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ORIGINAL ARTICLE
Year : 2023 | Volume
: 34
| Issue : 4 | Page : 199-203
Prevalence and risk factors of postmicturition dribble in men
Shih-Ping Liu1, Po-Wei Ko2, Chen-Hsun Ho3
1 Department of Urology, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
2 Division of Urology, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
3 Division of Urology, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei; School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
Correspondence Address:
Chen-Hsun Ho
No. 95, Wen Chang Road, Shih Lin, Taipei City 11101
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_110_22
Purpose: We investigated postmicturition dribble (PMD) prevalence rates and risk factors in men. Materials and Methods: This cross-sectional study included 1037 men aged 31–86 years who participated in a male health survey. PMD was defined by involuntary urine loss immediately after urine was passed and was scaled from 0 to 5, depending on symptom severity. A score of ≥3 was considered significant PMD. PMD prevalence was also determined by age group, and logistic regression analyses were performed to identify risk factors. Results: The mean age of participants was 55.3 ± 8.9 years. Overall, 232 (22.4%) reported significant PMD. PMD prevalence significantly increased with age (P = 0.013): it was 18.2%, 17.2%, 20.8%, 28.7%, and 30.1% in men aged 30–39, 40–49, 50–59, 60–69, and ≥70 years old, respectively. Univariate analyses revealed that age, peak flow rate (Qmax), and prostate specific antigen levels were associated with significant PMD, while in multivariate analyses, only decreased Qmax was an independent risk factor. Conclusion: PMD was identified as a common condition in men across all age groups, and its prevalence significantly increased with age. The condition correlated more with voiding symptoms when compared with storage symptoms, and was associated with decreased Qmax.
Keywords: Dribble, lower urinary tract symptoms, postmicturition, prevalence, uroflowmetry
Postmicturition dribble (PMD) is defined by the International Continence Society (ICS) as the involuntary loss of urine immediately after an individual has finished passing urine, usually after leaving the toilet for men or after rising from the toilet for women.[1] PMD is also a common reason for urological consultation, is considered one of the most bothersome lower urinary tract symptoms (LUTSs), and exerts a significant negative impact on the quality of life.[2] While underlying pathophysiological mechanisms are not fully understood, it is hypothesized that PMD in men arises from significant amounts of urine trapped in the urethra, which could be a penile, bulbar, or prostatic segment.[3] This was considered associated with various urological conditions, including benign prostatic hyperplasia (BPH), chronic prostatitis, chronic pelvic pain syndrome, urethral diverticulum, and urethral stricture;[3],[4] however, in many cases, patients do not have any of these urological diseases.
Compared with other LUTS, such as an overactive bladder, nocturia, and incontinence, epidemiological PMD data have been scarcely reported. The EPIC study reported that 16.9% of men aged ≥18 years experienced postmicturition symptoms,[5] while the EpiLUTS study reported that 29.7% of men aged ≥40 years reported some postmicturition incontinence.[6] However, intriguingly, these studies did not report postmicturition symptom prevalence in different age groups given that many LUTS types increase with age. To the best of our knowledge, PMD prevalence across all age groups has only been reported in a few studies.[2],[7],[8] However, variations in race, region, and PMD definitions make it difficult to draw satisfactory conclusions on PMD epidemiological characteristics.
In this study, we examined PMD prevalence in men across all age groups. We developed a single question to assess PMD severity based on the 2002 ICS definition.[1] We also explored risk factors for PMD.
Materials and MethodsStudy design and subjects
This cross-sectional study included 1037 men aged 31–86 years who voluntarily underwent a male health survey at the Health Management Center of the National Taiwan University Hospital in 2009. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study protocol was approved by the Institutional Review Board (IRB) of the National Taiwan University Hospital (201207058RIC). All data were de-identified, and the IRB waived the requirement for informed consent.
Basic data collection
Participants were administered a questionnaire, including questions on their basic demographics and medical histories. They were then interviewed by a physician, and history-taking and physical examinations were performed. LUTS were comprehensively assessed. Participants were also asked to complete the International Prostate Symptom Score (IPSS) questionnaire.
Assessing postmicturition dribble
PMD symptoms were assessed with the question, “During the past month, how often have you experienced involuntary loss of urine immediately after you finished passing urine, usually after leaving the toilet?” Question responses were summarized using a score range of 0–5:0 referred to “not at all;” 1 referred to “<1 in 5 times;” 2 referred to “<½ the time;” 3 referred to “about half the time;” 4 referred to “more than half the time;” and 5 referred to “almost always.” A score of ≥3 was considered significant PMD. Both IPSS and PMD questionnaires were completed by study participants. A trained study nurse was on hand to help complete questionnaires, but only when asked by participants. Few participants required assistance.
Uroflowmetry
Participants were asked to drink water until a comfortably full bladder (to personal levels) was achieved and then instructed to void in a standing position into an uroflowmeter, which yielded peak flow rate (Qmax) data.
Statistical analyses
Continuous data are presented as the mean ± standard deviation, and categorical data are presented as counts and percentages (%). Whole population characteristics were described, including age, body mass index (BMI), obesity (waist >90 cm), diabetes mellitus, hypertension, hyperlipidemia, cardiovascular diseases (CVDs), LUTS, BPH history and treatment, uroflowmetric parameters, and prostate volume. PMD prevalence in the whole population and age groups (per 10 years) was determined. PMD severity score correlations with IPSS symptoms (individual score, voiding subscore, storage subscore, and total score) were determined using Spearman's correlation tests. To determine risk factors for significant PMD (PMD score ≥3), univariate logistic regression analyses were performed to test PMD associations with variables, including age, BMI, obesity (waist >90 cm), diabetes mellitus, hypertension, hyperlipidemia, CVD, Qmax, and serum prostate specific antigen (PSA) levels. Multivariate logistic regression analyses were further performed to determine independent significant predictors for PMD incidence. Results were presented as odds ratios (ORs) with corresponding 95% confidence intervals (95% CI). All statistical assessments were two-sided, and a P < 0.05 value was considered statistically significant. Statistical procedures were performed using SPSS 19 (SPSS Inc., Chicago, IL, USA).
ResultsThe characteristics of the 1037 men are shown in [Table 1]. The mean age was 55.3 ± 8.9 years. Overall, 650 (62.7%) participants reported PMD ≥1, and 232 (22.4%) reported PMD ≥3 (significant PMD). Significant PMD prevalence was significantly increased with age [P = 0.013, [Figure 1]], which was 18.2% in men aged 30–39 years, 17.2% in the 40–49 years group, 20.8% in the 50–59 years group, 28.7% in the 60–69 years group, and 30.1% in those aged >70 years [Figure 1].
PMD scores were significantly correlated with all items in the IPSS questionnaire: IPSS voiding subscores, storage subscores, and total scores [all P < 0.001; [Figure 2]]. The relationships between PMD and assessed LUTS were weak to moderate. Spearman's rank correlation coefficients were highest with incomplete emptying (r = 0.549), followed by intermittency (r = 0.445) and weak stream (r = 0.415); the coefficient was higher with the voiding subscore (r = 0.560) when compared with the storage subscore (r = 0.413).
Figure 2: Correlation of postmicturition dribble scores with International Prostate Symptom ScoreUnivariate analyses revealed that age (OR 1.03, 95% CI: 1.01–1.05, P < 0.001), Qmax 10–15 mL/s (OR 1.67, 95% CI: 1.18–2.36, P < 0.01), Qmax <10 mL/s (OR 2.84, 95% CI: 1.83–4.39, P < 0.001), and PSA (OR 1.14, 95% CI: 1.06–1.23, P < 0.01) were associated with significant PMD. From multivariate analyses, only decreased Qmax remained an independent factor [Table 2].
Table 2: Univariate and multivariate analyses assessing the odds ratio and the 95% confidence interval of clinical parameters for significant postmicturition dribble (postmicturition dribble score ≥3) Discussion We examined PMD prevalence and risk factors and observed that significant PMD prevalence increased with age; 18.2%, 17.2%, 20.8%, 28.6%, and 30.1% in men aged 30–39, 40–49, 50–59, 60–69, and ≥70 years, respectively. PMD severity correlated with all symptom domains in the IPSS questionnaire, with greater coefficients identified with voiding symptoms (incomplete emptying, intermittency, and weak stream) compared with storage symptoms. Furthermore, low Qmax was independently associated with significant PMD, which suggested that PMD could be attributed, at least partially, to voiding dysfunction.
To our knowledge, only a few studies have investigated PMD prevalence. The Boston area community health survey showed that PMD symptom prevalence was 11.8% in men and 8.5% in women; prevalence increased with age in men but not in women. Furthermore, PMD symptoms indicated an impaired health-related quality of life.[9] The EPIC study reported that 16.9% of men aged ≥18 years had PMD symptoms,[5] while the EpiLUTS study revealed that 29.7% of men had at least some experience of postmicturition incontinence.[6] More recently, three studies reported PMD prevalence in different age groups. The Tampere Aging Male Urologic Study included 4383 Finnish men aged 30–80 years where PMD was defined by a yes/no question, “do you experience dribbling after voiding when you feel you have finished urination?” The study revealed that 17.0%, 20.0%, 20.7%, 23.0%, 28.0%, and 26.9% of men in their 30s, 40s, 50s, 60s, 70s, and 80s, respectively, experienced urine dribble into their trousers.[7] A Korean study assessed PMD using the question, “over the last month, how often have you experienced dribbling after voiding when you feel you have finished urination?” Participants reporting the aforementioned symptoms in 1/3 voids were considered having PMD. The study included 2134 male patients aged 40–91 years, of which 1088 (51.0%) reported PMD. The PMD prevalence was 51.3%, 52.2%, 55.6%, and 41.4% among participants aged 40–49, 50–59, 60–69, and 70 years or older, respectively. PMD prevalence increased with age until 70 years, after which it decreased.[8] A Japanese study of 172 men aged 40–79 years used a questionnaire similar to our study and defined PMD as more than “<½ the time” (equivalent to a PMD score of ≥3 in our study) as significant PMD. The PMD prevalence in men in their 40s, 50s, 60s, and 70s was 13.6%, 39.0%, 44.2%, and 41.2%, respectively.[2] Although assessment questionnaires and PMD definitions differed in studies to some extent, PMD prevalence in our study was generally comparable with Korean[8] and Japanese[2] studies if the same cutoff value, i.e., PMD severity, was applied. However, distinct from these studies, a Japanese survey of 3224 men revealed that the prevalence of postmicturition urinary incontinence was constant across generations (6.5% in men in their 30s, 6.6% in their 40s, 6.0% in their 50s, 6.3% in their 60s, and 5.1% in their 70s).[10] The authors concluded that postmicturition incontinence did not arise from mechanical or functional dysfunction induced by aging.[10]
Different mechanisms underlying PMD have been proposed to explain PMD development; however, no consensus exists.[11] It is hypothesized that PMD is a failure of the bulbocavernosus muscle to perform normal reflex postvoid evacuating mechanisms in the urethra.[12] Bulbar urethral massage and pelvic floor exercises have been proposed as PMD treatments.[4],[13],[14] It was also reported that prostate enlargement, urethral stricture, and congenital diverticulum may contribute to PMD.[15] Two previous studies using video cystourethrography demonstrated that PMD resulted from residual urine in the bulbar urethra.[16],[17] It was also recently demonstrated that the overall prevalence of postmicturition incontinence decreased, and severity improved significantly after anterior urethroplasty in urethral stricture disease.[4] On the other hand, PMD was shown to be a common symptom in patients with an underactive bladder.[18]
Although uroflowmetry is a widely available, noninvasive tool assessing voiding functions and urinary flow rate associations with PMD have rarely been investigated. A study of 17 men with PMD and 10 healthy controls revealed that participants with PMD had lower Qmax,[19] while another study in 172 men aged 40–79 years observed no such associations.[2] To our knowledge, our study had the largest cohort used to investigate relationships between PMD symptoms and uroflowmetry. We demonstrated that PMD was associated with decreased urinary Qmax, suggesting that PMD arises due to slower urine transit through the urethra. This also implied that PMD could be a voiding dysfunction symptom. This observation was supported by our finding that PMD scores correlated more with voiding symptoms when compared with storage symptoms, consistent with a previous study.[8] Further, studies using videourodynamic investigations are required to identify underlying mechanisms.
Our study had some limitations. First, to the best of our knowledge, only one validated questionnaire has been used to assess PMD. The Hallym PMD Questionnaire was developed by a Korean group in 2019.[8] Nevertheless, our questionnaire was based on the ICS definition[1] and was highly similar to another questionnaire in a Japanese study.[2] Second, postvoid residual (PVR) volume was not examined in our study. In the literature, few studies have investigated associations between PVR and PMD. In the aforementioned Korean study,[8] the authors reported that PVR correlated with PMD. However, of note, in the Korean study, the mean PVR volume was only 42.1 mL. This association does not necessarily mean that PMD is a consequence of significant PVR; increased PVR could be an indicator of voiding dysfunction, which contributes to PMD.
ConclusionPMD is a common urological symptom and increases with age. The condition correlated better with voiding than storage symptoms and was associated with decreased urinary flow rates. Further studies are required to delineate the underlying mechanisms of the condition.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Acknowledgment
This study was supported by a grant (2023SKHADR015) from Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
Financial support and sponsorship
This study was supported by a grant (2022SKHADR011) from Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
Conflicts of interest
There are no conflicts of interest.
References
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