The Use of Patient-Reported Outcome Measures in Men with Urethral Stricture Disease

Abstract

The use of patient-reported outcome measures represents a noninvasive, cost-effective method to assess voiding symptoms, sexual function, quality of life, and treatment outcomes in men with urethral stricture disease. The American Urological Association Symptom Index (AUASI) was originally designed to assess lower urinary tract symptoms (LUTS) in men with BPH. The use of this patient-reported questionnaire has also proven useful as a noninvasive method to assess men with LUTS related to urethral stricture. However, the inability of this instrument to capture the full range of voiding symptoms in men with urethral stricture limits its usefulness.

Abstract

The use of patient-reported outcome measures represents a noninvasive, cost-effective method to assess voiding symptoms, sexual function, quality of life, and treatment outcomes in men with urethral stricture disease. The American Urological Association Symptom Index (AUASI) was originally designed to assess lower urinary tract symptoms (LUTS) in men with BPH. The use of this patient-reported questionnaire has also proven useful as a noninvasive method to assess men with LUTS related to urethral stricture. However, the inability of this instrument to capture the full range of voiding symptoms in men with urethral stricture limits its usefulness.

Erectile dysfunction (ED) may occur after anterior urethral reconstruction in up to one-third of patients and may be even more common in men with pelvic fracture-related urethral injury. Likewise ejaculatory dysfunction (EjD) has been reported in up to one-fourth of men presenting for the treatment of a urethral stricture. The International Index of Erectile Function (IIEF) is a validated, patient-reported questionnaire that has proven useful as a noninvasive method to assess perioperative sexual function in men with urethral stricture. Similar to the IIEF, the ejaculatory domain of the Male Sexual Health Questionnaire (MSHQ) has also proven useful in the assessment of perioperative ejaculatory function in men undergoing treatment for urethral stricture.

The reported utility of existing patient-reported questionnaires represents a noninvasive method to assess men with urethral stricture; however, an instrument specifically designed and validated to assess perioperative LUTS, sexual function, and quality of life outcomes in men with urethral stricture has yet to be constructed.

Appendices

Appendix A: International Index of Erectile Function (IIEF)

Question	Response options
Q1. How often were you able to get an erection during sexual activity?	0 = No sexual activity
Q2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?	1 = Almost never/never
	2 = A few times (much less than half the time)
	3 = Sometimes (about half the time)
	4 = Most times (much more than half the time)
	5 = Almost always/always
Q3. When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?	0 = Did not attempt intercourse
Q4. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?	I = Almost never/never
	2 = A few times (much less than half the time)
	3 = Sometimes (about half the time)
	4 = Most times (much more than half the time)
	5 = Almost always/always
Q5. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?	0 = Did not attempt intercourse
	1 = Extremely difficult
	2 = Very difficult
	3 = Difficult
	4 = Slightly difficult
	5 = Not difficult
Q6. How many times have you attempted sexual intercourse?	0 = No attempts
	1 = One to two attempts
	2 = Three to four attempts
	3 = Five to six attempts
	4 = Seven to ten attempts
	5 = Eleven + attempts
Q7. When you attempted sexual intercourse, how often was it satisfactory for you?	0 = Did not attempt intercourse
	1 = Almost never/never
	2 = A few times (much less than half the time)
	3 = Sometimes (about half the time)
	4 = Most times (much more than half the time)
	5 = Almost always/always
Q8. How much have you enjoyed sexual intercourse?	0 = No intercourse
	1 = No enjoyment
	2 = Not very enjoyable
	3 = Fairly enjoyable
	4 = Highly enjoyable
	5 = Very highly enjoyable
Q9. When you had sexual stimulation or intercourse, how often did you ejaculate?	0 = No sexual stimulation/intercourse
Q10. When you had sexual stimulation or intercourse, how often did you have tile feeling of orgasm or climax?	1 = Almost never/never
	2 = A few times (much less than half the time)
	3 = Sometimes (about half the time)
	4 = Most times (much more than half the time)
	5 = Almost always/always
Q11. How often have you felt sexual desire?	1 = Almost never/never
	2 = A few times (much less than half the time)
	3 = Sometimes (about half the time)
	4 = Most times (much more than half the time)
	5 = Almost always/always
Q12. How would you rate your level of sexual desire?	1 = Very low/none at all
	2 = Low
	3 = Moderate
	4 = High
	5 = Very high
Q13. How satisfied have you been with your overall sex life?	1 = Very dissatisfied
Q14. How satisfied have you been with your sexual relationship with your partner?	2 = Moderately dissatisfied
	3 = About equally satisfied and dissatisfied
	4 = Moderately satisfied
	5 = Very satisfied
Q15. How do you rate your confidence that you could get and keep an erection?	1 = Very low
	2 = Low
	3 = Moderate
	4 = High
	5 = Very high

1. Note: All questions are preceded by the phrase “Over the past 4 weeks”

Appendix B: Male Sexual Health Questionnaire (MSHQ)

Ejaculation Scale

Question	Response options
1. In the last month, how often have you been able to ejaculate when having sexual activity?	5. All of the time
	4. Most of the time
	3. About half of the time
	2. Less than half of the time
	1. None of the time/could not ejaculate
2. In the last month, when having sexual activity, how often did you feel that you took too long to ejaculate or “cum”? (Check only one)	5. None of the time
	4. Less than half of the time
	3. About half of the time
	2. Most of the time
	1. All of the time
	0. Could not ejaculate
3. In the last month, when having sexual activity, how often have you felt like you were ejaculating (“cumming”), but no fluid came out?	5. None of the time
	4. Less than half of the time
	3. About half of the time
	2. Most of the time
	1. All of the time
	0. Could not ejaculate
4. In the last month, how would you rate the strength or force of your ejaculation?	5. As strong as it always was
	4. A little less strong than it used to be
	3. Somewhat less strong than it used to be
	2. Much less strong than it used to be
	1. Very much less strong than it used to be
	0. Could not ejaculate
5. In the last month, how would you rate the amount or volume of semen when you ejaculate?	5. As much as it always was
	4. A little less than it used to be
	3. Somewhat less than it used to be
	2. Much less than it used to be
	1. Very much less than it used to be
	0. Could not ejaculate
6. Compared to 1 month ago, would you say the physical pleasure you feel when you ejaculate has	5. Increased a lot
	4. Increased moderately
	3. Neither increased nor decreased
	2. Decreased moderately
	1. Decreased a lot
	0. Could not ejaculate
7. In the last month, have you experienced any physical pain or discomfort when you ejaculated? Would you say you have	5. No pain at all
	4. Slight amount of pain or discomfort
	3. Moderate amount of pain or discomfort
	2. Strong amount of pain or discomfort
	1. Extreme amount of pain or discomfort
	0. Could not ejaculate
EjD bother item	5. Not at all bothered
8. In the last month, if you have had any ejaculation difficulties or have been unable to ejaculate, have you been bothered by this?	4. A little bit bothered
	3. Moderately bothered
	2. Very bothered
	1. Extremely bothered

Appendix C: Patient-Reported Outcome Measure for Urethral Stricture Surgery (PROM-USS)

Question	Response
1. Is there a delay before you start to urinate?	○ Never
	○ Occasionally
	○ Sometimes
	○ Most of the time
	○ All of the time
2. Would you say that the strength of your urinary stream is…	○ Normal
	○ Occasionally reduced
	○ Sometimes reduced
	○ Reduced most of the time
	○ Reduced all of the time
3. Do you have to strain to continue urinating?	○ Never
	○ Occasionally
	○ Sometimes
	○ Most of the time
	○ All of the time
4. Do you stop and start more than once while you urinate?	○ Never
	○ Occasionally
	○ Sometimes
	○ Most of the time
	○ All of the time
5. How often do you feel your bladder has not emptied properly after you have urinated?	○ Never
	○ Occasionally
	○ Sometimes
	○ Most of the time
	○ All of the time
6. How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?	○ Never
	○ Occasionally
	○ Sometimes
	○ Most of the time
	○ All of the time
7. Overall, how much do your urinary symptoms interfere with your life?	○ Not at all
	○ A little
	○ Somewhat
	○ A lot
8. Please ring the number that corresponds with the strength of your urinary stream over the past month
9. Are you satisfied with the outcome of your operation?	○ Yes, very satisfied
	○ Yes, satisfied
	○ No, unsatisfied
	○ No, very unsatisfied
10. If you were unsatisfied or very unsatisfied is that because:	○ The urinary condition did not improve
	○ The urinary condition improved but there was some other problem
	○ The urinary condition did not improve and there was some other problem as well
By placing a tick in one box in each group below, please indicate which statements best describe your own health state today
Mobility	○ I have no problems in walking about
	○ I have some problems in walking about
	○ I am confined to bed
Self-care	○ I have no problems with self-care
	○ I have some problems washing or dressing myself
	○ I am unable to wash or dress myself
Usual activities (e.g., work, study, housework, family, or leisure activities)	○ I have no problems with performing my usual activities
	○ I have some problems with performing my usual activities
	○ I am unable to perform my usual activities
Pain/discomfort	○ I have no pain or discomfort
	○ I have moderate pain or discomfort
	○ I have extreme pain or discomfort
Anxiety/depression	○ I am not anxious or depressed
	○ I am moderately anxious or depressed
	○ I am extremely anxious or depressed
To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0
We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today