Qualitative insights into the experiences of living with moderate-to-severe lower urinary tract symptoms among community-dwelling ageing males
Qualitative insights into the experiences of living with moderate-to-severe lower urinary tract symptoms among community-dwelling ageing males
Lorna Kwai Ping Suen 0 1 2
Hui Lin Cheng 0 1 2
Simon Kai Wang Yeung 0 1 2
Cypher Ho Au- Yeung 0 1 2
Jillianne Chi Yen Lee 0 2
Kathy Kit Ying Ho 0 2
Natalie Ming Yan Lau 0 2
Cristina Ka Fu Ng 0 2
Iris Wai Sze Chan 0 2
0 Funding: This project was supported by the Block Grant (1-ZVD4), School of Nursing, The Hong Kong Polytechnic University
1 School of Nursing, The Hong Kong Polytechnic Univeristy, HungHom, Hong Kong, 2 Ambulatory Surgery Centre, Tseung Kwan O Hospital, Hong Kong, 3 Department of Surgery, Gleneagles Hong Kong Hospital, Hong Kong, 4 Nursing Department, Hong Kong Sanatorium Hospital , Hong Kong, 5 Operation Theatre , Princess Margaret Hospital, Hong Kong, 6 Department of Medical & Geriatric, Princess Margaret Hospital , Hong Kong
2 Editor: Jeremiah Chikovore, Human Sciences Research Council , SOUTH AFRICA
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Competing interests: The authors have declared
that no competing interests exist.
Lower urinary tract symptoms (LUTS) comprise a highly prevalent chronic condition among
the aging male population. Existing literature on the experiences of men with LUTS is scarce
given that only a few studies explored medical care-seeking behaviors and coping
strategies. The current understanding of the experiences of elderly males with LUTS is
considerably limited. Therefore, the present study aimed to identify the experiences of living with
moderate-to-severe LUTS among community-dwelling Chinese ageing males and their
coping strategies to facilitate the management of LUTS by healthcare providers.
Methods and findings
A qualitative exploratory design using thematic analysis was used. Semi-structured inter
views with 24 Chinese ageing males with moderate-to-severe LUTS were conducted.
According to the participants, LUTS adversely affect the physical aspects of their daily lives.
Most of them were unwilling to seek social support and were even embarrassed to share
this topic with their peers. A range of psychological responses could be observed from the
participants that range from regarding the condition as a natural life course to loss of one's
self-esteem. Most of the interviewees lacked knowledge and held misconceptions toward
LUTS, which prevented them from pursuing medical advice. Most of the participants also sought alternative treatments and developed self-help methods to cope with their symptoms.
LUTS affects the physical and social aspects of sufferers. The findings of this qualitative study can raise awareness about the life experiences, perceptions, misconceptions, and
help-seeking behaviors of Chinese elderly with LUTS. Proper health education and advice
can be provided for this population.
Lower urinary tract symptoms (LUTS) comprise a complex symptom cluster that encompasses
storage (e.g. nocturia), voiding (e.g. weak stream) and post-micturition (e.g. incomplete
emptying) symptoms [
]. LUTS is a highly prevalent chronic condition that affects almost half of
the world's population [
]. LUTS prevalence increases with age regardless of gender, but severe
LUTS is common among the male population [
]. The effect of LUTS among affected males is
significant and includes low quality of life (QoL), high risk of depression, sexual dysfunction
and falls [4±7].
Disease development varies across ethnicities. This observation is also true for the LUTS
prevalence, which highlights ethnical differences [
]. In the United Kingdom, a study on men
aged over 40 years showed that 36.5% of the South Asian group experienced at least one LUTS.
By contrast, only 29.0% of the Western group is affected by this problem [
Existing literature on the experiences of men with LUTS is scarce because only a few studies
explored medical care-seeking behaviour and coping strategies [10±14]. A considerable
number of studies focused on the experiences of ageing males with LUTS in the United Kingdom
], the United States [
], South Australia , New Zealand  and Central
]. However, information about this health problem is insufficient in Asian countries
]. Given that underlying ethnic, social and educational backgrounds may affect the attitudes
and coping strategies of patients [10±12], this study aimed to identify the experiences of living
with moderate-to-severe LUTS among community-dwelling Chinese ageing males and their
coping strategies to facilitate LUTS management by healthcare providers.
A qualitative exploratory descriptive design using thematic analysis was adopted in this study;
the analysis was guided by the philosophy of naturalistic enquiry [
]. Through this approach,
researchers were expected to uncover various aspects of the studied phenomenon and
underlying process, particularly when less is known about this phenomenon [
]. For the purpose of
this study, this design allowed us to explore and describe how ageing Chinese males live and
cope with moderate-to-severe LUTS in their daily lives. This study ultimately aimed to
generate new knowledge in the field. Individual face-to-face interviews were conducted because of
the sensitive nature of LUTS, which can relate to sexuality.
Setting and participants
Participants were recruited from four elderly community centres in Hong Kong that offer
social support for community-dwelling elders [
]. These participants were recruited from
this setting because it can provide researchers' access to community-dwelling elders. Purposive
sampling was employed to recruit appropriate participants who would be able to provide rich
information about their experiences with LUTS and obtain a mixture of participants with
moderate or severe LUTS symptoms. LUTS severity in each participant was assessed using the
Chinese version of the International Prostate Symptom Score (IPSS), a questionnaire for
evaluating symptom severity [
]. The participants completed the IPSS questionnaire after the
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researcher explained the items. The IPSS consists of seven Likert-scale questions (with scores
ranging from 0 `not at all' to 5 `almost always') related to LUTS. The total score ranged from
0 to 35 (1±7 = mildly symptomatic, 8±19 = moderately symptomatic and 20±35 = severely
symptomatic). Three questions involved filling problems (daytime frequency and nocturnal
urgency), whereas four questions assessed voiding problems (emptying, intermittency, weak
stream and straining). The instrument also included one question that evaluates the effect of
urinary symptoms on QoL. The scores ranged from 0 to 6 (0 = delighted, 1 = pleased, 2 = mostly
satisfied, 3 = mixed, about equally satisfied and dissatisfied, 4 = mostly dissatisfied, 5 = unhappy
and 6 = terrible). The participants were asked to urinate into a specific funnel connected to
a portable uroflowmeter (FloPoint Elite Uroflow System). This instrument was used to
measure the maximum urinary flow rate (Qmax) per second and evaluate the severity of urinary
obstruction. Only the participants with Qmax<15 mL/s were recruited.
Participants were considered eligible if they were Chinese men aged over 60 years old with
moderate-to-severe LUTS (IPSS score 12) and whose maximum urinary flow rate was
Qmax<15 mL/s for at least six months [
]. Participants with urinary tract infection or a
history of bladder surgery, prostate cancer or psychiatric illness were excluded.
The participants were screened and recruited by the trained researcher (SKWY). After consenting
to join the study, each participant was invited to an individual face-to-face interview at home or at
the elderly centre. Each semi-structured interview was limited to one participant because of the
sensitivity of the topic. The average length of each interview session was approximately 1 h.
A semi-structured interview guide was used to aid the interview and stimulate discussion
around the topic of interest. The guide was developed based on the literature review and
refined after discussions with the research team (Table 1). Open-ended and probing questions
were used to enable the participants to expand their responses and explanations, thereby
allowing the researchers to obtain significant data [
]. Probing questions are usually follow-up
questions when additional information is needed. Two researchers were involved in each
interview, and field notes were collected. Demographic data, including age, occupation,
marital status and length of time living with the symptoms, were obtained. Interviews were
audiorecorded after obtaining the consent of participants. Data saturation was reached at the 24th
participant when no new information was obtained [
Interviews were conducted in Cantonese and audio-recorded and transcribed verbatim for
subsequent data analysis. Data were coded using thematic analysis with Braun and Clarke's
]. This method is systematic and rigorous in identifying, analysing and reporting
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patterns from qualitative data chosen in relation to the research aim and objectives [
the purpose of this study, we analysed data based on the following study objective: to identify
the experiences of living with moderate-to-severe LUTS among community-dwelling ageing
Chinese males and their coping strategies to facilitate the management of LUTS by healthcare
providers. Braun and Clarke's analytical approach involves six steps, namely, a) data
familiarisation by repeated reading, b) generating initial codes, c) searching for themes, d) reviewing
potential themes, e) defining and naming themes and f) producing the report. Three research
team members (HLC, SKWY and CHAY) worked together to develop a coding scheme by
comparing and contrasting the findings across the interview data. Disagreements or
discrepancies in the coding scheme were resolved through group discussions until a consensus was
reached. Selected quotes were translated to English so that they can be cited in the publication.
The trustworthiness, including credibility, transferability, dependability and confirmability
of this study, was established by adhering to evaluative criteria by Lincoln and Guba [
Credibility refers to confidence in the truth of the data. For this study, we established
credibility by the following techniques including prolonged engagement with participants and
triangulation across different researchers. Through prolonged engagement, participants built trust
with the researchers, and they felt comfortable to share their experiences during the interview.
For triangulation across different researchers, the data were analysed using more than two
researchers to allow multiple interpretations and expand the depth of insights into the data,
consequently enhancing the credibility of data analysis. The first author (LKPS) regularly
discussed with the study team and randomly selected cases to ensure consistency between data
and researchers' interpretations. Transferability refers to the generalisability of the data.
Transferability was achieved by purposively sampling appropriate participants who were able to
provide thick and rich descriptions of the study phenomenon. Dependability reflects the
consistency of findings. We used a semi-structured interview guide to aid the interview and
stimulate discussion around the topic of interest. Audit trails for both study processes and products
including audio-recording files, transcripts, data deduction and analysis tables and other
discussion notes were kept to allow for verification by the first author (LKPS). Confirmability
refers to the neutrality of the findings. During data collection and analysis, the researchers
disregarded their knowledge, beliefs, values and experiences about LUTS to avoid researcher bias.
Audit trails and reflective journals were applied to enhance the study confirmability.
Ethical approval was obtained from the Human Subjects Ethics Subcommittee of the Hong
Kong Polytechnic University [HSEARS20140515003]. Consent was obtained before
audiorecording the interviews. The interviews were held in locations where absolute privacy was
guaranteed. To ensure the confidentiality of the collected data, the research team restricted
data access to the group alone. Participation was on a voluntary basis, and the participants
could withdraw from the study at any time.
Twenty-four participants were interviewed, and data saturation was reached. Fifteen men
presented moderate symptoms, and nine men presented severe symptoms. The IPSS scores of
the participants ranged from 12 to 35 (mean = 18.71), with a mean Qmax of 9.93 mL/s. The
mean age of the participants was 75.21 years (range = 65 to 87 years). The average number of
years living with LUTS was 6.38 years (range = 1 to 29), generally with unsatisfactory QoL
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IPSS score: 8±19: moderately symptomatic; 20±35: severely symptomatic. Only moderate-to-severe LUTS (IPSS score > = 12) were recruited; QoL:
Quality of life, with the score ranging from 0 to 6(0 = delighted, 1 = pleased, 2 = mostly satisfied, 3 = mixed, about equally satisfied and dissatisfied,
4 = mostly dissatisfied, 5 = unhappy, 6 = terrible); Qmax: maximum urinary flow rate per second. Only participants with Qmax< 15 mL/s were recruited.
(mean = 3.17). Majority of the participants (n = 15) received education up to the primary
school level, and nearly all of them were married (n = 23). Table 2 presents the demographic
and clinical characteristics of the participants.
The experiences of participants living with LUTS were grouped into three categories as
follows: (1) effect of LUTS, (2) perceptions and misconceptions and (3) managing LUTS (S1
Table). The consolidated criteria for reporting qualitative research (COREQ) were used, which
consisted of a 32-item checklist for interviews (S2 Table) [
1. Effect of LUTS
1.1. Frequent uncontrolled urinary habit. Among the different LUTS symptoms, the
most bothersome complaints of the participants included frequent urination, urge
incontinence, intermittent and slow urination and incomplete emptying. Ten participants experienced
frequent urination during day time, which was manifested in urination every less than 2 h.
Most of the time, I feel an urgent need to pee, and I always get my pants wet when I take off
my pants too slowly. (P7, moderate LUTS)
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If I feel an urgent need to pee, I can’t hold it. I have to pee before getting on the bus. If there
was a traffic jam, I would need to hold [urination] for one hour. I am fine with one hour only.
(P8, moderate LUTS)
My urinal flow often slows down and eventually stops. Then, I massage my penis and use force
to push it [urine] out. Sometimes, there is something inside blocking my urethra. My urinal
flow may suddenly stop, and then starts dripping. Once you think it [urination] is done, it
starts to drip again. (P6, severe LUTS)
The most troublesome symptom is incomplete emptying. I find it bothersome, especially when I
am on the street and in public areas. Sometimes, urine suddenly flows out, causing my pants to
get wet. (P9, severe LUTS)
Nocturia was a common symptom cited by all participants. They explained having to get up
to urinate at least three to four times a night. Three participants with severe nocturia reported
needing to urinate six to seven times a night. Sleep quality was affected in each case.
I need to wake up five to six times a night to urinate. Last night, I still had to urinate even
after urinating six to seven times. Usually, I must wake up every 1–1.5 hours (P20, moderate
1.2. Avoidance of social activities and a strain on relationship. Some of the participants
felt that LUTS affected their social activities and led to avoidance of social situations,
long-distance travel and other events that lack easily accessible toilets.
I want to go somewhere far, but I dare not to. Finding a toilet (in a public area) is very
troublesome. Sometimes, the elderly center has activities, such as travelling, but I dare not join any of
these activities. (P21, severe LUTS)
The symptoms also affected the peer relationships of some of the participants. Most of them
coped with the problems on their own and were unwilling to seek social support because they
viewed LUTS as an embarrassing topic to share with others.
No, we never talk about this problem. We usually do not talk about personal issues. It is
embarrassing. (P20, moderate LUTS)
The unwillingness to share with others, including one's family members, was commonly
observed among the participants. Thus, family relationship was negatively affected. Several
men slept separately from their spouse because of frequent nocturia. One man even claimed
that his spouse blamed him for frequent urination.
We sleep in different rooms. I feel troublesome because I always have to go to the toilet. This is
inconvenient for both of us. (P21, severe LUTS)
Not all participants actively responded when asked about the effect of LUTS on their sex
lives. Seven participants reported diminished sexual activities even before the LUTS onset, and
eight participants reported being sexually active. Regardless of the status of their sex life, all
participants acknowledged a decline in sexual desire and functioning as a result of ageing,
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particularly for elderly men with multiple co-morbid conditions. Three participants believed
that LUTS was associated with sexual dysfunction.
I do not have any sexual desires anymore, and it is difficult for me to get an erection during
sexual activities. (P13, severe LUTS)
I think that the decline in the ability to urinate and the decline in sexual ability are related.
(P14, moderate LUTS)
1.3. Psychological responses towards LUTS. Majority of the participants (n = 15)
reported that LUTS exerted no psychological effect because they believed that LUTS was a
consequence of normal ageing and a process of `letting nature take its course'.
No, no, no. I do not think this (LUTS) problem has any impact on me. The only inconvenience
is the need to go to the washroom more frequent than usual. I do not think it is a big problem.
I do not even mention this to my family (P3, moderate LUTS)
I do not feel guilty. LUTS are natural. Most elderly people have problems as they grow older.
Staying perfectly healthy is unrealistic. I do not feel embarrassed when nature takes it course.
Going to the toilet frequently is a sign of old age, and it is an inevitable deterioration. (P5,
Every older friend of mine has health issues, and there is no way for us to stop aging. We are
bound to have some health problems. (P8, moderate LUTS)
This problem does not cause me big trouble. The only thing I would say is. . ..I often go to
Guangzhou (city of China). I would not take the bus going there anymore. Rather, I like to
take the train, which has the toilets in it. (P24, moderate LUTS)
Some participants (n = 7) experienced negative emotions associated with LUTS. They
reported being embarrassed when they had to urinate frequently during social activities and
when they experienced incontinence at various instances.
LUTS have caused a bit, but not a lot, of embarrassment. Sometimes I would be laughed at
when I need to go to the bathroom amid a meal with friends. (P4, moderate LUTS)
It makes me feel bad to walk away to use the bathroom when my friends are gathered and
having fun. Like in yum cha (Chinese style brunch tea), everybody is interacting happily, and
walking away alone makes me feel isolated. (P15, moderate LUTS)
One participant disclosed that he became less confident, isolated himself and felt powerless
over his body and surroundings due to his LUTS.
I could no longer travel long distances after having LUTS. This affects my self-esteem. My
friends invited me to go out of the country, and they would even pay for my expenses. However,
I did not accept their offer because of LUTS. . .I had many friends when I was young. After I
retired, I isolated myself. . .I feel like I can do little for my body or the environment around me.
(P15, moderate LUTS)
A few participants were worried about the progression of symptoms. Their concerns
stemmed largely from their fear of developing urinary incontinence and consequently
becoming dependent on others for the rest of their lives.
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Patients in hospitals may not get out of bed freely. So, they must poo and pee in bed. . .. It is
distressing to have somebody else take care of your excretion. (P11, moderate LUTS)
2. Perceptions and misconceptions
2.1 Influenced by social media. The knowledge of the participants about LUTS
originated primarily from newspapers and the Internet and partly from attending health talks in
elderly centres. Although they were keen on learning how to lead good lives with LUTS, they
seldom sought information from health professionals.
When I learned about the effect of lycopene on alleviating LUTS from the newspaper, as well
as the Internet, I tried it to see if it would work or not. It was the information that I searched
on my own. (P2, moderate LUTS)
I tried lycopene tablets because of the advertisement on the newspapers. (P3, moderate LUTS)
2.2 Misconceptions of LUTS. Majority of the participants lacked knowledge about LUTS,
and some even admitted that they had no idea about the topic. Some of their conceptualised
causes and nature of LUTS showed a certain degree of misconceptions. For example, some of
them believed that LUTS was attributed to natural ageing and essentially untreatable.
I think it is normal. These problems arise as we become older. They are untreatable, and
will continue like this. The function has already declined. It cannot be treated. (P22, severe
Two participants related LUTS to cancers. One of them believed that pain indicated cancer,
and the other believed that LUTS was exclusive to men and equivalent to benign prostatic
hyperplasia (BPH) and potential cancer.
It is called prostate, BPH. . .and may lead to cancer and tumor. (P1, moderate LUTS)
One participant expressed his belief about the causal effect of frequent sexual activities on
one's prostate problems.
Men’s prostate (problems) are related to their sexual activities, but it does not mean that sexual
activities are harmful. (P3, moderate LUTS)
Two participants associated LUTS with their dietary habits, such as eating `liang-ye', which
are dishes that are `cool' in nature based on the teachings of traditional Chinese medicine
If I ate some ‘liang-ye’, I would urinate frequently in the day time and at night. Nothing
happens when I do not eat it. (P7, moderate LUTS)
One participant considered an unhealthy lifestyle as a possible reason for LUTS.
Nothing is more important than a healthy lifestyle, including keeping fit, not smoking and
drinking alcohol, as well as not having an affair outside of marriage. For eating habits, you
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should take care of it. It (healthy lifestyle) is also associated with a positive mind because
depression would worsen the problem. (P4, moderate LUTS)
3. Management of LUTS
3.1 Attitudes towards Western treatment approaches. LUTS affected the participants in
different ways, but eight participants never sought medical consultation for their LUTS
problem because of various reasons. Ten participants mentioned that seeking medical help was
unnecessary because the symptoms were tolerable at the moment. Three participants
expressed reluctance to see doctors because they were worried that they would be prescribed
with additional medications.
I did not go to a urologist because [the impact of LUTS on] my daily life is acceptable. I did not
even discuss my symptoms with my general practitioner because they are not very severe. (P17,
I do not want to see a doctor for my urinary problem because I am already taking many
medications, including those for blood pressure and high blood sugar and cholesterol level. I am
already taking so many medicines. I would rather adjust my lifestyle and diet [for LUTS]. (P1,
Only one participant received operation for LUTS, and three received Western medication
for this problem but quit due to ineffective treatment or worried about side effects of
treatment. Two participants strongly opposed using surgical approach for dealing with LUTS for
fear of a Foley catheter or that the treatment might recur after surgery. However, a significant
number of participants (n = 10) expressed that if LUTS deteriorates, they would prefer
receiving Western treatment instead of other treatment approaches, such as TCM.
I think the effect of the western treatment is so so. . .it is better than taking nothing. . ..I always
think that these drugs may have some side effects on my other organs. . .I have this thinking
probably due to my innocence to these drugs. (P7, moderate LUTS)
I feel embarrassed if there is a tube (Foley catheter) inserted on me after operation. . .I am
truly frightened if it occurs on me. Also, I know someone whose (LUTS) condition recur even
after surgery. (P12, severe LUTS)
If I cannot pass urine one day, I will certainly go to the medical doctor and seek for treatment.
I will not consider going to TCM doctor because the treatment effect comes slower. (P17,
3.2 Seeking alternative treatment approaches and dietary manipulation. Although
most of the participants sought Western medical advice, some of them sought alternative
treatments, such as TCM, phytotherapeutic agents and supplements.
It is controlled by (Western) medicine, but the low dosage is already intolerable. I asked the
Chinese medicine practitioner for (Chinese) medicine on my own. Otherwise, I cannot void.
(P23, severe LUTS)
My neighbor recommended me to use lycopene. It is quite expensive, and I bought it from the
chemist. I tried it for several months but find ineffective (P5, severe LUTS)
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For some participants who strongly believed in the association between diet and LUTS,
they either avoided taking `liang-ye' or ate foods that could help alleviate LUTS. Nearly half
(n = 11) of the participants claimed that they adopted dietary manipulation. Tomatoes and
other food products were mentioned.
I think drinking too much herbal teas (one type of ‘liang-ye’) is the reason why I urinate so
many times. When I stop drinking these herbal teas, my condition gets better. (P7, moderate
I am fond of eating a lot of tomatoes. I eat a lot of tomatoes when there are tomatoes in the
dishes. Sometimes, I buy a lot of pumpkin seeds and white melon seeds to eat. They are good
for improving LUTS. (P4, moderate LUTS)
3.3 Self-management strategies and lifestyle modification. Instead of actively seeking
medical help, some of them chose to adopt self-management strategies to prevent the
increasing severity of their LUTS. Most of the participants attempted to cope with the problem by
making certain changes in their lifestyle.
Only two participants mentioned exercise to maintain health and cope with the problem.
Doing more exercise makes me feel more energetic. It helps the situation. (P2, moderate LUTS)
Most of the participants reduced urinary frequency through fluid restriction.
I dare not drink too much tea. I also dare not drink water a few hours before sleeping or going
out. (P21, severe LUTS)
In addition to lifestyle modifications, the participants used other strategies to manage
LUTS. One man believed that staying positive could help in dealing with the situation, and
another sought comfort by comparing himself with others.
To be honest, when I go to the toilet, I see people standing to urinate, but some of those who
are the same age as me are still standing there long after I have finished and am about to leave.
This is why I comfort myself with the knowledge that my condition is not that bad. (P24,
Finally, some comments demonstrated cognitive manipulation to adapt to the problem.
Two participants did not think about the problem, and one felt good by not thinking about it
or by just `letting nature take its course'. Two others mentioned that the use of willpower could
control urinary frequency.
I have not prepared any special diet for my health. I did not even try beneficial foods
recommended by others. Just let nature take its course. (P5, severe LUTS)
Sometimes, it is about willpower. If you are psychologically prepared, the time between
urination can be longer. (P1, moderate LUTS)
Majority of the participants attributed LUTS as a natural ageing problem and did nothing
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Effect of LUTS
Urination difficulties were manifested among the participants in several ways. Some men had
to void often and went to the toilet as soon as they felt the need to void. Otherwise, they would
wet their trousers. Some men also reported a sting in the urinary tract and dribbling. Almost
half of the participants suffered from nocturia, which affected their sleeping quality.
According to the participants, LUTS affected their social activities and led to their
avoidance of social situations, long-distance travel and other events that lacked easily accessible
toilets. This observation matched the findings of Pinnock et al. [
], who conducted 19 focus
group studies in South Australia. They found that access to toilets in a shopping centre or a
bus stop can determine whether men with LUTS would participate in outings. In a
hermeneutic phenomenological study in the United Kingdom, the participants expressed
embarrassment for having to go to the toilet regularly, particularly when socialising in the presence of
family and friends .
Most of the participants were unwilling to seek social support and even embarrassed to
share this topic with their peers. This phenomenon was also observed in people from other
countries. Men in South Australia were reluctant to talk about their health, particularly those
topics that pertain to urinary or sexual problems [
]. In a Korean study, approximately 42.7%
of community-dwelling elderly with BPH never consulted anyone about their symptoms [
Contrary to Western literature, majority of the participants in our study reported that
LUTS showed minimal psychological effect, and they accepted these symptoms. They
considered LUTS as part of the normal ageing process and a process of `letting nature take its course'.
This finding may be governed by the underlying traditional Chinese philosophy that sickness
is part of life [
]. The cultural stereotype of the elderly as individuals who suffer from multiple
diseases may further affect participants' perception that LUTS is normal among ageing males.
These findings are consistent with those of Chinese cultural studies, which indicated that
individuals accept their diseases and embrace their fate [
]. Chinese naturalistic philosophy based
on Taoist principles may influence the perceptions and actions of elderly Chinese men [
Birth, ageing, sickness and death are viewed as parts of one's lifecycle that nobody can escape.
People should live in harmony with nature and accept the natural process of life [
Even though many participants claimed that LUTS was part of normal ageing and accepted
it as a nature of life, various emotional distresses, which included self-blaming and the feelings
of being troublesome, miserable, hopeless, sad and embarrassed, were also reported. In the
current study, LUTS severity was significantly correlated with life quality as reflected in the
generally unsatisfactory QoL of the interviewees (mean = 3.17). Urological symptoms may
exert adverse effects on the psychological well-being of men by affecting their emotions. These
conditions reduced the functions and QoL of patients [
]. Schulman et al. [
suggested that sleep disruption negatively affects mental health, reduces work performance, causes
memory impairment and induces depression. In a large prospective cohort of 2000 Chinese
men in Hong Kong, moderate-to-severe LUTS was significantly associated with increased
odds of having clinically relevant depressive symptoms even after adjustment .
Although the pathogenesis of the relationship between LUTS and erectile dysfunction is
unclear, various studies reported that sexual disorders increase with age and LUTS severity.
When the participants in the current study were asked about the effect of LUTS on their sexual
lives, only three participants mentioned the relationship between LUTS and sexual function.
This result suggests that sexuality is a sensitive and embarrassing topic among the elderly
Chinese population and is difficult to discuss openly. Despite the prevailing recognition in
Western society that LUTS adversely affects the sexual lives of the male population [36±38], half of
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the participants in our study already stopped having sexual activities even before the LUTS
onset. The remaining number of participants reported being sexually active, with very few
reporting sexual dysfunction. In Chinese culture, men accept decreased sexual desire or sexual
dysfunction as part of ageing [
]. An active sexual life is considered inappropriate,
particularly for the elderly. Traditional Chinese philosophies view sexuality as only a function of
procreation rather than a source of pleasure or enjoyment [
]. This view may explain the
discrepancies between our findings and those of Western populations. In addition, several
participants reported sleeping separately from their spouses to minimise the disturbance caused
by nocturia. This finding may be a distinct feature of Chinese couples or a coping method to
maintain spousal relationship when problems arise.
Perceptions and misconceptions
The current study indicated that most older Chinese men in Hong Kong lacked the knowledge
or even held misconceptions about LUTS. Some of them believed that LUTS was caused by
natural ageing and untreatable. A few related LUTS to cancers and even believed that frequent
sexual activities caused prostate problem.
Misconceptions among the elderly men are also common in other countries, such as Korea
] and Spain [
], wherein a high proportion of affected men do not seek medical advice
because they believe that LUTS is part of natural ageing. Thus, seeking medical help is
unnecessary. This result reflects the low rates of medical help consultation found in other studies
because of this misconception [
]. In the present work, one participant believed that LUTS
was the same as BPH, and another participant believed that BPH was directly related to cancer.
In a qualitative study conducted in the United States, 67% of the participants believed that
BPH (a common cause of LUTS) and cancer are associated; BPH surgery is performed for
cancer removal or BPH leads to cancer . One participant believed that LUTS only occurs in
males. The present study explicitly indicated that many older Chinese men may possess limited
knowledge about LUTS. Therefore, health educational interventions should be provided to
instill correct knowledge, empower the development of customised coping strategies and
encourage patients to seek medical consultation and care from health professionals for their
LUTS. In a randomised control study among 109 BPH patients, patient counselling was able to
significantly improve the knowledge, symptoms, management, treatment outcomes and QoL
of patients [
A number of participants (n = 10) expressed that if LUTS deteriorates or when some intolerant
symptoms arise, they would prefer receiving Western treatment instead of other treatment
approaches. However, their failure to detect symptoms that may indicate a serious condition
and their tendency to delay seeking medical attention can lead to kidney disease, urinary tract
infections and bladder damage . In a qualitative study conducted in Finland, pre-operative
medical investigations, endoscopy and decision making with regard to treatment are anxiety
provoking and difficult [
]. Therefore, health-care professionals should provide these patients
with sufficient knowledge and offer consultations to encourage them to participate in the
In this study, majority of the participants sought alternative treatments, such as TCM,
special voiding positions and phytotherapeutic agents and supplements, including lycopene
tablets and dietary consumption of tomatoes, pumpkin seeds and white melon seeds. Given that
lycopene belongs to the carotenoid family and mostly exists in nature [
], we found that
participants in this study preferred to consume great amounts of tomatoes in their diet. However,
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scientific evidence about the role of lycopene in combination with Serenoa repens (a
phytotherapeutic agent) in the management of LUTS secondary to BPH remains limited [
further studies should be conducted to gather scientific evidence that supports the effectiveness
of these supplements in managing LUTS.
A number of participants believed that the consumption of `liang-ye' may cause frequent
urination. Since the ancient times, TCM practitioners have recognised dietotherapy and used
the `warm' and `cool' nature of food to achieve body equilibrium [
]. From the TCM
perspective, frequent urination and dripping urination may be due to `deficiency cold' of the lower
jiao (pelvic region) [
]. Therefore, further consumption of `liang-ye', such as green tea,
melons, soy beans and pears, may aggravate LUTS. Meanwhile, difficulty in urination, dripping
urination and pain in micturition may be caused by `stagnation of damp heat' in which food in
`cold' nature may be beneficial [
]. Therefore, rehabilitation with diet should be guided by the
differentiation of syndromes and correct diagnoses if TCM principles are to be followed.
One participant shared his successful experience of using a specific voiding posture (i.e.
standing with heel raised during voiding) for complete bladder emptying. Previous studies did
not specifically investigate this specific voiding posture. However, a recent systematic review
indicates the influence of voiding position on the urodynamic profile of patients and reported
that sitting position can significantly decrease the post-void residual urine volume in patients
with LUTS [
]. Standing with heels raised may require abdominal muscle contraction to
maintain balance. This posture can increase intra-abdominal pressure and influence post-void
residual urine volume. Therefore, further research regarding the effects of different voiding
positions and their effects on the urodynamic profile of patients should be conducted.
Most of the participants tried to reduce urinary frequency through fluid restriction. Elstad
et al. [
] revealed that fluid manipulation is a common self-coping strategy used by
individuals with LUTS. Nevertheless, improper fluid restriction may negatively affect the health of
patients. Therefore, individuals with LUTS may need guidance in fluid management. In
addition, several participants mentioned performing exercises as a method to improve their LUTS
status. This method is a possible coping strategy for people who have LUTS. A recent
crosssectional study conducted by Fowke et al. [
] showed that high energy expenditure during
leisurely physical activities and light housework activities is significantly associated with low
LUTS severity. Surprisingly, some men cope with LUTS using their willpower to control
urinary frequency, cognitively ignore the problem or maintain a positive mood to alleviate their
Limitations and future directions
The major limitation of this study was that the subjects were recruited only from the
community centres in which majority of the participants were not receiving treatment using medical
or surgical approaches. Thus, the profile of participants was not varied enough to obtain data
saturation on the overall experience of ageing males with LUTS. As the participants were all
elderly men, the exploration of sensitive areas, such as the effect of LUTS on sexuality in some
of the participants, was hindered because of their hesitation to share with young female
interviewers. Future studies may consider extending the subject recruitment in other settings (e.g.
hospitals and urological clinics) to understand the motivation and challenges of those patients
who have adhered to active treatment to manage this problem.
The life experiences of older Chinese men with LUTS indicated that this condition could
adversely affect the physical aspects of their daily lives. Most of the participants were unwilling
13 / 17
to seek social support and even embarrassed to share this topic with their peers. Nevertheless,
majority of the participants reported that LUTS exerted no psychological effect because they
believed LUTS was a consequence of normal ageing and in `letting nature take its course'.
Most of the interviewees lacked knowledge about LUTS and held misconceptions about the
condition. This limitation prevented them from pursuing medical aid. Most of the participants
also sought alternative treatment and developed self-help methods to cope with the symptoms.
The strategies employed by the participants included use of Chinese medicine, supplements,
dietotherapy, specific voiding posture, fluid restrictions, exercise and the use of willpower to
alleviate the problem. The findings of this qualitative study can raise awareness about the life
experiences, perceptions, misconceptions and health-seeking behaviour of ageing Chinese
males with LUTS. This study can provide proper health education and advice for this
S1 Table. Categories of the experiences of community dwelling aging males living with
lower urinary tract symptoms.
S2 Table. COREQ checklist.
We extend our appreciation to the elderly centers and the subjects for their sincere support for
Conceptualization: Lorna Kwai Ping Suen, Jillianne Chi Yen Lee.
Data curation: Lorna Kwai Ping Suen, Hui Lin Cheng, Simon Kai Wang Yeung, Cypher Ho
Au-Yeung, Jillianne Chi Yen Lee, Kathy Kit Ying Ho, Natalie Ming Yan Lau, Cristina Ka
Fu Ng, Iris Wai Sze Chan.
Formal analysis: Lorna Kwai Ping Suen, Hui Lin Cheng, Simon Kai Wang Yeung, Cypher Ho
Au-Yeung, Jillianne Chi Yen Lee, Kathy Kit Ying Ho, Natalie Ming Yan Lau, Cristina Ka
Fu Ng, Iris Wai Sze Chan.
Funding acquisition: Lorna Kwai Ping Suen.
Investigation: Lorna Kwai Ping Suen.
Project administration: Lorna Kwai Ping Suen.
Resources: Lorna Kwai Ping Suen.
Supervision: Lorna Kwai Ping Suen.
Methodology: Lorna Kwai Ping Suen, Jillianne Chi Yen Lee, Kathy Kit Ying Ho, Natalie Ming
Yan Lau, Cristina Ka Fu Ng, Iris Wai Sze Chan.
Validation: Lorna Kwai Ping Suen, Hui Lin Cheng, Jillianne Chi Yen Lee.
Writing ± original draft: Lorna Kwai Ping Suen, Hui Lin Cheng, Simon Kai Wang Yeung,
Cypher Ho Au-Yeung.
14 / 17
Writing ± review & editing: Lorna Kwai Ping Suen, Hui Lin Cheng.
15 / 17
16 / 17
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