Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia

From Research to Bedside

Giuseppe Morgia,Giorgio Ivan Russo

• Publisher: Academic Press
• Year: 2018
• ISBN:
  9780128113981
• Topic: Medizin
• Subtopic: Urologie

Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia: From Research to Bedside offers full acknowledgment of the basic research of lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH), also connecting the clinical and practice management of the disease. It provides a full comprehension of LUTS and BPH from several aspects, allowing for a schematic interpretation of the disease and subsequent medical management. Going beyond the guidelines in the field, this title enhances the knowledge of BPH onset, allowing for the advancement of research, beneficial clinical implication and treatment.

Perfect for researchers, urologists, pathologists and endocrinologists, this must-have reference provides what is needed to understand LUTS and BPH in one easy to reference place.

• Provides a clear understanding of the pathological mechanisms that are present in lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH)
• Incorporates research with the clinical aspects of LUTS and BPH, including surgical techniques
• Presents an overview of LUTS and BPH in one easy to reference place

Chapter 1

Epidemiology of LUTS and BPH

Giorgio Ivan Russo; Daniele Urzì; Sebastiano Cimino University of Catania, Catania, Italy

Abstract

Lower urinary tract symptoms (LUTS) are very common in both sexes, especially in aged population and negatively affect health-related quality of life of afflicted individuals. The prevalence of benign prostatic hyperplasia is strongly related to age, ranging from 8% in men in their 50s to roughly 90% in men older than 80 years. The prevalence of LUTS/BPE depends on the age of the patients. In fact the disease is present in about 8% of men between 31 and 40 years old, and it reaches 90% within 90 years old. Moreover, the presence of LUTS is also associated with more complications like acute urine retention, showing 6.8 episodes per 1000 patients per year in the general population, reaching 34.7 episodes in patients over 70s. The odds of developing moderate to severe LUTS also increased gradually after age 50 and were 3.5 and 2.4 times more frequent in men with a prostate volume greater than 50 mL and less than 50 mL, respectively. The exact etiology of LUTS/BPE is not entirely known. Among several risk factors, metabolic syndrome, diabetes mellitus, obesity, race, and cardiovascular disease represent the most important.

Keywords

Benign prostatic hyperplasia; LUTS; Age; Risk factors; Metabolic syndrome

Lower urinary tract symptoms (LUTS) are very common in both sexes, especially in aged population and negatively affect health-related quality of life (QOL) of afflicted individuals. They are also associated with high-health care costs. The etiology is multifactorial. One of the most important causes of LUTS in men is benign prostatic hyperplasia (BPH). BPH is a histological diagnosis defined by the presence of abnormal proliferation of smooth muscle and epithelial cells in prostatic tissues that clinically translates into benign prostatic enlargement (BPE) or obstruction (BPO). Left untreated, serious complications can occur in men with BPH, including acute urinary retention (AUR), renal insufficiency and failure, urinary tract infection, and bladder stones. The prevalence of BPH is strongly related to age, ranging from 8% in men in their 50s to roughly 90% in men older than 80 years [1]. Although aging represents the strongest risk factor for this, chronic progressive disease, obesity, and metabolic syndrome (MS) have been recently shown to be associated with an increased risk of BPH. Not all men with histologic BPH develop LUTS that requires intervention. Several population-based studies evaluated the prevalence of LUTS using validated questionnaires. Particularly the International Prostate Symptoms Score (IPSS) questionnaire is a useful tool to stratify patients according to symptom severity of seven common LUTS. Indeed, patients can be classified in those with no or mild (IPSS ≤ 7), moderate (IPSS from 8 to 20), and greater-severe symptoms (IPSS ≥ 21). It is very difficult to compare different studies about LUTS, due to the varying disease definitions and assessment methods used (e.g., mail and telephone surveys, face to face interview). In addition, IPSS lacks questions on incontinence and pain that are reported in several subjects affected by LUTS. The impact of BPH on QOL can be significant and should not be underestimated. A self-administered questionnaire completed by 117 patients reported sleep, anxiety/worry over the condition, mobility, leisure, activities of daily living, and, to a larger extent, the effect on sexual activities as the most important concerns among patients with prostate symptoms (IPSS > 7) [2]. The impact of BPH-associated LUTS has also been studied in a community-based population in the United Kingdom. A total of 1500 individuals aged 50 years or older were assessed for BPH symptoms and their impact on QOL using a self-administered survey. Moderate-to-severe LUTS was seen in 41% of the patients (as assessed by an IPSS of 8). Respondents experienced decrements in both QOL and health status as symptomatic severity increased, with most men experiencing problems with ability, self-care, activities of daily living, pain or discomfort, and anxiety or depression. Despite the high prevalence of LUTS reported in this survey, only 11% were aware of the pharmacologic or surgical interventions available to treat BPH; watchful waiting was the most common primary treatment (34%). The findings of this study underscore the need for better education about BPH and its treatments [3]. In a Japanese study, nocturia twice at night doubled the risk of fractures and mortality [4]. Its association with daytime fatigue, reduced work productivity, and reduced vitality is also recognized [5].

During past years, many authors studied the prevalence of seven symptoms by IPSS. These studies report many differences in prevalence, from 47% to 49%. In 1997 the International Continence Society (ICS) assessed the bothersomeness of LUTS in 1271 male patients presenting at urology clinics in 12 countries by administering a questionnaire. This study showed that voiding symptoms are more common (90%–94%) than storage symptoms (66%–71%), but that the latter are the most bothersome. It also established that a postmicturition symptom, terminal dribble, is the most common symptom of all (prevalence: 96%) [6]. Several studies confirmed a significant increase in prevalence with advancing age for both individuals LUTS and for the total LUTS reported by men. LUTS often appear in clusters. Overactive bladder (OAB) is a common symptom cluster. The ICS defines OAB as urinary urgency, with or without urinary incontinence, usually with frequency and nocturia [7]. Most studies investigated OAB and reported a general prevalence of 10%–25% in men [8,9]. The longest follow-up study of the prevalence of symptoms has shown a significant increase in LUTS over an 11-year period with a mean annual incidence of 3.7% for OAB and 0.8% for incontinence. The prevalence of OAB increases with age, especially in the sixth and seventh decade of life. A pooled analysis of 126 studies has shown an increase in urinary incontinence prevalence with age from 21% to 32% for elderly men. The prevalence of daily urinary incontinence in this analysis was reported at 9% [10]. Many publications focused specifically on the prevalence of urinary incontinence among community dwelling men; 11% of men over the age of 40 had experienced an incontinent episode during the prior year, and daily UI may be as high as 9% among men over the age of 60. The prevalence is near to 32% over 80 years [11].

An estimated 15 million men in the United States over the age of 30 years are affected by BPH/LUTS [12]. Large variations in existing prevalence rates are reported due to differences in BPH/LUTS definitions, assessment methods, and geographic regions. BPH/LUTS prevalence estimates also vary by age [13–18]. Among men over the age of 50 years, 50%–75% experience BPH/LUTS [19,20]. For the majority of these men, without treatment, voiding and storage symptoms will significantly worsen with increasing age and time. Among men over the age of 70 years, 80% on average are impacted by BPH/LUTS. Prostate enlargement, peak flow rate, and LUTS have all been shown to be age-dependent conditions and are conditions that play a substantial role in BPH/LUTS development among aging men [21]. Urinary symptoms of urgency, nocturia, weak stream, intermittency, and incomplete emptying are the most strongly correlated with age, and prevalence estimates rise to as high as 88%–90% by 81 years of age or greater [22,23].

The BPH Registry and Patient Survey, a prospective observational disease registry documenting BPH/LUTS practices and patient outcomes among 6909 men in the United States, reported that 33% of men had mild LUTS; 52% of men had moderate LUTS, and 15% of men had severe LUTS. The average IPSS at baseline was 11.6 (range 0–35) [24]. In France 67% of men scored IPSS < 8, 13% scored IPSS < 19, and 1.2% scored IPSS > 19 [25]. Another study supported these results. Among only men aged 40–49 years, these prevalence estimates for mild, moderate, and severe symptoms were 89%, 9%, and 2%, respectively. This increased to 55% with mild, 37% with moderate, and 8% with severe LUTS among men over the age of 70 years [26]. Approximately 10% of men < 30 years old, 20% of men 30–40 years old, 50%–60% of men 40–60 years old, and greater than 80% of men 80 or more years old have enlarged prostates [27]. Prostate volume generally increases with age. Men with significant prostate enlargement (> 50 cm³) are 3.5 times more likely to have age-adjusted moderate-to-severe LUTS than men without prostate enlargement. About incidence of BPH/LUTS four longitudinal cohort studies are very important: The Prostate Cancer Prevention Trial, The Olmstead County study, The Health Professionals Follow-up Study, and a database review in the Netherlands. The Prostate Cancer Prevention Trial included 5667 men over the age of 55 years and reported the incidence of BPH to be 34.4 cases per 1000 person-years [13]. The Olmstead County study, which identified men living in Olmstead County, Minnesota, review between 1987 and 1997, estimated the overall incidence of BPH to be 8.54 cases per 1000 men [17]. The Health Professionals Follow-up Study followed 9628 men with moderate-to-severe LUTS (IPSS < 14) and 2557 men with severe LUTS (IPSS < 20) from LUTS onset for an average of 12.7 years to assess LUTS incidence and progression rates. Incidence rates of moderate and severe LUTS were 41 and 19 cases per 1000 person-years, respectively [28]. Verhamme et al. [29] utilized a longitudinal observational database in the Netherlands to assess incidence rates of BPH/LUTS among men over the age of 45 years who had at least 6 months of patient follow-up and reported the incidence of BPH/LUTS to be 15 cases per 1000 person-years of follow-up. The four studies with overall estimates mentioned previously also reported incidence rates by age and/or severity. The Prostate Cancer Prevention Trial reported that for every 1 year increase in patient age, the incidence of BPH increased by 4%. This corresponds to reports that an estimated 45% of urinary symptom-free men over the age of 45 will develop BPH/LUTS before the age of 75. The Health Professionals Follow-up Study reported increases in both moderate and severe LUTS incidence rates with increasing patient age. Verhamme and colleagues reported the incidence of BPH to linearly increase by an average of 6.15 cases per 1000 man-years for every 5-year increase in age increment between 45 and 79 years of age. This increase was from 3 cases per 1000 man-years at age 45–49 to 38 cases per 1000 man-years at age 75–79 years.

The EPIC survey was a population-based, cross-sectional, computer-assisted telephone survey conducted in five countries (Canada, Germany, Italy, Sweden, and the United Kingdom) [13]. A total of 19,165 men and women agreed to participate (33%) ...