european urology 50 (2006) 1306–1315

available at www.sciencedirect.com
journal homepage: www.europeanurology.com

Incontinence

Population-Based Survey of Urinary Incontinence, Overactive

Bladder, and Other Lower Urinary Tract Symptoms in Five
Countries: Results of the EPIC Study

Debra E. Irwin a,*, Ian Milsom b, Steinar Hunskaar c, Kate Reilly d,

Zoe Kopp d, Sender Herschorn e, Karin Coyne f, Con Kelleher g,
Christian Hampel h, Walter Artibani i, Paul Abrams j
a
Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
b
Department of Obstetrics and Gynecology, Sahlgrenska Academy at Goteborg University, Goteborg, Sweden
c
Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
d
Pfizer Inc, New York, NY, United States
e
Sunnybrook and Women’s College Health Science Centre, University of Toronto, Toronto, ON, Canada
f
Center for Health Outcomes, United BioSource Corporation, Bethesda, MD, United States
g
St. Thomas’ Hospital, London, United Kingdom
h
Urologische Klink und Polyklink, Johannes-Gutenberg-Universität, Mainz, Germany
i
Urology Unit, University of Padova, Padova, Italy
j
Bristol Urological Institute, Southmead Hospital, Bristol, United Kingdom

Article info Abstract

Article history: Objective: Estimate the prevalence of urinary incontinence (UI), overactive bladder (OAB), and other
lower urinary tract symptoms (LUTS) among men and women in five countries using the 2002
Accepted September 25, 2006
International Continence Society (ICS) definitions.
Published online ahead of Methods: This population-based, cross-sectional survey was conducted between April and December
print on October 2, 2006 2005 in Canada, Germany, Italy, Sweden, and the United Kingdom using computer-assisted telephone
interviews. A random sample of men and women aged  18 yr residing in the five countries and who
were representative of the general populations in these countries was selected. Using 2002 ICS
Keywords: definitions, the prevalence estimates of storage, voiding, and postmicturition LUTS were calculated.
Adult Data were stratified by country, age cohort, and gender.
Epidemiologic survey Results: A total of 19,165 individuals agreed to participate; 64.3% reported at least one LUTS. Nocturia
was the most prevalent LUTS (men, 48.6%; women, 54.5%). The prevalence of storage LUTS (men, 51.3%;
Lower urinary tract
women, 59.2%) was greater than that for voiding (men, 25.7%; women, 19.5%) and postmicturition
symptoms (men, 16.9%; women, 14.2%) symptoms combined. The overall prevalence of OAB was 11.8%; rates were
Nocturia similar in men and women and increased with age. OAB was more prevalent than all types of UI
Overactive bladder combined (9.4%).
Conclusions: The EPIC study is the largest population-based survey to assess prevalence rates of OAB,
Prevalence
UI, and other LUTS in five countries. To date, this is the first study to evaluate these symptoms
Urinary incontinence simultaneously using the 2002 ICS definitions. The results indicate that these symptoms are highly
prevalent in the countries surveyed.
# 2006 Published by Elsevier B.V. on behalf of European Association of Urology.

* Corresponding author. Department of Epidemiology, University of North Carolina,

CB#7435 McGavran Greenberg Bldg, Chapel Hill, NC 27599, United States.
Tel. +1 919 357 5379; Fax: +1 919 966 2089.
E-mail address: [email protected] (D.E. Irwin).
0302-2838/$ – see back matter # 2006 Published by Elsevier B.V. on behalf of European Association of Urology. doi:10.1016/j.eururo.2006.09.019
 european urology 50 (2006) 1306–1315 1307

1. Introduction 2.2. Questionnaire development

The term lower urinary tract symptoms (LUTS) was The CATI questionnaire was developed by a panel of clinical
and epidemiologic experts. The original questionnaire was
introduced in 1994 [1] and consists of storage,
written in English and translated into each country’s primary
voiding, and postmicturition symptoms [2]. Many
language. The translation was done to ensure that the cultural
adults experience LUTS, and the prevalence of these
and linguistic integrity of the questions was conveyed and not
symptoms increases with age [3]. Individuals with just a literal translation. Pilot interviews (n = 15) were
LUTS often experience urinary incontinence (UI) or conducted in each country. Based on the results of these
overactive bladder (OAB) symptoms. OAB is a subset interviews the questionnaire was revised.
of storage LUTS currently defined by the Interna- All survey participants were asked about the presence of
tional Continence Society (ICS) as urgency, with or urinary symptoms (see Appendix) and demographics. These
without urgency UI (UUI), usually with frequency initial questions included symptom items from the Interna-
and nocturia [2]. LUTS, including UI and OAB, have tional Prostate Symptom Score (IPSS) [16].
detrimental effects on health-related quality of life
[4–6]. 2.3. Case definitions
Several population-based studies have estimated
The 2002 ICS definitions were used for frequency, nocturia,
the prevalence of UI or subsets of LUTS [7–11], but
urgency, OAB, UUI, stress urinary incontinence (SUI), mixed
prevalence estimates differ based on type of UI and
urinary incontinence (MUI), intermittency, slow stream,
country surveyed. Many of these studies were also straining, terminal dribble, postmicturition dribble, and
limited by gender, examining UI in women and LUTS incomplete emptying [2]. Unless otherwise noted, the 2002
in men. Relatively few published prevalence surveys ICS definition of nocturia (1 episodes/night) is reported. For
in the general population have assessed the pre- comparison, when noted, we also report nocturia defined as
valence of OAB, and these have used different two or more nocturnal micturitions per night. Participants
definitions of OAB [6,12–15]. To date, no large who reported both UUI and SUI symptoms were classified as
population-based study has evaluated the preva- having MUI. Those who reported UI without symptoms of UUI
lence of all LUTS using the definitions recently or SUI were categorised as having other UI. We categorised
LUTS as storage (i.e., frequency, nocturia, urgency, UUI, SUI,
approved by the ICS [2]. Therefore, the aim of this
MUI, and other UI), voiding (i.e., intermittency, slow stream,
study was to estimate the population-based pre-
straining, and terminal dribble), and postmicturition symp-
valence of UI, OAB, and other LUTS among men and
toms (i.e., incomplete emptying and postmicturition dribble).
women aged  18 yr using the current ICS (2002)
definitions. 2.4. Statistical analyses

All statistical analyses were performed using SPSS (Version

2. Methods
14.0; SPSS Inc, Chicago, IL). To account for the underlying
sampling frame and to provide representative population
This was a population-based, cross-sectional telephone
prevalence estimates, the sample population was weighted by
survey of adults aged  18 yr in five countries: Canada,
age (5-yr groups), gender, household size (1, 2, 3, 4, and 5
Germany, Italy, Sweden, and the United Kingdom. All inter-
persons), and country size. Weighting goals were taken from
views were conducted using a computer-assisted telephone
national published sources and derived for each interview
interview (CATI) system. All interviewers underwent stan-
through a two-step process: (1) a weighted factor set was
dardised training and regular quality-control checks. Ethics
calculated to satisfy the weighting on both age and gender and
committee approval was obtained according to national
household size simultaneously (rim-weighting), and (2) the
regulations in each country.
weighting factors resulting from country population sizes
were applied. Prevalence data were analysed by country,
2.1. Survey sampling techniques gender, and 5-yr age cohorts. Three age groups were defined
(39 yr; 40–59 yr; 60 yr) for presentation in this paper. Results
A two-step sampling method was used to obtain a represen- are presented as numbers (unweighted) and percentages of
tative sample of the general population: (1) a random sample participants with 95% confidence limits.
of households with a residential telephone number was
selected, and (2) within a given household, an individual aged
 18 yr was randomly selected. This individual was asked for 3. Results
the number of adults aged  18 yr permanently living in the
household. The person with the most recent birthday was 3.1. Participants
selected for the interview. If the person was not present or
available, an appointment was made for an interview at a later A total of 58,139 individuals were contacted to
time. If the selected person was unwilling to participate, no participate in the study, and 19,165 agreed (33%
substitution was made in that household. response rate). Individuals were interviewed
1308 european urology 50 (2006) 1306–1315

Table 1 – Age and gender distributions of survey participants and the general population of Sweden, Germany, Italy,
Canada, and the United Kingdom

Age group, y Survey participants (n = 19,165) General population* (n = 192,399,205)

Men % Women % Total % Men % Women % Total %

18–29 16.4 13.6 14.7 19.2 17.5 18.3

30–34 7.5 7.5 7.5 9.4 8.6 9.0
35–39 10.0 10.2 10.1 10.6 9.7 10.2
40–44 11.1 11.7 11.5 10.3 9.5 9.9
45–49 10.0 10.5 10.3 9.1 8.5 8.7
50–54 9.6 9.7 9.7 8.4 7.9 8.1
55–59 8.9 9.2 9.1 7.6 7.3 7.4
60–64 7.9 8.0 8.0 7.2 7.0 7.1
65–69 7.3 7.0 7.1 6.3 6.5 6.4
70 11.4 12.5 12.1 12.0 17.6 14.9

*
2004 estimates.

between April 2005 and December 2005. Demo- occurred together most often (17.7% men; 14.9%
graphics for the survey participants and for the women), and all three types of LUTS were reported
general population within the five countries sur- simultaneously by 8.8% of men and 6.6% of women.
veyed are summarised in Table 1. Respondents were When nocturia was defined as two or more
predominantly white (95.6%), about 26.6% had a nocturnal micturitions per night instead of one or
university education or higher, and 58.5% were more, the prevalence of nocturia decreased to 20.9%
currently married. in men and to 24.0% in women (Table 2). Similarly,
the overall prevalence of any storage symptom
3.2. Prevalence of LUTS decreased (Table 2).
Country-specific prevalence rates for LUTS are
Table 2 reports the prevalence of LUTS in the survey shown in Fig. 1. Nocturia was the most commonly
population. Women (59.2%) reported storage symp- reported storage symptom for both men and women
toms more frequently than men (51.3%), whereas the in all five countries followed by UI in women
opposite was true for voiding (men, 25.7%; women, (Sweden, Canada, and the United Kingdom) and
19.5%) and postmicturition symptoms (men, 16.9%; urgency in men (Germany and Italy). Terminal
women, 14.2%). All symptoms among men increased dribble was the most prevalent voiding symptom
in prevalence with advancing age, especially for in three countries (Italy, Germany, and the United
those 60 yr of age. This trend was similar among Kingdom) and slow stream was the least prevalent
women for urgency, nocturia, UUI, MUI, other UI, in four of the five countries.
intermittency, slow stream, and postmicturition The LUTS that define OAB were reported by 12.8%
dribble. UI was reported by 13.1% of women and of women and 10.8% of men. Fig. 2 shows the overlap
5.4% of men, with SUI (6.4%) as the most common of OAB symptoms with and without UI. Nearly half of
type (48.9%) for women and other UI (2.9%) for men the women who reported symptoms of OAB also
(53.7%). The overall prevalence of any LUTS was reported UI (6.3%/12.8%). Among these women with
62.5% in men and 66.6% in women. Approximately OAB symptoms and UI, 23.8% experienced UI due to
1.4% of men and 1.8% of women with LUTS also UUI alone, 28.6% due to SUI alone, 38.1% due to MUI,
reported symptoms of urinary tract infection (UTI). and 9.5% due to other UI. About 28.7% of men with
Overall, storage symptoms were reported more OAB symptoms reported UI, and in 41.6% it was due
often than voiding or postmicturition symptoms. to UUI alone, 29% due to other UI, 19.4% due to MUI,
The most common storage symptom was nocturia and 10% due to SUI alone. Among those with other
(48.6% men; 54.5% women) followed by urgency UI, 31.7% of men and 23.0% of women reported
(10.8% men; 12.8% women). Men reported voiding symptoms of UI and urgency but did not attribute
and postmicturition symptoms more frequently their UI to UUI or SUI. Similarly, symptoms of
than women. Terminal dribble (14.2% men; 9.9% postmicturition dribble (34.5% men; 8.5% women) or
women) was the most common voiding symptom, terminal dribble (32.1% men; 15.9% women) coex-
and incomplete emptying (13.5% men; 12.3% isted among those with other UI. The proportion of
women) was the most frequently reported post- the other UI population with any one of these three
micturition symptom. Storage and voiding symp- additional symptoms (urgency not attributed to
toms were the two groups of symptoms that UUI, terminal dribble, or postmicturition dribble)
 european urology 50 (2006) 1306–1315 1309

was 62.1% for men and 36.7% for women (data not women (storage, 34.2%; voiding, 19.5%; postmicturi-
shown). tion, 14.2%). The clinical relevance of nocturia for
individuals who have only one episode per night is
yet to be determined. However, given the large
4. Discussion decrease in the prevalence of nocturia when the
definition was changed from at least one micturition
To date, the EPIC study is the largest of its kind to per night to two or more micturitions per night, even
report population-based prevalence rates of LUTS among those respondents 39 yr of age, our data
including OAB and UI, and in five countries. To our may suggest that experiencing one micturition per
knowledge, this is the first study published that night is a part of the normal clinical spectrum.
evaluated these symptoms simultaneously using The published prevalence rates of UI vary greatly
the 2002 ICS definitions. Our results demonstrate across studies. A meta-analysis of UI studies found
that LUTS are highly prevalent in men (62.5%) and that prevalence rates among men ranged from 4.6%
women (66.6%) 40 yr of age in the countries to 24% with a mean of 14.5%, and rates among
surveyed and that the prevalence of LUTS increases women ranged from 4.5% to 44% with a mean of
with age. Approximately 1.4% of men and 1.8% of 23.5% [20]. The prevalence rates of UI reported in our
women with LUTS also reported symptoms of UTI. study are at the lower end of the ranges reported in
The presence of UTI was not clinically confirmed in these other studies. The wide range of prevalence
these individuals, so we cannot be sure what the estimates is likely due to methodologic differences,
rates of UTI actually were. However, even if all men because the definitions of UI, design of question-
and women who reported symptoms of UTI were naires, study populations, and survey methods (e.g.,
excluded, the prevalence of LUTS in men and postal vs. telephone survey) vary across studies.
women would still be within the confidence limits Other studies report a lower prevalence of other
of our estimates. UI with a proportionately higher prevalence of MUI
Our findings are consistent with other epidemio- in women and UUI in men [9,11,20]. This suggests
logic studies of LUTS conducted in men [7,10], which that a larger proportion of our survey respondents
also showed that the prevalence of all symptoms were unable to attribute their UI symptoms to SUI or
increased linearly with age. Notably, the prevalence UUI and were thus classified as having other UI.
of LUTS in the current study is high compared with Despite the differences in overall UI prevalence
some male-specific studies of LUTS that estimated rates, our findings are consistent with other reports
the prevalence of ‘‘moderate to severe’’ LUTS, regarding the effects of age on UI prevalence [9,20].
defined as a score of at least 8 on the IPSS [8,17]. To date, few large population-based surveys in
This is not surprising, given that the survey used in Europe and North America have evaluated the
the current study measured the presence of indivi- prevalence of OAB. Two of these studies used an
dual LUTS as defined by the ICS. In contrast, the older definition of OAB [6,13]. Stewart et al. [6]
scoring system of the IPSS is such that a participant estimated the US prevalence of OAB in adults aged
could report experiencing any individual LUTS with 18 yr to be 16% in men and 16.9% in women. In
a frequency of ‘‘almost always’’ without being Europe, Milsom et al. [13] provided an OAB pre-
considered to have ‘‘moderate to severe’’ LUTS. valence rate in adults aged  40 yr of 15.6% for men
The 2002 ICS definition of nocturia (at least one and 17.4% for women. Given that the older, broader
nocturnal micturition per night) is relatively broad, definition of OAB comprised symptoms of fre-
which explains the high prevalence of nocturia quency, urgency, and UUI, occurring either singly
(48.6% men; 54.5% women) in our study population. or in combination, it is not surprising that our
The published prevalence of nocturia using this prevalence estimates are somewhat lower than
definition ranges from 30% to 53% [18,19]. When those reported by Milsom et al. [13]. In addition,
nocturia was defined as two or more micturitions our results confirm those of both previous studies
per night, the prevalence rates were reduced [6,13], which suggested that women have a higher
substantially in both men (20.9%) and women prevalence of OAB symptoms compared with men
(24.0%). Similarly, the overall prevalence of any before the age of 60 yr, whereas men have a higher
LUTS decreases when the definition of nocturia is prevalence of OAB symptoms after age 60 yr. Other
changed from at least one micturition per night to recent studies report similar results [12,14,15].
two or more micturitions per night, although storage The results of the current study should be viewed
LUTS remained more prevalent than voiding and within the context of its limitations. One limitation
postmicturition LUTS among both men (storage, involves the use of self-reports to measure LUTS.
26.9%; voiding, 25.7%; postmicturition, 16.9%) and Evidence indicates that self-reports are vulnerable
 1310
Table 2 – Prevalence (%, 95%CI) of LUTS by age and gender

Men Women

39 y 40–59 y 60 y Total 39 y 40–59 y 60 y Total

n* (%y, 95%CI) n* (%y, 95%CI) n* (%y, 95%CI) n* (%y, 95%CI) n* (%y, 95%CI) n* (%y, 95%CI) n* (%y, 95%CI) n* (%y, 95%CI)

Storage symptoms
Any storage symptom 964 (37.5, 1469 (50.6, 1413 (73.9, 3846 (51.3, 1916 (48.9, 2780 (56.3, 2434 (74.5, 7130 (59.2,
(nocturia  1 time/night) 35.9–39.0) 48.9–52.4) 72.1–75.7) 50.3–52.3) 47.3–50.6) 54.6–58.0) 73.0–76.1) 58.3–60.2)
Any storage symptom 465 (17.9, 748 (25.0, 864 (43.6, 2077 (26.9, 1025 (26.0, 1638 (32.0, 1577 (46.5, 4240 (34.2,
(nocturia  2 times/night) 16.6–19.1) 23.6–26.5) 41.6–45.6) 26.0–27.8) 24.5–27.4) 30.4–33.6) 44.7–48.2) 33.3–35.2)
Nocturia (1 time/night) 886 (34.5, 1387 (47.8, 1369 (71.9, 3642 (48.6, 1741 (43.9, 2513 (51.0, 2278 (70.8, 6532 (54.5,
33.0–36.1) 46.1–49.5) 70.0–73.7) 47.6–49.6) 42.3–45.5) 49.3–52.8) 69.2–72.4) 53.5–55.5)

european urology 50 (2006) 1306–1315

Nocturia (2 times/night) 334 (12.9, 576 (19.5, 704 (35.2, 1614 (20.9, 690 (16.9, 1097 (21.0, 1152 (35.6, 2939 (24.0,
11.9–14.0) 18.1–20.8) 33.3–37.2) 20.0–21.7) 15.7–18.1) 19.6–22.4) 33.9–37.3) 23.1–24.8)
Urgency 168 (7.1, 263 (8.9, 362 (19.1, 793 (10.8, 372 (9.7, 577 (11.2, 616 (18.3, 1565 (12.8,
6.3–8.0) 7.9–9.8) 17.5–20.7) 10.1–11.4) 8.8–10.7) 10.1–12.3) 16.9–19.6) 12.2–13.5)
Frequency 122 (4.6, 180 (5.9, 219 (11.4, 521 (6.8, 296 (7.9, 300 (5.8, 280 (8.4, 876 (7.4,
4.0–5.3) 5.1–6.7) 10.1–12.7) 6.3–7.3) 7.0–8.8) 5.0–6.6) 7.5–9.4) 6.9–7.9)
UUI 10 (0.4, 41 (1.3, 52 (2.5, 103 (1.2, 41 (1.0, 62 (1.1, 105 (2.5, 208 (1.5,
0.2–0.6) 0.9–1.7) 1.9–3.1) 1.0–1.5) 0.6–1.3) 0.7–1.5) 1.9–3.0) 1.2–1.7)
MUI 10 (0.4, 12 (0.4, 27 (1.2, 49 (0.6, 36 (1.0, 123 (2.4, 158 (4.1, 317 (2.4,
0.2–0.6) 0.2–0.6) 0.7–1.6) 0.4–0.7) 0.6–1.3) 1.9–3.0) 3.4–4.8) 2.1–2.7)
SUI 3 (0.1, 17 (0.6, 29 (1.6, 49 (0.6, 142 (3.7, 386 (7.9, 293 (8.0, 721 (6.4,
0.0–0.2) 0.3–0.8) 1.1–2.1) 0.5–0.8) 3.1–4.3) 7.0–8.8) 7.1–9.0) 5.9–6.9)
Other UI 44 (1.5, 91 (3.0, 103 (5.2, 238 (2.9, 74 (1.7, 114 (2.3, 141 (4.6, 329 (2.8,
1.1–1.9) 2.4–3.6) 4.3–6.1) 2.6–3.3) 1.3–2.1) 1.8–2.8) 3.9–5.4) 2.5–3.1)
Any UI (UUI, MUI, SUI, Other) 67 (2.4, 161 (5.2, 211 (10.4, 439 (5.4, 293 (7.3, 685 (13.7, 697 (19.3, 1675 (13.1,
1.9–2.9) 4.5–6.0) 9.2–11.7) 4.9–5.9) 6.5–8.1) 12.6–14.9) 17.9–20.7) 12.4–13.8)

Voiding symptoms
Any voiding symptom 507 (19.9, 708 (24.1, 723 (37.2, 1938 (25.7, 706 (17.4, 907 (17.0, 830 (24.6, 2443 (19.5,
18.6–21.2) 22.6–25.6) 35.3–39.2) 24.9–26.6) 16.2–18.7) 15.7–18.3) 23.0–26.1) 18.7–20.3)
Intermittency 148 (5.5, 238 (7.6, 298 (14.5, 684 (8.5, 240 (6.0, 319 (6.1, 341 (9.8, 900 (7.2,
4.8–6.2) 6.7–8.5) 13.1–16.0) 8.0–9.1) 5.3–6.8) 5.3–7.0) 8.7–10.8) 6.7–7.7)
Slow stream 109 (3.9, 229 (7.4, 377 (18.9, 715 (8.9, 205 (4.9, 269 (4.9, 294 (9.7, 768 (6.4,
3.2–4.5) 6.5–8.3) 17.4–20.5) 8.3–9.5) 4.2–5.6) 4.2–5.7) 8.6–10.7) 5.9–6.8)
Straining 123 (4.5, 205 (6.9, 180 (10.0, 508 (6.7, 167 (3.5, 184 (3.3, 166 (5.2, 517 (4.0,
3.8–5.1) 6.0–7.8) 8.8–11.2) 6.2–7.2) 2.9–4.1) 2.7–3.9) 4.4–6.0) 3.6–4.3)
Terminal dribble 294 (12.2, 380 (13.2, 341 (18.8, 1015 (14.2, 374 (10.1, 473 (8.7, 391 (10.9, 1238 (9.9,
11.2–13.3) 12.0–14.4) 17.2–20.3) 13.5–14.9) 9.2–11.1) 7.8–9.7) 9.8–12.0) 9.3–10.5)
Postmicturition symptoms
Any postmicturition 337 (12.7, 481 (16.1, 476 (24.7, 1294 (16.9, 521 (13.5, 617 (12.1, 557 (17.4, 1695 (14.2,
symptom 11.6–13.7) 14.8–17.3) 22.9–26.5) 16.1–17.7) 12.4–14.6) 11.0–13.2) 16.1–18.7) 13.5–14.9)
Incomplete emptying 257 (9.6, 364 (12.5, 396 (20.9, 1017 (13.5, 468 (11.9, 522 (10.4, 460 (15.0, 1450 (12.3,
8.6–10.5) 11.4–13.7) 19.3–22.6) 12.8–14.2) 10.8–12.9) 9.3–11.4) 13.7–16.2) 11.7–13.0)
Postmicturition 116 (4.5, 179 (5.4, 151 (7.1, 446 (5.5, 89 (2.6, 147 (2.7, 149 (4.2, 385 (3.1,
dribble 3.8–5.2) 4.7–6.2) 6.1–8.1) 5.0–6.0) 2.1–3.1) 2.1–3.3) 3.5–4.9) 2.8–3.5)

Any LUTS 1310 (51.3, 1793 (62.0, 1556 (80.7, 4659 (62.5, 2306 (58.7, 3148 (63.5, 2600 (79.3, 8054 (66.6,
(nocturia  1 time/night) 49.7–52.9) 60.3–63.6) 79.1–82.3) 61.5–63.5) 57.1–60.3) 61.9–65.2) 77.9–80.8) 65.7–67.5)
Storage and voiding 277 (10.3, 472 (15.8, 609 (31.8, 1358 (17.7, 478 (11.9, 661 (12.4, 716 (21.2, 1855 (14.9,
9.3–11.3) 14.5–17.0) 30.0–33.7) 16.9–18.4) 10.9–13.0) 11.3–13.5) 19.7–22.6) 14.2–15.6)
Storage and 196 (7.6, 354 (11.7, 424 (22.3, 974 (12.7, 363 (9.3, 495 (9.7, 490 (15.4, 1348 (11.3,
postmicturition 6.7–8.4) 10.6–12.8) 20.6–24.0) 12.1–13.4) 8.4–10.3) 8.7–10.7) 14.1–16.7) 10.7–11.9)
Voiding and 182 (7.0, 303 (9.9, 356 (18.5, 841 (10.9, 257 (6.7, 336 (6.3, 338 (10.5, 931 (7.7,
postmicturition 6.1–7.8) 8.9–11.0) 16.9–20.1) 10.3–11.5) 5.9–7.5) 5.5–7.2) 9.4–11.5) 7.2–8.3)

european urology 50 (2006) 1306–1315

All 3 symptoms 127 (4.8, 232 (7.5, 318 (16.8, 677 (8.8, 199 (5.1, 284 (5.4, 314 (9.7, 797 (6.6,
4.1–5.5) 6.6–8.4) 15.3–18.4) 8.2–9.4) 4.4–5.8) 4.7–6.2) 8.7–10.8) 6.1–7.1)

Any LUTS 958 (37.6, 1308 (44.7, 1228 (62.9, 3494 (46.5, 1659 (42.0, 2294 (44.9, 1984 (58.7, 5937 (48.1,
(nocturia  2 times/night) 36.0–39.2) 43.0–46.5) 61.0–64.9) 45.5–47.5) 40.4–43.6) 43.1–46.6) 57.0–60.5) 47.1–49.0)
Storage and voiding 172 (6.2, 306 (9.9, 441 (22.2, 919 (11.5, 323 (8.1, 477 (8.9, 565 (16.7, 1366 (11.0,
5.4–6.9) 8.9–11.0) 20.5–23.9) 10.9–12.2) 7.2–9.0) 7.9–9.8) 15.4–18.0) 10.4–11.6)
Storage and 196 (7.6, 354 (11.7, 424 (22.3, 974 (12.7, 363 (9.3, 495 (9.7, 490 (15.4, 1348 (11.3,
postmicturition 6.7–8.4) 10.6–12.8) 20.6–24.0) 12.1–13.4) 8.4–10.3) 8.7–10.7) 14.1–16.7) 10.7–11.9)
Voiding and 182 (7.0, 303 (9.9, 356 (18.5, 841 (10.9, 257 (6.7, 336 (6.3, 338 (10.5, 931 (7.7,
postmicturition 6.1–7.8) 8.9–11.0) 16.9–20.1) 10.3–11.5) 5.9–7.5) 5.5–7.2) 9.4–11.5) 7.2–8.3)
All 3 symptoms 94 (3.4, 167 (5.2, 258 (13.1, 519 (6.5, 161 (4.0, 239 (4.5, 276 (8.4, 676 (5.6,
2.8–3.9) 4.4–5.9) 11.8–14.5) 6.0–7.0) 3.4–4.7) 3.8–5.2) 7.5–9.4) 5.1–6.0)

CI = confidence interval; LUTS = lower urinary tract symptoms; MUI = mixed urinary incontinence; SUI = stress urinary incontinence; UI = urinary incontinence; UUI = urgency urinary
incontinence.
*
Unweighted.
y
Weighted.

1311
1312 european urology 50 (2006) 1306–1315

Fig. 2 – Prevalence (%) of UI subtypes among participants

with OAB. OAB = overactive bladder; MUI = mixed urinary
incontinence; SUI = stress urinary incontinence;
UI = urinary incontinence; UUI = urgency urinary
incontinence.

tion is that the results of self-report data may be

influenced by the mode of administration of the
questionnaire; different modes may differ in terms
of sampling error, response rates, data complete-
Fig. 1 – Prevalence (%) of LUTS by country and gender.
ness, and measurement error [23]. Evidence sug-
LUTS = lower urinary tract symptoms; UI = urinary
gests this may be true in the measurement of LUTS
incontinence.
[24,25]. Thus, our data may have been slightly
different if collected via mail or face-to-face inter-
to inaccuracy relative to the criterion standard of views, and this should be considered when compar-
physician diagnosis based on assessment of patient ing the EPIC study to studies that collected data via
history and urodynamic evaluation [21,22]. How- different modalities. However, this limitation is also
ever, the measurement of LUTS based on a rigorous common to large epidemiologic studies, because
physician examination would not be feasible in a there are advantages and disadvantages to each
large-scale, multinational epidemiologic study. mode of questionnaire administration [23]. A third
Moreover, the use of physician diagnosis would limitation is that many individuals who were
introduce a degree of subjectivity. A second limita- contacted declined to participate in the EPIC study.
 european urology 50 (2006) 1306–1315 1313

This may have affected the results, if the prevalence Astellas Pharma and Pfizer Inc for attending inter-
or distribution of LUTS was different in non- national conferences and has been paid by Astellas
respondents relative to those who did respond. Pharma and Pfizer Inc to deliver lectures at
However, when reporting the prevalence estimates, sponsored symposia. P.A. is a paid consultant for
we applied sampling weights to account for the Novartis, Pfizer Inc, and Plethora; a principal
demographic differences between the survey popu- investigator for Diagnostic Ultrasound, Ferring,
lation and the general population. Pfizer Inc, Plethora, and Schwarz-Pharma; and a
lecturer for Novartis.

5. Conclusions
Acknowledgements
This population-based survey confirms that LUTS
are highly prevalent, and the prevalence of LUTS The authors would like to acknowledge the invalu-
increases with age. The prevalence of LUTS was able expertise in statistical programming by Christer
higher in the EPIC study, which used 2002 ICS Eskvard and the editorial assistance of Linda Gold-
definitions, than in many studies that estimated the stein, PhD, from Complete Healthcare Communica-
prevalence of ‘‘moderate to severe’’ LUTS, defined as tions, Inc, in the preparation of this manuscript. This
a score of at least 8 on the IPSS. Storage symptoms study was funded by Pfizer Inc.
are more prevalent than voiding or postmicturition
LUTS, and nocturia was the most commonly
reported symptom. Based on these results, it is Appendix. Urinary symptom questions
anticipated that millions of men and women aged
 18 yr experience symptoms of OAB and UI. Symptom/ Defining question
condition

Frequency In your opinion, do you feel that you

Conflict of interest statement urinate too often during the day?
Nocturia Over the last week, how many times did
This study was sponsored by Pfizer Inc. D.I. is a paid you typically get up to urinate from the
time you went to bed at night until the
consultant to Pfizer Inc. I.M. is a member of time you got up in the morning?
International Advisory Boards regarding lower uri- Urgency Do you experience a sudden compelling
nary tract symptoms for Astellas Pharma, Novartis, desire to urinate which is difficult
and Pfizer Inc; an investigator in the STAR study to put off? What I mean is a sudden
intense feeling of urgency where
sponsored by Astellas Pharma; a recipient of you feel you must urinate immediately?
research grants for epidemiologic studies on lower Urinary How often do you experience
urinary tract symptoms from Astellas Pharma and incontinence (UI) urinary leakage?
Pfizer Inc to the Department of Obstetrics and Urgency urinary Do you leak urine in connection with a
incontinence sudden compelling desire to urinate?
Gynecology; and a recipient of honoraria for lectures
(UUI) By that, I mean in connection with a
presented at international meetings from Astellas sudden intense feeling of urgency?
Pharma, Novartis, and Pfizer Inc. S. Hunskaar has Stress urinary Do you leak urine in connection with
received consultation fees, honoraria for lectures, incontinence sneezing, coughing, or when doing
(SUI) physical activities such as exercising or
research grants, and funding for travel from Pfizer
lifting a heavy object?
Inc, Astellas Pharma, Yamanouchi, Lilly, and Boeh- Intermittency Over the past month, how often have you
ringer-Ingelheim. K.R. and Z.K. are employees of found you stopped and started again
Pfizer Inc. S. Herschorn is on advisory boards and several times when you urinated?
Slow stream Over the past month, how often have
has worked on educational programs sponsored by
you had a weak urinary stream?
Astellas Pharma, Janssen-Ortho, Pfizer Inc, and Straining Over the past month, how often have you
Paladin; he has been an investigator in clinical trials had to push or strain to begin urination?
sponsored by Lilly and Pfizer Inc; he has been Terminal dribble Do you experience prolonged trickle
or dribble at the end of your urine flow?
reimbursed by Bayer, Lilly, and Pfizer Inc for
Incomplete Over the past month, how often have you
attending meetings. K.C. is a paid consultant to emptying had a sensation of not emptying your
Pfizer Inc. C.K. has received research support from bladder completely after you finish
Astellas Pharma and Pfizer Inc and has delivered urinating?
Postmicturition Do you experience urine leakage almost
sponsored lectures for Astellas Pharma, Novartis,
dribble immediately after you have finished
Pfizer Inc, UCB, and Tena. C.H. has no competing urinating and walked away from the toilet?
interests to declare. W.A. has been reimbursed by
1314 european urology 50 (2006) 1306–1315

References managed? A population-based prevalence study. BJU Int

2001;87:760–6.
[1] Abrams P. New words for old: lower urinary tract symp- [14] Temml C, Heidler S, Ponholzer A, Madersbacher S. Pre-
toms for ‘‘prostatism’’. BMJ 1994;308:929–30. valence of the overactive bladder syndrome by applying
[2] Abrams P, Cardozo L, Fall M, et al. The standardisation the International Continence Society definition. Eur Urol
of terminology of lower urinary tract function: report 2005;48:622–7.
from the Standardisation Sub-committee of the Interna- [15] Homma Y, Yamaguchi O, Hayashi K. An epidemiological
tional Continence Society. Neurourol Urodyn 2002;21: survey of overactive bladder symptoms in Japan. BJU Int
167–78. 2005;96:1314–8.
[3] Boyle P, Robertson C, Mazzetta C, et al. The prevalence of [16] Barry MJ, Fowler Jr FJ, O’Leary MP, et al. The American
lower urinary tract symptoms in men and women in four Urological Association symptom index for benign pros-
centres. The UrEpik study. BJU Int 2003;92:409–14. tatic hyperplasia. The Measurement Committee of the
[4] Girman CJ, Jacobsen SJ, Tsukamoto T, et al. Health-related American Urological Association. J Urol 1992;148:1549–
quality of life associated with lower urinary tract symp- 57, discussion 64.
toms in four countries. Urology 1998;51:428–36. [17] Seim A, Hoyo C, Ostbye T, Vatten L. The prevalence and
[5] Mittmann N, Trakas K, Risebrough N, Liu BA. Utility scores correlates of urinary tract symptoms in Norwegian men:
for chronic conditions in a community-dwelling popula- The HUNT Study. BJU Int 2005;96:88–92.
tion. Pharmacoeconomics 1999;15:369–76. [18] Coyne KS, Zhou Z, Bhattacharyya SK, et al. The prevalence
[6] Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence of nocturia and its effect on health-related quality of life
and burden of overactive bladder in the United States. and sleep in a community sample in the USA. BJU Int
World J Urol 2003;20:327–36. 2003;92:948–54.
[7] Malmsten UG, Milsom I, Molander U, Norlen LJ. Urinary [19] Seim A, Hoyo C, Ostbye T, Vatten L. Prevalence and
incontinence and lower urinary tract symptoms: an epi- correlate of nocturia in men: a large community based
demiological study of men aged 45 to 99 years. J Urol study. Paper presented at the International Continence
1997;158:1733–7. Society, 2003; Florence, Italy.
[8] Andersson SO, Rashidkhani B, Karlberg L, Wolk A, Johans- [20] Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff
son JE. Prevalence of lower urinary tract symptoms in men JW. Definition of overactive bladder and epidemiology of
aged 45–79 years: a population-based study of 40000 urinary incontinence. Urology 1997;50(6A Suppl):4–14,
Swedish men. BJU Int 2004;94:327–31. discussion 15–7.
[9] Hunskaar S, Lose G, Sykes D, Voss S. The prevalence of [21] Sandvik H, Hunskaar S, Vanvik A, et al. Diagnostic classi-
urinary incontinence in women in four European coun- fication of female urinary incontinence: an epidemiolo-
tries. BJU Int 2004;93:324–30. gical survey corrected for validity. J Clin Epidemiol
[10] Engstrom G, Walker-Engstrom ML, Loof L, Leppert J. 1995;48:339–43.
Prevalence of three lower urinary tract symptoms [22] Kirschner-Hermanns R, Scherr PA, Branch LG, Wetle T,
in men—a population-based study. Fam Pract 2003; Resnick NM. Accuracy of survey questions for geriatric
20:7–10. urinary incontinence. J Urol 1998;159:1903–8.
[11] Simeonova Z, Milsom I, Kullendorff AM, Molander U, [23] Bowling A. Mode of questionnaire administration can
Bengtsson C. The prevalence of urinary incontinence have serious effects on data quality. J Public Health
and its influence on the quality of life in women from (Oxf) 2005;27:281–91.
an urban Swedish population. Acta Obstet Gynecol Scand [24] Rhodes T, Girman CJ, Jacobsen SJ, et al. Does the mode
1999;78:546–51. of questionnaire administration affect the reporting of
[12] Corcos J, Schick E. Prevalence of overactive bladder and urinary symptoms? Urology 1995;46:341–5.
incontinence in Canada. Can J Urol 2004;11:2278–84. [25] Garcia-Losa M, Unda M, Badia X, et al. Effect of mode of
[13] Milsom I, Abrams P, Cardozo L, et al. How widespread are administration on I-PSS scores in a large BPH patient
the symptoms of an overactive bladder and how are they population. Eur Urol 2001;40:451–7.

Editorial Comment Although urinary incontinence has received the

Antonella Giannantoni, Department of Urology, greatest attention in population-based surveys, it
University of Perugia, Italy is not the most common problem associated with
[email protected] OAB. Few published prevalence studies in the gen-
eral population have assessed the prevalence of
This article reports the results of the EPIC study, OAB, and these have used different definitions of
which is the largest population-based survey to OAB. Using a standardised terminology, as that
assess prevalence rates of urinary incontinence, suggested by the ICS, may help us to reach a clearer
overactive bladder (OAB), and other urinary tract and more unique definition of the problem.
symptoms in five selected countries, representa- Because lower urinary tract symptoms (LUTS),
tive of Europe and North America, using the 2002 and particularly OAB, are symptom-defined condi-
International Continence Society (ICS) definitions. tions, patient input is needed to evaluate responses
 european urology 50 (2006) 1306–1315 1315

and valid and reliable patient-reported outcome due to the validity of a survey, which may depend
measures are needed. Developing such measures on the accuracy of the responses given by the
and ensuring their validity is usually a time-con- interviewed subjects, the authors have been able
suming, multistep process. to give country-specific prevalence rates for LUTS
The authors of this article have made a great and OAB and new epidemiologic data that induce
effort to conduct this population-based survey, and us to open a debate, particularly on the new defini-
they present new epidemiologic data according to tion of nocturia. Their research surely represents
the recent ICS definitions of OAB, for which I offer an impetus for a large series of speculations, stu-
my congratulations. Despite of some limitations dies, and publications.