Benign prostatic hyperplasia and its treatment

Do weather parameters affect emergency room visits due to acute urinary retention?

Objective:

This study aimed to describe the effects of the various climate parameters on emergency room (ER) visits due to acute urinary retention (AUR).

Patients and methods:

This was a single-center retrospective analysis of the ER data of visits due to AUR in males and females between 2010 and 2017. We incorporated ER registries with data from the national meteorological service. Using multivariable logistic regression analyses, we assessed associations between climate parameters and the incidence of AUR.

Results:

A total of 1917 patients were admitted to the ER due to AUR during the study period, of whom 1706 (89%) were males and211 (11%) were females. Most AURs occurred in patients >70 years of age, with males on average being older than women (72.8 vs. 70.1 years old, p=0.01). Multivariable logistic regression analyses demonstrated that females had more AURs than men (odds ratio (OR)=1.3, 95% confidence interval (CI) 1.1–1.9, p=0.04) in spring. In all seasons except winter, a higher maximal temperature was associated with an increased risk of AUR, while in winter, a lower temperature was associated with an increased risk (OR=0.654, 95% CI 0.602–0.711, p<0.0001). Additionally, the following were associated with an increased AUR risk: increased wind speed and lower heat index during the spring, increased precipitation and a lower heat index during the autumn, and a higher heat index in the winter.

Conclusions:

Our data suggest that weather parameters might be associated with an increased AUR incidence in a Mediterranean coastline area, with maximal ambient temperature, wind speed, heat index, and precipitation playing a potential role.

Level of evidence:

6.

Prevalence of combined fecal and urinary incontinence: a community-based study

OBJECTIVE

To assess the prevalence of combined fecal and urinary incontinence.

DESIGN

A cross-sectional, community-based study.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

Men (n = 778) and women (n = 762), aged 50 years or older, selected randomly from the population.

MEASUREMENTS

Participants completed a previously validated self-administered questionnaire that assessed the occurrence of fecal and urinary incontinence in the previous year.

RESULTS

The age-adjusted prevalence of incontinence was 11.1% (95% Confidence Interval (CI), 8.8-13.5) in men and 15.2% (95% CI, 12.5-17.9) in women for fecal incontinence; 25.6% (95% CI, 22.5-28.8) in men and 48.4% (95% CI, 44.7-52.2) in women for urinary incontinence; and 5.9% (95% CI, 4.1-7.6) in men and 9.4% (95% CI, 7.1-11.6) in women for combined urinary and fecal incontinence. The prevalence of fecal incontinence increased with age in men but not in women, from 8.4% among men in their fifties to 18.2% among men in their eighties (P for trend = .001). For women, the prevalence increased from 13.1% among 50-year-old women to 20.7% among women 80 years or older (P for trend = .5). Among persons with fecal incontinence, the prevalence of concurrent urinary incontinence was 51.1% among men and 59.6% among women (P = .001 and P = .003, respectively). Cross-sectionally, the age-adjusted, relative odds of fecal incontinence among persons with urinary incontinence was greater in men than in women (Odds Ratio (OR) = 3.0; 95% CI, 1.9-4.8 in men and OR = 1.8; 95% CI, 1.2-2.7 in women, P = .04).

CONCLUSIONS

These findings suggest that persons with one form of incontinence are likely to have the other form as well. Despite the higher prevalence of urinary and fecal incontinence among women, the association between fecal incontinence and urinary incontinence was stronger among men than women. This finding, and the significant association between fecal incontinence and age observed in men but not in women, suggest that the etiologies may be more closely linked in men than in women.

Natural history and epidemiology of benign prostatic hyperplasia: relationship among urologic measures

Numerically weak correlations can stem from research studies for numerous reasons, some of which have little to do with lack of true physiologic relationships. Previous investigators have reported relatively weak correlations among urologic measures, mostly based on patients referred to urologic clinics. Such samples of patients may be prone to self-selection or referral bias. Men seeking medical care for urinary symptoms are more likely to have more severe symptoms, low urinary flow rates, and prostatic enlargement, and hence clinic-based samples may reflect a narrow spectrum in urologic measures, resulting in attenuated correlation coefficients. Measurement error in the technique or equipment, lack of specificity, and within-patient variability can also attenuate correlations. Thus, the characteristics of the sample upon which correlations are calculated must be considered in the interpretation of the magnitude of relationships among measurements. Possibly due to the broader spectrum, community-based studies have recently found modest but somewhat stronger relationships among urologic measures than previously documented. Such correlations are comparable to those found in other disease areas. In addition, such studies have documented that symptoms, urinary flow rate, and prostatic enlargement are predictive of long-term complications, such as acute urinary retention, with predictive relationships comparable to those found in other disease areas. Thus, the relationships among and predictive ability of urologic measures may be stronger than currently appreciated.

Health-related quality of life associated with lower urinary tract symptoms in four countries

OBJECTIVES

To describe health-related quality of life (HRQL) associated with lower urinary tract symptoms (LUTS) assessed by validated questionnaires in four countries.

METHODS

More than 6000 men, recruited by using community- or population-based sampling in four countries, completed questionnaires soliciting information about urinary symptom frequency, bother, degree of interference with daily activities, and other measures of HRQL.

RESULTS

In all countries, disease-specific HRQL worsened with increasing age. Adjusting for age, most disease-specific HRQL measures were significantly worse with increasing symptom severity. The correlation between symptoms and HRQL was strongest in countries with higher prevalence of symptoms, such as Japan or the United States, and less pronounced in countries with lower prevalence (France, Scotland), possibly reflecting the lower variability in scores.

CONCLUSIONS

HRQL measures are worse in older men, and increased urinary symptom severity is associated with worse disease-specific HRQL in all countries, despite potential cross-cultural differences in disease prevalence, medication use, perceptions, or willingness to report symptoms or worse HRQL. This cross-cultural consistency suggests that an assessment of symptom bother or interference with daily activities may be useful in patient evaluation.

Natural history of prostatism: risk factors for acute urinary retention

PURPOSE

We determined the occurrence of and risk factors for acute urinary retention in the community setting.

MATERIALS AND METHODS

A cohort of 2,115 men 40 to 79 years old was randomly selected from an enumeration of the Olmsted County, Minnesota population (55% response rate). Participants completed a previously validated baseline questionnaire that assessed symptom severity, and voided into a portable urometer to measure peak urinary flow rates. A 25% random subsample underwent transrectal sonographic imaging of the prostate to determine prostate volume. Followup was performed through a retrospective review of community medical records to determine the occurrence of acute urinary retention in the subsequent 4 years.

RESULTS

During the 8,344 person-years of followup 57 men had a first episode of acute urinary retention (incidence 6.8/1,000 person-years, 95% confidence interval [CI] 5.2, 8.9). Among men with no to mild symptoms (American Urological Association symptom index score 7 or less) the incidence of acute urinary retention increased from 2.6/1,000 person-years among men 40 to 49 years old to 9.3/1,000 person-years among men 70 to 79 years old. By contrast, rates increased from 3.0/1,000 person-years for men 40 to 49 years old to 34.7/1,000 person-years among men 70 to 79 years old among men with moderate to severe symptoms (American Urological Association symptom index score greater than 7). Men with depressed peak urinary flow rate (less than 12 ml. per second) were at 4 times the risk of acute urinary retention compared with men with urinary flow rates greater than 12 ml. per second (95% CI 2.3, 6.6). Men with an enlarged prostate (greater than 30 ml.) experienced a 3-fold increase in risk (95% CI 1.0, 9.0, p = 0.04).

CONCLUSIONS

Lower urinary tract symptoms, depressed peak urinary flow rates, enlarged prostates and older age are associated with an increased risk of acute urinary retention in community dwelling men. These findings may help to identify men at increased risk of acute urinary retention in whom closer evaluation may be warranted.

Adverse effects of medications on urinary symptoms and flow rate: a community-based study

The relationship between urinary symptoms and medication use was investigated in a community-based cross-sectional study involving a random sample of 2115 men 40-79 years of age in Olmsted County, Minnesota. The American Urological Association Symptom Index (AUASI) was generated from a validated self-administered questionnaire. Medication use was assessed by in-person interviews. While 1087 men reported daily medication use, only 136 reported daily use of medications known to affect urinary function adversely, including antidepressants (42), antihistamines (23), and bronchodilators (43). Age-adjusted AUASI scores were higher in men reporting daily use of antidepressants, and the association persisted after additionally adjusting for the Depression and Anxiety subscales of the General Psychological Well-Being Scale (adjusted mean difference, 2.1; 95% confidence interval (CI), 0.5-3.6; p = 0.008). The adjusted AUASI was also higher among men who took antihistamines daily (adjusted mean difference, 2.3; 95% CI, 0.3-4.3; p = 0.03). Lower age-adjusted urinary flow rates occurred with antidepressants, but not with antihistamines or bronchodilators. Clinicians evaluating men for causes of voiding dysfunction in accordance with the Agency for Health Care Policy and Research practice guideline for the diagnosis and management of benign prostatic hyperplasia should be aware that daily use of antidepressants or antihistamines may be associated with AUASI scores that are two to three points higher than in men not taking these medications.

Natural history of prostatism: relationship among symptoms, prostate volume and peak urinary flow rate

We describe relationships among symptoms, prostate volume and peak urinary flow rate in an age stratified, community based random sample of white men 40 to 79 years old with no prior prostate surgery, prostate cancer or other conditions known to interfere with voiding. Symptoms were assessed with an instrument comparable to the American Urological Association symptom index. Prostate volume was estimated by transrectal ultrasonography and peak urinary flow rate was measured by a portable device. Subject age was significantly associated with symptom score but accounted for only 3% of its variation, while prostate volume and peak urinary flow rate explained only an additional 10% of the symptom variability. The odds (95% confidence interval) of moderate to severe symptoms increased with age from 1.9 (1.1 to 3.1), 2.9 (1.7 to 5.0) and 3.4 (1.8 to 6.1) for men 50 to 59, 60 to 69 and 70 to 79 years old, respectively, relative to men 40 to 49 years old. Adjusting for age, the odds of moderate to severe symptoms were 3.5 times greater for men with prostatic enlargement (more than 50 ml.) than for men with smaller prostates, while the odds were similarly increased (2.4-fold) for men not achieving a peak urinary flow rate of 10 ml. per second. Estimated odds changed little when other cutoff points were considered for peak urinary flow rate (15 ml. per second) or prostate volume (40 ml.). These results, based on randomly selected white men, suggest a somewhat stronger, albeit modest, relationship among symptoms, prostate size and urinary flow rate than previously reported in clinic based studies. The strength of these relationships is comparable to that found with other diseases.

Natural history of prostatism: impact of urinary symptoms on quality of life in 2115 randomly selected community men

OBJECTIVES

To assess the impact of urinary symptoms on health-related quality of life (QoL), including degree of bother, worry, interference with daily activities, psychological well-being, sexual function, and general health in a community-based cohort of men.

METHODS

Eligible white men (n = 2115) aged 40 to 79 years who had not undergone previous prostate surgery or had prostate cancer were randomly selected from county residents. These subjects completed a questionnaire, which asked them about frequency and bother of urinary symptoms, interference with daily activities, psychological well-being, worry about urologic disease, sexual functioning, and general health.

RESULTS

Men with moderate to severe voiding symptoms reported, on average, four to six times the degree of bother and interference with daily activities and twice the level of worry of men with mild symptoms. Nearly five times the degree of bother and interference was reported for those with mild than with no symptoms. A higher percentage of men with moderate to severe symptoms (26% to 33%) than mild symptoms (< 8%) reported limiting fluids before bed, travel, or driving 2 hours. Receiver operating characteristic curves support the recommended symptom index cutpoint for moderate symptoms (= 8) by differentiating men with and without bother, interference with daily living, or dissatisfaction with urinary condition.

CONCLUSIONS

Moderate to severe urinary symptoms have a significant impact on men's lives in terms of degree of bother, worry, interference with daily living, and psychological well-being. The recommended cutpoint on symptom index differentiates men with and without decrement in health-related quality of life.

Cigarette smoking and prostatism: a biphasic association?

OBJECTIVE

To evaluate the association between cigarette smoking and prostatism in a community-based setting using standardized urinary symptom scores, peak urinary flow rates, and prostatic volume as indicators of disease.

METHODS

A population-based cohort of 2,115 Caucasian men aged forty to seventy-nine years from Olmsted County, Minnesota, was administered a previously validated questionnaire that elicited information on frequency of urinary symptoms (approximating the American Urological Association's symptom index), and a detailed history on cigarette smoking, including both amount and pack-years of smoking. Peak urinary flow rates were measured by a standard uroflowmeter (Dantec 1000). The prostatic volume was measured for a subsample of 471 men by transrectal ultrasound.

RESULTS

Compared to never-smokers, smokers were less likely to have moderate to severe urinary symptoms (age-adjusted odds ratio 0.82; 95% confidence interval [CI] 0.61 to 1.08). This varied by smoking intensity, however; in men who smoked less than 1 pack a day the age-adjusted odds ratio was 0.53 (95% CI 0.33 to 0.83) and among men smoking 1 to 1.4 packs a day, the odds ratio was 0.87 (95% CI 0.56 to 1.36). For men who smoked 1.5 packs or more a day, the odds ratio was elevated at 1.32 (95% CI 0.84 to 2.07). Smokers were less likely to have peak flow rates less than 15 mL/sec compared with never-smokers (age- and voided volume-adjusted odds ratio 0.48; 95% CI 0.35 to 0.66), or prostatic volume greater than 40 mL (odds ratio 0.54; 95% CI 0.19 to 1.55).

CONCLUSIONS

These data from a community-based sample suggest that light or moderate smokers are less likely to have moderate to severe prostatism, whereas heavy smokers are at least as likely to have moderate to severe prostatism compared with never-smokers.

LY191704: a selective, nonsteroidal inhibitor of human steroid 5 alpha-reductase type 1

Androgens, in particular dihydrotestosterone (DHT), play a key role in differentiation, growth, and maintenance of the mammalian prostate. Production of DHT from testosterone is catalyzed by two distinct membrane-bound steroid 5 alpha-reductase [5 alpha-reductase; 3-oxo-5 alpha-steroid delta 4-dehydrogenase; 3-oxo-5 alpha-steroid:(acceptor) delta 4-oxidoreductase, EC 1.3.99.5] isozymes designated types 1 and 2. Benign prostatic hyperplasia (BPH), a disease that occurs almost universally in males, is characterized by obstructive and irritative urinary voiding symptoms and has been associated with an overproduction of DHT. Recently, steroidal inhibitors of 5 alpha-reductase type 2 have been used successfully for treatment of BPH. Described here is a nonsteroidal inhibitor of 5 alpha-reductase type 1, LY191704 (8-chloro-4-methyl-1,2,3,4,4a,5,6,10b-octaahydro-benzo[f]quinol in-3(2H)-one). This compound was identified based on its capacity to inhibit 5 alpha-reductase activity in a human genital skin fibroblast cell line (Hs68). Surprisingly, LY191704 is inactive when tested in freshly isolated prostate cells obtained from subjects with BPH, whereas previously described 4-azasteroids are active. LY191704 is, however, a potent inhibitor of the 5 alpha-reductase activity of BPH cells that have been maintained in culture. Analysis of human and rat 5 alpha-reductases expressed from transfected cDNAs in simian COS cells indicates that LY191704 is a specific noncompetitive inhibitor of the human 5 alpha-reductase type 1. Taken together, the results suggest that prostate cells have the capacity to express both 5 alpha-reductase isozymes and that LY191704 may be useful in treatment of human endocrine disorders associated with overproduction of DHT by 5 alpha-reductase type 1.