ORIGINAL ARTICLE

Health-related quality of life and psychological well-being in patients

with benign prostatic hyperplasia
Julian Dong Oh Pinto, Hong-Gu He, Sally Wai Chi Chan, Poh Choo Toh, Kesavan Esuvaranathan
and Wenru Wang

Aims and objectives. To examine the health-related quality of life and psychologi- What does this paper contribute
cal well-being of patients with benign prostatic hyperplasia and identify the pre- to the wider global clinical
dictive factors of health-related quality of life. community?
Background. Benign prostatic hyperplasia is highly prevalent in ageing men and The results of this study show
causes bothersome lower urinary tract symptoms, which has a negative impact on that patients with benign pros-
their health-related quality of life. The current practice of managing benign pros- tatic hyperplasia (BPH) suffered
tatic hyperplasia focuses on relieving physical symptoms. However, the impact of poor health-related quality of life
benign prostatic hyperplasia on the patients health-related quality of life and psy- (HRQoL) compared with a nor-
mative population. Specifically,
chological well-being remains understudied, especially in the Asian population.
their psychological HRQoL was
Design. A descriptive correlational survey study. more severely impaired com-
Methods. A convenience sample of 97 patients with benign prostatic hyperplasia pared with their physical
was recruited at an outpatient urology clinic of a tertiary hospital in Singapore. HRQoL.
The health-related quality of life, lower urinary tract symptoms and psychological The study identified postvoid
residual urine (PVRU), bother-
well-being of the participants were assessed using the 12-item Short-Form Health
some lower urinary tract symp-
Survey, International Prostate Symptom Score and the Hospital Anxiety and toms (LUTS), anxiety and
Depression Scale, respectively. depression to be significant pre-
Results. The health-related quality of life scores were low with physical and men- dictive factors of HRQoL of
tal health component scores of 47
0 and 48
9, respectively, as assessed by the 12- patients with BPH.
item Short-Form Health Survey. There was a high prevalence of anxiety (10
3%) Due to the ageing population in
the near future, the prevalence of
and depression (21
6%). Correlation analysis revealed significantly negative rela-
BPH is expected to increase dra-
tionships between lower urinary tract symptoms, anxiety, depression and physical matically. Therefore, there is an
and mental health dimensions of the 12-item Short-Form Health Survey. Multiple urgent need to use the findings
linear regression analysis further identified that postvoid residual urine and lower from this study in the develop-
urinary tract symptoms were predictive factors of the physical health dimension, ment and implementation of
effective and culturally sensitive
whereas anxiety and depression were predictive factors of the mental health
interventions to improve the
dimension of the 12-item Short-Form Health Survey. HRQoL and psychological well-
Conclusions. The health-related quality of life of patients with benign prostatic being of patients with BPH.
hyperplasia was poor, and their psychological well-being was severely affected.

Authors: Julian Dong Oh Pinto, BSN (Honours), Bachelor of
Science Student, Alice Lee Centre for Nursing Studies, Yong Loo
Lin School of Medicine, National University of Singapore; Hong-
Gu He, PhD, Assistant Professor, Alice Lee Centre for Nursing
Studies, Yong Loo Lin School of Medicine, National University of
Singapore; Sally Wai Chi Chan, PhD, Professor, Alice Lee Centre
for Nursing Studies, Yong Loo Lin School of Medicine, National
University of Singapore; Poh Choo Toh, BSN, Advanced Practice
Nurse, Department of Urology, University Surgical Cluster,
National University of Hospital; Kesavan Esuvaranathan, FAMS
(Urol), MD, Professor, Department of Urology, University Surgical
Cluster, National University of Hospital; Wenru Wang, PhD, Assis-
tant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin
School of Medicine, National University of Singapore, Singapore,
Singapore
Correspondence: Wenru Wang, PhD, Assistant Professor, 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, Singapore. Telephone: +65-6601 1761.
E-mail: nurww@nus.edu.sg

2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 511522, doi: 10.1111/jocn.12636 511
JDO Pinto et al.

Postvoid residual urine, lower urinary tract symptoms, anxiety and depression
were identified to be significant predictive factors of the health-related quality of
life of patients with benign prostatic hyperplasia.
Relevance to clinical practice. Findings from this study provide useful evidence-
based information for healthcare professionals in the development and imple-
mentation of effective and culturally sensitive interventions to improve the
health-related quality of life and psychological well-being of patients with benign
prostatic hyperplasia.

Key words: benign prostatic hyperplasia, health-related quality of life, predictors,

psychological well-being

Accepted for publication: 13 April 2014

HRQoL of men with BPH. It is therefore critical to also

Introduction
Benign prostatic hyperplasia (BPH) is a chronic condition
that predominantly affects ageing men worldwide regardless
of culture or ethnic origin (Roehrborn 2011a). A large pro-
portion of BPH men eventually develop bothersome lower
urinary tract symptoms (LUTS), which present with symp-
toms of incomplete bladder emptying, frequency, intermit-
tency, urgency, weak urinary stream, hesitancy and nocturia
(Barry et al. 1992). It is estimated that one-quarter of men in
their 50s, one-third of men in their 60s and over half of all
men 80 years and above suffer from moderate-to-severe
LUTS due to BPH (De La Rosette 2000, Roehrborn 2011b).
Previous studies have consistently reported on the nega-
tive impact of LUTS on the health-related quality of life
(HRQoL) of men with BPH (Garraway & Kirby 1994, Gir-
man et al. 1994, Sagnier et al. 1995, Peters et al. 1997,
Eckhardt et al. 2001, Van Dijk et al. 2009). It is believed
that successful management of BPH is a cooperative effort
between healthcare professionals and the patient aimed at
reducing the impact of LUTS on the HRQoL of patients
with BPH (Browne 1999). Due to advanced treatment in
patients with BPH, BPH-related mortality rates have
decreased tremendously, but the HRQoL still remains to be
improved (Rossetti 2001, Fourcade et al. 2012). HRQoL is
a complex multidimensional concept that encompasses both
physical and psychological health; both domains are signifi-
cant indicators of health (Centers for Disease Control &
Prevention [CDC] 2000). The current management of BPH
focuses predominantly on medical therapy and surgical
interventions, which are primarily concerned with physical
aspects of patients with BPH. There have been few studies
performed that explored the psychological well-being of
patients with BPH; much is yet to be understood about the
psychological well-being and predictive factors of low
consider the psychological well-being of patients with BPH
and recognise its possible contribution to HRQoL.
Background
Health-related quality of life is a subjective sense of overall
well-being and satisfaction with health and is determined
by perceptions of physical and mental health (CDC 2000,
Ferrans et al. 2005). HRQoL is becoming an important fac-
tor to be considered in the management of illnesses. Previ-
ously, management of illness focused mainly on physical
parameters, which are now clearly insufficient in improving
a patients overall HRQoL. The impact caused by illnesses
and effects of treatment on the psychological and social
aspects of the patients health should also be considered.
This is especially relevant to BPH, as one of the main indi-
cators for treatment is the degree of bothersome LUTS on
the patients HRQoL (Browne 1999, Batista-Miranda et al.
2001).
Over the past decade, both generic and disease-specific
HRQoL tools have been used to measure HRQoL in men
with BPH. Generic HRQoL tools tend to measure the over-
all HRQoL, for example the 12-item Short-Form Health
Survey (SF-12) and 36-item Short-Form Health Survey (SF-
36). It has been criticised that generic HRQoL instruments
are not sensitive enough to detect significant changes in
men with BPH (Batista-Miranda et al. 2001). Therefore,
disease-specific HRQoL instruments have been developed to
be more sensitive to the specific condition it measures, and
the most commonly used tool for patients with BPH is the
International Prostate Symptom Score (IPSS; Barry et al.
1992, Lawrence 1996).
In terms of the disease-specific HRQoL of men with
BPH, several studies from the literature reported the mean

2014 John Wiley & Sons Ltd

512 Journal of Clinical Nursing, 24, 511522
Original Article
scores for the IPSS quality of life (QoL; Hutchison et al.
2006, Suzuki et al. 2006, Roehrborn et al. 2007, H ofner
et al. 2010, Komiya et al. 2010, Montorsi et al. 2010).
Using the mean IPSS QoL scores reported in these studies,
men had satisfied-to-mixed feelings (Barkin et al. 2009),
mixed-to-dissatisfied feelings (Roehrborn et al. 2007,
Hofner et al. 2010, Montorsi et al. 2010) and dissatisfied-
to-unhappy feelings (Suzuki et al. 2006, Komiya et al.
2010). This highlighted a lack of consistency in the QoL of
men with BPH. From the literature, four studies were found
to compare the HRQoL of men with BPH with men from
the general population using generic HRQoL tools. Among
these studies, one study compared the HRQoL with a con-
trol group, while the other three studies compared the
HRQoL with scores from the national norm (Jakobsson
et al. 2004, Suzuki et al. 2006, Roehrborn et al. 2007, Ko-
miya et al. 2010). Results from these studies suggested that
the HRQoL in men with BPH was significantly poorer
when compared to men from the general population.
Furthermore, the psychological well-being of men with
BPH has not been well studied. Very limited studies
assessed the psychological well-being of men with BPH.
From the literature, only two studies have been conducted
to investigate the risk of patients with BPH experiencing
depression symptoms (Clifford & Farmer 2002, Huang
et al. 2011). These studies reported a relationship between
depression and BPH. However, both studies used secondary
data from databases instead of primary sources. Hence, the
integrity of data obtained may be compromised.
To the best of the researchers knowledge, no studies have
explored the relationship between HRQoL and psychologi-
cal well-being of men with BPH. This may not be surprising
due to the miniscule amount of attention towards the psy-
chological well-being of men with BPH. Additionally, no
studies have explored the influence of lifestyle factors and
socio-demographic and clinical characteristics on the
HRQoL of men with BPH. This, despite these factors, has
been reported to affect the HRQoL of patients with other
chronic diseases (Wang et al. 2014). Hence, the aims of this
study were to examine the HRQoL and psychological well-
being of patients with BPH and the relationship between
these variables and identify the predictive factors of HRQoL.
Materials and methods
Study design and sample
This was a cross-sectional descriptive correlational study.
A convenience sample was recruited from an outpatient
urology clinic of a tertiary hospital in Singapore. Patients
2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 511522
HRQoL in patients with BPH
aged 21 years or older with a clinical diagnosis of BPH and
who were able to communicate in English were invited to
participate. Those who had previous prostate surgery, a
known history of major psychiatric illness or a severe physi-
cal disorder (e.g. cancer) were excluded.
The sample size was calculated based on the multiple lin-
ear regression analysis. Based on the literature (Roehrborn
2011a,b, Foottit & Anderson 2012, Lim et al. 2012), we
anticipated five variables age, smoking status, LUTS,
anxiety and depression that will affect the HRQoL of
men with BPH. To achieve a medium effect size, 80%
power at 0
05 significance level (two-sided), a minimum of
91 participants is needed (Cohen 1988). A total of 97 par-
ticipants were finally recruited in our study.
Research instruments
12-item Short-Form Health Survey (SF-12)
The SF-12 measures overall HRQoL by assessing both
physical and mental health domains, and the scores are
summarised into a physical component summary (PCS) and
mental component summary (MCS), respectively (Ware
et al. 1996, 2009). These summary scores are derived from
weighted summed scores of eight subscales: general health,
physical functioning, role limitations due to physical health,
bodily pain, vitality, role limitations due to emotional prob-
lems, mental health and social function (Ware et al. 1996).
Each subscale score ranges from 0100, with a higher score
indicating better quality of life (Ware et al. 1996). The SF-
12 has demonstrated acceptable reliability with Cronbachs
a of 0
77 for the PCS and 0
80 for the MCS (Luo et al.
2003). In this study, the internal consistency of the PCS
and MCS subscales was acceptable with Cronbachs a of
0
80 and 0
79, respectively.
International Prostate Symptom Score
The IPSS was developed to assess the severity of LUTS by
measuring the magnitude of urinary disturbance experi-
enced by patients with BPH and their disease-specific QoL
(Barry et al. 1992, Lawrence 1996, Liao et al. 2011), which
consisted of seven items that measure the severity of LUTS
and one item that assesses the disease-specific HRQoL
(Barry et al. 1992). The severity of LUTS as measured by
the IPSS ranges from 035 and can be categorised into mild
(07), moderate (819) and severe (2035) symptom sever-
ity. The IPSS QoL score ranges from 06, where 0 repre-
sents the best possible HRQoL and 6 represents the worst
possible HRQoL resulting from LUTS. The IPSS has been
used in exploratory and interventional studies to quantify
LUTS severity and disease-specific HRQoL of patients with
513
JDO Pinto et al.
LUTS (Rossetti 2001, Montorsi et al. 2010). It has demon-
strated good internal consistency and testretest reliability
with Cronbachs a of 0
86 and intraclass correlation coeffi-
cient (ICC) of 0
92 (Barry et al. 1992). Analysis of the IPSS
in this study revealed that the IPSS had acceptable internal
consistency with Cronbachs a of 0
78.
Hospital Anxiety and Depression Scale
The Hospital Anxiety and Depression Scale (HADS) was
developed to assess the presence of anxiety or depression in
patients who were physically ill (Zigmond & Snaith 1983).
It is a 14-item tool with anxiety (HADS-A) and depression
subscales (HADS-D). Both HADS-A and HADS-D subscales
have seven items that give a score ranging from 021 for
each scale. A case of anxiety or depression was defined by
a score of 8 or more on their respective subscale (Bjelland
et al. 2002). The HADS has demonstrated good internal
consistency with Cronbachs a ranging from 0
790
85 for
the total and two subscales (Woolrich et al. 2006).
Socio-demographic and clinical data sheets
A socio-demographic characteristics sheet was constructed
to collect data of participants age, marital status, monthly
household income, educational level, employment status
and ethnicity. A clinical data sheet was constructed to col-
lect data of the length of BPH diagnosis, smoking status,
medication treatment, uroflowmetry results, postvoid resid-
ual urine (PVRU) and prostate-specific antigen (PSA) levels.
Data collection procedure
Upon the ethical approval, the researcher (PJDO) worked
together with a nurse at the urology clinic to review
patients using the centralized patient support System and
outpatient medical records to identify potential participants.
The researcher then approached the potential participants
and invited them to participate in the study. The partici-
pants were given a detailed explanation of the study using
a participant information sheet, which documented the aim,
procedure, potential threats and benefits, before obtaining a
written informed consent. On acceptance to participate in the
study, the participants were invited to complete the SF-12,
IPSS and HADS; their socio-demographic information and
clinical data were also collected. The whole process took
about 20 minutes.
Ethical consideration
Ethical approval was obtained from the National Health-
care Group Domain Specific Review Board in Singapore.
514
The patients were informed that their participation in this
study was completely voluntary and they could withdraw
from the study at any time. The participants were given
ample time to consider participating in the study without
any pressure from the researcher. Their personal informa-
tion such as name and identification number was not
recorded to maintain their privacy and anonymity. Data
were securely locked and kept confidential, while access to
the data was only granted to the investigators of this study.
Data analysis
The IBM SPSS 20.0 (Armonk, NY, USA) was used for data
analysis. Descriptive statistics were used to summarise and
describe all the data. Mean and standard deviation were
used to describe continuous data, while frequency and
percentages were used to describe categorical data. Differ-
ences in HRQoL, LUTS and psychosocial well-being among
subgroups of socio-demographics and clinical data were
examined using either independent t-test for two groups or
one-way analysis of variance (ANOVA) for three or more
groups. The linear association between HRQoL, LUTS and
psychological well-being was analysed using Pearsons
productmoment correlation. Multiple linear regression
analysis using an enter method was conducted to determine
the predictors of PCS and MCS of SF-12, which were
entered as the two main dependent variables. All the poten-
tial predictive factors that demonstrated significant correla-
tions with PCS or MCS (i.e. p < 0
05) were included in the
multiple linear regression analysis to determine the predictive
factors of HRQoL. The level of significance of all statistical
tests performed was set at p < 0
05 and two-tailed.
Results
Of the 121 participants approached during a four-month
period of data collection from October 2012February
2013, a total of 99 (81
8%) participants were recruited and
22 excluded, because they either refused to participate or
did not meet the inclusion criteria. Two participants were
excluded from data analysis due to extensively incomplete
questionnaires, leaving the final sample size to 97 partici-
pants.
The socio-demographic and clinical characteristics of the
participants are summarised in Table 1. The median age of
the participants was 67
0 years (range: 5087 years). The
majority of the participants were 65 years (68
0%) and
married (94
8%). The highest education level of the most
participants was secondary education (48
5%), and over
half of the participants (62
9%) reported that the monthly
2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 511522
Original Article HRQoL in patients with BPH

Table 1 Socio-demographic and clinical characteristics of participants (n = 97)

Socio-demographic data (%) Clinical data (%)

Age Ex-smoking
<65 years 31 (32) Yes 41 (42
3)
65 years 66 (68) No 56 (57
7)
Marital status Current smoking
Married 92 (94
8) Yes 14 (14
4)
Unmarried* 5 (5
2) No 83 (85
6)
Educational level Medications
Primary or Lower 30 (30
9) None 17 (17
5)
Secondary 47 (48
5) Alpha-blockers 56 (57
7)
Tertiary 20 (20
6) Alpha-reductase inhibitors 6 (6
2)
Employment status Combination therapy 18 (18
6)
Employed 44 (45
4) PSA level
Unemployed 53 (54
6) Mean (SD) 2
6 (1
9)
Monthly household income (SGD) Maximum flow rate (Qmax)
<1000 28 (28
9) Low flow rate (15 ml/second) 73 (75
3)
10013000 33 (34) Normal flow rate (>15 ml/second) 24 (24
7)
30015000 20 (20
6) Mean (SD) 12
3 (6
2)
>5000 15 (15
5) Postvoid residual urine
Ethnicity Normal PVRU (100 ml) 87 (89
7)
Chinese 83 (85
6) High PVRU (>100 ml) 10 (10
3)
Malay 4 (4
1) Mean (SD) 43
2 (65
1)
Indian 8 (8
2)
Others 2 (2
1)

SGD, Singapore dollar (one Singapore dollar = 0
83 US dollar); PSA, prostate-specific antigen; PVRU, postvoid residual urine.
*Unmarried participants were either widowed or divorced.

Tertiary education comprises those received from junior college, polytechnic or institute of technical education.

Combination therapy denotes treatment with at least one of both alpha-blocker and alpha-reductase inhibitor.

household income was less than Singapore dollar (SGD)

3000 (i.e. 2500 USD). In terms of clinical characteristics, the Table 2 Mean, standard deviation and range of domains of SF-12,
IPSS and HADS (n = 97)
median length of BPH diagnosis was 14
0 months (range: 1
240 months) and the mean PSA level was 2
6 ng/ml Domains Mean (SD) Range
(SD = 1
9). A majority of the participants had a low maxi- SF-12
mum flow rate (Qmax) of 15 ml/second and normal PVRU Physical component summary 47
0 (8
2) 25
061
0
of 100 ml. Almost half of the participants had a history of General health 41
8 (10
0) 23
963
7
smoking (42
3%), and some were still smoking (14
4%). Physical function 48
2 (9
6) 25
657
1
Table 2 presents the mean, standard deviation and range Role physical 48
8 (8
6) 23
657
5
Bodily pain 47
7 (10
0) 21
757
7
of the subdomains of SF-12, IPSS and HADS. The mean
Mental component summary 48
9 (7
9) 30
567
4
SF-12 PCS score was 47
0 (SD = 8
2), whereas the mean Vitality 50
9 (9
2) 29
468
7
SF-12 MCS score was 48
9 (SD = 7
9). The IPSS symptom Social function 49
4 (8
7) 30
256
9
score ranged from 1
034
0, with a mean of 12
6 Role emotional 46
8 (9
3) 14
756
3
(SD = 7
5), indicating moderate symptom severity. Half of Mental health 48
7 (8
8) 24
164
2
IPSS
the participants reported moderate symptom severity
IPSS total score 12
6 (7
5) 1
034
0
(n = 49, 50
5%), and nearly one-fifth suffered severe symp- IPSS quality of life score 3
3 (1
5) 0
06
0
tom (n = 19, 19
6%). The IPSS QoL score ranged from HADS
0
06
0, with a mean of 3
3 (SD = 1
5), indicating a mixed- HADS anxiety 4
1 (3
3) 0
014
0
to-dissatisfied HRQoL due to their LUTS. For the anxiety HADS depression 4
8 (3
6) 0
014
0
and depression as measured by the HADS, the mean scores SF-12, 12-item Short-Form Health Survey; IPSS, International Pros-
were 4
1 (SD = 3
3) and 4
8 (SD = 3
6), respectively. Using tate Symptom Score; HADS, Hospital Anxiety and Depression
the cut-off point of 8 as recommended by Bjelland et al. Scale.

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Journal of Clinical Nursing, 24, 511522 515
JDO Pinto et al.

(2002), ten participants (10
3%) experienced anxiety symp-
toms, while over one-fifth (21
6%) were found to experi-
ence depressive symptoms.
The differences between PCS, MCS, IPSS symptom, IPSS
QoL, HADS-A and HADS-D mean scores among different
groups of socio-demographic and clinical characteristics are
presented in Table 3. The participants who were younger
than 65 years or who were employed scored a significantly
higher PCS score compared with those who were older than
65 years (p < 0
05) or who were unemployed (p < 0
05).
The participants who were ex-smokers or current smokers
reported significantly poorer IPSS QoL as compared to their
counterparts (p < 0
05). In addition, the participants with
normal PVRU of 100 ml had significantly better PCS
scores as compared to participants who had poorer PVRU
of >100 ml (p < 0
05).

Table 3 Comparison of mean scores of SF-12, IPSS and HADS among different socio-demographic and clinical subgroups

SF-12 IPSS HADS

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

Age
<65 years (n = 31) 49
4 (6
4) 48
7 (8
3) 13
5 (7
5) 3
7 (1
5) 4
5 (3
6) 4
4 (2
3)
65 years (n = 66) 45
9 (8
8) 49
0 (7
8) 12
2 (7
5) 3
1 (1
4) 3
8 (3
2) 5
0 (3
8)
t 2
23 0
18 0
79 2
03 0
88 0
83
p-value 0
03* 0
86 0
43 0
04* 0
38 0
41
Education level
Primary or lower (n = 30) 46
0 (9
3) 47
2 (8
6) 13
6 (8
5) 3
5 (1
5) 3
8 (3
6) 5
6 (4
0)
Secondary (n = 47) 46
9 (7
9) 48
8 (7
9) 11
8 (7
1) 3
4 (1
5) 4
1 (3
3) 4
7 (3
5)
Tertiary (n = 20) 48
7 (7
3) 51
6 (6
4) 12
9 (6
9) 2
8 (1
3) 4
5 (3
0) 4
0 (2
9)
F 0
63 1
88 0
57 1
67 0
26 1
3
p-value 0
54 0
16 0
57 0
19 0
78 0
28
Employment status
Employed (n = 44) 49
1 (7
0) 49
4 (8
3) 13
0 (7
9) 3
3 (1
5) 4
0 (3
5) 4
6 (3
8)
Unemployed (n = 53) 45
2 (8
8) 48
5 (7
7) 12
2 (7
1) 3
3 (1
4) 4
1 (3
2) 5
0 (3
4)
t 2
37 0
57 0
53 0
19 0
78 0
58
p-value 0
02* 0
57 0
60 0
85 0
94 0
56
Income (S$)
<1000 (n = 28) 47
2 (8
1) 51
0 (7
8) 11
5 (5
5) 3
2 (1
5) 3
4 (2
7) 5
0 (3
6)
10013000 (n = 33) 46
0 (8
6) 48
0 (7
4) 13
6 (8
8) 3
4 (1
4) 4
3 (3
6) 5
3 (3
6)
30015000 (n = 20) 45
7 (9
4) 48
7 (7
8) 12
3 (7
4) 3
3 (1
4) 3
7 (2
9) 4
7 (3
9)
>5000 (n = 15) 49
6 (5
3) 47
3 (9
3) 13
3 (7
8) 3
5 (1
7) 5
3 (3
7) 3
9 (3
0)
F 0
81 0
98 0
45 0
21 1
3 0
58
p-value 0
49 0
40 0
72 0
89 0
29 0
63
Ex-smoking
Yes (n = 41) 45
4 (9
4) 48
0 (7
2) 14
3 (7
3) 3
6 (1
3) 4
5 (3
3) 5
4 (3
8)
No (n = 56) 48
1 (7
1) 49
6 (8
4) 11
3 (7
4) 3
0 (1
5) 3
6 (3
2) 4
4 (3
4)
t 1
57 1
01 1
93 2
21 1
31 1
34
p-value 0
12 0
32 0
57 0
03* 0
19 0
19
Current smoking
Yes (n = 14) 44
0 (7
9) 48
1 (6
7) 14
4 (6
4) 4
6 (1
1) 5
0 (3
9) 6
1 (3
8)
No (n = 83) 47
5 (8
3) 48
8 (8
0) 12
4 (7
6) 3
1 (1
4) 4
0 (3
2) 4
7 (3
6)
t 1
33 0
27 0
85 3
37 0
98 1
24
p-value 0
18 0
79 0
40 0
002** 0
33 0
21
Postvoid residual volume
100 ml (n = 87) 47
6 (7
8) 49
0 (7
9) 12
2 (7
1) 3
3 (1
5) 4
0 (3
2) 4
7 (3
5)
>100 ml (n = 10) 41
2 (10
2) 47
9 (7
9) 16
0 (10
4) 3
4 (1
4) 4
1 (3
9) 5
8 (4
0)
t 2
40 0
44 1
13 0
21 0
05 0
91
p-value 0
02* 0
66 0
28 0
84 0
96 0
37

t, independent t-test; F, one-way ANOVA; SF-12, 12-item Short-Form Health Survey; IPSS, International Prostate Symptom Score; HADS,
Hospital Anxiety and Depression Scale; PCS, physical component summary; MCS, mental component summary; QoL, quality of life.
*Significance at p < 0
05.
**Significance at p < 0
01.

2014 John Wiley & Sons Ltd

516 Journal of Clinical Nursing, 24, 511522
Original Article HRQoL in patients with BPH

Table 4 reports the Pearsons correlations between PCS,
MCS, IPSS symptom, IPSS QoL, HADS-A and HADS-D
scores. The SF-12 PCS and the SF-12 MCS scores were found
to be negatively correlated with IPSS symptom (p < 0
01)
and IPSS QoL (p < 0
05) scores. These correlations were
found to be significant but weak (r = 0
24 to 0
34). The
SF-12 PCS and MCS scores also demonstrated significant
negative correlations with HADS-A (p < 0
01) and HADS-D
(p < 0
01) scores. In addition, the IPSS symptom and QoL
scores had weak, but significantly positive correlations with
HADS-A (p < 0
01) and HADS-D (p < 0
01) scores.
Two separate multiple linear regression analyses were
run using the PCS and MCS of SF-12 as the dependent vari-
ables. A total of eight variables (i.e. age, employment sta-
tus, PVRU, ex-smoking, current smoking, IPSS symptom,
HADS-A and HADS-D) were entered as independent vari-
ables, guided by prior statistical analyses (i.e. results from
Tables 3 and 4) and the current literature. Of these eight
factors used as independent variables, only PVRU
(p = 0
04) and IPSS symptom (p = 0
03) were identified as
significant predictive factors of the PCS of SF-12, which
accounted for 27
1% of the variance. The statistical
assumptions were satisfied given the tolerance level of col-
linearity diagnostic being ranged from 0
600
91 for the
eight independent variables and unstandardised residual
being normally distributed (p = 0
20).
Using the above eight factors as independent variables,
HADS-A and HADS-D were found to be significant predic-
tive factors of the MCS of SF-12, accounting for 31
0% of
the variance (Table 5). The tolerance level of collinearity
diagnostic for the independent variables ranged from 0
61
0
92, and unstandardised residual was also normally
distributed (p = 0
20), indicating the statistical assumptions
of regression analysis being satisfied.

Table 4 Correlation between SF-12, IPSS and HADS domains

Domains SF-12 PCS SF-12 MCS IPSS symptom IPSS QoL HADS-A HADS-D

SF-12 PCS 1
00

SF-12 MCS 0
14 1
00
IPSS symptom 0
34** 0
30** 1
00
IPSS QoL 0
25* 0
24* 0
50** 1
00
HADS anxiety 0
29** 0
46** 0
38** 0
33** 1
00
HADS depression 0
36** 0
45** 0
38** 0
25* 0
56** 1
00

SF-12, 12-item Short-Form Health Survey; IPSS, International Prostate Symptom Score; HADS, Hospital Anxiety and Depression Scale; PCS,
physical component summary; MCS, mental component summary; QoL, quality of life.
*Significance at p < 0
05.
**Significance at p < 0
01.

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

PCS of SF-12 MCS of SF-12

Standard Standard
Independent variables B error t p-value 95% CI for B B error t p-value 95% CI for B

Age 0
15 0
14 1
08 0
28 0
41 to 0
12 0
03 0
13 0
25 0
80 0
23 to 0
29
Employment status 3
05 1
82 1
67 0
09 6
67 to 0
52 0
67 1
78 0
38 0
71 4
20 to 2
86
Postvoid residual urine 0
02 0
01 2
05 0
04* 0
05 to 0
00 0
01 0
01 0
58 0
56 0
02 to 0
03
Ex-smoking 0
98 1
75 0
56 0
57 4
45 to 2
49 0
46 1
70 0
27 0
79 2
92 to 3
84
Current smoking 4
45 2
57 1
73 0
08 0
66 to 9
56 1
31 2
50 0
52 0
60 6
28 to 3
67
IPSS symptom 0
26 0
11 2
25 0
03* 0
49 to 0
03 0
09 0
11 0
83 0
41 0
32 to 0
13
HADS anxiety 0
39 0
29 1
36 0
18 0
97 to 0
18 0
59 0
28 2
08 0
04* 1
15 to 0
03
HADS depression 0
32 0
27 1
18 0
24 0
85 to 0
22 0
60 0
26 2
29 0
02* 1
12 to 0
08
R2 = 27
1% R2 = 31
0%

SF-12, 12-item Short-Form Health Survey; IPSS, International Prostate Symptom Score; HADS, Hospital Anxiety and Depression Scale; PCS,
physical component summary; MCS, mental component summary.
*Significance at p < 0
05.
**Significance at p < 0
01.

0 = not employment, 1 = employment.

0 = yes, 1 = no.

2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 511522 517
JDO Pinto et al.
Discussion
Our study indicates that over half of the patients with BPH
experienced a moderate severity of LUTS and nearly one-
fifth suffered a severe symptom of LUTS, which is in line
with the previous studies conducted in other countries
(Hutchison et al. 2006, Suzuki et al. 2006, Roehrborn
et al. 2007, H ofner et al. 2010, Komiya et al. 2010,
Montorsi et al. 2010). LUTS severity, as measured by IPSS,
significantly correlated with the physical health dimension
of SF-12 and was found to be a significant predictor of
physical health. In addition, a weak but significant relation-
ship between LUTS severity and the SF-12 mental health
dimension indicated that patients with severe LUTS experi-
enced poorer psychological well-being. A significant positive
correlation between LUTS with HADS-A and HADS-D fur-
ther suggested that the LUTS significantly affects patients
psychological status. This suggested that participants in this
study with severe LUTS reported higher levels of anxiety
and depression. This is in line with the previous studies that
reported a significant relationship between LUTS severity
and poorer psychological well-being (Gannon et al. 2005,
Wong et al. 2006). Our study further confirmed that LUTS
is the most significant predictor of low HRQoL for men
with BPH.
The IPSS QoL measured patients disease-specific HRQoL
based on their current LUTS severity. Participants from this
study reported that they had mixed-to-dissatisfied feelings
towards their LUTS. This is consistent with the previ-
ous studies conducted worldwide, which generally reported
a similar and consistent score range (Hutchison et al. 2006,
Suzuki et al. 2006, H ofner et al. 2010, Komiya et al. 2010,
Montorsi et al. 2010). The SF-12 was used to assess the gen-
eral HRQoL of participants, and both PCS and MCS mean
scores were lower than 50, which suggests that the HRQoL
of men with BPH was lower than average (Wee et al. 2010).
Roehrborn et al. (2007) conducted a population-based study
(n = 6, 609) in the USA on patients with BPH and reported
the PCS and MCS scores to be 47
4 and 52
2, respectively.
This indicates that the PCS scores between patients with
BPH from the USA and Singapore where the present study
was conducted were similar. However, the MCS scores were
found to be different with the participants in our study being
reported poorer psychological well-being than their counter-
parts in the USA. This could be due to the differences in
social, cultural and economic context between Singapore
and the USA.
The HADS-A and HADS-D scores were screened for
cases of anxiety and depression in patients, respectively.
The results of our study revealed that 10
3% of patients
518
with BPH experienced anxiety and an alarming 21
6% suf-
fered depression. The psychological well-being of men with
BPH has not been well studied previously, and to the best
of the researchers knowledge, none of the previous studies
have used the HADS to assess the psychological well-being
of patients with BPH. However, a couple of previous
studies had demonstrated the risk of the development of
depression in patients with BPH (Clifford & Farmer 2002,
Huang et al. 2011). Clifford and Farmer (2002) conducted
a retrospective study in the UK and reported that men with
BPH had a 1
382
09 times higher risk of developing
depression as compared to those without BPH. Another
study conducted in Taiwan reported similar results, where
Taiwanese men with BPH had a 1
87 times higher risk of
developing depression within a one-year period following
diagnosis (Huang et al. 2011). Although there were limited
studies pertaining to the psychological well-being of
patients with BPH, the results of our study indicate that
patients with BPH had poorer psychological well-being and
depression seemed to be more prevalent.
Previous studies have identified that anxiety and depres-
sion predicted the HRQoL of the general population (Lim
et al. 2012) and people with chronic disease, for example
chronic kidney disease (Lee et al. 2013) and heart disease
(Wang et al. 2014). However, this has not been reported
for patients with BPH. The regression analysis results in
our study indicated that anxiety and depression were pre-
dictive factors of poorer mental health. This further high-
lights the importance of effectively managing anxiety and
depression for patients with BPH so as to improve their
HRQoL.
Older and unemployed patients with BPH reported sig-
nificantly poorer physical health, and this was consistent
with many other studies due to increased severity of disease
and/or the presence of multiple comorbidities among older
people (K ugler & Rudofsky 2005, Foottit & Anderson
2012, Kim et al. 2012). It also suggests that physical health
may play an important role in whether patients were able
to maintain a job. Men with better physical health would
thus be more likely to continue working as compared to
those who had poor physical health (Hultman et al. 2006,
Rueda et al. 2011). In our study, PVRU was identified as a
predictor of poor physical health. Our results showed that
patients who had an abnormal PVRU (i.e. >100 ml)
reported significantly poorer physical health as compared to
those who had normal PVRU. Abnormal PVRU is attribut-
able to several causes such as bladder dysfunction and
obstruction and is associated with higher risk of complica-
tions and poorer health outcomes (Ruud Bosch 1995, Kelly
2004). This further confirmed that patients with more
2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 511522
Original Article HRQoL in patients with BPH

severe urinary tract symptoms will experience poorer physi-
cal health.
According to the IPSS QoL scores, ex-smokers and current
smokers reported poorer disease-specific HRQoL scores as
compared to nonsmokers. This highlights the negative impact
of cigarette smoking on HRQoL of men with BPH. In fact,
cigarette smoking has been evidenced to cause an increase in
testosterone and oestrogen levels, which are believed to play
a role in the development of BPH (Matzkin & Soloway
1993, Platz et al. 1999, Roehrborn 2011a,b). Therefore,
smoking cessation is critical for patients with BPH.
Limitations and conclusions
There are several limitations in this study. First, the use of
convenience sampling from a single tertiary hospital may
cause sampling bias and limits the generalisability of the find-
ings. Caution must be exercised when extrapolating these
results to patients with BPH in other settings. Second, using
questionnaire surveys to evaluate the HRQoL, LUTS, anxiety
and depression of patients with BPH may cause response
bias. The sensitive and possible intrusive nature of this study
could have caused patients to respond with socially desirable
answers and understate the severity of their scores (Polit &
Beck 2010). Third, the sample size was slightly less than the
recommended number for the eventual number of predictive
variables, which was more than what was planned based on
the literature review. Finally, the multiple statistical tests
conducted (i.e. Table 3) may have inflated the type I error.
Nevertheless, this study provided new knowledge regard-
ing the HRQoL and psychological well-being of patients
with BPH in Singapore. The HRQoL of patients with BPH
was poor, and their psychological well-being was severely
affected. The PVRU, LUTS, anxiety and depression were
identified to be significant predictive factors of HRQoL of
patients with BPH.
interventions. However, even with these interventions, the
HRQoL and psychological well-being in some of these
patients remain poor, suggesting that other aspects of their
HRQoL might have been missed out. With the rapid
growth of the ageing population in Singapore, the preva-
lence of BPH is expected to increase. Therefore, there is
an urgent need to use the findings from this study in the
development and implementation of effective and cultur-
ally sensitive interventions to improve the HRQoL and
psychological well-being of patients with BPH. Due to the
chronic nature of BPH, management should not focus
solely on resolving the severity and presence of LUTS, but
also on the HRQoL and psychological well-being of BPH
patient. Findings from this study may provide useful
pointers for healthcare professionals to develop effective
and culturally sensitive interventions to improve the
HRQoL and psychological well-being of patients with
BPH.
Acknowledgements
We wish to acknowledge and extend our gratitude to the
patients who participated in this study and the doctors and
nurses who provided the support to this study. We would
also like to express our heartfelt thanks to Professor Roger
Watson for language editing this paper.
Disclosure
The authors have confirmed that all authors meet the IC-
MJE criteria for authorship credit (www.icmje.org/ethi-
cal_1author.html), as follows: (1) substantial contributions
to conception and design , acquisition of data, or analysis
and interpretation of data; (2) drafting the article or
revising it critically for important intellectual content
and (3) final approval of the version to be published.

Relevance to clinical practice Conflict of interest

The current management of BPH falls mainly within the The authors declare that they have no conflict of interests.
responsibility of doctors through medical and surgical

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