic surgery remains the only option for patients who
have severe LUTS or do not respond to medications (Priest, Garzotto,
& Kaufman, 2012). Transurethral resection of the prostate (TURP) is
the gold standard of surgical treatment of BPH (Gravas et al., 2011).
However, criticism of the complications of TURP and the development
⁎ Corresponding author at: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore
117597. Tel.: +65 6601 1761; fax: +65 6776 7135.
E-mail addresses: canyouwakeupyouridea@gmail.com (P.W.C. Yim),
nurww@nus.edu.sg (W. Wang), nurjiy@nus.edu.sg (Y. Jiang), nurzhs@nus.edu.sg
(H.A.S. Zakir), poh_choo_toh@nuhs.edu.sg (P.C. Toh), nurvl@nus.edu.sg (V. Lopez),
nurhhg@nus.edu.sg (H.-G. He).
proportion of TURPs performed (Gravas et al., 2011). Nonetheless,
there are approximately 6000 TURPs performed annually in Singapore
(Ministry of Health, 2013).
Over the past decade, HRQoL has assumed increasing prominence as
an important measure of health outcomes. There is no consensus about
the definition of HRQoL, and it refers to an individual's life expectancy,
satisfaction with life, functional ability, and physiological and psychologi-
cal well-being (Cella et al., 2007). HRQoL can be measured using generic
or disease-specific instruments. The 12-item Short Form Health Survey
version 2 (SF-12v2) is an example of a generic measure, while the Inter-
national Prostate Symptom Score (IPSS) is a widely used disease-
specific HRQoL measure in patients with BPH (Seki et al., 2008). Generic
instruments measure a wide spectrum of HRQoL components and are
comparable between diseases and different cultural populations, whereas
disease-specific instruments provide greater sensitivity for populations
with specific illnesses or conditions (Mortimer & Segal, 2008). Using a
combination of both generic and disease-specific instruments provides a
more comprehensive evaluation of the impact of the disease and effects

http://dx.doi.org/10.1016/j.apnr.2015.02.007
0897-1897/© 2015 Elsevier Inc. All rights reserved.
 P.W.C. Yim et al. / Applied Nursing Research 28 (2015) 274–280
of treatment (Cam et al., 2013). However, few studies have been found
that measure the HRQoL in patients with BPH after surgery using a com-
bination of generic and disease-specific instruments.
A recent meta-analysis reported that prostatic surgery improves the
HRQoL of patients with BPH by up to 69%, using the disease-specific
IPSS-QoL scale (Ahyai et al., 2010). Although the development of hema-
turia after surgery occurred in 3.5% of patients, the improvements in
HRQoL within 1 to 3 months after surgery were between 36% and 50%,
which was significantly greater than with pharmacological interven-
tions (Ahyai et al., 2010). However, most of the studies reviewed were
conducted with patients from the west (Ahyai et al., 2010), and there
is a paucity of research emanating from the east, such as Singapore,
where cultural, social, and economic contexts are significantly different.
In addition, the HRQoL of BPH patients after prostatic surgery has not
been fully explored using generic instruments that allow for compari-
son with general population norms and other medical conditions. Like-
wise, psychological well-being and sexual function of these patients are
not well understood. Hence, the purpose of this study was to investigate
the HRQoL, psychological well-being, and sexual function of BPH
patients after prostatic surgery and to identify the predictors of HRQoL
in this group of patients in Singapore.
2. Research methods
2.1. Study design and sample
A cross-sectional, descriptive, correlational design was used. The study
was conducted in a urology center at a tertiary public hospital in Singapore.
The data were collected from October 2013 to February 2014. The target
population was BPH patients after prostatic surgery in this tertiary hospital
in Singapore. A convenience sampling was adopted. The inclusion criteria
were patients who were: (1) diagnosed with BPH and had undergone
either TURP or MISTs (e.g. transurethral needle ablation of the prostate);
(2) aged 21 years and older; and (3) able to read and understand English
or Chinese. Patients with significant renal dysfunction, neurogenic bladder
dysfunction or with a history of mental illness and/or cognitive impair-
ment, or who had undergone open prostatectomy were excluded.
In this study, multiple linear regression analysis was one of the main
statistical tests used. For the multiple linear regression, five indepen-
dent variables (i.e. age, LUTS, anxiety, depression, and sexual function)
were anticipated as significant predictors of HRQoL based on the litera-
ture review (Gacci et al., 2011; Quek, 2005; Reich, Gratzke, & Stief, 2006;
Roehrborn et al., 2011). To achieve a medium effect size at 80% and
power at 5% significance level (2-sided), a minimum of 91 participants
was required (Cohen, 1992).
2.2. Research instruments
2.2.1. 12-item Short Form Health Survey version 2 (SF-12v2)
The SF-12v2 is a widely used generic HRQoL questionnaire consisting
of 12 items. Respondents score eight subscales of general health, physical
function, role—physical, bodily pain, vitality, role—emotional, mental
health, and social function (Ware, Kosinski, & Keller, 1996). These sub-
scales are grouped into two domains: physical component summary
(PCS) and mental component summary (MCS), allowing an evaluation
of the physical and mental HRQoL of an individual. The SF-12v2 has
good internal consistency with Cronbach's alpha of 0.77 and 0.80 for the
PCS and the MCS respectively (Luo et al., 2003). The Chinese version of
the SF-12v2 also demonstrated good reliability and has been widely
used for Chinese-speaking patients (Lam, Tse, & Gandek, 2005). In this
study, the SF-12v2 has also showed acceptable internal consistency
with Cronbach's alpha of 0.74 for the total scale.
2.2.2. International Prostate Symptom Score (IPSS)
The IPSS is a measure of the severity of LUTS, including seven symp-
toms: incomplete emptying, frequency of urination, intermittency,
275
urgency, weak stream, hesitancy, and nocturia. The frequency of these
symptoms is recorded on a Likert scale ranging from 0 (symptoms not
present) to 5 (symptoms always present) (Barry et al., 1992). The IPSS
also includes a disease-specific QoL item, in which the individuals express
their satisfaction with their urinary symptoms on a scale of 0 to 6 (delight-
ed to terrible). The total score is then tabulated, and the following ranges
reflect the severity of LUTS: mild (0–7), moderate (8–19), and severe
(20–35) (Barry et al., 1992). The IPSS has good internal consistency and
test–retest reliability with Cronbach's alpha of 0.86 and an intraclass cor-
relation coefficient (ICC) of 0.92 (Barry et al., 1992). The Chinese version
of the IPSS also demonstrated good reliability with a Cronbach's alpha of
0.90 to 0.98, and the ICC was 0.91 to 0.99 for the subscales respectively
(Quek, Chua, Razack, Low, & Loh, 2005). In this study, the IPSS has
acceptable internal consistency reliability with Cronbach's alpha of 0.70.
2.2.3. Hospital Anxiety and Depression Scale (HADS)
The HADS is a widely used screening tool to assess anxiety and
depression (Zigmond & Snaith, 1983). It consists of 14 items, equally di-
vided into questions that assess either anxiety (HADS-A) or depression
(HADS-D). Patients rank each question on a Likert scale from 0 to 3, and
ranging from 0 to 21 for each subscale. A total score of 8 or above was
identified as an optimal cut-off score for caseness for both anxiety and
depression (Bjelland, Dahl, Haug, & Neckelmann, 2002). The HADS has
been validated extensively in numerous studies spanning various ill-
nesses and showed good internal consistency with a Cronbach's
alpha of 0.85 to 0.91 for the anxiety scale and 0.79 to 0.92 for the de-
pression scale (Hinz, Zweynert, Kittel, Igl, & Schwarz, 2009; Mehnert,
Lehmann, Graefen, Huland, & Koch, 2010). The Chinese version of the
HADS also has good internal consistency with Cronbach's alpha of
0.85 and acceptable ICC of 0.90 (Wang, Chair, Thompson, & Twinn,
2009). In this study, the HADS had good internal consistency with
Cronbach's alpha of 0.85 and 0.82 for the subscales of HADS-A and
HADS-D respectively.
2.2.4. 5-Item International Index of Erectile Function (IIEF-5)
The IIEF-5 is a 5-item questionnaire generated from the validated
and translated IIEF-15 (Dargis et al., 2013). It was developed to be a sim-
ple yet accurate diagnostic test of sexual dysfunction (Cappelleri &
Rosen, 2005). The possible scores for the IIEF-5 range from 5 to 25,
and erectile dysfunction (ED) was classified into five categories based
on the scores (severe: range = 5–7; moderate: range = 8–11; mild to
moderate: range 12–16; mild: range = 17–21; and no ED: range =
22–25) (Cappelleri & Rosen, 2005). The IIEF-5 has good internal consis-
tency, with a Cronbach's alpha of 0.83 to 0.96 (Dargis et al., 2013). The
IIEF-5 Chinese version has been used in many studies with Chinese-
speaking patients and has demonstrated good reliability and validity
(Gwee et al., 2012; Liang et al., 2010). In this study, the IIEF-5 has
good internal consistency with Cronbach's alpha of 0.96.
2.2.5. Socio-demographic profile and clinical data sheet
The socio-demographic profile of the participants—including age,
marital status, education level, employment status, monthly income,
and race—was assessed. Clinical data—including type of prostatic sur-
gery, post-operative duration, length of hospital stay, smoking status,
maximum flow rate (Qmax), and post-void residual urine (PVRU)—were
also collected from the participant's medical chart.
2.3. Data collection procedure
Recruitment of participants took place during their visits to the uro-
logy center. A staff nurse from the urology center was assigned to facil-
itate proper identification of suitable participants based on the
methodical screening of the daily appointment list and inclusion and
exclusion criteria. A total of 202 patients were screened, and the eligible
participants who met the study criteria were approached in a waiting
area of the urology center. Those who agreed to participate in this
276 P.W.C. Yim et al. / Applied Nursing Research 28 (2015) 274–280

study signed the informed consent form. Participants then completed Table 1
the questionnaires in a quiet room separate from the waiting area. It Sample characteristics (n = 94).

took approximately 15 minutes for the data collection process. The Socio-demographic n (%) Clinical characteristics n (%)
clinical data were collected from the medical chart. Age Surgery type
b65 22 (23.4) TURP1 75 (79.8)
2.4. Ethical considerations 65 and above 72 (76.6) TUNA2 10 (10.6)
Laser TURP 3 (3.2)
PlasmaKinetic TURP 6 (6.4)
Ethical approval was obtained from the National Healthcare Group
Marital status Smoker
Domain Specific Review Board in Singapore. We emphasized that Married 91 (96.8) Yes 18 (19.1)
participants had the right to contact the study investigators at any Not married 3 (3.2) No 76 (80.9)
point in time to clarify doubts or to withdraw from the study. In order Education level Maximum flow rate (Qmax)
to protect the identities and the responses of participants, a data storage Primary or lower 33 (35.1) Low flow rate (≤15 mL/s) 41 (43.6)
Secondary 37 (39.4) Normal flow rate (N15 mL/s) 53 (56.4)
protocol was drawn up. Completed questionnaires were stored in a
Tertiary 24 (25.5)
locked cupboard and on a password-protected computer. The study Employment status Post-void residual urine
investigators were the only ones who had access to the data. Employed 39 (41.5) Normal PVRU3 (≤100 mL) 88 (93.6)
Unemployed or retired 55 (58.5) High PVRU (N100 mL) 6 (6.4)
Monthly income (SGD)
2.5. Data analysis
b1000 7 (7.4)
1001–3000 63 (67.0)
The data were analyzed using IBM SPSS 21.0 (IBM Corporation, 3001–5000 12 (12.8)
Armonk, NY, USA). The descriptive statistics including mean, standard de- N5000 12 (12.8)
viation, and frequency were used to summarize socio-demographic and Race
Chinese 77 (81.9)
clinical data, as well as the study variable (i.e. SF-12v2, IPSS, HADS, and
Malay 6 (6.4)
IIEF-5). Independent t-test and ANOVA were used to test the mean differ- Indian 6 (6.4)
ences of the study variables, while Pearson product–moment correlation Others 5 (5.3)
was used to examine the association between PCS, MCS, IPSS, IPSS-QoL, Others include Arabs, Japanese, Indonesians, and Caucasians.
HADS-A, HADS-D, and IIEF-5 scores. The multiple linear regression analy- TURP: transurethral resection of the prostate.
sis was used to identify the predictors of HRQoL, and the PCS and MCS TUNA: transurethral needle ablation of the prostate.
were used as independent variables separately. PVRU: post-void residual urine.

3. Results dysfunction and 13.8% (n = 13) of participants experiencing severe

3.1. Social-demographic and clinical characteristics of the participants
Out of a total of 106 patients who approached to participate in this
study, 94 completed the questionnaires, achieving a response rate of
88.7%. The mean age was 70.4 (SD = 8.6, range = 51–93), with the ma-
jority being older than 65 years of age (76.6%). The majority of the par-
ticipants were married (96.8%) and Chinese (81.9%). More than half of
the participants were unemployed or retired and two-thirds of partici-
pants reported a monthly income of between SGD$1001 and SG$3000
(US$803 and US$2409). As for the clinical characteristics, nearly 80%
of the patients had TURP surgery followed by transurethral needle abla-
tion of the prostate (TUNA), which is a main form of MIST. The mean
post-operative length was 33.7 months (SD = 34.3), while the mean
length of hospitalization was 3.4 days (SD = 2.7). The uroflow results
showed that the mean Qmax was 15.1 mL/s (SD = 7.7) and the mean
(range = 5–7) erectile dysfunction (Cappelleri & Rosen, 2005).
3.3. Comparison of SF-12v2, IPSS, HADS, and IIEF-5 between different
socio-demographic and clinical characteristics
The mean scores of the PCS, MCS, IPSS symptoms, IPSS-QoL, HADS-A,
HADS-D, and IIEF-5 were compared between different socio-
demographic and clinical groups using univariate analysis (Table 3).
The mean scores of SF-12v2 MCS (t = –2.2, p = 0.03), HADS-A (t =
2.05, p b 0.01) and HADS-D (t = 2.38, p = 0.02) were significantly dif-
ferent between income groups. Participants earning less than SG$3000
(US$2409) per month reported significantly lower mean scores of SF-
Table 2
Mean, standard deviation, and range of domains of SF-12, IPSS, HADS, and IIEF-5 (n = 94).

PVRU was 45.9 mLs (SD = 49.8). Most participants (93.6%) had normal Domains Mean (SD) Range
PVRU of ≤ 100 mL, but 43.6% of the participants had a low flow rate with SF-12
Qmax of ≤ 15 mL/s (Table 1). Physical component summary 47.8 (8.6) 26.0–58.6
General health 48.6 (10.5) 23.9–63.7
3.2. Mean scores and ranges of SF-12v2, IPSS, HADS, and IIEF-5 Physical function 48.4 (10.1) 25.6–57.1
Role—physical 47.9 (8.4) 23.6–57.5
Bodily pain 54.1 (6.4) 30.7–57.7
Table 2 presents the mean scores and ranges of the SF-12v2 sub- Mental component summary 55.1 (6.7) 31.5–66.3
scales, IPSS, HADS, and IIEF-5. The mean SF-12v2 PCS score was 47.8 Vitality 54.7 (8.5) 39.2–68.7
(SD = 8.6) while the mean score of SF-12v2 MCS was 55.1 (SD = Social function 48.5 (9.3) 21.3–56.9
6.7). The IPSS symptom scores ranged from 0.0 to 22.0, with a mean of Role—emotional 53.3 (5.8) 25.1–56.3
Mental health 55.5 (8.1) 29.8–64.2
5.8 (SD = 5.0), indicating mild severity of LUTS. The majority of the par-
IPSS
ticipants (n = 67, 71.3%) reported mild symptoms, 26.6% (n = 25) re- IPSS total score 5.8 (5.0) 0–22.0
ported moderate symptoms, and a small fraction reported severe IPSS quality of life score 2.3 (1.5) 0.0–6.0
symptoms (n = 2, 2.1%). The mean scores of the anxiety and depression HADS
HADS-Anxiety 1.9 (2.9) 0–14.0
subscales were 1.9 (SD = 2.9) and 1.8 (SD = 2.5) respectively. Using the
HADS-Depression 1.8 (2.5) 0–13.0
cut-off point of 8 as recommended by Bjelland et al. (2002), only seven IIEF-5 total score 12.9 (4.7) 5.0–21.0
participants experienced anxiety (7.5%, n = 7) and five experienced de-
SF-12: 12-item Short-Form Health Survey.
pression (5.4%, n = 5). The mean score of IIEF-5 was 12.9 (SD = 4.7), IPSS: International Prostate Symptom Score.
with the majority of the participants (n = 59, 62.7%) reporting mild to HADS: Hospital Anxiety and Depression Scale.
moderate (range = 12–16) or moderate (range = 8–11) erectile ILEF-5: 5-Item International Index of Erectile Function.
 P.W.C. Yim et al. / Applied Nursing Research 28 (2015) 274–280 277

Table 3
Comparison of mean scores of SF-12, IPSS, HADS, and IIEF-5 between different socio-demographic and clinical characteristics (n = 94).

SF-12 IPSS HADS IIEF-5

PCS mean (SD) MCS mean (SD) Symptom mean (SD) QoL mean (SD) Anxiety mean (SD) Depression mean (SD) Mean (SD)

Age
b65 (n = 22) 50.7 (6.8) 56.7 (5.6) 5.1 (5.2) 2.0 (1.5) 1.2 (1.6) 1.0 (1.8) 15.3 (4.7)
65 and above (n = 74) 47.0 (9.0) 54.6 (7.0) 6.0 (4.9) 2.4 (1.5) 2.1 (3.2) 2.0 (2.6) 12.2 (4.5)
t 1.82 1.29 –0.76 –1.11 –1.73 –1.91 2.83
p-value 0.07 0.20 0.45 0.27 0.09 0.06 b0.01⁎⁎
Education level
Primary or lower (n = 23) 46.0 (9.9) 55.4 (7.3) 5.4 (5.0) 2.1 (1.5) 2.0 (3.6) 1.9 (3.0) 11.2 (4.8)
Secondary (n = 37) 49.0 (6.6) 54.5 (6.5) 6.3 (5.3) 2.6 (1.4) 1.6 (2.2) 1.7 (2.3) 13.0 (4.3)
Tertiary (n = 24) 48.6 (9.4) 55.6 (6.3) 5.5 (4.4) 2.2 (1.7) 2.0 (3.1) 1.6 (2.0) 15.1 (4.7)
F 1.25 0.25 0.31 1.25 0.18 0.09 4.95
p-value 0.29 0.78 0.73 0.29 0.83 0.91 0.01⁎
Employment
Employed (n = 39) 49.1 (7.9) 54.7 (6.3) 6.2 (5.2) 2.4 (1.8) 2.2 (3.3) 2.1 (2.8) 14.3 (5.1)
Unemployed or retired (n = 55) 47.0 (9.0) 55.3 (7.0) 5.5 (4.8) 2.3 (1.4) 1.6 (2.7) 1.5 (2.3) 11.9 (4.3)
t 1.11 –0.43 0.58 0.48 0.91 1.02 2.43
p-value 0.24 0.67 0.56 0.63 0.36 0.31 0.02⁎
Income
b$3000 (n = 70) 46.8 (9.0) 54.4 (7.3) 6.1 (5.2) 2.4 (1.6) 2.2 (3.2) 2.0 (2.7) 12.4 (4.5)
≥$3000 (n = 24) 50.8 (6.8) 57.1 (4.2) 5.0 (4.2) 2.0 (1.4) 0.9 (1.4) 1.0 (1.4) 14.3 (5.2)
t –1.94 –2.21 0.87 1.33 2.05 2.38 –1.68
p-value 0.06 0.03⁎ 0.39 0.19 b0.01⁎⁎ 0.02⁎ 0.10
Race
Chinese (n = 77) 48.0 (9.0) 55.2 (6.6) 5.6 (4.8) 2.3 (1.5) 1.9 (3.0) 1.8 (2.6) 13.1 (4.7)
Others (n = 17) 47.1 (6.8) 54.3 (7.3) 6.8 (5.7) 2.7 (1.5) 1.6 (2.5) 1.5 (2.1) 12.1 (5.0)
t 0.41 0.55 –0.89 –0.97 0.41 0.43 0.75
p-value 0.68 0.59 0.38 0.34 0.69 0.67 0.45
Surgery type
TURP (n = 75) 47.8 (8.7) 55.4 (6.6) 5.5 (4.9) 2.2 (1.6) 1.8 (2.8) 1.7 (2.5) 13.2 (4.8)
Others (n = 19) 48.0 (8.3) 53.9 (7.1) 7.1 (5.2) 2.6 (1.4) 2.1 (3.4) 1.9 (2.7) 11.9 (4.4)
t –0.01 0.89 –1.29 –0.99 –0.42 –0.25 1.04
p-value 0.92 0.38 0.200 0.32 0.68 0.80 0.30
Smoker
Yes (n = 18) 48.2 (7.1) 54.0 (7.5) 5.6 (5.5) 2.5 (1.7) 2.2 (3.2) 2.0 (2.6) 12.5 (5.0)
No (n = 76) 47.8 (9.0) 55.3 (6.5) 5.9 (4.9) 2.3 (1.5) 1.8 (2.9) 1.7 (2.5) 13.0 (4.7)
t 0.20 –0.77 –0.23 0.55 0.59 0.44 –0.40
p-value 0.85 0.45 0.82 0.58 0.55 0.66 0.69
Qmax
≤15 mL/s (n = 41) 47.1 (9.3) 54.5 (6.8) 7.6 (5.9) 2.6 (1.7) 2.0 (2.9) 2.1 (2.8) 13.1 (5.0)
N15 mL/s (n = 53) 48.4 (8.1) 55.5 (6.6) 4.4 (3.6) 2.1 (1.4) 1.7 (3.0) 1.5 (2.3) 12.8 (4.6)
t –0.76 –0.69 3.00 1.62 0.50 1.05 0.35
p-value 0.45 0.49 b0.01⁎ 0.11 0.62 0.30 0.73
PVRU
≤100 mL (n = 88) 48.2 (8.3) 55.5 (6.6) 5.4 (4.6) 2.2 (1.4) 1.7 (2.8) 1.7 (2.5) 12.9 (4.8)
N100 mL (n = 6) 42.8 (12.4) 48.8 (5.4) 12.3 (6.4) 4.7 (1.4) 4.0 (4.8) 2.8 (2.6) 13.3 (3.6)
t 1.51 2.40 –3.54 –4.19 –1.16 –1.09 –0.23
p-value 0.14 0.02⁎ b0.01⁎⁎ b0.01⁎⁎ 0.29 0.28 0.82

t: independent t-test.
F: one-way ANOVA.
⁎ Significant level at 0.05.
⁎⁎ Significant level at 0.01.

12v2 MCS, and higher mean scores of HADS-A and HADS-D than those
earning more than SG$3000 (US$2409) per month. The mean scores
of IIEF-5 were significantly different between age groups (t = 2.83,
p b 0.01), education levels (F = 4.95, p = 0.01) and employment status
(t = 2.43, p = 0.02). Participants who were ≥ 65 years, had primary or
lower education, and were not employed or retired reported significant-
ly poorer erectile function than their younger, higher educated, and
employed counterparts. In addition, participants with abnormal PVRU
reported significantly lower SF-12v2 MCS (t = 2.40, p = 0.02), higher
IPSS (t = –3.54, p b 0.01) and IPSS-QoL (t = –4.19, p b 0.01) scores,
while those with low Qmax showed significantly higher IPSS scores
(t = 3.00, p b 0.01).
3.4. Correlations between SF-12v2, IPSS, HADS, and IIEF-5
Pearson's correlation analysis was used to test for relationships be-
tween the subscales of the SF-12v2, IPSS, HADS, and IIEF-5 (Table 4).
SF-12v2 PCS and MCS scores were found to be moderate and positively
correlated with IIEF-5 (p b 0.01) but negatively correlated with IPSS,
IPSS-QoL, and HADS-A, as well as HADS-D scores (p b 0.01). IPSS
symptom and IPSS-QoL scores were moderate and positively correlated
with HADS-A and HADS-D (p b 0.01) but negatively correlated with
IIEF-5 (p b 0.01).
3.5. Predictive factors of physical and mental HRQoL
Using SF-12v2 PCS and MCS as dependent variables, two separate
multiple linear regression analyses were performed respectively. Eight
variables (i.e. age, income, Qmax, PVRU, IPSS symptoms, HADS-A,
HADS-D, and IIEF-5) that showed significant associations with PCS
and MCS were selected as independent variables to determine the pre-
dictors of physical and mental health as assessed by the SF-12v2 PCS
and MCS respectively. Out of these eight variables, Qmax (B = –0.23,
p = 0.02) and IPSS symptoms (B = –0.51, p = 0.02) were significant
in predicting SF-12v2 PCS, which accounted for 45.9% of variance
(Table 5). Using the same eight factors as independent variables, IPSS
278 P.W.C. Yim et al. / Applied Nursing Research 28 (2015) 274–280

Table 4 In addition, a significant and positive relationship was found between

Correlations between SF-12v2, IPSS, HADS, and IIEF-5 mean scores. LUTS and HADS-A and HADS-D, which further suggests that LUTS plays
SF-12v2 IPSS HADS IIEF-5 a significant role in affecting patients' psychological well-being. Komiya
PCS MCS Symptom QoL Anxiety Depression ED
et al. (2010) and Suzuki et al. (2006) reported that poorer physical health
was associated with increasing difficulty in performing daily living acti-
PCS 1.00
vities as LUTS symptoms worsened, necessitating changes in urinary
MCS 0.35⁎ 1.00
IPSS –0.50⁎ –0.56⁎ 1.00 habits, reliance on caregivers, and switching to diapers. With worsened
IPSS-QoL –0.56⁎ –0.64⁎ 0.76⁎ 1.00 physical symptoms, changes in role functioning and daily living routine
HADS-Anxiety –0.54⁎ –0.71⁎ 0.48⁎ 0.59⁎ 1.00 are, sometimes, inevitable and could therefore be anxiety provoking.
HADS- –0.56⁎ –0.69⁎ 0.60⁎ 0.66⁎ 0.84⁎ 1.00 Alonso et al. (2004) argued that mental health is affected in patients
Depression
IIEF-5 0.39⁎ 0.33⁎ –0.40⁎ –0.35⁎ –0.26⁎ –0.40⁎ 1.00
with high LUTS severity after surgery because of frequent follow-ups,
return to taking medications, and being on long-term catheterization.
SF-12v2: 12-item Short-Form Health Survey version 2.
The IPSS QoL measured patients' disease-specific HRQoL based on
IPSS: International Prostate Symptom Score.
HADS: Hospital Anxiety and Depression Scale. their LUTS severity. Ahyai et al. (2010) found that before surgery, pa-
ILEF-5: 5-Item International Index of Erectile Function. tients generally reported that they had “mostly dissatisfied” or “terrible”
PCS: physical component summary. feelings towards their LUTS. In the current study, participants reported a
MCS: mental component summary. mean IPSS-QoL score of 2.3 (SD = 1.5), indicating that participants had
⁎ Significant at p b 0.01.
a “mostly satisfied” feeling towards their LUTS. Such findings are consis-
tent with previous studies, which reported similar mean IPSS-QoL
symptoms (B = –0.32, p = 0.03) and HADS-Anxiety (B = –1.07, scores of 0.8 to 2.9 after surgery (Gacci et al., 2011; Gravas et al.,
p b 0.01) were identified as predicative factors for SF-12v2 MCS, 2011). This finding suggests that patients' disease-specific HRQoL im-
accounting for 57.2% of variance (Table 5). proved after operation. The SF-12 V2 was used to assess the general
HRQoL of participants. The mean scores of PCS and MCS in this study
4. Discussion were 47.8 and 55.1 respectively. Compared to the general population
norms, the PCS was below average while the MCS was above average
The results of the current study indicate that TURP was performed in (Wee, Wu, Thumboo, Lee, & Tai, 2010). Compared to the local popula-
nearly 80% of patients with BPH, making it the primary form of surgery tion norms, participants in the current study had poorer physical health
for BPH in Singapore. There was no significant difference between people but better mental health (Lim, Jin, & Ng, 2012; Mak, Tang, Chan, Cheak,
who had undergone TURP and other types of prostatic surgery in physical & Ho, 2011; Wee et al., 2010). And similarly, the mean PCS score was
health and mental health dimensions of SF-12, LUTS severity, HADS-A, lower, and the MCS score was higher than in the similar studies con-
and HADS-D. However, previous studies reported that TURP is preferred ducted in western countries (Buckley, Lapitan, & Glazener, 2012). Par-
because of its favorable clinical and long-term efficacy in terms of Qmax ticipants of comparator studies were middle-aged (40.4–49.9 years)
(Lei et al., 2012; Mamoulakis, Ubbink, & de la Rosette, 2009; McVary and were relatively free of disease, which could explain the difference
et al., 2011; Reich et al., 2008), and better cost-efficiency and shorter in SF-12v2 scores. Although age may result in poorer physical function,
hospital stays due to the constant refinement of techniques and post- it may improve mental fortitude and response to life events such as
operative care (Roehrborn, 2011). undergoing surgery and adapting to the physical constraints of LUTS
Previous studies have consistently reported that over half of the pa- (Mehta et al., 2008).
tients with BPH experienced moderate severity of LUTS and nearly one- The HADS-A and HADS-D scores were used to screen for cases of
fifth suffered severe symptoms of LUTS (Höfner et al., 2010; Komiya anxiety and depression in patients, respectively. The results of our
et al., 2010; Montorsi et al., 2010; Pinto et al., 2014). While surgery to study revealed that 7.5% of participants experienced anxiety and 5.4%
treat LUTS has improved (Burke et al., 2010; Cai et al., 2006), 26.6% of suffered depression. Specifically, participants with lower income re-
patients in the current study reported moderate severity of LUTS ported significantly greater anxiety and depressive symptoms. In
while 2.1% suffered severe symptoms of LUTS. Patients with normal Singapore, the lifetime prevalence of depressive disorder was 5.8%,
Qmax reported significantly less severe LUTS symptoms than patients while the lifetime prevalence of anxiety was 3.6% (Chong et al., 2012).
with low Qmax post-operatively. Likewise, patients with normal PVRU The percentage of anxiety among participants in the current study
experienced significantly lower LUTS severity than patients with high was considerably higher compared to the lifetime prevalence in the
PVRU post-operatively. LUTS severity, as measured by IPSS, was found general population in Singapore. Quek (2005) suggests that most pa-
to be a significant predictor of both physical health and mental health tients remain anxious due to worry over unresolved LUTS, post-
as assessed by SF-12v2, indicating that patients with severe LUTS not operative pain, or complications that result in extended hospital stays.
only perceived poorer physical health but also poorer mental health. Persistent and unsolved urinary symptoms could affect a person's

Table 5
Predictive factors of health-related quality of life according to multiple linear regression analysis.

Independent variables PCS of SF-12 MCS of SF-12

B Std. error t p-value 95% CI for B B Std. error t p-value 95% CI for B

Age –0.16 0.09 –1.78 0.08 –0.33 to –0.02 0.04 0.06 0.64 0.52 –0.08 to –0.16
Income 1.53 1.64 0.93 0.35 –1.73 to –4.78 0.43 1.13 0.38 0.71 –1.82 to –2.68
Qmax –0.23 0.10 –2.32 0.02⁎ –0.42 to –0.03 0.01 0.07 0.19 0.85 –0.12 to –0.15
PVRU –0.01 0.02 –0.43 0.67 –0.04 to –0.03 0.00 0.01 0.20 0.84 –0.02 to –0.03
IPSS symptoms –0.51 0.21 –2.41 0.02⁎ –0.94 to –0.08 –0.32 0.15 –2.19 0.03⁎ –0.62 to –0.03
HADS-A –0.79 0.46 –1.73 0.09 –1.71 to –0.12 –1.07 0.32 –3.37 b 0.01⁎⁎ –1.70 to –0.44
HADS-D –0.40 0.61 –0.65 0.52 –1.60 to –0.81 –0.31 0.42 –0.73 0.47 –1.14 to –0.53
IIEF-5 0.17 0.18 0.92 0.36 –0.19 to –0.53 0.11 0.13 0.88 0.38 –0.14 to –0.36
R2: 0.459; Adjusted R2: 0.409; F = 9.03; p b 0.01⁎⁎ R2: 0.572; Adjusted R2: 0.532; F = 14.22; p b 0.01⁎⁎
⁎ Significant at p b 0.05.
⁎⁎ Significant at p b 0.01.
 P.W.C. Yim et al. / Applied Nursing Research 28 (2015) 274–280
ability to function normally and incur a higher financial burden. As a re-
sult, participants on lower incomes experience more stress. The regres-
sion analysis results in our study indicated that together with LUTS
symptoms, anxiety was a predictive factor of poorer mental health.
This further highlights the importance of effectively managing anxiety
for patients after prostatic surgery to improve their overall HRQoL.
Studies using an alternative HRQoL instrument found similar results.
That is, that anxiety was a predictor of poorer social, psychosocial, and
global HRQoL in both western and Asian populations (Beiramijam,
Anoosheh, & Mohammadi, 2013; Brown & Roose, 2011; Quek, 2005).
In Singapore, Lim et al. (2012) found that anxiety was a significant pre-
dictor of both SF-12 PCS and MCS scores. As frontline staff, nurses have
the unique role to play in detecting changes in patient's condition, both
physically and psychologically, and to render early support. In general,
patients are more readily to report physical symptoms, while changes
in mental health could be more subtle. It is not uncommon that anxiety
may manifest as physical symptoms, especially in Asian context (Lim
et al., 2012). Therefore, it is crucial for nurses and other health care
workers to be aware of such dynamics and address it accordingly.
Though participants in the current study did not demonstrate a
higher risk of depression, previous studies report that patients with
BPH have a greater risk of developing depression as compared to
those without BPH (Huang et al., 2011). A plausible explanation for
this difference could be that a different sampling method was used, as
a high percentage of participants was older adults who were married
and living with family. Chong et al. (2012) reported that age had some
association with the risk for depression, as older persons tend to be more
satisfied with life than their younger counterparts. In their study, they
found that the highest rate of depression was in those aged 18 to
34 years, and that this decreased and leveled off with increasing age. In ad-
dition, being married and living with family builds up social capital, confers
protection from distress, and lets patients draw on resources from their
community, which served as a buffer to the development of more severe
mental illness like depression (Lau, Chow, Chan, & Wang, 2014).
Erectile dysfunction (ED) is caused by LUTS and persists for 80% of
patients after prostatic surgery if left untreated (Bouza, Lopez, Magro,
Navalpotro, & Amate, 2006). Over half of the participants in the current
study reported mild to moderate or moderate ED, and 13.8% experienced
severe ED. The mean scores across the five IIEF-5 questions were similar
(2.5–2.7). This meant that participants found equal difficulty in achieving
and maintaining an erection during penetration, completion of, and
getting satisfaction from sexual intercourse (Rosen et al., 2009). Older
age, lower education, and unemployed/retired participants reported
more difficulty compared to their counterparts. As Asian men are less
likely to seek treatment for ED, the carry-over effect could have resulted
in the high ED rate reported in the current study (Tan et al., 2007). The
IIEF-5 score was found to be significantly correlated with HAD-A,
HAD-D, IPSS-QoL, and SF-12 MCS, suggesting that ED severity is associ-
ated with psychological well-being. Poorer mental health could be due
to shame, self-perception of negative body image, and the possible
adverse impact on marital relations stemming from ED (Briganti et al.,
2006; Bruyère et al., 2010; Gacci et al., 2011; Meston & Buss, 2007;
Muntener et al., 2007).
Qmax was identified as one of the two predictors of poor physical
health. Patients who had an abnormal Qmax (i.e. ≤15 mL/s) reported sig-
nificantly poorer physical health as compared to those who had normal
Qmax. As reported by Roehrborn (2011), patients seek treatment for BPH
primarily for poor urinary flow, therefore it is possible that patients per-
ceived better health outcomes when Qmax improved post-operatively.
This further confirmed that patients with fewer urinary tract symptoms
will experience better physical health.
4.1. Limitations and conclusions
There are several limitations in this current study. First, the use of
convenience sampling from a single tertiary hospital may cause
279
sampling bias and limit the findings' generalizability. There were imbal-
anced age groups and ethnic ratios in this study, owing to the linguistic
limitations of the inclusion criteria. Therefore, caution must be exercised
when extrapolating the results to patients after prostatic surgery in
other settings. Second, the use of self-rating questionnaire surveys
may result in response bias. Patients may respond with socially desir-
able answers and under-report their symptoms due to the sensitive na-
ture of certain questions.
Nevertheless, the results of this study provided knowledge on
HRQoL, psychological well-being, and sexual function of BPH patients
after prostatic surgery in Singapore. Overall, the physical health of BPH
patients after surgery was poorer when compared to the results derived
from western populations. However, mental health scores were equal to
or higher than the population norms derived from studies conducted in
Singapore and in western countries. Sexual dysfunction was present in a
large percentage of participants, which calls for concern. LUTS, Qmax,
and anxiety were identified as predictive factors of HRQoL in this popu-
lation, providing a precedence for future studies.
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