Metabolic syndrome and smoking are associated with an increased risk of nocturia in male patients with benign prostatic enlargement

Link between circadian rhythm and benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS)

BACKGROUND

Benign prostatic hyperplasia (BPH) is the most common urologic disease in aging males, affecting 50% of men over 50 and up to 80% of men over 80 years old. Its negative impact on health-related quality of life implores further investigation into its risk factors and strategies for effective management. Although the exact molecular mechanisms underlying pathophysiological onset of BPH are poorly defined, the current hypothesized contributors to BPH and lower urinary tract symptoms (LUTS) include aging, inflammation, metabolic syndrome, and hormonal changes. These processes are indirectly influenced by circadian rhythm disruption. In this article, we review the recent evidence on the potential association of light changes/circadian rhythm disruption and the onset of BPH and impact on treatment.

METHODS

A narrative literature review was conducted using PubMed and Google Scholar to identify supporting evidence. The articles referenced ranged from 1975 to 2023.

RESULTS

A clear relationship between BPH/LUTS and circadian rhythm disruption is yet to be established. However, common mediators influence both diseases, including proinflammatory states, metabolic syndrome, and hormonal regulation that can be asserted to circadian disruption. Some studies have identified a possible relationship between general LUTS and sleep disturbance, but little research has been done on the medical management of these diseases and how circadian rhythm disruption further affects treatment outcomes.

CONCLUSIONS

There is evidence to implicate a relationship between BPH/LUTS and circadian rhythm disruptions. However, there is scarce literature on potential specific link in medical management of the disease and treatment outcomes with circadian rhythm disruption. Further study is warranted to provide BPH patients with insights into circadian rhythm directed appropriate interventions.

Sleep-related disorders and lower urinary tract symptoms in middle-aged and elderly males: a cross-sectional study based on NHANES 2005-2008

PURPOSE

Lower urinary tract symptoms (LUTS) and sleep disorders both commonly affect people's quality of life. This study aimed to explore the associations between sleep-related disorders and LUTS through epidemiological investigations.

METHODS

Data were generated from the cross-sectional study called the National Health and Nutrition Examination Survey (NHANES) 2005-2008. Multivariable logistic regression models were conducted to investigate the relationships between sleep-related disorders and LUTS.

RESULTS

A total of 2516 men were included in the study. Participants sleeping ≤ 6 h/night had higher odds ratios of LUTS (OR: 1.38; 95% CI 1.08, 1.77), daytime LUTS (OR: 1.26; 95% CI 1.03, 1.54), and nocturia (OR: 1.23; 95% CI 1.02, 1.49) than those sleeping 7-8 h/night. Participants who required > 30 min to fall asleep had an approximately 39% higher odds ratios of nocturia than those who fell asleep within 6 to 30 min (OR: 1.39; 95% CI 1.12, 1.73). Sleep problems were positively related to LUTS (OR: 1.42; 95% CI 1.11, 1.82), daytime LUTS (OR: 1.32; 95% CI 1.08, 1.61), urinary hesitancy (OR: 1.75; 95% CI 1.31, 2.34), and nocturia (OR: 1.52; 95% CI 1.26, 1.84). Obstructive sleep apnea (OSA) symptoms were positively associated with urinary incontinence (OR: 1.52; 95% CI 1.12, 2.08). In addition, participants with daytime sleepiness were at higher prevalence of LUTS (OR: 1.66; 95% CI 1.29, 2.15), daytime LUTS (OR: 1.44; 95% CI 1.16, 1.78), urinary hesitancy (OR: 1.95; 95% CI 1.45, 2.63), and nocturia (OR: 1.66; 95% CI 1.35, 2.05).

CONCLUSION

The findings suggested that sleep-related disorders were associated with LUTS, daytime LUTS, urinary hesitancy, incomplete emptying, urinary incontinence, and nocturia in middle-aged and elderly males.

Age and metabolic syndrome are associated with unsatisfactory improvement in nocturia after holmium laser enucleation of the prostate

Objective

To investigate the association between age, metabolic syndrome (MetS) and improvement in nocturia in patients with benign prostate hyperplasia (BPH) receiving holmium laser enucleation of the prostate (HoLEP).

Methods

The retrospective study was conducted on patients treated for BPH using HoLEP between January 2021 and May 2022. Lower urinary tract symptoms (LUTS) were measured before surgery and at 3 months postoperatively using the International Prostate Symptom Score (IPSS). The criteria of the Adult Treatment Panel III (ATP III) were adopted to diagnose the MetS. Unsatisfactory improvement in nocturia was defined as <50% reduction in nocturia from baseline on the IPSS.

Results

One hundred and seventy-five patients were eventually enrolled, with a median age of 69 years (IQR: 63/73). Unsatisfactory improvement in nocturia was reported in 95 patients (54%) after HoLEP. These patients were older (73; IQR: 67/79 vs. 66; IQR: 60/71, P < 0.001) and more likely to present with higher postoperative total (6; IQR: 4/9 vs. 3; IQR:2/5, P < 0.001), voiding (1; IQR: 0/3 vs. 1; IQR: 0/2, P = 0.017), and storage (4; IQR: 3/6 vs. 2; IQR: 1/4, P < 0.001) IPSS when compared to patients with satisfactory improvement in nocturia. Overall, 63 of 175 (36%) patients were diagnosed with MetS and of these, 44 (70%) reported unsatisfactory improvement in nocturia (P = 0.002) after HoLEP. Multivariate analysis revealed that age (OR = 1.117, 95% CI: 1.068-1.169, P < 0.001) and MetS (OR = 3.613, 95% CI: 1.727-7.562, P = 0.001) were independent risk factors for unsatisfactory improvement in nocturia after HoLEP.

Conclusion

Our findings suggest that increased age and MetS were associated with unsatisfactory improvement in nocturia in patients with BPH after HoLEP. Lifestyle management, including weight loss, may be of great importance in the improvement of nocturia.

The Circadian Syndrome Predicts Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia Better Than Metabolic Syndrome in Aging Males: A 4-Year Follow-Up Study

Background: The prevalence of lower urinary tract symptoms (LUTS) suggestive of benign prostate hyperplasia (BPH) increases in men. Although several risk factors, including metabolic syndrome (MetS) and depression, were identified, the underlying etiological factor remains unclear. Recently, circadian syndrome (CircS) was proposed as a novel risk cluster based on MetS. To compare the predictive power of the CircS and MetS for LUTS/BPH, this study was performed.

Materials and Methods: In the baseline survey, 4,390 men older than 40 years from the China Health and Retirement Longitudinal Study were enrolled. Of them, 3,658 men were followed in the 2015 survey. Logistic regression was adopted to examine the relationships between CircS, MetS, and LUTS/BPH. To further verify the association, propensity score matching was used for sensitivity analyses. Moreover, the participants who had LUTS/BPH at the baseline were excluded to test the longitudinal relationships between CircS, MetS, and LUTS/BPH. In addition, we employed the receiver operating characteristic (ROC) curve analysis to compare the predictive power using the number of components of CircS and MetS. The DeLong test was used to test the disparities of area under the curves (AUCs).

Results: The prevalence of CircS and MetS in aging men was 30.23 and 38.36%, respectively. The odds ratios for prevalent LUTS/BPH were 1.61 (95% CI = 1.29–2.00, P < 0.001) and 1.34 (95% CI = 1.08–1.66, P < 0.01), respectively, in aging men. This increased risk was also observed in incident LUTS/BPH. The prevalence of LUTS/BPH in normal, CircS alone, MetS alone, and both CircS and MetS groups was 6.96, 8.77, 7.83, and 10.77%, respectively. The AUCs for CircS predicting prevalent and incident LUTS/BPH were higher than those for MetS (0.582 vs. 0.556 for incident LUTS/BPH, P < 0.001; 0.574 vs. 0.561 for prevalent LUTS/BPH, P < 0.05).

Conclusions: The CircS predicts both incident and prevalent LUTS/BPH better than MetS.

Physical activity decreases the risk of cancer reclassification in patients on active surveillance: a multicenter retrospective study

BACKGROUND

Physical activity (PA) is associated with favorable outcomes in prostate cancer (PCa) patients. We assessed its effect on the risk of PCa reclassification (PCaR) during active surveillance.

METHODS

Anthropometric, demographic, and clinical data concerning men diagnosed with a low-risk PCa and initially managed with active surveillance at the two participating institutions were retrospectively collected. The Physical Activity Scale for the Elderly (PASE) was used for patients' self-assessment of their daily exercise and their consequent stratification into three groups: sedentary (PASE ≤ 65), moderately active (65 < PASE < 125), active (PASE ≥ 125). Kaplan-Meier model was used to evaluate the predictive role of PA on PCaR, computed at 2, 5, 10 years after diagnosis; differences between lifestyle groups were assessed using the log-rank and uni-/multivariable Cox analyses applied to identify predictors of reclassification.

RESULTS

Eighty-five patients were included in the analysis, with a median age of 66 years (IQR: 59-70); 16% were active, 45% were former smokers, and 3 presented with metabolic syndrome (MetS). Prostate-specific antigen (PSA) density was 0.12 (IQR: 0.07-0.15); 34 men showed a PSA doubling time <10 years. The Median PASE score was 86 (IQR: 61.5-115.8): 24 patients were sedentary, 46 moderately active, and 15 active. At a median follow-up of 37 months (IQR: 14-53), 25% of patients experienced PCaR. These were less physically active (PASE score 69.3 vs 87.8; p = 0.056) and presented with significantly smaller prostates (46 ml vs 50.7 ml; p = 0.001) and a higher PSAD (0.14 vs 0.10; p = 0.019). At 2 years, the risk of reclassification was 25 ± 5%, while it was 38 ± 7% at both 5 and 10 years. The risk was significantly different in the three PA groups (Log Rank p = 0.033). PASE score was the only independent predictor of PCaR (HR: 0.987; 95%CI: 0.977-0.998; p = 0.016).

CONCLUSIONS

PA influences PCa evolution, as increasing levels are associated with a significantly reduced risk of tumor reclassification among patients undergoing active surveillance.

Metabolic syndrome is associated with prostate enlargement: a systematic review, meta-analysis, and meta-regression on patients with lower urinary tract symptom factors

BACKGROUND

Metabolic syndrome (MetS) is defined by at least three of the following five criteria: blood pressure ⩾130/85 mmHg, fasting blood glucose ⩾5.6 mmol/l, triglycerides concentration ⩾1.7 mmol/l, waist circumference ⩾102 cm (for men), and high-density lipoprotein cholesterol concentration <1.03 mmol/l (for men). MetS has been associated with worse lower urinary tract symptoms (LUTS) and higher International Prostate Symptom questionnaire scores.

MATERIALS AND METHODS

MEDLINE, Cochrane, ClinicalTrials.gov, and SCOPUS were critically appraised for all peer-reviewed manuscripts that suitably fulfilled our protocol's inclusion criteria established a priori. Meta-analytical and meta-regression calculations were performed in R using the Sidik-Jonkman and Hartung-Knapp random effects model and predefined covariates.

RESULTS

A total of 70 studies (n = 90,206) were included in qualitative synthesis. From these, 60 studies focused on MetS and LUTS: 44 reported positive correlations, 5 reported negative correlations, 11 reported no association, and 10 studies focused on MetS and total prostate volume (TPV). MetS positively correlated with moderate LUTS [odds ratio (OR)  = 1.56, 95% confidence interval (CI) = 1.35-1.80], severe LUTS (OR = 2.35, 95% CI = 1.82-3.03), overactive bladder (OAB; OR = 3.2, 95% CI = 1.6-5.8), and nocturia severity (OR = 2.509, 95% CI = 1.571-4.007) at multivariate analysis. A total of 30 studies (n = 22,206) were included in meta-analysis; MetS was significantly associated with higher TPV (mean differences = 4.4450 ml, 95% CI = 2.0177-6.8723), but no significant predictive factors for effect sizes were discovered.

CONCLUSION

Our meta-analysis demonstrates a significant association between the aggravating effects of MetS, which commonly coexists with obesity and benign prostate enlargement.

The association between metabolic syndrome and benign prostatic hyperplasia: a systematic review and meta-analysis

OBJECTIVE

We performed this meta-analysis to assess the association between metabolic syndrome (MetS) and benign prostatic hyperplasia (BPH).

METHOD

We conducted extensive searches on the PubMed, Science and Cochrane Library to identify all articles. Outcomes including annual prostate growth rate, prostate volume (PV), International Prostate Symptom Score (IPSS), IPSS sub-scores (voiding and storage), prostate- specific antigen (PSA), maximum urine flow rate (Qmax), post-void residual urine volume (PVR) and quality of life (QoL) were assessed.

RESULTS

21 studies with 15,317 patients were included. Patients with MetS had higher annual prostate growth rate [weighted mean difference (WMD) = 0.79; p < .001], larger PV (WMD = 2.62; p < .001), lower Qmax (WMD = -0.48; p = .001) and more PVR (WMD = 8.28; p < .001). However, no significant differences were found between two groups in IPSS (WMD = 0.20; p = .37), IPSS-voiding (WMD = -0.05; p = .78), IPSS-storage (WMD = -0.22; p = .26), PSA (WMD = 0.04; p = .43), and QoL (WMD = -0.01; p = .70).

CONCLUSIONS

The study suggested that MetS may be one of the risk factors for the clinical progress of BPH. However, further study is warranted to support these results.

Metastasis-directed therapy and prostate-targeted therapy in oligometastatic prostate cancer: a systematic review

INTRODUCTION

The aim of this review was to summarize the available evidence on the role of metastasis-directed therapy (MDT) and/or prostate-targeted therapy (PTT) in the setting of oligometastatic prostate cancer (PCa).

EVIDENCE ACQUISITION

We searched PubMed, the Web of Science, and the Cochrane Library databases. The following keywords were used: ("prostate cancer" OR "prostate carcinoma" OR "prostate neoplasm" OR "prostate tumor") AND ("oligometastatic" OR "oligometastasis" OR "PSMA") AND ("surgery" OR "prostatectomy" OR "radical prostatectomy" OR "cytoreductive" OR "local treatment" OR "radiotherapy" OR "stereotactic" OR "stereotaxic") AND ("survival" OR "mortality").

EVIDENCE SYNTHESIS

After evaluating the selection criteria, 81 studies were evaluated for our endpoints. We included 22 studies for PTT of synchronous mPCa. There have been no randomized studies on cytoreductive prostatectomy (cRP). Four prospective studies showed that cRP was feasible but did not contribute to a positive effect on overall survival (OS). Regarding PTT-radiotherapy, two randomized controlled phase 3 trials showed that OS was improved in men with a low metastatic burden. Regarding MDT of metachronous lymph node recurrence, we included 29 retrospective studies. For MDT of oligometastases, we included 30 studies. One randomized phase 2 trial showed that androgen deprivation therapy-free survival improved with stereotactic body radiation therapy compared to that with surveillance; however, benefits on OS remain unclear.

CONCLUSIONS

We performed a comprehensive overview of the current literature on MDT and PTT. The feasibility of MDT and PTT is supported by several retrospective studies. Nevertheless, there remains a lack of high-quality trials to prove its survival benefits. Results from ongoing prospective trials data are awaited.

Duration of smoking cessation is negatively associated with the magnitude of chronic prostatic inflammation and storage dysfunction in patients with benign prostatic hyperplasia

OBJECTIVES

To evaluate the impact of smoking and the benefit of smoking cessation on lower urinary tract function and prostatic inflammation in patients with benign prostatic hyperplasia.

METHODS

The medical records of 118 benign prostatic hyperplasia patients who underwent transurethral prostatic surgery between 2006 and 2016 were analyzed. Their smoking history was confirmed. The relationship between smoking and main clinical parameters, International Prostate Symptom Scores, uroflowmetry, pressure flow study, magnitude of prostatic inflammation and the level of serum C-reactive protein was investigated. Furthermore, the relationships between smoking cessation and these clinical parameters were assessed.

RESULTS

The International Prostate Symptom Scores for straining among the non-smokers were significantly lower than those of the smokers (1.71 vs 2.60, P = 0.029). In the pressure flow study, there were negative correlations between the duration of smoking and strong desire to void (correlation coefficient -0.314, P = 0.013), urgency (correlation coefficient -0.349, P = 0.008) and bladder volume at initial detrusor overactivity (correlation coefficient -0.417, P = 0.021). The duration of smoking cessation was negatively correlated with the magnitude of chronic prostatic inflammation (correlation coefficient -0.253, P = 0.027). In the pressure flow study, the duration of smoking cessation was positively correlated with urgency (correlation coefficient 0.286, P = 0.030) and maximum cystometric capacity (correlation coefficient 0.241, P = 0.050).

CONCLUSIONS

Smoking could be a risk factor for the exacerbation of storage dysfunction in benign prostatic hyperplasia patients. Smoking cessation is effective in improving chronic prostatic inflammation and storage dysfunction.

Association between lower urinary tract symptoms and cigarette smoking or alcohol drinking

Background

Although there have been several studies about the relationship between alcohol or smoking and lower urinary tracts symptoms (LUTS). This study aimed to investigate the association between alcohol or smoking and severity of LUTS in men, as alcohol intake and cigarette smoking is important modifiable lifestyle factors for LUTS.

Methods

A cross-sectional analysis has been performed and a total of 86,707 participants in Korean Community Health Survey were included for final analysis. The adjusted odds ratio (OR) or coefficient with 95% confidence interval (CI) estimates were described to show the association between alcohol consumption or cigarette smoking and LUTS.

Results

Among the total subjects, 77,398 (89.3%), 7,532 (8.7%), and 1,777 (2.0%) had mild, moderate, and severe symptoms, respectively, according to International Prostate Symptom Score (IPSS) grade. Those who drank alcohol at least once per month were significantly associated with decreased risk of having the worst IPSS grade (OR: 0.80, 95% CI: 0.68 to 0.93). Those who smoked in the past but currently quitted and those who were daily smokers showed significantly increased risk of having the worst IPSS grade (past smoker, OR: 1.26, 95% CI: 1.14 to 1.39; daily smoker, OR: 1.21, 95% CI: 1.10 to 1.34). For nocturia, daily smoking showed positive effect (OR: 0.79, 95% CI: 0.75 to 0.84) whereas heavy alcohol drinking showed negative effect (OR: 1.22, 95% CI: 1.14 to 1.32)

Conclusions

Alcohol showed positive effect on LUTS except nocturia whereas cigarette smoking had negative effect on LUTS except nocturia. Daily smoking showed positive effect on nocturia whereas heavy alcohol drinking showed negative effect on nocturia.

Metabolic syndrome and smoking are associated with persistence of nocturia after transurethral resection of the prostate

AIMS

The aim of our study was to evaluate the relationship between smoking, metabolic syndrome (MetS) and persistence of nocturia in patients with moderate/severe nocturia (nocturia episodes ≥2), lower urinary tract symptoms (LUTSs), and benign prostatic enlargement (BPE) undergoing transurethral resection of the prostate (TURP).

METHODS

From 2015 onward, a consecutive series of patients with moderate/severe nocturia (nocturia episodes ≥2), LUTS, and BPE undergoing TURP were prospectively enrolled. Medical history, physical examination, and smoking status were recorded. MetS was defined according to Adult Treatment Panel III. Moderate/severe persistent nocturia after TURP was defined as nocturia episodes ≥2. Binary logistic regression analysis was used to evaluate the risk of persisting nocturia.

RESULTS

One hundred two patients were enrolled with a median age of 70 years (interquartile range: 65/73). After TURP, moderate/severe nocturia was reported in 43 of 102 (42%) of the patients. Overall 40 of 102 (39%) patients presented a MetS, and out of them, 23 of 40 (58%) presented a moderate/severe persistent nocturia after TURP ( P = .001). Overall 62 of 102 (61%) patients were smokers, and out of them, 32 of 62 (52%) presented moderate/severe persistent nocturia after TURP ( P = .034). On multivariate analysis, prostate volume, MetS, and smoking were independent risk factors for moderate/severe persistent nocturia after TURP.

CONCLUSION

In our single-center study, MetS and smoking increased the risk of moderate/severe persistent nocturia after TURP in patients with LUTS-BPE. Although these results should be confirmed, and the pathophysiology is yet to be completely understood, counseling smokers and MetS patients about the risk of postoperative persistent nocturia is warranted.

Physical Activity as a Protective Factor for Lower Urinary Tract Symptoms in Male Patients: A Prospective Cohort Analysis

OBJECTIVE

To assess the association between physical activity, evaluated by the Physical Activity Scale for Elderly (PASE) questionnaire and lower urinary tract symptoms (LUTS) in male patients.

METHODS

From 2009 onward, a consecutive series of patients with LUTS-benign prostatic enlargement were enrolled. Symptoms were evaluated using the International Prostate Symptom Score (IPSS) with its subscores and prostate volume using transrectal ultrasound. Physical activity was evaluated with the PASE questionnaire, consisting of 12 questions regarding frequency and duration of leisure activity and recently used to evaluate physical activity in patients with prostatic disorders. The risk of detecting LUTS (IPSS ≥8), voiding LUTS (vIPSS≥5), and storage LUTS (sLUTS) (sIPSS ≥4) was evaluated using binary logistic regression analysis.

RESULTS

Six hundred and seventeen patients were enrolled in 2 centers (Rome, Vasto, Italy). Median PASE score was 118 (IQR 73/169), and median IPSS was 9 (IQR 5/15). Overall 189 of 617 (30%) patients presented moderate/severe LUTS. These patients presented a lower PASE score (111 IQR 69/160 vs 125 IQR 83/180; P = .016) when compared to patients with total IPSS ≤7. On multivariate analysis, PASE score (OR = 0.997 per unit, 95%CI: 0.994-1.000; P = .023), and prostate volume (OR = 1.008 per mL, 1.000-1.016; P = .045) were independent predictors of LUTS severity. As well PASE score was an independent predictor of moderate/severe sLUTS (OR = 0.996, 95%CI:0.993-0.999; P = .015).

CONCLUSION

In our study a reduced physical activity, assessed using the PASE questionnaire, is associated with an increased risk of moderate severe LUTS, more specifically of moderate/severe sLUTS.

Impact of Testosterone Deficiency and Testosterone Therapy on Lower Urinary Tract Symptoms in Men with Metabolic Syndrome

Lower urinary tract function is modulated by neural, vascular and urethral and bladder structural elements. The pathophysiological mechanisms of lower urinary tract symptoms (LUTS) encompass prostate enlargement, alterations in urethra histological structure bladder fibrosis and alterations in pelvic neuronal and vascular networks, The complex pathophysiological relationship between testosterone (T) deficiency (TD) and the constellations LUTS, and metabolic dysfunction manifested in the metabolic syndrome (Met S) remains poorly understood. TD has emerged as one the potential targets by which Met S may contribute to the onset and development as well as worsening of LUTS. Because it has been recognized that treatment of men with Met S with T therapy ameliorates Met S components, it is postulated that T therapy may represent a therapeutic target in improving LUTS. Furthermore, the effect of TD on the prostate remains unclear, and often debatable. It is believed that T exclusively promotes prostate growth, however recent evidence has strongly contradicted this belief. The true relationship between benign prostatic hyperplasia, TD, and LUTS remains elusive and further research will be required to clarify the role of T in both benign prostatic hypertrophy (BPH) and LUTS as a whole. Although there is conflicting evidence about the benefits of T therapy in men with BPH and LUTS, the current body of literature supports the safety of using this therapy in men with enlarged prostate. As the population afflicted with obesity epidemic continues to age, the number of men suffering from Met S and LUTS together is expected to increase.