Serum sex hormones and the 20‐year risk of lower urinary tract symptoms in community‐dwelling older men

Study Type – Prognosis (inception cohort)
Level of Evidence 2b

OBJECTIVE

To evaluate serum sex steroid hormone concentrations and long‐term risk of subsequent lower urinary tract symptoms (LUTS) in a cohort of community‐dwelling older men.

SUBJECTS AND METHODS

Between 1984 and 1987, serum sex hormone concentrations were measured in participants in the Rancho Bernardo Study, a prospective, community‐based study. In 2006, the American Urological Association Symptom Index (AUA‐SI) was mailed to surviving male participants. Logistic regression was used to examine associations of baseline hormone concentrations with AUA‐SI.

RESULTS

Among 158 surviving men with complete data and no history of prostate cancer, the mean (sd ) age at serum sex steroid assessment was 58 (6.6) years with a mean (sd ) follow‐up of 20.3 (0.6) years. In age‐adjusted logistic regression, there was a significant inverse association of testosterone : dihydrotestosterone (DHT) with LUTS (P = 0.05). Also, men with higher concentrations of bioavailable testosterone had a 56% decreased risk of LUTS compared with those with hypogonadal concentrations, although the association was not statistically significant (odds ratios 0.44, 95% confidence interval 0.14–1.40) or distributed evenly among quartiles. There were no significant associations of total testosterone, oestradiol (E₂), testosterone : E₂, DHT, or dehydroepiandrosterone with LUTS or with any measured hormones and urinary bother.

CONCLUSIONS

In this cohort, men with higher mid‐life levels of testosterone : DHT and bioavailable testosterone had a decreased 20‐year risk of LUTS. These data support other studies reporting inverse associations of serum testosterone with LUTS. Clinical trials of testosterone therapy should include LUTS and clinical benign prostatic hyperplasia as outcomes.     

Videourodynamic analysis in men with lower urinary tract symptoms: Correlation between age and prostate size with lower urinary tract dysfunction

ObjectivesLower urinary tract symptoms (LUTS) are highly prevalent in aging men. In this study we examined the relationship between age, total prostate volume (TPV), and videourodynamic study findings.MethodsWe retrospectively analyzed a total of 971 men ≥ 40 years of age referred to us for investigation of LUTS. We analyzed the distribution of the different videourodynamic study diagnoses in male LUTS by correlating their age and prostate size.ResultsThe most common diagnosis in the bladder outlet obstruction (BOO) group differed significantly by age and poor relaxation of the external sphincter (PRES) in those aged < 50 years; bladder neck dysfunction in those aged 50–69 years, and benign prostatic obstruction in those ≥ 60 years. Detrusor overactivity was the most common diagnosis in all ages in the bladder dysfunction group, and the cases of hyperactivity with impaired contractility (DHIC) increased with age. In patients < 50 years of age, PRES was the most common diagnosis in the BOO group in both those with small prostates (total prostate volume ≤ 40 mL) and large prostates (total prostate volume > 40 mL). In patients aged 50–69 years, the most common diagnosis in those with BOO and a small prostate was bladder neck dysfunction, and that in those with BOO and a large prostate was benign prostatic obstruction. Similar results were observed in patients aged ≥ 70 years. In all age groups, the majority of patients with detrusor overactivity, hypersensitive bladder, detrusor underactivity, and DHIC had a small prostate.ConclusionIn male LUTS, the diagnoses in the BOO group differed by age and prostate volume. In young patients with BOO, the leading diagnosis was PRES, and the contribution of prostate volume to BOO increased with age. As age increased, the bladder function became more complex with an increased percentage of patients with DHIC. Both bladder outlet and bladder functions were affected by age.     

Prevalence of conditions potentially associated with lower urinary tract symptoms in men

OBJECTIVE: To estimate the frequency of conditions associated with lower urinary tract symptoms (LUTS, typically included when assessing benign prostatic hyperplasia, BPH), as other causes of LUTS should be excluded when diagnosing BPH, using data from the Olmsted County Study of Urinary Symptoms and Health Status among Men. SUBJECTS AND METHODS: During 1989-91, Caucasian men aged 40-79 years were randomly selected from the Olmsted County population. Before contact, eligibility was determined by reviewing the community medical records. Baseline exclusion criteria included comorbid pre-existing conditions or treatments, e.g. prostate, bladder or lower back surgery, bladder neck contracture or cancer, diabetes with lower extremity amputation, and neurological diseases, including Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, tabes dorsalis and stroke. Men with these conditions were excluded from the Olmsted County Study at baseline, because these conditions are potentially associated with LUTS. RESULTS: Of the 5100 randomly sampled men, 13.4% met at least one of the pre-existing exclusion criteria. Individually, the frequency of exclusions was 7.8% for prostate cancer or surgery, 4.8% for back surgery, 1.3% for bladder surgery and 1.4% for neurological conditions. All other conditions represented <1.0% of the study exclusions. Older men were more likely to meet at least one of the exclusion criteria, with men in their fifth to eighth decade having a total exclusion frequency of 1.4%, 5.4%, 8.5% and 32.8%, respectively. The most common reason for men in their fifth decade to be excluded was lower back surgery (0.9%), whereas the most common reason in the eighth was prostate surgery (21.8%). CONCLUSIONS: In men, conditions that may contribute to LUTS, other than BPH, are prevalent in the community and increase in frequency with age. It is important that other conditions associated with LUTS be excluded before a definitive diagnosis of BPH. Any oversight in this initial evaluation can potentially result in misclassification bias, misdiagnosis and incorrect treatment of patients.     

良性前列腺增生术后下尿路症状分析及对策

目的 分析良性前列腺增生术后伴下尿路症状的病因及对策。方法 对26例良性前列腺增生术后仍存在下尿路症状临床资料进行分析并行尿动力学检查。结果 26例中膀胱功能障碍16例，单纯下尿路梗阻9例，尿道括约肌损伤1例。结论 良性前列腺增生术后仍存在下尿路症状的主要原因为膀胱逼尿肌功能障碍和梗阻解除不全，尿动力学检查对分析其原因及进一步治疗具有重要的价值。     

Clinical guidelines for male lower urinary tract symptoms associated with non-neurogenic overactive bladder

The purpose of this guideline is to direct urologists and patients regarding how to identify overactive bladder (OAB) in male patients with lower urinary tract symptoms (LUTS) and to make an accurate diagnosis and establish treatment goals to improve the patients' quality of life (QoL). LUTS are commonly divided into storage, voiding, and postmicturition symptoms, and are highly prevalent in elderly men. LUTS can result from a complex interplay of pathophysiologic features that can include bladder dysfunction and bladder outlet dysfunction such as benign prostatic obstruction (BPO) or poor relaxation of the urethral sphincter. Diagnosis of OAB in male LUTS leads to accurate diagnosis of pure OAB and bladder outlet-related OAB, and appropriate treatment in men with residual storage symptoms after treatment for LUTS.     

Extended-release tolterodine with or without tamsulosin in men with lower urinary tract symptoms and overactive bladder: effects on urinary symptoms assessed by the International Prostate Symptom Score

OBJECTIVE

To evaluate the efficacy of tolterodine extended‐release (ER) plus tamsulosin on lower urinary tract symptoms (LUTS) as assessed by changes in the International Prostate Symptom Score (IPSS) in men who met symptom entry criteria for both overactive bladder (OAB) and benign prostatic hyperplasia (BPH) trials.

PATIENTS AND METHODS

Men aged ≥40 years with an IPSS of ≥12 and diary‐documented OAB symptoms (≥8 voids/24 h and ≥3 urgency episodes/24 h, with or without urgency urinary incontinence) who reported at least moderate problems related to their bladder condition were randomized to receive placebo, tolterodine ER (4 mg), tamsulosin (0.4 mg), or tolterodine ER (4 mg) + tamsulosin (0.4 mg) once daily for 12 weeks. Patients completed the IPSS at baseline and at 1, 6 and 12 weeks.

RESULTS

Patients receiving tolterodine ER + tamsulosin had significantly greater improvements than those taking placebo on IPSS storage subscale scores and scores for all three individual storage items included on the IPSS (urinary frequency, urgency, and nocturnal micturitions) by 12 weeks. Storage subscale and urgency scores were significantly improved vs placebo at 1 and 6 weeks, whereas frequency scores were significantly improved at 6 weeks. Changes in IPSS storage subscale and individual storage item scores in the tolterodine ER and tamsulosin monotherapy groups were not significantly different from placebo at most time points. IPSS voiding subscale scores and scores for three of four individual voiding items (sensation of incomplete emptying, intermittency, and weak stream) were significantly improved by 12 weeks for patients receiving tamsulosin monotherapy vs placebo. Voiding subscale and intermittency scores were significantly improved vs placebo at 1 week; weak stream scores were significantly improved at 1 and 6 weeks. The IPSS voiding subscale and individual voiding item scores in the tolterodine ER + tamsulosin and tolterodine ER groups were not significantly different from placebo at most time points.

CONCLUSIONS

In this distinct clinical research population of men who met traditional symptom entry criteria for both OAB and BPH trials, tolterodine ER + tamsulosin was significantly more effective than placebo in treating storage LUTS, including OAB symptoms. Tamsulosin monotherapy produced significant improvements in voiding LUTS.     

Significant intravesical prostatic protrusion and prostatic calcification predict unfavorable outcomes of medical treatment for male lower urinary tract symptoms

ObjectiveTo evaluate the impact of intravesical prostatic protrusion (IPP) and prostatic calcification on medical treatment for male lower urinary tract symptoms (LUTS).Materials and methodsMen over the age of 40 years with total International Prostate Symptom Score (IPSS) ≥ 8 were recruited from January to August 2013. The maximal flow rate, postvoiding residual (PVR) urine volume, total prostate volume (TPV), transitional zone volume (TZV), transitional zone index (TZI), and grades of IPP and prostate calcification were recorded. All patients received α-blocker monotherapy, and Global Response Assessment (GRA) was used to determine treatment response 1 month after the treatment. The primary end point was to compare the treatment results in patients with and without significant IPP or prostate calcification. Univariate and multivariate logistic regression analyses were performed to determine whether IPP and prostatic calcification are predictors of improved outcome (GRA ≥ 1).ResultsWe enrolled 112 men with a mean age of 65.5 (range, 42–89) years. IPP was significantly positively correlated with TPV, TZV, TZI, and PVR. Prostatic calcification was significantly negatively correlated with total IPSS, IPSS Voiding, and IPSS Storage. After 1-month treatment with α-blockers, the average total IPSS decreased from 18.2 ± 7.4 to 13.1 ± 4.5. Sixty-nine patients (61.6%) reported improved outcomes. Patients with large prostate volumes (TPV ≥ 40 mL) and small prostate volumes (TPV < 40 mL) had similar improved outcome rates (56.5% and 65.1%, respectively). Patients with significant IPP (Grades II and III) had significantly lower improved outcome rates (36.8%) than those without significant IPP (74.3%). Patients with prostatic calcification also had a significantly lower rate of improved outcome (47.9%) than those who did not (71.9%). Multivariate logistic regression analyses showed that IPP and prostatic calcification are predictors of unfavorable outcome (GRA < 1) after adjusting for age, TPV, and total IPSS.ConclusionSignificant IPP and prostatic calcification are unfavorable predictors of successful α-blocker treatment for benign prostatic hyperplasia-induced male LUTS.     

PDE5抑制剂治疗LUTS的进展及意义

勃起功能障碍及下尿路症状均为中老年男性常见疾病,多个流行病学研究证实二者密切相关。近年来多项研究证实PDE5抑制剂在改善ED患者勃起功能的同时,可有效改善患者的LUTS,但对患者的尿动力学指标无改善。本文就国内外ED与LUTS之间的联系、PDE5抑制剂治疗LUTs的进展及其可能的机制做一概述。     

Effectiveness of medical and surgical therapies for lower urinary tract symptoms in the community setting

Study Type – Therapy (outcomes research) Level of Evidence 2c What's known on the subject? and What does the study add? It is known that benign prostatic hyperplasia is a common condition affecting most men by the age of 80 years. There are multiple treatment options available, including both medical and surgical interventions. However, what is not known is how affective the different types of interventions are in the general population. Previous studies have focused on centre‐specific data. What is unique about our study is that it is a prospective cross‐section analysis of a community cohort of men. Through this study we were able to assess the outcomes in the general population as opposed to in a high‐volume surgical centre. Our findings show that in this community medical management was poor at symptomatic improvement, whereas surgical intervention produced the best improvement.

OBJECTIVE

• ? To describe the use and symptomatic outcomes of different therapies for lower urinary tract symptoms (LUTS) in a community‐based population of men followed for 17 years.

PATIENTS AND METHODS

• ? Data from a randomly selected cohort of 2184 men, aged 40–79 years in 1990, from Olmsted County, Minnesota, USA were included in the study. Participants completed a questionnaire similar to the American Urological Association Symptom Index (AUASI) and reported on incontinence.
• ? Men were followed biennially through 2007 (median follow‐up: 13.7 years; Q1, Q3: 8.8, 15.7). Medical and surgical treatments for LUTS were reported on biennial questionnaires and abstracted from community medical records.

RESULTS

• ? Overall, 610 (28%) men received medical or surgical therapy for treatment of LUTS. Patients undergoing vaporization and transurethral resection of the prostate (TURP) had the highest pre‐intervention AUASI scores (P < 0.001) and the most rapid increase in scores over time (P= 0.002) compared with those treated with medications or no therapy. After intervention, symptom progression slowed in all treatment groups.
• ? However, the greatest improvement in AUASI score (median % change) was observed in the TURP group: ?27.45%. The TURP group also reported a significant decrease in incontinence after surgery (% change): TURP: ?22.58%.

CONCLUSION

• ? All therapies were effective at slowing the progression of LUTS, but only TURP patients reported a significant decrease in both LUTS and incontinence after therapy.

     

锯叶棕果实提取物治疗BPH引起的下尿路症状疗效观察

目的:探讨锯叶棕果实提取物治疗BPH引起的下尿路症状的疗效。方法:采用锯叶棕果实提取物单药治疗30例前列腺增生伴下尿路症状患者8周,分别比较患者治疗前后的最大尿流率、前列腺体积、剩余尿量、IPSS评分及QOL评分的变化情况。结果:治疗8周后,患者的最大尿流率、剩余尿量、IPSS评分及QOL评分均有明显改善,前列腺体积则无明显变化。所有患者均无明显不良反应。结论:锯叶棕果实提取物能有效改善BPH患者的下尿路症状。     

联合应用坦索罗辛和托特罗定治疗男性顽固性下尿路症状的临床研究

目的:探讨及对比联合应用高选择性α受体阻滞剂(坦索罗辛)和M受体阻滞剂(托特罗定)及单用高选择性α受体阻滞剂治疗男性顽固性下尿路症状的临床疗效及安全性。方法:2009年4月至2009年12月期间收集我院184例顽固性下尿路症状(LUTS)的男性前列腺增生患者,病程4周至2年。所有患者均为应用高选择性α受体阻滞剂(坦索罗辛)0.2 mg,1次/d,治疗1周后LUTS症状无改善。入选病例随机分成2组,其中坦索罗辛组89例继续应用坦索罗辛0.2 mg,1次/d,治疗4周;联合治疗组95例联合应用高选择性α受体阻滞剂(坦索罗辛)和M受体阻滞剂(托特罗定),给予坦索罗辛0.2 mg 1次/d+托特罗定2 mg 2次/d,治疗4周。分组治疗前后分别进行国际前列腺症状储尿期症状评分(储尿期IPSS)、生活质量评分(QOL)和最大尿流率(Qmax)检测,评估治疗后LUTS症状的改善情况。结果:坦索罗辛组储尿期IPSS、QOL总体评分分别由治疗前的(13.23±4.39)、(4.23±1.27)分下降到治疗后的(12.21±4.07)、(3.53±0.9)分,Qmax由治疗前的(12.31±8.39)ml/s上升到治疗后的(14.12±8.62)ml/s,与治疗前相比差异均无显著性(P>0.05)。联合治疗组储尿期IPSS、QOL总体评分分别由治疗前的(14.45±5.31)、(4.45±0.79)分降到治疗后的(6.56±2.03)、(2.34±0.73)分,Qmax由治疗前的(11.41±9.21)ml/s上升到治疗后的(15.52±8.35)ml/s,与联合治疗前相比差异均有显著性(P<0.01)。184例患者均无严重并发症出现。结论:联合应用坦索罗辛和托特罗定能明显缓解男性顽固性下尿路症状,改善患者的生活质量。未见严重不良反应和急性尿潴留发生。     

Efficacy of alfuzosin and sildenafil combination in male patients with lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are frequently encountered in ageing males. We compared the efficacy of alfuzosin 10 mg alone or in combination with sildenafil 50 mg in the treatment of LUTS due to benign prostatic hyperplasia. One hundred male patients older than 45 years were randomized to two groups containing 50 patients each; one group receiving alfuzosin 10 mg and the other group alfuzosin 10 mg combined with sildenafil 50 mg. International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Q(max)), prostate volume and post-void residual urine were evaluated. The mean age was 60.2 ± 17.8. Mean data of evaluated parameters in both groups at the end of 3rd month compared with baseline values are given respective order as; 5.1 (26.8%) and 5.8 (28.2%) points decreases in IPSS; 1.6 (41.1%) and 1.8 (45%) points decreases in QoL; and 3.4 (29.6%) and 3.4 (33%) points increases in Q(max) . The outcomes of our study cannot be interpreted in such a way to report that alpha blocker-PDE5 inhibitor combination has a better efficacy than alpha blocker treatment alone in patients with LUTS.     

Association among the symptoms, quality of life and urodynamic parameters in patients with improved lower urinary tract symptoms following a transurethral resection of the prostate

AIMS: To investigate the associations of symptoms and the quality of life (QOL) with objective variables in a strictly selected large cohort of subjects with symptomatic benign prostatic obstruction (BPO). METHODS: A retrospective study was conducted in 557 males with BPO in whom a symptomatic improvement had been achieved by transurethral resection of the prostate (TURP), thus suggesting that their lower urinary tract symptoms were primarily due to BPO. The association between the preoperative International Prostate Symptom Score (IPSS) and QOL score with objective variables including the residual volumes, prostate size and urodynamic parameters was statistically analyzed. RESULTS: Maximum flow rate (Q(max)) positively and a residual urine volume (PVR) negatively correlated with symptoms and QOL score. Detrusor overactivity (DO) also was weakly, but broadly associated with the symptoms. Degree of detrusor contractility and bladder capacity had a weak association with only some storage symptoms. The degree of bladder outlet obstruction (BOO) positively related to the scores on urgency, straining and total IPSS. Patients' age had positive correlation with the score on nocturia. The prostate volume was only negligibly correlated with either any symptoms or the QOL score. CONCLUSIONS: Parameters, such as Q(max) or PVR, obtained from the noninvasive urodynamics were most widely correlated with symptoms and QOL. Despite a large group with strict selection of men with LUTS possibly relating to BPO being studied, only weak association between the symptoms or QOL and objective parameters including urodynamics was confirmed.     

Factors correlated with prostate volume in middle-aged men with bothersome lower urinary tract symptoms

ObjectiveThe aim of this study was to investigate the predictive factors of prostate volume (PV) by analyzing potential predictors in a population of middle-aged men with bothersome lower urinary tract symptoms (LUTS) and use a prediction model for PV estimation to compare with digital rectal examination (DRE) alone.Materials and methodsPatients between the ages of 40 years and 64 years who underwent transrectal prostate ultrasound as part of a self-paid medical check-up were enrolled. Participant demographics, medical history, and voiding symptoms were assessed by the International Prostate Symptoms Score (IPSS) questionnaire. A multiple linear regression with stepwise selection was used to analyze the correlations between PV and all potential predictors.ResultsTwo hundred and twenty-eight men with bothersome LUTS (IPSS > 7) were enrolled as study participants at a mean age of 56.4 years. Patients with PV > 25 mL were significantly older and had higher serum prostate-specific antigen (PSA) levels and scores for total IPSS, storage, urgency items, and nocturia items. DRE, serum PSA, age, and urgency score were independent predictors for PV, especially for men with PV > 25 mL, for which the standardized regression equation was PV = 0.74 × (DRE estimation) + 0.10 × (age) + 0.12 × (serum PSA) + 0.079 × (urgency score) (adjusted R² = 0.80).ConclusionIn the current study, we confirmed that serum PSA, age, and urgency score are significant predictors of PV. The prediction model including DRE, PSA, age, and urgency score was a better method to estimate PV than DRE alone, especially for men with a larger prostate (PV > 25 mL).