Study design

This was a cross-sectional, qualitative research study comprising in-depth interviews among urologists across six countries from different parts of the world. Using a multi-national approach enabled the identification of key barriers that urologists face across diverse healthcare and cultural settings. Australia, South Korea and Thailand were selected to represent the Asia-Pacific perspective, while Brazil and Colombia were selected to represent a Latin American perspective. Russia was also included for a Russian perspective. In determining the geographic scope of this study, regions with a scarcity of literature on OAB diagnosis and treatment barriers were prioritized. Within these regions, countries were selected to ensure variability in the cultural contexts and health systems represented. The identification of common barriers across these countries, despite their varied contexts, would suggest that they are widely experienced and are, therefore, key barriers to OAB management in men with LUTS. Where notable differences between countries emerge, these were acknowledged as areas necessitating further investigation.

Development of the interview discussion guide was informed by a literature review and the Capability, Opportunity, Motivation and Behavior (COM-B) framework, an evidence-based behavioral change model [16]. Questions in the discussion guide addressed each component of the COM-B model to systematically and comprehensively capture individual-level factors that influenced urologists’ behavior and practices in managing OAB in male LUTS patients (Table 1 and S1).

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Table 1. Discussion guide questions mapped to COM-B components.

https://doi.org/10.1371/journal.pone.0328723.t001

Given the multi-national scope of the study, the discussion guide, which was developed in English, was translated into local language where applicable – Portuguese for Brazil, Spanish for Colombia, Russian for Russia, Korean for South Korea, and Thai for Thailand. The original English language discussion guide was used for Australia. Two cognitive interviews per country were conducted to optimize and validate the discussion guide in local languages.

Sampling and data collection

Recruitment and data collection were conducted between 10 July 2023 and 5 August 2023. In-depth interviews were conducted among a total of 60 urologists, comprising 10 urologists from each country. The urologists were recruited via convenience sampling against a set of screening criteria and were approached by email or telephone. Urologists responsible for prescribing pharmacological treatment to a minimum number of male LUTS patients with OAB were recruited. Urologists who strongly recommended surgery over pharmacological treatment were excluded. Efforts were made to recruit an even representation of urologists from public and private practice. The sample size was determined before data collection and was designed to attain data saturation. Past research suggests that 9–17 interviews sufficiently achieved data saturation in qualitative research [17].

The interviews lasted approximately 60 minutes each and were conducted either face-to-face or via teleconference without others present. All interviews were moderated by experienced qualitative interviewers fluent in the local language (S2 Table). While the co-authors developed the interview discussion guides, they did not conduct the interviews. The urologists interviewed did not have any prior relationships with the co-authors or interviewers. No repeat interviews were carried out and all interviews were audio-recorded for transcription purposes only. Neither transcripts nor study findings were shared with interviewees.

The respondents were asked about their understanding and current practices towards OAB in male LUTS. This included OAB’s disease burden in terms of symptoms, QoL impact, diagnosis, and initiation of OAB add-on atop BPO treatment. Treatment monitoring, adjustment and patients’ treatment persistence were also explored. Urologists’ unmet needs in clinical practice were investigated to uncover barriers to optimal patient management. The open-ended nature of the discussion guide questions allowed participants to speak of their clinical experience freely and spontaneously. Each interview was transcribed, and where applicable translated, for data analysis in English.

Data analysis

Data analysis was conducted by two data coders using Microsoft Word. Both inductive and deductive thematic analysis approaches were used. Responses gathered from the interviews were first analyzed via an inductive approach where transcripts were coded into conceptual categories. Each transcript was first read line-by-line in its entirety to build data familiarity. Thereafter, preliminary coding was conducted where excerpts which contributed to answering the research question were identified and assigned initial descriptive labels. The codes were then grouped to form themes and subthemes through repeated comparisons. Using a deductive approach, themes and subthemes were mapped to the COM-B framework. Mapping the themes to urologists’ capability, opportunity and/or motivation factors will help to inform behavioral change strategies to promote effective management of OAB in men with LUTS. As themes began to reoccur, it was deemed that data saturation had been attained. The final set of themes was reviewed, refined, and defined into core themes. As a quality assurance step, an additional researcher independently reviewed 10% of the transcripts to verify the replicability and reliability of data analysis. The research team members, consisting of urology experts based in the selected countries, ultimately concurred with the core themes in a final discussion meeting, affirming its consistency with their experience and observations in clinical practice.

Ethics and quality statement

The study was granted exemption from ongoing regulatory requirements and Institutional Review Board (IRB) oversight by Pearl IRB (IN, US, IRB ID: 2023−0219), according to 45 CFR 46.104(d)(2) Tests, Surveys, Interviews. The study was conducted according to the principles of the Declaration of Helsinki. All respondents provided written informed consent for participation after being informed of the interview objectives, the voluntary nature of their participation and a guarantee of their confidentiality and anonymity. The COREQ (COnsolidated criteria for REporting Qualitative research) Checklist was adhered to and is provided as S3 Table.

Themes identified from interviews

The following major themes were identified: (1) OAB diagnosis in men with LUTS is complicated by the multi-factorial causes of storage symptoms; (2) patient-reported outcome (PRO) tools are underutilized by urologists; (3) stigmatization and normalization of OAB discourage men from seeking care; (4) challenges exist in tracking OAB symptoms and in patient-urologist communication; (5) the underestimation of OAB contributes to the non-urgency of its management; and (6) urologists may not fully appreciate the trade-offs between different OAB treatments. Narrative excerpts and citations are provided throughout the section and in S4 Table to illustrate participants’ perspectives. Each theme is mapped to its relevant COM-B component from a urologist’s perspective, as presented in Table 3.

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Table 3. Themes mapped to COM-B components.

https://doi.org/10.1371/journal.pone.0328723.t003

OAB diagnosis in men with LUTS is complicated by the multi-factorial causes of storage symptoms

Many urologists intuitively associate male LUTS with BPO and OAB with female patients (see S4 Table, Q1). Therefore, at first consultation, urologists may not consider OAB as a potential contributor to storage symptoms in male patients.

“There is an incorrect impression of OAB being gendered in that it’s a female disease. And so, I think they see a man walk in the door and if he’s got bladder symptoms, [they] immediately [focus on] the prostate.” (P19)

Additionally, the multi-factorial causes of storage symptoms make it difficult to pinpoint OAB as a cause. Comorbidities (e.g., diabetes, BPO) (Q2 – Q4), lifestyle factors (e.g., caffeine consumption) (Q5, Q6) and aging can all contribute to storage symptoms. Moreover, urologists mentioned that their male patients with both BPO and OAB tended to be older (>50 years) and more comorbid than BPO-only patients (<50 years).

“To confirm OAB in our patients, often we have to rule out many other conditions. So if we rule out all possible conditions, but symptoms still persist, we can confirm OAB.” (P54)

PRO tools are underutilized by many urologists

Less than half of urologists reported using PRO tools, such as the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS) and bladder diaries, to guide OAB management. Of urologists using PRO tools, most were observed to be from Russia and South Korea and were more likely to make treatment adjustments within a month of initiation. Urologists’ rationale for PRO use included enabling baseline comparisons of symptoms (Q7), identification of the need to adjust treatment (Q8) and challenging patients’ verbal reporting should they contradict (Q9).

“If the size of the prostate is less than 50g, and… if the score is 8 or higher in the OABSS questionnaire… tamsulosin + mirabegron is prescribed.” (P25)

Urologists who recognized the value of PRO tools proactively helped patients access and complete them effectively through printouts (Q10), digital applications (Q11), and selecting simple, patient-friendly PRO tools such as the OABSS (Q12).

Nevertheless, the majority of urologists interviewed mentioned that treatment decisions are ultimately centered around patients’ verbal reports and satisfaction. Urologists often only consider the diagnosis of OAB when patients complain of persistent storage symptoms despite BPO treatment. This is because OAB is generally not perceived as life-threatening, but rather, a non-urgent condition that primarily impacts QoL (Q13). Therefore, OAB management is observed to only begin from follow-up consultations, up to three months away. Even if OAB is identified, urologists may delay adding-on treatment, should patients claim to be satisfied despite persistent storage symptoms (Q14, Q15).

“OAB never killed anybody… So, [the decision to add-on OAB treatment] depends on how much [OAB] bothers the patients, how much it affects their QoL.” (P31)

Urologists who rely on patients’ verbal reports perceived existing PRO tools as unnecessary, time-consuming, and not patient-friendly (Q16 – Q20). This trend was more pronounced in countries other than Russia and South Korea, and was consistently seen among urologists in both public and private practice, regardless of years of experience or seniority levels.

“I do not do IPSS because that table seems very long, cumbersome, it requires academic preparation for the patient who reads it and we handle patients of all sociocultural levels.” (P42)

Nonetheless, a few of these urologists acknowledged the usefulness of PRO tools in understanding patient experiences and symptomatic improvements. As a compromise, some reportedly administered selected questions from PRO tools (Q21, Q22).

“I try to summarize the IPSS because it is difficult to reach the patient [and for them] to understand.” (P45)

Stigmatization and normalization of OAB discourage men from seeking care

Urologists acknowledged that men feel stigmatized and ashamed of their storage symptoms, contributing to reluctance in seeking medical care (Q23). Additionally, men may normalize OAB symptoms as part of ageing (Q24).

“Some feel ashamed because…social embarrassment. The smell of the urine, need to use diapers.” (P34)

“Patients…consider that it is normal to have such problems in their age.” (P56)

Urologists reported that their male patients typically seek care only when forced to, either by their family (Q25) or when symptoms become intolerable. However, even if they do seek care, they may downplay their OAB experience (Q26). Sensitive topics like sexual (e.g., erectile dysfunction) and mental health (e.g., anxiety and depression) are not often fully discussed between patients and urologists (Q27, Q28).

“I think the poor mental health is the biggest concern that gets underrated and underplayed… Quite a few numbers of patients are depressed because of their condition. And I think we don’t really delve much into it.” (P15)

Challenges exist in tracking OAB symptoms and in patient-urologist communication

Even when men seek medical care, urologists note their struggles in understanding, identifying and tracking the correct symptoms. Urgency and nocturia were symptoms identified as overly complex for patients to comprehend and accurately track (Q29 – Q31).

“Some patients may consider [night urination] to be lying awake and getting up to urinate at night... However, that’s not the definition of night urination for urologists as the patient does not wake up due to the need to urinate.” (P3)

Should patients successfully track their symptoms, some urologists noted that patients face yet another barrier in accurately articulating their symptoms to urologists (Q32, Q33).

In the absence of PRO tools, the onus is on urologists to ask the right questions to extract the necessary information from patients (Q34). This is challenging, as patients may be dishonest, for example, when reporting treatment compliance (Q35, Q36).

“My experience is [that] patients will lie to you. They’re very unreliable.” (P12)

Additionally, many urologists find probing time-consuming and challenging as their communication skills and willingness to engage patients vary (Q37 – Q39). These communication barriers limit urologists’ understanding of patients’ OAB experience (Q26, Q40).

The underestimation of OAB contributes to the non-urgency of its management

The aforementioned barriers contribute to OAB in men with LUTS being underdiagnosed, and its prevalence underestimated by urologists (Q41).

“We tend to underestimate the incidence of [OAB in men with LUTS]… We see the reports in the literature. And they are much higher than what we end up seeing in practice. We end up believing that’s the way it is.” (P37)

Nonetheless, urologists were optimistic that diagnosis is improving, as current medical training considers OAB in men with LUTS more, compared to its previous prostate focus (Q42). However, urologists still report greater use of the IPSS over OABSS, and BPO remains the focus of treatment over OAB (Q43, Q44).

“Well, I see it in my own colleagues. I see it in patients who have been sent for a second opinion, who I think have bleedingly obvious diagnosis of OAB, and they’ve been offered a transurethral resection of the prostate.” (P19)

Only a third of urologists appreciated the urgency of diagnosing and treating OAB early, citing implications such as worsening symptomatology (Q45), kidney dysfunction (Q46) and psychogenic neurological issues (Q47). OAB’s QoL impact is also underestimated. When presented with evidence of OAB’s impact on sexual health, more than a third of urologists saw it as new information. Even when sexual health impact was acknowledged, it was typically attributed to treatment side effects (e.g., retrograde ejaculation from dutasteride) rather than OAB itself (Q48). Some urologists spontaneously mentioned that QoL is less important in elderly patients, who are assumed to be retired, less active, and thus less bothered by daily inconveniences (Q49).

“[OAB] doesn’t create a lot of burden in terms of impact on physical health because older people usually accept the physical changes, they are not afraid, they have poorer mental health, they’re usually retired, and they don’t have much of an economic burden…” (P3)

With an incomplete understanding of OAB’s disease burden, the perceived drawbacks of adding-on OAB treatment outweigh the benefits. These drawbacks include polypharmacy (Q50), added treatment cost and potential side effects (Q51) which can lead to treatment non-persistence. Moreover, adding-on OAB treatment risks compromising BPO treatment (Q52).

“The problem with OAB medication is that they are bladder suppressants… if the patient takes OAB medication alongside LUTS medication, the patient may struggle to urinate.” (P3)

Therefore, urologists may delay adding on OAB treatment to allow more time for BPO treatment to take “full effect” (Q53), underscoring their non-urgency in diagnosing and treating OAB.

“The medication used to treat LUTS often also improves OAB symptoms to some extent. That is, OAB can sometimes wait.” (P1)

Urologists may not fully appreciate the trade-offs between different OAB treatments

When asked to describe their OAB treatment approach among male LUTS patients, most urologists described a similar approach. Patients who first present with obstructive outflow tract symptoms or an enlarged prostate are typically prescribed α-blockers (with/without 5αRIs). However, the time between treatment initiation and re-evaluation varied widely from 3 weeks to 3 months. At follow-up, about 10% of patients would report improvements in their obstructive symptoms but persistent OAB symptoms. These patients would be prescribed OAB add-on treatment. Across urologists, beta-3 agonists and antimuscarinics were prescribed at comparable frequencies.

Most urologists (57%) perceived beta-3 agonists and antimuscarinics as equally efficacious. 25% perceived beta-3 agonists as more effective in reducing the frequency of storage symptoms, and 18% felt that antimuscarinics were more effective, especially at higher doses.

In terms of safety profile, most urologists recognized beta-3 agonists as safer; and associated with fewer side effects such as dry mouth and constipation (Q54). Beta-3 agonists are therefore preferred over antimuscarinics for elderly patients (Q55) and those with comorbidities (e.g., cognitive disorders, constipation, glaucoma, autoimmune diseases).

“[Beta-3 agonists are] probably the best, because it doesn’t have constipation, dry mouth.” (P13)

However, beyond dry mouth and constipation, beta-3 agonists’ reduced risk of urinary retention compared to antimuscarinics did not resonate with most urologists (Q56, Q57) (only 20% spontaneously mentioned). Urologists who acknowledged beta-3 agonists’ reduced risk of urinary retention suggested that prescribing it can increase patients’ acceptance of OAB add-on treatment (Q58).

“Intuitively, people worry about going into retention with the OAB drugs, and we’ve got good literature which says it doesn’t happen. And I think if this was out there, people would be inclined to treat OAB symptoms early.” (P12)

Recognizing beta-3 agonists’ full safety profile also helped urologists in tailoring their treatment approach based on the key concerns of each patient, such as urinary retention (Q59, Q60).

“Since [beta-3 agonists have] fewer side effects related to residual urine after voiding compared to anticholinergic drugs, this can be relatively safely used in male LUTS patients who are anxious that they suddenly may not be able to urinate anytime and anywhere.” (P24)

Treatment costs were reported as one of several barriers to prescribing beta-3 agonists. Almost a third of urologists mentioned reserving beta-3 agonists for more affluent patients. Less affluent patients were perceived as more willing to accept antimuscarinic side effects (Q61, Q62). Additionally, some urologists mentioned that they or their colleagues tend to prescribe antimuscarinics habitually, sometimes without considering alternatives (Q63).

“Some doctors are so used to prescribing [antimuscarinics], they do not consider any other options.” (P56)