Prevalence of Postmicturition Dribble in Young Saudi Males: A Mixed-methods Study

Abstract

Background:

Postmicturition dribble (PMD) is categorized as one of the most common symptoms that can occur in the lower urinary tract system after urination and affects nearly one-third of men worldwide. This study aimed to measure PMD prevalence in young Saudi males and explore potential associations with demographic and clinical factors, informing targeted interventions and improving quality of life (QoL).

Methodology:

A mixed-methods study employing both quantitative and qualitative approaches was conducted among a sample of young Saudi males. The study was conducted from August 2023 to November 2023. The data collection sheet included demographic information, the International Prostate Symptom Score, and the Hallym PMD Questionnaire to assess PMD. Key informant interviews and focus group discussions were conducted to gain insights into the lived experiences and perceived causes of PMD. The data were collected using a prestructured and validated questionnaire.

Results:

A total of 1758 eligible young Saudi males completed the study questionnaire. Participants’ ages ranged from 18 to 35 years, with a mean age of 21.7 ± 6.4 years old. A total of 918 (52.2%) young Saudi males had PMD, where 568 (32.3%) of them experienced PMD once every three times, 10.8% experienced it two out of three times, and 160 (9.1%) experienced PMD nearly every time. Participants with PMD had a severity score of 1.7 ± 1.1, a bother score of 1.4 ± 1.1, and a QoL score of 1.3 ± 1.1.

Conclusions:

The study revealed a high prevalence of PMD among young Saudi males with frequent occurrence, moderate severity, and an average impact on their QoL.

INTRODUCTION

Postmicturition dribble (PMD) is an involuntary loss of urine immediately after urination, categorized as one of the lower urinary tract symptoms (LUTS).[1] It is commonly associated with elderly men experiencing erectile dysfunction (ED) and pelvic muscle floor weakness. Generally, LUTS, which encompass storage, voiding, and postmicturition symptoms, can cause discomfort in a significant proportion of adults worldwide, with prevalence rates ranging from approximately 15.8% to 82.0%.[2] PMD is among the prevalent LUTS that cause significant bother to individuals as it causes discomfort and inconvenience.[3,4] It is a common LUTS in men, affecting nearly 30% of them.[5,6]

The exact cause of PMD is not fully understood, but earlier studies have proposed that it is the result of a small amount of residual urine remaining in either the bulbar or prostatic urethra.[7] This urine is suggested to be pushed back into the bladder during the final stages of urination, leading to dribbling after completing the act of urinating.[7] Moreover, weakness or dysfunction of the muscles in the pelvic floor has a significant effect and is considered to be the primary factor.[8] Whereas bulbar urethral massage and pelvic floor exercises have been established as effective treatments for PMD, there has been little exploration of pharmacologic interventions until recently.[8] A suggestion has been made regarding the potential use of phosphodiesterase-5 inhibitors and tadalafil for treating PMD.[8,9] Generally, patients with LUTS exhibit a poor quality of life (QoL) and high rates of psychological distress.[10] A study has indicated that those with multiple storage, voiding, and postmicturition LUTS were more likely to report clinically significant levels of anxiety and depression.[10] Recognizing symptoms that are both prevalent and distressing as PMD is crucial as a preventive measure.[11]

This study aims to measure the prevalence of PMD among young Saudi males, explore potential associations with demographic and clinical factors, and assess the impact on QoL.

METHODOLOGY

Study design

This study utilized a mixed-methods approach, incorporating both quantitative and qualitative design, to conduct this study in all 13 regions of Saudi Arabia. This study was conducted in Al-Hasa, Saudi Arabia, from August 2023 to November 2023. The qualitative component included key informant interviews and focus group discussions to complement the cross-sectional survey and understand why PMD occurs in this younger population. Two validated questionnaires were used in addition to questions aimed at collecting demographic data. The first was the Hallym PMD Questionnaire (HPMDQ), which specifically focuses on PMD and has been validated for use in research studies. To ensure its applicability to the Saudi population, the HPMDQ was translated into Arabic and underwent a rigorous validation process. The second questionnaire used was the Arabic version of the International Prostate Symptom Score (IPSS) to assess its association with PMD.

Study population and sampling

The study sampled 1758 Saudi citizens, encompassing participants from all 13 regions across Saudi Arabia. Care was taken to maintain a convergent sample size across regions to provide a comprehensive overview and to highlight potential regional variations. The study inclusion criteria were young Saudi males aged 18–35 years who were willing to participate. Non-Saudi individuals, men outside the specified age range, and females were excluded. A random sampling technique was employed to select participants from the target population. The sample size was determined using appropriate statistical methods, with a confidence interval (CI) of 95% and a margin of error of 5%.

Instruments and measurements

A prestructured and validated Google Forms questionnaire translated into Arabic was distributed online to the targeted population to collect the data. The questionnaire comprised three sections. The first section contained questions related to demographics, economic data, habits (smoking and exercises), and medical conditions. The second was the HPMDQ, which assesses the prevalence of PMD and its impact on QoL. It consists of five questions regarding frequency, severity, bother, QoL, and response to treatment. The fifth question is not to be answered before any treatment. Each question has answers on a four-grade response scale (0–3). The HPMDQ total score was defined as the sum of the scores of questions 1, 2, 3, and 4. Finally, the third section was the IPSS, used to evaluate its association with PMD. The IPSS overall score is calculated by summing the scores of each individual item, and then the severity of the symptoms is classified as mild, moderate, or severe based on specific score ranges: 1–7 is mild, 8–19 moderate, and 20–35 severe.

Data analysis

The data were collected, reviewed, and then transferred to the Statistical Package for the Social Sciences version 21 (SPSS: an IBM Company, Chicago, Illinois, USA). All statistical methods used were two-tailed with an alpha level of 0.05, considering significance if P ≤ 0.05. PMD was assessed based on the HPMDQ score for prevalence, severity, bother, and QoL effect.[7] Moreover, the overall IPSS score was obtained by adding all discrete item scores and then categorized into mild, moderate, or severe using 1–7, 8–19, and 20–35 ranges, respectively.[12] The prevalence of PMD was graphed, while its effect was displayed in the frequency table, and the mean with standard deviation for severity, bother, and QoL was used. Cross-tabulation to show factors associated with PMD among young Saudi males and association with IPSS was conducted with a Pearson’s Chi-square test for significance and an exact probability test if there were small frequency distributions. Multiple logistic regression models were used to assess adjusted relationships between different predictors and PMD based on the adjusted odds ratio (OR) with its 95% CI.

Ethical considerations

Approval for this study was obtained from the Research Ethics Committee at King Faisal University (IRB Ref. No. KFU-REC-2023-NOV-ETHICS1401). The participants were provided with a clear explanation of the study’s objectives, and their consent was obtained. To ensure confidentiality, all information gathered was kept anonymous, and no private data pertaining to the study was accessible.

RESULTS

A total of 1758 eligible young Saudi males completed the study questionnaire. Participants’ ages ranged from 18 to 35 years, with a mean of 21.7 ± 6.4 years old. Of these, 1172 (66.7%) had an intermediate monthly income. Concerning daily habits, 1278 (72.7%) were nonsmokers, 248 (14.1%) were ex-smokers, and 232 (13.2%) were current smokers. A total of 444 (25.3%) never exercise, 398 (22.6%) practice 1–2 days weekly, and 524 (29.8%) 5–7 days per week. Regarding chronic health problems, 1296 (73.7%) had no chronic diseases, 144 (8.2%) had depression, 98 (5.6%) had morbid obesity, and 76 (4.3%) were diabetic [Table 1]. A total of 918 (52.2%) participants had PMD, while 840 (47.8%) did not [Figure 1].

Table 1.

Sociodemographic characteristics of participants

Sociodemographic	n (%)
Age (years)
18–23	1028 (58.5)
24–29	392 (22.3)
30–35	338 (19.2)
Monthly income
Low	304 (17.3)
Intermediate	1172 (66.7)
High	282 (16.0)
Smoking
Nonsmoker	1278 (72.7)
Ex-smoker	248 (14.1)
Current smoker	232 (13.2)
Exercising (days/week)
Never	444 (25.3)
1–2	398 (22.6)
3–4	392 (22.3)
5–7	524 (29.8)
Chronic health problems
None	1296 (73.7)
Depression	144 (8.2)
Morbid obesity	98 (5.6)
Rheumatoid arthritis	82 (4.7)
Diabetes mellitus	76 (4.3)
Cardiac disease	48 (2.7)
Cancer	14 (0.8)

Figure 1.

Prevalence of postmicturition dribble among participants. PMD: Postmicturition dribble

Table 2 depicts PMD frequency, severity, and impact on QoL. Of participants, a total of 568 (32.3%) experienced PMD once every three times urinating, 190 (10.8%) experienced it two out of three times, and 160 (9.1%) every time [Figure 2]. Participants with PMD had a severity score of 1.7 ± 1.1, a bother score of 1.4 ± 1.1, and a QoL score of 1.3 ± 1.1.

Table 2.

Postmicturition dribble frequency, severity, and impact

HPMDQ
PMD, n (%)
None	840 (47.8)
1 every 3 times	568 (32.3)
2 every 3 times	190 (10.8)
Mostly every time	160 (9.1)
PMD impact, mean±SD
Severity	1.7±1.1
Bother	1.4±1.1
QoL	1.3±1.1

PMD=Postmicturition dribble, SD=Standard deviation, QoL=Quality of life, HPMDQ=Hallym Postmicturition Dribble Questionnaire

Figure 2.

Postmicturition dribble frequency among participants. PMD: Postmicturition dribble

Table 3 presents factors associated with PMD among young Saudi males. Of the participants, 66.3% of men aged 30–35 years complained of PMD compared with 46.9% of those aged 18–23 years, with a recorded statistical significance (P = 0.001). PMD was also detected among 78.4% of currently smoking participants in comparison with 44.6% of nonsmokers (P = 0.001). A total of 44.3% who exercised 5–7 days a week had PMD, compared with 48.6% of those who never practiced (P = 0.001). Finally, PMD was found in 86.3% of participants with rheumatoid arthritis, 66.7% with cardiac disease, 61.2% with morbid obesity, and 57.9% of diabetics compared with 48.6% with no chronic health problems (P = 0.001).

Table 3.

Factors associated with postmicturition dribble

Factors	Postmicturition dribble		P
	PMD, n (%)	No PMD, n (%)
Age (years)
18–23	482 (46.9)	546 (53.1)	0.001*
24–29	212 (54.1)	180 (45.9)
30–35	224 (66.3)	114 (33.7)
Monthly income
Low	168 (55.3)	136 (44.7)	0.078
Intermediate	590 (50.3)	582 (49.7)
High	160 (56.7)	122 (43.3)
Smoking
Nonsmoker	570 (44.6)	708 (55.4)	0.001*
Ex-smoker	166 (66.9)	82 (33.1)
Current smoker	182 (78.4)	50 (21.6)
Practicing exercises
Never	216 (48.6)	228 (51.4)	0.001*
1–2 days	236 (59.3)	162 (40.7)
3–4 days	234 (59.7)	158 (40.3)
5–7 days	232 (44.3)	292 (55.7)
Chronic health problems
None	630 (48.6)	666 (51.4)	0.001*,^
Depression	88 (61.1)	56 (38.9)
Diabetes mellitus	44 (57.9)	32 (42.1)
Morbid obesity	60 (61.2)	38 (38.8)
Cardiac disease	32 (66.7)	16 (33.3)
Rheumatoid arthritis	56 (68.3)	26 (31.7)
Cancer	8 (57.1)	6 (42.9)

*P<0.05 significant, ^{^}Exact probability test. P=Pearson Chi-square test. PMD=Postmicturition dribble

Table 4 depicts the association between PMD among young Saudi males and IPSS. A total of 1002 (57%) of the study participants had mild IPSS scores, and only 148 (8.4%) had severe IPSS scores. Furthermore, 91.9% of participants with severe IPSS scores had PMD compared with 71.4% of those with moderate scores and 34.7% with mild scores (P = 0.001).

Table 4.

Association between postmicturition dribble and International Prostate Symptom Score

BPH	Total, n (%)	PMD		P
		PMD, n (%)	No PMD, n (%)
Mild	1,002 (57.0)	348 (34.7)	654 (65.3)	0.001*
Moderate	608 (34.6)	434 (71.4)	174 (28.6)
Severe	148 (8.4)	136 (91.9)	12 (8.1)

*P<0.05 (significant). P=Pearson Chi-square test. PMD=Postmicturition dribble, BPH=Benign prostatic hyperplasia

Next, Table 5 shows a multiple logistic regression for predictors of PMD among young Saudi males, followed by a forest plot. Among all included factors, older age was associated with a 50% higher risk of experiencing PMD than in younger adults (OR = 1.5; 95% CI: 1.1–2.0). In addition, ex-smokers exhibited 2.5 times more likelihood of PMD than nonsmokers, and current smokers showed 3.4 times more likelihood (ORs = 2.5 [1.8–3.5] and 3.4 [2.4–4.9], respectively). Similarly, a higher IPSS score was associated with 4.6 times more likelihood of having PMD (OR = 4.6; 95% CI [3.8–5.6]), keeping all other factors constant.

Table 5.

Multiple logistic regression for predictors of postmicturition dribble

Predictors	P	AOR	95% CI
			Lower	Upper
Age (years)	0.009*	1.5	1.1	2.0
Smoking
Ex-smoker versus nonsmoker	0.001*	2.5	1.8	3.5
Current versus nonsmoker	0.001*	3.4	2.4	4.9
Exercising	0.750	0.9	0.7	1.1
Chronic disease	0.935	1.0	0.8	1.3
IPSS	0.001*	4.6	3.8	5.6
Model significance	P=0.001*
Model accuracy	70.6%

*P<0.05 (significant). AOR: Adjusted odds ratio, CI: Confidence interval, IPSS=International Prostate Symptom Score

DISCUSSION

PMD is not caused by stress from exertion or a problem with the bladder and should be distinguished from terminal dribble, which occurs at the end of passing urine.[8] However, the condition can be a nuisance and may cause embarrassment.[13] While women may also experience it, it is much more common in men.[14]

This study found a high prevalence of PMD (32%) among a study population with a mean age of 21 years, which is younger than the typically affected demographic of elderly men with pelvic muscle floor weakness and ED. This high prevalence among younger males suggests alternative contributing factors such as lifestyle habits, sedentary behavior, high rates of smoking, and potential undiagnosed pelvic floor dysfunction. The qualitative findings from key informant interviews and focus group discussions support this hypothesis, as participants reported concerns about urinary habits, fluid intake patterns, and physical activity levels as potential contributors to PMD.

This study aimed to determine the prevalence of PMD and associated factors among young males in Saudi Arabia and assess its impact on their daily lives. It showed that more than half of the participants reported meeting the criteria for PMD. The highest prevalence of PMD was assessed in the Najran region, followed by Makkah, and then Hail. The least assessed frequency was in the Al-Gouf and Tabuk regions. This prevalence is much higher than estimated by Malmsten among Swedish adults, which was 29%.[15] Another study in Finland by Koskimäki et al. showed a prevalence of 38%,[16] and one in Japan by Furuya et al. found 11.5%.[17] However, a study by Wille et al. showed a prevalence of 86%.[18] Nonetheless, all of these were old studies that used different diagnostic methods, which explains the high variability in estimated PMD prevalence.

According to a recent population-based study conducted in Western countries, the prevalence rate of PMD is 5.5%.[19] A second population-based study including US males 30–79 years old reported a prevalence of 8.7%.[20] In a Chinese population study involving over 1500 males aged 18 years or older, the prevalence rate of PMD was found to be 9.4%.[2] Another study among males 18 years or older in three Western countries assessed a prevalence rate of 29.7%.[21] In contrast, a population-based study of males aged 30–80 years estimated a prevalence of 58.1%,[22] and one with males aged 18 years or more in Southeast Asia showed a prevalence rate of 55.0%.[11] In most studies, an increased drift was observed between PMD prevalence and advancing age.[19,20]

Despite the research above, there is limited information available about the frequency and quantity of PMD. Ko et al. conducted a study of men aged 20–70 years who had PMD and other LUTS and documented that 42.8%, 32.6%, and 24.6% of patients experienced PMD once out of three times, twice out of three times, and almost always, respectively.[5] Another study conducted by Yang et al. on males 40 years or older with LUTS showed that 65.7%, 22.9%, and 11.4% of patients experienced PMD once out of three times, twice out of three times, and almost always, respectively.[3]

Regarding severity and impact on QoL, this study found that most participants had a low frequency of PMD after each time, but the severity score was average with an intermediate effect on their QoL (mean scores were around 1.4 of 3). These findings indicate an average effect on mood and daily life. Similar findings were reported in Finland, where the most reported urinary symptom causing moderate or severe bother was PMD.[23] Pöyhönen et al. also found that PMD was the most bothersome urinary symptom in males aged 30–40 years.[24] Maserejian et al. showed that postmicturition symptoms, including PMD, were indicative of impaired physical and mental health-related QoL.[20] Similarly, Wang et al. concluded that PMD was one of the most worrisome LUTS in China,[2] and a practice-based study in Southeast Asia reported that more than half of the males felt at least some degree of bother from PMD, similar to others.[11]

The main limitation of this study is that the study relied on self-reported data from participants, which may be subject to recall bias or social desirability bias. Objective measurements or clinical assessments could provide more reliable data on PMD. Furthermore, the study was conducted among young Saudi males aged 18–35 years. The findings may not be generalizable to other age groups, females, or populations outside of Saudi Arabia. Further research is needed to assess the prevalence and factors associated with PMD in more diverse populations.

CONCLUSIONS AND RECOMMENDATIONS

In conclusion, the current study revealed a high prevalence of PMD among young Saudi males, not infrequent with moderate severity and an average impact on their QoL. The unexpected high prevalence of PMD among young Saudi males, challenges the conventional belief that PMD is primarily linked to older age groups. The inclusion of qualitative data provided insights into possible behavioral and lifestyle contributors. Higher PMD rates were reported among older adults, smokers, and those with high levels of bladder dysfunction according to high IPSS scores. Nevertheless, recent evidence has suggested that PMD requires further attention. More research is needed to fully understand this disorder and its pathophysiology, especially among young males.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.