Urological Science xxx (2017) 1e5

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Urological Science
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Original article

Health care-seeking behavior in benign prostatic hyperplasia patients

Yu-Hua Fan a, b, c, Alex T.L. Lin a, b, c, *, Yi-Hsiu Huang a, b, c, Kuang-Kuo Chen a, b, c
a
Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan
b
School of Medicine, National Yang-Ming University, Taipei, Taiwan
c
Shu-Tien Urological Science Research Center, Taipei, Taiwan

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

Article history: Objective: Lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) are highly
Received 30 April 2014 prevalent in aging men and have a significant impact on the quality of life of patients. Moreover, BPH is
Received in revised form progressive and can cause worsening symptoms and the risk of serious long-term morbidity. An efficient
6 December 2016
diagnostic approach is an essential beginning in the management of BPH; thus, we conducted this study
Accepted 8 December 2016
Available online xxx
to assess health care-seeking behaviour in BPH patients.
Materials and Methods: We recruited 101 patients with BPH which was defined as enlarged prostate with
the exclusion of the possibility of prostate cancer between September 2007 and April 2008. All patients
Keywords:
benign prostatic hyperplasia were proved to have an enlarged prostate as measured by ultrasonography. All patients completed two
health-seeking questionnaires: one is International Prostate Symptom Score (IPSS)/quality-of-life questionnaire, and the
lower urinary tract symptoms other one consists of principal reasons for patients to seek medical advice, the expectation for BPH
treatments and the unwanted side effect of medical treatments.
Results: The majority of patients (71.3%) reported that bothersome urinary symptoms were the principal
reason they sought medical advice. Other reasons included fear of prostate cancer (8.9%), attendance
through physical check-up (14.9%), and a request by family or friends (1.0%). Patients seeking advice due
to bothersome urinary symptoms had an average IPSS of 6.2 higher than those attending for any other
reasons. As for ranking attributes of therapies, about half of the patients (48.6%) were very concerned
about the risks of long-term complications, namely acute urinary retention and surgery. Other prefer-
ences for treatments comprised prostate size decrease (24.8%) and avoidance of prostate cancer (24.8%).
Conclusion: Bothersome urinary symptoms drive most BPH patients to consult a physician. When
considering medical treatments for BPH, about half of the patients wish to reduce the risk of long-term
complication, such as acute urinary retention and BPH-related surgery.
Copyright © 2017, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Benign prostatic hyperplasia (BPH) is a highly prevalent disor-
der in aging male. The bladder outlet obstruction caused by this
condition occurs despite variations in prostate size. Symptoms of
BPH include the irritative (frequency, nocturia, and urgency) and
obstructive (weak stream, dribbling, intermittency, and hesitancy)
symptoms termed as lower urinary tract symptoms (LUTS).1 These
symptoms have a negative influence on the patient’s quality of life
and can interfere with daily activities.2 Both the incidence and
prevalence of LUTS/BPH increase linearly with age; symptomatic
*Corresponding author. Department of Urology, Taipei Veterans General
Hospital, Number 201, Section 2, Shi-Pai Road, Taipei 11217, Taiwan.
E-mail address: lin.alextl@gmail.com (A.T.L. Lin).
BPH has been reported in approximately 25% of men over 40 years
and more than 30% of men over 65 years.3
BPH is also a progressive disease, mainly characterized by a
deterioration of LUTS gradually, and in some patients by the
development of serious complications such as acute urinary reten-
tion and the need for BPH-related surgery.4 In addition, comorbid
conditions frequently exist in parallel with LUTS/BPH; diabetes is
associated with greater BPH symptom severity, and significant re-
lationships between hypertension and LUTS secondary to BPH have
been reported.5,6
Studies demonstrate that men often recognize LUTS as an
inevitable result of aging and that they are poorly educated about
their symptoms. They often delay consultation, primarily due to
uncertainty or cognitive deficit, but also by reason of more delib-
erate neglect.7 An efficient diagnostic approach is an essential

http://dx.doi.org/10.1016/j.urols.2016.12.003
1879-5226/Copyright © 2017, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Fan Y-H, et al., Health care-seeking behavior in benign prostatic hyperplasia patients, Urological Science
(2017), http://dx.doi.org/10.1016/j.urols.2016.12.003
2 Y.-H. Fan et al. / Urological Science xxx (2017) 1e5

beginning in the management of BPH; thus, we conducted this
study to assess health care-seeking behavior in BPH patients.
2. Materials and methods
A total of 101 patients with newly diagnosed BPH with LUTS,
which was defined as an enlarged prostate with the exclusion of the
possibility of prostate cancer, were recruited from the urological
outpatient department in our institution between September 2007
and April 2008. All patients underwent digital rectal examination
and prostate-specific antigen blood test to rule out the possibility of
prostate cancer. All patients were proved to have an enlarged
prostate, defined as a prostate volume of more than 20 c.c., as
measured by ultrasonography.8 Patients with obvious bladder pa-
thology, such as a bladder tumor or vesical stone, were excluded. At
recruitment, all patients completed two questionnaires: one is In-
ternational Prostate Symptom Score (IPSS)/quality-of-life ques-
tionnaire, and the other consists of principal reasons for patients to
seek medical advice, expectation for BPH treatments, and un-
wanted side effects of medical treatments (Table 1). In addition, all
the patients underwent uroflowmetry.
Statistical analysis was carried out with the use of Statistical
Package for Social Science (SPSS) version 15.0. Collected data are
presented descriptively. Besides, t test and ManneWhitney U test
were used to examine the differences between groups.
(Figure 1). Other reasons were fear of prostate cancer (8.9%),
attendance through physical checkup (14.9%), and a request by
family or friends (1.0%).
As for ranking attributes of therapies, about half of the patients
(48.6%) were very concerned about the risks of long-term compli-
cations, namely, acute urinary retention and surgery (Figure 2).
Other preferences for treatments comprise prostate size decrease
(24.8%) and avoiding of prostate cancer (24.8%).
Kidney or liver function impairment was reported as the most
concerned side effect of medical treatment (73.3%), followed by
other reasons (10.9%), sexual function impairment (6.9%), and
dizziness (3.0%). No one worried about the development of hypo-
tension. Five (5.0%) patients stated that they did not care about any
side effects (Figure 3).
The differences in IPSS and uroflowmetry between patients
seeking advice as a result of bothersome urinary symptoms and
those attending for any other reason are shown in Figures 4 and 5.
All the parameters of IPSS were significantly different between
patients seeking advice as a result of bothersome urinary symp-
toms and those attending for any other reason (all p < 0.05). Pa-
tients seeking advice because of bothersome urinary symptoms
had an average IPSS of 6.2 higher than that of patients attending for
any other reasons. There were no statistically significant differences
in uroflowmetry variables and age distribution between these two
groups.

3. Results
4. Discussion
Patient characteristics at recruitment are summarized in Table 2.
The majority of patients (71.3%) reported that bothersome urinary The results of our study showed that about 70% of men initially
symptoms were the chief reason for them to seek medical advice consulted their physician because of bothersome urinary symp-
toms. Such patients had a significantly higher IPSS than those
attending for any other reason. On the whole, our findings are
Table 1 consistent with those observed in prior studies. The TransEuropean
Questionnaire about health-seeking behavior Research Into the Use of Management Policies for LUTS suggestive
Reasons of patients seeking medical advice of BPH in Primary Health care study found that the majority (77%)
Bothersome urinary symptoms of the patients reported that bothersome urinary symptoms were
Fear of prostate cancer the reason why they sought medical advice.2 The Prostate Research
Attendance through physical check-up
on Behavior and Education survey reported that most men initially
Request by family or friends
Others
consult their physician because of classic signs and symptoms of
Expectation for BPH treatments BPH related to LUTS.9 In a population-based study of black Amer-
Reduction in the risk of requiring surgery ican men, Sarma et al10 found that the frequencies of irritative
Reduction in the risk of AUR symptoms such as frequency, nocturia, and urgency were most
Reduction in the risk of prostate cancer
highly associated with health care-seeking behavior.
Reduction in prostate size
Others As for ranking attributes of therapies, about half of the patients
Unwanted side effects of medical treatments (48.6%) were very concerned about the risks of long-term compli-
Impairment of liver or kidney function cations, namely, acute urinary retention and surgery. The Prostate
Impairment of sexual function
Research on Behavior and Education survey indicated that more
Dizziness
Hypotension
than three-quarters of patients reported that they would prefer a
Others drug that provides a 50% reduction in the risk of needing surgery
rather than a drug offering faster symptom relief.9 In addition, re-
AUR ¼ acute urinary retention; BPH ¼ benign prostatic hyperplasia.
sults from US and British surveys demonstrated that patients are
Table 2 willing to trade immediate symptom relief for a reduction in the
Patient characteristics risk of progression.11,12 We believe that BPH patients are more
Mean ± SD concerned about symptoms than long-term complications, but this
Age at recruitment 72.14 ± 10.31
survey showed the opposite observation. The progressive nature of
IPSS BPH might be used as a prescription driver.
Total score 16.22 ± 7.82 Kidney or liver function impairment was reported as the most
Storage subscore 6.13 ± 4.05 concerned side effect of medical treatment (73.3%). The two main
Voiding subscore 10.41 ± 5.79
medications for the management of BPH are alpha-blockers and 5a-
Quality of life 3.54 ± 1.24
Uroflowmetry reductase inhibitors. Actually, lead to kidney or liver function
Voided volume 235.08 ± 114.05 impairment. Interestingly, about three-quarters of BPH patients
Maximum flow rate 11.86 ± 4.95 were concerned about this issue. Additionally, rare adverse effects
Mean flow rate 5.77 ± 2.38 resulted from BPH treatments, such as hearing impairment and
IPSS ¼ International Prostate Symptom Score; SD ¼ standard deviation. hepatotoxicity, should be kept in mind. The result reflects the views

Please cite this article in press as: Fan Y-H, et al., Health care-seeking behavior in benign prostatic hyperplasia patients, Urological Science
(2017), http://dx.doi.org/10.1016/j.urols.2016.12.003
 Y.-H. Fan et al. / Urological Science xxx (2017) 1e5 3

Figure 1. Responses to the reasons of patients seeking medical advice.

Figure 2. Responses to the expectation for BPH treatments. AUR ¼ acute urinary retention; BPH ¼ benign prostatic hyperplasia.

Figure 3. Responses to the unwanted side effects of medical treatments.

Please cite this article in press as: Fan Y-H, et al., Health care-seeking behavior in benign prostatic hyperplasia patients, Urological Science
(2017), http://dx.doi.org/10.1016/j.urols.2016.12.003
4 Y.-H. Fan et al. / Urological Science xxx (2017) 1e5

Figure 4. Differences in IPSS between patients seeking advice as a result of bothersome urinary symptoms and those attending for any other reason. IPSS ¼ International Prostate
Symptom Score; LUTS ¼ lower urinary tract symptoms; QoL ¼ quality of life.

Figure 5. Differences in uroflowmetry between patients seeking advice as a result of bothersome urinary symptoms and those attending for any other reason. LUTS ¼ lower urinary
tract symptoms.

of general population on medicines that potentially cause vital or-
gan damage.
There are some limitations in the present study. The study
population is small. In the group of patients attending through
physical checkup, some might have been educated about the
management of BPH by family physicians or physical examination
physicians, which could affect the answers of study questionnaires.
Although most of the patients attending through physical checkup
were merely due to the reports on the prostate volume rather than
the interview with physicians.
5. Conclusions
This survey provides a valuable insight into the views and beliefs
of patients regarding BPH and its management. Bothersome uri-
nary symptoms drive most BPH patients to consult a physician.
When considering medical treatment for BPH, about half of the
patients prefer to reduce the risk of long-term complications, such
as acute urinary retention and the need for surgery.
Conflict of interest
There is no conflict of interest.
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(2017), http://dx.doi.org/10.1016/j.urols.2016.12.003
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Please cite this article in press as: Fan Y-H, et al., Health care-seeking behavior in benign prostatic hyperplasia patients, Urological Science
(2017), http://dx.doi.org/10.1016/j.urols.2016.12.003