Georg Schatzl

Urinary Incontinence in Both Sexes: Prevalence Rates and Impact on Quality of Life and Sexual Life

The aim of this study was to determine the prevalence of urinary incontinence in both sexes in Austria and to assess its impact on quality of life and sexual function. Voluntary health examinations free of charge are regularly organized in the area of Vienna. From May 1998 to April 1999 we have included in this health examination an incontinence questionnaire containing 37 items, which was largely based on the Bristol female lower urinary tract symptoms (LUTS) questionnaire. This questionnaire asks in detail for various aspects of urinary incontinence/voiding problems, including the impact of urinary incontinence on quality of life and sexual function. In this questionnaire, urinary incontinence was defined as any involuntary loss of urine within the past 4 weeks. The data of 2,498 participants (1,262 women [f]: mean age: 49.7±13.6 years and 1,236 men [m]: 48.6±13.0 years; age range: 20–96 years) were analyzed. Overall, 26.3% of women and 5.0% of men reported on episodes of urinary incontinence during the past 4 weeks. Prevalence rates increased constantly with age in both sexes: 20–29 years: 4.1% (f), 1.7% (m); 30–39 years: 10.8% (f), 2.7% (m); 40–49 years: 22.9% (f); 3.9% (m); 50–59 years: 34.9% (f), 3.7% (m); 60–69 years: 36.9% (f), 7.6% (m); 70 years or older: 36.0%% (f), 11.5% (m). Overall, 65.7% of women and 58.3% of men stated that quality of life was affected by their incontinence status. A moderate or severe impairment was reported by 18.3% of women and 16.6% of men. Impairment of quality of life was related as statistically significant (P < 0.05) to frequency and degree of incontinence (irrespective of the type of incontinence), the impact on sexual function and need for pads or other incontinence devices. Patient gender, age, and the duration of incontinence had no effect (P > 0.05) on quality of life. An impairment of sexual life by urinary incontinence was stated by 25.1% of women and 30.5% of women, respectively. Although only 65.7% of women and 58.3% men with urinary incontinence reported on an impairment of quality of life, these data underline the high prevalence and socioeconomic implications of this disorder. The impact of urinary incontinence on quality of life is significantly higher than on sexual function. Neurourol. Urodynam. 19:259–271, 2000.

CAN URINE BOUND DIAGNOSTIC TESTS REPLACE CYSTOSCOPY IN THE MANAGEMENT OF BLADDER CANCER

PURPOSE We compare the diagnostic value of NMP22 and BTA stat testing, and QUANTICYT computer assisted dual parameter image analysis to cytology and cystoscopy in patients who had symptoms suggestive of transitional cell cancer or were being followed after treatment for that disease. MATERIALS AND METHODS We prospectively evaluated voided urine and/or barbotage specimens from 291 patients a mean of 65.2 years old. All voided urine samples were evaluated by quick staining and standard cytology, the BTA stat 1-step qualitative assay (which detects a bladder tumor associated antigen) and the NMP22 test (which detects a nuclear mitotic apparatus protein). In addition, barbotage specimens were evaluated by QUANTICYT computer assisted dual parameter image analysis. All patients underwent subsequent cystoscopy and biopsy evaluation of any suspicious lesion. Sensitivity, specificity, and the predictive value of positive and negative results were determined in correlation with endoscopic and histological findings. RESULTS In 91 patients with histologically proved transitional cell carcinoma overall sensitivity was 48, 57, 58, 59 and 59% for the NMP22 test, the BTA stat test, rapid staining cytology of barbotage samples, rapid staining cytology of voided urine specimens and image analysis, respectively. For histological grades 1 to 3 underlying transitional cell carcinoma sensitivity was 17, 61 and 90% for urinary cytology, 48, 58 and 63% for the BTA stat test, and 52, 45 and 50% for the NMP22 test, respectively. Specificity was 100% for cytology, 93% for image analysis, 70% for the NMP22 test and 68% for the BTA stat test. CONCLUSIONS Immunological markers are superior to cytological evaluation and image analysis for detecting low grade transitional cell carcinoma but they have low specificity and sensitivity in grade 3 transitional cell carcinoma. Urine bound diagnostic tools cannot replace cystoscopy.

The aging lower urinary tract: a comparative urodynamic study of men and women

OBJECTIVES The fact that aging women report similar voiding symptoms as age-matched men prompted us to compare age-related changes of urodynamic parameters in both sexes. METHODS Four hundred thirty-six patients (253 men and 183 women) 40 years of age or older underwent the following investigations: free uroflowmetry, measurement of postvoid residual volume, and full urodynamic testing, including a pressure-flow study (pQs). Additional investigations were a urethral pressure profile in women and quantification of prostate volume by transrectal ultrasonography in men. All men were referred for lower urinary tract symptoms suspicious of bladder outflow obstruction and women predominantly for urinary incontinence. Patients with previous surgery of the lower urinary tract (prostate, bladder, urethra) and those taking medication with a major effect on voiding function (alpha-receptor blockers, 5 alpha-reductase inhibitors, anticholinergic agents) were excluded. RESULTS The mean +/- standard deviation (SD) age in the female (f) population (n = 183) was 59 +/- 16 years (range 40 to 93), in the male population (m) (n = 253) 67 +/- 9 years (range 40 to 90). In both sexes, we observed a statistically significant increase of postvoid residual volume (f: P = 0.0001; m: P = 0.02) and a decrease of peak flow rate (f: P = 0.019; m: P = 0.014), average flow rate (f: P = 0.007; m: P = 0.04), voided volume (f: P = 0.007; m: P = 0.002), and bladder capacity determined by urodynamics (f: P = 0.003; m: P = 0.0004) with progressing age. In both sexes, there were no age-related changes (P >0.05), demonstrable for maximum detrusor pressure and detrusor pressure at peak flow rate. In women, there was a significant decrease of functional urethral length (P = 0.012) and maximum urethral closing pressure (P = 0.0001) with higher age; in men, the prostate volume increased significantly with age (P = 0.0001). With respect to detrusor instability, we observed an increase in men from 23.4% (40 to 60 years) to 46.7% (more than 80 years) (P = 0.004), whereas in women no significant age-related changes were present (P >0.05). CONCLUSIONS These data show that age-associated urodynamic changes in both sexes are comparable for a number of parameters. They provide an explanation for the fact that aging women report comparable voiding symptoms as men and suggest a primary, non-sex-specific aging process of the urinary bladder.

Morbidity of the evaluation of the lower urinary tract with transurethral multichannel pressure-flow studies

PURPOSE The aim of this prospective study was to determine morbidity and complication rate of invasive urodynamic evaluation of the lower urinary tract after transurethral multichannel pressure-flow studies. MATERIALS AND METHODS The study included 63 men with the clinical diagnosis of benign prostatic hyperplasia and 56 women with stress urinary incontinence. All patients underwent routine pressure-flow study as part of the urodynamic evaluation. A week later the patients returned for followup which also included a detailed interview on post-evaluation morbidity. RESULTS The overall complication rate, including urinary retention, gross hematuria, urinary tract infection and fever, was 19.0% (12 of 63) for men and 1.8% (1 of 56) for women. In men there was no statistically significant correlation between post-void residual urine or age and complication rate (p > 0.05). Of the men 4.8% experienced post-investigational urinary retention and all of them had significant bladder outflow obstruction. In addition, obstructed men reported a higher incidence of dysuria and pain (76.2%, 32 of 42) compared to those without obstruction (57.1%, 12 of 21), whereas only 53.6% of women reported these complaints. Of the 63 men 4 (6.2%) had significant urinary tract infections, while only 1 woman (1.8%) had infections. CONCLUSIONS Invasive urodynamic investigation is associated with a considerable rate of complications and morbidity, particularly in men with infravesical obstruction. These facts must be considered and discussed with the patient before urodynamic testing.

Cross-sectional study of nocturia in both sexes: analysis of a voluntary health screening project

OBJECTIVES To assess the prevalence of nocturia and its impact on the quality of life in both sexes by analyzing almost 2500 individuals participating in a health survey. METHODS During a 12-month period, we included an incontinence questionnaire, which was largely based on the Bristol female lower urinary tract symptoms questionnaire, in the voluntary health examinations in the area of Vienna. In parallel, we recorded the medical history, concurrent medical therapy, physical examination findings, sociodemographic parameters, and blood laboratory study results. RESULTS The data of 1247 women (age 49.8 +/- 13.5 years) and 1221 men (age 48.5 +/- 11.9 years) were analyzed. The percentage of individuals with nocturia of two or more times increased constantly with age: less than 30 years, 3.1% of women and 3.4% of men; 30 to 59 years, 7.2% of women and 5. 7% of men; and 60 years old or older, 26.7% of women and 32.4% of men. Age-adjusted extrapolation to the general population (older than 20 years) currently living in Austria yielded that 10.8% of men and 11.8% of women have nocturia of two or more times. Overall, 66. 9% of women and 62.2% of men reported a negative impact of nocturia on their quality of life. The correlation was close between the degree of nocturia with the quality-of-life impairment in both sexes. Several voiding symptoms correlated significantly (P <0.001) with nocturia. CONCLUSIONS Nocturia is almost equally present in both sexes, and the incidence and severity increase constantly from early adolescence to senescence. Approximately 10% of the general population (older than 20 years) have nocturia of two or more times, which impairs the quality of life in two thirds.

A POLYMORPHISM IN THE CYP17 GENE IS ASSOCIATED WITH PROSTATE CANCER RISK

CYP17 encodes the enzyme cytochrome P‐450c17α, which mediates both 17α‐hydroxylase and 17,20‐lyase in the steroid biosynthesis pathway. A polymorphism in the 5` promoter region of the CYP17 gene has been described. Steroid hormones, especially androgens, are believed to play a key role in the etiology of prostate cancer. Therefore, polymorphisms in genes involved in the androgen metabolism may affect the risk of prostate cancer. We conducted a case‐control study of 63 patients with untreated histologically proven prostate cancer and 126 age‐matched control men with benign prostatic hyperplasia (BPH) to determine whether a polymorphism in the CYP17 gene is associated with prostate cancer risk. This polymorphism was investigated by PCR/RFLP using DNA from lymphocytes. The transition (T→C) in the risk allele (A2) creates a new recognition site for the restriction enzyme MspAI, which permits designation of the wildtype (A1) and the risk allele (A2). The prevalence of the A2/A2 genotype was significantly higher (P = 0.03) in the cancer group (23.8%) than in the BPH control group (9.5%). We found an increased risk in men carrying 2 A2 alleles (OR = 2.80, 95%CI = 1.02–77.76). For carrier with at least 1 A2 allele, the OR was 0.90 (95%CI = 0.43–1.89). After stratification by median age (66 years) at time of diagnosis, a marked increased risk was found in carriers of the A2/A2 genotype older than 66 years (OR = 8.93, 95%CI = 1.78–49.19, P = 0.01). Although the sample size is rather small and the controls are BPH patients, our results suggest that the CYP17A2/A2 genotype may be a biomarker for prostate cancer risk, especially for older men. Int. J. Cancer 87:434–437, 2000.

Two–Year Results of Transurethral Resection of the Prostate versus Four ‘Less Invasive’ Treatment Options

Objective: The aim of this study was to compare the efficacy or transurethral resection of the prostate (TURP) versus four less invasive treatment options during a 2–year follow–up.Material and Methods: 95 elderly men with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) were assigned prospectively to the following five treatment arms; transurethral resection of the prostate (TURP; n = 28), transurethral electrovaporization (TUVP; n = 17), visual laser ablation of the prostate (VLAP; n = 17), transrectal high intensity focused ultrasound (HIFU; n = 20) and transurethral needle ablation (TUNA); n = 15). Preoperative workup included the International Prostate Symptom Score (IPSS), uroflowmetry, post–void residual volume (PVR), prostate volume determined by transrectal ultrasonography and a multichannel pressure flow study. Postoperative follow–up at 6, 12, 18 and 24 months included assessment of IPSS, PVR and uroflowmetry.Results: At study entry, patients assigned to one of the five treatment arms were comparable with respect to age, peak flow rate (Qmax), IPSS, prostate size and the degree of bladder outflow obstruction. During study, 1 patient in the TURP group (4%) required a secondary TURP, as compared to 23.5% (n = 4) after TUVP, 26.7% (n = 4) after VLAP, 15% (n = 4) after HIFU and 20% (n = 3) following TUNA. In patients not subjected to a secondary procedure, the IPSS decreased a mean 13.9 after TURP, as compared to 12.7 after TUVP, 12.9 after VLAP, 7.0 after HIFU, and 9.8 after TUNA. Qmax increased 11.5 ml/s (mean) after TURP, as compared to 11.1 ml/s after TUVP, 5.6 ml/s after VLAP, 2.5 ml/s after HIFU and 2.3 ml/s after TUNA.Conclusion: In up to a quarter of the patients, a secondary TURP is performed within the first 2 years after ‘less invasive’ procedures. These data underline the need for long–term studies to reliably assess the role of less invasive procedures and to indicate that TURP is still competitive.

Endocrine status in elderly men with lower urinary tract symptoms: correlation of age, hormonal status, and lower urinary tract function

OBJECTIVES To correlate endocrine parameters in elderly men with lower urinary tract symptoms (LUTS) to patient age and clinical parameters such as prostate volume, prostate-specific antigen (PSA) levels, and uroflowmetry and to compare the clinical and endocrinologic parameters in men with or without hypogonadism. METHODS Men (40 years old or older) with untreated LUTS as defined by an International Prostate Symptom Score (IPSS) of 7 or greater due to benign prostatic hyperplasia were included in this study and underwent the following investigations: IPSS, free uroflow study, postvoid residual volume, transrectal ultrasound for assessment of prostate volume, serum PSA determination, and an endocrine study, including testosterone, human luteinizing hormone, human follicle-stimulating hormone, prolactin, dehydroepiandrostendione-sulphate (DHEA-S), and prolactin. RESULTS Three hundred twelve men (mean age 62.8 +/- 10.6 years, range 40 to 91) were analyzed. The serum levels of estradiol (correlation coefficient [r] = 0.19), human luteinizing hormone (r = 0.32), human follicle-stimulating hormone (r = 0.19), and DHEA-S (r = -0.39) correlated (P <0.05) with age; no such correlation was seen for testosterone (r = 0.04; P0.05) or prolactin (r = 0.09; P0.05). Estradiol (but not testosterone) correlated (r = 0.17, P = 0.01) with prostate volume. The peak flow rate and PSA did not correlate with any endocrinologic parameter. Hypogonadism (serum testosterone less than 3.0 ng/mL) was detected in 22.1% of patients and had no impact on clinical (IPSS, peak flow rate, prostate volume, and PSA level) or endocrine (human luteinizing hormone, human follicle-stimulating hormone, estradiol, prolactin, and DHEA-S) parameters. CONCLUSIONS A number of age-related endocrine changes are seen in elderly men with LUTS. Hypogonadism is seen in approximately one fifth of elderly men with LUTS, but in our study it had no impact on symptom status, PSA level, prostate volume, uroflowmetry, or endocrine parameters.

Long-term outcome of transrectal high- intensity focused ultrasound therapy for benign prostatic hyperplasia.

Objective: The aim of this study was to determine the long–term outcome after transrectal high–intensity focused ultrasound (HIFU) therapy for patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).Methods: Between June 1992 and March 1995, 98 men (mean age: 66 years) with LUTS due to BPH underwent transrectal HIFU therapy at our institution, and the data of 80 patients were included in this long–term analysis. Principal inclusion criteria were a peak flow rate (Qmax) ≤15 ml/s, AUA/IPSS score ≥18 and a prostate volume ≤75 ml. Postoperatively, patients were seen at 6–month intervals with assessment of symptom score, uroflowmetry and post–void residual volume. In the present analysis, follow–up was terminated at 4 years. The mean follow–up of the study population (excluding the patients who underwent transurethral resection of the prostate, TURP, due to insufficient therapeutic response) was 41.3 months (range: 13–48 months).Results: In treatment responders (HIFU only; n = 45), the symptom score decreased from preoperatively 19.6 to 8.5 (–53%) after 12 months and subsequently showed only marginal fluctuations within the 4–year study period. The Qmax increased from preoperatively 9.1 to 11.8 ml/s (+30%) after 12 months and gradually declined to 10.2 ml/s (+12%) after 4 years. 35 men (43.8%) underwent TURP due to insufficient therapeutic response during the 4–year study period. The mean time interval between HIFU therapy and TURP was 26.5±2.7 months (range: 1–48 months). The retreatment–free period was significantly longer for patients with a pretreatment average flow rate >5 ml/s (p = 0.05) and lower grades of urodynamically documented bladder outflow obstruction (p = 0.03). A similar trend, which did not reach statistical significance, was noted for individuals with higher Qmax and lower post–void residuals.Conclusions: These long–time data indicate that transrectal HIFU therapy for BPH, at least in its present form, did not stand the test of time, as 43.8% of patients had to undergo TURP within 4 years after initial therapy. These data underline the need for long–term studies with follow–ups over several years to reliably assess the role of less invasive treatment options for BPH.

Extracorporeal ablation of renal tumours with high-intensity focused ultrasound

coefficient of the incident tissues and the site intensity achieved [2,3]. In a defined biological environment, the size of the thermal lesion can be controlled by the power and duration of the ultrasound pulses [4]. With higher site intensities ( > 3.5 kW/cm 3 ) cavitation phenomena with bubble implosion and mechanical tissue disruption are added, which are more difficult to control [5,6]. HIFU has been used for targeted tissue ablation in several organs, including the brain, liver, eye, bladder, prostate, testis and kidney [3]. In many experimental studies HIFU ablation of malignant tumours has not been shown to result in tumour cell dissemination or an increased rate of metastases [5].