4. Discussion
According to International Continence Society, PMD is defined as
“involuntary loss of urine immediately after he or she has finished
passing urine, usually leaving after the toilet for men or after rising
from the toilet for women” 15. It is a symptom of
LUTS, but cannot be assessed with in the widely used symptom
questionnaires such as IPSS, DAN-PSS-1 16. These
questionnaires have been validated to evaluate BPH or obstructive
pathologies affecting the lower urinary system; nevertheless, they do
not contain a query for PMD 13,17. Therefore, current
literature is insufficient to evaluate PMD and lacking detailed reports
of PMD compared with other urinary symptoms. Recently, Jeong et
al.12 have developed a multidimensional tool (HPMDQ)
to evaluate PMD; however, further studies are required to prove its
clinical utility.
In this study, the validity and reliability of the Turkish version of
HPMDQ were evaluated using the data collected from PMD patients residing
in Turkey. For assessing the reliability, the test-retest reliability
and inter-item correlation of HPMDQ were evaluated. The IIC for this
study was 0.727, which provided a sufficient condition for clinical
trials. For each item in HPMDQ, weighted kappa coefficients ranging from
0.628 to 0.838 were found. The highest weighted kappa coefficient was
for the fourth question (quality of life), while the lowest weight was
for the amount of PMD. For internal consistency, a Cronbach α value of
0.903 was calculated, and it was determined that the survey was valid.
Most of the previous published reports on PMD have focused on the
prevalence of PMD rather than its clinical significance. The prevalence
of PMD in the male population varied in a wide range in the literature.
This could be caused by the various tools that were used to evaluate the
PMD. Besides, some studies categorised patients symptomatic if they had
symptoms at least “sometimes” , but some other studies defined the
symptomatic patients as they had symptoms at least “fairly
often”5,10. Nevertheless, more recent studies have
shown that the prevalence rates of PMD are around 30-60%4,10,11,18. In the HPMDQ development study, the
prevalence rate of PMD in 2134 patients was found 51%, which is
consistent with our findings as the 52.3% of the participants were
symptomatic.
Previous studies have also shown that PMD is positively associated with
aging men and BPH, but this symptom can also occur in young adults and
impair quality of life 18,19. While enlargement of the
prostate in aging men explains the pathophysiological mechanism of PMD,
its occurrence in young and middle ages indicates that other factors are
interwoven in its pathophysiology. In a urodynamic study, it has been
shown that the bulbocavernosus contraction insufficiency at the end of
micturition causes PMD with pooling of urine in the bulbar urethra20. In several different studies, it was thought that
the weakening of the urethra-corpora cavernosal reflex with a similar
mechanism could cause both erectile dysfunction and PMD and that these
two diseases were found related to each other 21,22.
Regarding the clinical significance of PMD, the data on literature is
scarce. In the BACH study, post micturition symptoms were more closely
associated with voiding symptoms than the storage symptoms5. Similarly, Jeong et al. found that the HPMDQ total
score was significantly correlated with the voiding symptoms of LUTS,
PVR and prostate size but not with the irritative (storage) symptoms of
LUTS 12. In a Japanese-men based study, PMD did not
show significant association with prostate volume and peak flow rate18. In our study, PMD showed a significant correlation
with total IPSS score, voiding symptoms of LUTS and PVR, indicating that
Turkish version of HPMDQ can reflect PMD well, as in the original
development study.
Considering the treatment options for PMD, bulbar urethral massage and
pelvic floor exercise (PFE) are the recommended treatment strategies.
The rationale behind these treatments is based on the hypothesis that
weakened pelvic floor muscle might induce PMD. It was shown that while
bulbar urethral massage may show immediate treatment effect, PFE may
need longer times to take effect (3 to 6 months)23,24. In this study, we recommended bulbar urethral
massage method to patients and found that it is an effective and safe
method for relieving PMD. Currently, no pharmacological treatment has
been established to relieve PMD, but recently a 75 mg of udenafil has
been introduced as an effective treatment for PMD 25.
Several factors may limit the extrapolation and transferability of
findings from this study. First, we did not include female patients as
PMD is seen in males more common and the original symptom assessment
tool (HPMDQ) was developed on male patients with LUTS12. Second, we did not use paper test to measure the
amount of PMD, instead we relied on the self-assessments of the patients
with PMD. Third, to evaluate the fifth question only bulbar urethral
massage was suggested as a treatment method. Although PFE was shown to
be more effective than bulbar urethral massage in relieving PMD, bulbar
urethral massage has also proven itself as a simple and effective
self-help technique in the literature 26,27.
In conclusion, The Turkish version of HPMDQ, which assesses the
different aspects of PMD including frequency, severity, amount and
discomfort has been developed and determined as a reliable tool for
evaluating patients with PMD. PMD was also significantly correlated with
IPSS scores, which generally assess the severity of LUTS. This study
also showed that bulbar urethra massage is an effective method to
relieve PMD. This simple questionnaire would aid researchers in clinical
studies and facilitate the understanding of medical applications’
responses among Turkish speaking patients with PMD.
Funding:
None