Nocturia is defined by the International Continence Society (ICS) as the complaint that the individual has to get up one or more times to void at night and the void has to be preceded and followed by sleep [1]. It is prevalent and the degree of bother increases with night time frequency. Hesitancy is defined, as difficulty in initiation of voiding resulting in a delay in the onset of voiding after an individual is ready to void [1]. This symptom tends to be neglected as it is difficult to measure. Current uroflowmetry machine is unable to measure hesitancy objectively. Having both bothersome nocturia and compounded by hesitancy, an individual would have more distressing voiding symptoms and more likely to seek medical advice. Few studies had looked into the impact of hesitancy in patients with bothersome nocturia. Using a new generation of ′smart toilet′ we were able to measure hesitancy objectively using TOTO Flowsky® [2]. Our aim was to determine the significance of bothersome nocturia and hesitancy in patients with lower urinary tract symptom (LUTS) using TOTO Flowsky®.

TOTO Flowsky® is a 'new generation' of uroflowmetry machine. It is a 'smart toilet' with a uroflow machine incorporated into a normal toilet. Thereby, patients will void naturally in a more familiar environment. When a patient was ready to void, he would press a button to activate the ′smart toilet′. Thus, capturing the delay in the initiation of voiding onto a uroflow tracing. This was marked and recorded as the 'Hesitancy time'. 

236 patients with lower urinary tract symptoms (LUTS) were recruited into a prospective randomised controlled trial (RCT) for the validation study of TOTO Flowsky® [3]. They completed the International Prostate Symptom Score (IPSS) Questionnaire and would indicate whether they experienced worsening hesitancy symptom at night. Prism GraphPad was used for statistical analysis. Analysis was done using Mann-Whitney U test and one-way ANOVA.

236 patients (mean aged 65 years) completed the study and Table 1 showed the uroflow parameters according to Nocturia and Hesitancy. In those patients with worsening nocturia, they experienced more marked symptoms of hesitancy (p<0.0001). No differences were found for prostate volume and intravesical prostate protrusion (IPP). International Prostate Symptom Score (IPSS) (p<0.0001) and QOL (p=0.0012) deteriorated more with increasing nocturia episodes. 

For uroflow parameters, the maximum flow rate (p<0.0001) and the average flow rate (p<0.0001) deteriorated more with increasing episodes of nocturia. The voided volume  (p=0.0003) was smaller with worsening bothersome symptoms. Bladder voiding efficiency (BVE) was lower in patients with hesitancy. Hesitancy time (p=0.0045) was increased for patients experiencing more bothersome nocturia.

Nocturia and hesitancy affected IPSS score (p<0.0001) and QOL (p=0.0012). Maximum (p<0.0001) and average (p<0.0001) flow rates were affected together with voided volume (p=0.0003) and Hesitancy time (p=0.0045).

Bothersome nocturia and hesitancy had a great impact on uroflow parameters resulting in a poorer uroflow. TOTO Flowsky® provided a novel method of measuring hesitancy and represented a major technological advance. Patient with bothersome nocturia and hesitancy would more likely to seek medical advice and this should not be underestimated and ignored. Additional research for measuring nocturia and hesitancy objectively using this novel method would be warranted.

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Hesitancy Symptom: The Forgotten Symptom in International Prostate Symptom Score (IPSS) Questionnaire. JUrol ; 199 (4); e996 - 997
Validation of TOTO Flowsky®. Euro Urol 2017; 16 (3); e1959 -1960