Laurel A. Panser

The prevalence of Prostatism: A Population-Based Survey of Urinary Symptoms

To establish the age-specific prevalence of urinary symptoms among a community-based cohort of men, a randomly selected sample of men were screened and invited to participate in a longitudinal survey of urinary symptoms. The population of Olmsted County, Minnesota, as enumerated by the Rochester Epidemiology Project, formed the sampling base for this study. Men between 40 and 79 years old with no history of prostate or other urological surgery, and who also were free of conditions associated with neurogenic bladder were invited to participate. A previously validated questionnaire was completed by the subject. Urine flow measures, current medications and family histories of urinary disease were also obtained. Nonresponse corrected scores for a composite of obstructive symptoms showed moderate to severe symptomatology among 13% of the men 40 to 49 years old and 28% of those older than 70 years. Prostatism is a highly prevalent symptom complex among unselected men in the community. The specific urinary symptoms of nocturia, weak stream, restarting, urgency and sensation of incomplete emptying are strongly age-related and, therefore, may be predictive of a prostatic disease process.

NATURAL HISTORY OF PROSTATISM: RELATIONSHIP AMONG SYMPTOMS, PROSTATE VOLUME AND PEAK URINARY FLOW RATE

We describe relationships among symptoms, prostate volume and peak urinary flow rate in an age stratified, community based random sample of white men 40 to 79 years old with no prior prostate surgery, prostate cancer or other conditions known to interfere with voiding. Symptoms were assessed with an instrument comparable to the American Urological Association symptom index. Prostate volume was estimated by transrectal ultrasonography and peak urinary flow rate was measured by a portable device. Subject age was significantly associated with symptom score but accounted for only 3% of its variation, while prostate volume and peak urinary flow rate explained only an additional 10% of the symptom variability. The odds (95% confidence interval) of moderate to severe symptoms increased with age from 1.9 (1.1 to 3.1), 2.9 (1.7 to 5.0) and 3.4 (1.8 to 6.1) for men 50 to 59, 60 to 69 and 70 to 79 years old, respectively, relative to men 40 to 49 years old. Adjusting for age, the odds of moderate to severe symptoms were 3.5 times greater for men with prostatic enlargement (more than 50 ml.) than for men with smaller prostates, while the odds were similarly increased (2.4-fold) for men not achieving a peak urinary flow rate of 10 ml. per second. Estimated odds changed little when other cutoff points were considered for peak urinary flow rate (15 ml. per second) or prostate volume (40 ml.). These results, based on randomly selected white men, suggest a somewhat stronger, albeit modest, relationship among symptoms, prostate size and urinary flow rate than previously reported in clinic based studies. The strength of these relationships is comparable to that found with other diseases.

Validation of a new quality of life questionnaire for benign prostatic hyperplasia

In planning a longitudinal study to characterize the natural history of benign prostatic hyperplasia (BPH), we validated a new disease-specific quality of life questionnaire in a pilot study. We studied 110 men in Rochester, Minnesota who spanned the severity of BPH, from men with no known BPH to men who underwent surgery for this condition. Baseline data were obtained on all men, and the 30 who underwent prostatectomy were re-interviewed to test responsiveness. Reproducibility was examined on the pre-post responses (10 weeks apart) of the 37 men with BPH who did not undergo prostatectomy. Six of twelve question domains were retained in the final questionnaire on the basis of their responsiveness to change, reproducibility, internal consistency, and validity. These were: urinary symptoms, degree of bother due to urinary symptoms, BPH-specific interference with activities, general psychological well-being, worries and concerns, and sexual satisfaction. Most of the more generic measures were deleted.

Natural history of prostatism: Impact of urinary symptoms on quality of life in 2115 randomly selected community men

OBJECTIVES To assess the impact of urinary symptoms on health-related quality of life (QoL), including degree of bother, worry, interference with daily activities, psychological well-being, sexual function, and general health in a community-based cohort of men. METHODS Eligible white men (n = 2115) aged 40 to 79 years who had not undergone previous prostate surgery or had prostate cancer were randomly selected from county residents. These subjects completed a questionnaire, which asked them about frequency and bother of urinary symptoms, interference with daily activities, psychological well-being, worry about urologic disease, sexual functioning, and general health. RESULTS Men with moderate to severe voiding symptoms reported, on average, four to six times the degree of bother and interference with daily activities and twice the level of worry of men with mild symptoms. Nearly five times the degree of bother and interference was reported for those with mild than with no symptoms. A higher percentage of men with moderate to severe symptoms (26% to 33%) than mild symptoms (< 8%) reported limiting fluids before bed, travel, or driving 2 hours. Receiver operating characteristic curves support the recommended symptom index cutpoint for moderate symptoms (= 8) by differentiating men with and without bother, interference with daily living, or dissatisfaction with urinary condition. CONCLUSIONS Moderate to severe urinary symptoms have a significant impact on mens lives in terms of degree of bother, worry, interference with daily living, and psychological well-being. The recommended cutpoint on symptom index differentiates men with and without decrement in health-related quality of life.

Sexual Function of Men Ages 40 to 79 Years: The Olmsted County Study of Urinary Symptoms and Health Status Among Men

OBJECTIVES: Knowledge of male sexual function is somewhat limited because of a lack of current population‐based data. This study provides information on sexual function and satisfaction in a population‐based sample of men.

Natural history of prostatism: Urinary flow rates in a community-based study

Urinary flow rates were measured in a randomly selected community sample of more than 2,000 men 40 to 79 years old with no history of prostate surgery, prostate cancer or certain other diseases known to interfere with normal voiding. Peak urinary flow rates decreased from a median of 20.3 ml. per second in men 40 to 44 years old to 11.5 ml. per second for men 75 to 79 years old, while voided volumes decreased from a median of 355.5 to 222.5 ml. for the same age ranges. Peak flow rates of less than 10 ml. per second were found in 6% of the men aged 40 to 44 years, increasing to 35% among men aged 75 to 79 years. Urological standards for peak urinary flow rate should be based on community data, and should account for age and voided volume. Our study may serve as the starting point for the development of community-based flow rate normal ranges. Nomograms are given to permit estimating flow rate percentiles as a function of age and voided volume.

Decline of sexual function with age in japanese men compared with american men—results of two community-based studies☆

OBJECTIVES To investigate the self-reported sexual function of Japanese men aged 40 to 79 years in a community-based study and compare the results to a similarly conducted study in Olmsted County, Minnesota. METHODS Two hundred eighty-nine Japanese and 2115 American men from the community were queried about ability to have erections when stimulated, sexual drive, and satisfaction with sexual activity using a self-administered questionnaire. RESULTS Both Japanese and American men showed an age-related decline in erectile function, sexual libido, and sexual satisfaction. In particular, 71% of Japanese men aged 70 to 79 years reported having erections only a little of the time or less when sexually stimulated, and 80% perceived sexual drive once per month or less during the past month. Although more Japanese than American men reported erectile dysfunction and decreased libido, there were no striking differences in self-reported sexual satisfaction between the studies. However, cultural and perceptual differences could play a role in these results, despite attempts to ensure linguistic equivalency in the questionnaires. CONCLUSIONS Although erectile dysfunction and decreased libido were noted by a greater proportion of Japanese than American men, the self-reported degree of satisfaction was comparable between the studies. Perceptions of elderly male sexual function and its impact on health-related quality of life may differ among races, sites, and countries.

Similar levels of urological symptoms have similar impact on Scottish and American men--although Scots report less symptoms.

Urinary symptoms and the extent to which they interfere with living activities were compared in 2 community-based investigations that enrolled men 40 to 79 years old who were randomly sampled from Olmsted County, Minnesota (2,119) and the Forth Valley of Scotland (1,385). Both investigations included symptom questions with wording that is nearly identical to that of the American Urological Association (AUA) symptom index. Following AUA scoring conventions we grouped scores into mild (AUA score 0 to 7), moderate (score 8 to 19) and severe (score 20+) categories. Minnesota men had symptoms that were more frequent, more bothersome and caused greater interference with living activities than did Scottish men of comparable age (p < 0.0002). However, within each symptom score category, the extent to which symptoms interfered with living activities was essentially the same in both populations. Although there appear to be important differences in urinary symptom prevalence between Scotland and Minnesota, the AUA symptom index provides a consistent measure of the extent to which urinary symptoms interfere with living activities in both populations. These findings support use of the AUA symptom index in the diagnostic evaluation of men with benign prostatic hyperplasia.

Natural history of prostatism: worry and embarrassment from urinary symptoms and health care-seeking behavior.

OBJECTIVE To assess the interrelationships among psychosocial symptoms of worry and embarrassment about urinary function, prevalent urinary symptoms, psychological well-being, and health care-seeking behavior in a population-based cohort of men. METHODS A cohort of 2,119 men aged forty to seventy-nine years, randomly selected from the Olmsted County, Minnesota population between December 1989 and March 1991, were administered a previously validated questionnaire that elicited information about the frequency of urinary symptoms, the degree to which they were perceived as a bother, and if the participant had seen a doctor in the previous twelve months for evaluation of any of these urinary symptoms. Psychological well-being was assessed by a subset of the Psychological General Well-Being Index, and sociodemographic information was also sought. RESULTS Urinary symptom indices (measured by American Urological Association frequency and bother scores and psychological general well-being subscales) were significantly associated with worry and embarrassment about urinary symptoms in bivariate analyses. Multiple logistic regression analyses demonstrated that men with moderate or severe urinary symptoms or impaired psychological well-being were more likely to be worried or embarrassed about their urinary symptoms than men with mild symptoms. Furthermore, men who were worried about their urinary function were more likely to have sought medical care for their symptoms than men who were not worried. The association between health care-seeking behavior and embarrassment was especially strong among men with little bother associated with their urinary symptoms. CONCLUSIONS Worry and embarrassment about urinary symptoms reflect quality-of-life issues that appear important in the health care-seeking behavior of men with prostatism. The results underscore findings that prevalent urinary symptoms alone do not determine a mans health care-seeking behavior, and treatment for psychosocial symptoms may be beneficial in some men with symptoms of prostatism.

Natural history of prostatism : factors associated with discordance between frequency and bother of urinary symptoms

The objective of this study was to assess the association between frequency and bother of urinary symptoms in a population-based cohort of men and to identify psychosocial factors that are related to reporting heightened or subdued bother relative to symptom frequency. The survey was conducted among men aged forty to seventy-nine years in Olmsted County, Minnesota, the baseline component of a prospective cohort study. Men were queried about the frequency of urinary symptom occurrence and the perceived bother associated with the symptoms. A regression analysis of American Urologic Association (AUA) bother scores on AUA frequency scores demonstrated a tight correspondence (r2 = 0.71). Men with bother scores greater than predicted from their frequency scores were more likely to have sought health care for their urinary symptoms than men whose bother was close to predicted (14 versus 5 percent, respectively). These men with heightened bother were older, poorer, more anxious, and had lower general psychologic well-being scores than the men whose bother was similar to that expected from their reported frequency. Men whose bother was lower than would be expected were less likely to have sought health care for urinary symptoms in the past year (3%) but were of similar age and socioeconomic status as compared with men whose bother was close to expected. These men, however, were more depressed than men whose bother was commensurate with reported frequency. While the men who reported greater bother than expected from their symptom frequency were more likely to have sought medical care for urinary symptoms in the past year, it is not clear whether this greater health-care-seeking behavior is because bother captures an additional component of urologic disease or is a manifestation of psychosocial differences.