Comparison of Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with benign prostatic hyperplasia: A prospective study from an Indian population

Comparison of Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with benign prostatic hyperplasia: A prospective study from an Indian population

Accepted Manuscript Comparison of Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with Benign Prostati...

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Accepted Manuscript Comparison of Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with Benign Prostatic Hyperplasia: A prospective study from Indian population DR Yogesh Taneja, M.S. DNB Trainee, DR Priyatama Ram, D.A. Senior Resident, DR Satish Kumar, M.S., DNB Urology, Head of Department, DR Kishan Raj, M.S. DNB Urology Trainee, DR Charan Kanwal Singh, M.S. DNB Urology Trainee, DR Santosh Kumar Dhaked, M.S. DNB Urology Trainee, DR Jiten Jaipuria, M.S. DNB Urology Trainee PII:

S2287-8882(17)30009-0

DOI:

10.1016/j.prnil.2017.04.004

Reference:

PRNIL 100

To appear in:

Prostate International

Received Date: 27 January 2017 Revised Date:

17 March 2017

Accepted Date: 13 April 2017

Please cite this article as: Taneja Y, Ram P, Kumar S, Raj K, Singh CK, Dhaked SK, Jaipuria J, Comparison of Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with Benign Prostatic Hyperplasia: A prospective study from Indian population, Prostate International (2017), doi: 10.1016/j.prnil.2017.04.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT TITLE: Comparison of Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with Benign Prostatic Hyperplasia: A prospective study from

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Indian population.

Institution: SRI SATHYA SAI INSTITUTE OF HIGHER MEDICAL SCIENCES, PRASHANTIGRAM, ANANTHPUR

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DR YOGESH TANEJA1, M.S. DNB TRAINEE.

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Authors:

DR PRIYATAMA RAM2, D.A. SENIOR RESIDENT.

DR SATISH KUMAR1, M.S., DNB UROLOGY, HEAD OF DEPARTMENT. DR KISHAN RAJ1, M.S. DNB UROLOGY TRAINEE.

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DR CHARAN KANWAL SINGH1, M.S. DNB UROLOGY TRAINEE. DR SANTOSH KUMAR DHAKED1, M.S. DNB UROLOGY TRAINEE.

Department of Urology, Sri Sathya Sai institute of higher medical sciences, Prashantigram,

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DR JITEN JAIPURIA1, M.S. DNB UROLOGY TRAINEE.

Ananthapur. 2

Department of Anesthesiology, Sri Sathya Sai general hospital, Prashantigram, Ananthpur.

CORRESPONDING AUTHOR: NAME: DR YOGESH TANEJA, M.S. DNB TRAINEE.

ACCEPTED MANUSCRIPT ADDRESS: DEPARTMENT OF UROLOGY, SRI SATHYA SAI INSTITUTE OF HIGHER MEDICAL SCIENCES, PRASHANTIGRAM, ANANTHPUR, ANDHRA PRADESH- 515134.

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EMAIL ID: [email protected]

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PH. NO. 9491533284

TOTAL WORD COUNT

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Abstract: 331

TEXT (not including title, abstract, acknowledgment, references, tables, and figure legends) -

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ORIGINAL ARTICLE TITLE: Comparison of Visual Prostate Symptom Score and International Prostate Symptom

Indian population.

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RUNNING TITLE: IPSS vs VPSS in Indian population.

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Score in the evaluation of men with Benign Prostatic Hyperplasia: A prospective study from

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ABSTRACT BACKGROUND: Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia

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(BPH) are common conditions in middle-age or older men. The International Prostate Symptom Score (IPSS) is a useful and validated questionnaire to evaluate LUTS secondary to BPH. Van der walt, et al have developed an alternative questionnaire named Visual Prostate Symptom

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Score (VPSS). This study aimed to evaluate the relationship between Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with lower urinary

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tract symptoms due to Benign Prostatic Hyperplasia in Indian population.

METHODS: This was a prospectively designed study conducted at Sri Sathya Sai institute of Higher Medical Sciences, Prashantigram. A total number of 121 patients who presented to urology outpatient department with LUTS due to BPH were enrolled in the study. Patients were

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followed up at 1 month and 3 months interval. All the patients were given both the questionnaires. The correlation test was used to assess correlation between two symptom scores and various parameters. Observations with a P<0.05 were considered statistically significant.

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RESULTS: There was a statistically significant difference in number of patients requiring assistance to fill the questionnaires per their education level. There was a positive correlation

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between IPSS total score and VPSS total score (r=0.7235; p <0.0001), VPSS total score and VPSS Qol (r=0.70753; p <0.0001), IPSS total vs IPSS Qol (r=0.65583; p <0.0001), IPSS Qol vs VPSS Qol (r=0.84093; p <0.0001). A negative correlation was observed between total VPSS with Qmax, total IPSS with Qmax, IPSS total vs Qavg (r= -0.479; p <0.0001) and VPSS total vs Qavg (r= -0.5; p <0.0001). All VPSS questions showed statistically significant correlation with corresponding IPSS questions.

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CONCLUSION: There is a statistically significant correlation between VPSS and IPSS and it can be completed by a greater no of patients without assistance.

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urinary tract symptoms, Visual Prostate Symptom Score.

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KEYWORDS: Benign Prostate Hyperplasia, International Prostate Symptom Score, Lower

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INTRODUCTION Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are common

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conditions in middle-age or older men. [1] The International Prostate Symptom Score (IPSS) is a useful and validated questionnaire to evaluate LUTS secondary to BPH. [2] Thus it has become a very useful tool for a urologist in day to day practice for evaluation and follow up of LUTS

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patients. However, most patients with low education level are not able to answer IPSS questionnaire correctly. [3] Furthermore, BPH incidence increases more after 50 years of age. In

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this age group, most of the men are having eyesight related problems &/or cognitive impairment. [4] Because of all these reasons, patients usually have to take assistance from medical fraternity. This may lead to bias in the patient’s responses. [5]

To avoid the above said problems with the IPSS, Van der Walt, et al have developed an

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alternative questionnaire named Visual Prostate Symptom Score (VPSS). [6] It assesses frequency, nocturia, and weak stream and quality of life by means of pictograms. There are many advantages with the use of VPSS. It is easy to understand and simple to use even

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for elderly and less educated persons. [7] Various studies have been conducted in Turkish, Indonesian, South African and Korean population to assess its usefulness. There is limited data

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available about its usefulness and applicability in Indian population. [8-11]

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MATERIALS AND METHODS This was a prospectively designed study conducted at Sri Sathya Sai institute of Higher Medical

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Sciences, Prashantigram. Sri Sathya Sai Institute is a tertiary care center with daily outpatients visit of around 150-160 patients. Ethical committee approval was sought for the study as per institute’s protocol. The study was conducted from March 2016 to September 2016. A total

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number of 121 patients who presented to urology outpatient department with LUTS due to BPH were enrolled in the study.

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Inclusion criteria:

1. All patients who presented to Urology outpatient clinic with lower urinary tract symptoms.

Exclusion criteria:

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2. Age >40 years

1. Patients with uncontrolled diabetes, PSA > 4ng/dl

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2. History of TURP, surgery for urethral stricture, vesical calculus in the past. 3. On evaluation found to have LUTS due to a cause other than BPH.

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Patients were followed up at 1 month and 3 months interval. All patients were evaluated and after routine investigations, they were given both the IPSS and VPSS questionnaires. Uroflowmetry (UFR), serum PSA, renal function tests, USG for prostate were done. Various parameters including the total scores, uroflowmetry parameters, age, education level, assistance required to fill the questionnaires were noted down and compared using chi square test. The

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correlation test was used to assess correlation between two symptom scores and various parameters. Observations with a P<0.05 were considered statistically significant.

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RESULTS: TABLE1 Patients characteristics

The characteristics of the patients included in this study are shown in Table 1. The patients’

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mean age was 66 years with a range of 44 – 79 years. All the patients were divided in two groups as per education level. Patients with education level < 9th standard were included in group A and

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> 9th standard in group B. Around fifty five percent of patients had education level < 9th standard. TABLE 2 Relationship between education level and requirement of assistance to complete the questionnaires

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A greater proportion of patients could complete VPSS without assistance as compared to IPSS. In group A (education level < 9th) the VPSS questionnaire was completed without assistance by 44 out of 60 patients whereas only 12 out of 60 patients could complete IPSS without assistance.

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In group B (education level > 9th) the VPSS questionnaire was completed without assistance by 45 out of 50 patients whereas only 36 out of 50 patients could complete IPSS without assistance.

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This difference was found to be statistically significant. (p valve < 0.0001) TABLE 3 Time taken to fill the questionnaires There was a significant difference in time taken by the patients to fill VPSS questionnaire vs IPSS and this was found to be statistically significant (p value <0.0001) as shown in table 3. TABLE 4 Correlation between VPSS and IPSS

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Both the questionnaires were evaluated for correlation. All the results are summarized in table 4. There was a positive correlation between IPSS total score and VPSS total score (r=0.7235; p

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<0.0001). Similarly, a positive correlation was observed between VPSS total score and VPSS Qol (r=0.70753; p <0.0001), IPSS total vs IPSS Qol (r=0.65583; p <0.0001), IPSS Qol vs VPSS Qol (r=0.84093; p <0.0001). Both total VPSS and total IPSS showed a negative correlation with

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Qmax : IPSS total vs Qmax (r= -0.6287; p <0.0001), VPSS total vs Qmax (r= -0.5782; p <0.0001). Similarly, a negative correlation was observed between IPSS total vs Qavg (r= -0.479;

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p <0.0001), VPSS total vs Qavg (r= -0.5; p <0.0001). All VPSS questions showed statistically significant correlation with corresponding IPSS questions - Poor stream: VPSS Q3 vs IPSS Q 5 (r= 0.76122; p <0.0001), Nocturia: VPSS Q2 vs IPSS Q7 (r= 0.88558; p <0.0001), Frequency:

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VPSS Q1 vs IPSS Q2 (r= 0.5083; p <0.0001).

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DISCUSSION:

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In this study, we attempted to evaluate the relationship between VPSS [Figure 1] and IPSS [ Figure 2] in Indian population.

The IPSS questionnaire has 7 questions which are used to evaluate storage and voiding

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symptoms in patients with BPH. The patient is given 5 options for first 7 questions and each option indicates severity of that symptom. The total score ranges from 0 to 35 and LUTS are

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classified as mild to severe depending on the total score. Patients having a total score of less than or equal to 7 are classified as having mild symptoms, scores from 8 to 19 are classified as moderate symptoms, and symptom scores of greater than or equal to 20 are classified as severe symptoms. [12] The last question of the IPSS is about QoL. Studies have shown that this

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question is the single best predictor of outcome related to treatment prescribed. [13] One of the major problem associated with IPSS questionnaire is its complex nature. In their Rodrigues et al showed that almost fifty percent of the patients were unable to compete the

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IPSS questionnaire when freedom was given not to answer any question for which they are not clear. [14] Another study from Lujan et al confirmed these findings. They found that around

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thirty three percent of patients could not complete the IPSS questionnaire. [15] Cam et al., in their study found that 34% of patients with a low (elementary school)

educational level do not even fill the IPSS questionnaire and return them totally unmarked. [16] In their study van der Walt et al. observed that 87% of patients with an education level ≤7 required assistance to complete the IPSS as compared to 24% of patients with an education

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level≥10. In this study, it was clear that patients with education level ≤9th require more assistance for completing the IPSS questionnaire. [6]

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There have been previous studies from Namibia, Turkish society, Korean population and Indonesian population who have evaluated the correlation between IPSS and VPSS. [8-11]

They all found a positive correlation between IPSS total score and VPSS total score.

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Similarly, a positive correlation was observed between VPSS total score and VPSS Qol, IPSS total vs IPSS Qol, IPSS Qol vs VPSS Qol. Both total VPSS and total IPSS showed a negative

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correlation with Qmax. Similarly, a negative correlation was observed between IPSS total vs Qavg and VPSS total vs Qavg. All VPSS questions showed statistically significant correlation with corresponding IPSS questions - Poor stream: VPSS Q3 vs IPSS Q 5, Nocturia: VPSS Q2 vs IPSS Q7, Frequency: VPSS Q1 vs IPSS Q2. Our results were found to be consistent with all

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these studies.

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STUDY LIMITATIONS AND IMPORTANCE

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As this study included data from a single institution, a potential selection bias may have

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occurred. Nevertheless, our study results are valuable because limited data is available from rural

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Indian population to elucidate an association between VPSS and IPSS.

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CONCLUSION AND TAKE HOME MESSAGE

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There is a statistically significant correlation between VPSS and IPSS and it can be completed by a greater no of patients without assistance. VPSS can be a handy tool in evaluation

level.

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CONFLICTS OF INTEREST: NONE

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of severity of symptoms in patients presenting with LUTS due to BPH even with low education

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REFERENCES:

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1. Cornu, J. N., Cussenot, O., Haab, F. & Lukacs, B. A widespread population study of actual medical management of lower urinary tract symptoms related to benign prostatic hyperplasia

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across Europe and beyond official clinical guidelines. Eur. Urol. 58, 450–456 (2010). 2. Barry MJ, Fowler FJ, Jr, O’Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992;148:1549–57.

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3. Netto Junior NR, de Lima ML. The influence of patient education level on the International Prostatic Symptom Score. J Urol. 1995;154:97–9.

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4. Huh JS, Kim YJ, Kim SD. Prevalence of benign prostatic hyperplasia on Jeju Island: analysis from a cross-sectional community-based survey. World J Mens Health. 2012;30:131–7.

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5. Cam K. BPH: how useful is a visual prostate symptom score for patients? Nat Rev Urol. 2011;8:536–7.

6. Van der Walt CL, Heyns CF, Groeneveld AE, Edlin RS, van Vuuren SP. Prospective comparison of a new visual prostate symptom score versus the international prostate symptom score in men with lower urinary tract symptoms. Urology. 2011;78:17–20.

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7. Heyns CF, van der Walt CL, Groeneveld AE. Correlation between a new visual prostate symptom score (VPSS) and uroflowmetry parameters in men with lower urinary tract

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symptoms. S Afr Med J. 2012;102:237–40. 8. Yasin Ceylan, Bulent Gunlusoy, Tansu Degirmenci, Zafer Kozacioglu, Deniz Bolat, Suleyman Minareci. Is New Visual Prostate Symptom Score Useful as International Prostate Symptom

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Score in the Evaluation of Men With Lower Urinary Tract Symptoms? A Prospective Comparison of 2 Symptom Scores in Turkish Society. Urology. 2015 Mar;85(3):653-7

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9. Andika Afriansyah, Yogi Ismail Gani, Hari Nusali . Comparison between visual prostate symptom score and international prostate symptom score in males older than 40 years in rural Indonesia. Prostate Int. 2014 Dec; 2(4): 176–181.

10. Heyns CF, Steenkamp BA, Chiswo J, Stellmacher GA, Fortsch HE, Van der Merwe A.

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Evaluation of the visual prostate symptom score in a male population with great language diversity and limited education: a study from Namibia. S Afr Med J. 2014;104:353–7.

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11. Park YW, Lee JH. Correlation between the visual prostate symptom score and international prostate symptom score in patients with lower urinary tract symptoms. Int Neurourol

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J. 2014;18:37–41.

12. Reohrborn GC. Beningn prostatic hyperplasia: etiology, pathophysiology, epidemiology, and natural history. In: Kavaoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Wash urology. 10th. Philadelphia: Saunders Esavier; 2012. pp. 2576–81. 13. Barry MJ, Girman CJ, O’Leary MP, Walker-Corkery ES, Binkowitz BS, Cockett AT, et al. Using repeated measures of symptom score, uroflowmetry and prostatespecific antigen in the

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clinical management of prostate disease. Benign Prostatic Hyperplasia Treatment Outcomes Study Group. J Urol. 1995;153:99–103.

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14. Rodrigues Netto, N. Jr et al. Latin American study on patient acceptance of the International Prostate Symptom Score (IPSS) in the evaluation of symptomatic benign prostatic hyperplasia. Urology 49, 46–49 (1997).

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15. Luján Galán, M., Páez Borda, A., Martín Osés, E., Llanes González, L. & Berenguer Sánchez, A. The validity of the IPSS questionnaire in a sample of 262 patients with

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benign prostatic hyperplasia. Arch. Esp. Urol. 50, 847–853 (1997).

16. Cam K, Senel F, Akman Y, Erol A. The efficacy of an abbreviated model of the International

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Prostate Symptom Score in evaluating benign prostatic hyperplasia. BJU Int. 2003;91:186–9.

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TABLE 1 Patients characteristics Characteristics

Value

Age (in years)

66(44-79)

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Education Level Grade < 9th (Group A)

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60/110 (54.5)

Grade > 9th (Group B)

50/110(45.5)

TABLE 2 Relationship between education level and requirement of assistance to complete the questionnaires VPSS Assistance

Group A < 9th

P Value

16/60

48/60

< 0.0001

5/50

14/50

<0.0001

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Group B > 9th

IPSS Assistance

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Group

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TABLE 3 Average time taken to fill the questionnaires Questionnaires VPSS IPSS

Time taken (in sec )

P Value

166 (30-480)

<0.0001

283(90-600)

TABLE 4 Correlation between various VPSS and IPSS parameters recorded in study

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GROUP

CORRELATION

P Value

COEFICIENT (r) 0.7235

<0.0001

IPSS total vs Qmax

-0.6287

<0.0001

VPSS total vs Qmax

-0.5782

IPSS total vs Qavg

-0.479

VPSS total vs Qavg

-0.5

IPSS total vs IPSS Qol IPSS Qol vs VPSS Qol Frequency: VPSS Q1 vs IPSS

<0.0001 <0.0001

0.65583

<0.0001

0.84093

<0.0001

0.5083

<0.0001

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Q2

<0.0001

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0.70753

<0.0001

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VPSS total vs VPSS Qol

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IPSS total vs VPSS total

0.88558

<0.0001

Poor stream: VPSS Q3 vs IPSS

0.76122

<0.0001

Poor stream: IPSS Q 5 vs Qmax

-0.7134

<0.0001

Poor stream: VPSS Q3 vs Qmax

-0.7533

<0.0001

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Q5

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Nocturia: VPSS Q2 vs IPSS Q7

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LEGENDS FIG 1 VISUAL PROSTATE SYMPTOM SCORE

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FIG 2 INTERNATIONAL VISUAL PROSTATE SYMPTOM SCORE