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The American Urological Association Symptom Index for Benign Prostatic Hyperplasia

The American Urological Association Symptom Index for Benign Prostatic Hyperplasia - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


0022-534 7 /92/1485-1549$03.00/0
THE JOURNAL OF UROLOGY
Copyright' 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 148, 1549-1557, November 1992
Printed in U.S.A.
THE AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX
FOR BENIGN PROSTATIC HYPERPLASIA
MICHAEL J. BARRY, FLOYD J. FOWLER, JR., MICHAEL P. O’LEARY,
REGINALD C. BRUSKEWITZ, H. LOGAN HOLTGREWE, WINSTON K. MEBUST,
ABRAHAM T. K. COCKETT AND THE MEASUREMENT COMMITTEE OF THE AMERICAN
UROLOGICAL ASSOCIATION*
From the Medical Practices Evaluation Center, Massachusetts General Hospital and Harvard Medical School, Center for Survey Research,
University of Massachusetts and Department of Urology, Tufts University School of Medicine, Boston, Massachusetts; Departments of Urology,
University of Wisconsin at Madison, Madison, Wisconsin, Johns Hopkins University, Baltimore, Maryland and University of Rochester Medical
Center, Rochester, New York; Section of Urology, The University of Kansas Medical Center, Kansas City, Kansas, and
the American Urological Association
ABSTRACT
A symptom index for benign prostatic hyperplasia (BPH) was developed and validated by a
multidisciplinary measurement committee of the American Urological Association (AU A). Valida›
tion studies were conducted involving a total of 210 BPH patients and 108 control subjects. The
final AUA symptom index includes 7 questions covering frequency, nocturia, weak urinary stream,
hesitancy, intermittence, incomplete emptying and urgency. On revalidation, the index was inter›
nally consistent (Cronbach’s a = 0.86) and the score generated had excellent test-retest reliability
(r = 0.92). Scores were highly correlated with subjects’ global ratings of the magnitude of their
urinary problem (r = 0.65 to 0. 72) and powerfully discriminated between BPH and control subjects
(receiver operating characteristic area 0.85). Finally, the index was sensitive to change, with
preoperative scores decreasing from a mean of 17.6 to 7.1 by 4 weeks after prostatectomy (p <0.001).
The AUA symptom index is clinically sensible, reliable, valid and responsive. It is practical for use
in practice and for inclusion in research protocols.
KEY WORDS: prostatic hypertrophy, prostatic diseases, statistics
Benign prostatic hyperplasia (BPH) is a common condition
among older men.
1
In the Unitec;l States approximately 400,000
prostatectomies are performed annually for BPH, making sur›
gery for this condition the second most common major opera›
tion for Medicare-aged men (after cataract extraction).
2
Annual
costs for the surgical care of BPH alone in the United States
total more than $3.5 billion.’
1
BPH is fundamentally a disease that causes morbidity
through the urinary symptoms with which it is associated.4
While a minority of American men undergo prostatectomy for
absolute indications, such as recurrent or refractory urinary
retention, urinary tract infections, obstructive uropathy or
severe hematuria, the majority of men undergo an operation to
relieve bothersome urinary symptoms and improve the quality
of life: For many years prostatectomy, particularly transure›
thral prostatectomy, has been the standard treatment for symp›
tomatic BPH. More recently, however, a plethora of competing
therapies is being used to treat patients with symptomatic
BPH.
6
These treatments include transurethral incision of the
prostate, laser prostatotomy, balloon dilation, hyperthermia,
insertion of prostatic stents, a-adrenergic blockade and hor›
monal therapy. Each of these treatments has its advocates.
Urologists, their patients, insurers and government regulators
are all struggling to determine how these treatments compare
with more traditional treatments, such as prostatectomy and
Accepted for publication March 20, 1992.
Supported by Patient Outcome Research Team (PORT) Grant HSO
6336 from the Center for Medical Effectiveness Research of the Agency
for Health Care Policy and Research, and by the American Urological
Association, Inc.
*Additional members of the American Urological Association Meas›
urement Committee: Dr. Jerry G. Blaivas, Department of Urology,
College of Physicians and Surgeons, Columbia University, New York,
New York and Dr. Alan J. Wein, Division of Urology, University of
Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
expectant management (watchful waiting), and how they
should fit into the modern management ofBPH. Data on which
to base these judgments are relatively sparse. The American
Urological Association (AUA) has collaborated with a team of
experts in patient outcomes research to develop plans for a
technology assessment network in urology to provide data for
comparisons of treatment effectiveness. Ongoing randomiza›
tion of patients to different treatments is the methodologically
optimal way to compare new and old technologies for the
treatment of BPH.
Step 1 in this process is to develop reliable and valid outcome
measures for the treatment of BPH. Several different symptom
indexes have been used in clinical research in BPH, including
the Madsen-Iversen score,
7
Boyarsky score
8
and Maine Medical
Assessment Program (MMAP) score.
9
The first 2 indexes to
our knowledge have not been formally studied to determine
their reliability and validity. They also rely on interviews and
clinical judgment rather than direct reports from patients. Self›
administered instruments are easier to use and may prevent
differences in interviewing technique or the mindset of the
interviewer from introducing bias into recorded responses. The
MMAP includes at least 1 item (dysuria) that some urologists
did not consider a symptom of BPH, while not including some
items (for example a weak stream) that were believed to be
important.
We focus on the development and formal validation of an
AUA symptom index. This study was conducted by a Measure›
ment Committee, a multidisciplinary group of urologists and
health services researchers, appointed by the AUA. Because
none of the previously published symptom measures was be›
lieved to be completely satisfactory, the goal of the Committee
was to develop a short, practical, self-administered, clinically
sensible index with excellent psychometric properties to cap›
ture the severity of urinary symptoms related to BPH as it is
1549

1 5 5 0 B A R R Y A N D A S S O C I A T E S
d i a g n o s e d a n d t r e a t e d i n t h e c o u r s e o f u s u a l u r o l o g i c a l c a r e
t h r o u g h o u t t h e U n i t e d S t a t e s .
M A T E R I A L S A N D M E T H O D S
I n s t r u m e n t d e v e l o p m e n t . T h e m e m b e r s o f t h e M e a s u r e m e n t
C o m m i t t e e r e v i e w e d p r e v i o u s l y p u b l i s h e d s y m p t o m i n d e x e s , a s
w e l l a s u n p u b l i s h e d i n d e x e s s u p p l i e d b y p h a r m a c e u t i c a l c o m ›
p a n i e s c o n d u c t i n g c l i n i c a l r e s e a r c h i n B P H t o d e v e l o p a l i s t o f
p o t e n t i a l q u e s t i o n s f o r t h e i n d e x . B e c a u s e t h e s y m p t o m s i n a n
i n d i v i d u a l c a n v a r y o n a d a y - t o - d a y b a s i s , s y m p t o m q u e s t i o n s
w e r e w o r d e d b y a s k i n g t h e r e s p o n d e n t t o i n t e g r a t e h i s i m p r e s ›
s i o n o f t h e f r e q u e n c y o r s e v e r i t y o f t h a t s y m p t o m d u r i n g a 1 -
m o n t h p e r i o d . R e s p o n s e f r a m e s f o r q u e s t i o n s w e r e c o n s t r u c t e d
t o b e m u t u a l l y e x c l u s i v e a n d c o l l e c t i v e l y e x h a u s t i v e . T h e s e t o f
1 5 i t e m s c o m p r i s i n g t h e i n i t i a l s y m p t o m q u e s t i o n n a i r e i s p r o ›
v i d e d i n A p p e n d i x 1 . T o e n s u r e a d e q u a t e f a c e o r c o n t e n t
v a l i d i t y , q u e s t i o n s c o v e r e d t h e c o n c e p t u a l s y m p t o m d o m a i n s o f
d a y t i m e f r e q u e n c y , n o c t u r i a , h e s i t a n c y , i n t e r m i t t e n c y , w e a k
s t r e a m , i n c o m p l e t e e m p t y i n g , t e r m i n a l d r i b b l i n g a n d d y s u r i a .
I n a d d i t i o n , s e v e r a l g l o b a l q u e s t i o n s w e r e a s k e d a b o u t t h e
o v e r a l l u r i n a r y d i f f i c u l t i e s i n t h e s u b j e c t ( A p p e n d i x 2 ) .
T h e C o m m i t t e e d i d n o t w i s h a p r i o r i t o s e p a r a t e t h e s e
s y m p t o m s i n t o o b s t r u c t i v e a n d i r r i t a t i v e c a t e g o r i e s , a s h a s b e e n
d o n e s u b j e c t i v e l y w i t h o t h e r i n d e x e s . R a t h e r , t h e g o a l w a s t o
a l l o w e m p i r i c d a t a , c o l l e c t e d f r o m a d m i n i s t e r i n g t h e q u e s t i o n s
t o p a t i e n t s , t o d e t e r m i n e w h e t h e r i n d e e d t h e r e w e r e s e p a r a b l e
c a t e g o r i e s o f q u e s t i o n s i n t h e i n d e x .
F i r s t v a l i d a t i o n s t u d y . T h e f u l l q u e s t i o n n a i r e w a s t h e n a d ›
m i n i s t e r e d t o p a t i e n t s i n t h e f i r s t v a l i d a t i o n s t u d y . P a t i e n t s
w i t h c l i n i c a l l y d e f i n e d B P H w e r e r e c r u i t e d c o n s e c u t i v e l y a t
o f f i c e v i s i t s t o t h e p r a c t i c e s o f 3 u r o l o g i c a l i n v e s t i g a t o r s ( M . P .
0 . , R . C . B . a n d H . L . H . ) . O n l y p a t i e n t s w h o t h e i n v e s t i g a t o r s
b e l i e v e d c l e a r l y h a d s y m p t o m a t i c B P H w e r e i n c l u d e d i n t h e
s t u d y c o h o r t . H o w e v e r , n o s t a n d a r d d i a g n o s t i c e v a l u a t i o n w a s
i m p o s e d , s i n c e B P H i s m o s t c o m m o n l y d e f i n e d o n c l i n i c a l
g r o u n d s i n t h e U n i t e d S t a t e s . T o b e s u r e q u e s t i o n s w e r e s e l e c t e d
t h a t w e r e r e l a t i v e l y s p e c i f i c f o r B P H , n o n u r o l o g i c a l p a t i e n t s
w e r e a l s o r e c r u i t e d f r o m t h e g e n e r a l m e d i c a l p r a c t i c e s o f t h e
M a s s a c h u s e t t s G e n e r a l H o s p i t a l b y a n o t h e r i n v e s t i g a t o r ( M . J .
B . ) . T h e s e c o n t r o l s u b j e c t s w e r e u n l i k e l y t o h a v e B P H o n
e p i d e m i o l o g i c a l g r o u n d s , s i n c e t h e y w e r e r e q u i r e d t o b e 1 8 t o
5 5 y e a r s o l d , w e r e n o t b e i n g s e e n f o r a u r i n a r y c o m p l a i n t a n d ,
w h e n a p p r o a c h e d , d e n i e d a n y p r o s t a t e d i s e a s e s o r u r i n a r y p r o b ›
l e m s .
A f t e r c o n s e n t i n g t o t h e s t u d y t h e s u b j e c t s s e l f - a d m i n i s t e r e d
t h e q u e s t i o n n a i r e a n d w e r e i n s t r u c t e d t o m a r k a n y q u e s t i o n s
t h e y f o u n d c o n f u s i n g o r d i f f i c u l t t o a n s w e r . A r e s e a r c h a s s i s t a n t
o r u r o l o g i c a l n u r s e t h e n d e b r i e f e d t h e p a t i e n t a b o u t t h e q u e s ›
t i o n n a i r e a n d a b o u t m a r k e d q u e s t i o n s i n p a r t i c u l a r . P a t i e n t
d e s c r i p t i o n s o f p r o b l e m s w i t h q u e s t i o n s w e r e r e c o r d e d v e r b a ›
t i m . T h e i d e n t i c a l q u e s t i o n n a i r e w a s t h e n a d m i n i s t e r e d b y m a i l
a p p r o x i m a t e l y 1 w e e k a f t e r t h e i n i t i a l a d m i n i s t r a t i o n t o e x ›
a m i n e s h o r t - t e r m - t e s t - r e t e s t r e l i a b i l i t y .
D a t a f r o m t h e f i r s t v a l i d a t i o n s t u d y i n i t i a l l y w e r e a n a l y z e d
b y c a l c u l a t i n g t h e p e r c e n t a g e o f s u b j e c t s w h o h a d d i f f i c u l t y
w i t h a q u e s t i o n , a n d b y s t u d y i n g t h e i r c o m m e n t s a n d s u g g e s ›
t i o n s . T h e d i s t r i b u t i o n s o f a n s w e r s w e r e e x a m i n e d f o r i n d i v i d ›
u a l q u e s t i o n s t o d e t e r m i n e i f s u b j e c t s s p r e a d t h e i r a n s w e r s
a c r o s s t h e e n t i r e r e s p o n s e f r a m e . T h e c o r r e l a t i o n s o f t h e i n d i ›
v i d u a l s y m p t o m q u e s t i o n s w e r e e x a m i n e d a n d r e s p o n s e s w e r e
c o r r e l a t e d w i t h t h e g l o b a l p r o b l e m q u e s t i o n s i n A p p e n d i x 2 .
T i m e 1 - T i m e 2 t e s t - r e t e s t r e l i a b i l i t i e s w e r e e x a m i n e d f o r i n d i ›
v i d u a l q u e s t i o n s a n d f o r s c o r e s c r e a t e d f r o m g r o u p s o f q u e s ›
t i o n s . T h e s e a s s o c i a t i o n s w e r e p r i m a r i l y e x a m i n e d b y c a l c u l a t ›
i n g P e a r s o n p r o d u c t - m o m e n t c o r r e l a t i o n c o e f f i c i e n t s .
1 0
H o w ›
e v e r , f o r i n d i v i d u a l q u e s t i o n s w i t h s k e w e d r e s p o n s e d i s t r i ›
b u t i o n s , a s s o c i a t i o n s w e r e c o n f i r m e d b y c a l c u l a t i n g G o o d m a n
a n d K r u s k a l ’ s ’ Y s t a t i s t i c .
1 1
W h e n q u e s t i o n s w e r e c o m b i n e d t o
f o r m a n i n d e x , t h e i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y o f e a c h i n d e x
w a s e x a m i n e d w i t h C r o n b a c h ’ s a s t a t i s t i c . ’ " C o n s t r u c t v a l i d i t y
w a s t e s t e d b y c o r r e l a t i n g d e r i v e d i n d e x e s w i t h p a t i e n t g l o b a l
r a t i n g s o f b o t h e r c a u s e d b y t h e u r i n a r y s y m p t o m s , a n d b y u s i n g
s c o r e s c a l c u l a t e d f r o m t h e d e r i v e d i n d e x e s t o p r e d i c t p a t i e n t
r a t i n g s o f b o t h e r i n l i n e a r r e g r e s s i o n m o d e l s . F i n a l l y , w e t e s t e d
t h e c r i t e r i o n v a l i d i t y o f d e r i v e d i n d e x e s b y u s i n g t h e s c o r e s
f r o m t h e s e i n d e x e s t o a t t e m p t t o d i s c r i m i n a t e B P H p a t i e n t s
f r o m c o n t r o l s u b j e c t s . T h e s e a n a l y s e s w e r e c o n d u c t e d b y c o n ›
s t r u c t i n g l o g i s t i c r e g r e s s i o n m o d e l s u s i n g t h e s c o r e s t o p r e d i c t
g r o u p m e m b e r s h i p ( B P H v e r s u s c o n t r o l ) , a n d b y c a l c u l a t i n g
t h e a r e a u n d e r r e c e i v e r o p e r a t i n g c h a r a c t e r i s t i c c u r v e s
1
’ i u s i n g
m a x i m u m l i k e l i h o o d e s t i m a t i o n . T h e s e c a l c u l a t i o n s , a s w e l l a s
c o m p a r i s o n s o f r e c e i v e r o p e r a t i n g c h a r a c t e r i s t i c a r e a s u s i n g a
u n i v a r i a t e z s c o r e t e s t , w e r e p e r f o r m e d u s i n g t h e R O C F I T ( f o r
r a t i n g s f r o m i n d i v i d u a l q u e s t i o n s ) a n d C L A B R O C ( f o r c o n t i n ›
u o u s s y m p t o m s c o r e s ) s o f t w a r e f o r t h e I B M p e r s o n a l c o m p u t e r .
T h e s e a n a l y s e s a l l o w e d u s t o m o d i f y t h e q u e s t i o n n a i r e i n
p r e p a r a t i o n f o r t h e s e c o n d v a l i d a t i o n s t u d y .
S e c o n d v a l i d a t i o n s t u d y . U s i n g t h e s h o r t e r , r e v i s e d q u e s t i o n ›
n a i r e t h e v a l i d a t i o n e x e r c i s e w a s r e p e a t e d , a g a i n r e c r u i t i n g
p a t i e n t s f r o m t h e s a m e i n s t i t u t i o n s . T h e m e t h o d s o f a d m i n i s ›
t r a t i o n a n d r e a d m i n i s t r a t i o n w e r e i d e n t i c a l t o t h e f i r s t s t u d y ,
e x c e p t t h a t p a t i e n t s w e r e n o t f o r m a l l y d e b r i e f e d a f t e r t h e i n i t i a l
a d m i n i s t r a t i o n .
T e s t o f r e s p o n s i v e n e s s . S i n c e p r o s t a t e c t o m y h a s p r e v i o u s l y
b e e n s h o w n t o l e s s e n B P H s y m p t o m s i n m o s t p a t i e n t s , w e
s t u d i e d t h e c h a n g e s i n s c o r e s o n i n d i v i d u a l q u e s t i o n s a n d
d e r i v e d i n d e x e s i n m e n w h o u n d e r w e n t p r o s t a t e c t o m y . M e n
w h o s e s y m p t o m s c o r e s a r e r e p o r t e d i n t h i s s u b s t u d y a r e p a r t i c ›
i p a n t s i n t h e A U A s p o n s o r e d B P H T r e a t m e n t O u t c o m e s P i l o t
S t u d y . T h i s 5 - c e n t e r s t u d y i s f o l l o w i n g m e n t r e a t e d w i t h p r o s ›
t a t e c t o m y a n d a l t e r n a t i v e t r e a t m e n t s f o r s y m p t o m a t i c B P H t o
r e f i n e s t u d y l o g i s t i c s a n d d a t a f o r m s f o r t h e l a r g e t e c h n o l o g y
a s s e s s m e n t n e t w o r k d i s c u s s e d p r e v i o u s l y . C o n s e c u t i v e m e n
w h o u n d e r w e n t t r a n s u r e t h r a l o r o p e n p r o s t a t e c t o m y i n t h i s
s t u d y c o m p l e t e d t h e f u l l q u e s t i o n n a i r e ( A p p e n d i x 1 ) a t b a s e l i n e ,
a n d a g a i n 4 w e e k s p o s t o p e r a t i v e l y . S t u d e n t ’ s t t e s t f o r p a i r e d
d a t a w a s u s e d t o c o m p a r e b a s e l i n e w i t h p o s t t r e a t m e n t s c o r e s .
R E S U L T S
F i r s t v a l i d a t i o n s t u d y . A t o t a l o f 1 5 0 s u b j e c t s a n s w e r e d t h e
f i r s t q u e s t i o n n a i r e : 9 1 B P H p a t i e n t s f r o m t h e 3 u r o l o g y p r a c ›
t i c e s a n d 5 9 c o n t r o l s u b j e c t s . O f t h e 9 1 B P H p a t i e n t s 1 5 h a d
u n d e r g o n e p r i o r p r o s t a t e c t o m y a n d w e r e e x c l u d e d f r o m f u r t h e r
a n a l y s e s , l e a v i n g 7 6 B P H p a t i e n t s w i t h o u t a h i s t o r y o f s u r g e r y
i n t h i s p h a s e o f t h e v a l i d a t i o n s t u d y . B y d e s i g n t h e B P H
p a t i e n t s ( m e a n a g e 6 4 – 9 y e a r s , r a n g e 4 4 t o 8 2 ) w e r e o l d e r
t h a n t h e c o n t r o l s u b j e c t s ( m e a n a g e 3 9 – 9 y e a r s , r a n g e 2 1 t o
5 5 ) .
T a b l e 1 p r o v i d e s a c o r r e l a t i o n m a t r i x , l i s t i n g t h e P e a r s o n
c o r r e l a t i o n c o e f f i c i e n t s b e t w e e n e a c h o f t h e s y m p t o m q u e s t i o n s
l i s t e d i n A p p e n d i x 1 a n d t h e q u e s t i o n s a b o u t g l o b a l u r i n a r y
b o t h e r f r o m A p p e n d i x 2 . M e a s u r e s o f a s s o c i a t i o n u s i n g t h e ’ Y
s t a t i s t i c w e r e s i m i l a r a n d a r e n o t p r e s e n t e d . B e c a u s e o u r g o a l
w a s t o d e v e l o p a q u e s t i o n n a i r e t h a t b e s t c a p t u r e d t h e m o r b i d i t y
o f B P H f r o m a p a t i e n t ’ s p e r s p e c t i v e , w e i n i t i a l l y s e l e c t e d q u e s ›
t i o n s f o r a t e n t a t i v e s y m p t o m i n d e x b y c h o o s i n g i t e m s w i t h a
c o r r e l a t i o n c o e f f i c i e n t o f 0 . 5 o r g r e a t e r w i t h 1 o f t h e 2 b o t h e r
q u e s t i o n s . W h e n t h e r e w e r e 2 q u e s t i o n s m e e t i n g t h i s c r i t e r i o n
t h a t s e e m e d t o b e c o v e r i n g t h e s a m e c o n c e p t , t h a t f a c t w a s
c o n f i r m e d b y s e e k i n g a h i g h c o r r e l a t i o n c o e f f i c i e n t b e t w e e n t h e
2 q u e s t i o n s . I n f a c t , t h e r e w e r e 2 q u e s t i o n s a b o u t d a y t i m e
u r i n a r y f r e q u e n c y ( f r e q u e n c y N o . 1 a n d 3 ) a n d 2 q u e s t i o n s
a b o u t a w e a k s t r e a m ( w e a k s t r e a m N o . 1 a n d 2 ) t h a t w e r e
c l o s e l y c o r r e l a t e d . I n e a c h c a s e t h e q u e s t i o n t h a t w a s m o r e
c l o s e l y c o r r e l a t e d w i t h t h e b o t h e r q u e s t i o n s w a s s e l e c t e d t o
a v o i d r e d u n d a n c y i n t h e t e n t a t i v e i n d e x . W i t h t h e s e c r i t e r i a 6
q u e s t i o n s w e r e s e l e c t e d f o r t h e t e n t a t i v e i n d e x ( q u e s t i o n 3 -
e m p t y i n g , q u e s t i o n 4 - f r e q u e n c y N o . 1 , q u e s t i o n 5 - i n t e r m i t -

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AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX 1551
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tency, question 9-urgency No. 2, question 10-weak stream
No. 1 and question 14-nocturia). This 6-question set will
henceforth be called AUA-6. Of these 6 questions 5 had a 6-
category response frame and 1 had a 5-category response frame
(nocturia).
The 3 conceptual urinary symptoms left out of AUA-6 are
terminal dribbling, dysuria and hesitancy. The first 2 symptoms
are generally considered less specific for BPH and, in fact, they
had relatively low correlations with the global bother questions
and the questions included in AUA-6. Hesitancy, on the other
hand, is generally regarded as a fairly classical symptom of
BPH; correlations with the bother questions and the questions
in AUA-6 were modest. Therefore, we created another index,
AUA-7, that adds the hesitancy question best correlated with
the global bother questions (question 1-hesitancy No. 1) to
AUA-6; this index may have added face validity by virtue of
including this concept.
In general, the questions included in these indexes were clear
to study subjects, with 53 or fewer having comments on most
of the items. The 2 exceptions were the questions about fre›
quency (73 of the subjects made a comment) and nocturia
(113 of the subjects made a comment). The comments on the
frequency question usually pertained to subjects noting that
frequency depended on intake of fluid, alcohol or other exoge›
nous factors. However, many of the comments on the nocturia
question (How often did you most typically get up at night to
urinate? -with responses from not at all to at least once every
hour) criticized the response frame, which was believed to be
confusing by some and not collectively exhaustive by others
(that is some patients wanted other choices than those listed).
To develop a score from each index, responses were given
points as indicated in Appendix 1. Each question on AUA-6
and AUA-7 had a maximum of 5 points except for the nocturia
question, which had 4 points due to its fewer response cate›
gories. Table 2 presents a simpler correlation matrix, this time
demonstrating correlations among the 7 retained questions
individually, the total scores on AUA-6 (range 0 to 29) and
AUA-7 (range 0 to 34), and the global problem questions. Not
surprisingly, given the method of retaining questions for AUA-
6 and AUA-7, these indexes were closely correlated (r = 0.76
to 0. 78) with patient ratings of global bother, providing evidence
of the construct validity of these indexes. In addition, the
correlation between AUA-6 and AUA-7 was extremely close (r
= 0.99), highlighting the fact that the question on hesitancy
adds little independent information to AUA-6.
As another test of whether important questions were left out
of the index, AUA-6 was used to predict patient responses to
the 2 global bother questions in a general linear regression
model. Patient scores on AUA-6 explained 58 to 613 of the
variance (r
2
= 0.58 to 0.61) in their ratings of the global bother
of the urinary symptoms (corresponding to r = 0.76 to 0.78),
for the 2 questions (Appendix 2). None of the other questions
in the longer survey, including the question on hesitancy, alone
or in groups, added significantly to this predictive ability; using
all questions 64 3 of the variance in either of the 2 ratings of
global bother was explained.
We also used this model to test whether better prediction of
patient ratings of global bother could be achieved by weighting
the component items differently, that is by putting more or less
value on individual questions. Again, we could not improve our
model by using the individual items as independent variables
(allowing optimal individual weights to be assigned), rather
than the unweighted sum of the responses.
The psychometric basis for combining individual questions
into an index is strong when the individual items are measuring
the same concept. A summary measure of the correlation of
each item with the overall index is Cronbach’s a statistic. For
AUA-6 and AUA-7, Cronbach’s a statistic was 0.85. This value
is considered excellent and does not suggest that 2 disparate

1 5 5 2 B A R R Y A N D A S S O C I A T E S
T A B L E 2 . C o r r e l a t i o n s o f i n d i v i d u a l q u e s t i o n s i n A U A - 6 a n d A U A - 7 , g l o b a l q u e s t i o n s a b o u t d i f f i c u l t y u r i n a t i n g , a n d t o t a l s y m p t o m s c o r e s
( n u m b e r o f s u b j e c t s f o r i n d i v i d u a l c o r r e l a t i o n s r a n g e s f r o m 1 1 8 t o 1 3 5 d u e t o o c c a s i o n a l i t e m n o n r e s p o n s e )
Q u e s t i o n Q u e s t i o n Q u e s t i o n Q u e s t i o n
1 3 4 5
Q u e s t i o n I - h e s i t a n c y N o . I 1 . 0 0
Q u e s t i o n 3 - e m p t y i n g 0 . 4 4 1 . 0 0
Q u e s t i o n 4 - f r e q u e n c y N o . I 0 . 3 2 0 . 7 0 1 . 0 0
Q u e s t i o n 5 - i n t e r m i t t e n c y 0 . 3 2 0 . 6 8 0 . 4 8 1 . 0 0
Q u e s t i o n 9 - u r g e n c y N o . 2 0 . 0 5 0 . 3 4 0 . 4 4 0 . 4 I
Q u e s t i o n I O - w e a k s t r e a m 0 . 4 I 0 . 5 8 0 . 4 5 0 . 7 0
N o . I
Q u e s t i o n I 4 - n o c t u r i a 0 . 2 4 0 . 4 2 0 . 4 9 0 . 3 7
T o t a l s c o r e ( A U A - 6 ) 0 . 4 0 0 . 8 2 0 . 7 8 0 . 8 0
T o t a l s c o r e ( A U A - 7 ) 0 . 5 4 0 . 8 3 0 . 7 7 0 . 7 9
B o t h e r N o . I 0 . 4 0 0 . 5 8 0 . 5 6 0 . 5 9
B o t h e r N o . 2 0 . 3 8 0 . 6 4 0 . 5 9 0 . 5 4
* A U A - 6 = s u m o f q u e s t i o n s 3 , 4 , 5 , 9 , 1 0 a n d I 4 .
t A U A - 7 = A U A - 6 p l u s q u e s t i o n 1 .
c o n c e p t s a r e b e i n g c o m b i n e d , t h a t i s a n o b s t r u c t i v e a n d a n
i r r i t a t i v e d o m a i n , a t l e a s t i n t e r m s o f h o w p a t i e n t s p e r c e i v e t h e
s y m p t o m s . T o d e t e r m i n e i f s e p a r a t i n g t h e s e i n d e x e s i n t o o b ›
s t r u c t i v e a n d i r r i t a t i v e s u b s e t s w o u l d c o n s i d e r a b l y i m p r o v e
i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y , w e c a l c u l a t e d C r o n b a c h ’ s a
s t a t i s t i c f o r 2 q u e s t i o n s u b s e t s : 1 ) h e s i t a n c y , i n c o m p l e t e e m p ›
t y i n g , i n t e r m i t t e n c y a n d w e a k s t r e a m ( 4 o b s t r u c t i v e i t e m s ) ,
a n d 2 ) f r e q u e n c y , u r g e n c y a n d n o c t u r i a ( 3 i r r i t a t i v e i t e m s ) . N o
i m p r o v e m e n t s i n i n t e r n a l c o n s i s t e n c y w e r e s e e n b y c r e a t i n g
t h e s e 2 c a t e g o r i e s ( C r o n b a c h ’ s a s t a t i s t i c 0 . 8 2 a n d 0 . 7 2 , r e s p e c ›
t i v e l y ) .
A n o t h e r i m p o r t a n t p r o p e r t y o f a u s e f u l s y m p t o m i n d e x i s
t e s t - r e t e s t r e l i a b i l i t y . A t o t a l o f 1 1 7 o f 1 3 5 s u b j e c t s r e t u r n e d
t h e T i m e 2 q u e s t i o n n a i r e f o r t h e a s s e s s m e n t o f t e s t - r e t e s t
r e l i a b i l i t y i n t h e f i r s t v a l i d a t i o n s t u d y ( 8 7 3 ) . T a b l e 3 g i v e s t h e
P e a r s o n c o r r e l a t i o n c o e f f i c i e n t s c o m p a r i n g T i m e 1 a n d T i m e 2
r e s p o n s e s f o r e a c h r e t a i n e d q u e s t i o n , a s w e l l a s f o r A U A - 6 a n d
A U A - 7 . O n l y t h e q u e s t i o n s o n f r e q u e n c y a n d h e s i t a n c y s h o w e d
m u c h i n s t a b i l i t y ( r = 0 . 6 7 f o r b o t h ) . T h i s f i n d i n g f o r f r e q u e n c y
m a y b e a c o r r e l a t e o f p a t i e n t c o m m e n t s t h a t t h e f r e q u e n c y o f
u r i n a t i o n v a r i e s f r o m d a y t o d a y d e p e n d i n g o n e x o g e n o u s
f a c t o r s . H o w e v e r , t h e t e s t - r e t e s t c o r r e l a t i o n s o f t h e t o t a l s c o r e s
c a l c u l a t e d f r o m t h e 2 i n d e x e s w e r e e x c e l l e n t ( r = 0 . 9 2 a n d 0 . 9 3 ) .
W e h a d h y p o t h e s i z e d t h a t a s y m p t o m i n d e x f o r B P H s h o u l d
b e a b l e t o d i s c r i m i n a t e B P H p a t i e n t s f r o m c o n t r o l s u b j e c t s .
F i g u r e 1 d e m o n s t r a t e s t h e d i s t r i b u t i o n o f s c o r e s f o r t h e s e 2
g r o u p s o f s u b j e c t s u s i n g A U A - 6 a n d A U A - 7 . T h e s e a n a l y s e s
a r e b a s e d o n t h e r e s p o n s e s o f 1 1 8 s u b j e c t s w h o p r o v i d e d a n s w e r s
t o a l l s y m p t o m q u e s t i o n s i n c l u d e d i n A U A - 6 a n d A U A - 7 . T h e
d i s t r i b u t i o n s o f s c o r e s o n t h e 7 r e t a i n e d q u e s t i o n s f o r B P H
p a t i e n t s a n d c o n t r o l s a r e p r o v i d e d i n d i v i d u a l l y i n t a b l e 4 .
I n t e r e s t i n g l y , a n s w e r s t o q u e s t i o n s a b o u t d y s u r i a a n d d r i b b l i n g ,
w h i c h h a v e b e e n i n c l u d e d i n p r e v i o u s s y m p t o m i n d e x e s f o r
B P H , h a d r o u g h l y s i m i l a r d i s t r i b u t i o n s i n B P H p a t i e n t s a n d
y o u n g e r c o n t r o l s ( t a b l e 5 ) . N e x t , r e c e i v e r o p e r a t i n g c h a r a c t e r -
T A B L E 3 . T e s t - r e t e s t r e l i a b i l i t y o f i n d i v i d u a l s y m p t o m q u e s t i o n s a n d
s c o r e s c a l c u l a t e d f r o m A U A - 6 a n d A U A - 7 ( i n c l u d e s q u e s t i o n 1 o n
h e s i t a n c y )
Q u e s t i o n
3 - e m p t y i n g
4 - f r e q u e n c y N o . I
5 - i n t e r m i t t e n c y
9 - u r g e n c y N o . 2
I O - w e a k s t r e a m N o . I
I 4 - n o c t u r i a
T o t a l s c o r e A U A - 6
I - h e s i t a n c y
T o t a l s c o r e A U A - 7 *
* A U A - 7 = A U A - 6 p l u s q u e s t i o n 1 .
T e s t - R e t e s t
R e l i a b i l i t y
( r )
0 . 7 9
0 . 6 7
0 . 8 5
0 . 8 I
0 . 9 I
0 . 8 4
0 . 9 3
0 . 6 7
0 . 9 2
Q u e s t i o n Q u e s t i o n Q u e s t i o n
A U A - 6 * A U A - 7 t
B o t h e r B o t h e r
9 1 0 1 4 N o . I N o . 2
1 . 0 0
0 . 4 3 1 . 0 0
0 . 4 7 0 . 3 2 1 . 0 0
0 . 6 8 0 . 7 7 0 . 6 7 1 . 0 0
0 . 6 4 0 . 7 8 0 . 6 6 0 . 9 9 1 . 0 0
0 . 5 4 0 . 7 2 0 . 5 2 0 . 7 8 0 . 7 8 1 . 0 0
0 . 5 I 0 . 6 6 0 . 5 3 0 . 7 6 0 . 7 7 0 . 8 2 1 . 0 0
3 0
0 i : m
0 0
0
2 s 1
0 0
l l l l l l l C l l l l l l l l
= 0
=
2 0 1
[ I l l
0 i : m
l l l l l l l
[ I l l
0
1 : 1 1 1 1 1 1 : 1 1 1 1 1 1 1 1 1 1
[ I l l
0
1 5 - I c m
= 0 l l l l l l l 0 0
l l l l l l l C l l l l l l l l
C l l l l l l l l 0 c m
0 1 : 1 1 1 1 1 1 : 1 0 t l l l l l l l l l i J
1 0 - I 0 c m 0 0
l l l l l l l C l l l l l l l l l l l l l l l l l l l l l l
0 1 1 1 1 1 1 1 1 1 C l l l l l l l l l l
=
C l l l l l l l l
=
c m
c m c m
=
0
=
c m
= = 1 1 1 1 1 1 1 1 1
[ 1 1 1 1 1 ! )
1 1 1 1 1 1 1 1 : 1
= 1 1 1 1 1 1 1 1 : 1 C l l l l l l l l l l l l l
l i l l l l l l l l l l l l c m C l l l l l l l l l l l c m
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0
-
0
a l l l ! I
-
C o n t r o l s B P H P a t i e n t s C o n t r o l s B P H P a t i e n t s
( n = 5 3 ) ( n = 6 5 ) ( n = 5 3 ) ( n = 6 5 )
A U A - 6 A U A - 7
F I G . 1 . D i s t r i b u t i o n o f s c o r e s o n A U A - 6 a n d A U A - 7 a m o n g B P H
p a t i e n t s a n d c o n t r o l s u b j e c t s .
i s t i c c u r v e s w e r e c o n s t r u c t e d f o r e a c h i n d e x ( f i g . 2 ) . W h i l e t h e
d i s t r i b u t i o n o f s c o r e s f o r c o n t r o l s u b j e c t s w a s s o m e w h a t
s k e w e d , t h e b i n o r m a l a s s u m p t i o n s u s e d i n f i t t i n g r e c e i v e r o p ›
e r a t i n g c h a r a c t e r i s t i c c u r v e s h a v e b e e n s h o w n t o b e r e m a r k a b l y
r o b u s t f o r r a t i n g d a t a w i t h d i f f e r e n t d i s t r i b u t i o n s .
1 4
T h e a r e a
u n d e r t h e r e c e i v e r o p e r a t i n g c h a r a c t e r i s t i c c u r v e f o r A U A - 6 i s
0 . 8 7 ( s t a n d a r d d e v i a t i o n 0 . 0 3 ) , w h i c h c a n b e i n t e r p r e t e d a s
m e a n i n g t h a t A U A - 6 w o u l d c o r r e c t l y c l a s s i f y a r a n d o m l y s e ›
l e c t e d B P H p a t i e n t a n d a r a n d o m l y s e l e c t e d c o n t r o l s u b j e c t
f r o m t h e s t u d y p o p u l a t i o n 8 7 3 o f t h e t i m e . T h e a r e a u n d e r t h e
r e c e i v e r o p e r a t i n g c h a r a c t e r i s t i c c u r v e f o r A U A - 7 , 0 . 8 7 ( s t a n d ›
a r d d e v i a t i o n 0 . 0 3 ) , i s t h e s a m e a s A U A - 6 . I n l o g i s t i c r e g r e s s i o n
m o d e l s c o n s t r u c t e d t o p r e d i c t g r o u p m e m b e r s h i p , u s i n g A U A -
6 a s a n i n d e p e n d e n t v a r i a b l e y i e l d e d a m o d e l c h i - s q u a r e o f 6 3 . 0
( p < 0 . 0 0 1 ) . A d d i n g a n y o f t h e o t h e r e x c l u d e d q u e s t i o n s , i n c l u d ›
i n g h e s i t a n c y , a l o n e o r i n c o m b i n a t i o n , d i d n o t s i g n i f i c a n t l y
i m p r o v e t h e g o o d n e s s - o f - f i t o f t h e m o d e l . S i m i l a r l y , d i f f e r e n t
w e i g h t i n g s o f r e s p o n s e s o n i n d i v i d u a l q u e s t i o n s d i d n o t s i g n i f ›
i c a n t l y i m p r o v e p r e d i c t i o n b e y o n d a s i m p l e s u m o f a l l r e ›
s p o n s e s .
A t t h e c o m p l e t i o n o f t h e a n a l y t i c p h a s e o f t h e f i r s t v a l i d a t i o n
s t u d y , A U A - 6 a p p e a r e d t o b e a r e l i a b l e a n d v a l i d s y m p t o m
i n d e x f o r c l i n i c a l l y d e f i n e d B P H . H o w e v e r , w e w i s h e d t o r e v a l ›
i d a t e t h e s e f i n d i n g s p r o s p e c t i v e l y a n d t o a n s w e r s e v e r a l q u e s ›
t i o n s t h a t h a d b e e n r a i s e d i n t h e i n i t i a l s t u d y . W e w a n t e d t o
r e c o m p a r e t h e p e r f o r m a n c e o f A U A - 7 w i t h A U A - 6 , g i v e n t h e
h i g h e r f a c e v a l i d i t y o f t h e f o r m e r . W e a l s o b e l i e v e d t h a t t h e

AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX 1553
TABLE 4. Distribution of answers to questions in the A UA symptom index among BPH patients and control subjects
Question 1- Question 3- Question 4-
Point Score
Hesitancy No. 1 Emptying Frequency No. 1
BPH Controls BPH Controls BPH Controls
0 38 (51) 47 (80) 19
(25)
44 (75) 8 (11) 16 (29)
1 18 (24) 11 (19) 25 (33) 12 (20) 18 (25) 23 (41)
2 9
(12)
0 (0) 6
(8)
2 (3) 17 (23) 7
(12)
3 3 (4) 0
(0) 13 (17) 0
(0) 14 (19) 7 (12)
4 4 (5) 0 (0) 8 (11) 1
(2) 8 (11) 2 (4)
5 3 (4) 1 (2) 4 (5) 0 (0) 8 (11) 1 (2)
Totals 75 (100) 59 (100) 75 (100) 59 (100) 73 (100) 56 (100)
Receiver operating
characteristic 0.71 (0.07) 0.83 (0.04) 0.71 (0.05)
area (SD)
Values are given as number of subjects(%).
TABLE 5. Distribution of answers to several questions left out of the
AUA symptom index among BPH patients and control subjects
Totals
Point Score
0
1
2
3
4
5
Receiver operating characteristic
area (SD)
Question 2-
Dysuria
BPH Controls
54 (71) 47 (80)
11 (14) 10 (16)
1 (1) 0 (0)
3
(4) 1 (1)
3
(4) 1 (1)
4 (5) 0 (0)
76 (100) 59 (100)
0.46 (0.09)
Values are given as number of subjects(%).
True Positive Ratio
0.8
0.6
0.4
0.2
Question?›
Dribbling
BPH Controls
23 (31) 21 (37)
27 (36) 25 (44)
10 (13) 5 (9)
9 (12) 4 (0)
3
(4) 1 (7)
3 (4) 1 (2)
75 (100) 57 (100)
0.57 (0.05)
-& AUA-6 -9-- AUA-7
0 0.2 0.4 0.6 0.8
False Positive Ratio
FIG. 2. Receiver operating characteristic curves constructed with
scores from AUA-6 and AUA-7 to discriminate BPH patients from
control subjects.
underweighting of the question on nocturia due to its fewer
response categories was undesirable. Moreover, the response
frame for the nocturia question was criticized by some subjects.
Finally, we wanted to be sure we had asked about daytime
urinary frequency in the optimal manner given the lower test›
retest reliability documented for this question.
Question 5- Question 9- Question 10- Question 14-
lntermittency Urgency No. 2 Weak Stream No. 1 Nocturia
BPH Controls BPH Controls BPH Controls BPH Controls
20 (27) 38 (66) 21 (28) 37 (63) 16 (21) 41 (72) 5 (7) 28 (48)
20 (27) 17 (29) 19
(26) 15 (25) 18 (24) 11 (19) 12 (17) 18 (31)
11 (15) 3 (5) 11 (15) 3 (5) 12 (16) 3 (5) 31 (45) 8
(14)
12 (16) 0 (0) 5
(7)
2 (3) 10 (13) 2
(4) 19 (28) 4 (7)
6 (8) 0 (0) 12 (16) 2 (3) 10 (13) 0 (0) 2
(3)
0
(0)
5 (7) 0 (0) 6 (8) 0 (0) 9 (12) 0 (0)
74 (100) 58 (100) 74 (100) 59 (100) 75 (100) 57 (100) 69 (100) 58 (100)
0.76 (0.05) 0.74 (0.05) 0.83 (0.04) 0.83 (0.04)
Second validation study. In the second validation study a
shortened version of the questionnaire was administered to
another 107 BPH patients and 49 control subjects. The age
distribution of subjects was almost identical to the first vali›
dation study. All of the questions in AUA-7 were administered
without change, except that a sixth response category, once
every 3 hours, was added for the nocturia question. In addition,
2 questions were added asking subjects to specify the number
of times they urinated during the day and at night, with 6
collectively exhaustive response categories (Appendix 1). The
global bother questions were also repeated (Appendix 2).
Our original day frequency question correlated closely with
the new frequency question (r = 0.68) and was superior in terms
of a slightly higher correlation with the 2 global problem
questions (0.54 and 0.53 versus 0.49 and 0.51, respectively).
Moreover, the test-retest reliability of the original frequency
question was better in the second validation study, with a
correlation coefficient of 0.77. The 2 nocturia questions were
even more closely correlated (r = 0.78) and performed roughly
similarly from a psychometric perspective. Because of a per›
sisting concern that some patients would not view the response
frame for our original question as collectively exhaustive, we
chose the new nocturia question for our analyses of the index
in this validation phase.
In the revalidation study AUA-6 and AUA-7 (using the
original 5 or 6 questions with the new nocturia question)
remained internally consistent (Cronbach’s a statistic 0.85 and
0.86, respectively), and reliable on short-term (1 week) retesting
(r = 0.93 and 0.92, respectively). Both indexes were strongly
related to the patients’ 2 global ratings of bother (r = 0.65 and
0.71 for AUA-6 and AUA-7), and discriminated BPH patients
from control subjects (receiver operating characteristic area
0.87 – 0.03 and 0.85 – 0.03, respectively). In the final analysis
we preferred AUA-7 for its higher face validity given its vir›
tually identical psychometric performance.
The final phase of validation involved testing the sensitivity
of the 7-item AUA symptom index to clinically important
change. A total of 27 consecutive patients was administered the
AUA symptom index before and 1 month after prostatectomy
in the AUA BPH Treatment Outcomes Pilot Study. The mean
age of patients in this study is 66 years and the mean peak
urine flow rate is 10.0 ml. per second. All but 1 patient had a
decrease in score and 56% had a decrease of greater than 7
points (20% of the total range, fig. 3). The mean AUA symptom
score decreased from 17.6 preoperatively to 7.1 at 4 weeks
postoperatively (mean decrease 10.5, 95% confidence interval
8.1 to 12.9, p <0.001). A further decrease may be expected as
more time elapses from each prostatectomy. Changes in re›
sponse distributions on individual questions from the AUA
index are given in table 6.
For some purposes categorizing men with symptomatic BPH
into groups with different symptom levels may be desirable.
Although the cutoff points in score used to create these cate-

1 5 5 4 B A R R Y A N D A S S O C I A T E S
A U A S y m p t o m S c o r e
3 0
2 5
2 0
1 5
1 0
5
P r e - S u r g e r y
S c o r e
P o s t - S u r g e r y
S c o r e
F I G . 3 . A U A s y m p t o m s c o r e s b e f o r e a n d 4 w e e k s a f t e r p r o s t a t e c ›
t o m y f o r m e n i n A U A B P H T r e a t m e n t O u t c o m e s P i l o t S t u d y .
g o r i e s a r e a r b i t r a r y a n d m i g h t l e g i t i m a t e l y d i f f e r f o r d i f f e r e n t
p u r p o s e s , w e e x p l o r e d t h e p o s s i b i l i t y o f u s i n g t h e r e l a t i o n s h i p
o f p a t i e n t A U A s y m p t o m s c o r e s , r a n g i n g f r o m 0 t o 3 5 , w i t h t h e
b o t h e r r a t i n g s t o c r e a t e c a t e g o r i e s o f m e n w i t h m i l d , m o d e r a t e
a n d s e v e r e s y m p t o m s . T a b l e 7 p o o l s r e s p o n s e s f r o m t h e f i r s t
a n d s e c o n d v a l i d a t i o n s t u d i e s . A s i n d i c a t e d i n t h i s t a b l e , m e n
w i t h a n A U A s c o r e o f 7 o r b e l o w m o r e c o m m o n l y r a t e t h e
u r i n a r y c o n d i t i o n a s n o t a t a l l a s o p p o s e d t o a l i t t l e b o t h e r s o m e ,
a n d o n l y 1 o f 1 2 0 o f t h e s e m e n w a s b o t h e r e d s o m e . T h e s e m e n
m i g h t b e c o n s i d e r e d t h e m i l d s y m p t o m g r o u p . M e n w i t h A U A
s c o r e s o f 8 t o 1 9 g e n e r a l l y g a v e i n t e r m e d i a t e r a t i n g s o f b o t h e r ,
a n d c a n b e d e f i n e d a s a g r o u p w i t h m o d e r a t e s y m p t o m s . S t i l l ,
m o s t o f t h e s e m e n r a t e t h e s y m p t o m s a s n o t a t a l l o r a l i t t l e
b o t h e r s o m e , a n d o n l y 4 o f 1 0 8 a r e b o t h e r e d a l o t . F i n a l l y , m e n
w i t h A U A s c o r e s o f 2 0 o r a b o v e a r e g e n e r a l l y b o t h e r e d s o m e o r
a l o t b y t h e s y m p t o m s , a n d c o u l d b e c o n s i d e r e d a g r o u p w i t h
s e v e r e s y m p t o m s . W i t h t h e s e c u t o f f p o i n t s , 2 1 3 o f B P H p a ›
t i e n t s v e r s u s 8 3 3 o f c o n t r o l s u b j e c t s f a l l i n t h e m i l d r a n g e ,
5 7 3 v e r s u s 1 5 3 h a v e m o d e r a t e s y m p t o m s a n d 2 3 3 v e r s u s 2 3
h a v e s e v e r e s y m p t o m s . U s i n g t h e m i l d - m o d e r a t e c u t o f f p o i n t
g i v e s t h e A U A s y m p t o m s c o r e a s e n s i t i v i t y o f 7 9 3 f o r B P H
p a t i e n t s a n d a s p e c i f i c i t y o f 8 3 3 f o r c o n t r o l s u b j e c t s e n r o l l e d
i n o u r v a l i d a t i o n s t u d i e s .
D I S C U S S I O N
O u r r e s u l t s d o c u m e n t t h a t t h e A U A s y m p t o m i n d e x i s a
r e l i a b l e a n d v a l i d m e a n s o f c a p t u r i n g t h e s y m p t o m s e v e r i t y o f
c l i n i c a l l y d e f i n e d B P H , a n d t h a t t h e s c o r e t h a t c a n b e g e n e r a t e d
f r o m t h i s i n d e x i s s e n s i t i v e t o c l i n i c a l l y i m p o r t a n t c h a n g e s
w i t h i n i n d i v i d u a l p a t i e n t s w i t h t i m e . T h e s e f e a t u r e s a r e a l l
d e s i r a b l e i n a q u e s t i o n n a i r e t h a t m a y b e a l t e r n a t i v e l y u s e d f o r
d i s c r i m i n a t i v e , p r e d i c t i v e o r e v a l u a t i v e p u r p o s e s . " U n l i k e p r e ›
v i o u s l y p u b l i s h e d s y m p t o m s c o r e s , s u c h a s t h e M a d s e n - I v e r s e n
a n d B o y a r s k y s c o r e s , t h i s i n d e x h a s b e e n d e s i g n e d f o r s e l f ›
a d m i n i s t r a t i o n i n a u n i f o r m m a n n e r a n d v a l i d a t e d i n t h a t m o d e
o f a d m i n i s t r a t i o n . U n l i k e t h e s y m p t o m s c o r e d e v e l o p e d f o r a
p r o s p e c t i v e c o h o r t s t u d y o f p r o s t a t e s u r g e r y i n t h e M M A P , t h e
A U A i n d e x h a s h i g h e r f a c e v a l i d i t y t h r o u g h t h e i n c l u s i o n o f
m o r e c o n c e p t u a l s y m p t o m s t h a t a r e s e e n a s c l o s e l y r e l a t e d t o
B P H b y c l i n i c i a n s .
R e a d e r s s h o u l d b e c a u t i o u s i n i n t e r p r e t i n g t h e d a t a . o n d i s ›
c r i m i n a t i o n o f B P H p a t i e n t s f r o m c o n t r o l s u b j e c t s . T h e s e
a n a l y s e s w e r e m e a n t a s a t e s t o f t h e d i s c r i m i n a n t v a l i d i t y o f
t h e A U A i n d e x a n d i t s c o m p o n e n t q u e s t i o n s . H o w e v e r , t h e
A U A i n d e x w o u l d c e r t a i n l y p e r f o r m l e s s w e l l i n d i s c r i m i n a t i n g
p a t i e n t s o f s i m i l a r a g e s w i t h a n d w i t h o u t B P H . W h e t h e r a n y
s y m p t o m q u e s t i o n s c a n r e l i a b l y d i s c r i m i n a t e p a t i e n t s w i t h
p r o s t a t i s m w h o a r e p h y s i o l o g i c a l l y o b s t r u c t e d f r o m t h o s e w h o
a r e n o t r e m a i n s t o b e s e e n . T h e r e f o r e , w e d o n o t r e c o m m e n d
t h e u s e o f t h e A U A i n d e x t o s c r e e n f o r B P H . R a t h e r , c l i n i c i a n s
c o u l d u s e t h e i n d e x t o a s s e s s t h e s e v e r i t y o f s y m p t o m s a m o n g
p a t i e n t s w h o p r e s e n t w i t h s u g g e s t i v e c o m p l a i n t s a n d h a v e o t h e r
e v i d e n c e o f B P H .
T h e l a c k o f c o m p a r a b i l i t y i n o u t c o m e m e a s u r e m e n t s h a s
b e e n a p r o b l e m i n i n t e r p r e t i n g c l i n i c a l r e s e a r c h o n B P H f o r
u s e i n c l i n i c a l p r a c t i c e . A s a p a r t i a l s o l u t i o n t o t h i s p r o b l e m ,
w e p r o p o s e t h a t t h e 7 q u e s t i o n s i n t h e A U A s y m p t o m i n d e x b e
i n c l u d e d i n t h e p r o t o c o l s o f p r o s p e c t i v e s t u d i e s o f t h e n a t u r a l
h i s t o r y a n d e p i d e m i o l o g y o f B P H , a n d t h a t t h e A U A s y m p t o m
s c o r e b e r e p o r t e d w h e n r e s u l t s o f t r e a t m e n t a r e d e s c r i b e d .
I n v e s t i g a t o r s a r e e n c o u r a g e d t o i n c l u d e o t h e r s y m p t o m q u e s ›
t i o n s t h a t t h e y b e l i e v e a r e i m p o r t a n t a s w e l l b u t t h e i n c l u s i o n
o f t h i s b a s i c q u e s t i o n s e t w i l l p r o v i d e a n u n p a r a l l e l e d o p p o r ›
t u n i t y t o c o m p a r e r e s u l t s a m o n g s t u d i e s . T o f a c i l i t a t e t h e u s e
o f t h e A U A i n d e x , t h e q u e s t i o n n a i r e i s p r o v i d e d i n a f o r m t h a t
c a n b e r e a d i l y a d m i n i s t e r e d a n d s c o r e d i n t a b l e 8 .
T h e m e a s u r e m e n t o f B P H s y m p t o m s i s o n l y 1 f a c e t o f t h e
e v a l u a t i o n o f t h e n a t u r a l h i s t o r y a n d t h e r e s p o n s e t o t r e a t m e n t
o f B P H , a l b e i t a n e x t r e m e l y i m p o r t a n t o n e f r o m t h e p a t i e n t ’ s
p e r s p e c t i v e . I n v e s t i g a t o r s w i l l w a n t t o s t u d y o t h e r p a r a m e t e r s ,
i n c l u d i n g p h y s i o l o g i c a l m e a s u r e s a n d r a t i n g s o f p a t i e n t q u a l i t y
o f l i f e , t o o b t a i n a c o m p l e t e p i c t u r e o f d i s e a s e p r o g r e s s i o n o r
t r e a t m e n t e f f e c t i v e n e s s . I n a d d i t i o n , t h e m e a s u r e m e n t o f t h e
r a t e s o f i m p o r t a n t o u t c o m e e v e n t s , s u c h a s a c u t e u r i n a r y r e t e n ›
t i o n a n d s e r i o u s u r i n a r y t r a c t i n f e c t i o n , a r e a l s o n e e d e d . F i n a l l y ,
i m p o r t a n t t r e a t m e n t c o m p l i c a t i o n s , s u c h a s i n c o n t i n e n c e a n d
s e x u a l d y s f u n c t i o n , s h o u l d b e d e s c r i b e d . T h e A U A M e a s u r e ›
m e n t C o m m i t t e e i s c o n t i n u i n g t o w o r k o n d e v e l o p i n g p a r s i ›
m o n i o u s , r e l i a b l e a n d v a l i d m e a s u r e s o f q u a l i t y o f l i f e a s w e l l
a s i n c o n t i n e n c e a n d s e x u a l d y s f u n c t i o n f o r u s e i n o u t c o m e s
r e s e a r c h i n B P H . O u r q u a l i t y o f l i f e i n s t r u m e n t s w i l l i n c l u d e
m e a s u r e m e n t s o f b o t h e r d u e t o u r i n a r y s y m p t o m s , t h e i m p a c t
o f t h e p r o s t a t e c o n d i t i o n o n d i f f e r e n t d o m a i n s o f h e a l t h , s u c h
a s p h y s i c a l f u n c t i o n i n g a n d m e n t a l h e a l t h , a n d o v e r a l l h e a l t h
s t a t u s .
B P H i s a d i s e a s e t h a t c a n b e d e f i n e d a t a h i s t o l o g i c a l ,
p h y s i o l o g i c a l , r a d i o l o g i c a l o r c l i n i c a l l e v e l . I n t h e U n i t e d S t a t e s
m o s t t r e a t m e n t d e c i s i o n s a r e m a d e o n t h e b a s i s o f a c l i n i c a l
d i a g n o s i s o f B P H , s u p p l e m e n t e d w i t h t a r g e t e d t e s t i n g i n i n d i -
T A B L E 6 . D i s t r i b u t i o n o f a n s w e r s t o q u e s t i o n s i n t h e A U A s y m p t o m i n d e x b e f o r e a n d a f t e r p r o s t a t e c t o m y
P o i n t
H e s i t a n c y E m p t y i n g F r e q u e n c y l n t e r m i t t e n c y U r g e n c y W e a k S t r e a m N o c t u r i a
S c o r e
B e f o r e A f t e r B e f o r e A f t e r B e f o r e A f t e r B e f o r e A f t e r B e f o r e A f t e r B e f o r e A f t e r B e f o r e A f t e r
0 8 2 1 4 1 4 0 8 3 1 9 5 8 1 1 5 0 0
1 5 5 4 9 2 8 6 6 5 1 0 2 1 0 1 8
2 7 1 9 2 8 4 9 1 4 5 6 1 9 1 1
3 4 0 5 1 7 3 5 0 3 0 8 0 9 4
4 2 0 3 1 5 3 0 1 6 2 5 1 5 3
5 1 0 2 0 5 1 4 0 4 2 5 0 3
M e a n 1 . 6 0 . 3 2 . 2 0 . 7 3 . 1 1 . 6 2 . 2 0 . 4 2 . 4 1 . 4 3 . 0 0 . 6 3 . 0 2 . 2
1 . 3 1 . 5 1 . 5 1 . 8 1 . 0 2 . 4 0 . 8
’ . {
j

AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX
1555
TABLE 7. Correlation of A UA symptom scores with patient global
ratings of the urinary problem, providing a rationale for dividing the
scores into mild, moderate and severe categories
Overall, How Bothersome Has Any
AUA Symptom
Trouble With Urination Been in Last
Score
Month? Totals
Not at All A Little Some A Lot
0 10 0 0 0 10
1 22 0 0 0 22
2 18 1 0 0 19
3 19 0 0 0 19
4 10 2 0 0 12
5 9 4 1 0 14
6 6 4 0 0 10
7 9 5 0 0 14
8 4 4 2 0 10
9 4 5 0 0 9
10 1 6 0 0 7
11 5 6 7 1 19
12 1 8 2 0 11
13 2 6 2 0 10
14 3 4 3 0 10
15 0 1 1 0 2
16 1 4 3 0 8
17 0 6 1 1 8
18 1 3 2 2 8
19 0 4 2 0 6
20 0 2 6 0 8
21 2 0 3 0 5
22 0 1 3 1 5
23 0 3 3 0 6
24 0 1 2 0 3
25 0 1 1 2 4
26 0 1 0 1 2
27 0 0 2 2 4
28 0 0 1 1 2
29 0 0 0 1 1
30 0 0 0 0 0
31 0 0 0 0 0
32 0 0 0 0 0
33 0 0 0 0 0
34 0 0 0 0 0
35 0 0 0 0 0
vidual cases. Measurements at each of these levels must be
correlated with each other and their importance as predictors
of patient outcomes with treatment (including watchful wait›
ing) must be assessed. We are planning to make these correla›
tions among patients enrolled in the BPH Treatment Outcomes
Pilot Study and report them at a later date.
A caution must be sounded about the quality of measure-
ments at these different conceptual levels. Some urologists have
regarded symptom measures as subjective and physiological
measures as objective, implying greater precision in the latter
than the former values. However, as we have demonstrated,
careful attention to the design and validation of symptom
indexes can yield instruments with a high degree of precision.
In fact, the short-term test-retest reliability of the AUA symp›
tom index is much higher than some of the physiological
parameters commonly used to evaluate BPH patients in clinical
practice, such as the post-void residual volume and peak urinary
flow rate.
17
All measurements used to quantitate BPH severity
must be evaluated for their reliability, validity and sensitivity
to change.
Although we have tried to develop the best symptom index
possible for BPH, future improvements may be possible. We
are currently continuing to evaluate the AUA symptom index
among patients from a spectrum of educational, cultural and
socioeconomic backgrounds. We suspect minor wording
changes may eventually make the index more adaptable to the
broadest possible population of urological patients. We hope
that the evaluation strategy we have outlined will serve as a
model to evaluate future modifications of this index or alter›
native symptom indexes for BPH, as well as for other important
problems in urology.
APPENDIX 1
Initial Question List
During the last month or so:
Question 1. How often have you had to push or strain to
begin urination?
Question 2. How often have you had a burning feeling
when you urinate?
Question 3. How often have you had a sensation of not
emptying your bladder completely after you
finished urinating?
Question 4. How often have you had to urinate again less
than 2 hours after you finished urinating?
Question 5. How often have you found you stopped and
started several times when you urinated?
Question 6. How often have you had to urinate again
within ten minutes of urinating.?
Question 7. How often have you dribbled urine after you
thought you were finished urinating?
Question 8. How often have you felt a strong need to
urinate with little or no warning?
TABLE 8. The AUA symptom index
Not at
Less
Less Than Half About Half More Than Half
Question
All
Than 1
the Time the Time the Time
Almost Always
Time in 5
1. During the last month or so, how often have you @] Q]
m
ill
[.] @]
had a sensation of not emptying your bladder com-
pletely after you finished urinating?
@] [jJ
m
[}]
2. During the last month or so, how often have you
ill
[i]
had to urinate again less than 2 hours after you
finished urinating?
@] [jJ []]
CD
[[]
3. During the last month or so, how often have you
GU
found you stopped and started again several times
when you urinated?
@]
m
[I]
[i] @]
4. During the last month or so, how often have you
OJ
found it difficult to postpone urination?
@] [jJ
[]]
[I]
CD
@]
5. During the last month or so, how often have you
had a weak urinary stream?
II]
[TI [] @]
6. During the last month or so, how often have you @]
0
had to push or strain to begin urination?
7. During the last month, how many times did you
most typically get up to urinate from the time you None 1 Time 2 Times 3 Times 4 Times 5 or More times
went to bed at night until the time you got up in
@] Q] []]
GU CD
[[)
the morning?
AU A symptom score = sum of questions 1 to 7.

1 5 5 6
B A R R Y A N D A S S O C I A T E S
Q u e s t i o n 9 . H o w o f t e n d o y o u f i n d i t d i f f i c u l t t o p o s t p o n e
u r i n a t i o n ?
Q u e s t i o n 1 0 . H o w o f t e n h a v e y o u h a d a w e a k u r i n a r y
s t r e a m ?
R e s p o n s e s f o r q u e s t i o n s 1 t o 1 0 :
0 - N o t a t a l l
1 - L e s s t h a n 1 t i m e i n 5
2 - L e s s t h a n h a l f t h e t i m e
3 - A b o u t h a l f t h e t i m e
4 - M o r e t h a n h a l f t h e t i m e
5 - A l m o s t a l w a y s
D u r i n g t h e l a s t m o n t h o r s o :
Q u e s t i o n 1 1 . H o w l o n g h a v e y o u m o s t c o m m o n l y h a d t o
w a i t a t t h e t o i l e t b e f o r e u r i n e s t a r t s t o c o m e
o u t ?
0 - N o t a t a l l
1 - A f e w s e c o n d s
2 - A b o u t 1 5 s e c o n d s
3 - A b o u t 3 0 s e c o n d s
4 - A m i n u t e o r m o r e
Q u e s t i o n 1 2 . A b o u t h o w m a n y t i m e s d i d y o u u r i n a t e f r o m
t h e t i m e y o u g o t u p i n t h e m o r n i n g u n t i l t h e
t i m e y o u w e n t t o b e d a t n i g h t ?
0 - 1 t o 4 t i m e s a d a y
1 - 5 t o 7 t i m e s a d a y
2 - 8 t o 1 2 t i m e s a d a y
3 - 1 3 o r m o r e t i m e s a d a y
Q u e s t i o n 1 3 . O n c e y o u g e t t h e u r g e t o u r i n a t e , h o w l o n g
c o u l d y o u u s u a l l y w a i t c o m f o r t a b l y b e f o r e
g o i n g t o t h e b a t h r o o m ?
0 - 1 h o u r o r m o r e
1 - A b o u t 3 0 m i n u t e s
2 - A b o u t 1 5 m i n u t e s
3 - A f e w m i n u t e s
4 - L e s s t h a n 1 m i n u t e
5 - L e s s t h a n 1 0 s e c o n d s
Q u e s t i o n 1 4 . H o w o f t e n d i d y o u m o s t t y p i c a l l y g e t u p a t
n i g h t t o u r i n a t e ?
0 - N o t a t a l l
1 - 0 n c e e v e r y 8 h o u r s
2 - 0 n c e e v e r y 4 h o u r s
3 - 0 n c e e v e r y 2 h o u r s
4 - A t l e a s t o n c e e v e r y h o u r
Q u e s t i o n 1 5 . H o w w o u l d y o u d e s c r i b e t h e s i z e a n d f o r c e o f
y o u r u r i n a r y s t r e a m c o m p a r e d t o w h e n y o u
w e r e 2 0 y e a r s o l d ?
0 - N o i m p a i r m e n t o r r e s t r i c t i o n
1 - M i n i m a l i m p a i r m e n t o r r e s t r i c t i o n ( b a r e l y n o t i c e a ›
b l e )
2 - M i l d i m p a i r m e n t o r r e s t r i c t i o n ( m i l d b u t c l e a r l y n o ›
t i c e a b l e )
3 - M o d e r a t e i m p a i r m e n t o r r e s t r i c t i o n
4 - S e v e r e i m p a i r m e n t o r r e s t r i c t i o n
Q u e s t i o n s A d d e d f o r t h e S e c o n d V a l i d a t i o n S t u d y
D u r i n g t h e l a s t m o n t h o r s o :
Q u e s t i o n 1 6 . A b o u t h o w m a n y t i m e s d i d y o u u r i n a t e f r o m
t h e t i m e y o u g o t u p i n t h e m o r n i n g u n t i l t h e
t i m e y o u w e n t t o b e d a t n i g h t ?
0 - 1 t o 3 t i m e s a d a y
1 - 4 t o 5 t i m e s a d a y
2 - 6 t o 7 t i m e s a d a y
3 - 8 t o 9 t i m e s a d a y
4 - 1 0 t o 1 1 t i m e s a d a y
5 - 1 2 o r m o r e t i m e s a d a y
Q u e s t i o n 1 7 . H o w m a n y t i m e s d i d y o u m o s t t y p i c a l l y g e t
u p t o u r i n a t e f r o m t h e t i m e y o u w e n t t o b e d
a t n i g h t u n t i l t h e t i m e y o u g o t u p i n t h e
m o r n i n g ?
0 - N o n e
1 - 1 t i m e
2 - 2 t i m e s
3 - 3 t i m e s
4 - 4 t i m e s
5 - 5 o r m o r e t i m e s
A P P E N D I X 2
G l o b a l Q u e s t i o n s A b o u t a S u b j e c t ’ s D i f f i c u l t y W i t h U r i n a t i o n
a n d P r o s t a t e R e l a t e d P r o b l e m s
G l o b a l q u e s t i o n 1 . O v e r a l l , h o w b o t h e r s o m e h a s a n y t r o u b l e
w i t h u r i n a t i o n b e e n d u r i n g t h e l a s t m o n t h ?
0 - N o t a t a l l b o t h e r s o m e
1 - B o t h e r s m e a l i t t l e
2 - B o t h e r s m e s o m e
3 - B o t h e r s m e a l o t
G l o b a l q u e s t i o n 2 . I f y o u w e r e t o s p e n d t h e r e s t o f y o u r l i f e
w i t h y o u r p r o s t a t e s y m p t o m s j u s t a s t h e y a r e n o w , h o w w o u l d
y o u f e e l a b o u t t h a t ?
0 - D e l i g h t e d
1 - P l e a s e d
2 - M o s t l y s a t i s f i e d
3 - M i x e d ( a b o u t e q u a l l y s a t i s f i e d a n d d i s s a t i s f i e d )
4 - M o s t l y d i s s a t i s f i e d
5 - U n h a p p y
6 - T e r r i b l e
I n v e s t i g a t o r s p a r t i c i p a t i n g i l l t h e A U A B P H T r e a t m e n t O u t ›
c o m e s P i l o t S t u d y a r e D r . A b r a h a m T . K . C o c k e t t ( p r i n c i p a l
i n v e s t i g a t o r ) , U n i v e r s i t y o f R o c h e s t e r M e d i c a l C e n t e r , R o c h ›
e s t e r , N e w Y o r k ; D r s . S t e v e n S i h e l n i k a n d D a v i d G . M c L e o d ,
W a l t e r R e e d A r m y M e d i c a l C e n t e r , a n d D r s . M i c h a e l J .
M a n y a k a n d H a r r y C . M i l l e r , J r . , G e o r g e W a s h i n g t o n U n i v e r ›
s i t y S c h o o l o f M e d i c i n e , W a s h i n g t o n , D . C . ; D r . J o h n D .
M c C o n n e l l , U n i v e r s i t y o f T e x a s S o u t h w e s t e r n M e d i c a l C e n t e r ,
D a l l a s , T e x a s , a n d D r s . H o w a r d N . W i n f i e l d a n d R i c h a r d D .
W i l l i a m s , U n i v e r s i t y o f I o w a S c h o o l o f M e d i c i n e , I o w a C i t y ,
I o w a . M e r c k S h a r p & D o h m e R e s e a r c h L a b o r a t o r i e s s h a r e d
v e r s i o n s o f t h e i r s y m p t o m s c o r i n g s y s t e m s f o r B P H w i t h t h e
M e a s u r e m e n t C o m m i t t e e d u r i n g t h e p r o c e s s o f i t e m d e v e l o p ›
m e n t . P a m e l a S a p y t a a n d E l i z a b e t h W a l k e r - C o r k e r y p r o v i d e d
a n a l y t i c a l a s s i s t a n c e . D r . C h a r l e s E . M e t z , D e p a r t m e n t o f
R a d i o l o g y , T h e U n i v e r s i t y o f C h i c a g o , C h i c a g o , I l l i n o i s , d e ›
s i g n e d t h e R O C F I T a n d C L A B R O C s o f t w a r e .
R E F E R E N C E S
1 . B a r r y , M . J . : E p i d e m i o l o g y a n d n a t u r a l h i s t o r y o f b e n i g n p r o s t a t i c
h y p e r p l a s i a . U r o l . C l i n . N . A m e r . , 1 7 : 4 9 5 , 1 9 9 0 .
2 . G r a v e s , E . J . : D e t a i l e d d i a g n o s e s a n d p r o c e d u r e s , N a t i o n a l H o s p i t a l
D i s c h a r g e S u r v e y : 1 9 8 7 . N a t l . C e n t e r f o r H e a l t h S t a t i s t i c s . V i t a l
H e a l t h S t a t . , 1 3 : 2 9 5 , 1 9 8 9 .
3 . H o l t g r e w e , H . L . : A m e r i c a n U r o l o g i c a l A s s o c i a t i o n s u r v e y o f t r a n s ›
u r e t h r a l p r o s t a t e c t o m y a n d t h e i m p a c t o f c h a n g i n g M e d i c a r e
r e i m b u r s e m e n t . U r o l . C l i n . N . A m e r . , 1 7 : 5 8 7 , 1 9 9 0 .
4 . B a r r y , M . J . : M e d i c a l o u t c o m e s r e s e a r c h a n d b e n i g n p r o s t a t i c
h y p e r p l a s i a . P r o s t a t e , s u p p l . , 3 : 6 1 , 1 9 9 0 .
5 . M e b u s t , W . K . , H o l t g r e w e , H . L . , C o c k e t t , A . T . K . a n d P e t e r s , P .
C . : T r a n s u r e t h r a l p r o s t a t e c t o m y : i m m e d i a t e a n d p o s t o p e r a t i v e
c o m p l i c a t i o n s . A c o o p e r a t i v e s t u d y o f 1 3 p a r t i c i p a t i n g i n s t i t u ›
t i o n s e v a l u a t i n g 3 , 8 8 5 p a t i e n t s . J . U r o l . , 1 4 1 : 2 4 3 , 1 9 8 9 .
6 . L e p o r , H . : N o n o p e r a t i v e m a n a g e m e n t o f b e n i g n p r o s t a t i c h y p e r ›
p l a s i a . J . U r o l . , 1 4 1 : 1 2 8 3 , 1 9 8 9 .
7 . M a d s e n , P . 0 . a n d I v e r s e n , P . : A p o i n t s y s t e m f o r s e l e c t i n g o p e r a ›
t i v e c a n d i d a t e s . I n : B e n i g n P r o s t a t i c H y p e r t r o p h y . E d i t e d b y F .
H i n m a n , J r . N e w Y o r k : S p r i n g e r - V e r l a g , c h a p t . 7 9 , p p . 7 6 3 - 7 6 5 ,
1 9 8 3 .
8 . B o y a r s k y , S . , . J o n e s , G . , P a u l s o n , D . F . a n d P r o u t , G . R . , J r . : A n e w
l o o k a t b l a d d e r n e c k o b s t r u c t i o n b y t h e F o o d a n d D r u g A d m i n ›
i s t r a t i o n r e g u l a t o r s : g u i d e l i n e s f o r i n v e s t i g a t i o n o f b e n i g n p r o s -

AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX 1557
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logic Research: Principles and Quantitative Methods. New York:
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~3. Hanley, J. A. and McNeil, B. J.: The meaning and use of the area
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residual urine determination in evaluation of prostatism. Urol›
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147: 1044, 1992.

0 0 2 2 - 5 3 4 7 / 9 2 / 1 4 8 5 - 1 5 6 4 $ 0 3 . 0 0 / 0
T H E J O U R N A L O F U R O L O G Y
C o p y r i g h t ' 1 9 9 2 b y A M E R I C A N U R O L O G I C A L A S S O C I A T I O N , I N C .
V o l . 1 4 8 , 1 5 6 4 , N o v e m b e r 1 9 9 2
P r i n t e d i n U . S . A .
E D I T O R I A L
T h e 3 p r e c e d i n g a r t i c l e s ( p a g e s 1 5 4 6 , 1 5 4 9 a n d 1 5 5 8 ) p r e s e n t
v a r i o u s a s p e c t s o f a n e f f o r t u t i l i z i n g s y m p t o m s t o d e v e l o p
r e l i a b l e a n d v a l i d m e a s u r e s f o r t h e t r e a t m e n t o f b e n i g n p r o s ›
t a t i c h y p e r p l a s i a ( B P H ) . T h e o b s e r v a t i o n s m a d e a r e p r e s e n t e d
o b j e c t i v e l y a n d e v a l u a t e d t h o u g h t f u l l y . U s e o f t h e s y m p t o m
i n d e x s h o u l d m i m i c i t s d e v e l o p m e n t . T h e d a t a p r e s e n t e d r e v e a l
a n o v e r l a p i n i n d i v i d u a l c o n t r o l a n d B P H p a t i e n t s c o r e s ( f i g .
1 , p a g e 1 5 5 2 ) t h a t p r o v i d e s v i s u a l e v i d e n c e t o s u p p o r t t h e
a d m o n i t i o n n o t t o u s e t h e i n d e x t o s c r e e n f o r B P H . T h e B P H
p a t i e n t s u s e d t o d e v e l o p t h i s i n d e x w e r e s e l e c t e d b y 3 e x p e r i ›
e n c e d u r o l o g i s t s f r o m t h e i r p r a c t i c e a s b e i n g l i k e l y t o h a v e B P H
r e l a t e d u r i n a r y d y s f u n c t i o n . T h e c o n t r o l g r o u p w a s s e l e c t e d o n
t h e b a s i s o f p a t i e n t a g e a n d a b s e n c e o f u r i n a r y p r o b l e m s o r
p r o s t a t e d i s e a s e s . C o n s e q u e n t l y , t h e s u g g e s t i o n t h a t t h e i n d e x
w o u l d p e r f o r m l e s s w e l l i n d i s c r i m i n a t i n g u n s e l e c t e d p a t i e n t s
o f s i m i l a r a g e s w i t h a n d w i t h o u t B P H s e e m s l i k e l y t o b e c o r r e c t .
T h e a u t h o r s d i s c u s s o t h e r l i m i t a t i o n s o f t h e i n f o r m a t i o n
p r e s e n t e d . T h e y e m p h a s i z e t h a t s y m p t o m a t i c a s s e s s m e n t i s
o n l y 1 f a c e t o f t h e e v a l u a t i o n o f t h e r e s p o n s e t o t r e a t m e n t a n d
n a t u r a l h i s t o r y o f p a t i e n t s w i t h B P H . T o m e t h e p r i m a r y
s y m p t o m a t i c g o a l o f a n y t h e r a p e u t i c i n t e r v e n t i o n i n p a t i e n t s
w i t h u r i n a r y d y s f u n c t i o n , e x c l u d i n g t h o s e w i t h m a j o r c o m p l i ›
c a t i o n s f r o m s e v e r e o b s t r u c t i o n o r o t h e r c a u s e s , i s t o a l l o w t h e
t r e a t e d p a t i e n t t o v o i d a t r e a s o n a b l e i n t e r v a l s c h o s e n b y h i m
w i t h o u t w e t t i n g h i m s e l f , o r e x p e r i e n c i n g g r e a t i n c o n v e n i e n c e
o r d i f f i c u l t y . S i m p l i s t i c a l l y , t h e p h y s i o l o g i c a l g o a l o f v o i d i n g
w o u l d s e e m t o b e t o e m p t y t h e b l a d d e r w i t h o u t d o i n g a n y
s i g n i f i c a n t h a r m t o i m p o r t a n t b o d i l y f u n c t i o n s . S o m e h o w t h e
d e g r e e t o w h i c h o u r t h e r a p e u t i c i n t e r v e n t i o n s a c c o m p l i s h t h e s e
g o a l s a n d o t h e r s i d e n t i f i e d b y q u e s t i o n i n g i n d i v i d u a l s w i t h
r e g a r d t o t h e i r g l o b a l a s s e s s m e n t s s h o u l d b e r e c o r d e d a n d
c o m m u n i c a t e d . T h e A m e r i c a n U r o l o g i c a l A s s o c i a t i o n ( A U A )
s y m p t o m s c o r e a p p e a r s t o b e a s i m p l e , e a s i l y a d m i n i s t e r e d t o o l
t o a s s e s s t h e s y m p t o m a t i c e f f e c t s o f t r e a t m e n t . H o w e v e r , i f t h e
o v e r a l l s y m p t o m s c o r e s a r e r e p o r t e d e x c l u s i v e l y , t h e r e c o r d e d
r e s u l t s o f t h e s c o r e q u e s t i o n n a i r e m a y b e l e s s i n f o r m a t i v e t h a n
1 5 6 4
i s d e s i r a b l e . A c o n c i s e m e t h o d o f r e p o r t i n g r e s u l t s a c h i e v e d i n
i n d i v i d u a l c o m p o n e n t s o f t h e q u e s t i o n n a i r e a n d i n i n d i v i d u a l
p a t i e n t s i s e s s e n t i a l t o a l l o w a n i n d e p e n d e n t c r i t i c a l e v a l u a t i o n
o f t h e d a t a . T h i s c h a l l e n g i n g i m p o r t a n t g o a l s h o u l d n o t b e
o v e r l o o k e d . O b v i o u s l y , t h e a u t h o r s o f t h e s e a r t i c l e s r e a l i z e t h e
i m p o r t a n c e o f p r e s e n t i n g s u f f i c i e n t i n f o r m a t i o n t o p e r m i t i n ›
d e p e n d e n t a s s e s s m e n t a n d t h e y d o s o t h o u g h t f u l l y i n t h e i r
m a n u s c r i p t s . I h a v e a l r e a d y r e f e r r e d t o t h e i n d i v i d u a l d a t a
p r e s e n t e d i n f i g u r e 1 o n p a g e 1 5 5 2 . I a l s o f o u n d t h e d a t a
p r e s e n t e d i n t a b l e 4 o n p a g e 1 5 5 3 i n f o r m a t i v e . M y s u p e r f i c i a l
a n a l y s i s o n l o o k i n g a t t h i s t a b l e i s t h a t a l m o s t n o c o n t r o l
p a t i e n t s h a d h e s i t a n c y ( 9 9 3 , 0 t o 1 s c o r e ) , i n c o m p l e t e e m p t y i n g
( 9 5 3 , 0 t o 1 s c o r e ) o r i n t e r m i t t e n c y ( 9 5 3 , 0 t o 1 s c o r e ) .
C o n s e q u e n t l y , i f t h i s o b s e r v a t i o n i s c o r r e c t a n d c o n f i r m e d ,
i n d i v i d u a l s w i t h t h e s e s y m p t o m s s h o u l d b e e v a l u a t e d w h e t h e r
o r n o t t h e y a r e l i k e l y t o h a v e B P H .
T h e a u t h o r s h a v e m a d e a s i g n i f i c a n t e f f o r t t o a d d t o o u r
k n o w l e d g e w i t h r e g a r d t o v o i d i n g a n d t h e e f f e c t o f B P H o n i t .
T h e f a c t t h a t t h e s t u d i e s r e p o r t e d w e r e p a r t i a l l y s u p p o r t e d b y
t h e A U A a n d b e a r t h e d e s i g n a t i o n A U A i n t h e t i t l e d o e s n o t
e l i m i n a t e t h e n e e d t o s c r u t i n i z e a n d e v a l u a t e t h e m c r i t i c a l l y
a n d r e p e a t e d l y . S i m i l a r l y , I h o p e t h e r e a d e r i s a w a r e t h a t I
r e c o g n i z e t h a t t h e a t t i t u d e s o f a n d c o m m u n i c a t i o n s f r o m e d i ›
t o r s w a r r a n t t h e s a m e o r g r e a t e r s k e p t i c a l s c r u t i n y . A s q u a l i t y
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