European Urology

Editorials

Information about the health care seeking behaviour of the population is an important issue. This is certainly true for the elderly in whom lower urinary tract symptoms (LUTS) are common. Community-based surveys in various western countries have demonstrated a high prevalence of LUTS. Moderate to severe LUTS was reported by 28% percent of all men aged 40–79 in the community of Bridge of Allan (Scotland) [1], 13% of men 40–49 and 28% of those older than 70 in Olmsted County (USA) [2], and 29% of men 50–80 in the community of Herne (Germany) [3]. This number and proportion will increase as the western population ages. The number of people older than 65 is expected to double within the next 20 years [4]. Furthermore, “LUTS awareness” is increasing so more patients will seek help for their symptoms. If the health care seeking behaviour of men (or women) with LUTS were known more in detail, we could draw a patient profile that could help us to predict doctor visits, provide resources for assessment, provide treatment, and prepare primary health care providers accordingly. Scientific evidence is also important to convince health care providers and politicians to make the right decisions in this process and to predict and guide developments.

Several studies have been published about the health care seeking behaviour of elderly people in general and people with LUTS in particular. In Denmark, Nørby et al. conducted a large study in which the prevalence of urinary symptoms and the associated health care seeking behaviour were investigated [5]. The authors concluded that LUTS are very common for men and women, but a substantial number of those with high symptom burdens do not visit their physicians. Common reasons for not visiting a doctor are “a problem considered to be common at this age” and “fear of surgery” [6]. Patients who will postpone a doctor visit try to adjust their lifestyles to self-manage their symptoms [7]. However, little information is available about the exact complaints or abnormalities that will guide people to their physicians. Urinary symptoms—besides concern about prostate cancer—are believed to be the main reasons for doctor visits [8]. Irritative urinary symptoms (urgency, frequency, nocturia, or incontinence) are more bothersome than obstructive urinary symptoms [9], and [10]. Therefore, irritative symptoms should reduce the Quality of Life (QoL) more significantly and cause health seeking behaviour. However, other factors for health seeking behaviour might also be important. In this issue of European Urology Kok et al. published “Determinants of seeking of primary care for lower urinary tract symptoms: The Krimpen study in community-dwelling men” [11]. The authors conducted in the community of Krimpen, The Netherlands, a prospective study in which 1,688 men aged 50–78 participated (50% of men of this age). Of these, 1,506 (89%) were identified who had not visited their general practitioners for LUTS. Therefore, these men were at risk to develop LUTS in the next two years and to visit their general practitioners because of this condition. Fifty-eight (3.9%) were identified who visited their general practitioners for LUTS. Subanalysis of these men demonstrated that they had a higher International Prostate Symptom Score (IPSS) value, prostate volume, post-void residual urine volume, and lower social score of the Sickness Impact Scale compared to men who did not visit their general practitioners. The main conclusion of the study is that urological measurements, symptoms, and QoL issues guide men to seek medical care. Health care seeking behaviour therefore depends not only on irritative symptoms, but is rather complex and multifactorial.

The study has three problems that might reduce the main message. Only 50% of men 50–78 who live in Krimpen participated in the study. The prevalence of an IPSS value >7 of the non-participants was lower than of the participants, but all other measurements of the non-responders remain unknown. This bias gives incorrect numbers of men who will visit their general practitioners for LUTS. If we assume that non-participants are less symptomatic, have fewer problems, and have a better QoL, these men will be unlikely to seek help in the near future. The prevalence of men who seek help would therefore be lower and at about 50% of the number reported. The second disadvantage is the study design. All men had to undergo rather invasive measurements at baseline. These investigations, together with the attention given to LUTS and complaints, could have influenced the medical care seeking behaviour. The third problem is related to the result that the prostate volume is one factor that guides men to seek for medical help. The commentators of this article cannot give any information about their prostate size. Other unknown factors behind the prostate size seem to be responsible for the decision to visit a doctor.

In conclusion, this paper adds valuable information to our knowledge about the health care seeking behaviour of men. However, more detailed information is needed to identify men who will visit doctors in the future.