Utility of the Visual Prostate Symptom Score in Men with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Enlargement: A Prospective Observational Study

Technical Summary: Utility of the Visual Prostate Symptom Score in Men with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Enlargement

Problem Statement
Lower Urinary Tract Symptoms (LUTS) are a primary reason for urological consultation in adult and elderly men, often associated with benign prostatic enlargement (BPE). The International Prostate Symptom Score (IPSS) is the standard validated instrument for assessing symptom severity and quality of life (QoL). However, the IPSS is text-based, requiring adequate literacy, language comprehension, and numeracy. In high-volume outpatient settings, particularly in India where patients may be elderly, multilingual, or variably literate, the text-based format can lead to misunderstandings, increased consultation times, and a reliance on assisted completion, which may introduce interpreter bias. The Visual Prostate Symptom Score (VPSS), which utilizes pictograms for key domains (urinary stream, frequency, nocturia, and QoL), was developed to address these barriers, but its performance in the specific context of Indian tertiary urology practice required prospective validation.

Methodology
This was a prospective observational study conducted over six months (August 2025 to January 2026) at the Department of Urology, SRM Medical College Hospital and Research Centre, Tamil Nadu, India.

• Population: 50 men aged >40 years presenting with LUTS suggestive of symptomatic BPE.
• Exclusion Criteria: Uncontrolled diabetes, urinary tract infection, indwelling catheters, visual impairment preventing pictogram use, prior prostate/urethral surgery, or PSA >4 ng/mL.
• Procedure: Participants completed both the IPSS and VPSS during the same visit. Assistance was provided by attending physicians only when patients could not complete forms independently, without suggesting responses.
• Metrics Recorded: Completion time, need for assistance, educational level, symptom severity (categorized as mild, moderate, severe), QoL scores, and maximum urinary flow rate (Qmax) via uroflowmetry.
• Statistical Analysis: Paired t-tests compared completion times; McNemar tests assessed differences in self-completion rates; Pearson's correlation coefficients evaluated relationships between scores and Qmax; Cohen's kappa measured agreement between severity categories.

Key Contributions and Results
The study provided a direct, same-visit comparison of VPSS and IPSS performance in a real-world clinical setting:

• Efficiency: VPSS was completed significantly faster than IPSS (mean 49.36 ± 9.63 seconds vs. 115.98 ± 39.89 seconds; P<0.001), representing a mean reduction of 66.62 seconds.
• Independence: Self-completion rates were substantially higher for VPSS (62.0%) compared to IPSS (18.0%) (P<0.001). Conversely, 82.0% of IPSS forms required assistance versus 38.0% for VPSS.
• Correlation: Total VPSS scores showed a strong positive correlation with total IPSS scores (Pearson r=0.823, P<0.001). VPSS QoL scores also correlated significantly with IPSS QoL scores (r=0.504, P<0.001).
• Severity Agreement: While there was a statistically significant association between IPSS and VPSS severity categories (Chi-square=24.77, P<0.001), the agreement was only fair-to-moderate (Cohen's kappa=0.357).
• Uroflowmetry: Correlations between symptom scores (both IPSS and VPSS) and Qmax were weak and statistically nonsignificant.
• Educational Impact: All men with no formal education required assistance for IPSS, whereas two such men completed VPSS unaided. All tertiary-educated men completed VPSS independently.

Significance and Claims
The paper concludes that the VPSS is a rapid, practical, and patient-friendly tool for assessing LUTS in men with symptomatic BPE within Indian urology outpatient practice. Its primary utility lies in settings constrained by patient literacy levels or consultation time. The study claims that VPSS serves as a valid adjunct or alternative to IPSS, offering strong concurrent validity regarding total symptom burden and QoL while significantly reducing the administrative burden and need for staff assistance.

The authors modestly note that while VPSS simplifies symptom elicitation, it does not replace objective clinical evaluation. The weak correlation with Qmax reinforces that symptom questionnaires and uroflowmetry measure distinct dimensions of LUTS/BPE and should be used as complementary tools. The study suggests a pragmatic workflow where VPSS is utilized first for rapid triage, particularly for patients with limited literacy, while IPSS and objective testing remain essential for detailed assessment and longitudinal monitoring. The authors acknowledge limitations including the modest sample size, single-center design, and the need for future studies to validate locally appropriate VPSS severity cut-offs in larger Indian cohorts.