Do urological symptoms cluster among women? Results from the Boston Area Community Health Survey

OBJECTIVES

To conduct a cluster analysis of urological symptoms among women in the Boston Area Community Health (BACH) Survey, to describe the distribution of urological symptoms within each cluster, and to determine whether comorbidities, demographic characteristics, and lifestyle factors were associated with cluster membership.

SUBJECTS AND METHODS

The BACH Survey is a racially and ethnically diverse random sample (3205 women) of community‐dwelling residents of Boston, MA, USA, aged 30–79 years. Fourteen urological symptoms measured by participant self‐report (using previously validated scales) were included in this analysis. Cluster analyses were conducted using hierarchical and non‐hierarchical (k‐means) methods. Within clusters, demographic characteristics, risk factors for urological symptoms and the interference of symptoms with daily activities were also assessed.

RESULTS

Three‐quarters of the sample reported at least one urological symptom; four symptom clusters were identified. Most symptomatic women (54%) were assigned to Cluster 1, which was characterized by storage symptoms (nocturia and urinary frequency) with an accompanying low prevalence of other urological symptoms; a second cluster was distinguished by frequency symptoms. Clusters 3 and 4 were characterized by a high prevalence of urinary incontinence and had increased interference scores and more symptoms overall (including voiding and post‐voiding symptoms) than the other two clusters. Cluster 4 (8% of symptomatic women) was characterized by a high prevalence of nearly all urological symptoms and the highest interference score. In this most symptomatic cluster, body size and waist circumference were markedly higher, as was the prevalence of diabetes, hypertension and cardiovascular disease than in the other cluster groups or asymptomatic women. Women in Cluster 4 were more likely to be surgically menopausal, or to have had other forms of urogynaecological surgeries than women in the other clusters.

CONCLUSION

Four distinct clusters of urological symptoms were identified among symptomatic women in the BACH Survey, two of which had a high prevalence of urinary incontinence. These cluster patterns provide a novel, empirically‐based framework for investigating aetiological mechanisms and management outcomes for common urological symptoms in women.     

Long term follow-up study of the marsupialization technique for urethral diverticula in women

Fifty-seven women with urethral diverticula were evaluated between 1977 and 1986. Thirty-seven patients had a history of documented recurrent urinary tract infections. Other common leading symptoms were dysuria, frequency, stress urinary incontinence and dyspareunia. The diagnosis was established in 26 patients by voiding cystourethrography. A Spence marsupialization procedure was performed upon 40 patients. Postoperatively, all patients had normal voiding cystourethrograms, sterile urine and relief of symptoms. On long term follow-up study (mean of five years), 53 patients considered the operation as having been successful. Complications were encountered in four patients--stress urinary incontinence grade I in three patients and recurrent urinary tract infection in association with urethral stricture in one patient. The Spence marsupialization procedure is associated with a high success rate and low morbidity, thus, making it applicable to the majority of all distal urethral diverticula in women.     

Efficacy and tolerability of the dual 5alpha-reductase inhibitor, dutasteride, in the treatment of benign prostatic hyperplasia in African-American men

The efficacy and tolerability of dutasteride (0.5 mg daily for 2 years) in African-Americans (n=161), compared with Caucasians (n=3961), was assessed in a post hoc analysis of data from three Phase III clinical trials. Dutasteride significantly reduced serum dihydrotestosterone levels by >90% and significantly improved subjective (symptom score) and objective (prostate volume, peak urinary flow rate, risk of benign prostatic hyperplasia-related surgery and acute urinary retention) outcomes in both African-Americans and Caucasians. For all efficacy measures, there was no statistically significant treatment-by-race interaction and dutasteride was well tolerated in both racial groups. Therefore, dutasteride demonstrated similar efficacy and safety profiles in African-Americans and Caucasians.     

Definition of at-risk patients: baseline variables

Benign prostatic hyperplasia (BPH) represents a significant burden in ageing men due to frequently associated lower urinary tract symptoms (LUTS), which may impair their quality of life. Some men will have progressive disease, mainly characterized by symptom deterioration of > or = 4 points on the International Prostate Symptom Score, but also by the occurrence of acute urinary retention (AUR) and BPH-related surgery. Identifying those at risk of unfavourable outcomes is important to optimize their management. Community-based longitudinal studies provide excellent data on the natural history of BPH. Baseline variables such as age, severe LUTS, low peak flow rate, high postvoid residual urine volume (PVR), enlarged prostate and high serum prostate-specific antigen (PSA) levels, have been identified as risk factors for AUR and BPH-related surgery in such studies. Placebo arms of controlled studies have more limited value for assessing the natural history, due to strong selection criteria which generate a regression to the mean artefact and narrow the applicability to the general population. Nevertheless, in these controlled studies, baseline serum PSA level and to a lesser extent prostate size consistently predicted the risk of AUR and BPH-related surgery. Conversely, quantitative variables such as baseline symptom severity and peak flow rate behaved paradoxically, probably as a consequence of strict inclusion criteria, resulting regression to the mean, and 'ceiling' effects. Results from the Medical Therapy of Prostatic Symptoms study and the Alfuzosin Long-Term Efficacy and Safety Study also suggest that using the PVR in clinical practice needs to be reconsidered as a predictor of BPH progression. Further research is needed to clarify the role of chronic inflammation in the process of BPH progression.     

Significant upgrading affects a third of men diagnosed with prostate cancer: predictive nomogram and internal validation

OBJECTIVE: To explore the rate of significant upgrading from biopsy to radical prostatectomy (RP) specimens in a contemporary cohort, and to develop a prognostic model capable of predicting the probability of significant upgrading, as previous reports indicate that up to 43% of men with low-grade prostate cancer at biopsy will be diagnosed with high-grade cancer at RP. PATIENTS AND METHODS: The study cohort comprised 4789 men (median age 63 years, range 39-82) treated with RP, with available clinical stage, prostate-specific antigen levels, biopsy and RP Gleason sum values. These variables were used as predictors in multivariate logistic regression models (LRMs) addressing the rate of significant Gleason sum upgrading, defined as a Gleason sum increase either from < or = 6 to > or = 7 or from 7 to > or = 8 between the biopsy and RP specimens. Regression coefficients were used to develop and validate (200 bootstrap re-samples) a nomogram predicting significant biopsy Gleason sum upgrading. RESULTS: Significant biopsy Gleason sum upgrading was recorded in 1349 (28.2%) patients. In multivariate LRMs, all predictors were highly significant (all P < 0.001). The bootstrap-corrected accuracy of the nomogram predicting the probability of significant Gleason sum upgrading between biopsy and RP specimens was 75.7%. CONCLUSION: Our nomogram might prove highly useful when the possibility of a more aggressive Gleason variant could change the treatment options.