2009 THE AUTHORS.

JOURNAL COMPILATION 2009 BJU INTERNATIONAL

Lower Urinary Tract
RESULTS FROM THE EpiLUTS STUDY
COYNE

et al.

The prevalence of lower urinary tract symptoms

BJUI BJU INTERNATIONAL

(LUTS) in the USA, the UK and Sweden: results
from the Epidemiology of LUTS (EpiLUTS) study
Karin S. Coyne, Chris C. Sexton, Christine L. Thompson, Ian Milsom*,
Debra Irwin†, Zoe S. Kopp‡, Christopher R. Chapple§, Steven Kaplan¶,
Andrea Tubaro††, Lalitha P. Aiyer‡ and Alan J. Wein‡‡
United BioSource Corporation, Bethesda, MD, †University of North Carolina, Chapel Hill, NC, ‡Pfizer Inc, Outcomes
Research, and ¶Weill Cornell Medical College, New York, NY, ‡‡Hospital of the University of Pennsylvania,
Philadelphia, PA, USA, *Department of Obstetrics & Gynecology, Sahlgrenska University Hospital, Göteborg, Sweden,
§
The Royal Hallamshire Hospital, Sheffield, UK, and ††Sant’Andrea Hospital, ‘La Sapienza’ University, Rome, Italy
Accepted for publication 21 November 2008

Study Type – Symptom (cross-sectional
epidemiologic)
Level of Evidence 1b
OBJECTIVE
To estimate and compare the prevalence and
associated bother of lower urinary tract
symptoms (LUTS) in the general populations
of the USA, UK and Sweden using current
International Continence Society (ICS)
definitions, as no previous population-based
studies evaluating the prevalence of LUTS in
the USA, using the 2002 ICS definitions, have
been conducted.
SUBJECTS AND METHODS
This cross-sectional, population-
representative survey was conducted via the
Internet in the USA, the UK and Sweden.
Members of Internet-based panels were
randomly selected to receive an e-mailed
invitation to participate. If interested,
respondents selected a link to an informed
consent page, followed by the survey.
Participants were asked to rate how often
they experienced individual LUTS during the
previous 4 weeks, on a five-point Likert scale,
and, if experienced, how much the symptom
bothered them. Descriptive statistics were
used to summarize and present the data.
RESULTS
Responses rates for the USA, the UK and
Sweden were 59.6%, 60.6% and 52.3%,
respectively, with a final sample of 30 000
(USA 20 000; UK 7500; Sweden 2500). The
mean age (range) of the participants was
56.6 (40–99) years; the mean percentages
for race were 82.9% white, 6.7% black,
6.0% Hispanic and 4.4% Asian/other. The
prevalence of LUTS was defined by two
symptom frequency thresholds, i.e. at least
‘sometimes’ and at least ‘often’ for all LUTS
except incontinence, where frequency
thresholds were at least ‘a few times per
month’ and at least ‘a few times per week’.
The prevalence of at least one LUTS at least
‘sometimes’ was 72.3% for men and 76.3%
for women, and 47.9% and 52.5% for
at least ‘often’ for men and women,
respectively. For most LUTS, at least half of
the participants were bothered ‘somewhat’
or more using a frequency threshold of at
least ‘sometimes’. For a threshold of at least
‘often’, ‘somewhat’ or more bother was
reported by ≥70% of participants except for
terminal dribble in men and split stream in
women.
CONCLUSION
In this large population study of three
countries, LUTS are highly prevalent among
men and women aged >40 years. In general,
LUTS experienced ‘often’ or more are
bothersome to most people.
KEYWORDS
LUTS, epidemiology, bother, prevalence,
community-survey, urology

INTRODUCTION
LUTS are experienced by individuals with
pathology affecting the LUT, including
detrusor overactivity, sphincteric weakness,
sensory bladder disorders, and BPH [1], and
are generally divided into three groups:
storage, voiding and postmicturition
symptoms. Storage symptoms (inclusive of
overactive bladder, OAB) include increased
urinary frequency, nocturia, urinary urgency,
and urinary incontinence. Voiding symptoms
include slow/weak stream, hesitancy and
terminal dribble, whereas postmicturition
symptoms consist of incomplete emptying
and postmicturition dribble. LUTS also
encompass symptoms associated with sexual
intercourse and genital and LUT pain.
The prevalence of LUTS has often been
assessed in men (and infrequently in women)
using the IPSS [2–9]; however, the IPSS was
developed for men [10] and only three of the
seven questions ask about bothersome
storage symptoms. Also, the prevalence of
LUTS associated with the IPSS is typically
reported as a summed score (i.e. none = 0,
mild = 1–7) rather than by individual
symptoms, thereby limiting the ability to
consider the prevalence and impact of
individual LUTS. Nonetheless, previous
research has noted LUTS to be highly
prevalent [3,11–13]. As noted by Irwin et al.

© 2009 THE AUTHORS

352 JOURNAL COMPILATION © 2 0 0 9 B J U I N T E R N A T I O N A L | 1 0 4 , 3 5 2 – 3 6 0 | doi:10.1111/j.1464-410X.2009.08427.x

[11] in EPIC, a large population-based study,
the prevalence of at least one LUTS, using the
2002 ICS definitions, was found to be 62.5%
in men and 66.6% in women aged ≥40 years.
Certainly, not all epidemiological studies have
found estimates of LUTS of the magnitude
reported by Irwin et al., and the prevalence
of various LUTS in community and clinical
populations will differ depending on how
questions are asked, linguistic interpretation,
cultural differences, and what level of severity
or frequency was used to determine the
presence of the symptom. To illustrate, in EPIC
the ICS definition of nocturia (one or more
voids/night) yielded a prevalence of 48.6% in
men and 54.5% in women; however, when
nocturia was defined as at least two voids per
night, prevalence rates were 20.9% in men
and 24.0% in women.
Importantly, regardless of how researchers
define LUTS, from a patient perspective LUTS
greatly affect health-related quality of life
(HRQL) and are ‘bothersome’ to the men and
women who experience them [2,5,14–22].
However, the lack of a consistent definition of
bother and the multitude of tools and scoring
methods used to assess this construct make it
difficult to evaluate rates of bothersomeness
across different samples. Thus, there is a need
for an assessment of the frequency of
individual LUTS and their respective ‘bother’
rating.
Consequently, the objective of the
Epidemiology of LUTS (EpiLUTS) study was
to evaluate the prevalence and bother of
individual LUTS in population-representative
samples in the USA, the UK and Sweden, using
the most recent symptom definitions created
by the ICS [1,23], with modifications as
necessary to optimize patient understanding.
SUBJECTS AND METHODS
A population-based, cross-sectional Internet-
survey was conducted in the USA, the UK and
Sweden to examine the prevalence and
symptom-specific bother of LUTS and
evaluate the impact of these symptoms on
HRQL, work productivity, mental and sexual
health. The three countries were selected
because an epidemiological investigation of
such magnitude for LUTS had not been
conducted in the USA; the UK and Sweden
were included because they represented the
range of LUTS (highest and lowest prevalence)
in EPIC [11]. In all, 30 000 men and women
© 2009 THE AUTHORS
JOURNAL COMPILATION © 2009 BJU INTERNATIONAL
aged ≥40 years were targeted for recruitment
(20 000 in the USA, 7500 in the UK, and 2500
in Sweden) from three Internet-based panels
developed from consumer and voter
databases in each country. The rationale for
this recruitment approach and study design
are described elsewhere [24], but importantly,
each country’s most recent population census
was used as the basis for creating a ‘target
sample’ to ensure that the data collected
would be representative of the general
population according to the demographics of
age, gender, race and education. Inclusion
criteria were: (i) age ≥40 years; (ii) provision
of informed consent; (iii) ability to read
the local language; and (iv) ability to use
a computer and access the Internet.
Respondents who reported currently being
pregnant or having a UTI were excluded from
participation.
Procedures for recruitment were comparable
across countries. An e-mail invitation with a
uniform resource locator link was sent to
panel members. If interested, potential
respondents clicked on the link, which
directed them to an informed consent screen;
consent must have been provided to proceed
to the survey. The Internet survey was
designed so that participants could omit
questions or stop the survey at any time.
The EpiLUTS survey was developed with
clinicians and epidemiologists and is based on
extensive qualitative research in clinical and
community samples of 129 patients with and
without a history of LUTS. This research
included focus groups and cognitive
debriefing interviews to elicit patient
descriptions of their urinary symptoms
(unpublished). LUTS were defined using ICS
definitions [1] with language modifications to
increase lay-person understanding of the
questions. LUTS assessed were: storage
(urinary frequency, urinary urgency, nocturia,
incontinence, as stress, urgency or mixed, and
nocturnal enuresis, leaking during sexual
activity, and leaking for no reason); voiding
(weak stream, terminal dribble, hesitancy,
straining, intermittency, split stream);
postmicturition (incomplete emptying,
postmicturition incontinence); and other
(bladder pain and dysuria). The response
options for most LUTS were on a five-point
Likert scale, i.e. ‘never’, ‘rarely’, ‘sometimes’,
‘often’, and ‘almost always’. For every LUTS
frequency response of at least ‘rarely’,
participants were asked ‘how bothered’ they
were by the particular LUTS. Similarly, bother
RESULTS FROM THE EpiLUTS STUDY
ratings were assessed on a five-point Likert
scale as ‘not at all’, ‘a little bit’, ‘somewhat’,
‘quite a bit’, and ‘a great deal’.
The original questionnaire was written in
American English and translated into each
country’s primary language following the
Good Practice Guidelines for the Translation
and Cultural Adaptation Process of the
International Society of Pharmacoeconomics
and Research Outcomes [25]. Harmonized
translations were created in UK English and
Swedish through a reiterative process of
forward and back translations, and were
reviewed by survey research experts and local
users. Pilot Internet-surveys and cognitive
debriefing interviews were conducted in each
country to further assess cultural and
linguistic integrity, the ease of the Internet-
survey format, and overall content validity.
All participants were asked to complete the
following: questions about LUTS frequency
and bother, comorbid conditions,
sociodemographics, generic HRQL (Short
Form-12 [26]), overall bladder condition
(Patient Perception of Bladder Condition [27]),
general healthcare seeking, general risk
factors, anxiety and depression (Hospital
Anxiety and Depression Scale [28,29]), sexual
health (Sexual Quality of Life instrument for
females [30], Abbreviated Sexual Function
Questionnaire [31], Male Sexual Health
Questionnaire to Assess Ejaculatory
Dysfunction [32], Index of Premature
Ejaculation [33], Erectile Function domain of
the International Index of Erectile Function
[34]), and the IPSS [35]. Disease-specific HRQL
(OAB questionnaire short-form [36]), work
productivity (modified Work Limitation scale
[37]), and healthcare-seeking behaviour
questions were presented to respondents
reporting at least one LUTS during the
prevalence questions. Figure 1 illustrates the
survey question flow. Because of the skip-
pattern format, the number and type of
questions asked varied across participants.
Upon survey completion, the participant
received incentive points for their
participation (translating to ≈$2.00 in
the USA, £1.50 in the UK and SEK 1.33 in
Sweden).
For statistical analysis, sample matching was
used to construct population-representative
samples of respondents within each country’s
Internet-based panel, and poststratification
weights were calculated to correct small
amounts of imbalance based on differences in
353
C OY N E ET AL.
response rates. Weights were calculated by
raking the completed interviews to the
marginals for the matching variables (e.g. age,
race, gender and education) before all
analyses. All data presented are weighted to
each country’s population census. Given the
homogenous ethnicity in Sweden, race was
not used for sample matching or weighting in
the Swedish sample.
Demographic variables were evaluated by
descriptive analyses and are presented by
gender. The prevalence of individual LUTS was
defined by dividing the Likert responses in two
ways: (i) ‘never’ and ‘rarely’ vs ‘sometimes’ or
more (at least sometimes); and (ii) ‘never’,
‘rarely’ and ‘sometimes’ vs ‘often’ or more (at
least often). Bother levels associated with
each symptom were analysed by each bother
question. Bother was also defined by dividing
the Likert responses in two ways: (i) ‘not at all’
and ‘a little bit’ vs ‘somewhat’ or more; and (ii)
‘not at all’, ‘a little bit’, and ‘somewhat’ vs
‘quite a bit’ or more. Correlations between
LUTS frequency and bother were examined
using Spearman correlations for men and
women separately.
RESULTS
Invitations to complete the EpiLUTS survey
were sent to 62 301 members of the USA
Internet-based panel, 18 558 in the UK and
7291 in Sweden. Data collection started in the
USA (5 June 2007 to 8 July 2007) followed by
the UK (26 September 2007 to 25 October
2007) and Sweden (29 January 2008 to 2 April
2008). Recruitment periods were extended to
recruit sufficient numbers of men and women
aged ≥65 years. The number of eligible
individuals who responded to the e-mailed
invitation was 36 821 in the USA (59.6%
response rate), 10 961 in the UK (60.6%
response rate), and 3764 in Sweden (52.3%
response rate). In all, 7947 participants (5233
USA, 1993 UK and 721 in Sweden) were
excluded owing to high rates of missing or
inconsistent data, or discontinuation of the
survey.
The final sample included 20 000 participants
in the USA, 7500 in the UK and 2500 in
Sweden who were randomly selected from
the pool of completed survey respondents
through ‘sample matching’, a process used to
construct gender, age, race and education
population-representative samples from large
panels of Internet-survey responders. Overall,
354
FIG. 1. The survey flow. ASFQ, Abbreviated Sexual Function Questionnaire; HADS, Hospital Anxiety and
Depression Scale; IIEF, International Index of Erectile Function; IPE, Index of Premature Ejaculation; MSHq-
EjD, Male Sexual Health questionnaire to Assess Ejaculatory Dysfunction; OABq, OAB questionnaire; PPBC,
Patient Perception of Bladder Condition; SF, Short Form.
If YES to pregrant or Sociodemographics
UTI, stop interview
(receive incentive) Medical
comorbidity
LUTS screening
frequency
IPSS (LUTS
benchmark)
Generic HRQL
(SF-12)
Generic bladder
questions (PPBC +
other questions)
General risk factors
Anxiety and
depression (HADS)
Generic
sexual QoL
Men only: IIEF,
Women only: ASFQ
MSHq−EjD, IPE
the mean age (SD, range) was 56.5 (10.9,
40–95) years for men and 56.7 (10.5, 40–
99) years for women, and most participants
were white (men, 82%; women, 83%),
reflecting the population demographics of all
three countries (Table 1).
As expected, all voiding symptoms were more
common among men than women, regardless
of LUTS definition (at least ‘sometimes’ or at
least ‘often’). Storage symptoms, associated
with OAB were more prevalent in women than
men (Table 2) but, notably, voiding and
storage symptoms were common in men as
well as women. The prevalence of at least one
LUTS at least ‘sometimes’ was 72.3% for men
and 76.3% for women, and 47.9% and 52.5%
for at least ‘often’ for men and women,
respectively. Most participants reported
waking to urinate at least once per night (men
69.4%; women 75.8%), and more than a
quarter reported two or more nocturia
episodes (men 28.5%; women 33.7%). Results
for LUTS prevalence classifications according
to the symptom frequency category at least
‘sometimes’ and at least ‘often’ were similar,
with lower frequencies when the ‘often’
threshold was used (most were about a third
JOURNAL COMPILATION
For each question, if symptomatic,
ask about bother impact
OAB-q SF
Participants with
IPSS QoL

1 LUTS
Impact of bladder
symptoms on sexual
activity
Healthcare seeking
and treatment
Work productivity
of the prevalence found using at least
‘sometimes’). To simplify the results presented
here, discussions focus on the ‘at least
sometimes’ LUTS presence/absence threshold.
Symptoms suggestive of BOO due to possible
BPH were highly prevalent among men,
including voiding symptoms (terminal dribble
45.5%; weak stream 27.0%; hesitancy 20.1%);
storage symptoms (nocturia twice or more
28.5%; urgency 22.4%; perceived daytime
frequency 20.5%); and incomplete emptying
(22.7%). Also common in men were
postmicturition incontinence (29.7%), split
stream (19.5%) and intermittency (18.7%).
Interestingly, men were far less likely to report
urgency described as ‘a sudden need to rush
to urinate for fear of leaking urine’ (14.0%)
compared with urgency not described in
relation to leaking (22.4%). Rates of other
types of incontinence were generally low
among men, with urgency incontinence
reported most frequently (9.3%).
Terminal dribble was the most common
symptom in women (38.3%). Two other
symptoms often described in relation to the
prostate in men were prevalent in women, i.e.
© 2009 THE AUTHORS
© 2009 BJU INTERNATIONAL
 RESULTS FROM THE EpiLUTS STUDY

incontinence. Some of the least prevalent

TABLE 1 The demographics of the participants by gender
symptoms were among those most
commonly reported as bothersome, such as
Demographic Men Women P
leaking urine during sexual activity, which
No. of participants* 14 139 15 861
was most frequently reported as bothersome
Mean (SD) age, years 56.5 (10.9) 56.7 (10.5) 0.070
by both men (82.1%) and women (87.2%).
Race, n (%)
Other storage symptoms associated with
White 11 694 (82.7) 13 169 (83.0) 0.008
incontinence that were at least ‘somewhat’
Black 900 (6.4) 1 120 (7.1)
bothersome among men included urgency
Asian 384 (2.7) 372 (2.3)
with fear of leaking (73.3%), leaking for no
Hispanic 887 (6.3) 925 (5.8)
reason (72.1%), nocturnal enuresis (71.5%),
Other 275 (1.9) 274 (1.7)
urgency incontinence (63.8%), and stress
Marital status, n (%)
incontinence associated with physical
Single 1 518 (10.7) 1 154 (7.3) <0.001
activities (62.1%). Bladder pain (67.5%),
Married/living with partner 10 516 (74.4) 10 292 (64.9)
straining (66.7%), dysuria (65.4%), urgency
Divorced 1 724 (12.2) 2 898 (18.3)
(59.0%), and incomplete emptying (54.4%)
Widow/widower 369 (2.6) 1 504 (9.5)
also were frequently reported to be at least
Missing 12 (0.1) 12 (0.1)
‘somewhat’ bothersome.
Education, n (%)
High school or less 6 120 (43.3) 8 613 (54.3) <0.001
A similar pattern was evident among women,
Some college 3 922 (27.7) 3 848 (24.3)
with incontinence symptoms frequently
4-year college 2 236 (15.8) 1 968 (12.4)
receiving at least ‘somewhat’ bothersome
Postgraduate 1 794 (12.7) 1 345 (8.5)
endorsements (leaking for no reason 84.7%;
Missing 67 (0.5) 86 (0.5)
nocturnal enuresis 84.0%; urgency with
Current employment status, n (%)
fear of leaking 74.7%; stress incontinence
Working full-time 7 207 (51.0) 4 593 (29.0) <0.001
associated with physical activities 74%;
Working part-time 1 011 (7.1) 2 336 (14.7)
urgency incontinence 71.3%) followed by
Temporarily laid off 106 (0.7) 103 (0.6)
dysuria (73.5%) and bladder pain (69.3%).
Unemployed 399 (2.8) 472 (3.0)
Terminal dribble, the most prevalent LUTS
Retired 4 210 (29.8) 4 736 (29.9)
among both men and women, had relatively
Permanently disabled 825 (5.8) 908 (5.7)
low rates of bother (men 40.6%; women
Homemaker 96 (0.7) 2 279 (14.4)
40.2%). With the exception of a few LUTS, the
Student 49 (0.3) 51 (0.3)
correlations between frequency and bother
Other work for pay 153 (1.1) 224 (1.4)
for men and women were moderate to strong,
Other 63 (0.4) 141 (0.9)
with r-values of >0.45 (range 0.45–0.74; data
Missing 21 (0.1) 19 (0.1)
not shown), indicating a strong relationship
between LUTS frequency and bother.
*All numbers are weighted; subgroups might or might not equal total N due to rounding or weighted
values.
The prevalence of all LUTS increased with
advancing age in men, but only certain LUTS
increased with age in women (urgency,
urgency with fear of leaking, weak stream,
incomplete emptying (27.4%) and weak Fig. 3 (women). As expected, rates of bother urgency incontinence, and nocturnal
stream (20.1%). Storage symptoms were were lower for LUTS classified as at least enuresis). When examining prevalence by
reported frequently, including urgency, the ‘sometimes’ than those classified as at least country, rates of LUTS for both men and
cardinal symptom of OAB (35.7%), nocturia ‘often’ (data not shown). Likewise, the women were generally highest in the USA,
(two or more voids per night, 33.7%), urgency proportion of those bothered ‘quite a bit’ or followed by the UK and Sweden. In terms of
with fear of leaking (33.3%) and perceived more was lower in the at least ‘sometimes’ bother ratings associated with LUTS, the
frequency (24.6%). Incontinence was classification than in the at least ‘often’ Swedish participants generally reported the
also highly prevalent, particularly stress group. highest rates of bother for all LUTS, whereas
incontinence related to laughing, sneezing or the UK participants consistently reported the
coughing (31.8%), followed by urgency Most LUTS were described as at least lowest.
incontinence (24.4%) and postmicturition ‘somewhat’ bothersome by at least half of the
incontinence (14.9%). participants who experienced them. Overall, To benchmark these data among other
similar proportions of men and women epidemiological studies, the IPSS grouped by
The proportions of those bothered ‘somewhat’ described symptoms as at least ‘somewhat’ severity score, i.e. none, mild (1–7), moderate
or more and ‘quite a bit’ or more for the bothersome, with slightly higher percentages (8–19), and severe (≥20) was used (Table 3)
respective LUTS classifications of at least of bother evident among women on storage [3,13,15]. Importantly, the IPSS sum scores
‘sometimes’ are presented in Fig. 2 (men) and symptoms, particularly those related to found in this sample are similar to those

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C OY N E ET AL.

found in previous epidemiological studies

TABLE 2 A summary of the prevalence of LUTS at least ‘sometimes’ and at least ‘often’, by gender
using a self-administered IPSS.
Frequency of LUTS
at least ‘sometimes’ at least ‘often’
DISCUSSION
Condition, n (%) Men Women Men Women
No. of participants* 14 139 15 861 14 139 15 861
To our knowledge, EpiLUTS is the first
Voiding symptoms
epidemiological study using the current ICS
Weak stream 3 803 (27.0) 3 176 (20.1) 1 356 (9.6) 690 (4.4)
definitions of LUTS conducted in the USA, the
Split stream 2 743 (19.5) 1 614 (10.2) 694 (4.9) 372 (2.4)
UK and Sweden. Irwin et al. [11] used ICS
Intermittency 2 632 (18.7) 2 509 (15.9) 721 (5.1) 639 (4.0)
definitions when evaluating the prevalence of
Hesitancy 2 833 (20.1) 1 859 (11.8) 751 (5.3) 442 (2.8)
OAB and some LUTS, but did not examine all
Straining 1 092 (7.7) 942 (5.9) 275 (2.0) 222 (1.4)
LUTS and did not assess the acceptability of
Terminal dribble 6 410 (45.5) 6 057 (38.3) 2 755 (19.6) 2 291 (14.5)
laymen’s language as applied to these
Storage symptoms
definitions [11]. The rigorous efforts in this
Perceived frequency†, yes 2 895 (20.5) 3 888 (24.6) 2 895 (20.5) 3 888 (24.6)
survey development established the content
Nocturia‡ ≥1 9 788 (69.4) 11 977 (75.8) – –
validity of the questionnaire and ensured that
Nocturia ≥2 4 021 (28.5) 5 327 (33.7) – –
lay people understood the questions being
Nocturia ≥3 – – 1 825 (12.9) 2 373 (15.0)
asked. The Internet-based data collection used
Urgency 3 104 (22.4) 5 509 (35.7) 674 (4.9) 1 707 (11.1)
here was a departure from the standard of
Urgency with fear of leaking 1 975 (14.0) 5 261 (33.3) 546 (3.9) 1 860 (11.8)
random digit telephone dialling to collect
Urgency incontinence§ 1 315 (9.3) 3 869 (24.4) 639 (4.5) 2 072 (13.1)
epidemiological data, and provided a rapid,
Stress incontinence
efficient venue of data collection that allowed
(laughing, sneezing, coughing)§ 163 (1.2) 5 004 (31.8) 63 (0.4) 2 340 (14.8)
participants to complete the survey when
(physical activities)§ 183 (1.3) 1 951 (12.3) 85 (0.6) 1 067 (6.7)
convenient to them. Using Internet-based
Leak for no reason§ 196 (1.4) 916 (5.8) 124 (0.9) 617 (3.9)
self-administered data collection also negates
Nocturnal enuresis§ 201 (1.4) 606 (3.8) 116 (0.8) 410 (2.6)
the possibility of interviewer-bias and allows
Leak during sexual activity§ 36 (0.3) 311 (2.0) 11 (0.1) 106 (0.7)
for a greater number of relevant questions to
Postmicturition
be asked. In EpiLUTS, the number of questions
Incomplete emptying 3 209 (22.7) 4 347 (27.4) 764 (5.4) 1 171 (7.4)
asked ranged from 123 to 185, with a mean
Postmicturition incontinence 4 202 (29.7) 2 363 (14.9) 2 333 (16.5) 1 488 (9.4)
completion time of 22 min.
Other genitourinary symptoms
Bladder pain 708 (5.0) 1 195 (7.6) 203 (1.4) 352 (2.2)
Importantly, although Internet-based studies
Dysuria 332 (2.6) 453 (3.1) 84 (0.6) 89 (0.6)
are a promising method for conducting large-
scale epidemiological studies, the concern
*All numbers are weighted; subgroups might or might not equal total N due to rounding or weighted
of general applicability and whether this
values. †Assessed as dichotomous yes/no variable. ‡Nocturia episodes are dichotomized ≥1, ≥2, and ≥3
Internet-based sample population is
to provide prevalence rates of each variable; nocturia episodes were collected as a continuous variable.
representative of the general population
Due to grouping by symptom prevalence, nocturia episodes ≥1 and ≥2 were calculated for the LUTS at
must be addressed. Critical to the success
least ‘sometimes’ group only; nocturia episodes ≥3 were calculated for the LUTS at least ‘often’ group
of EpiLUTS was ensuring population
only. §In the LUTS at least ‘sometimes’ group, incontinence episodes occur a few times a month or more;
representativeness by maximizing population
in the LUTS at least ‘often’ group, incontinence episodes occur a few times a week or more.
coverage and minimizing selection bias using
sample-matching techniques. The sampling in
EpiLUTS is based on each country’s current
population census, focusing on the
demographics of age, gender, race and high-school education or less. Given the lower prevalence rates. Also, the prevalence
education. Members of the pool of Internet- current trends of telephone use with caller rates of LUTS in the UK were higher than the
based panel participants were matched to the identification and cellular phones, this Swedish rates, whereas the inverse was
census demographics and randomly selected Internet-based approached with sample previously reported [11]. There are likely to be
to receive the e-mail invitation to participate. matching is likely to have greater general various factors to explain the differences in
Although the concern that Internet users applicability than random-digit dialling. prevalence rates, with the first being the
tend to be over-represented by the higher recognition that how a question is asked will
educated, younger, majority population is Because the method of epidemiological alter the response. Previous epidemiological
valid, this survey method targeted a lower research for EpiLUTS differs from previous studies used various surveys and
educated, older, minority population to match studies, the prevalence rates of individual questionnaires (e.g. IPSS, ICS-male, Danish
the population census demographics of each LUTS noted in EpiLUTS were considerably Prostatic Symptom Score) to assess the
country. In the USA, minorities comprised higher when using the at least ‘sometimes’ prevalence of LUTS, and each questionnaire
24% of the sample (nearly 10% in the UK), threshold than previously noted [3,11,13], asks about LUTS in different ways.
and 43% of men and 54% of women had a whereas the at least ‘often’ threshold yielded Respondent interpretation of each question

© 2009 THE AUTHORS

356 JOURNAL COMPILATION © 2009 BJU INTERNATIONAL
 RESULTS FROM THE EpiLUTS STUDY

FIG. 2. Summary of the prevalence of LUTS and associated bother in men.

50%
Prevalence
45% ≥ sometimes
Bother ≥
40% somewhat
Bother ≥
35% quite a bit
Prevalence ≥ sometimes

30%

25%

20%

15%

10%

5%

0%
m

cy

cy

ble

cy

ou lau t.

sic ss ) ,

In xua k du s

in st-m ying

Bl ce n

ain

ria
hy re g g
ki h
am

se Lea resi
nc
in

na aso

en io
g,c t. ( con

ple ctiv ng
(p St ghin ghin
t
ea

en

an

en

sn ss i Urg ng

No or n ies)

te ity

su
lea wi
≥

ak iv t.
rib

rp
in

in rit
ge
tre

i
str

Le l act con

pt
nu

co l a r
itt

qu
sit

e
ia

Dy
zin on in
a

nt tu
ld

of cy

ct o r

de
Ur

f it
r

em
ks

ur
rm

St

le
He

fre
lit

co ic
a in
ar n
a

ad
ct

fe ge
ea

in
Sp

te

ed

No
rm
W

Ur
In

ur
eiv
Te

Po
ee nc

m
rc
Pe

re
St

Post-micturition Other
Voiding Symptoms Storage Symptoms Symptoms genito-urinary
Symptoms

TABLE 3 The IPSS results compared with previous reports

Men, % Women, %
Details EpiLUTS [3] UrEpik [15] [13] EpiLUTS UrEpik [15]
Countries Sweden NL, Fr, UK, Korea Norway NL, Fr, UK, Korea
No. of subjects 13 967 40 000 4979* 21 694 15 675 4979*
Subject age, years – 45–79 – Men ≥40† – –
IPSS
None (0) 10.5 17.2 74.9–80.8 80 7.6 76.3–87.4
Mild (1–7) 61.2 59.5 57.9
Moderate (8–19) 24.1 18. 12.5–20 20 30.2 11–9.5
Severe (≥20) 4.2 4.8 3.0–5.1 4.3 1.6–4.2

Fr, France; NL, the Netherlands. Mode of administration: EpiLUTS Web survey; all others mail survey. *Range reporting of four countries. †Sample was >20 years,
but results only ≥40 years.

might result in widely varied responses. The
translation in different languages and the
interpretation of the individual questions
might result in the varied responses and
differences in prevalence among these
countries. Also, when considering the
responses presented to individuals, a
dichotomous yes/no response will yield a very
different result from a Likert scale of four to
six potential response options. Notably, for
most questions in EpiLUTS, five-point Likert
scales were used to allow respondents the
opportunity to provide a real-life response of
‘sometimes’ when responding to the presence
of a symptom. For example, when examining
urgency, a symptom that is indicative of OAB,
the ‘at least sometimes’ threshold prevalence
rate of urgency is 22.4% for men and 35.7%
for women, which is higher than previously
reported by Irwin et al. [11]. However, when
the at least ‘often’ threshold is used, the

© 2009 THE AUTHORS

JOURNAL COMPILATION © 2009 BJU INTERNATIONAL 357
 C OY N E ET AL.

FIG. 3. Summary of the prevalence of LUTS and associated bother in women.

40%
Prevalence
≥ sometimes
35% Bother ≥
somewhat
30% Bother ≥
quite a bit
Prevalence ≥ sometimes

25%

20%

15%

10%

5%

0%
m

cy

cy

ble

cy

cy

ou lau t.

sic ss ) ,

In xua k du s

in t-m ying

Bl ce n

ain

ria
hy re g g
ki h
am

se Lea resi
in

na aso

en io
g,c t. ( con

ple ctiv ng
(p St ghin ghin
ea it
ea

en

an

en

Ur rgen

sn ss i Urg ng

No or n ies)

te ity

su
≥

ak iv t.
rib

rp
in

in rit
w
tre

i
str

Le l act con

pt
nu

co l a r
itt

qu
sit

e
ia

Dy
zin on in
a

nt tu
ld

of cy

ct o r

de
f it
r

em
ks

ur

U
rm

St

le
He

fre
lit

co ic
a in
ar n
a

ad
ct

l
fe ge
ea

in
Sp

te

ed

No
rm
W

In

ur
eiv

s
Te

Po
ee nc

m
rc
Pe

re
St

Post-micturition Other
Voiding Symptoms Storage Symptoms Symptoms genito-urinary
Symptoms

prevalence of urgency is 4.9% in men and
11.1% in women, which is much lower than
previously reported by Irwin et al.
Although the way the questions were asked
and the response option formats probably
explain much of the difference in noted
prevalence rates, the lack of an interviewer-
response bias might also contribute to noted
differences. The inclusion of the IPSS as a
benchmark assessment of LUTS shows that
similar rates were found when comparing
self-administered versions of the IPSS (albeit
written vs computerized). The IPSS rates from
EpiLUTS were quite similar to those noted by
Anderson et al. [3], Boyle et al. [15] and Seim
et al. [13], with the prevalence being 28.3% of
men with moderate to severe IPSS indicative
of BPH.
It is important to acknowledge that although
LUTS prevalence rates vary according to the
chosen threshold, LUTS are highly prevalent in
men and women aged ≥40 years. Voiding
symptoms that are frequently associated with
BOO and BPH in men were highly prevalent
in women, while storage symptoms were
prevalent in men. Importantly, LUTS are
bothersome to those individuals experiencing
them. In EpiLUTS, the level of bother was
assessed with each LUTS, and the prevalence
was reported as ‘rarely’ or more. Consistent
with previous research, the most prevalent
symptoms were not the most bothersome;
in fact, the least prevalent symptom of
incontinence during sexual activity was the
most bothersome symptom for both men and
women. Terminal dribble, the most prevalent
LUTS, was among the least bothersome.
Further examination of the present data will
provide greater insight into the level of bother
and associated treatment-seeking behaviour
for individual LUTS, as well as LUTS
constellations among this population. For
example, EpiLUTS data can provide an insight
into what symptom or symptoms have the
greatest adverse effect on people’s lives. Such
information might be useful to clinicians and
researchers in identifying levels of specific
symptoms that lead to treatment-seeking. Is
there a symptom ‘tipping point’ at which one
can no longer tolerate coping with specific
LUTS? Do specific symptoms trigger treatment
seeking? While this study shows that LUTS are
highly prevalent, there is a need for further
longitudinal research to evaluate when
symptom presence merits examination and
treatment. Certainly, the mere presence of a
symptom does not mandate either, but little is
known about the natural progression of LUTS,
and whether early identification and
treatment will reduce future morbidity.
Additional analyses within EpiLUTS should
help clinicians to gain an understanding and
awareness of the trend between the highly
prevalent and bothersome symptoms, and
patterns of patient presentation, including
association with comorbid conditions,
with important implications for clinical
management. Future research is needed to
ascertain the clinical relevance, if any, of LUTS
presenting individually or as a constellation
of symptoms. Furthering cluster-analyses

© 2009 THE AUTHORS

358 JOURNAL COMPILATION © 2009 BJU INTERNATIONAL

approaches [38,39] to examine not only the
presentation of LUTS but risk factors and
comorbid conditions associated with
symptom constellations will enhance
clinicians’ understanding of LUTS
presentation from a patient’s perspective
rather than an ‘organ’ (i.e. bladder or prostate)
perspective [40]. Lastly, from a clinical
perspective, future longitudinal research is
needed to see if there is a development of
these symptoms into a perceivable and
bothersome condition, to gain an
understanding of the importance of early
diagnosis and management of LUTS.
ACKNOWLEDGEMENTS
Additional editorial support was provided by
Diane Warner and Janet E. Matsuura, PhD, at
Complete Healthcare Communications, Inc.,
and was funded by Pfizer Inc. This research
was supported by funding from Pfizer Inc.
CONFLICT OF INTEREST
Karin S. Coyne, Chris C. Sexton and Christine
L. Thompson are employees of UBC and
consultants to Pfizer Inc; Zoe S. Kopp and
Lalitha P. Aiyer are employees of Pfizer Inc;
Christopher R. Chapple is a Scientific
consultant/researcher with Allergan, Astellas,
Novartis and Pfizer Inc; Steven Kaplan is a
consultant/lecturer with Pfizer Inc; Andrea
Tubaro is a consultant for Allergan, Astellas,
Ferring, GSK Novartis and Pfizer Inc; Alan J.
Wein is a consultant to Allergan, Astellas,
Novartis and Pfizer Inc; Ian Milsom is a
consultant to Pfizer Inc and UBC, an
investigator for Pfizer Inc and Astellas, a
lecturer for Pfizer Inc, Astellas and Novartis,
and receives grant support from Pfizer Inc and
Astellas; Debra Irwin is a consultant for Pfizer
Inc.
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Correspondence: Karin Coyne, United
BioSource Corporation, Center for Health
Outcomes Research, 7101 Wisconsin Avenue,
Suite 600, Bethesda, MD 20814, USA.
e-mail: karin.coyne@unitedbiosource.com
Abbreviations: EpiLUTS, Epidemiology of
LUTS; OAB, overactive bladder; HRQL, health-
related quality of life.
© 2009 THE AUTHORS
© 2009 BJU INTERNATIONAL