Design

A qualitative exploratory descriptive design using thematic analysis was adopted in this study; the analysis was guided by the philosophy of naturalistic enquiry [22]. Through this approach, researchers were expected to uncover various aspects of the studied phenomenon and underlying process, particularly when less is known about this phenomenon [23]. For the purpose of this study, this design allowed us to explore and describe how ageing Chinese males live and cope with moderate-to-severe LUTS in their daily lives. This study ultimately aimed to generate new knowledge in the field. Individual face-to-face interviews were conducted because of the sensitive nature of LUTS, which can relate to sexuality.

Setting and participants

Participants were recruited from four elderly community centres in Hong Kong that offer social support for community-dwelling elders [24]. These participants were recruited from this setting because it can provide researchers’ access to community-dwelling elders. Purposive sampling was employed to recruit appropriate participants who would be able to provide rich information about their experiences with LUTS and obtain a mixture of participants with moderate or severe LUTS symptoms. LUTS severity in each participant was assessed using the Chinese version of the International Prostate Symptom Score (IPSS), a questionnaire for evaluating symptom severity [25]. The participants completed the IPSS questionnaire after the researcher explained the items. The IPSS consists of seven Likert-scale questions (with scores ranging from 0 ‘not at all’ to 5 ‘almost always’) related to LUTS. The total score ranged from 0 to 35 (1–7 = mildly symptomatic, 8–19 = moderately symptomatic and 20–35 = severely symptomatic). Three questions involved filling problems (daytime frequency and nocturnal urgency), whereas four questions assessed voiding problems (emptying, intermittency, weak stream and straining). The instrument also included one question that evaluates the effect of urinary symptoms on QoL. The scores ranged from 0 to 6 (0 = delighted, 1 = pleased, 2 = mostly satisfied, 3 = mixed, about equally satisfied and dissatisfied, 4 = mostly dissatisfied, 5 = unhappy and 6 = terrible). The participants were asked to urinate into a specific funnel connected to a portable uroflowmeter (FloPoint Elite Uroflow System). This instrument was used to measure the maximum urinary flow rate (Qmax) per second and evaluate the severity of urinary obstruction. Only the participants with Qmax<15 mL/s were recruited.

Participants were considered eligible if they were Chinese men aged over 60 years old with moderate-to-severe LUTS (IPSS score≥12) and whose maximum urinary flow rate was Qmax<15 mL/s for at least six months [25]. Participants with urinary tract infection or a history of bladder surgery, prostate cancer or psychiatric illness were excluded.

Data collection

The participants were screened and recruited by the trained researcher (SKWY). After consenting to join the study, each participant was invited to an individual face-to-face interview at home or at the elderly centre. Each semi-structured interview was limited to one participant because of the sensitivity of the topic. The average length of each interview session was approximately 1 h.

A semi-structured interview guide was used to aid the interview and stimulate discussion around the topic of interest. The guide was developed based on the literature review and refined after discussions with the research team (Table 1). Open-ended and probing questions were used to enable the participants to expand their responses and explanations, thereby allowing the researchers to obtain significant data [23]. Probing questions are usually follow-up questions when additional information is needed. Two researchers were involved in each interview, and field notes were collected. Demographic data, including age, occupation, marital status and length of time living with the symptoms, were obtained. Interviews were audio-recorded after obtaining the consent of participants. Data saturation was reached at the 24th participant when no new information was obtained [26].

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Table 1. Interview guide.

https://doi.org/10.1371/journal.pone.0187085.t001

Data analysis

Interviews were conducted in Cantonese and audio-recorded and transcribed verbatim for subsequent data analysis. Data were coded using thematic analysis with Braun and Clarke’s approach [27]. This method is systematic and rigorous in identifying, analysing and reporting patterns from qualitative data chosen in relation to the research aim and objectives [27]. For the purpose of this study, we analysed data based on the following study objective: to identify the experiences of living with moderate-to-severe LUTS among community-dwelling ageing Chinese males and their coping strategies to facilitate the management of LUTS by healthcare providers. Braun and Clarke’s analytical approach involves six steps, namely, a) data familiarisation by repeated reading, b) generating initial codes, c) searching for themes, d) reviewing potential themes, e) defining and naming themes and f) producing the report. Three research team members (HLC, SKWY and CHAY) worked together to develop a coding scheme by comparing and contrasting the findings across the interview data. Disagreements or discrepancies in the coding scheme were resolved through group discussions until a consensus was reached. Selected quotes were translated to English so that they can be cited in the publication.

Trustworthiness

The trustworthiness, including credibility, transferability, dependability and confirmability of this study, was established by adhering to evaluative criteria by Lincoln and Guba [28]. Credibility refers to confidence in the truth of the data. For this study, we established credibility by the following techniques including prolonged engagement with participants and triangulation across different researchers. Through prolonged engagement, participants built trust with the researchers, and they felt comfortable to share their experiences during the interview. For triangulation across different researchers, the data were analysed using more than two researchers to allow multiple interpretations and expand the depth of insights into the data, consequently enhancing the credibility of data analysis. The first author (LKPS) regularly discussed with the study team and randomly selected cases to ensure consistency between data and researchers’ interpretations. Transferability refers to the generalisability of the data. Transferability was achieved by purposively sampling appropriate participants who were able to provide thick and rich descriptions of the study phenomenon. Dependability reflects the consistency of findings. We used a semi-structured interview guide to aid the interview and stimulate discussion around the topic of interest. Audit trails for both study processes and products including audio-recording files, transcripts, data deduction and analysis tables and other discussion notes were kept to allow for verification by the first author (LKPS). Confirmability refers to the neutrality of the findings. During data collection and analysis, the researchers disregarded their knowledge, beliefs, values and experiences about LUTS to avoid researcher bias. Audit trails and reflective journals were applied to enhance the study confirmability.

Ethical consideration

Ethical approval was obtained from the Human Subjects Ethics Subcommittee of the Hong Kong Polytechnic University [HSEARS20140515003]. Consent was obtained before audio-recording the interviews. The interviews were held in locations where absolute privacy was guaranteed. To ensure the confidentiality of the collected data, the research team restricted data access to the group alone. Participation was on a voluntary basis, and the participants could withdraw from the study at any time.

1. Effect of LUTS

2. Perceptions and misconceptions

3. Management of LUTS

Effect of LUTS

Urination difficulties were manifested among the participants in several ways. Some men had to void often and went to the toilet as soon as they felt the need to void. Otherwise, they would wet their trousers. Some men also reported a sting in the urinary tract and dribbling. Almost half of the participants suffered from nocturia, which affected their sleeping quality.

According to the participants, LUTS affected their social activities and led to their avoidance of social situations, long-distance travel and other events that lacked easily accessible toilets. This observation matched the findings of Pinnock et al. [18], who conducted 19 focus group studies in South Australia. They found that access to toilets in a shopping centre or a bus stop can determine whether men with LUTS would participate in outings. In a hermeneutic phenomenological study in the United Kingdom, the participants expressed embarrassment for having to go to the toilet regularly, particularly when socialising in the presence of family and friends [13].

Most of the participants were unwilling to seek social support and even embarrassed to share this topic with their peers. This phenomenon was also observed in people from other countries. Men in South Australia were reluctant to talk about their health, particularly those topics that pertain to urinary or sexual problems [18]. In a Korean study, approximately 42.7% of community-dwelling elderly with BPH never consulted anyone about their symptoms [21].

Contrary to Western literature, majority of the participants in our study reported that LUTS showed minimal psychological effect, and they accepted these symptoms. They considered LUTS as part of the normal ageing process and a process of ‘letting nature take its course’. This finding may be governed by the underlying traditional Chinese philosophy that sickness is part of life [30]. The cultural stereotype of the elderly as individuals who suffer from multiple diseases may further affect participants’ perception that LUTS is normal among ageing males. These findings are consistent with those of Chinese cultural studies, which indicated that individuals accept their diseases and embrace their fate [31]. Chinese naturalistic philosophy based on Taoist principles may influence the perceptions and actions of elderly Chinese men [32]. Birth, ageing, sickness and death are viewed as parts of one’s lifecycle that nobody can escape. People should live in harmony with nature and accept the natural process of life [31].

Even though many participants claimed that LUTS was part of normal ageing and accepted it as a nature of life, various emotional distresses, which included self-blaming and the feelings of being troublesome, miserable, hopeless, sad and embarrassed, were also reported. In the current study, LUTS severity was significantly correlated with life quality as reflected in the generally unsatisfactory QoL of the interviewees (mean = 3.17). Urological symptoms may exert adverse effects on the psychological well-being of men by affecting their emotions. These conditions reduced the functions and QoL of patients [8,12,21,33]. Schulman et al. [34] suggested that sleep disruption negatively affects mental health, reduces work performance, causes memory impairment and induces depression. In a large prospective cohort of 2000 Chinese men in Hong Kong, moderate-to-severe LUTS was significantly associated with increased odds of having clinically relevant depressive symptoms even after adjustment [35].

Although the pathogenesis of the relationship between LUTS and erectile dysfunction is unclear, various studies reported that sexual disorders increase with age and LUTS severity. When the participants in the current study were asked about the effect of LUTS on their sexual lives, only three participants mentioned the relationship between LUTS and sexual function. This result suggests that sexuality is a sensitive and embarrassing topic among the elderly Chinese population and is difficult to discuss openly. Despite the prevailing recognition in Western society that LUTS adversely affects the sexual lives of the male population [36–38], half of the participants in our study already stopped having sexual activities even before the LUTS onset. The remaining number of participants reported being sexually active, with very few reporting sexual dysfunction. In Chinese culture, men accept decreased sexual desire or sexual dysfunction as part of ageing [39]. An active sexual life is considered inappropriate, particularly for the elderly. Traditional Chinese philosophies view sexuality as only a function of procreation rather than a source of pleasure or enjoyment [40]. This view may explain the discrepancies between our findings and those of Western populations. In addition, several participants reported sleeping separately from their spouses to minimise the disturbance caused by nocturia. This finding may be a distinct feature of Chinese couples or a coping method to maintain spousal relationship when problems arise.

Perceptions and misconceptions

The current study indicated that most older Chinese men in Hong Kong lacked the knowledge or even held misconceptions about LUTS. Some of them believed that LUTS was caused by natural ageing and untreatable. A few related LUTS to cancers and even believed that frequent sexual activities caused prostate problem.

Misconceptions among the elderly men are also common in other countries, such as Korea [21] and Spain [41], wherein a high proportion of affected men do not seek medical advice because they believe that LUTS is part of natural ageing. Thus, seeking medical help is unnecessary. This result reflects the low rates of medical help consultation found in other studies because of this misconception [20,40]. In the present work, one participant believed that LUTS was the same as BPH, and another participant believed that BPH was directly related to cancer. In a qualitative study conducted in the United States, 67% of the participants believed that BPH (a common cause of LUTS) and cancer are associated; BPH surgery is performed for cancer removal or BPH leads to cancer [42]. One participant believed that LUTS only occurs in males. The present study explicitly indicated that many older Chinese men may possess limited knowledge about LUTS. Therefore, health educational interventions should be provided to instill correct knowledge, empower the development of customised coping strategies and encourage patients to seek medical consultation and care from health professionals for their LUTS. In a randomised control study among 109 BPH patients, patient counselling was able to significantly improve the knowledge, symptoms, management, treatment outcomes and QoL of patients [43].

Managing LUTS

A number of participants (n = 10) expressed that if LUTS deteriorates or when some intolerant symptoms arise, they would prefer receiving Western treatment instead of other treatment approaches. However, their failure to detect symptoms that may indicate a serious condition and their tendency to delay seeking medical attention can lead to kidney disease, urinary tract infections and bladder damage [14]. In a qualitative study conducted in Finland, pre-operative medical investigations, endoscopy and decision making with regard to treatment are anxiety provoking and difficult [44]. Therefore, health-care professionals should provide these patients with sufficient knowledge and offer consultations to encourage them to participate in the decision-making process.

In this study, majority of the participants sought alternative treatments, such as TCM, special voiding positions and phytotherapeutic agents and supplements, including lycopene tablets and dietary consumption of tomatoes, pumpkin seeds and white melon seeds. Given that lycopene belongs to the carotenoid family and mostly exists in nature [45], we found that participants in this study preferred to consume great amounts of tomatoes in their diet. However, scientific evidence about the role of lycopene in combination with Serenoa repens (a phytotherapeutic agent) in the management of LUTS secondary to BPH remains limited [46]. Therefore, further studies should be conducted to gather scientific evidence that supports the effectiveness of these supplements in managing LUTS.

A number of participants believed that the consumption of ‘liang-ye’ may cause frequent urination. Since the ancient times, TCM practitioners have recognised dietotherapy and used the ‘warm’ and ‘cool’ nature of food to achieve body equilibrium [47]. From the TCM perspective, frequent urination and dripping urination may be due to ‘deficiency cold’ of the lower jiao (pelvic region) [48]. Therefore, further consumption of ‘liang-ye’, such as green tea, melons, soy beans and pears, may aggravate LUTS. Meanwhile, difficulty in urination, dripping urination and pain in micturition may be caused by ‘stagnation of damp heat’ in which food in ‘cold’ nature may be beneficial [48]. Therefore, rehabilitation with diet should be guided by the differentiation of syndromes and correct diagnoses if TCM principles are to be followed.

One participant shared his successful experience of using a specific voiding posture (i.e. standing with heel raised during voiding) for complete bladder emptying. Previous studies did not specifically investigate this specific voiding posture. However, a recent systematic review indicates the influence of voiding position on the urodynamic profile of patients and reported that sitting position can significantly decrease the post-void residual urine volume in patients with LUTS [49]. Standing with heels raised may require abdominal muscle contraction to maintain balance. This posture can increase intra-abdominal pressure and influence post-void residual urine volume. Therefore, further research regarding the effects of different voiding positions and their effects on the urodynamic profile of patients should be conducted.

Most of the participants tried to reduce urinary frequency through fluid restriction. Elstad et al. [50] revealed that fluid manipulation is a common self-coping strategy used by individuals with LUTS. Nevertheless, improper fluid restriction may negatively affect the health of patients. Therefore, individuals with LUTS may need guidance in fluid management. In addition, several participants mentioned performing exercises as a method to improve their LUTS status. This method is a possible coping strategy for people who have LUTS. A recent cross-sectional study conducted by Fowke et al. [51] showed that high energy expenditure during leisurely physical activities and light housework activities is significantly associated with low LUTS severity. Surprisingly, some men cope with LUTS using their willpower to control urinary frequency, cognitively ignore the problem or maintain a positive mood to alleviate their problems.

Limitations and future directions

The major limitation of this study was that the subjects were recruited only from the community centres in which majority of the participants were not receiving treatment using medical or surgical approaches. Thus, the profile of participants was not varied enough to obtain data saturation on the overall experience of ageing males with LUTS. As the participants were all elderly men, the exploration of sensitive areas, such as the effect of LUTS on sexuality in some of the participants, was hindered because of their hesitation to share with young female interviewers. Future studies may consider extending the subject recruitment in other settings (e.g. hospitals and urological clinics) to understand the motivation and challenges of those patients who have adhered to active treatment to manage this problem.

Conclusion

The life experiences of older Chinese men with LUTS indicated that this condition could adversely affect the physical aspects of their daily lives. Most of the participants were unwilling to seek social support and even embarrassed to share this topic with their peers. Nevertheless, majority of the participants reported that LUTS exerted no psychological effect because they believed LUTS was a consequence of normal ageing and in ‘letting nature take its course’.

Most of the interviewees lacked knowledge about LUTS and held misconceptions about the condition. This limitation prevented them from pursuing medical aid. Most of the participants also sought alternative treatment and developed self-help methods to cope with the symptoms. The strategies employed by the participants included use of Chinese medicine, supplements, dietotherapy, specific voiding posture, fluid restrictions, exercise and the use of willpower to alleviate the problem. The findings of this qualitative study can raise awareness about the life experiences, perceptions, misconceptions and health-seeking behaviour of ageing Chinese males with LUTS. This study can provide proper health education and advice for this population group.