Epidemiology and Natural History of Male Lower Urinary Tract Symptoms
1.6 Epidemiology of Benign Prostatic Hyperplasia
1.6.5 Additional factors
1.6.5.1 Race
No clear patterns have as yet emerged with respect to BPH risk and race. Observational studies comparing black, Asian, and white men have produced variable results. Studies of black men in the US have observed an increased prostate transition zone and total volume compared with white men (180,181). Large analyses of the US Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and the Health Professionals Follow-Up Study observed no differences in clinical BPH risk between black and white men (182,183), while another study of 21,949 men living in the southeastern US noted that black men were half as likely to report a history of BPH diagnosis as white men, but were 65% more likely to report a history of TURP (184). Some data have suggested a decreased risk of clinical BPH in Asian compared with white men (182,183).
1.6.5.2 Prostate cancer
During the 1940s, autopsy studies noted an increased prevalence of histological BPH occurring in association with prostate cancer (185,186). Some investigators have since suggested that common initiating events may drive the concomitant development of BPH and prostate cancer (187,188).
Epidemiological data have been conflicting, and connections of clinical BPH with prostate cancer remain unclear. A large cohort analysis of more than 3 million men from five national registries in Denmark concluded that men with clinical BPH had a 2- to 3-fold increased risk of subsequent pros-tate cancer diagnosis and were 2 to 8 times more likely to die from prospros-tate cancer compared with
men without clinical BPH (186). However, a study of 5,068 men in the placebo arm of the Prostate Cancer Prevention Trial determined that there were no associations of symptomatic BPH with pros-tate cancer prevalence or prevalence plus incidence, as measured by three different definitions of clinical BPH (189). Other studies have noted a diminished likelihood of aggressive prostate cancer in patients with larger prostate volumes (190,191).
1.7 Summary
The Major findings of this chapter are:
1. Male LUTS, as assessed by validated ques-tionnaires, are common in men, with noctu-ria and terminal dribble the most prevalent.
2. Voiding symptoms are predominant, and incontinence is rare in men compared with women.
3. LUTS symptoms are likely to wax and wane, but do slowly and steadily progress with aging.
4. The presence of LUTS is associated with age, metabolic syndrome or vascular risk factors, medications, inflammation, hormonal status, and erectile dysfunction.
5. Risk factors for clinical progression include age, enlarged prostate, elevated PSA, LUTS with bother, impaired HRQOL, and decreased urinary flow rate.
6. Risk factors for development of BPH are age, genetic predisposition, higher serum concen-trations of DHT, metabolic syndrome, and some lifestyles.
7. LUTS negatively influences the HRQOL of individuals and imposes health care costs on society.
Limitations of the available data should be considered.
First, there is no standard assessment tool to measure male LUTS. IPSS, the most commonly used metric, lacks questions on incontinence and pain. Substantial variation of definition or questioning of OAB may have resulted in large differences in OAB prevalence among studies. There is no widely accepted working epidemiologic definition for “clinically important BPH,” whether in terms of histological condition or clinical manifestations. The prevalence of “LUTS” or “BPH” is thus highly sensitive to the working definition applied. Future studies should focus on LUTS assessments that include a wider spectrum of symptoms related to urinary bother, which will allow for more robust comparisons across clinical settings.
Second, incidence studies of risk factors that explore temporal exposures-and-disease inferences are limited. The external validity of findings from studies performed within the placebo arms of clinical trials is questionable for community-dwelling men. Identification of the valid risk factors, especially modifiable lifestyles, may promote prevention of both clinical manifestations and LUTS consequences, thus lessening the individual and societal burden attributable to LUTS.
1.8 References
1. Abrams P, Kelleher CJ, Kerr LA, et al. Overactive bladder significantly affects quality of life. Am J Manag Care. 2000;6(Suppl 11):S580–90.
2. Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int.
2008;101(11):1388–95.
3. Irwin DE, Mungapen L, Milsom I, et al. The economic impact of overactive bladder syndrome in six Western countries. BJU Int 2009;103(2):202–9.
4. Homma Y, Araki I, Igawa Y, et al. Clinical guideline for male lower urinary tract symptoms. Int J Urol. 2009;16(10):775–90.
5. Haidinger G, Madersbacher S, Waldhoer T, et al. The prevalence of lower urinary tract symptoms in Austrian males and associations with sociodemographic variables. Eur J Epidemiol. 1999;15(8):717–22.
6. Tuncay Aki F, Aygun C, Bilir N, et al. Prevalence of lower urinary tract symptoms in a community-based survey of men in Turkey.
Int J Urol. 2003;10(7):364–70.
7. Boyle P, Robertson C, Mazzetta C, et al. The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study. BJU Int. 2003;92(4):409–14.
8. Rosen RC, Link CL, O’Leary MP, et al. Lower urinary tract symptoms and sexual health: the role of gender, lifestyle and medical comorbidities. BJU Int. 2009;103(Suppl 3):42–7.
9. Temml C, Brossner C, Schatzl G, et al. The natural history of lower urinary tract symptoms over five years. Eur Urol.
2003;43(4):374–80.
10. Seim A, Hoyo C, Ostbye T, et al. The prevalence and correlates of urinary tract symptoms in Norwegian men: the HUNT study.
BJU Int. 2005;96(1):88–92.
11. Litman HJ, Steers WD, Wei JT, et al. Relationship of lifestyle and clinical factors to lower urinary tract symptoms: results from Boston Area Community Health survey. Urology. 2007;70(5):916–21.
12. Markland AD, Thompson IM, Ankerst DP, et al. Lack of disparity in lower urinary tract symptom severity between community-dwelling non-Hispanic white, Mexican-American, and African-American men. Urology. 2007;69(4):697–702.
13. Campbell B. High rate of prostate symptoms among Ariaal men from Northern Kenya. Prostate. 2005;62(1):83–90.
14. Stranne J, Damber JE, Fall M, et al. One-third of the Swedish male population over 50 years of age suffers from lower urinary tract symptoms. Scand J Urol Nephrol. 2009;l43(3):199–205.
15. Penson DF, Munro HM, Signorello LB, et al. Obesity, physical activity and lower urinary tract symptoms: results from the Southern Community Cohort Study. J Urol. 2011;186(6):2316–2322.
16. Shamliyan TA, Wyman JF, Ping R, et al. Male urinary incontinence: prevalence, risk factors, and preventive interventions. Rev Urol. 2009;11(3):145–165.
17. Koskimaki J, Hakama M, Huhtala H, et al. Prevalence of lower urinary tract symptoms in Finnish men: a population-based study.
Br J Urol. 81(3):364–369.
18. Lee AJ, Garraway WM, Simpson RJ, et al. The natural history of untreated lower urinary tract symptoms in middle-aged and elderly men over a period of five years. Eur Urol. 1998;34(4):325–332.
19. Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol. 2006;50(6):1306–1314; discussion 1314–1305.
20. Homma Y, Yamaguchi O, Hayashi K, et al. Epidemiologic survey of lower urinary tract symptoms in Japan. Urology.
2006;68(3):560–564.
21. Coyne KS, Sexton CC, Thompson CL, et al. The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: results from the Epidemiology of LUTS (EpiLUTS) study. BJU Int. 2009;104(3):352–360.
22. Malmsten UG, Molander U, Peeker R, et al. Urinary incontinence, overactive bladder, and other lower urinary tract symptoms: a longitudinal population-based survey in men aged 45–103 years. Eur Urol. 2010;58(1):149–156.
23. Lee YS, Lee KS, Jung JH, et al. Prevalence of overactive bladder, urinary incontinence, and lower urinary tract symptoms: results of Korean EPIC study. World J Urol. 2011;29(2):185–190.
24. Irwin DE, Milsom I, Kopp Z, et al. Prevalence, severity, and symptom bother of lower urinary tract symptoms among men in the EPIC study: impact of overactive bladder. Eur Urol. 2009;56(1):14–20.
25. Cinar A, Hall SA, Link CL, et al. Cluster analysis and lower urinary tract symptoms in men: findings from the Boston Area Community Health Survey. BJU Int. 2008;101(10):1247–1256.
26. Sexton CC, Coyne KS, Kopp ZS, et al. The overlap of storage, voiding and postmicturition symptoms and implications for treatment seeking in the USA, UK and Sweden: EpiLUTS. BJU Int. 2009;103(Suppl 3):12–23.
27. Coyne KS, Matza LS, Kopp ZS, et al. Examining lower urinary tract symptom constellations using cluster analysis. BJU Int.
2008;101(10):1267–1273.
28. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167–178.
29. Milsom I, Abrams P, Cardozo L, et al. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001;87(9):760–766.
30. Temml C, Heidler S, Ponholzer A, et al. Prevalence of the overactive bladder syndrome by applying the International Continence Society definition. Eur Urol. 2005;48(4):622–627.
31. Castro D, Espuna M, Prieto M, et al. Prevalence of overactive bladder in Spain: a population-based study [Article in Spanish].
Arch Esp Urol. 2005;58(2):131–138.
32. Tikkinen KA, Tammela TL, Rissanen AM, et al. Is the prevalence of overactive bladder overestimated? A population-based study in Finland. PLoS One. 2007;2(2):e195.
33. Correia S, Dinis P, Rolo F, et al. Prevalence, treatment and known risk factors of urinary incontinence and overactive bladder in the non-institutionalized Portuguese population. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(12):1481–1489.
34. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol.
2003;20(6):327–336.
35. Benner JS, Becker R, Fanning K, et al. Bother related to bladder control and health care seeking behavior in adults in the United States. J Urol. 2009;181(6):2591–2598.
36. Coyne KS, Sexton CC, Vats V, et al. National community prevalence of overactive bladder in the United States stratified by sex and age. Urology. 2011;77(5):1081–1087.
37. Coyne KS, Sexton CC, Kopp ZS, et al. The impact of overactive bladder on mental health, work productivity and health-related quality of life in the UK and Sweden: results from EpiLUTS. BJU Int. 2011;108(9):1459–1471.
38. Corcos J, Schick E: Prevalence of overactive bladder and incontinence in Canada. Can J Urol. 2004;11(3):2278–2284.
39. Herschorn S, Gajewski J, Schulz J, et al. A population-based study of urinary symptoms and incontinence: the Canadian Urinary Bladder Survey. BJU Int. 2008;101(1):52–58.
40. Teloken C, Caraver F, Weber FA, et al. Overactive bladder: prevalence and implications in Brazil. Eur Urol. 2006;49(6):1087–1092.
41. Moorthy P, Lapitan MC, Quek PL, et al. Prevalence of overactive bladder in Asian men: an epidemiological survey. BJU Int.
2004;93(4):528–531.
42. Homma Y, Yamaguchi O, Hayashi K, et al. An epidemiological survey of overactive bladder symptoms in Japan. BJU Int.
2005;96(9):1314–1318.
43. Yu HJ, Liu CY, Lee KL, et al. Overactive bladder syndrome among community-dwelling adults in Taiwan: prevalence, correlates, perception, and treatment seeking. Urol Int. 2006;77(4):327–333.
44. Choo MS, Ku JH, Lee JB, et al. Cross-cultural differences for adapting overactive bladder symptoms: results of an epidemiologic survey in Korea. World J Urol. 2007;25(5):505–511.
45. Ikeda Y, Nakagawa H, Ohmori-Matsuda K, et al. Risk factors for overactive bladder in the elderly population: a community-based study with face-to-face interview. Int J Urol. 2011;18(3):212–218.
46. Wang Y, Xu K, Hu H, et al. Prevalence, risk factors, and impact on health related quality of life of overactive bladder in China.
Neurourol Urodyn. 2011;30(8):1448–1455.
47. Bowling A. Mode of questionnaire administration can have serious effects on data quality. J Public Health (Oxf).
2005;27(3):281–291.
48. Rhodes T, Girman CJ, Jacobsen SJ, et al. Does the mode of questionnaire administration affect the reporting of urinary symptoms? Urology. 1995;46(3):341–345.
49. Garcia-Losa M, Unda M, Badia X, et al. Effect of mode of administration on I-PSS scores in a large BPH patient population. Eur Urol. 2001;40(4):451–457.
50. Fujimura T, Kume H, Nishimatsu H, et al. Assessment of lower urinary tract symptoms in men by international prostate symptom score and core lower urinary tract symptom score. BJU Int. 2012;109(10):1512–1516.
51. Irwin DE, Milsom I, Kopp Z, et al. Symptom bother and health care-seeking behavior among individuals with overactive bladder.
Eur Urol. 2008;53(5):1029–1037.
52. Irwin DE, Milsom I, Kopp Z, et al. Impact of overactive bladder symptoms on employment, social interactions and emotional well-being in six European countries. BJU Int. 2006;97(1):96–100.
53. Irwin DE, Milsom I, Chancellor MB, et al. Dynamic progression of overactive bladder and urinary incontinence symptoms: a systematic review. Eur Urol. 2010;58(4):532–543.
54. Dallosso HM, Matthews RJ, McGrother CW, et al. The association of diet and other lifestyle factors with the onset of overactive bladder: a longitudinal study in men. Public Health Nutr. 2004;7(7):885–891.
55. Goode PS, Burgio KL, Redden DT, et al. Population based study of incidence and predictors of urinary incontinence in black and white older adults. J Urol. 2008;179(4):1449–1453; discussion 1453–1444.
56. Liu C, Andrews GR. Prevalence and incidence of urinary incontinence in the elderly: a longitudinal study in South Australia. Chin Med J (Engl). 2002;115(1):119–122.
57. Herzog AR, Diokno AC, Brown MB, et al. Two-year incidence, remission, and change patterns of urinary incontinence in noninstitutionalized older adults. J Gerontol. 1990;45(2):M67–74.
58. Anger JT, Saigal CS, Stothers L, et al. The prevalence of urinary incontinence among community dwelling men: results from the National Health and Nutrition Examination survey. J Urol. 2006;176(5):2103–2108; discussion 2108.
59. Braun MH, Sommer F, Haupt G, et al. Lower urinary tract symptoms and erectile dysfunction: co-morbidity or typical “Aging Male”
symptoms? Results of the “Cologne Male Survey”. Eur Urol. 2003;44(5):588–594.
60. Gao Y, Wang M, Zhang H, et al. Are metabolic syndrome and its components associated with lower urinary tract symptoms?
Results from a Chinese male population survey. Urology. 2012;79(1):194–201.
61. Kim S, Jeong JY, Choi YJ, et al. Association between lower urinary tract symptoms and vascular risk factors in aging men: The Hallym Aging Study. Korean J Urol. 2010;51(1):477–482.
62. Martin SA, Haren MT, Marshall VR, et al. Prevalence and factors associated with uncomplicated storage and voiding lower urinary tract symptoms in community-dwelling Australian men. World J Urol. 2011;29(2):179–184.
63. Naya Y, Ochiai A, Soh J, et al. Association between ED and LUTS in Japanese motorcyclists. Int J Impot Res. 2008;20(6):574–577.
64. Ohgaki K, Hikima N, Horiuchi K, et al. Association between metabolic syndrome and male lower urinary tract symptoms in Japanese subjects using three sets of criteria for metabolic syndrome and International Prostate Symptom Score. Urology.
2011;77(6):1432–1438.
65. Ozayar A, Zumrutbas AE, Yaman O: The relationship between lower urinary tract symptoms (LUTS), diagnostic indicators of benign prostatic hyperplasia (BPH), and erectile dysfunction in patients with moderate to severely symptomatic BPH. Int Urol Nephrol. 2008;40(4):933–939.
66. Ponholzer A, Temml C, Obermayr R, et al. Association between lower urinary tract symptoms and erectile dysfunction. Urology.
2004;64(6):772–776.
67. Tomita K, Mizoue T, Matsumoto T: Lower urinary tract symptoms in relation to lifestyle and medical conditions in Japanese workers. Int J Urol. 2009;16(5):493–498; discussion 498.
68. Van Den Eeden SK, Shan J, Jacobsen SJ, et al. Evaluating racial/ethnic disparities in lower urinary tract symptoms in men. J Urol. 2012;187(1):185–189.
69. Wennberg AL, Altman D, Lundholm C, et al. Genetic influences are important for most but not all lower urinary tract symptoms:
a population-based survey in a cohort of adult Swedish twins. Eur Urol. 2011;59(6):1032–1038.
70. Wong SY, Woo J, Hong A, et al. Risk factors for lower urinary tract symptoms in southern Chinese men. Urology.
2006;68(5):1009–1014.
71. Wong SY, Woo J, Leung JC, et al. Depressive symptoms and lifestyle factors as risk factors of lower urinary tract symptoms in Southern Chinese men: a prospective study. Aging Male. 2010;13(2):113–119.
72. Parsons JK. Modifiable risk factors for benign prostatic hyperplasia and lower urinary tract symptoms: new approaches to old problems. J Urol. 2007;178(2):395–401.
73. Parsons JK, Messer K, White M, et al. Obesity increases and physical activity decreases lower urinary tract symptom risk in older men: the Osteoporotic Fractures in Men study. Eur Urol. 2011;60(6):1173–1180.
74. Laven BA, Orsini N, Andersson SO, et al. Birth weight, abdominal obesity and the risk of lower urinary tract symptoms in a population based study of Swedish men. J Urol. 2008;179(5):1891–1895; discussion 1895–1896.
75. Rohrmann S, Crespo CJ, Weber JR, et al. Association of cigarette smoking, alcohol consumption and physical activity with lower urinary tract symptoms in older American men: findings from the third National Health And Nutrition Examination Survey. BJU Int. 2005;96(1):77–82.
76. Parsons JK, Kashefi C: Physical activity, benign prostatic hyperplasia, and lower urinary tract symptoms. Eur Urol.
2008;53(6):1228–1235.
77. Joseph MA, Harlow SD, Wei JT, et al. Risk factors for lower urinary tract symptoms in a population-based sample of African-American men. Am J Epidemiol. 2003;157(10):906–914.
78. Ponholzer A, Temml C, Wehrberger C, et al. The association between vascular risk factors and lower urinary tract symptoms in both sexes. Eur Urol. 2006;50(3):581–586.
79. Demir O, Akgul K, Akar Z, et al. Association between severity of lower urinary tract symptoms, erectile dysfunction and metabolic syndrome. Aging Male. 2009;12(1):29–34.
80. Paick JS, Yang JH, Kim SW, et al. Are age, anthropometry and components of metabolic syndrome-risk factors interrelated with lower urinary tract symptoms in patients with erectile dysfunction? A prospective study. Asian J Androl. 2007;9(2):213–220.
81. Aktas BK, Gokkaya CS, Bulut S, et al. Impact of metabolic syndrome on erectile dysfunction and lower urinary tract symptoms in benign prostatic hyperplasia patients. Aging Male. 2011;14(1):48–52.
82. Ng CF, Wong A, Li ML, et al. The prevalence of cardiovascular risk factors in male patients who have lower urinary tract symptoms.
Hong Kong Med J. 2007;13(6):421–426.
83. Maserejian NN, Giovannucci EL, McKinlay JB: Dietary macronutrients, cholesterol, and sodium and lower urinary tract symptoms in men. Eur Urol. 2009;55(5):1179–1189.
84. Maserejian NN, Giovannucci EL, McVary KT, et al. Dietary, but not supplemental, intakes of carotenoids and vitamin C are associated with decreased odds of lower urinary tract symptoms in men. J Nutr. 2011;141(2):267–273F.
85. Kok ET, Schouten BW, Bohnen AM, et al. Risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia in a community based population of healthy aging men: the Krimpen Study. J Urol. 2009;181(2):710–716.
86. Parsons JK, Im R: Alcohol consumption is associated with a decreased risk of benign prostatic hyperplasia. J Urol.
2009;182(4):1463–1468.
87. Hall SA, Maserejian NN, Link CL, et al. Are commonly used psychoactive medications associated with lower urinary tract symptoms? Eur J Clin Pharmacol. 2012;68(5):783–791.
88. Alanee S, Heiner J, Liu N, et al. Horseback riding: impact on sexual dysfunction and lower urinary tract symptoms in men and women. Urology. 2009;73(1):109–114.
89. Choi WS, Lee WK, Lee SH, et al. Is high–sensitivity C-reactive protein associated with lower urinary tract symptoms in aging men? Results from the hallym aging study. Korean J Urol. 2012;53(5):335–341.
90. Chang IH, Oh SY, Kim SC: A possible relationship between testosterone and lower urinary tract symptoms in men. J Urol.
2009;182(1):215–220.
91. Breyer BN, Van den Eeden SK, Horberg MA, et al. HIV status is an independent risk factor for reporting lower urinary tract symptoms. J Urol. 2011;185(5):1710–1715.
92. Trifiro MD, Parsons JK, Palazzi-Churas K, et al. Serum sex hormones and the 20–year risk of lower urinary tract symptoms in community-dwelling older men. BJU Int. 2010;105(11):1554–1559.
93. Antunes AA, Srougi M, Dall’oglio MF, et al. The role of BPH, lower urinary tract symptoms, and PSA levels on erectile function of Brazilian men who undergo prostate cancer screening. J Sex Med. 2008;5(7):1702–1707.
94. Aslan G, Cavus E, Karas H, et al. Association between lower urinary tract symptoms and erectile dysfunction. Arch Androl.
2006;52(3):155–162.
95. El-Sakka AI. Lower urinary tract symptoms in patients with erectile dysfunction: analysis of risk factors. J Sex Med.
2006;3(1):144–149.
96. Liu CC, Huang SP, Li WM, et al. Are lower urinary tract symptoms associated with erectile dysfunction in aging males of Taiwan?
Urol Int. 2006;77(3):251–254.
97. Wong SY, Chan D, Hong A, et al. Depression and lower urinary tract symptoms: Two important correlates of erectile dysfunction in middle-aged men in Hong Kong, China. Int J Urol. 2006;13(10):1304–1310.
98. McVary KT. Erectile dysfunction and lower urinary tract symptoms secondary to BPH. Eur Urol. 2005;47(6):838–845.
99. Rhodes T, Girman CJ, Jacobsen SJ, et al. Longitudinal prostate growth rates during 5 years in randomly selected community men 40 to 79 years old. J Urol. 1999;161(4):1174–1179.
100. Bosch JL, Bohnen AM, Groeneveld FP, et al. Validity of three calliper-based transrectal ultrasound methods and digital rectal examination in the estimation of prostate volume and its changes with age: the Krimpen study. Prostate. 2005;62(4):353–363.
101. Bosch JL, Tilling K, Bohnen AM, et al. Establishing normal reference ranges for prostate volume change with age in the population-based Krimpen-study: prediction of future prostate volume in individual men. Prostate. 2007;67(16):1816–1824.
102. Bosch JL, Bangma CH, Groeneveld FP, et al. The long-term relationship between a real change in prostate volume and a significant
102. Bosch JL, Bangma CH, Groeneveld FP, et al. The long-term relationship between a real change in prostate volume and a significant