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Introduction
According to the literature, more than 70% of patients with ureteral stents experience stent-related discomfort. Most of the tools for evaluating said discomfort are challenging for both the urologist and the patient, given that the majority are self-applied and there is insufficient application time. 1,2
In addition, the design characteristics of questionnaires for evaluating ureteral stent discomfort, such as the ureteral stent symptom questionnaire (USSQ) and its validated spanish version, are often not compatible with the public healthcare systems used by patients and application time is limited because of the high volume of patients seen in public institutions.
Ureteral stent discomfort is defined as a set of urinary symptoms and alterations in sexual function, work performance, and quality of life related to having an indwelling ureteral stent.3
In general, there is no consensus for the description if this syndrome. It is usually associated with urinary storage symptoms, such as frequency, nocturia and urgency, pain and alteration of quality of life.
Many studies have described the incidence of the main ureteral stent-related symptoms, which are: pain in the lumbar region and strangury and the urinary symptoms of frequency (50-60%), urgency (57-60%), dysuria (40%), tenesmus (76%), flank pain (19-32%), suprapubic pain (30%), incontinence, and hematuria (25%). Those symptoms are shown in Table 1.
Table 1 Symptoms
| Urinary Symptoms | Pain | Symptoms that affect sexual performance or ordinary physical activities | Quality of life |
| Frequency | Lumbar region | Dyspareunia | Has an overall effect on quality of life |
| Nocturia | Strangury | Inability to perform ordinary physical activities | Effects daily activities |
| Urgency | |||
| Urgency incontinence | |||
| Stress incontinence | |||
| Tenesmus | |||
| Hematuria | |||
| Dysuria |
Frequency is attributed to the mechanical stimulation exerted by the inferior loop of the stent in the bladder. Together with urgency, urinary frequency is one of the most important symptoms of ureteral stent discomfort.4
Statistically, ureteral stent-related symptoms have a negative impact on the patient’s economy. A study found that 58% of patients had reduced work capacity due to the discomfort of the stent, and approximately half of the patients sought medical attention for the stent-related symptoms. 5
In another study, Leibovici et al. reported that, in 135 patients with a stent, 45% had not been able to work for at least 2 days, for a total of 435 workdays lost.6
In the context of analyzing the patient with ureteral stent discomfort, there are few validated tools for objectively evaluating ureteral stent-related symptoms.
In 2003, Joshi et al. published the USSQ, which consists of a questionnaire that evaluates stent-related symptoms, as well as their impact on quality of life.5 That tool has been the standard for evaluating ureteral stent-related symptoms for many years and has been validated in italian, korean, spanish, french, and other languages.
The USSQ consists of 38 items, which are divided into 6 domains: Urinary symptoms, Pain, Global Health, Job performance, Symptoms related to sexual performance, Additional problems and Quality of life. Nowdays, there are few reported questionnaires to evaluate the ureteral stent discomfort, so the prototype has been the USSQ. 7-10
Material & Methods
After ethical approval, a validation study was carried out in two phases. First, a pilot instrument was designed, which was based on the USSQ. It utilized the same domains and the most common symptoms reported in the literature. Both the USSQ and the pilot instrument were applied to a group of 9 patients that underwent semirigid ureteroscopy. The tests were applied on days 7 and 14, after ureteral stent placement, and on day 7, after ureteral stent extraction. The sociodemographic characteristics of the patients are shown in Table 2.
Table 2 Sociodemographics characteristics
| n | % | ||
| Socieconomic status | Lower | 12 | 16.67% |
| Upper-lower | 35 | 48.61% | |
| Lower-middle | 18 | 25.00% | |
| Upper-middle | 7 | 9.72% | |
| Education | None | 4 | 5.56% |
| Primary | 32 | 44.44% | |
| Secondary | 25 | 34.72% | |
| High school | 4 | 5.56% | |
| College | 7 | 9.72% | |
| Comorbilities | None | 13 | 18.06% |
| Diabetes | 6 | 8.33% | |
| HTA | 18 | 25.00% | |
| Obesity | 32 | 44.44% | |
| Metabolic syndrome | 3 | 4.17% | |
| Type of surgery | Elective | 56 | 77.78% |
| Emergency | 16 | 22.22% | |
All patients underwent semirigid ureteroscopy with the placement of a 6Fr x 24cm Cook Medical UNIVERSA stent. The pilot instrument was applied, analyzed, and corrected by the Delphi method. After the corrections were made, the pilot and the USSQ were applied to 36 patients that underwent ureteroscopy with ureteral stent placement. A total of 72 tests were carried out and the pilot instrument was compared with the USSQ, using the Pearson’s correlation coefficient. The final design of the USDT is based on the Likert scale and consists of 6 domains (13 items) that evaluate: urinary symptoms, pain, daily life, sexual life, medical care and the use of analgesics, and quality of life, with 6, 2, 1, 1, 2, and 1 items, respectively. It is evaluated by the frequency of symptom presentation in each domain. The pain domain is evaluated through the Verbal Descriptive Scale validated by Heft et al. The score increases according to symptom severity, with a maximum score of 61 points.
Results
Validation studies showed the questionnaire to be internally consistent (Cronbach’s alpha coefficient: 0.820), with good test-retest reliability (Pearson’s correlation coefficient: 00.850). The correlation of urinary symptoms of both questionnaires was statistically significant (r = 0.929, p = 0.00), as were the pain domain (r=0.880, p=0.00), daily life domain (r=0.625, p=0.00), and quality of life domain (r=0.768, p=0.00). Sexual performance (r =0.190) was the domain with no statistically significant correlation. The length of time with the indwelling ureteral stent and the severity of symptoms had a correlation of (r=0.00). The mean application time of the USDT and USSQ was 1.8min (SD=0.76) and 8.36min (SD=1.87), respectively.
Discusion
Different tools have been designed to evaluate ureteral stent-related symptoms. However, most of the questionnaires present a challenge for the clinician and the patient, especially in public institutions, because they are self-administered, which means the patient must answer them. That becomes a problem when the patient is unable to read or write or when the patient is older and has a comorbidity, such as visual impairment, affecting his or her ability to answer that type of questionnaire.
In addition, the application of questionnaires that evaluate ureteral stent discomfort, such as the USSQ and its validated Spanish version, is often not compatible with public health systems, given that consultation times are limited by the high number of patients seen at public institutions. Another feature of those questionnaires is their extended length, which makes their application difficult during consultation. Therefore, we decided to design a simple, effective, and easy-to-use tool based on the USSQ to evaluate ureteral stent discomfort (Figure 1).
Conclusion
Our results suggest that the USDT is a tool that is as reliable as the USSQ, as well as being a simpler alternative for evaluating ureteral stent discomfort. The most correlated domains were urinary symptoms, pain, and quality of life, which are also the most commonly affected domains, according to the literature. Sexual performance (r=0.190) was the domain that had no statistically significant correlation, most likely because the majority of the patients with an indwelling ureteral stent were sexually abstinent. Our sample size was limited, therefore future studies are needed to confirm the reliability of the USDT.
