The International Prostate Symptom Score (IPSS) was created in 1992 and is the tool of choice for assessing the severity of lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) and their impact on quality of life (QoL). 
The overall literacy in the U.S. has shown a steady decline over the last several decades (1). Males over 65 years of age, in whom LUTS-BPH is more prevalent compared to younger individuals, have the lowest literacy level. While 21% of the adults in the U.S. read below a 5th grade level, the conventional IPSS has a calculated readability at the 8th-grade level, corresponding to a 12-14 year old individual. Moreover, longitudinal studies demonstrated that the IPSS was not a reliable tool to assess temporal changes in LUTS-BPH (2), and many patients needed to be overseen by the healthcare provider to better understand and answer all the questions. 
We propose a simplified version of the IPSS (S-IPSS) which inherited the same goals as the original IPSS, but was tailored to the literacy level of the present-day elderly male population with LUTS-BPH in the U.S. In addition, given the growth of the Spanish-speaking population in the U.S., a Spanish version of the S-IPSS has also been developed. Our objective is to offer an updated, user-friendly tool for urologists and a more easily comprehensible questionnaire for patients.

The S-IPSS has the same framework and scoring system as the conventional IPSS. In an effort to improve readability, which was calculated using readabilityformulas.com (3), wording was simplified without altering the meaning of the questions (Figure 1: English version of the S-IPSS). Male patients, aged 65 or older, who presented to the Urology clinic due to LUTS-BPH between 10/7/2019 and 10/18/2019 were asked to complete both the S-IPSS and IPSS (either in English or Spanish, depending on the patient’s preference). The individuals who consented to participate in this study were randomly assigned to complete one questionnaire before their clinical appointment, and the second one after the visit. Two additional questions were added at the end of both questionnaires to gauge the difficulty of completing the survey and whether the respondent needed help from another person.

A total of 18 patients completed both questionnaires, 13 in English and 5 in Spanish. The proposed S-IPSS had a calculated readability at the 4th-5th grade level or that of an 8-9 year old individual. Respondents reported more severe symptoms on the S-IPSS than on the IPSS. S-IPSS respondents also indicated a lower perceived QoL (Figure 2). Overall, respondents found the S-IPSS easier to comprehend and complete than the IPSS (Figure 2). These findings were evident for both the English and Spanish versions of the S-IPSS. Three respondents needed help to complete the IPSS, while none needed help to complete the S-IPSS.

The readability level of the IPSS is not compatible with the low reading comprehension rates of the current elderly male U.S. population. The readability level of the proposed S-IPSS (in both English and Spanish) demonstrated the potential to make LUTS-BPH assessment more comprehensible for the vast majority of the target population, thus allowing better identification of symptom severity and their impact on QoL. More patients can be able to fill out the updated questionnaire independently. This can potentially increase the sensitivity and specificity of the symptomatic assessment, the efficiency of clinical visits, the accuracy of collected data, and the accessibility of the patient experience. A small sample size is the major limitation of this study, which necessitates validation of the findings in a larger cohort of patients.

The optimized readability level of the S-IPSS (in both English and Spanish) may translate into better comprehension and increased likelihood of independent completion of the questionnaire by the patients, hence potentially enabling more accurate LUTS-BPH assessment with improved time-efficiency of the clinical encounter.

"National Assessment Of Adult Literacy". National Center for Education Statistics, 2003. https://nces.ed.gov/naal/kf_demographics.asp.
Mcvary* Kevin, et al. “What Minimal Important Difference In Urinary Symptom Relief Benefits Patient Quality Of Life?” Journal of Urology, vol. 201, no. Supplement 4, 1 Apr. 2019, doi:10.1097/01.ju.0000554866.89348.4e.
Readability Formulas, free readability tools to check for reading levels. https://readabilityformulas.com/