Biofeedback-assisted pelvic floor muscle training and pelvic electrical stimulation in women with overactive bladder: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This meta-analysis aims to compare biofeedback-assisted pelvic muscle floor training (PFMT) and pelvic electrical stimulation (ES) as an intervention group, with PFMT or bladder training (BT) as the control group, in women with an overactive bladder (OAB). METHOD: PubMed, Cochrane, CINAHL, EMBASE, and Scopus were systematically searched for randomized controlled trials (RCTs) published up to November 2021. The RCTs were screened for our eligibility criteria and quality was evaluated using the Cochrane Risk Index of Bias tools. The outcomes were changes in quality of life (QoL), episodes of incontinence, and the number of participants cured/improved. RESULTS: Eight studies involving 562 patients (comprising 204 patients with biofeedback-assisted PFMT, 108 patients with pelvic ES, and 250 patients who received PFMT alone or BT and lifestyle recommendations only, as the control group) were included. The ES group showed significant differences in terms of changes to QoL (mean difference [MD]: 7.41, 95% confidence interval [CI]: 7.90-12.92, p = 0.008), episodes of incontinence (MD: -1.33, 95% CI: -2.50 to -0.17, p = 0.02), and the number of participants cured or improved (risk ratio [RR]: 1.46, 95% CI: 1.14-1.87, p = 0.003), while the biofeedback group resulted in nonsignificant changes in QoL (MD: 0.13, 95% CI: 7.87-8.12, p = 0.98), episodes of incontinence (MD: 0.01, 95% CI: -0.89 to 0.90, p = 0.99), and the number of participants cured or improved (RR: 1.15, 95% CI: 0.99-1.33, p = 0.08), both compared to the control group respectively. CONCLUSION: This meta-analysis shows that low-frequency pelvic ES appears to be sufficient and effective as an additional intervention for women with OAB in clinical practice according to improvements in the subjects' QoL and reduction of symptoms. Meanwhile, biofeedback-assisted PFMT does not appear to be a significant adjuvant for conservative OAB therapy.

Survival analysis and development of a prognostic nomogram for bone-metastatic prostate cancer patients: A single-center experience in Indonesia.

OBJECTIVES: To analyze predictive clinical factors of survival in bone-metastatic prostate cancer, and to develop a prognostic nomogram for patients with this condition. METHODS: The present study included 392 patients with bone-metastatic prostate cancer treated with androgen deprivation therapy. Pretreatment parameters were analyzed using the Cox proportional hazards model to identify the predictors of overall survival. Covariates - which showed statistical significance on multivariate analysis - were used to develop a nomogram. A linear predictor model was utilized to develop the nomogram. RESULTS: The median overall survival was 40.3 months (95% confidence interval 32.2-48.5). Univariate analysis showed that clinical T stage, Gleason score, initial prostate-specific antigen value and the number of metastatic lesions were independent prognostic factors for overall survival. These predictors remained significant as independent prognostic factors for overall survival after analysis using the multivariate Cox regression model. The nomogram constructed from those prognostic factors showed good discrimination for predicting the 5-year overall survival, with an area under the curve of 0.69. Acceptable agreement of the observed and predicted probabilities was observed in the calibration plot. CONCLUSIONS: The present prognostic nomogram might be a useful tool for predicting overall survival in pretreatment bone-metastatic prostate cancer, specifically among Indonesian patients. Further studies are required to provide external validation to support the utilization of this nomogram.

Bilateral Giant Renal Angiomyolipoma in a Patient with Tuberous Sclerosis Complex: A Case Report.

Tuberous sclerosis complex (TSC) has several renal manifestations including angiomyolipomas (AML) and renal epithelial neoplasms. A bilateral giant renal AML is extremely rare. We report a case of giant bilateral AML and discuss the diagnosis and treatment of it. The 22-year-old man was admitted due to bilateral flank pain, gross hematuria, and abdominal fullness. He had history of epilepsy, mental retardation, and delayed development during childhood. He had angiofibroma on his face since 10 years ago. Abdominal CT and MRI revealed large lobulated heterogeneous mass with fatty content. Based on those findings, we diagnosed the patient with bilateral giant renal AML. We gave conservative management for the patient and planned to total nephrectomy on the left kidney if the continued bleeding occurred. AML associated with TSC occur more frequently as multiple lesions and grows to larger size than idiopathic AML. Bilateral giant AML, which is very rare, could be treated with conservative management if no significant hemorrhage occurred.

Effectiveness of a comprehensive integrated module using interactive lectures and workshops in understanding and knowledge retention about infant feeding practice in fifth year medical students: a quasi-experimental study.

BACKGROUND: Sixty percent of the 10.9 million under-5 deaths every year are related to malnutrition. More than two thirds of malnutrition is caused by inappropriate infant feeding practice. Only 35 % of mothers worldwide provide 4 months of exclusive breast-feeding, while complementary feeding is often untimely, nutritionally inadequate, hygienically poor, and improperly delivered. The existing pediatric nutrition module in our institution does not include proper delivery of food that involves oral-motor skills and feeding behavior. To scale up the knowledge and skill of medical students regarding evidence-based infant feeding practice, we designed a new module composed of comprehensive and integrated lectures with additional multidisciplinary lectures on oral-motor skill development and feeding behavior. METHODS: A quasi-experimental study was conducted to evaluate the efficacy of the new module compared to the previous module. Fifth year medical students of Universitas Indonesia were divided into intervention and control groups. The control group received lectures and a paper-based workshop. The intervention group received comprehensive and integrated interactive lectures with additional multidisciplinary lectures on oral-motor skill development and behavioral approaches to feeding problems. A hands-on workshop using real cases shown on recorded video and role-play sessions was also presented to the intervention group. A pre-/post-test, 3-month retention test, and Observed Structured Clinical Examination (OSCE) were performed to evaluate understanding, knowledge retention, and counseling skills. RESULTS: A linear mixed effect model with a random intercept analysis for pre-test, post-test, and retention test scores showed significant higher result for intervention group compared to control group (p < 0.001). Comprehensive knowledge and counselling skills were better in the intervention group than in the control group as shown by the OSCE score (68.6 vs 59.3, p < 0.001). CONCLUSIONS: Our comprehensive integrated infant feeding practice module, which incorporates multidisciplinary learning processes and an interactive hands-on workshop with a role-play session yields better knowledge understanding and counseling skills compared with the existing module. Comprehensive knowledge and good counseling skills of medical students as future doctors are a pre-requisite to provide effective education to parents to support successful infant feeding practices.

Targeted Therapy for Metastatic Renal Cell Carcinoma.

In the past 10 years, recent development of targeted therapy in metastatic renal cell carcinoma (mRCC) has provided a new hope and significantly enhanced the prognosis of the disease. Three class of targeted therapy were developed, including multi-targeted tyrosine kinase inhibitors (TKI), the mammalian target of rapamycin (mTOR) complex-1 kinase inhibitors, and the humanized antivascular endothelial growth factor (VEGF) monoclonal antibody. Hence, the objective of this article was to critically examine the current evidence of targeted therapy treatment for patients with mRCC. In the majority of trials evaluating targeted therapy, patients were stratified according to Memorial Sloan Kattering Cancer Center (MSKCC) risk model and the recommendation of targeted treatment based on risk features. In first-line setting (no previous treatment), sunitinib, pazopanib, or bevacizumab plus IFN-α were recommended as treatment options for patient with favorable- or intermediate- risk features and clear cell histology. Patients who progressed after previous cytokine therapy would have sorafenib or axitinib as treatment options. Clear-cell mRCC with favorable- or intermediate- risk features and failure with first-line TKI therapy might be treated with sorafenib, everolimus, temsirolimus or axitinib. However, the current evidence did not show the best treatment sequencing after first-line TKI failure. In patients with poor-risk clear-cell and non-clear cell mRCC, temsirolimus was the treatment option supported by phase III clinical trial. In addition, several new drugs, nowadays, are still being investigated and waiting for the result of phase II or III clinical trial, and this might change the standard therapy for mRCC in the future.

The Effectiveness of a Three Day Course Antibiotic Post-urodynamic Study in Preventing Lower Urinary Tract Infection.

AIM: to evaluate the effect of a 3-day course antibiotic post-urodynamic study (UDS) to prevent urinary tract infection (UTI). METHODS: this was a randomized double blind clinical trial on the proportion of UTI in patients who received levofloxacin 500 mg once a day for 3 days after UDS compared to nontreated patients. The outcome of this study was the incidence of lower UTI in levofloxacin group and placebo group. Lower UTI was defined as patient with one or more clinical symptoms of lower UTI and one or more urinalysis parameter of UTI. Chi-square was used to evaluate the association between the lower UTI and treatment group. RESULTS: a total of 126 patients were enrolled in this study from two outpatient urology clinics in Jakarta: Cipto Mangunkusumo Hospital and Asri Hospital. Overall, 26 patients (20.6%) had UTI post UDS (8 out of 63 patients from levofloxacin arm (12.7%) and 18 out of 63 patients from placebo arm (28.6%); p=0.028). The most common isolate found was E. coli (n=18 patients; 69.2%). The most common indications to perform UDS were Lower Urinary Tract Symptoms (LUTS) with failure of therapy (n=43 patients; 25%), LUTS after invasive treatment (n=29 patients; 16.9%), and overactive bladder with failure of therapy (n=22 patients; 12.7%). CONCLUSION: the use of antibiotic post-UDS can prevent incidence of lower UTI.

A rare case report of renal vein embolization after failed selective angioembolization to treat delayed complication of percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) has been considered the standard procedure for renal caliculi for its safety, shorter operative time, and cost-effectivity. Despite being minimally invasive, rare complications may still occur. This case presented a rare case of renal venous pseudoaneurysm after PCNL. PRESENTATION OF CASE: A 34-year-old male was diagnosed with left lower calyx renal stone sized 14x13x8 mm with 388-571 Hounsfield Unit (HU). He underwent left mini PCNL with standard protocol. However, on two-weeks follow-up, gross haematuria was presented on emergency department admission. Patient underwent two times cystoscopy and blood clot evacuation. Postoperative contrast-enhanced CT showed saccular lesion sized 6.7 mm × 4.8 mm in the interlobar vein of left kidneys' lower pole. Patient was then consulted to Cardiothoracic-Vascular division, and undergone selective angiography and left renal artery embolization-coiling (VortX Diamond-18). Complaints and haemoglobin decline persists; thus, another attempt of embolization was performed with a different approach. Follow-up arteriography and venography showed complete obliteration of the aneurysm sac, followed by cessation of symptoms. This study is reported in line with SCARE criteria. DISCUSSION: This is a rare case where a second embolization attempt (specifically via vein) was needed to overcome PCNL postoperative complication. Reviewing vascular complications risk factors after PCNL is crucial. This case report suggests complication management could be handled appropriately through procedures of selective angiography and embolization. CONCLUSION: Coil embolization targeting the vein is a potentially effective and safe for selective cases of renal vein pseudoaneurysm. This case shows the importance of multidisciplinary approach and collaboration for better patient management.

Efficacy in Using Urodynamic Parameters of Intravesical Electrical Stimulation for Detrusor Underactivity.

OBJECTIVE: Intravesical electrical stimulation (IVES) remains a controversial therapy for detrusor underactivity (DUA). The purpose of this study is to determine the efficacy of IVES in patients with DUA using pre- and post-IVES urodynamic parameters. METHODS: Intravesical electrical stimulation procedure is performed using a specific catheter equipped with an internal electrical electrode (cathode). The anode is subsequently affixed to the lower abdomen (suprapubic). Afterward, this specialized catheter is connected to a stimulator. Patients undergo a series of 12 IVES procedures in 1 month with the following predetermined parameters: 20 mA amplitude, 20 Hz frequency, 200 µs pulse width, and 60 minutes stimulation time. Patients underwent a follow-up urodynamic examination 1 month after the IVES series is completed. RESULTS: After IVES, several notable changes were observed, including an increase in Qmax from 7.28 ± 5.24 to 7.29 ± 4.09 (P=.030), a decrease in post-void residual (PVR) from 73.03 ± 43.91 to 62.07 ± 39.10 (P=.005), and an increase in PDet@tQmax from 17.10 ± 12.35 to 18.87 ± 12.47 (P=.009). The aetiologies of DUA were categorized into 3 groups: chronic obstruction (CO), idiopathic (Idio), and neurological disorder (ND). The CO group exhibited significant changes in urodynamic parameters, specifically Qmax (P=.001), PVR (P=.001), and PDet@Qmax (P=.035). Similarly, the idiopathic group also demonstrated improvements in Qmax (P=.008), PVR (P=.037), and PDet@ Qmax (P=.033). CONCLUSION: Intravesical electrical stimulation has been shown to have a positive effect on patients diagnosed with DUA, particularly those whose DUA is idiopathic or due to chronic obstruction.

Transperitoneal vs extraperitoneal radical cystectomy: A systematic review and meta-analysis.

BACKGROUND: One of the most complex surgeries including radical cystectomy (RC) has a high rate of morbidity. The standard approach for the muscle-invasive bladder is conventional transperitoneal radical cystectomy. However, the procedure is associated with significant morbidities like ileus, urinary leak, bleeding, and infection. The aim of this study is to compare the transperitoneal RC approach with the extraperitoneal RC approach in the treatment of bladder cancer patients. The outcomes of this study are Operative time, Estimated Blood Loss, Hospital Stay, Post-Operative Ileus, Infection, and Major Complication (Clavien-Dindo Grade 3-5). METHODS: PubMed, Cochrane Library, and Science Direct were systematically searched for different publications related to the meta-analysis. Keywords used for searching were Radical Cystectomy AND Extraperitoneal AND Transperitoneal up until 31st August 2022. The studies were screened for our eligibility criteria. Demographic parameters, perioperative variables, and postoperative complications were recorded and analyzed. The Newcastle-Ottawa Scale was used to evaluate the risk of bias in each study. The Review Manager (RevMan) software version 5.4.1 was used for statistical analysis. RESULTS: Eight studies (3 laparoscopic and 5 open methods) involving 1207 subjects (588 patients using the extraperitoneal approach and 619 using the transperitoneal approach) were included. The incidence of postoperative ileus is significantly lower after the extraperitoneal approach compared to the transperitoneal approach (p < 0.00001). The two techniques did not differ in operative time, estimated blood loss, duration of hospital stay, total infection, and major complication events. CONCLUSION: This meta-analysis shows that extraperitoneal radical cystectomy benefits in terms of reduced postoperative ileus.

A rare case report of paratesticular spindle cell tumor: Inflammatory myofibroblastic tumor.

INTRODUCTION AND IMPORTANCE: Spindle cell tumors in the paratesticular region are infrequent. Accurate diagnosis requires clinical assessment, pathological analysis, and immunohistochemical (IHC) analysis. CASE PRESENTATION: The present study reports a 33-year-old male who presented with a painless mass in his right testis. The mass grew from the size of a marble to that of a tennis ball in two years. Physical examination and ultrasonography revealed a solid mass in the right paratesticular area. The patient underwent a right paratesticular tumor excision, without interfering the right testis. Histopathologic analysis showed spindle cell tumor appearance referring to inflammatory myofibroblastic tumor (IMT). CLINICAL DISCUSSION: IMT, also known as inflammatory pseudotumor, is a rare and benign neoplasm that can occur anywhere. Diagnosis is challenging, because it mimics other neoplasms. Immunohistochemical profiles were decisive in concluding a definitive diagnosis. Treatment, on the other hand, depends on tumor burden and connectivity to other region. CONCLUSION: Spindle cell tumors are very rare and can be treated with simple excision if no organ adhesion is detected. Therefore, right orchidectomy was not required in our case.

Transperitoneal Versus Extraperitoneal Approach for Laparoscopic and Robot-Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis.

To conduct a comparative analysis of outcomes from 2 different surgical approaches, transperitoneal radical prostatectomy (TP-RP) and extraperitoneal radical prostatectomy (EP-RP) in minimally invasive surgery. A comprehensive search was conducted up to September 2022 using 5 online databases, namely PubMed, Cochrane, Scopus, EMBASE, and Science Direct. Studies were screened per the eligibility criteria, and outcomes included operative duration, estimated blood loss (EBL), hospital stay, operative complication, and positive surgical margin. Total of 13 studies compiled of 2387 patients were selected, with TP-RP and EP-RP performed on 1117 (46.79%) and 1270 (53.21%) patients, respectively. Six laparoscopy radical prostatectomy (LRP) studies and 7 robotassisted radical prostatectomy (RARP) studies with 1140 and 1247 patients, respectively, were also included. The EP-RP demonstrated a marked advantage in terms of operative complications (Risk Ratio [RR]=0.78, 95% CI=0.62, 0.98; P=.04), but no significant difference concluded for operative duration, EBL, hospital stay, and surgical margin. In the RARP group, there was a significant difference in operative duration for EP-RARP and TP-RARP (Mean difference [MD]=-17.27, 95% CI=-26.89, -7.65; P=.0004), hospital stay (MD=-0.54, 95% CI=-0.94, -0.14; P=.008), and operative complications (RR=0.7, 95% CI=0.49, 0.99; P=.04). There were no noteworthy variations identified in EBL and surgical margin. Furthermore, the LRP group did not show any significant differences. This study shows that regardless of the techniques used, EP-RP has a lower risk of operative complications than TP-RP, with no significant difference in other outcomes.

Comparison of the Effectiveness of Pre-urodynamic Single-dose Levofloxacin with Post-urodynamic Levofloxacin for Three Days Related to the Incidence of Urinary Tract Infection: A Randomized Control Trial.

PURPOSE: The current study aims to compare the effectiveness of pre-urodynamic single-dose levofloxacin and post-urodynamic levofloxacin for three days related to the incidence of urinary tract infections post-urodynamic examination. MATERIALS AND METHODS: This is a single-blind randomized clinical trial conducted in three outpatient urology centers in Jakarta: Cipto Mangunkusumo General Hospital, Siloam Asri Hospital, and Persahabatan General Hospital using a consecutive sampling method between July 2019 - February 2022. The outcome of the study is the incidence of urinary tract infections in both treatment groups. Urinary tract infection was defined as a patient with one or more clinical symptoms of lower urinary tract infection and one or more urinalysis parameters positive for urinary tract infections. Chi-square was used to evaluate the association where p < 0.05 was used to determine statistical significance. RESULTS: A total of 126 patients (63 patients in each arm) were included in the evaluation and analysis. Overall, urinary tract infections were detected in 25 cases (19.8%), 12 patients from the pre-urodynamic antibiotic group (9.5%) and 13 patients from the post-urodynamic antibiotic group (10.3%) (P = .823). E.coli was the most common bacteria found in the urine culture. CONCLUSION: There is no significant difference between a single dose of 500 mg of Levofloxacin administered one hour before the urodynamic study and a once-daily dose of 500 mg of Levofloxacin for three days following the urodynamic study related to urinary tract infections prevention post-urodynamic examination.

Laparoscopic procurement of single versus multiple artery kidney allografts: Meta-analysis of comparative studies.

Laparoscopic donor nephrectomy has become the standard procedure to procure kidney graft. Transplantation using multiple arteries allograft is technically more challenging and still controversial with respect to renal transplantation outcomes. The objective of this study was to examine the transplantation outcome in both donor and recipient outcome of multiple arteries allograft kidney compared with single renal artery kidney. Eligible studies were identified from electronic databases: PubMed, Cochrane CENTRAL, Science Direct, and CINAHL as of October 2016. Relevant parameters explored using Review Manager V5.2 included donor and recipient outcomes. Twenty-four studies were included in this meta-analysis. Compared with SA, MA kidneys were associated with a longer donor operative time. There was no difference between donor length of stay, intraoperative blood loss, hospital stay, first warm ischemic time (WIT-I), and donor surgical complications in donors with multiple arteries compared with single. There was an increased risk of one-year graft loss (OR 1.57, 95% CI 1.09 to 2.26, p = 0.016), recipient vascular complications and recipient ureteral complications in multiple arteries compared with single artery allografts. Kidney transplantation with multiple arteries is relatively as safe as single artery in terms of donor outcomes. However, transplantation with multiple arteries allograft had several potential negative impacts on the recipient outcomes.

Prostate specific antigen (PSA) kinetic as a prognostic factor in metastatic prostate cancer receiving androgen deprivation therapy: systematic review and meta-analysis.

Aim: Metastatic prostate cancer (mPCa) has a poor outcome with median survival of two to five years. The use of androgen deprivation therapy (ADT) is a gold standard in management of this stage.  Aim of this study is to analyze the prognostic value of PSA kinetics of patient treated with hormonal therapy related to survival from several published studies Method: Systematic review and meta-analysis was performed using literature searching in the electronic databases of MEDLINE, Science Direct, and Cochrane Library. Inclusion criteria were mPCa receiving ADT, a study analyzing Progression Free Survival (PFS), Overall Survival (OS), or Cancer Specific Survival (CSS) and prognostic factor of survival related to PSA kinetics (initial PSA, PSA nadir, and time to achieve nadir (TTN)). The exclusion criteria were metastatic castration resistant of prostate cancer (mCRPC) and non-metastatic disease. Generic inverse variance method was used to combine hazard ratio (HR) within the studies. Meta-analysis was performed using Review Manager 5.2 and a p-value <0.05 was considered statistically significant. Results: We found 873 citations throughout database searching with 17 studies were consistent with inclusion criteria. However, just 10 studies were analyzed in the quantitative analysis. Most of the studies had a good methodological quality based on Ottawa Scale. No significant association between initial PSA and PFS. In addition, there was no association between initial PSA and CSS/ OS. We found association of reduced PFS (HR 2.22; 95% CI 1.82 to 2.70) and OS/ CSS (HR 3.31; 95% CI 2.01-5.43) of patient with high PSA nadir. Shorter TTN was correlated with poor result of survival either PFS (HR 2.41; 95% CI 1.19 - 4.86) or CSS/ OS (HR 1.80; 95%CI  1.42 - 2.30) Conclusion: Initial PSA before starting ADT do not associated with survival in mPCa.  There is association of PSA nadir and TTN with survival.

Intracorporeal Dilatation Plus Al-Ghorab Corporoglandular Shunt for Salvage Management of Prolonged Ischemic Priapism.

Ischemic priapism (IP) is a urological emergency that requires early intervention in order to prevent irreversible structural and functional changes. The purpose of penile shunt surgery is to passage out ischemic blood in the corpus cavernosum (CC), restoring the normal circulation within these structures. Here, we present our first experience using modification of Al-Ghorab shunt procedure to treat severe and prolonged IP. The Al-Ghorab shunt procedure was modified by the retrograde insertion of a 7/8 Hegar dilator into the opening of the distal cavernous tissue via the original Al-Ghorab incision. Priapism was successfully relieved, and no recurrent IP was reported.

Comparison between visual prostate symptom score and international prostate symptom score in males older than 40 years in rural Indonesia.

PURPOSE: To evaluate the effect of education and literacy status on completion of the Visual Prostate Symptom Score (VPSS) and the International Prostate Symptom Score (IPSS) in males aged over 40 years in a rural Indonesian area. METHODS: We enrolled 103 men who had visited Tc-Hillers Maumere Hospital. Four questions related to frequency, nocturia, weak stream, and quality of life (QoL) were presented by pictogram in the VPSS. Data on age, educational level, and literacy status were analyzed to determine associations with the capability to complete the IPSS and the VPSS questionnaires. Correlation test was used to identify correlation between the VPSS and the IPSS. RESULTS: The median age of the 103 respondents was 60 years. A total of 69 patients (67.0%) were able to read, 99 patients (96.1%) understood the Indonesian language, and 52 patients (50.5%) had an education grade>9. The IPSS was completed without assistance by 55 patients (53.4%) and the VPSS by 82 patients (79.6%). None of the patients who could not read could complete the IPSS without assistance, whereas 15 patients (44.1%) who could not read could complete the VPSS without assistance (P<0.001). In the analysis of education level, 40 of 51 patients (78.4%) with an education grade≤9 required assistance to complete the IPSS compared with 8 of 52 patients (15.4%) with an education grade>9 (P>0.001). In the same groups, 19 of 51 patients (37.3%) compared with 2 of 52 patients (3.8%) required assistance to complete the VPSS (P<0.001). Total VPSS, VPSS obstructive symptoms, VPSS irritative symptoms, and VPSS QoL scores significantly correlated with the total IPSS, IPSS obstructive symptoms, IPSS irritative symptoms, and IPSS QoL, respectively (correlation coefficient, P-value: 0.675, <0.001; 0.503, <0.001; 0.731, <0.001; and 0.823, <0.001, respectively). CONCLUSIONS: The VPSS correlated significantly with the IPSS and could be completed without assistance by a greater proportion of men with low levels of education. The VPSS might be useful in evaluating men with lower urinary tract symptoms in rural Indonesian areas with a high level of illiteracy and low level of education.