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

Urinary Incontinence in Primary Care-The Gap Between Recommendations and Real World

IMPORTANCE

Routine screening for urinary incontinence (UI) by primary care providers (PCPs) is recommended.

OBJECTIVES

We aimed to describe the rate of incident UI diagnosed at annual PCP visits, the prevalence of UI in a large primary care population, and estimate the rate of screening for UI during primary care preventive and annual wellness visits. Secondary aims were to describe PCP knowledge and behavior as they relate to UI screening and diagnosis.

STUDY DESIGN

The electronic health record was used to abstract the number of adult female patients seen by PCPs within a regional health system with a diagnosis of UI before our study period and with a new diagnosis over a 2-year period. Additional new diagnoses and screening practices were found on chart review of an additional 824 representative charts. Primary care providers within the health system were surveyed about their screening practices and knowledge about UI.

RESULTS

There were 192,053 women primary care patients seen over 2 years. A total of 5.7% had a UI diagnosis preceding the study period and 3.4% had a UI diagnosis during the study period. A total of 42% of PCPs reported that they screen for UI at least half the time and none were completely satisfied with their ability to screen for UI. Sixteen percent of annual wellness visits had any documentation of screening for UI.

CONCLUSION

In a large primary care population, screening for and detection of UI in women was low.

Developing a urinary incontinence primary care pathway: a mixed methods study

BACKGROUND

While nearly 50% of adult women report at least one episode of urinary incontinence (UI), most never receive treatment.

OBJECTIVE

To better integrate primary and specialty UI care, we conducted (i) an environmental scan to assess the availability of key pathway resources in primary care, (ii) interviews with primary care providers to understand barriers to care, and (iii) a pilot UI care pathway intervention.

METHODS

Environmental scan: Clinic managers from all primary care clinics within a Midwestern healthcare system were invited to participate in an interview covering the availability of clinic resources. Provider interviews: Primary care providers were invited to participate in an interview covering current practices and perceived barriers to UI care. Pilot UI care pathway: Patients who screened positive for UI were provided resources for first-line behavioral management. Pilot patients completed questionnaires at baseline, 8 weeks, and 6 months.

RESULTS

While many clinics had point-of-care urinalysis (17/21, 81%), most did not have a working bladder ultrasound (14/21, 67%) or on-site pelvic floor physical therapy (18/21, 86%). Providers (n = 5) described barriers to completing almost every step of diagnosis and treatment for UI. The most persistent barrier was lack of time. Patients (n = 15) reported several self-treatment strategies including avoiding bladder irritants (7/15, 47%) and performing Kegel exercises (4/15, 27%). Five patients (33%) requested follow-up care. At 6 months, patients reported small improvements in UI symptoms.

CONCLUSION

Promising results from a novel UI care pathway pilot indicate that streamlining UI care may assist primary care providers in the first-line treatment of UI.

Comparison between combination of tamsulosin and Pentoxifylline versus tamsulosin alone in the treatment of lower urinary tract symptoms due to benign prostate hyperplasia: A preliminary study

BACKGROUND

In older adults, bladder outlet obstruction (BOO) is prevalent, primarily due to benign prostatic hyperplasia (BPH). These patients' lower urinary tract symptoms can be treated surgically and with medical therapy. Compared to standard treatment with tamsulosin, Pentoxifylline, a phosphodiesterase inhibitor, could benefit patients with BOO due to its properties on microcirculatory blood flow and oxygenation of ischemic tissues. Hence, this trial intended to study the efficacy of Pentoxifylline combined with tamsulosin in treating BOO patients.

MATERIALS AND METHODS

This randomized, double-blind clinical trial recruited 60 patients with BPH from a single center in 2022. Upon consent of patients meeting the eligibility criteria, they were randomly allocated to intervention (Pentoxifylline + tamsulosin) and control (placebo + tamsulosin) groups. The patients were evaluated for international prostate symptom score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax ) by uroflowmetry, and post-void residual volume (PVR) by abdominal sonography at the onset of the study and after the 12th week.

RESULTS

Patients who used the combination therapy had significantly better results of prostate symptoms and quality of life improvement (IPSS: -36.6%, QoL: -45.3%) compared to patients who received tamsulosin alone (IPSS: -21.2%, QoL: -27.7%) (p < .001). Also, this study shows that the improvement in maximum urinary flow rate and residual volume by combination therapy is significantly higher (Qmax : +42.5%, PVR: -42.6%) compared to monotherapy (Qmax : +25.1%, PVR: -26.1%) (p < .001).

CONCLUSION

When combined with tamsulosin, Pentoxifylline could significantly improve the lower urinary symptoms of BPH patients. It is well tolerated, and the treatment outcomes are better in patients who receive the combination of Pentoxifylline and tamsulosin than those who only receive tamsulosin.

The association of lower urinary tract symptoms with schizophrenia and its treatments: A narrative review

BACKGROUND

A higher incidence of lower urinary tract symptoms (LUTS) in people with schizophrenia compared to the general population is often suggested. However, it is not clear whether this is a genuine association, and whether it is a direct result of schizophrenia itself, or a side-effect of certain antipsychotics.

METHODS

We undertook a narrative review evaluating how the published literature reports the relationship between LUTS and schizophrenia and its treatments. We searched Embase, Ovid Emcare, and Ovid MEDLINE(R) ALL to August 2022, limited to the English language. We selected the following search terms: schizophrenia, schizophrenic, LUTS, overactive bladder, urinary urgency, urinary incontinence, overactive bladder, enuresis, nocturnal enuresis, and voiding dysregulation. We identified seven domains for assessment in advance of commencing the review. These were the categorization, description, and treatment status of schizophrenia; evaluation of LUTS; categorization of LUTS confounders; recapturing of the disease states of both schizophrenia and LUTS after therapies; assessment of the association between LUTS and schizophrenia and/or antipsychotics.

RESULTS

The association between LUTS and schizophrenia was poorly described. The evidence was low quality and focused predominantly on urinary incontinence as an antipsychotic side effect, neglecting other LUTS. The status of schizophrenia was often incompletely characterized, and no papers made use of a bladder diary or LUTS-specific questionnaires to assess symptoms. No papers collected information about LUTS in patients not on antipsychotics, nor did any thoroughly evaluate the influence of confounding variables. Despite the tendency of symptoms and severity of both conditions to fluctuate over time, no studies fully assessed the status of both schizophrenia and LUTS at baseline, therapy initiation, and follow-up.

CONCLUSIONS

It is not possible to state whether there is an association between LUTS and schizophrenia or its treatments. This review highlights the need to improve research and clinical management of the urinary tract in schizophrenia, with meticulously designed longitudinal studies.

Stigmatization as a Barrier to Urologic Care: A Review

Heavy societal stigma of certain conditions has created an environment where individuals may be hesitant to seek professional care. Urology is a specialized field that focuses on many of these conditions that society has deemed taboo to discuss. In this review, we address barriers that have prevented patients from seeking urologic care in order to better understand and elucidate important concerns within development of the physician-patient relationship. Recognizing these concerns can also assist in public health outreach approaches to motivate patients for seeking urologic care. The scope of this review was limited to three highly prevalent conditions affecting both men and women, including urinary incontinence, erectile dysfunction, and genitourinary syndrome of menopause.

Effect of Diabetes Mellitus on Symptomatic Improvement After Surgery for Benign Prostatic Hyperplasia in Patients With Lower Urinary Tract Symptom and its Relations With Prostatic Urethral Angulation

PURPOSE

To compare improvement of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia in diabetic versus nondiabetic patients after transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP).

METHODS

The medical records of 437 patients who underwent TURP or HoLEP at a tertiary referral center from January 2006 to January 2022 were retrospectively analyzed. Among them, 71 patients had type 2 diabetes. Patients in the diabetic mellitus (DM) and non-DM groups were matched 1:1 according to age, baseline International Prostate Symptom Score (IPSS), and ultrasound measured prostate volume. Changes in LUTS were assessed at 3 months after surgery using IPSS and evaluated by categorizing patients according to prostatic urethral angulation (PUA; <50° vs. ≥50°). Medication-free survival after surgery was also investigated.

RESULTS

No significant differences were noted between the DM and non-DM groups in baseline characteristics except for comorbidities (i.e., hypertension, cerebrovascular disease, and ischemic heart disease, P=0.021, P=0.002, and P=0.017, respectively) and postvoid residual urine volume (115±98 mL vs. 76±105 mL, P=0.028). Non-DM patients showed significant symptomatic improvement regardless of PUA, while DM patients demonstrated improvement in obstructive symptoms only in those with large PUA (≥51°). Among patients with small PUA, DM patients had worse medication-free survival after surgery compared to controls (P=0.044) and DM was an independent predictor of medication reuse (hazard ratio, 1.422; 95% confidence interval, 1.285-2.373; P=0.038).

CONCLUSION

DM patients experienced symptomatic improvement after surgery only in those with large PUA. Among patients with small PUA, DM patients were more likely to reuse medication after surgery.

Clinical hypnosis can reduce lower urinary tract symptoms in individuals with chronic pain

STUDY PURPOSE

Lower urinary tract symptoms (LUTS) can occur in chronic pain populations at high rates and drastically affect quality of life. Hypnosis is a nonpharmacological treatment used in chronic pain known to have beneficial implications to health outside of pain reduction. This study evaluated the potential for hypnosis to reduce LUTS in a sample of individuals with chronic pain, if baseline LUTS severity affected outcomes, and specific LUTS that may respond to hypnosis.

METHODS

Sixty-four adults with chronic pain and LUTS at a level of detectable symptom change (American Urological Association Symptom Index, AUASI   3) participated in an 8-week group hypnosis protocol. Participants completed validated assessments of LUTS, pain, and overall functioning before, after, 3- and 6-months posttreatment. Linear mixed effects models assessed improvement in LUTS over time while accounting for known factors associated with outcome (e.g., age, gender). The interaction of baseline symptom severity and treatment assessed the potential effect of baseline symptoms on change scores.

RESULTS

Participants experienced significant and meaningful improvements in LUTS following group hypnosis (p = 0.006). There was a significant interaction between baseline symptom severity and treatment (p < 0.001), such that those with severe symptoms experienced the most pronounced gains over time (e.g., an 8.8 point reduction). Gains increased over time for those with moderate and severe symptoms. Changes in LUT symptoms occurred independently of pain relief.

CONCLUSIONS

This pilot study suggests hypnosis has the potential to drastically improve LUTS in individuals with chronic pain, even when pain reduction does not occur. Results provide initial evidence for the treatment potential of hypnosis in urologic pain (and possibly non-pain/benign) populations, with randomized trials needed for definitive outcomes.

Protocol for mixed-method systematic review of urology in medical school education

INTRODUCTION

Throughout clinical practice, most doctors will encounter patients with urological conditions. Inclusion of urological topics within medical school curriculums is important to allow doctors to effectively diagnose and manage these conditions, independently and with support from urologists. Awareness of urological education interventions and their effectiveness is essential for improving the quality and outcomes of medical student education. No systematic review of medical school education interventions on urological topics has previously been conducted. This mixed-method systematic review will assess the effectiveness of medical school education interventions on urological topics.

METHODS AND ANALYSIS

This mixed-methods systematic review will include qualitative and quantitative studies involving education interventions or practices regarding urological topics conducted within a medical school curriculum. Studies regarding other curriculums including premedical education, junior doctor prevocational education or vocational urological training will be excluded. A search of CINAHL, ERIC, EMBASE, MEDLINE will be conducted for studies published since the year 2001. Dual independent screening of titles and abstracts prior to full text review will be undertaken for all identified results during the initial searches. Any disagreement will be settled by a third reviewer. A convergent segregated approach will be used to synthesise qualitative and quantitative data independently, with the results juxtaposed to identify shared and divergent findings between study types.

ETHICS AND DISSEMINATION

No ethical approval was required for this review. Findings from this review will be disseminated via publication, reports and conference presentations.

Subtyping of common complex diseases and disorders by integrating heterogeneous data. Identifying clusters among women with lower urinary tract symptoms in the LURN study

We present a methodology for subtyping of persons with a common clinical symptom complex by integrating heterogeneous continuous and categorical data. We illustrate it by clustering women with lower urinary tract symptoms (LUTS), who represent a heterogeneous cohort with overlapping symptoms and multifactorial etiology. Data collected in the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN), a multi-center observational study, included self-reported urinary and non-urinary symptoms, bladder diaries, and physical examination data for 545 women. Heterogeneity in these multidimensional data required thorough and non-trivial preprocessing, including scaling by controls and weighting to mitigate data redundancy, while the various data types (continuous and categorical) required novel methodology using a weighted Tanimoto indices approach. Data domains only available on a subset of the cohort were integrated using a semi-supervised clustering approach. Novel contrast criterion for determination of the optimal number of clusters in consensus clustering was introduced and compared with existing criteria. Distinctiveness of the clusters was confirmed by using multiple criteria for cluster quality, and by testing for significantly different variables in pairwise comparisons of the clusters. Cluster dynamics were explored by analyzing longitudinal data at 3- and 12-month follow-up. Five clusters of women with LUTS were identified using the developed methodology. None of the clusters could be characterized by a single symptom, but rather by a distinct combination of symptoms with various levels of severity. Targeted proteomics of serum samples demonstrated that differentially abundant proteins and affected pathways are different across the clusters. The clinical relevance of the identified clusters is discussed and compared with the current conventional approaches to the evaluation of LUTS patients. The rationale and thought process are described for the selection of procedures for data preprocessing, clustering, and cluster evaluation. Suggestions are provided for minimum reporting requirements in publications utilizing clustering methodology with multiple heterogeneous data domains.

Patient Engagement With Urologists on Social Media in a Community Practice

Background

Based on the Boston Area Community Health Survey, 52 million adults in the United States will have lower urinary tract symptoms, urine leakage, painful bladder syndrome, and prostatitis, which may parallel the prevalence of cardiovascular disease. In the year 2000, benign prostatic hyperplasia (BPH) accounted for 117,000 emergency department visits and 105,000 hospitalizations. These numbers underscore the burden of urological conditions and highlight the importance of patient education in preventing unnecessary hospitalizations and emergency department visits. Certain factors that may alter the progression and severity of disease include physical activity and other lifestyle changes. Based on current trends, patient education via social media may be an invaluable tool in limiting the burden on urologists and the healthcare system in the future.

Aims

This study aims to determine whether patients in a community urology practice would engage with their urologists over social media and if the likelihood to engage was associated with various demographic factors. Furthermore, the likelihood to engage actively (defined as commenting/sharing) versus passively (defined as liking a post) on two different topics within the scope of urology was determined. The two topics used were erectile dysfunction (ED)/urinary incontinence and kidney stone prevention.

Methods

Participants were recruited from a community urologic clinic in Alabama. During the month of April 2021, 293 participants completed a survey that included basic demographic questions as well as questions with a visual analog 5-point Likert scale. Responses on the Likert scale were given a value of one (very unlikely) to five (very likely), and a two-tailed Mann-Whitney U test with an α of 0.05 was used to determine significance in differences of responses. In the case of ties, the mid-rank method was used to assign ranks. For analysis of the Likert scale responses, only those respondents who had social media accounts were included.

Results

Overall, respondents were more likely to interact with a post by their urologist passively engage rather than actively. They were also less likely to passively and actively engage on a topic concerning ED/urinary incontinence versus kidney stone prevention. On the topic of kidney stone prevention, respondents were less likely to engage actively than passively. There was no difference in the likelihood of actively or passively engaging on the topic of ED/urinary incontinence. Compared to men, women were more likely to actively and passively engage on social media. On the topic of ED/urinary incontinence, women were more likely than men to actively engage; however, there was no difference in passive engagement. On the topic of kidney stone prevention, women were more likely to actively and passively engage. When looking at the likelihood of engagement based on age, there was no difference in active or passive engagement between those 55 and under or older than 55. This held true when data were stratified by topic.

Conclusion

Based on these results, the maximum impact of a social media page from a urological practice would be gained by focusing on preventative practices for less sensitive urological conditions. Furthermore, the data suggests that as the population of social media users continues to age, physicians should not expect a change in engagement patterns anytime soon.

Pumpkin seed oil (Cucurbita pepo) versus tamsulosin for benign prostatic hyperplasia symptom relief: a single-blind randomized clinical trial

BACKGROUND

Benign prostatic hyperplasia (BPH) is very common in aging men. We aimed to compare the effects of tamsulosin and pumpkin (Cucurbita pepo) seed oil on BPH symptoms.

METHODS

This single-blind randomized clinical trial included patients with BPH aged ≥ 50 years referred to the Urology Clinic of Shahid Beheshti Hospital, Hamadan, Iran, from August 23, 2019 to February 19, 2020. Patients were randomized into two groups. One group received 0.4 mg tamsulosin every night at bedtime and the other received 360 mg pumpkin seed oil twice a day. Patients' age, weight, height, and body mass index (BMI) were recorded. The International Prostate Symptom Score (IPSS) was filled out by the patients at baseline and then 1 month and 3 months after the initiation of treatment. The BPH-associated quality of life (QoL), serum prostate-specific antigen, prostate and postvoid residual volume, and maximum urine flow were also assessed at baseline and 3 months later. Drug side effects were also noted.

RESULTS

Of the 73 patients included in this study with a mean age of 63.59 ± 7.04 years, 34 were in the tamsulosin group and 39 in the pupkin seed oil group. Patients were comparable with respect to age, weight, height, BMI, and baseline principal variables in both groups. Also, there was no significant difference between groups in terms of principal variables at any time point. However, there was a significant decrease in IPSS and a significant improvement in QoL in both groups. Although the decrease in IPSS from baseline to 1 month and 3 months was significantly higher in the tamsulosin group compared to the pumpkin group (P = 0.048 and P = 0.020, respectively), the decrease in IPSS from 1 to 3 months was similar (P = 0.728). None of the patients in the pumpkin group experienced drug side effects, while dizziness (5.9%), headache (2.9%), retrograde ejaculation (2.9%), and erythema with pruritus occurred in the tamsulosin group.

CONCLUSIONS

Pumpkin (Cucurbita pepo) seed oil relieved BPH symptoms with no side effects, but was not as effective as tamsulosin. Further studies are required to confirm the role of pumpkin seed oil as an option for the treatment of BPH symptoms. Trial registration Iranian Registry of Clinical Trials, IRCT20120215009014N340. Registered 19.02.2020. Retrospectively registered, https://en.irct.ir/trial/45335 .

Longitudinal Changes in Adiposity and Lower Urinary Tract Symptoms Among Older Men

BACKGROUND

Adiposity increases risk for male lower urinary tract symptoms (LUTS), although longitudinal studies have produced conflicting results. No prior studies have evaluated longitudinal associations of changes in adiposity with concurrent LUTS severity among older men.

METHODS

We used repeated adiposity measurements from dual-energy x-ray absorptiometry (DXA), body mass index (BMI), and American Urological Association Symptom Index (AUASI) measured at four study visits over a 9-year period among 5949 men enrolled in the Osteoporotic Fractures in Men (MrOS) study. Linear mixed effect models adjusted for age, health-related behaviors, and comorbidities were created to evaluate the association between baseline and change in visceral adipose tissue (VAT) area, total fat mass, and BMI with change in LUTS severity measured by the AUASI.

RESULTS

A non-linear association was observed between baseline VAT area and change in AUASI: men in baseline VAT tertile (T) 2 had a lower annual increase in AUASI score compared to men in T1 and T3 (T2 versus T1: β=-0.07; 95% CI -0.12, -0.03; P= 0.008; T3 versus T1: NS) but differences were small. No significant associations were observed between change in VAT area and change in AUASI score. Neither baseline tertiles nor change in total fat mass or BMI were associated with change in AUASI score.

CONCLUSIONS

Changes in VAT area, total fat mass, and BMI were not associated with change in LUTS severity in this cohort. Thus, despite other health benefits, interventions targeting adiposity alone are unlikely to be effective for preventing or treating LUTS among older men.

Prolieve® Transurethral Thermodilatation for treatment of Symptomatic Benign Prostatic Hyperplasia: 5-Year Results from a Prospective Multi-Center Trial

Introduction & Objective Prolieve® transurethral thermodilatation (TUTD) is the only third-generation transurethral microwave thermotherapy (TUMT) device that incorporates balloon dilation/compression of the prostatic urethra with cooled TUMT, at ≤50W power. We evaluated its 5-year efficacy in the treatment of symptomatic benign prostatic hyperplasia (BPH) in an open-label prospective multi-center trial. Methods Eligible patients with AUA symptom score (AUASS) ≥ 9, peak urine flow rate (Qmax) <12 ml/s, and prostate size 20-80 g without obstructing median lobe anatomy were enrolled. Prolieve® TUTD was delivered in the office setting under local anesthesia. AUASS, Quality of Life (QOL), BPH impact index (BPHII), Qmax and other measures were assessed at baseline, and at least annually thereafter to year 5. Adverse events (AEs) were recorded. Treatment success over time was analyzed using the Kaplan-Meier method while changes from baseline were evaluated using paired t-tests. Results Intention to treat (ITT) population was 225, of whom 220 with a mean (SD) age of 65 (5.9). completed treatment. 187/220 (85%) did not require urethral catheterization. AUAS, QOL and BPHII scores significantly improved from baseline in ≤ 3 months, with sustained improvements to year 5. Qmax also significantly improved from baseline at each annual follow up evaluation. Cumulative 5-year surgical retreatment rate was 14.2% (95% CI 9.5-20.8%). Transient urinary urgency and dysuria were the most commonly reported AEs. Conclusions Prolieve® TUTD is a safe and effective treatment option for BPH, with durable long-term improvements in voiding subjective symptoms and urinary flow rates. It is deliverable in the office setting and has a low catheterization rate and sexual side effects are rare.

After the Randomized Trial: Implementation of Community-Based Continence Promotion in the Real World

BACKGROUND/OBJECTIVES

Most women aged 65 and older have incontinence, associated with high healthcare costs, institutionalization, and negative quality of life, but few seek care. Mind over Matter: Healthy Bowels, Healthy Bladder (MOM) is a small-group self-management workshop, led by a trained facilitator in a community setting, proven to improve incontinence in older women.

DESIGN

We used mixed methods to gather information on the real-world adoption, maintenance, and implementation of MOM by community agencies following a randomized controlled trial (RCT) that tested intervention effects on incontinence.

SETTING

Community agencies serving older adults in six Wisconsin communities.

PARTICIPANTS

Community agency administrators and facilitators trained to offer MOM for the RCT.

MEASUREMENTS

Investigators tracked rates of adoption (offering MOM in the 12 months following the RCT) and maintenance (offering MOM more than once in the next 18 months) in six communities. Individual interviews and focus groups (N = 17) generated qualitative data about barriers and facilitators related to adoption and maintenance. Trained observers assessed implementation fidelity (alignment with program protocol) at 42 MOM sessions.

RESULTS

A total of 67% of communities (four of six) adopted MOM, and 50% (three of six) maintained MOM. No implementation fidelity lapses occurred. Facilitators of adoption and maintenance included MOM's well-organized protocol and lean time commitment, sharing of implementation efforts between partner organizations, staff specifically assigned to health promotion activities, and high community interest in continence promotion. Other than stigma associated with incontinence, barriers were similar to those seen with other community-based programs for older adults: limited funding/staffing, competing organizational priorities, challenges identifying/training facilitators, and difficulty engaging community partners/participants.

CONCLUSION

Using design for dissemination and community engagement, assessment of implementation outcomes is feasible in conjunction with a clinical RCT. Partner-centered implementation packages can address barriers to adoption and maintenance.

Modern best practice in the management of benign prostatic hyperplasia in the elderly

Benign prostatic hyperplasia (BPH), with its associated lower urinary tract symptoms (LUTS), can be a debilitating disease in the elderly male. Transurethral resection of the prostate (TURP) remains the gold standard; however, many patients will choose to avoid surgery if possible. Medical therapy is an effective alternative, however, new studies are showing that there may be more side effects than previously realized in the elderly male. Newer, novel minimally invasive techniques, including UroLift® and Rezūm™, are gaining favor as alternative office-based procedural techniques that do not require general anesthesia and may better preserve ejaculatory function. Though promising, at this point, these techniques are not approved for all patients. With a range of medical, procedural, and surgical options for treatment of BPH with LUTS, it is important to have a discussion with your patient regarding the short- and long-term risks and benefits, as well as alternatives, before deciding on a treatment plan for your patient with BPH.

Effect of mirabegron on cognitive function in elderly patients with overactive bladder: MoCA results from a phase 4 randomized, placebo-controlled study (PILLAR)

Background

Antimuscarinics are often used for treatment of overactive bladder (OAB), but exposure to medications such as antimuscarinics that have anticholinergic properties has been linked to adverse cognitive effects. A phase 4 placebo-controlled study (PILLAR; NCT02216214) described the efficacy and safety of mirabegron, a β₃-adrenoreceptor agonist, for treatment of wet OAB in patients aged ≥65 years. This pre-planned analysis aimed to measure differences in cognitive function between mirabegron and placebo, using a rapid screening instrument for mild cognitive impairment: the Montreal Cognitive Assessment (MoCA).

Methods

Outpatients aged ≥65 years with wet OAB were randomized 1:1 to mirabegron or placebo, stratified by age (<75/≥75 years). There were no exclusion criteria regarding cognitive status. Patients randomized to mirabegron initially received 25 mg/day with an optional increase to 50 mg/day after week 4/8 based on patient/investigator discretion. The MoCA was administered at baseline and end of treatment (EoT, week 12). The study protocol was Independent Ethics Committee/Institutional Review Board-approved.

Results

Of the 887 randomized patients who received ≥1 dose of study drug, 72.3% were female, 79.5% were white, and 28.1% were aged ≥75 years. All patients had ≥1 comorbidity and 94.3% were receiving ≥1 concomitant medication. One third of patients had a history of psychiatric disorders, the most common being depression (17.2%), insomnia (15.7%), and anxiety (11.4%). Baseline mean (standard error, SE) MoCA total scores were 26.9 (0.1) and 26.8 (0.1) in the mirabegron and placebo groups, respectively. Among patients with MoCA data available at baseline/EoT, 27.1% (115/425) and 25.8% (106/411) of mirabegron and placebo group patients, respectively, had impaired cognitive function at baseline (MoCA total score <26). There was no statistically significant change in adjusted mean (SE) MoCA total score from baseline to EoT in the mirabegron group (−0.2 [0.1]) or the placebo group (−0.1 [0.1]).

Conclusions

Treatment with mirabegron for 12 weeks did not contribute to drug-related cognitive side effects in patients aged ≥65 years, as measured by the MoCA. Furthermore, the pattern of change in cognition over time in an older OAB trial population does not appear to differ from that of subjects receiving placebo.

Trial registration

NCT02216214 (prospectively registered August 13, 2014).

High serum concentration of estradiol may be a risk factor of prostate enlargement in aging male in China

Objective: Assess the association between serum sex hormone level and prostate volume in men with benign prostatic hyperplasia (BPH).Material and methods: The study involved 239 BPH patients from January 2013 to June 2015 in our hospital. Each patient collected age, medical history, height, weight, body mass index, as well as a full examination of sex hormones, and transrectal ultrasound results.Results: Estradiol (E2) was significantly associated with prostate volume (r = 0.151, p = .02) and transitional zone volume (r = 0.136, p = .035). The association was more significant after adjusting age and BMI (r = 0.253 and 0.250, p <.001). Patients were divided into two groups according to prostate volume and E2, respectively. E2 in patients with prostate volume ≤50 ml was significantly lower than those with prostate volume >50 ml. Prostate volume, transitional zone volume and age were all significantly higher in the patients with E2 ≥ 160 umol/l than those in the patients with E2 < 160 umol/l. Through logistics regression, E2 (p = .012, OR = 1.004) are the only independent risk factor for prostate volume.Conclusions: E2 is significantly associated with prostate volume. High concentrations of E2 may be a risk factor for the large volume of prostate.

Urology in Undergraduate Medical Education

PURPOSE OF REVIEW

Urology is an essential topic in undergraduate medical education (UME). The objective of this article is to review the current state of exposure to urology in medical school, to discuss why it is critical to maintain a urology curriculum, and to review methods in establishing an effective curriculum for all students with limited resources.

RECENT FINDINGS

UME curriculum in urology should be geared toward the widest group of students, namely those entering primary care or internal medicine, where patients with urologic complaints are most likely to first present. Hands-on teaching should focus on skills such as the genitourinary exam and Foley catheter placement, while ancillary modules should be utilized for complex concepts. Medical schools do not sufficiently incorporate didactics in urology as part of their core curriculum. As such, educators in urology must develop curricula that provide fundamental knowledge to all students, especially those pursuing non-urologic specialties who will undoubtedly treat patients with urologic complaints.

Burden of Urological Complications in Men and Women With Long-standing Type 1 Diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Cohort

OBJECTIVE

Type 1 diabetes has been associated with high rates of urinary and sexual problems, but the cumulative burden and overlap of these complications are unknown. We sought to determine prevalence of urological complications in persons with type 1 diabetes, associations with clinical and diabetes-related factors, and rates of emergence, persistence, and remission.

RESEARCH DESIGN AND METHODS

This ancillary longitudinal study among participants in the Diabetes Control and Complications Trial (DCCT) and observational follow-up study Epidemiology of Diabetes Interventions and Complications (EDIC) (652 women and 713 men) was conducted in 2003 and 2010/2011. Urinary incontinence (UI), lower urinary tract symptoms, urinary tract infection, female sexual dysfunction, erectile dysfunction, low male sexual desire, and orgasmic dysfunction were measured with validated instruments. Logistic regression determined association of complications with demographics and clinical characteristics.

RESULTS

Of sexually active women completing the 2010/2011 survey, 35% reported no complications, 39% had one, 19% two, 5% three, and 2% four. In men, 31% had no complications, 36% had one, 22% two, 9% three, and 3% four. Sexual dysfunction was most prevalent (42% women and 45% men) followed by UI in women (31%) and low sexual desire in men (40%). Urological complications were associated with age, BMI, and HbA_1c. Remission rates ranged from 4 to 12% over the 7-year interval between surveys.

CONCLUSIONS

Urological complications are prevalent and frequently co-occur in persons with type 1 diabetes. Remission rates in a minority subset indicate a rationale for future studies to mitigate the onset or impact of urological complications of diabetes.

OAB score: a clinical model that predicts the probability of presenting overactive detrusor in the urodynamic study

Purpose

To create a predictive model of involuntary detrusor contraction (IDC) to improve the diagnostic accuracy of overactive detrusor (OAD), associating overactive bladder (OAB) symptoms with other clinical parameters in the female population.

Materials and Methods

A total of 727 women were studied retrospectively. In all of them, urodynamic study was conducted for urogynecological causes. Demographics information, personal history, symptoms, physical exam, a 3-day frequency/volume chart and urinary culture, were collected in all patients and they subsequently underwent uroflowmetry and urodynamic studies. A logistic regression model was performed in order to determine independent predictors of presence of IDC. Odd ratio (OR) estimation was used to assign a score to each one of the significant variables (p≤0.05) in the logistic regression model. We performed a ROC curve in order to determine the predictive ability of the score in relation to the presence of OAD.

Results

presence of OAD was evident in 210 women (29%). In the logistic regression analysis, independent predictors of OAD were urgency, urgency incontinence, nocturia, absence of SUI symptoms, diabetes mellitus, reduction of vaginal trophism and bladder capacity below 150 mL. The probability of IDC diagnosis increases as the score raises (Score 0: 4% until Score ≥10: 88%). Sensitivity was 71% and specificity 72%. The area under the curve of OAB score was 0.784 (p>0.001).

Conclusions

OAB score is a clinical tool that shows higher diagnostic accuracy than OAB symptoms alone to predict overactive detrusor.

Transurethral resection of the prostate achieves favorable outcomes in stroke patients with symptomatic benign prostate hyperplasia

OBJECTIVES

To evaluate the surgical outcomes of stroke patients with symptomatic benign prostatic hyperplasia (BPH) who underwent transurethral resection of the prostate (TURP) and compare the clinical outcomes between patients with stroke and those without stroke receiving this procedure.

METHODS

This retrospective cohort study analyzed claims data collected during the period of 1997-2012 from Taiwan National Health Insurance Research Database. We enrolled 6625 patients who had persistent lower urinary tract symptoms and underwent TURP for BPH. They were categorized into a stroke (n = 577) and nonstroke (n = 6048) group. Patient characteristics, postoperative clinical outcomes, medication records, and medical expenses were compared.

RESULTS

Compared with the stroke group patients, those in the nonstroke group were younger, had fewer comorbidities, and more favorable postoperative clinical outcomes. Nevertheless, TURP achieved favorable outcomes in stroke patients with symptomatic BPH. In the stroke group, the rate of urinary tract infection (UTI) decreased from 34.7% during 1 year preoperatively to 29.8% during 1 year postoperatively (p = .05). The rate of urinary retention (UR) also decreased from 55.5% during 1 year preoperatively to 22.5% during 1 year postoperatively (p = .05). TURP reduced the overall medical expenses of patients with stroke. Annual patient medical expense during 1 year preoperatively, 1 year postoperatively, 2 years postoperatively, and 3 years postoperatively was NT$659,000, NT$646,000, NT$560,000, and NT$599,000, respectively.

CONCLUSIONS

In patients with stroke, TURP reduces the risks of UTI and UR and annual total medical expense.

Is diabetes mellitus associated with clinical outcomes in aging males treated with transurethral resection of prostate for bladder outlet obstruction: implications from Taiwan Nationwide Population-Based Cohort Study

PURPOSE

We assessed the lower urinary tract symptoms (LUTSs) and clinical outcomes between diabetes mellitus (DM) patients and non-diabetic (non-DM) patients receiving transurethral resection of prostate (TUR-P).

METHODS

This analysis was a retrospective cohort study using 13 years (2000-2012) of claims data from Taiwan's National Health Insurance Research Database (NHIRD). A total of 4,887 patients who had persistent LUTSs and underwent TUR-P for prostate enlargement (benign prostate enlargement [BPE]) were enrolled and divided into two groups: DM and non-DM groups. The patients' characteristics, postoperative clinical outcomes, and the medication records after TUR-P were compared. Chi-square test was used for categorical variables and independent samples t-test for continuous variables. Multivariable logistic regression analysis was used to compare the risk of postoperative outcomes. Finally, we estimated the medication-free survival rate after TUR-P using Kaplan-Meier method and compared it between study groups using log-rank test.

RESULTS

DM group patients had a higher prevalence of comorbidities. Postoperatively, the DM group had lower rates of urinary tract infection (UTI; odds ratio [OR], 0.78; P=0.009) and higher rates of urinary retention requiring catheterization (OR, 1.35; P=0.01) within 1 month after TUR-P. A higher proportion of patients with DM took anti-muscarinics (OR, 1.23; P=0.032) within the first 3 months and α-blockers (OR, 1.18; P=0.049) during 3-12 months after receiving TUR-P. Overall, the DM group patients had a worse postoperative medication-free survival compared to that of non-DM group patients (95% confidence interval [95% CI], 1.14; P=0.005).

CONCLUSION

DM patients require higher rates of continuing medication after TUR-P, especially anti-muscarinics in 3 months postoperatively and alpha-blocker after 3 months postoperatively. DM patients also had higher incidence of urine retention after surgery. DM patients had relatively poor treatment outcomes compared to DM-free patients.

Future Directions of Research and Care for Urinary Incontinence: Findings from the National Institute of Diabetes and Digestive and Kidney Diseases Summit on Urinary Incontinence Clinical Research in Women

PURPOSE

Female urinary incontinence is prevalent, costly and morbid. Participants in a NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) sponsored summit reviewed findings from NIH (National Institutes of Health) funded clinical research on urinary incontinence in women and discussed the future of urinary incontinence research.

MATERIALS AND METHODS

The NIDDK convened the Summit on Urinary Incontinence Clinical Research in Women on March 14, 2014. Participants representing a broad range of clinical expertise reviewed completed NIH sponsored urinary incontinence related studies, including results from community based epidemiological studies such as the BACH (Boston Area Community Health) Survey and from randomized clinical trials such as PRIDE (Program to Reduce Incontinence by Diet and Exercise), and studies conducted by the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network.

RESULTS

BACH Survey results improved our understanding of precursors, incidence, prevalence and natural history of urinary incontinence in a diverse group of women. The Pelvic Floor Disorders Network study found that anticholinergic medications and onabotulinumtoxinA are efficacious for treating urge urinary incontinence, and Burch colposuspension and retropubic mid urethral polypropylene slings are efficacious for decreasing stress urinary incontinence following pelvic organ prolapse surgery in women with potential stress urinary incontinence. The Urinary Incontinence Treatment Network study found that fascial slings were better than colposuspension, and that retropubic and transobturator mid urethral polypropylene slings were equivalent for stress urinary incontinence. In patients with stress urinary incontinence a preoperative urodynamic study was noninferior to basic office examinations for surgical outcome. The addition of behavioral intervention did not allow female patients to discontinue antimuscarinics for urge urinary incontinence. PRIDE showed that modest weight reductions significantly decreased urinary incontinence.

CONCLUSIONS

Strategies for future research on urinary incontinence should include a focus on early disease, risk factor identification, better phenotyping, incorporation of new technologies, patient centered research and prevention.

The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates

This article assesses the reported prevalence and incidence rates for benign prostatic hyperplasia and lower urinary tract symptoms (BPH/LUTS) by age, symptom severity, and race/ethnicity. BPH/LUTS prevalence and incidence rates increase with increasing age and vary by symptom severity. The BPH/LUTS relationship is complex due to several factors. This contributes to the range of reported estimates and difficulties in drawing epidemiologic comparisons. Cultural, psychosocial, economic, and/or disease awareness and diagnosis factors may influence medical care access, symptom reporting and help-seeking behaviors among men with BPH/LUTS. However, these factors and their epidemiologic association with BPH/LUTS have not been thoroughly investigated.

Advancing a Comprehensive Approach to the Study of Lower Urinary Tract Symptoms

PURPOSE

Lower urinary tract symptoms are common in the United States population, leading to significant economic, quality of life and public health issues. The burden will increase as the population ages, and risk factors for lower urinary tract symptoms, including diabetes and obesity, remain highly prevalent. Improving clinical management and establishing the knowledge base to prevent lower urinary tract symptoms will require a comprehensive research approach that examines factors beyond the lower urinary tract. While the study of extra-lower urinary tract factors has increased recently, current urological research does not systematically account for the broad set of potential contributing factors spanning biological, behavioral, psychological/executive function and sociocultural factors. A comprehensive assessment of potential contributors to risk, treatment response and progression is necessary to reduce the burden of this condition in the United States.

MATERIALS AND METHODS

We considered challenges to continuing the predominantly lower urinary tract dysfunction centric approach that has dominated previous research of lower urinary tract symptoms.

RESULTS

We developed a new, comprehensive framework for urology research that includes a broader set of potential factors contributing to lower urinary tract symptoms. This framework aims to broaden research to consider a comprehensive set of potential contributing factors and to engage a broad range of researchers in the investigation of as many extra-lower urinary tract factors as possible, with the goal of improving clinical care and prevention.

CONCLUSIONS

We propose a new framework for future urology research, which should help to reduce the medical and economic burden of lower urinary tract symptoms in the United States population.

Heritability of Lower Urinary Tract Symptoms in Men: A Twin Study

PURPOSE

Symptoms of urinary irritation, urgency, frequency and obstruction, known as lower urinary tract symptoms, are common in urological practice. However, little is known about the etiology or pathogenesis of lower urinary tract symptoms, especially the relative contributions of genetic and environmental factors to the development of these symptoms. We used a classic twin study design to examine the relative contributions of genetic and environmental factors to the occurrence of lower urinary tract symptoms in middle-aged men.

MATERIALS AND METHODS

Twins were members of the Vietnam Era Twin Registry. We used a mail survey to collect data on lower urinary tract symptoms using the I-PSS (International Prostate Symptom Score) instrument. Twin correlations and biometric modeling were used to determine the relative genetic and environmental contributions to variance in I-PSS total score and individual items.

RESULTS

Participants were 1,002 monozygotic and 580 dizygotic middle-aged male twin pairs (mean age 50.2 years, SD 3.0). Nearly 25% of the sample had an I-PSS greater than 8, indicating at least moderate lower urinary tract symptoms. The heritability of the total I-PSS was 37% (95% CI 32-42). Heritability estimates ranged from 21% for nocturia to 40% for straining, with moderate heritability (34% to 36%) for urinary frequency and urgency.

CONCLUSIONS

Genetic factors provide a moderate contribution (20% to 40%) to lower urinary tract symptoms in middle-aged men, suggesting that environmental factors may also contribute substantially to lower urinary tract symptoms. Future research is needed to define specific genetic and environmental mechanisms that underlie the development of these symptoms and conditions associated with lower urinary tract symptoms.

Rural vs. urban disparities in association with lower urinary tract symptoms and benign prostatic hyperplasia in ageing men, NHANES 2001-2008

OBJECTIVE

The objective of this study was to investigate rural/urban and socio-demographic disparities in lower urinary tract symptoms and benign prostatic hyperplasia (LUTS/BPH) in a nationally representative population of men.

METHODS

Data on men age ≥40 years (N = 4,492) in the 2001-2008 National Health and Nutrition Examination Surveys were analysed. Self-report of physician-diagnosed enlarged prostate and/or BPH medication use defined recognised LUTS/BPH. Urinary symptoms without BPH diagnosis/medications defined unrecognised LUTS/BPH. Rural-Urban Commuting Area Codes assessed urbanisation. Unadjusted and multivariable associations (odds ratios (OR)) between LUTS/BPH and covariates were calculated using logistic regression.

RESULTS

Recognised and unrecognised LUTS/BPH weighted-prevalence estimates were 16.5% and 9.6%. There were no significant associations between LUTS/BPH and rural/urban status. Significant predisposing factors for increased adjusted odds of recognised and unrecognised LUTS/BPH included age, hypertension (OR=1.4;1.4), analgesic use (OR=1.4;1.4) and PSA level >4 ng/mL (OR=2.3;1.9) when adjusted for rural/urban status, race, education, income, alcohol, health insurance, health care and proton pump inhibitor (PPI) use (all p ≤ 0.1). Restricting to urban men only (N = 3,371), healthcare use (≥4visits/year) and PPI's increased adjusted odds of recognised LUTS/BPH (OR=2.0;1.6); no health insurance and <high school education decreased odds (OR=0.5;0.6) after adjusting for variables listed above, antidepressant and calcium channel blocker use (p ≤ 0.1). Also among urban men, adjusted odds of unrecognised LUTS/BPH increased for blacks (OR=1.9), Hispanic/Other (OR=1.9) and income<$34,999 (OR=1.6). Among rural men only (N = 1,121), adjusted odds of recognised and unrecognised LUTS/BPH increased for age, hypertension (OR=1.9;1.7) and analgesic use (OR=2.0;1.5) when adjusting for race, CRP, antidepressant and dyslipidaemic use (p ≤ 0.1).

CONCLUSION

Rural/urban status was not associated with significantly increased adjusted odds of either recognised or unrecognised LUTS/BPH.

Do baseline estrogen and testosterone affect lower urinary tract symptoms (LUTS) prior to or after pharmacologic treatment with tadalafil?

Little is known about how total testosterone and estradiol-17β influence lower urinary tract symptoms (LUTS) in men with benign prostatic hypertrophy (BPH). We analyzed data from a subset of men aged ≥18 years randomized to tadalafil 5 mg once-daily or placebo who had ≥6 month history of LUTS and an International Prostate Symptom Score (IPSS)≥13 enrolled in one of three randomized, placebo-controlled tadalafil clinical trials (N = 958). Three specific aims were addressed, as follows: (i) To characterize enrolled men by treatment randomization and testosterone level; (ii) to assess cross-sectional associations of estradiol-17β, testosterone, and LUTS prior to treatment with tadalafil; and, (iii) to assess longitudinal associations between baseline estradiol-17β and testosterone and improvements or worsening of LUTS during a 12-week period of tadalafil or placebo administration. LUTS were assessed by total IPSS, IPSS voiding sub-score (IPSS-V) and IPSS storage sub-score (IPSS-S) for cross-sectional analyses, and change in total IPSS (ΔIPSS), ΔIPSS-V, and ΔIPSS-S between baseline and 12-week visit for longitudinal analyses. Correlation analyses and linear regression examined associations. Baseline testosterone was not significantly associated with IPSS. In contrast, estradiol-17β was inversely correlated with IPSS (r = -0.08; p < 0.05) and IPSS-S (r = -0.14; p < 0.05). Tadalafil treatment resulted in greater IPSS improvements in men with lower baseline estradiol-17β versus those with higher baseline estradiol-17β. Lower baseline estradiol-17β was significantly associated with modestly improved ΔIPSS-V (p = 0.04) and Δtotal IPSS (p = 0.05) but not with ΔIPSS-S, following treatment which may substantiate the role of bladder dysfunction because of nerve and smooth muscle changes in the bladder in addition to benign prostatic enlargement in LUTS. Circulating baseline testosterone did not predict ΔIPSS. Men with lower baseline estradiol-17β levels showed greater responsiveness to tadalafil 5 mg treatment than those with higher baseline estradiol-17β levels when responsiveness was measured using total IPSS and IPSS-V.

Relationship of urologic complications with health-related quality of life and perceived value of health in men and women with type 1 diabetes: the Diabetes Control and Complications Trial/Epidemiology of Interventions and Complications (DCCT/EDIC) cohort

OBJECTIVE

Limited information exists about the influence of urologic complications on health-related quality of life (HRQOL) in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

We studied 664 men and 580 women from the Diabetes Control and Complications Trial/Epidemiology of Interventions and Complications Study: mean ages were 51.6 ± 6.6 and 50.6 ± 7.2 years and duration of diabetes was 29.5 ± 4.8 and 29.8 ± 5.1 years, respectively. We assessed associations of sexual dysfunction, lower urinary tract symptoms (LUTS), and, in women, urinary incontinence (UI) with general quality of life (SF-36), perceived value of health (EuroQol-5), diabetes-related quality of life (Diabetes Quality of Life Scale [DQOL]), and psychiatric symptoms (Symptom Checklist 90-R).

RESULTS

In both men and women, urologic complications adversely affected HRQOL and psychiatric symptoms, even after accounting for history of depression leading to treatment. Multivariable analyses accounting for the presence of diabetic retinopathy, neuropathy, and nephropathy also revealed substantial independent effects. In men, for example, the odds (95% CI) of a low DQOL score (≤25th percentile) were 3.01 (1.90-4.75) times greater with erectile dysfunction and 2.65 (1.68-4.18) times greater with LUTS and in women, 2.04 (1.25-3.35) times greater with sexual dysfunction and 2.71 (1.72-4.27) times greater with UI/LUTS combined compared with men and women without such complications. Similar effects were observed for the other measures.

CONCLUSIONS

Sexual dysfunction and urinary complications with type 1 diabetes are associated with decreased quality of life and perceived value of health and with higher levels of psychiatric symptoms, even after accounting for other diabetes complications and depression treatment.

Hyperglycemia and insulin resistance and the risk of BPH/LUTS: an update of recent literature

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) are highly prevalent in older men and represent a substantial challenge to public health. Increasing epidemiologic evidence suggests that diabetes and associated hyperglycemia and insulin resistance significantly increase the risks of BPH and LUTS. Plausible pathophysiologic mechanisms to explain these associations include increased sympathetic tone, stimulation of prostate growth by insulin and related trophic factors, alterations in sex steroid hormone expression, and induction of systemic inflammation and oxidative stress. This article presents a comprehensive update of the current understanding of clinical and epidemiologic research on diabetes and BPH/LUTS, describes hypothesized pathophysiologic mechanisms linking these conditions, and recommends future directions for research.

Sexually transmitted infections, benign prostatic hyperplasia and lower urinary tract symptom-related outcomes: results from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

OBJECTIVE

To examine whether a history of sexually transmitted infections (STIs) or positive STI serology is associated with prevalent and incident benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS)-related outcomes in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial.

METHODS

Self-reported history of STIs (gonorrhoea, syphilis) was ascertained at baseline, and serological evidence of STIs (Chlamydia trachomatis, Trichomonas vaginalis, human papillomavirus (HPV)-16, HPV-18, herpes simplex virus type 2, human herpesvirus type 8 and cytomegalovirus) was detected in baseline serum specimens. We used data collected on the baseline questionnaire, as well as results from the baseline prostate-specific antigen (PSA) test and digital rectal examination (DRE), to define prevalent BPH/LUTS-related outcomes as evidence of LUTS (self-reported diagnosis of an enlarged prostate/BPH, BPH surgery or nocturia [waking ≥2 times/night to urinate]) and evidence of prostate enlargement (PSA > 1.4 ng/mL or prostate volume ≥30 mL) in men without prostate cancer. We created a similar definition of incident BPH using data from the follow-up questionnaire completed 5-13 years after enrolment (self-reported diagnosis of an enlarged prostate/BPH or nocturia), data on finasteride use during follow-up, and results from the follow-up PSA tests and DREs. We used Poisson regression with robust variance estimation to calculate prevalence ratios (PRs) in our cross-sectional analysis of self-reported (n = 32 900) and serologically detected STIs (n = 1 143) with prevalent BPH/LUTS, and risk ratios in our prospective analysis of self-reported STIs with incident BPH/LUTS (n = 5 226).

RESULTS

Generally null results were observed for associations of a self-reported history of STIs and positive STI serologies with prevalent and incident BPH/LUTS-related outcomes, with the possible exception of T. vaginalis infection. This STI was positively associated with prevalent nocturia (PR 1.36, 95% confidence interval (CI) 1.18-1.65), prevalent large prostate volume (PR 1.21 95% CI 1.02-1.43), and any prevalent BPH/LUTS (PR 1.32 95% CI 1.09-1.61); too few men had information on both STI serologies and incident BPH/LUTS to investigate the associations between T. vaginalis infection and incident BPH/LUTS-related outcomes.

CONCLUSIONS

Our findings do not support associations of several known STIs with BPH/LUTS-related outcomes, although T. vaginalis infection may warrant further study.

Overactive bladder in the vulnerable elderly

Overactive bladder (OAB) is a common problem that may occur in individuals of all ages. It has a considerable impact on patient quality of life, and although moderately effective management strategies do exist, this condition often remains undiagnosed and untreated. OAB needs to be viewed as a symptom complex. Its presentation and management are complicated in the vulnerable elderly by the presence of baseline frailty and multiple coexisting chronic conditions. Furthermore, and beyond a simple understanding of symptomatology, providers must address patient goals and motivations as well as the expectations of caretakers. These multiple levels of perception, function, expectations, and treatment efficacy/risks must be tailored to the individual patient. While the vulnerable elderly patient may often have evidence of urinary tract dysfunction, OAB and urge urinary incontinence in this population must be understood as a multifactorial geriatric syndrome and viewed in the context of medical and functional baseline and precipitating risk factors. Expectations and goals must be tailored to the resources of vulnerable elderly patients and their caregivers, and care must be coordinated with other medical care providers. The management of OAB in the vulnerable elderly often poses significant management challenges. Nonetheless, with a thoughtful approach and an aim towards future research specifically for this population, significant reductions in morbidity and mortality long with enhancement in health-related quality of life are possible.

Initial treatment of men with newly diagnosed lower urinary tract dysfunction in the Veterans Health Administration

OBJECTIVE

To examine initial treatments given to men with newly diagnosed lower urinary tract dysfunction (LUTD) within a large integrated health care system in the United States.

METHODS

We used data from 2003 to 2009 from the Veteran's Health Administration to identify newly diagnosed cases of LUTD using established ICD-9CM codes. Our primary outcome was initial LUTD treatment (3 months), categorized as watchful waiting (WW), medical therapy (MT), or surgical therapy (ST); our secondary outcome was pharmacotherapy class received. We used logistic regression models to examine patient, provider, and health system factors associated with receiving MT or ST when compared with WW.

RESULTS

There were 393,901 incident cases of LUTD, of which 58.0% initially received WW, 41.8% MT, and 0.2% ST. Of the MT men, 79.8% received an alpha-blocker, 7.7% a 5-alpha reductase inhibitor, 3.3% an anticholinergic, and 7.3% combined therapy (alpha-blocker and 5-alpha reductase inhibitor). In our regression models, we found that age (higher), race (white/black), income (low), region (northeast/south), comorbidities (greater), prostate-specific antigen (lower), and provider (nonurologist) were associated with an increased odds of receiving MT. We found that age (higher), race (white), income (low), region (northeast/south), initial provider (urologist), and prostate-specific antigen (higher) increased the odds of receiving ST.

CONCLUSION

Most men with newly diagnosed LUTD in the Veteran's Health Administration receive WW, and initial surgical treatment is rare. A large number of men receiving MT were treated with monotherapy, despite evidence that combination therapy is potentially more effective in the long-term, suggesting opportunities for improvement in initial LUTD management within this population.

Lower urinary tract dysfunction in male Iraq and Afghanistan war veterans: association with mental health disorders: a population-based cohort study

OBJECTIVE

To determine the prevalence and correlates of lower urinary tract symptoms (LUTS) among returned Iraq and Afghanistan veterans; in particular its association with mental health diagnoses and medication use.

METHODS

We performed a retrospective cohort study of Iraq and Afghanistan veterans who were new users of U.S. Department of Veterans Affairs health care. Mental health diagnoses were defined by International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes from medical records. LUTS was defined by ICD-9-CM code, use of prescription medication for LUTS, or procedure for LUTS. We determined the independent association of mental health diagnoses and LUTS after adjusting for sociodemographic and military service characteristics, comorbidities, and medications.

RESULTS

Of 519,189 veterans, 88% were men and the mean age was 31.8 years (standard deviation ± 9.3). The overall prevalence of LUTS was 2.2% (11,237/519,189). Veterans with post-traumatic stress disorder (PTSD) were significantly more likely to have a LUTS diagnosis, prescription, or related procedure (3.5%) compared with veterans with no mental health diagnoses (1.3%) or a mental health diagnosis other than PTSD (3.1%, P <.001). In adjusted models, LUTS was significantly more common in veterans with PTSD with and without other mental health disorders vs those without mental health disorders (adjusted relative risk [ARR] = 2.04, 95% confidence interval [CI] = 1.94-2.15) and in veterans prescribed opioids (ARR = 2.46, 95% CI = 2.36-2.56).

CONCLUSION

In this study of young returned veterans, mental health diagnoses and prescription for opioids were independently associated with increased risk of receiving a diagnosis, treatment, or procedure for LUTS. Provider awareness may improve the detection and treatment of LUTS, and improve patient care and quality of life.

Cohort profile: the Boston Area Community Health (BACH) survey

The Boston Area Community Health (BACH) Survey is a community-based, random sample, epidemiologic cohort of n = 5502 Boston (MA) residents. The baseline BACH Survey (2002-05) was designed to explore the mechanisms conferring increased health risks on minority populations with a particular focus on urologic signs/symptoms and type 2 diabetes. To this end, the cohort was designed to include adequate numbers of US racial/ethnic minorities (Black, Hispanic, White), both men and women, across a broad age of distribution. Follow-up surveys were conducted ∼5 (BACH II, 2008) and 7 (BACH III, 2010) years later, which allows for both within- and between-person comparisons over time. The BACH Survey's measures were designed to cover the following seven broad categories: socio-demographics, health care access/utilization, lifestyles, psychosocial factors, health status, physical measures and biochemical parameters. The breadth of measures has allowed BACH researchers to identify disparities and quantify contributions to social disparities in a number of health conditions including urologic conditions (e.g. nocturia, lower urinary tract symptoms, prostatitis), type 2 diabetes, obesity, bone mineral content and density, and physical function. BACH I data are available through the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Central Repositories (www.niddkrepository.org). Further inquiries can be made through the New England Research Institutes Inc. website (www.neriscience.com/epidemiology).

Impact of partial urethral obstruction on bladder function: time-dependent changes and functional correlates of altered expression of Ca²⁺ signaling regulators

In animal models of partial urethral obstruction (PUO), altered smooth muscle function/contractility may be linked to changes in molecules that regulate calcium signaling/sensitization. PUO was created in male rats, and urodynamic studies were conducted 2 and 6 wk post-PUO. Cystometric recordings were analyzed for the presence or absence of nonvoiding contractions [i.e., detrusor overactivity (DO)]. RT-PCR and Western blots were performed on a subpopulation of rats to study the relationship between the expression of RhoA, L-type Ca(2+) channels, Rho kinase-1, Rho kinase-2, inositol 1,4,5-trisphosphate, ryanodine receptor, sarco(endo)plasmic reticulum Ca(2+)-ATPase 2 and protein kinase C (PKC)-potentiated phosphatase inhibitor of 17 kDa, and urodynamic findings in the same animal. Animals displayed DO at 2 (38%) and 6 wk (43%) post-PUO, increases were seen in in vivo pressures at 2 wk, and residual volume at 6 wk. Statistical analysis of RT-PCR and Western blot data at 2 wk, during the compensatory phase of detrusor hypertrophy, documented that expression of molecules that regulate calcium signaling and sensitization was consistently lower in obstructed rats without DO than those with DO or control rats. Among rats with DO at 2 wk, linear regression analysis revealed positive correlations between in vivo pressures and protein and mRNA expression of several regulatory molecules. At 6 wk, in the presence of overt signs of bladder decompensation, no clear or consistent alterations in expression of these same targets were observed at the protein level. These data extend prior work to suggest that molecular profiling of key regulatory molecules during the progression of PUO-mediated bladder dysfunction may shed new light on potential biomarkers and/or therapeutic targets.

Are commonly used psychoactive medications associated with lower urinary tract symptoms?

PURPOSE

Lower urinary tract symptoms (LUTS) such as urinary frequency and urgency are bothersome and associated with reduced quality of life. Atypical antipsychotics (AAPs) have been implicated in increasing the risk of urinary incontinence. In a large community-based sample of men and women, we examined the associations of AAP and selective serotonin reuptake inhibitor (SSRIs) use with LUTS.

METHODS

Data were collected (2002-2005) from a generalizable sample of Boston, MA, USA, residents aged 30-79 (N = 5503). LUTS were assessed using the American Urologic Association Symptom Index (AUA-SI). The prevalence of clinically-significant LUTS was estimated using a cutoff AUA-SI score of 8+ to indicate moderate-to-severe symptoms. Confounder-adjusted odds ratios (ORs) and 95% confidence intervals (CI) were calculated from multivariate logistic regression to estimate the associations for psychoactive drugs used in the previous month (SSRIs, AAPs, both) and LUTS.

RESULTS

Among women, AAP users had a higher prevalence of LUTS (46.2%) compared with SSRI users (23.5%) and those with depressive symptoms not using SSRIs or AAPs (26.3%). Corresponding prevalence estimates among men were 32.7%, 29.8%, and 33.3%. In multivariate models, AAP use was significantly associated with LUTS among women when used either with (OR = 2.72, 95% CI:1.45-5.10) or without (OR = 3.05, 95% CI:1.30-7.16) SSRIs, but SSRI use without AAP use was not associated with LUTS compared with nonusers without depressive symptoms. No associations were observed among men.

CONCLUSIONS

In our study, AAPs but not SSRIs were associated with increased prevalence of LUTS among women only. Further prospective research is needed to determine time sequence and cause and effect.

Prevalence of post-micturition symptoms in association with lower urinary tract symptoms and health-related quality of life in men and women

OBJECTIVE

• To estimate the prevalence of post-micturition symptoms (a feeling of incomplete emptying following urination and post-micturition dribble) in a population-based sample of men and women, and to examine overlap with storage and voiding LUTS and associations with health-related quality of life (HRQL).

PATIENTS AND METHODS

• Data were obtained by in-person interview in the Boston Area Community Health survey, a population-based random sample of 2301 men and 3202 women aged 30-79 years in the USA. • Lower urinary tract symptoms (LUTS) were defined using the International Prostate Symptom Score and standardized terminology. • Multivariate linear regression was used to evaluate associations between urological symptoms and validated HRQL measures (SF-12 and activities interference) cross-sectionally.

RESULTS

• The overall prevalence of post-micturition symptoms was 11.8% in men and 8.5% in women. • The prevalence increased with age in men but not women. • In men, post-void dribbling contributed to much of the post-micturition symptoms, whereas, in women, incomplete emptying was more common. • For both genders, over 50% with voiding symptoms also had post-micturition symptoms, compared to less than 50% of respondents who reported storage symptoms. • The presence of post-micturition symptoms, particularly incomplete emptying, was indicative of mildly impaired physical HRQL and activities interference in men and women, and mental HRQL in men (P < 0.01).

CONCLUSIONS

• Post-micturition symptoms were more prevalent than any individual voiding symptom and commonly overlapped with other LUTS. • Over half of men and women with a voiding symptom also had a post-micturition symptom. • The presence of post-micturition symptoms was indicative of impaired HRQL.

Commonly used antihypertensives and lower urinary tract symptoms: results from the Boston Area Community Health (BACH) Survey

Study Type - Prevalence (inception cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Certain antihypertensives, particularly diuretics and calcium channel blockers, are known to be associated with increased risk of LUTS including nocturia, but little is known about gender-specific effects. This is the first epidemiological study, to our knowledge, to compare the prevalence of several urological symptoms (storage, voiding and nocturia) among male and female users of a wide variety of common antihypertensives using a community-based sample.

OBJECTIVE

To examine differences in the prevalence of lower urinary tract symptom (LUTS) among users of five common AHT classes compared with non-users, adjusted for LUTS risk factors in a large, representative sample.

SUBJECTS AND METHODS

Data were from the Boston Area Community Health Survey, a population-based study of community-dwelling male and female (30-79 years) residents of Boston, MA, USA for whom prescription drug information was collected between 2002 and 2005. The urological symptoms of storage, voiding, and nocturia were assessed using interviewer-administered questionnaires and the American Urological Association Symptom Index. This analysis was conducted among 1865 participants with an AHT indication. Associations of angiotensin-converting enzyme inhibitors, beta blockers, calcium channel blockers (CCBs) and loop and thiazide diuretics with the three groups of LUTS were estimated using odds ratios (ORs) and 95% confidence intervals (CIs) from multivariate logistic regression (referent group: untreated hypertension). Overlap in use was accounted for using monotherapy and combination therapy exposure categories.

RESULTS

Among women, monotherapy with CCBs was associated with increased prevalence of nocturia (OR = 2.65, 95% CI: 1.04-6.74) and voiding symptoms (OR = 3.84, 95% CI: 1.24-11.87); these results were confined to women aged <55 years. Among men of all ages, positive associations were observed for thiazides and voiding symptoms (monotherapy OR = 2.90, 95% CI: 1.17-7.19), and loop diuretics and nocturia (combination therapy OR = 2.55, 95% CI: 1.26-5.14).

CONCLUSION

Results are consistent with the hypothesis that certain AHTs may aggravate LUTS. The presence of new or worsening LUTS among AHT users suggests medications should be reviewed and a change in AHT class considered.

Physical function and health-related quality-of-life in a population-based sample

BACKGROUND. It is of interest to understand whether impaired physical function is associated with health-related quality-of-life (HRQOL). We examined upper and lower body physical function and its relationship with two domains of HRQOL among men. METHODS. We conducted a population-based observational study of musculoskeletal health among Boston, MA residents, the Boston Area Community Health/Bone Survey. Participants were 1219 randomly-selected Black, Hispanic, and White males (30-79 years). Upper body function was measured using hand grip strength, while lower body function was measured by combining a timed walk and a chair stand test. HRQOL was measured using the physical (PCS-12) and mental health (MCS-12) component scores of the SF-12. Multivariate linear regression models were used to estimate the association between poor function and HRQOL. RESULTS. There was a significant association of poor upper body physical function with the MCS-12 (β coefficient: -4.12, p = 0.003) but not the PCS-12 (β coefficient: 0.79, p = 0.30) compared to those without poor function. Those with poor lower body physical function had significantly lower PCS-12 scores (β: -2.95, p = 0.007), compared to those without poor function, but an association was not observed for MCS-12 scores. CONCLUSIONS. Domains of physical function were not consistently related to domains of HRQOL.

Recruitment of participants to a clinical trial of botanical therapy for benign prostatic hyperplasia

OBJECTIVES

The timely recruitment of study participants is a critical component of successful trials. Benign prostatic hyperplasia (BPH), a common nonmalignant urologic condition among older men, is characterized by lower urinary tract symptoms (LUTS). Successful recruitment methods for a trial of medical therapy for BPH, Medical Therapy of Prostate Symptoms (MTOPS), were mass mailing and advertising. The Complementary and Alternative Medicines Trial for Urological Symptoms (CAMUS) was designed to evaluate a botanical therapy, saw palmetto, for the treatment of BPH. The objective of this study was to evaluate recruitment strategies for CAMUS and to contrast the baseline characteristics of CAMUS participants with those recruited to a similar trial using conventional medical therapy.

DESIGN

CAMUS is a randomized, double-blind, placebo-controlled trial designed to evaluate the effects of saw palmetto given at escalating doses over an 18-month period on relief from LUTS.

SUBJECTS

The target enrollment goal was 350 men with LUTS from 11 clinical centers over a 12-month period. The recruitment techniques used and participants contacted, screened, and randomized through each technique were obtained from the clinical centers. Baseline characteristics of the CAMUS participants were compared with participants in the MTOPS trial who met the CAMUS eligibility criteria for LUTS.

RESULTS

The target enrollment goal was achieved in 11 months. The overall monthly recruitment rate per site was 3.7 and ranged from 2.4 to 8.0. The most successful recruitment methods were mass mailing and advertising, which accounted for 39% and 35% of the study participants, respectively. In comparison to MTOPS participants, CAMUS participants were younger, more highly educated, more diverse, and had less severe urinary symptoms.

CONCLUSIONS

Successful recruitment methods for CAMUS were similar to those in MTOPS. The use of botanical therapy attracted a less symptomatic and more educated study population.

Dietary, but not supplemental, intakes of carotenoids and vitamin C are associated with decreased odds of lower urinary tract symptoms in men

Lower urinary tract symptoms (LUTS) in men may be related to micronutrients involved in prevention of oxidative damage or cell growth and differentiation. We tested the hypothesis that carotenoid, vitamin A, and vitamin C intake were inversely associated with total LUTS, voiding, and storage symptoms. We conducted a cross-sectional multivariate analysis of 1466 men aged 30-79 y in the Boston Area Community Health survey (2002-2005), a population-based random sample survey. Data were collected by in-person interview and validated FFQ. Moderate-to-severe LUTS were defined using the American Urological Symptom Index and analyzed using multivariate logistic regression. Overall, men consuming greater dietary lycopene, β-carotene, total carotenoid, or vitamin A had ~40-50% decreased odds of LUTS compared with the lowest intake quartiles (e.g. β-carotene and storage symptoms, OR = 0.56, 95% CI = 0.39, 0.82; P-trend = 0.02). Interactions were observed between dietary iron and vitamin C or β-cryptoxanthin, whereby inverse associations with LUTS, particularly voiding symptoms, occurred only among men with moderate-to-high iron intake (P-interaction = 0.001). High-dose supplemental and total vitamin C were positively associated with LUTS (e.g. supplemental vitamin C ≥ 250 mg/d, OR = 1.83, 95% CI = 1.21, 2.77; P-trend = 0.02). An interaction between β-carotene and smoking status (P-interaction = 0.004) indicated greater odds of LUTS with higher β-carotene intake among current smokers. Results suggest that modifying consumption of carotenoids and vitamin C may influence LUTS in men.

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.