Symptom scores in benign prostatic hyperplasia

Performance of the American Urological Association Symptom Index with and without an additional urge incontinence item

OBJECTIVE

To examine the value of adding an urge incontinence question to the American Urological Association Symptom Index (AUASI) among men in the Complementary and Alternative Medicine for Urological Symptoms (CAMUS) trial.

METHODS

The CAMUS study was a randomized trial of Saw palmetto fruit extract versus placebo among men aged ≥45 years with an AUASI score of ≥8 and ≤24. The baseline measurements included the AUASI, a question about urge incontinence (UI), the International Prostate Symptom Score quality of life question, and the Benign Prostatic Hyperplasia Impact Index. We correlated the items and scales and examined whether adding the UI question resulted in better prediction of disease-specific health status.

RESULTS

The mean age of the 369 men in the CAMUS trial was 61 years, and mean baseline AUASI score was 14.6. UI was reported infrequently; about 82% of the respondents answered the question "not at all" or "<1 time in 5." UI correlated significantly with all other AUASI items, except for weak stream; the strongest correlation was to urgency (R=0.51, P<.0001). The correlation between the AUASI score and the AUASI+UI score was 0.98 (P<.0001). In a logistic regression analysis predicting the International Prostate Symptom Score quality of life score, adding UI to the AUASI slightly increased the discriminating ability (c statistic increased from 0.77 to 0.78, P<.0001). Similarly, in a linear regression analysis predicting the Benign Prostatic Hyperplasia Impact Index score, adding UI to the AUASI slightly increased the predictive ability (R2 statistic increased from 0.22 to 0.26, P<.0001).

CONCLUSION

According to our analysis in the CAMUS trial population, the value of adding a UI question to the AUASI in terms of predicting bother seemed small at best.

Overlap of different urological symptom complexes in a racially and ethnically diverse, community-based population of men and women

OBJECTIVE

To define the prevalence and overlap of symptom patterns traditionally associated with benign prostatic hyperplasia, chronic prostatitis/chronic pelvic pain syndrome, interstitial cystitis/painful bladder syndrome, and incontinence among men and women in a racially and ethnically diverse, community-based population.

SUBJECTS AND METHODS

In all, 5506 men and women aged 30-79 years were recruited to participate in the Boston Area Community Health Survey, using a stratified-cluster sampling technique to obtain roughly similar representative samples by age group, gender and race/ethnicity (White, Black, Hispanic). Survey data were collected by bilingual interviewers in subjects' homes. Scales measuring symptom patterns were derived from validated instruments, with minor changes to eliminate different recall periods and overlap in items that might have confused subjects.

RESULTS

About a quarter of men and women of all ages met the definition for one or more of the target symptom patterns; there was no significant variation in the prevalence of any of the symptom patterns by race/ethnicity. Overall, approximately 16% of men and women had one symptom pattern, while 7% had overlap patterns. Except for urinary incontinence and interstitial cystitis/painful bladder syndrome in both men and women, the prevalence of all symptom complexes were associated with one another significantly more often that would be expected by chance.

CONCLUSIONS

Overlapping patterns of lower urinary tract symptoms and pelvic pain are common. These overlapping patterns present challenges for clinical practice and research, and require further investigation of their causes, diagnosis and optimum treatment.

Absence of Lower Urinary Tract Symptoms Is an Independent Predictor for Cancer at Prostate Biopsy, but Prostate-Specific Antigen Is Not: Results from a Prospective Series of 569 Patients

PURPOSE

Prostate needle biopsy (PNB) is the definitive method for the diagnosis of prostate cancer. Our objective was to evaluate prebiopsy parameters, including lower urinary tract symptoms, that may be predictive of positive biopsy.

PATIENTS AND METHODS

We performed a prospective review of 569 consecutive men who underwent transrectal ultrasound (TRUS)-guided PNB. The prebiopsy variables recorded included age, prostate-specific antigen (PSA) levels, prostate volume (PV), percent free PSA levels, suspicious digital rectal examination (DRE) findings, TRUS-detected lesions, race, and American Urologic Association Symptom Score (AUASS).

RESULTS

Low AUASS, PV, patient age, and abnormal TRUS findings were independent predictors of positive PNB results (P < 0.05). In patients with PSA levels between 4 and 10 ng/mL, the positive predictive value of a low AUASS (< 8) in predicting a positive PNB result is 68.7%. When race was considered (black vs. white), univariate analysis (UVA) indicated that race was a significant predictor (P = 0.034) of positive PNB. A subgroup analysis was performed for black men undergoing PNB (n = 256). Multivariate analysis (MVA) indicates that abnormal TRUS findings; low AUASS, PV, and PSA levels; and absence of prior biopsy are all independent predictors of PNB in the black patient group. A final subgroup analysis (UVA and MVA) was performed for white men (n = 310). Only patient age and PV demonstrated significance as independent predictors of PNBs in this group.

CONCLUSION

This prospective analysis of 569 men demonstrates that traditional indicators for PNB (abnormal DRE findings and PSA levels) are not significant predictors of prostate cancer. Independent predictors for prostate included age, low AUASS, low PV, and abnormal TRUS findings. A low AUASS (indicative of the absence of benign disease) is an important predictor of prostate cancer.

Low AUA symptom score independently predicts positive prostate needle biopsy: results from a racially diverse series of 411 patients

OBJECTIVES

To evaluate the prebiopsy parameters, including the American Urological Association symptom score (AUASS), that may be predictive of positive biopsy. Transrectal ultrasound (TRUS) biopsy of the prostate represents the reference standard in the diagnosis of prostate cancer.

METHODS

A total of 411 consecutive men undergoing TRUS biopsy were prospectively evaluated. The indications for biopsy were abnormal digital rectal examination (DRE) findings and/or an elevated prostate-specific antigen (PSA) level. A single surgeon (C.R.P.) examined all the men. DRE and TRUS were each given a level of suspicion between 1 (low suspicion--smooth DRE, homogeneous TRUS) and 5 (high suspicion--hard DRE, hypoechoic lesion). A level of suspicion of 3 or greater was considered abnormal. The prebiopsy parameters examined included PSA level, age, race, biopsy history, prostate volume, TRUS-detected lesion, and AUASS.

RESULTS

Of 411 men, 62% were African American and 38% were white. The mean PSA level was 11.6 ng/mL. The mean patient age was 65.3 years. Overall, 39% of men had abnormal DRE and 32% abnormal TRUS findings. The mean AUASS was 9.3. The positive biopsy rate was 40.8%. Univariate analysis demonstrated that age, PSA level, prostate volume, abnormal DRE findings, TRUS-detected lesion, and AUASS (less than 7, low) were all predictive of a positive biopsy (P <0.05). Race was not statistically significant (P = 0.38). Detailed analysis of the AUASS in the 411 men indicated that 41% had low symptom scores (less than 7), 32% had moderate scores (8 to 19), and 27% had severe scores (20 to 35). In the group of men with low symptom scores (n = 169), univariate analysis demonstrated that age, PSA level, prostate volume, and abnormal TRUS findings were all statistically significant predictors of positive biopsy (P <0.05). Multivariate analysis of the data from the 411 men demonstrated that age, PSA level, prostate volume, abnormal DRE findings, and low AUASS were all independent predictors of positive biopsy (P <0.05).

CONCLUSIONS

In this prospective study, the independent predictors of positive TRUS biopsy included age, PSA level, prostate volume, abnormal DRE findings, and low AUASS. A low AUASS may be an important variable to consider when counseling patients before biopsy and when designing patient algorithms for prostate biopsy.

Use of symptom questionnaires in the assessment and follow-up of men with benign prostatic disease

The assessment of lower urinary tract symptoms is an essential component of the evaluation of men with benign prostatic disease in clinical practice and research. Symptom evaluation is necessary for the formal evaluation of the effectiveness of treatments in randomized controlled trials and in the assessment of outcome in individuals, and can also be useful in determining the numbers of individuals in the community who might potentially require or benefit most from treatment. Increasingly, symptom assessments are being undertaken using a small number of questionnaires that are self-completed by patients and have been tested for validity and reliability.

Office evaluation of men with lower urinary tract symptoms

In the past decade, the symptom score has been considered the essential part of the evaluation of patients with lower urinary tract symptoms (LUTS). At the University of Wisconsin, the author's have stopped routine use of symptom scores because of their limited utility in dealing with the patient's concerns. Except from men electing invasive treatment, the authors do not serve the patients better with urodynamic testing either. Bothersomeness, not symptom score or objective measures is what drives the decision making process in benign prostatic hyperplasia (BPH) management. Generally, the authors now select patients for treatment according to the degree to which they are bothered by their LUTS.

Quality of life in geriatric patients with lower urinary tract dysfunction

Lower urinary tract dysfunctions, such as urinary incontinence, detrusor instability, and benign prostatic hyperplasia, are prevalent in older adults. These conditions, which can occur alone or in combination, result in irritative or obstructive symptoms that can interfere with everyday functioning, leading to negative consequences on health-related quality of life. The nature and severity of these symptoms and the perception of their impact on daily activities can be quite variable. Until recently, relatively little was known about the effect of lower urinary tract dysfunctions on general health status and quality of life. An increasing research base is now available that shows the impact of different urologic dysfunctions in clinical and general populations. This article will provide a brief background on the definition and measurement of health-related quality of life and will summarize the literature about the quality of life of community-dwelling elderly patients with urinary incontinence or prostate conditions. Implications to guide clinical practice and future research will be derived.