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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 470 and 489, respectively, as assessed by the 12- patients with BPH.
item Short-Form Health Survey. There was a high prevalence of anxiety (103%) Due to the ageing population in
the near future, the prevalence of
and depression (216%). 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 (Urol), MD, Professor, Department of Urology, University Surgical
Science Student, Alice Lee Centre for Nursing Studies, Yong Loo Cluster, National University of Hospital; Wenru Wang, PhD, Assis-
Lin School of Medicine, National University of Singapore; Hong- tant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin
Gu He, PhD, Assistant Professor, Alice Lee Centre for Nursing School of Medicine, National University of Singapore, Singapore,
Studies, Yong Loo Lin School of Medicine, National University of Singapore
Singapore; Sally Wai Chi Chan, PhD, Professor, Alice Lee Centre Correspondence: Wenru Wang, PhD, Assistant Professor, Alice Lee
for Nursing Studies, Yong Loo Lin School of Medicine, National Centre for Nursing Studies, Yong Loo Lin School of Medicine,
University of Singapore; Poh Choo Toh, BSN, Advanced Practice Level 2, Clinical Research Centre, Block MD 11, 10 Medical
Nurse, Department of Urology, University Surgical Cluster, Drive, Singapore 117597, Singapore. Telephone: +65-6601 1761.
National University of Hospital; Kesavan Esuvaranathan, FAMS E-mail:

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

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

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

scores for the IPSS quality of life (QoL; Hutchison et al. aged 21 years or older with a clinical diagnosis of BPH and
2006, Suzuki et al. 2006, Roehrborn et al. 2007, H ofner who were able to communicate in English were invited to
et al. 2010, Komiya et al. 2010, Montorsi et al. 2010). participate. Those who had previous prostate surgery, a
Using the mean IPSS QoL scores reported in these studies, known history of major psychiatric illness or a severe physi-
men had satisfied-to-mixed feelings (Barkin et al. 2009), cal disorder (e.g. cancer) were excluded.
mixed-to-dissatisfied feelings (Roehrborn et al. 2007, The sample size was calculated based on the multiple lin-
Hofner et al. 2010, Montorsi et al. 2010) and dissatisfied- ear regression analysis. Based on the literature (Roehrborn
to-unhappy feelings (Suzuki et al. 2006, Komiya et al. 2011a,b, Foottit & Anderson 2012, Lim et al. 2012), we
2010). This highlighted a lack of consistency in the QoL of anticipated five variables age, smoking status, LUTS,
men with BPH. From the literature, four studies were found anxiety and depression that will affect the HRQoL of
to compare the HRQoL of men with BPH with men from men with BPH. To achieve a medium effect size, 80%
the general population using generic HRQoL tools. Among power at 005 significance level (two-sided), a minimum of
these studies, one study compared the HRQoL with a con- 91 participants is needed (Cohen 1988). A total of 97 par-
trol group, while the other three studies compared the ticipants were finally recruited in our study.
HRQoL with scores from the national norm (Jakobsson
et al. 2004, Suzuki et al. 2006, Roehrborn et al. 2007, Ko-
Research instruments
miya et al. 2010). Results from these studies suggested that
the HRQoL in men with BPH was significantly poorer 12-item Short-Form Health Survey (SF-12)
when compared to men from the general population. The SF-12 measures overall HRQoL by assessing both
Furthermore, the psychological well-being of men with physical and mental health domains, and the scores are
BPH has not been well studied. Very limited studies summarised into a physical component summary (PCS) and
assessed the psychological well-being of men with BPH. mental component summary (MCS), respectively (Ware
From the literature, only two studies have been conducted et al. 1996, 2009). These summary scores are derived from
to investigate the risk of patients with BPH experiencing weighted summed scores of eight subscales: general health,
depression symptoms (Clifford & Farmer 2002, Huang physical functioning, role limitations due to physical health,
et al. 2011). These studies reported a relationship between bodily pain, vitality, role limitations due to emotional prob-
depression and BPH. However, both studies used secondary lems, mental health and social function (Ware et al. 1996).
data from databases instead of primary sources. Hence, the Each subscale score ranges from 0100, with a higher score
integrity of data obtained may be compromised. indicating better quality of life (Ware et al. 1996). The SF-
To the best of the researchers knowledge, no studies have 12 has demonstrated acceptable reliability with Cronbachs
explored the relationship between HRQoL and psychologi- a of 077 for the PCS and 080 for the MCS (Luo et al.
cal well-being of men with BPH. This may not be surprising 2003). In this study, the internal consistency of the PCS
due to the miniscule amount of attention towards the psy- and MCS subscales was acceptable with Cronbachs a of
chological well-being of men with BPH. Additionally, no 080 and 079, respectively.
studies have explored the influence of lifestyle factors and
socio-demographic and clinical characteristics on the International Prostate Symptom Score
HRQoL of men with BPH. This, despite these factors, has The IPSS was developed to assess the severity of LUTS by
been reported to affect the HRQoL of patients with other measuring the magnitude of urinary disturbance experi-
chronic diseases (Wang et al. 2014). Hence, the aims of this enced by patients with BPH and their disease-specific QoL
study were to examine the HRQoL and psychological well- (Barry et al. 1992, Lawrence 1996, Liao et al. 2011), which
being of patients with BPH and the relationship between consisted of seven items that measure the severity of LUTS
these variables and identify the predictive factors of HRQoL. 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
Materials and methods
(07), moderate (819) and severe (2035) symptom sever-
ity. The IPSS QoL score ranges from 06, where 0 repre-
Study design and sample
sents the best possible HRQoL and 6 represents the worst
This was a cross-sectional descriptive correlational study. possible HRQoL resulting from LUTS. The IPSS has been
A convenience sample was recruited from an outpatient used in exploratory and interventional studies to quantify
urology clinic of a tertiary hospital in Singapore. Patients LUTS severity and disease-specific HRQoL of patients with

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JDO Pinto et al.

LUTS (Rossetti 2001, Montorsi et al. 2010). It has demon- The patients were informed that their participation in this
strated good internal consistency and testretest reliability study was completely voluntary and they could withdraw
with Cronbachs a of 086 and intraclass correlation coeffi- from the study at any time. The participants were given
cient (ICC) of 092 (Barry et al. 1992). Analysis of the IPSS ample time to consider participating in the study without
in this study revealed that the IPSS had acceptable internal any pressure from the researcher. Their personal informa-
consistency with Cronbachs a of 078. tion such as name and identification number was not
recorded to maintain their privacy and anonymity. Data
Hospital Anxiety and Depression Scale were securely locked and kept confidential, while access to
The Hospital Anxiety and Depression Scale (HADS) was the data was only granted to the investigators of this study.
developed to assess the presence of anxiety or depression in
patients who were physically ill (Zigmond & Snaith 1983).
Data analysis
It is a 14-item tool with anxiety (HADS-A) and depression
subscales (HADS-D). Both HADS-A and HADS-D subscales The IBM SPSS 20.0 (Armonk, NY, USA) was used for data
have seven items that give a score ranging from 021 for analysis. Descriptive statistics were used to summarise and
each scale. A case of anxiety or depression was defined by describe all the data. Mean and standard deviation were
a score of 8 or more on their respective subscale (Bjelland used to describe continuous data, while frequency and
et al. 2002). The HADS has demonstrated good internal percentages were used to describe categorical data. Differ-
consistency with Cronbachs a ranging from 079085 for ences in HRQoL, LUTS and psychosocial well-being among
the total and two subscales (Woolrich et al. 2006). subgroups of socio-demographics and clinical data were
examined using either independent t-test for two groups or
Socio-demographic and clinical data sheets one-way analysis of variance (ANOVA) for three or more
A socio-demographic characteristics sheet was constructed groups. The linear association between HRQoL, LUTS and
to collect data of participants age, marital status, monthly psychological well-being was analysed using Pearsons
household income, educational level, employment status productmoment correlation. Multiple linear regression
and ethnicity. A clinical data sheet was constructed to col- analysis using an enter method was conducted to determine
lect data of the length of BPH diagnosis, smoking status, the predictors of PCS and MCS of SF-12, which were
medication treatment, uroflowmetry results, postvoid resid- entered as the two main dependent variables. All the poten-
ual urine (PVRU) and prostate-specific antigen (PSA) levels. tial predictive factors that demonstrated significant correla-
tions with PCS or MCS (i.e. p < 005) were included in the
multiple linear regression analysis to determine the predictive
Data collection procedure
factors of HRQoL. The level of significance of all statistical
Upon the ethical approval, the researcher (PJDO) worked tests performed was set at p < 005 and two-tailed.
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 Of the 121 participants approached during a four-month
and invited them to participate in the study. The partici- period of data collection from October 2012February
pants were given a detailed explanation of the study using 2013, a total of 99 (818%) participants were recruited and
a participant information sheet, which documented the aim, 22 excluded, because they either refused to participate or
procedure, potential threats and benefits, before obtaining a did not meet the inclusion criteria. Two participants were
written informed consent. On acceptance to participate in the excluded from data analysis due to extensively incomplete
study, the participants were invited to complete the SF-12, questionnaires, leaving the final sample size to 97 partici-
IPSS and HADS; their socio-demographic information and pants.
clinical data were also collected. The whole process took The socio-demographic and clinical characteristics of the
about 20 minutes. participants are summarised in Table 1. The median age of
the participants was 670 years (range: 5087 years). The
majority of the participants were 65 years (680%) and
Ethical consideration
married (948%). The highest education level of the most
Ethical approval was obtained from the National Health- participants was secondary education (485%), and over
care Group Domain Specific Review Board in Singapore. half of the participants (629%) reported that the monthly

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514 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 (423)
65 years 66 (68) No 56 (577)
Marital status Current smoking
Married 92 (948) Yes 14 (144)
Unmarried* 5 (52) No 83 (856)
Educational level Medications
Primary or Lower 30 (309) None 17 (175)
Secondary 47 (485) Alpha-blockers 56 (577)
Tertiary 20 (206) Alpha-reductase inhibitors 6 (62)
Employment status Combination therapy 18 (186)
Employed 44 (454) PSA level
Unemployed 53 (546) Mean (SD) 26 (19)
Monthly household income (SGD) Maximum flow rate (Qmax)
<1000 28 (289) Low flow rate (15 ml/second) 73 (753)
10013000 33 (34) Normal flow rate (>15 ml/second) 24 (247)
30015000 20 (206) Mean (SD) 123 (62)
>5000 15 (155) Postvoid residual urine
Ethnicity Normal PVRU (100 ml) 87 (897)
Chinese 83 (856) High PVRU (>100 ml) 10 (103)
Malay 4 (41) Mean (SD) 432 (651)
Indian 8 (82)
Others 2 (21)

SGD, Singapore dollar (one Singapore dollar = 083 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 140 months (range: 1
240 months) and the mean PSA level was 26 ng/ml Domains Mean (SD) Range
(SD = 19). 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 470 (82) 250610
of 100 ml. Almost half of the participants had a history of General health 418 (100) 239637
smoking (423%), and some were still smoking (144%). Physical function 482 (96) 256571
Table 2 presents the mean, standard deviation and range Role physical 488 (86) 236575
Bodily pain 477 (100) 217577
of the subdomains of SF-12, IPSS and HADS. The mean
Mental component summary 489 (79) 305674
SF-12 PCS score was 470 (SD = 82), whereas the mean Vitality 509 (92) 294687
SF-12 MCS score was 489 (SD = 79). The IPSS symptom Social function 494 (87) 302569
score ranged from 10340, with a mean of 126 Role emotional 468 (93) 147563
(SD = 75), indicating moderate symptom severity. Half of Mental health 487 (88) 241642
the participants reported moderate symptom severity
IPSS total score 126 (75) 10340
(n = 49, 505%), and nearly one-fifth suffered severe symp- IPSS quality of life score 33 (15) 0060
tom (n = 19, 196%). The IPSS QoL score ranged from HADS
0060, with a mean of 33 (SD = 15), indicating a mixed- HADS anxiety 41 (33) 00140
to-dissatisfied HRQoL due to their LUTS. For the anxiety HADS depression 48 (36) 00140
and depression as measured by the HADS, the mean scores SF-12, 12-item Short-Form Health Survey; IPSS, International Pros-
were 41 (SD = 33) and 48 (SD = 36), 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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(2002), ten participants (103%) experienced anxiety symp- higher PCS score compared with those who were older than
toms, while over one-fifth (216%) were found to experi- 65 years (p < 005) or who were unemployed (p < 005).
ence depressive symptoms. The participants who were ex-smokers or current smokers
The differences between PCS, MCS, IPSS symptom, IPSS reported significantly poorer IPSS QoL as compared to their
QoL, HADS-A and HADS-D mean scores among different counterparts (p < 005). In addition, the participants with
groups of socio-demographic and clinical characteristics are normal PVRU of 100 ml had significantly better PCS
presented in Table 3. The participants who were younger scores as compared to participants who had poorer PVRU
than 65 years or who were employed scored a significantly of >100 ml (p < 005).

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


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

<65 years (n = 31) 494 (64) 487 (83) 135 (75) 37 (15) 45 (36) 44 (23)
65 years (n = 66) 459 (88) 490 (78) 122 (75) 31 (14) 38 (32) 50 (38)
t 223 018 079 203 088 083
p-value 003* 086 043 004* 038 041
Education level
Primary or lower (n = 30) 460 (93) 472 (86) 136 (85) 35 (15) 38 (36) 56 (40)
Secondary (n = 47) 469 (79) 488 (79) 118 (71) 34 (15) 41 (33) 47 (35)
Tertiary (n = 20) 487 (73) 516 (64) 129 (69) 28 (13) 45 (30) 40 (29)
F 063 188 057 167 026 13
p-value 054 016 057 019 078 028
Employment status
Employed (n = 44) 491 (70) 494 (83) 130 (79) 33 (15) 40 (35) 46 (38)
Unemployed (n = 53) 452 (88) 485 (77) 122 (71) 33 (14) 41 (32) 50 (34)
t 237 057 053 019 078 058
p-value 002* 057 060 085 094 056
Income (S$)
<1000 (n = 28) 472 (81) 510 (78) 115 (55) 32 (15) 34 (27) 50 (36)
10013000 (n = 33) 460 (86) 480 (74) 136 (88) 34 (14) 43 (36) 53 (36)
30015000 (n = 20) 457 (94) 487 (78) 123 (74) 33 (14) 37 (29) 47 (39)
>5000 (n = 15) 496 (53) 473 (93) 133 (78) 35 (17) 53 (37) 39 (30)
F 081 098 045 021 13 058
p-value 049 040 072 089 029 063
Yes (n = 41) 454 (94) 480 (72) 143 (73) 36 (13) 45 (33) 54 (38)
No (n = 56) 481 (71) 496 (84) 113 (74) 30 (15) 36 (32) 44 (34)
t 157 101 193 221 131 134
p-value 012 032 057 003* 019 019
Current smoking
Yes (n = 14) 440 (79) 481 (67) 144 (64) 46 (11) 50 (39) 61 (38)
No (n = 83) 475 (83) 488 (80) 124 (76) 31 (14) 40 (32) 47 (36)
t 133 027 085 337 098 124
p-value 018 079 040 0002** 033 021
Postvoid residual volume
100 ml (n = 87) 476 (78) 490 (79) 122 (71) 33 (15) 40 (32) 47 (35)
>100 ml (n = 10) 412 (102) 479 (79) 160 (104) 34 (14) 41 (39) 58 (40)
t 240 044 113 021 005 091
p-value 002* 066 028 084 096 037

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 < 005.
**Significance at p < 001.

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516 Journal of Clinical Nursing, 24, 511522
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Table 4 reports the Pearsons correlations between PCS, Tables 3 and 4) and the current literature. Of these eight
MCS, IPSS symptom, IPSS QoL, HADS-A and HADS-D factors used as independent variables, only PVRU
scores. The SF-12 PCS and the SF-12 MCS scores were found (p = 004) and IPSS symptom (p = 003) were identified as
to be negatively correlated with IPSS symptom (p < 001) significant predictive factors of the PCS of SF-12, which
and IPSS QoL (p < 005) scores. These correlations were accounted for 271% of the variance. The statistical
found to be significant but weak (r = 024 to 034). The assumptions were satisfied given the tolerance level of col-
SF-12 PCS and MCS scores also demonstrated significant linearity diagnostic being ranged from 060091 for the
negative correlations with HADS-A (p < 001) and HADS-D eight independent variables and unstandardised residual
(p < 001) scores. In addition, the IPSS symptom and QoL being normally distributed (p = 020).
scores had weak, but significantly positive correlations with Using the above eight factors as independent variables,
HADS-A (p < 001) and HADS-D (p < 001) scores. HADS-A and HADS-D were found to be significant predic-
Two separate multiple linear regression analyses were tive factors of the MCS of SF-12, accounting for 310% of
run using the PCS and MCS of SF-12 as the dependent vari- the variance (Table 5). The tolerance level of collinearity
ables. A total of eight variables (i.e. age, employment sta- diagnostic for the independent variables ranged from 061
tus, PVRU, ex-smoking, current smoking, IPSS symptom, 092, and unstandardised residual was also normally
HADS-A and HADS-D) were entered as independent vari- distributed (p = 020), indicating the statistical assumptions
ables, guided by prior statistical analyses (i.e. results from 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 100

SF-12 MCS 014 100
IPSS symptom 034** 030** 100
IPSS QoL 025* 024* 050** 100
HADS anxiety 029** 046** 038** 033** 100
HADS depression 036** 045** 038** 025* 056** 100

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 < 005.
**Significance at p < 001.

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 015 014 108 028 041 to 012 003 013 025 080 023 to 029
Employment status 305 182 167 009 667 to 052 067 178 038 071 420 to 286
Postvoid residual urine 002 001 205 004* 005 to 000 001 001 058 056 002 to 003
Ex-smoking 098 175 056 057 445 to 249 046 170 027 079 292 to 384
Current smoking 445 257 173 008 066 to 956 131 250 052 060 628 to 367
IPSS symptom 026 011 225 003* 049 to 003 009 011 083 041 032 to 013
HADS anxiety 039 029 136 018 097 to 018 059 028 208 004* 115 to 003
HADS depression 032 027 118 024 085 to 022 060 026 229 002* 112 to 008
R2 = 271% R2 = 310%

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 < 005.
**Significance at p < 001.

0 = not employment, 1 = employment.

0 = yes, 1 = no.

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with BPH experienced anxiety and an alarming 216% suf-

fered depression. The psychological well-being of men with
Our study indicates that over half of the patients with BPH BPH has not been well studied previously, and to the best
experienced a moderate severity of LUTS and nearly one- of the researchers knowledge, none of the previous studies
fifth suffered a severe symptom of LUTS, which is in line have used the HADS to assess the psychological well-being
with the previous studies conducted in other countries of patients with BPH. However, a couple of previous
(Hutchison et al. 2006, Suzuki et al. 2006, Roehrborn studies had demonstrated the risk of the development of
et al. 2007, H ofner et al. 2010, Komiya et al. 2010, depression in patients with BPH (Clifford & Farmer 2002,
Montorsi et al. 2010). LUTS severity, as measured by IPSS, Huang et al. 2011). Clifford and Farmer (2002) conducted
significantly correlated with the physical health dimension a retrospective study in the UK and reported that men with
of SF-12 and was found to be a significant predictor of BPH had a 138209 times higher risk of developing
physical health. In addition, a weak but significant relation- depression as compared to those without BPH. Another
ship between LUTS severity and the SF-12 mental health study conducted in Taiwan reported similar results, where
dimension indicated that patients with severe LUTS experi- Taiwanese men with BPH had a 187 times higher risk of
enced poorer psychological well-being. A significant positive developing depression within a one-year period following
correlation between LUTS with HADS-A and HADS-D fur- diagnosis (Huang et al. 2011). Although there were limited
ther suggested that the LUTS significantly affects patients studies pertaining to the psychological well-being of
psychological status. This suggested that participants in this patients with BPH, the results of our study indicate that
study with severe LUTS reported higher levels of anxiety patients with BPH had poorer psychological well-being and
and depression. This is in line with the previous studies that depression seemed to be more prevalent.
reported a significant relationship between LUTS severity Previous studies have identified that anxiety and depres-
and poorer psychological well-being (Gannon et al. 2005, sion predicted the HRQoL of the general population (Lim
Wong et al. 2006). Our study further confirmed that LUTS et al. 2012) and people with chronic disease, for example
is the most significant predictor of low HRQoL for men chronic kidney disease (Lee et al. 2013) and heart disease
with BPH. (Wang et al. 2014). However, this has not been reported
The IPSS QoL measured patients disease-specific HRQoL for patients with BPH. The regression analysis results in
based on their current LUTS severity. Participants from this our study indicated that anxiety and depression were pre-
study reported that they had mixed-to-dissatisfied feelings dictive factors of poorer mental health. This further high-
towards their LUTS. This is consistent with the previ- lights the importance of effectively managing anxiety and
ous studies conducted worldwide, which generally reported depression for patients with BPH so as to improve their
a similar and consistent score range (Hutchison et al. 2006, HRQoL.
Suzuki et al. 2006, H ofner et al. 2010, Komiya et al. 2010, Older and unemployed patients with BPH reported sig-
Montorsi et al. 2010). The SF-12 was used to assess the gen- nificantly poorer physical health, and this was consistent
eral HRQoL of participants, and both PCS and MCS mean with many other studies due to increased severity of disease
scores were lower than 50, which suggests that the HRQoL and/or the presence of multiple comorbidities among older
of men with BPH was lower than average (Wee et al. 2010). people (K ugler & Rudofsky 2005, Foottit & Anderson
Roehrborn et al. (2007) conducted a population-based study 2012, Kim et al. 2012). It also suggests that physical health
(n = 6, 609) in the USA on patients with BPH and reported may play an important role in whether patients were able
the PCS and MCS scores to be 474 and 522, respectively. to maintain a job. Men with better physical health would
This indicates that the PCS scores between patients with thus be more likely to continue working as compared to
BPH from the USA and Singapore where the present study those who had poor physical health (Hultman et al. 2006,
was conducted were similar. However, the MCS scores were Rueda et al. 2011). In our study, PVRU was identified as a
found to be different with the participants in our study being predictor of poor physical health. Our results showed that
reported poorer psychological well-being than their counter- patients who had an abnormal PVRU (i.e. >100 ml)
parts in the USA. This could be due to the differences in reported significantly poorer physical health as compared to
social, cultural and economic context between Singapore those who had normal PVRU. Abnormal PVRU is attribut-
and the USA. able to several causes such as bladder dysfunction and
The HADS-A and HADS-D scores were screened for obstruction and is associated with higher risk of complica-
cases of anxiety and depression in patients, respectively. tions and poorer health outcomes (Ruud Bosch 1995, Kelly
The results of our study revealed that 103% of patients 2004). This further confirmed that patients with more

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

severe urinary tract symptoms will experience poorer physi- interventions. However, even with these interventions, the
cal health. HRQoL and psychological well-being in some of these
According to the IPSS QoL scores, ex-smokers and current patients remain poor, suggesting that other aspects of their
smokers reported poorer disease-specific HRQoL scores as HRQoL might have been missed out. With the rapid
compared to nonsmokers. This highlights the negative impact growth of the ageing population in Singapore, the preva-
of cigarette smoking on HRQoL of men with BPH. In fact, lence of BPH is expected to increase. Therefore, there is
cigarette smoking has been evidenced to cause an increase in an urgent need to use the findings from this study in the
testosterone and oestrogen levels, which are believed to play development and implementation of effective and cultur-
a role in the development of BPH (Matzkin & Soloway ally sensitive interventions to improve the HRQoL and
1993, Platz et al. 1999, Roehrborn 2011a,b). Therefore, psychological well-being of patients with BPH. Due to the
smoking cessation is critical for patients with BPH. 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
Limitations and conclusions
patient. Findings from this study may provide useful
There are several limitations in this study. First, the use of pointers for healthcare professionals to develop effective
convenience sampling from a single tertiary hospital may and culturally sensitive interventions to improve the
cause sampling bias and limits the generalisability of the find- HRQoL and psychological well-being of patients with
ings. Caution must be exercised when extrapolating these BPH.
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 We wish to acknowledge and extend our gratitude to the
could have caused patients to respond with socially desirable patients who participated in this study and the doctors and
answers and understate the severity of their scores (Polit & nurses who provided the support to this study. We would
Beck 2010). Third, the sample size was slightly less than the also like to express our heartfelt thanks to Professor Roger
recommended number for the eventual number of predictive Watson for language editing this paper.
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- The authors have confirmed that all authors meet the IC-
ing the HRQoL and psychological well-being of patients MJE criteria for authorship credit (
with BPH in Singapore. The HRQoL of patients with BPH cal_1author.html), as follows: (1) substantial contributions
was poor, and their psychological well-being was severely to conception and design , acquisition of data, or analysis
affected. The PVRU, LUTS, anxiety and depression were and interpretation of data; (2) drafting the article or
identified to be significant predictive factors of HRQoL of revising it critically for important intellectual content
patients with BPH. 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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