The future magnitude of urological symptoms in the USA: projections using the Boston Area Community Health survey

What is the predictive value of urodynamics to reproduce clinical findings of urinary frequency, urge urinary incontinence, and/or stress urinary incontinence?

INTRODUCTION AND HYPOTHESIS

The aim of this study was to determine the predictive value of urodynamics to reproduce clinical findings of urinary frequency (UF), urge urinary incontinence (UUI), and/or stress urinary incontinence (SUI).

METHODS

We retrospectively reviewed the data of patients diagnosed with UF, UUI, and/or SUI and subsequently underwent urodynamics. Urodynamic findings were correlated with clinical findings to determine the predictive value of urodynamics.

RESULTS

A total of 537 patients (366 females and 171 males) met study criteria. Two hundred seventy-eight patients had symptoms of UUI; 59% demonstrated detrusor overactivity on urodynamics. Three hundred eight patients had SUI on history and physical examination; 45% had urodynamic stress incontinence. A low maximum cystometric capacity (<200 ml) was not significantly associated with urinary frequency (p = 0.4).

CONCLUSIONS

Urodynamics has a low predictive value to reproduce clinical findings of UF, UUI, and/or SUI. Many patients with evidence of UF, UUI, and/or SUI on history and/or physical examination do not demonstrate supporting urodynamic evidence.

Redesigning a large-scale clinical trial in response to negative external trial results: the CAMUS study of phytotherapy for benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH), a common condition among older men, confers its morbidity through potentially bothersome lower urinary tract symptoms. Treatments for BPH include drugs such as alpha-adrenergic receptor blockers and 5-alpha reductase inhibitors, minimally invasive therapies that use heat to damage or destroy prostate tissue, and surgery including transurethral resection of the prostate. Complementary and alternative medicines are gaining popularity in the US. Two phytotherapies commonly used for BPH are extracts of the fruit of Serenoa repens, the Saw palmetto dwarf palm that grows in the Southeastern US, and extracts of the bark of Pygeum africanum, the African plum tree.

PURPOSE

The objective of the Complementary and Alternative Medicines for Urological Symptoms (CAMUS) clinical trial is to determine if phytotherapy is superior to placebo in the treatment of BPH.

METHODS

CAMUS was originally designed as a 3300-participant, four-arm trial of S. repens, P. africanum, an alpha-adrenergic blocking drug, and placebo with time to clinical progression of BPH, a measure of long-term efficacy, as the primary endpoint. Before enrollment started, a randomized, double-blind, placebo-controlled, single institution clinical trial showed that S. repens at the usual dose did not demonstrate any benefit over placebo with respect to symptom relief at 1 year. Consequently, the focus of CAMUS shifted from evaluating long-term efficacy to determining if any short-term (6-18 months) symptom relief could be achieved with increasing doses of S. repens, the phytotherapy most commonly used in the US for BPH.

RESULTS

Results are anticipated in 2011.

CONCLUSIONS

Trial design occurs in an environment of continually evolving information. In this case, emerging results from another trial suggested that a study of long-term efficacy was premature, and that an effective dose and preparation of S. repens had to be established before proceeding to a long-term clinical trial.

Drug treatment of urological symptoms: estimating the magnitude of unmet need in a community-based sample

OBJECTIVE

To examine, in a community-based sample, the use of prescription drugs for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH), overactive bladder, erectile dysfunction, urinary incontinence, and painful bladder syndrome; and to determine whether the use of recommended medications varied by sociodemographics, symptom severity, access to care, and other factors.

SUBJECTS AND METHODS

In a cross-sectional analysis of data obtained from 5503 men and women residents participating in the Boston Area Community Health Survey of Boston, MA, urological symptoms were ascertained by in-person interviews conducted during 2002-2005, using validated symptom scales. Medication use in the past 4 weeks was captured using a combination of drug-inventory methods and self-report.

RESULTS

Compared to the prevalence of symptoms, the prevalence of use of medications for urological conditions was very low among men and women. The highest prevalence of use was among men with moderate-to-severe LUTS/BPH symptoms, where 9.6% used recommended drugs. Use of medications did not vary consistently by race/ethnicity or socioeconomic status, but was often associated with symptom severity. More frequent and more recent use of medical care was also associated with greater use of urological medications.

CONCLUSIONS

Only a small proportion of community-dwelling men and women with urological symptoms are receiving recommended effective drug treatments for urological conditions. While not all persons are candidates for drug treatment, our results suggest that there is a substantial unmet need in the general population.

Gender and age differences in the perception of bother and health care seeking for lower urinary tract symptoms: results from the hospitalised and outpatients' profile and expectations study

BACKGROUND

Few comparisons have been made of health care seeking behaviour for lower urinary tract symptoms (LUTS) between men and women, as well as trends across age groups.

OBJECTIVE

To investigate the bother from LUTS and effect on health care seeking in both men and women of different age groups and in comparison between the two genders.

DESIGN, SETTING, AND PARTICIPANTS

A representative cross section of each of 13 clinics of a general academic hospital, with equal numbers of subjects recruited in each of six design cells that were defined by age (18-40, 41-60, 61-80 yr) and gender.

INTERVENTION

A 2-h in-person interview, conducted by a trained psychologist/interviewer in a clinic office.

MEASUREMENTS

Severity of LUTS was measured by the International Prostate Symptom Score (IPSS). Treatment seeking was measured by a single item. A bother question was modified to assess overall bother. Impact on quality of life (QoL) was measured by the IPSS QoL question.

RESULTS AND LIMITATIONS

The final study sample comprised 415 patients. More women than men reported the presence of LUTS (85.5% vs 75.2%; p=0.01). LUTS were more bothersome in women (25.4% of women vs 17.6% of men with bother "some" or "a lot"; p=0.02). Severity of LUTS increased with age in both genders (men: p<0.001; women: p=0.03). Bother from LUTS increased as severity of symptoms increased in both genders (p<0.001) but was associated with age only in men (p<0.001). QoL showed similar results as bother. Although men and women had equal prevalence of treatment seeking (27.9% vs 23.7%; p=0.40), men, but not women, were more likely to seek treatment as age (p<0.01) and severity of LUTS (p<0.001) increased. In multivariate logistic regressions, only bother from LUTS was associated with treatment seeking in women, compared with bother, age, and the presence of voiding symptoms in men.

CONCLUSIONS

In our hospital-based sample, differences in LUTS frequency, bother, and health care seeking profiles between men and women suggest a different perception and response to LUTS between the two genders.

Urological symptom clusters and health-related quality-of-life: results from the Boston Area Community Health Survey

OBJECTIVE To determine whether urological symptom clusters, as identified in previous studies, were associated with health-related quality-of-life (HRQoL) and use of healthcare. SUBJECTS AND METHODS The Boston Area Community Health Survey is a population-based epidemiological study of 2301 male and 3201 female residents of Boston, MA, USA, aged 30-79 years. Baseline data collected from 2002 to 2005 were used in this analysis. Data on 14 urological symptoms were used for the cluster analysis, and five derived symptom clusters among men and four among women were used in multivariate linear regression models (adjusted for age group, race/ethnicity, and comorbidity) to determine their association with physical (PCS-12) and mental health component scores (MCS-12) calculated from the Medical Outcomes Study 12-item Short Form Survey. RESULTS For both men and women, being in the most symptomatic cluster was associated with decrements in the PCS-12 score (men, cluster 5, -10.42; women, cluster 4, -9.80; both P < 0.001) and the MCS-12 score (men, cluster 5, -9.35; women, cluster 4, -6.24; both P < 0.001) compared with the asymptomatic groups. Both men and women in these most symptomatic clusters appeared to have adequate access to healthcare. CONCLUSION For men and women, those with the most urological symptoms reported poorer HRQoL in two domains after adjusting for age and comorbidity, and despite adequate access to care.

Differences in lower urinary tract symptoms, treatment and mortality among African-American and white elderly men

BACKGROUND

There are limited population-based studies of benign prostate hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in men, and most studies examined to date have been restricted to predominately white populations. This study examines treatment and all-cause mortality among a cohort of African-American and white men aged > or =65 with BPH/LUTS symptoms over time.

METHODS

Data were collected from the Piedmont Health Survey of the Elderly-Established Populations for the Epidemiological Study of the Elderly for 5 North Carolina counties from 1994 (N=502) to 1998 (N=322).

RESULTS

From 1994-1998, there were no significant racial differences in treatment by catheter insertion, prostate surgery or drug therapy for BPH/LUTS. However, overall use of the 3 treatments increased from 1994-1998, with drug therapy showing the largest increase. Adjusted analyses revealed racial differences in prostate surgery only, with African-American men nearly 40% more likely to receive prostate surgery than white men. Men with comorbid conditions were less likely to receive drug therapy, whereas those with poor self-reported health or cancer were more likely to receive prostate surgery. Catheter insertion was more likely for those who had resided in a nursing home. Men who received drug therapy treatment or had regular rectal exams showed decreased risk of mortality.

CONCLUSION

Findings suggest that healthcare providers should direct more attention to the management of LUTS in white and African-American elderly men. Data also demon-strate the need for studies that focus on treatment modalities as well as important correlates of LUTS.

The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study

OBJECTIVES

To examine the effect overactive bladder (OAB) and other lower urinary tract symptoms (LUTS) on health-related quality of life (HRQoL) in a population sample, as OAB often occurs in conjunction with many other LUTS.

SUBJECTS AND METHODS

A nested case-control analysis was performed on men and women with (cases) and without (controls) OAB, from the EPIC study. OAB was assessed using 2002 International Continence Society definitions. Based on their responses to questions about LUTS, cases were classified into five groups; continent OAB, OAB with incontinence, OAB + postmicturition, OAB + voiding, and OAB + postmicturition + voiding. Both cases and controls were asked questions about symptom bother (OAB-q), generic QoL (EQ-5D), work productivity (Work Productivity and Activity Impairment, WPAI), depressive symptoms (Center for Epidemiologic Studies Depression Scale), sexual satisfaction, and erectile dysfunction (men only) using the Massachusetts Male Aging Study. Cases answered additional condition-specific questions HRQoL (OAB-q short form), Patient Perception of Bladder Condition and work productivity related to a specific health problem (WPAI-SHP). General linear models were used to evaluate group differences.

RESULTS

Of the EPIC participants, 1434 identified OAB cases were matched by age, gender and country, with 1434 participants designated as controls. Cases and controls were primarily Caucasian (96.2% and 96.7%, respectively), and most (65%) were female; the mean age was 53.8 and 53.7 years, respectively. Comorbid conditions differed significantly by case/control status, with cases reporting significantly greater rates of chronic constipation, asthma, diabetes, high blood pressure, bladder or prostate cancer, neurological conditions and depression. There were significant differences between the cases and controls in all reported LUTS. The OAB + postmicturition + voiding group reported significantly greater symptom bother, worse HRQoL, higher rates of depression and decreased enjoyment of sexual activity, than the other subgroups.

CONCLUSION

OAB has a substantial, multidimensional impact on patients; OAB with additional LUTS has a greater impact. The diagnosis and treatment of OAB should be considered in conjunction with other LUTS, to maximize treatment options and optimize patient outcomes.

Do urological symptoms cluster among women? Results from the Boston Area Community Health Survey

OBJECTIVES

To conduct a cluster analysis of urological symptoms among women in the Boston Area Community Health (BACH) Survey, to describe the distribution of urological symptoms within each cluster, and to determine whether comorbidities, demographic characteristics, and lifestyle factors were associated with cluster membership.

SUBJECTS AND METHODS

The BACH Survey is a racially and ethnically diverse random sample (3205 women) of community-dwelling residents of Boston, MA, USA, aged 30-79 years. Fourteen urological symptoms measured by participant self-report (using previously validated scales) were included in this analysis. Cluster analyses were conducted using hierarchical and non-hierarchical (k-means) methods. Within clusters, demographic characteristics, risk factors for urological symptoms and the interference of symptoms with daily activities were also assessed.

RESULTS

Three-quarters of the sample reported at least one urological symptom; four symptom clusters were identified. Most symptomatic women (54%) were assigned to Cluster 1, which was characterized by storage symptoms (nocturia and urinary frequency) with an accompanying low prevalence of other urological symptoms; a second cluster was distinguished by frequency symptoms. Clusters 3 and 4 were characterized by a high prevalence of urinary incontinence and had increased interference scores and more symptoms overall (including voiding and post-voiding symptoms) than the other two clusters. Cluster 4 (8% of symptomatic women) was characterized by a high prevalence of nearly all urological symptoms and the highest interference score. In this most symptomatic cluster, body size and waist circumference were markedly higher, as was the prevalence of diabetes, hypertension and cardiovascular disease than in the other cluster groups or asymptomatic women. Women in Cluster 4 were more likely to be surgically menopausal, or to have had other forms of urogynaecological surgeries than women in the other clusters.

CONCLUSION

Four distinct clusters of urological symptoms were identified among symptomatic women in the BACH Survey, two of which had a high prevalence of urinary incontinence. These cluster patterns provide a novel, empirically-based framework for investigating aetiological mechanisms and management outcomes for common urological symptoms in women.

Cluster analysis and lower urinary tract symptoms in men: findings from the Boston Area Community Health Survey

OBJECTIVES

To classify lower urinary tract symptoms (LUTS) in a large, representative sample of men in the USA by means of cluster analysis and to investigate risk factors and comorbidities associated with the resulting cluster patterns.

SUBJECTS AND METHODS

A combination of hierarchical and non-hierarchical cluster methods was used to assign men with LUTS in the Boston Area Community Health (BACH) study to symptom-based categories or clusters. Of the 2301 men in the BACH study, those reporting one or more of 14 common LUTS (1592 men) were included in the analysis. The prevalence and frequency of symptoms in each cluster was assessed, in addition to the demographic, lifestyle risk factors, comorbidities, quality of life, and interference with activities of daily living associated with each cluster. We used anova methods for assessing cluster effects on continuous variables, and cross-classification and chi-square tests for categorical measures. Internal validity of the cluster solution was tested by means of a split-half replication, and external validity by comparison with previously published data.

RESULTS

Five clusters were identified among symptomatic men. About half of the symptomatic men were assigned to Cluster 1, which included individuals with a low prevalence and frequency of urological symptoms and a correspondingly low level of interference with activities of daily living. There were intermediate levels of symptom frequency and prevalence in Clusters 2-4, which were characterized by mixed patterns of voiding, storage and postvoiding symptoms. Cluster 5 consisted of predominantly older men (mean age 58.9 years), with a high prevalence and frequency of urological symptoms with a mean (SD) number of symptoms of 9.9 (2.1), and with elevated levels of comorbid cardiovascular disease (P < 0.001). These men also had higher rates of kidney and bladder infections and previous urological surgery. Men with increased waist circumference and more sedentary lifestyles were over-represented in the more symptomatic clusters.

CONCLUSION

Cluster analysis provides an empirically based method for categorizing men with LUTS. These findings provide a new framework for examining aetiological pathways and mechanisms, the potential impact of and consequences for comorbid conditions, and for assessing prognosis and outcomes associated with common urological disorders.