ABSTRACT
Introduction:
This study analyzes clinical associations of pain in young men presenting with a primary complaint of a lower urinary tract symptom (LUTS).
Methods:
A secondary analysis of the SciCOM 3 study examining young men presenting with LUTS was performed. Bladder pain was recorded by Q4 of the Interstitial Cystitis Symptom Score, while nonbladder pain was captured by the Visual Analog Scale. LUTS, sexual dysfunction, stool consistency, perception of problems related to the bladder, and general well-being were captured by questionnaires.
Results:
A total of 448 young men (18–40 years; median 30 years, interquartile range: 25–35 years) were studied across 16 centers. Eighty-seven (19.8%) reported no pain (Group 1), 143 (32.6%) bladder pain alone (Group 2), 39 (8.9%) only nonbladder pain (Group 3), and 170 (38.7%) both bladder and nonbladder pain (Group 4). Men in Group 4 were more likely to report reduced strength of stream (odds ratio [OR] 1.95; 95% confidence interval [CI]: 1.27 and 3.01), need to stop and start (OR 1.81; 95% CI: 1.19 and 2.74), sense of incomplete evacuation (OR: 2.64; 95% CI: 1.58 and 4.40), and urgency (OR: 1.73; 95% CI: 1.16 and 2.59), while men in Group 2 were more likely to report urine leak for no apparent reason (OR: 1.85; 95% CI: 1.17 and 2.90). Group 1 was the least likely to report an abnormal sense of well-being.
Conclusions:
Pain is commonly reported by young men presenting with LUTS. The pattern of pain in LUTS is associated with a distinct clinical epidemiology, including both storage and voiding LUTS, with an impact on bother and quality of life. It is important to assess pain in young men presenting with LUTS.
INTRODUCTION
Both pain and lower urinary tract symptoms (LUTSs) are common in society and have a major impact on quality of life.[1,2] It has been estimated that about 20% of the general population suffers from pain.[1] LUTS has been reported in about 50% of the population of young men.[3] There is a remarkable paucity of data on young men presenting with LUTSs, a gap that has recently been addressed by the SciCOM 3 project of the Functional and Female Urology Section of the Urological Society of India.[4] Pain has not been generally recognized as a common association in young men presenting with LUTSs and does not figure in the current guideline algorithm for management.[5] SciCOM 3 noted a high prevalence of pain in young men presenting with a primary complaint of LUTS. This secondary analysis from SciCOM 3 examines the associations of pain in a large cohort of young men presenting with LUTS.
METHODS
Detailed methodology and the primary findings of SciCOM 3 have been published earlier.[4] SciCOM 3 examined the clinical epidemiology of young men presenting with LUTS across 16 nationwide centers using validated questionnaires in a cross-sectional study. Only the relevant details are discussed here. The ethics committee approval was taken. LUTS was captured by the International Consultation on Incontinence Male LUTSs Questionnaire (ICIQ-mLUTS).[6] Each of the 13 questions was marked as “present” for the analysis in this study if the patient marked a score of more than “never or 0.” For Q13 (daytime frequency), a score of >0 was recorded as “present.” Stool consistency was measured by the Bristol Stool Chart (BSC) and reclassified as constipation (class 1 or 2), normal (class 3 or 4), and loose stools (classes 5–7).[7] Sexual function was captured by the single-question Massachusetts Male Aging Study questionnaire and the Premature Ejaculation Profile Q1, and the symptoms were marked as “present” if patients scored any degree of abnormality.[8,9] Severity of problems related to the bladder was measured by the Patient Perception of Bladder Condition (PPBC) questionnaire, and any degree of bother was marked as “bother present.”[10] Well-being was captured by the World Health Organization WHO-5 Well-being Scale.[11] Men who marked a score less than the best score were recorded as having abnormal well-being. Any comorbidities, and significant urological history was recorded. The maximum flow rate, postvoid residual urine, and the presence of hydronephrosis (by abdominal ultrasonography) were recorded by testing done at recruitment into the study.
Bladder pain was captured by the validated questionnaire, Interstitial Cystitis Symptom Index (ICSI) Q4.[12] Bladder pain was recorded as “present” when patients recorded a score other than (pain experienced) “not at all.” Nonbladder pain was captured by a (nonvalidated) Visual Analog Scale (VAS) scored from 0 to 10 and classified as pain “present” when the score was >1. This was in response to the question “During the past month, have you experienced pains anywhere in the body other than your bladder?” Based on the response to these two questions, four mutually exclusive classes of young men with LUTS were identified: no pain (Group 1), bladder pain only (Group 2), nonbladder pain only (Group 3), and both bladder and nonbladder pain (Group 4).
The inclusion and exclusion criteria, sample size estimation, and statistical analyses have been described earlier.[4] All adult men between the ages of 18 and 40 years presenting with a primary complaint of LUTS were included, after informed consent. Those with other specific urological diagnoses were excluded. Target recruitment of 422 was based on a population prevalence of 50% for LUTS in young men, a 95% confidence level of the estimate, and a ±5% margin of error.[3] The current study is a secondary analysis of the original data. Descriptive statistics were reported as median and interquartile range (IQR). The Kruskal–Wallis test was used for comparisons with Dunn–Bonferroni intergroup testing with correction for multiple testing, as appropriate.
All analysis was done with available data, ignoring any missing data points in the calculations. Missing data were expected to be minimal in view of the digital tablet-based recording system that was used. For examining the association of each individual symptom with pain, Pearson’s Chi-square analysis was performed with Bonferroni correction for intergroup testing. P < 0.05 (two-sided) was regarded as significant. Analysis was performed by IBM SPSS version 25.0.0 (IBM Corp, United States, 2017).
RESULTS
A total of 448 men were part of the study (median age 30 years, IQR: 25 and 35 years). Around 71.9% of men reported experiencing some degree of bladder pain, on ICSI Q4, including a few times (222, 49.6%), fairly often (51, 11.6%), usually (29, 6.6%), and almost always (13, 3.0%). Nonbladder pain on VAS was reported by 48.1% including mild pain (144, 32.2%), moderate pain (56, 12.5%), and severe pain (15, 3.4%). Of these men, 87 (19.8%) reported no pain (Group 1), 143 (32.6%) only bladder pain (Group 2), 39 (8.9%) only nonbladder pain (Group 3), and 170 (38.7%) both bladder and nonbladder pain (Group 4). The foundational assessment can be found in Table 1. Group 4 patients had a lower body mass index compared with the other groups, while Group 3 had the longest duration of symptoms. Patients in Group 4 were more likely to report a history of urinary tract infection (UTI) as compared with those in Group 1 (24.7% vs. 10.3%, P < 0.05).
Table 1.
Young men with lower urinary tract symptoms. Clinical characteristics of the patients stratified by location of pain. Four classes were defined, ‘no associated pain’, ‘bladder pain only’, ‘non-bladder pain only’, and ‘both bladder and non-bladder pain’. Bladder pain was captured by the Interstitial Cystitis Symptom Index (ICSI) Q4. Bladder pain was recorded as ‘present’ when patients recorded a score other than (pain experienced) ‘not at all’. Non-bladder pain was captured by a (non-validated) visual analogue scale (VAS) scored from 0-10 and classified as pain ‘present’ when the score was >1
| Clinical presentation (median, IQR, Kruskal–Wallis test) | No pain | Bladder pain only | Nonbladder pain only | Both bladder and nonbladder pain | P |
|---|---|---|---|---|---|
| Age | 30 (26–34) | 31 (25–35) | 30 (25–34) | 30 (24–35) | 0.837 |
| BMI | 24.3 (22.1–26.3) | 24.1 (21.5–26.1) | 23.4 (21.3–27.8) | 22.4 (19.8–24.9) | 0.001 |
| Duration of symptoms | 6 (3–16) | 5 (3–12) | 12 (6–24) | 8 (3–18) | 0.003 |
| Postvoid residual | 35 (25–45) | 35 (25–45) | 35 (20–45) | 40 (25–60) | 0.246 |
| Maximum flow rate | 16.0 (11.5–17.0) | 15.0 (11.0–17.0) | 15.0 (10.0–19.0) | 14.8 (10.0–17.0) | 0.704 |
| Present n (%) of column, Pearson’s Chi-square test | |||||
| Hypertension (n=439) | 3 (3.4) | 4 (2.8) | 4 (10.3) | 4 (2.4) | 0.099 |
| Diabetes (n=439) | 4 (4.6) | 3 (2.1) | 1 (2.6) | 3 (1.8) | 0.564 |
| History of urinary tract infection (n=439) | 9 (10.3) | 20 (14.0) | 3 (7.7) | 42 (24.7) | 0.004 |
| Hydronephrosis (n=433) | 3 (3.5) | 8 (5.7) | 2 (5.3) | 12 (7.1) | 0.724 |
ICSI=Interstitial Cystitis Symptom Index, VAS=Visual Analog Scale, IQR=Interquartile range, BMI=Body mass index
There was a significant association of pain classes with five of the 13 questions of the ICIQ-mLUTS [Table 2]. When compared with Group 1, those in Group 4 were more likely to report reduced strength of urine stream (76.5% vs. 57.5%, P < 0.05), need to stop and start (72.9% vs. 51.7%, P < 0.05), a sense of incomplete evacuation (86.5% vs. 65.5%, P < 0.05), and urgency (68.2% vs. 51.7%, P < 0.05). Overall, men in Group 4 were more likely to report reduced strength of stream (odds ratio [OR]: 1.95; 95% confidence interval [CI]: 1.27 and 3.01), need to stop and start (OR: 1.81; 95% CI: 1.19 and 2.74), sense of incomplete evacuation (OR: 2.64; 95% CI: 1.58 and 4.40), and urgency (OR: 1.73; 95% CI: 1.16 and 2.59) as compared with the other groups. Men in Group 2 were more likely to report urine leak for no apparent reason as compared with those presenting with Group 4 (31.5% vs. 17.6%, P < 0.05) with OR: 1.85 (95% CI: 1.17 and 2.90) as compared with the other groups.
Table 2.
Association of each question of the International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms and class of pain, in young men with lower urinary tract symptoms
| ICIQ-mLUTS symptom (symptom present n (%) of column) | No pain, n (%) | Bladder pain only, n (%) | Nonbladder pain only, n (%) | Both bladder and nonbladder pain, n (%) | P |
|---|---|---|---|---|---|
| 2A. Is there a delay before you can start to urinate? (n=436) | 59 (68.6) | 105 (73.4) | 26 (68.4) | 136 (80.5) | 0.133 |
| 3A. Do you have to strain to continue urinating? (n=437) | 58 (66.7) | 97 (68.3) | 24 (61.5) | 132 (78.1) | 0.067 |
| 4A. Reduced strength of your urinary stream (n=439) | 50 (57.5) | 92 (64.3) | 26 (66.7) | 130 (76.5) | 0.012 |
| 5A. Do you stop and start more than once while you urinate? (n=439) | 45 (51.7) | 89 (62.2) | 27 (69.2) | 124 (64.9) | 0.007 |
| 6A. Feel that bladder has not emptied properly after urination (n=437) | 57 (65.5) | 101 (71.1) | 31 (81.6) | 147 (86.5) | 0.001 |
| 7A. Do you have a sudden need to rush to the toilet to urinate? (n=439) | 45 (51.7) | 81 (56.6) | 23 (59.0) | 116 (68.2) | 0.042 |
| 8A. Does urine leak before you can get to the toilet? (n=439) | 21 (24.1) | 53 (37.1) | 11 (28.2) | 44 (25.9) | 0.100 |
| 9A. Does urine leak when you cough or sneeze? (n=438) | 16 (18.6) | 33 (23.1) | 4 (10.3) | 28 (16.5) | 0.240 |
| 10A. Leak for no obvious reason (n=439) | 20 (23.0) | 45 (31.5) | 9 (23.1) | 30 (17.6) | 0.041 |
| 11A. Do you leak urine when you are asleep? (n=437) | 24 (27.6) | 40 (28.2) | 5 (12.8) | 36 (21.3) | 0.151 |
| 12A. Slight wetting of pants after you finish urinating (n=439) | 33 (37.9) | 64 (44.8) | 20 (51.3) | 79 (46.5) | 0.473 |
| 13A. How often do you pass urine during the day (n=439) | 67 (77.0) | 118 (82.5) | 28 (71.8) | 127 (74.7) | 0.313 |
| 14A. How many times do you get up to urinate at night (n=439) | 77 (88.5) | 132 (92.3) | 32 (82.1) | 149 (87.6) | 0.284 |
ICIQ-mLUTS=International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms
No specific association was noted between pain classes and erectile dysfunction [Table 3]. However, those in Groups 2 and 4 (those having any bladder pain) were more likely to report premature ejaculation on the Premature Ejaculation Profile Q1 as compared with Group 1 (88.3% and 87.2% vs. 73.6%, P < 0.05). Regarding stool consistency, those in Group 3 were more likely to report loose stools as compared with Group 2 (28.2% vs. 8.4%, P < 0.05) on the BSC. Group 1 was less likely to report an abnormal sense of well-being on the WHO Well-being Questionnaire Q1 as compared with all the other pain classes. Those in Group 4 were more likely to report bother due to their bladder condition on the PPBC Questionnaire as compared with all the other pain classes.
Table 3.
Analysis of associated symptoms and pain in young men presenting with lower urinary tract symptoms
| Clinical epidemiology (symptom, bother or impairment present n (%) of column) | No pain | Bladder Pain only | Nonbladder pain only | Both bladder and nonbladder pain | P |
|---|---|---|---|---|---|
| Erectile dysfunction (MMAS) (n=439) | 43 (49.4) | 80 (55.9) | 17 (43.6) | 80 (47.1) | 0.353 |
| Premature ejaculation (PEP Q1) (n=427) | 64 (73.6) | 121 (88.3) | 34 (87.2) | 143 (87.2) | 0.013 |
| Stool consistency (BSC) (n=439) | |||||
| Constipation | 15 (17.2) | 32 (22.4) | 6 (15.4) | 52 (30.6) | 0.006 |
| Loose stools | 12 (13.8) | 12 (8.4) | 11 (28.2) | 22 (12.9) | |
| Bother with bladder condition (PPBC) (n=438) | 74 (85.1) | 133 (93.0) | 33 (84.6) | 168 (98.8) | 0.001 |
| Quality of life (WHO Well-being Q1) (n=438) | 67 (77.9) | 128 (89.5) | 22 (84.6) | 155 (91.2) | 0.018 |
MMAS=Massachusetts Male Aging Study, PEP Q1=Premature Ejaculation Profile Q1, BSC=Bristol Stool Chart, PPBC=Patient Perception of Bladder Condition, WHO=World Health Organization
DISCUSSION
Pain was commonly reported by this cohort of young men presenting with a primary complaint of LUTS to the urology outpatient department. The pattern of pain was associated with specific clinical findings, with those having a generalized form of pain more likely to report poor stream, intermittency, a sense of incomplete evacuation, and urgency. The presence of any pain was associated with a significantly higher degree of bother with the bladder condition and a greater impact on general well-being, with those having generalized pain showing the worst scores.
Patients with LUTS have previously been shown to report generalized body pain, fibromyalgia, and low back pain. An association was noted between musculoskeletal pain and LUTS in older men attending the orthopedics clinic. The odds of finding such pain, including that of pain in multiple locations, increased with the severity of LUTS.[13] An association has also been described between back pain and LUTS.[14] A population-based study of 3143 older men found an association between arthritis and LUTS (adjusted OR: 1.5, 95% CI: 1.2, 2.0).[15] An association has also been noted between postmicturition “incontinence” and low back ache (OR: 1.58, P = 0.003). The prevalence of symptomatic postmicturition “incontinence” in this study was age independent at about 6%.[16] In contrast, 44% of young men in the SciCOM 3 cohort reported at least some postmicturition wetting (median score: 0), with 2.7% reporting it all the time.[4]
Several studies have examined LUTS in patients presenting with pelvic or bladder pain. Abnormal afferent sensations from the bladder have been described as ranging from extremes of abnormal urgency to pain, with considerable overlap between the conditions.[17,18] This could explain the association between pain and LUTS in some of our patients. Intriguingly, while patients reporting both bladder and nonbladder pain (Group 4) showed a higher prevalence of urgency symptoms, this was not noted in men who had exclusively bladder pain. It appears that in men with LUTS and pain, men with exclusive bladder pain showed different clinical associations as compared with those who report more global forms of pain.
Sexual function in men is closely connected with pelvic pain and pelvic floor function. Men with pelvic pain are more likely to report erectile dysfunction and premature ejaculation.[19,20] In turn, sexual dysfunction is associated with LUTS.[21] The SciCOM cohort has shown clustering of young men with LUTS having pain with erectile dysfunction and premature ejaculation.[4] This study analyzed pain as mutually exclusive categories based on bladder and nonbladder pain and noted an association with premature ejaculation but not with erectile dysfunction. Those without any pain were least likely to report premature ejaculation as compared with those who reported any form of pain.
This study found an association between stool consistency and pain in young men presenting with LUTS. As reported earlier, SciCOM 3 data showed that loose stools might be a key finding in young men presenting with LUTS and a marker for a more severe presentation.[22] Analysis of pain suggests that men with LUTS who also complain of nonbladder pain are particularly likely to report loose stools. Patients with irritable bowel syndrome are more likely to report myofascial pain, and an association has been described with chronic prostatitis and pelvic pain.[23] Accordingly, myofascial manipulations have been shown to help resolve some of these symptoms.[24] The clinical constellation of generalized pain and irritable bowel symptoms also shows an association with poor mental health and impaired quality of life.[25] Depression was the most common psychiatric morbidity reported in patients with fibromyalgia and irritable bowel syndrome. As has been noted earlier, the BSC does not allow for making a specific diagnosis of the underlying bowel condition. Hence, it is uncertain what proportion of men reporting loose stools might have been suffering from irritable bowel syndrome.[7]
There are several potential mechanisms that might explain an association between pain and LUTS. Pelvic pain could interact with LUTSs through a variety of cross-talk mechanisms, including neuronal cross-sensitization at the peripheral neural, spinal central, and supraspinal central levels, as well as several nonneuronal mechanisms.[26] There is an association between pelvic pain, overactive pelvic floor, and LUTS, both storage and voiding.[27,28,29] Such associations also interact with mental health.[30,31] An association has been noted between pain of fibromyalgia, anxiety, and autonomic dysfunction.[32] Patients with affective disorders might be particularly at risk. In some of these patients, adverse childhood experiences might underpin both the LUTS as well as the pain through mechanisms that include but are not limited to mental health.[33] Patients with pelvic myofascial pain have increased risks of presenting with rectal evacuation disorders and with resultant impact on LUTS.[26,34] Pelvic ischemia could potentially play a role in both the pathogenesis of pain as well as LUTS, although this might be less likely in a cohort of young adults.[35]
This study made no attempt to arrive at a specific diagnosis of chronic prostatitis. However, patients who presented with a chief complaint of discomfort or pain did not fulfil the inclusion criteria for entry. It is conceivable that some men with chronic prostatitis might present primarily with LUTS rather than pain. However, in many men, the link between the prostate, LUTS, and pain is tenuous. This often leads to marked differences in the diagnostic labels across different centers. In fact, similar symptoms can be seen in women. In the absence of a clear definition of what constitutes chronic prostatitis, men often get a diagnosis of chronic prostatitis for symptoms that are diagnosed with bladder pain syndrome in women.[36,37] Pain is also associated with LUTS in children.[38] It is conceivable that in applying a label of chronic prostatitis to men with LUTS and pain, the association of pain in men presenting with LUTS has largely been ignored.
There are other caveats to this work. Patients who had a primary complaint of pain rather than LUTS would not have qualified for inclusion. The authors made no attempt to distinguish pelvic pain from nonpelvic pain. Given the large amount of data being collected from these subjects and the complexity of distinguishing pelvic from nonpelvic pain on a simple questionnaire, all nonbladder pain was assessed using a composite score using a VAS. SciCOM 3 was largely based on validated questionnaires for assessment. As such, the use of such questionnaires in clinical practice remains low, resulting in difficulties in translating the results into patient care.[39] Data were analyzed with regard to the location of pain rather than its severity. As is common with secondary analyses, SciCOM 3 was not specifically designed to examine pain in young men with LUTS. Accordingly, the sample size was powered based on the prevalence of LUTS in the general population of young men, rather than the prevalence of pain. No specific workup for chronic prostatitis was done for these men. However, the evaluation excluded a regular UTI or other acute conditions that might have accounted for pain. While it is uncertain what proportion of these patients would receive a final diagnosis of bladder pain syndrome, it is conceivable that many of these patients might have had a component of idiopathic bladder or nonbladder pain.
CONCLUSIONS
Pain is commonly reported by young men presenting with LUTS. Pattern of pain in LUTS is associated with distinct clinical epidemiology, including both storage and voiding LUTS, with impact on bother and quality of life. It is important to assess pain in young men presenting with LUTS.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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