Turkish version of the Ureteral Stent Symptoms Questionnaire:
linguistic and psychometric validation
Yiloren Tanidir1 · Naside Mangir2 · Ahmet Sahan1 · Muhammed Sulukaya1

Received: 11 September 2016 / Accepted: 14 October 2016
© Springer-Verlag Berlin Heidelberg 2016

Results A total of 68 patients with ureteral stents and 37

controls were available for the final analysis. The Cron-
bach’s alpha value was higher than 0.7 at week 1 for all

sub-domains except additional problems domain. The

test–retest reliability of the T-USSQ was high for all sub-
domains except the additional problems domain. Relatively

high correlation coefficients were found for the visual
analog scale for pain, IPSS (for males), mOAB score (for

females) with the corresponding USSQ domains, suggest-
ing good convergent validity. Also the T-USSQ could effec-
tively differentiate between patients and controls.

Conclusions The T-USSQ is a reliable and robust instru-
ment that can be self-administered to patients of Turkish

population with ureteral stent in the clinical applications.
Keywords Ureteral stent · Symptom score ·
Questionnaire · Validation

Introduction
Since its first introduction in 1978 [1], the double-J ureteral
stent has become an indispensable part of the urologist’s
routine practice. Traditionally, ureteral stents are placed to

relieve ureteric obstruction, generally as an adjunct to treat-
ment of urinary stone disease after surgery or shock wave

lithotripsy. With advances in stent manufacturing, various
designs using different materials with or without different
coatings have been produced, resulting in an expansion in

the use of stents in clinic despite the absence of robust evi-
dence on patient morbidity and cost-effectiveness [2]. The

lack of standardized evaluation of patient experiences with
ureteral stents has surely contributed to expansion.
Ureteric stents are safe in most cases; however, they can
also cause complications such as migration, fragmentation and

Abstract
Purpose Ureteric stents are frequently used in urology
practice and can cause significant impairment in quality of

life (QoL). The aim of this study was to validate the Ure-
teral Stent Symptoms Questionnaire (USSQ) to be used in

the evaluation of stent-related symptoms and impairment in
QoL in Turkish-speaking patients.
Methods After linguistic validation of the original USSQ
into Turkish language, the Turkish version of the USSQ
(T-USSQ) was self-administered to all participants at

week 1 and 4 after stent placement for test–retest reliabil-
ity and internal consistency and at week 8 (4 weeks after

stent removal) for sensitivity to change analysis. Control
patients completed the form only once. Additionally male

and female patients completed the validated Turkish ver-
sions of International Prostate Symptom Score (IPSS) and

Marmara Overactive Bladder (mOAB) Symptom Scores,
respectively.

Naside Mangir and Ahmet Sahan contributed equally to this
study.
* Yiloren Tanidir
[email protected]
Naside Mangir
[email protected]
Ahmet Sahan
[email protected]
Muhammed Sulukaya
[email protected]
1 Department of Urology, Marmara University School
of Medicine, Istanbul, Turkey
2 Department of Materials Science and Engineering, University
of Sheffield, Sheffield, UK

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calcification, the management of which may necessitate fur-
ther invasive interventions [3, 4]. Ureteral stents may also be

associated with significant discomfort, with more than 70 %
of patients experiencing voiding symptoms and pain requiring

analgesia as well as impairment in quality of life (QoL) result-
ing from interference with daily activities, work performance,

general health and interpersonal relationships [5].
A patient-reported outcome measure has recently been

developed by Joshi et al. to evaluate symptom bother/sever-
ity and impairment in QoL caused by the ureteral stent

[6]. The Ureteral Stent Symptoms Questionnaire (USSQ)

designed to define and quantify a range of symptoms expe-
rienced by men and women with ureteral stents that involve

six domains: urinary symptoms, pain, sexual health, general
health, work performance and additional problems. Up until

now, validations of cross-cultural adaptations have been per-
formed in French [7], Spanish [8], Italian [9], Korean [10],

Arabic [11], Persian [12] and German [13]. These efforts

will ensure improved assessment of stent effects in clini-
cal trials, monitoring patient symptoms in clinical practice,

patient counseling and clinical decision-making.
The aim of this study is to validate the USSQ to be used
in the evaluation of discomfort and impairment in QoL in
Turkish-speaking patients with ureteric stents.

Materials
The linguistic validation

Two professional translators translated the original Eng-
lish USSQ into the Turkish language independently of each

other. Taking these two translations, the translators and the

researchers synthesized a final Turkish version of the ques-
tionnaire, giving particular attention to using clear, simple

language. Afterward, a bilingual (Turkish and English)
researcher who did not have access to the original English
version performed a back-translation of the final document.
The back-translated version and the original version were
then compared, and a final consensus document was agreed
upon. Finally, a pilot test was performed with 10 patients to
verify the comprehensibility of the questionnaire. With the

feedback received from the pilot group, further minor mod-
ifications were made and a final version was agreed upon.

The study population

Patients who underwent a ureteral stent placement pro-
cedure in a tertiary referral center (Marmara University

School of Medicine, Department of Urology) between
June 2014 and September 2015 and controls without stents

were included in this study. The inclusion criteria were ure-
teral stent placement for a diagnostic/therapeutic purpose

performed for a benign upper urinary tract condition. Illit-
erate patients and patients with a history of malignancy,

any previous lower urinary tract dysfunction, voiding dys-
function or any previous operations in the upper urinary

tract that resulted in mucosal damage or perforation were
excluded. A standard polyurethane 6 Fr double-J ureteral
stent (26 or 30 cm) was inserted in all cases.
The Turkish version of the USSQ was self-administered
to all patients at weeks 1 and 4 after stent placement for
test–retest reliability and internal consistency and at week 8
(4 weeks after stent removal) for sensitivity to change analysis.
In addition, male and female patients completed the validated
Turkish version of International Prostate Symptom Score
(IPSS) and validated Marmara Overactive Bladder (mOAB)

Symptom Score [14], respectively, at weeks 1 and 4. The con-
trol group patients completed the Turkish USSQ once only.

This study was approved by the institutional review

board. The purpose of the study was explained to each par-
ticipant, and written informed consent was obtained from

each of them. The demographic characteristics of all of the
study participants were recorded separately.
Statistical analysis
Statistical analysis was performed using SPSS version 17.0
software. Descriptive statistics were analyzed for statistical
significance (p < 0.05) using Chi-square test and Student’s
t test for categorical and continuous variables, respectively.

Normal distribution of the data was checked by Kolmogo-
rov–Smirnov test. Mean scores are given with correspond-
ing standard deviations in brackets.

Reliability of the questionnaire was evaluated by two
measures: internal consistency (Cronbach’s alpha) and rest–
retest analysis of week 1 and week 4 scores (Spearman’s

correlation coefficient). Cronbach alpha and test–retest cor-
relations were calculated for each of the six domains indi-
vidually, following the methodology of the original article.

Correlations between the Turkish USSQ scores and

other validated symptom scores were tested with Spear-
man’s correlation coefficient. Correlation coefficient (CC)

values of >0.8, >0.6, >0.4 and >0.2 were designated as very
strong, strong, moderately strong and weak correlations,
respectively. Sensitivity to change analysis was performed
using a paired samples t test.

Results
Demographic characteristics of the study population are
shown in Table 1. The mean age of the patients and the
controls were 43.23 (13.1) and 41.14 (13.8), respectively
(p = 0.44). Out of the initial 78 patients and 45 controls,
68 (87.1 %) and 37 (82.2 %) respectively were available for

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the final analysis. The proportion of sexually active patients
in the patient and control groups was 66.1 and 54.0 %,
respectively (p = 0.22). The patient and control groups
were also comparable in terms of employment status and
male-to-female ratio (Table 1).
Reliability of Turkish USSQ

The Cronbach’s alpha value, a measure of internal con-
sistency, was higher than 0.7 at week 1 for all domains

except for the additional problems domain. At week 4, only

the work performance domain had a Cronbach’s alpha of
higher 7 (Table 2).

The test–retest reliability of the Turkish USSQ was dem-
onstrated by strong correlations between the mean scores

at weeks 1 and 4 for each domain (Table 2). Correlations
between week 1 and week 4 scores were very strong for

the work performance domain, strong for the urinary symp-
toms and body pain domain and moderately strong for the

general health and sexual matters domains. The test–retest
correlation for the additional problems domain was the
lowest (Table 2).
Correlations of individual domain scores with others
are shown in Table 3, with the highest correlation observed
between urinary symptoms and the general health domains
(CC = 0.67), followed by the body pain and additional
problems domains (CC = 0.43) at week 1.
Discriminant validity and sensitivity to change
The Turkish USSQ was able to effectively differentiate
between patients with and without stents, as demonstrated by
the significant differences in all of the domain scores between
patients and controls (Table 4). Of 45 sexually active patients
in the stent group, 62.2 % reported disturbance in sexual
activity, whereas of all patients in the stent group 77.9 % had
some amount of body pain due to the stent.

Table 1 Patient characteristics

Patients (n = 68) Controls (n = 37) P value
Male-to-female ratio 42/26 23/14 0.96
Mean age (SD) 43.23 (13.1) 41.14 (13.8) 0.44
Employment status
Employed 31/68 18/37 0.76
Student 13/68 7/37 0.98
Retired 3/68 2/37 0.81
Unemployed and
others

21/68 10/37 0.67

Number sexually
active

45/68 20/37 0.22

Table 2 Internal consistency and test–retest reliability for each domain of Turkish Ureteral Stent Symptoms Questionnaire

Internal consistency Test–retest reliability
(Cronbach’s alpha) Mean score (SD) Spearman’s correlation coefficient P value
Week 1
with stent
(n = 68)

Week 4
with stent
(n = 55)

Week 1
with stent
(n = 68)

Week 4
with stent
(n = 55)

Urinary symptoms 0.819 0.667 24.88 (4.89) 20.30 (3.02) 0.718 0.001
Body pain 0.714 0.693 17.17 (3.17) 11.13 (2.50) 0.666 0.001
General health 0.767 0.586 12.69 (3.25) 9.41 (1.90) 0.570 0.001
Work performance 0.920 0.742 7.90 (1.49) 6.88 (1.57) 0.911 0.001
Sexual matters 0.839 0.637 5.47 (1.88) 2.80 (1.02) 0.612 0.001
Additional problems 0.570 0.691 6.89 (1.57) 5.20 (1.64) 0.353 0.014

Table 3 Correlation of each domain score with other domain scores at week 1/week 4

Urinary symptoms Body pain General health Work performance Sexual matters Additional problems

Urinary symptoms 1.00/1.00
Body pain 0.42/0.25 1.00/1.00
General health 0.67/0.40 0.30/0.41 1.00/1.00
Work performance 0.23/0.11 0.14/0.20 0.41/0.07 1.00/1.00
Sexual matters 0.15/0.33 0.10/0.14 0.21/0.22 0.22/0.42 1.00/1.00
Additional problems 0.40/0.07 0.43/0.05 0.13/0.30 0.29/0.17 0.47/0.27 1.00/1.00

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Mean domain scores of patients at weeks 1 and 4 were
significantly higher than the scores at week 8 (after stent
removal), except in the sexual matters domain which was
not significantly different at week 8 compared with week 4
(Table 5).
Convergent validity
Among male patients with a stent, the urinary symptoms
index at weeks 1 and 4 demonstrated a high correlation
with IPSS total score (CC 0.503 [p = 0.002] and 0.463
[p = 0.005], respectively). Among female patients with a

stent, the urinary symptoms index demonstrated a high cor-
relation with mOAB total score only at week 1 (CC 0.558

[p = 0.01]). The urinary symptoms index also showed
a high correlation with the quality of life domains of the
corresponding questionnaires in male and female patients

(Table 6). The body pain index showed a strong correla-
tion with the visual analog scale (VAS) score at weeks

1 and 4 (CC 0.603 [p = 0.001] and 0.908 [p = 0.001],
respectively).

Discussion
This study demonstrates the validity and reliability of the

Turkish version of the USSQ to characterize the symp-
toms and quantify the associated impairment in QoL in

Turkish-speaking male and female patients with ureteral

stents. Overall, our results are in line with those of the pre-
vious studies that have validated cross-cultural adaptations

of the USSQ. We have demonstrated that all six domains
of the Turkish USSQ can effectively differentiate between

patients with and patients without stents with good inter-
nal consistency, test–retest reliability and responsiveness to

change. We hope that our study will contribute to standard

reporting of symptoms in Turkish-speaking patient popula-
tions, which can then lead to improved assessment of out-
comes of ureteral stent insertion.

The internal consistency within each domain of the Turk-
ish USSQ was overall very satisfactory as demonstrated

with a Cronbach’s alpha value of >0.7 for all domains at
week 1 other than additional problems domain. Lower (but
closer to 0.7) values were observed at week 4. In terms

Table 4 Ability of the Turkish USSQ to discriminate between patients with and without ureteric stents

Mean domain score (SD) P value
Patients with stent (n = 68) Controls
(n = 37)

Main domain scores
Urinary symptoms 24.88 (4.83) 13.51 (2.07) 0.009
Body pain 17.17 (3.17) – –
General health 12.69 (3.25) 8.02 (2.68) 0.001
Work performance 7.90 (1.49) 3.31 (0.66) 0.003
Sexual matters 5.47 (1.88) 2.60 (0.81) 0.001
Global QOL 5.29 (0.91) 3.32 (2.01) 0.001
No of patients reporting disturbance in sexual activity 28/45 0/20 –
No of patients reporting body pain 53/68 0/37 –
Number of whole days lost due to stent 2.6 (3.71) – –
Number of half days lost due to stent 5.8 (3.54) – –

Table 5 Sensitivity to change
analysis Mean score (SD) n = 30 P value
(week 1 vs. week 8)
P value
(week 4 vs. week 8) With stent Without stent
Week 1 Week 4 Week 8

Urinary symptoms 24.70 (3.37) 20.60 (2.89) 15.83 (5.07) 0.001 0.001
Body pain 15.0 (1.58) 9.75 (0.0) 0 – –
General health 12.17 (3.58) 9.13 (1.54) 8.06 (3.58) 0.001 0.013
Work performance 7.71 (1.43) 6.64 (1.82) 3.42 (1.08) 0.001 0.001
Sexual matters 5.40 (1.69) 2.52 (0.60) 2.25 (0.78) 0.001 0.479
QoL 5.41 (0.77) 1.62 (0.67) 0.86 (0.9) 0.001 0.001

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of test–retest reliability, our results show that the Turkish
USSQ can consistently quantify the symptoms of patients
with ureteral stents, although with slightly lower scores for
all domains at week 4 compared with week 1. This can be
explained by the developing tolerance to the stent over time
[15]. It may also be due to a potential recall bias since the
questionnaires were administered 4 weeks apart. Although
Park et al. [10] performed the retest at week 2, we chose,
like the majority of researchers, to follow the methodology
of the original article [8–10].
The Turkish USSQ effectively differentiated between

patients with a stent and those, and it was found to be sensi-
tive to stent removal. The exception to this was the sexual

domain score, which that did not change after stent removal
compared to week 4 with stent. This raises the question
whether it is possible that stent-associated bother could
persist in some cases despite stent removal.
We have demonstrated moderate to strong correlations

between the Turkish USSQ and other validated instru-
ments to evaluate urinary symptoms and their bother. The

IPSS in men and the mOAB score in women correlated
with the urinary symptoms domain score at weeks 1 and 4,
with week 1 correlations being generally higher compared

with those of week 4. Also, the QoL items of both ques-
tionnaires correlated well with the urinary symptoms score

of the USSQ. Not surprisingly, the highest correlation was
observed between the body pain domain score and the VAS
score of the USSQ.
The USSQ was originally designed as a 38-item
questionnaire, with 33 Likert-type questions and 5
more descriptive items organized in six main domains.
Although this questionnaire provides a comprehensive
assessment of urinary symptoms, general health, pain,
sexual health, work performance and other additional

problems related to in situ ureteral stents, it does not
allow us to calculate a single total USSQ score, as one

would expect. Thus, as the creators of the original ques-
tionnaire have suggested we recommend that each

domain of the Turkish USSQ be used to evaluate a par-
ticular construct. Also, it has been argued that the origi-
nal USSQ could be impractical to use in daily practice

for non-research purposes and that a shorter version of
the form may be more practical [16]. A similar situation

was experienced with the development of different deriv-
atives of the 33-item OAB-q questionnaire (the OAB-q

short form and the OAB-V8), which are now frequently
used to evaluate symptom bother and QoL of patients

with overactive bladder [17]. Thus, we welcome fur-
ther efforts to find briefer derivatives of the USSQ that

can effectively evaluate symptoms and QoL while being
more practical in the clinical setting.
A limitation of this study is that the Turkish USSQ is
validated for use only in patients with unilateral stents for

benign conditions and excludes those patients with malig-
nant conditions or complicated cases, and others.

Conclusion
The Turkish version of the USSQ can be used as a reliable
instrument to quantify patient-reported symptoms and the
bother associated with use of indwelling ureteral stents.
This instrument will help in standardized reporting of
patient outcomes in the literature, which can then lead to
improved understanding of stent burden.
Acknowledgments We would like to thank Ayshe Slocum and
Abdulkadir Slocum for reviewing the translated questionnaires.

Table 6 Correlation of each
domain score with IPSS, mOAB
and VAS score at weeks 1 and 4

Spearman’s correlation coefficient P value

Urinary symptoms and IPSS total score (n = 34)
Week 1 0.503 0.002
Week 4 0.463 0.005
Urinary symptoms and mOAB total score (n = 20)
Week 1 0.558 0.010
Week 4 0.233 0.320
Urinary symptoms and IPSS QoL question (n = 34)
Week 1 0.720 0.001
Week 4 0.397 0.020
Urinary symptoms and mOAB QoL question (n = 20)
Week 1 0.628 0.003
Week 4 0.116 0.620
Body pain index and VAS score (n = 38)
Week 1 0.603 0.001
Week 4 0.908 0.001

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Authors’ contributions Y. Tanidir was involved in project develop-
ment, data collection, data analysis, manuscript writing and editing,

and supervision. N. Mangir performed data analysis, and manuscript
writing and editing. A. Sahan took part in data collection and data
analysis. M. Sulukaya carried out data collection.
Compliance with ethical standards
Conflict of interest The authors have no conflict of interest to declare.

Ethical standards This prospective study was conducted after receiv-
ing approval from the institutional review board.

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