Urinary Incontinence and Nocturia in Older Men: Associations with Body Mass, Composition and Strength in the Health ABC Study

Pre-therapeutical assessment of lower urinary tract symptoms in adult men: Systematic review and clinical practice guidelines

INTRODUCTION

The aim was to propose initial and pre-therapeutical assessment of lower urinary tract symptoms in adult men through a systematic review and clinical practice guidelines.

METHODS

These guidelines were based on a systematic review performed between January 2011 and November 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The protocol was registered in the International Prospective Register of Systematic Reviews database (CRD42022336418). The recommendations and the methodology of elaboration were prospectively validated by the French Health Authority (Haute Autorité de santé [HAS]).

RESULTS

In total, 1662 publications were screened for eligibility and 311 met the inclusion criteria, 167 studies were retained among them 17 guidelines from French, European or International institutions. Perform on initial evaluation: identification of cardiovascular risk factors, metabolic syndrome, current medication, urinary and sexual symptoms (by structured interview or validated self-questionnaires), physical examination (lumbar fossa, pelvis, prostate, genitalia), urinalysis (dipstick or microscopy), abdominal ultrasound of the urinary tract (kidneys, bladder, prostate), post-void residual urine measurement (by ultrasound or automated measurement; under physiological conditions). Micturition flowmetry is recommended (except for general practitioners). Update and complete initial assessment before medication, interventional or surgical treatment if too old or incomplete. Perform a preoperative assessment (bleeding risk, infectious risk, geriatric risk). Urodynamic assessment, endorectal ultrasound and cystoscopy should not be systematically performed (only if additional information is needed). Perform urodynamics and urethrocystoscopy in case of failed interventional or surgical treatment. Following the initial workup, it is recommended to refer the patient to a urologist in case of: macroscopic hematuria, recurrent urinary tract infection or persistent perineal and/or suprapubic pain, persistent microscopic hematuria or leukocyturia in absence of urinary tract infection, predominant storage-phase symptoms, abnormal examination of the genitals or suspected prostate cancer, urinary retention, urinary tract stones, ureterohydronephrosis or morphological abnormalities of the prostate or the urinary tract.

CONCLUSION

These guidelines aimed to define the recommended investigation for LUTS in adult men at diagnosis, before medical treatment and before surgical and interventional treatments, in order to better personalize management and avoid unnecessary and/or invasive examinations.

Association between obesity and urinary incontinence in older adults from multiple nationwide longitudinal cohorts

BACKGROUND

Obesity and urinary incontinence (UI) among older adults, particularly older men, are yet to be fully explored. Utilizing multiple nationwide prospective longitudinal cohorts representative of the US, UK, and European samples, we examined the association of body mass index (BMI) and waist circumference (WC) with UI among both older women and men.

METHODS

We derived the data from multiple longitudinal cohorts that surveyed UI. Participants were asked if they had experienced urine leakage within the past 12 months or within the past six months. The measure of obesity was based on BMI and WC. We employed a random-effect logistic model to associate BMI and WC with UI, adjusting for covariates including age, race, education, residence area, marital status, number of children, smoking, drinking, hypertension, diabetes, cancer, stroke, functional ability, and cognitive impairment. We visualized the associations by using restricted cubic spline curves.

RESULTS

A total of 200,717 participants with 718,822 observations are included in the baseline analysis. Compared to those without UI, both female and male participants with UI demonstrate a higher BMI and WC. Among females, the fully adjusted models show linear associations between BMI, WC, and UI (Ps < 0.001). However, we observe U-shaped associations of BMI, WC with UI among males. The lowest likelihood of having UI is found among male participants with a BMI between 24 and 35 kg/m2.

CONCLUSIONS

Interventions aimed at preventing UI among older adults must take sex into account. Weight loss intervention could be an effective treatment among older females who are overweight and with obesity as well as older males with obesity rather than all older males.

A scoping review of risk factors for urinary incontinence in older men

BACKGROUND

Most epidemiological studies have not systematically identified or categorized risk factors for urinary incontinence (UI) in older men, despite a higher prevalence than in younger men. Considering the burden of UI, an understanding of risk factors can inform cost-effective prevention/treatment programs. This scoping review aimed to identify and categorise risk factors for UI in older men, identify gaps in the evidence, and opportunities for future research.

METHODS

The Joanna Briggs Institute (JBI) method for scoping reviews guided the conduct and reporting of this review alongside the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews checklist. JBI's Population, Concept, and Context approach framed the inclusion criteria (all evidence sources on UI risk factors that included older men [65 +]). We employed JBI's three-step search strategy, which included a limited initial search in Ovid MEDLINE, a detailed comprehensive database search, and a search of reference lists of included studies, Google Scholar and grey literature. There were no restrictions on language, study type, or publication date. Two independent reviewers screened, selected, and extracted eligible studies. Data were analyzed using descriptive statistics and qualitative content analysis.

RESULTS

Forty-seven articles that met the inclusion criteria identified 98 risk factors across six categories. Behavioural risk factors, reported by only two studies, were the least investigated of all the categories, whereas medical factors/diseases were the most investigated. No genetic factors were documented. The top five risk factors were increasing age/advanced age (n = 12), Benign Prostatic Hyperplasia (n = 11), Diabetes Mellitus (n = 11), Detrusor overactivity (n = 10), limitation in physical function/ADL disability (n = 10), increased Body Mass Index (BMI)/overweight/obesity (n = 8), Dementia (n = 8), and Parkinson's disease (n = 7).

CONCLUSION

There is a dearth of evidence to describe the role behavioural risk factors have in UI in older men. These factors may play a role in health promotion and disease prevention in this area.

REGISTRATION

A protocol detailing the methods was developed and published, and is registered in the Open Science Framework [Feb 07 2023; https://osf.io/xsrge/ ].

Determinants of Urinary Incontinence and Subtypes Among the Elderly in Nursing Homes

Urinary incontinence (UI) is a common problem among older adults. This study investigated the prevalence of UI in nursing home residents aged ≥75 years in China and examined potential risk factors associated with UI and its subtypes. Data were collected during face-to-face interviews using a general questionnaire, the International Consultation Incontinence Questionnaire Short-Form, and the Barthel Index. A total of 551 participants aged ≥75 years residing in Changsha city were enrolled from June to December 2018. The UI prevalence rate among nursing home residents aged ≥75 years was 24.3%. The most frequent subtype was mixed (M) UI (38.1%), followed by urge (U) UI (35.1%), stress (S) UI (11.9%), and other types (14.9%). In terms of severity, 57.5% had moderate UI, while 35.1% had mild and 7.5% had severe UI. Constipation, immobility, wheelchair use, cardiovascular disease (CVD), and pelvic or spinal surgery were significant risk factors for UI. Participants with a history of surgery had higher risks of SUI (odds ratio [OR] = 4.87, 95% confidence interval [CI]: 1.55–15.30) and UUI (OR = 1.97, 95% CI: 1.05–3.71), those who were immobile or used a wheelchair had higher rates of MUI (OR = 11.07, 95% CI: 4.19–29.28; OR = 3.36, 95% CI: 1.16–9.78) and other UI types (OR = 7.89, 95% CI: 1.99–31.30; OR = 14.90, 95% CI: 4.88–45.50), those with CVD had a higher rate of UUI (OR = 2.25, 95% CI: 1.17–4.34), and those with diabetes had a higher risk of UUI (OR = 2.250, 95% CI: 1.14–4.44). Use of oral antithrombotic agents increased UUI risk (OR = 4.98, 95% CI: 2.10–11.85) whereas sedative hypnotic drug use was associated with a higher risk of MUI (OR = 3.62, 95% CI: 1.25–10.45). Each UI subtype has distinct risk factors, and elderly residents of nursing homes with a history of CVD and pelvic or spinal surgery who experience constipation should be closely monitored. Reducing time spent in bed and engaging in active rehabilitation including walking and muscle strengthening may aid in UI prevention and treatment.

Assessment of Frailty and Association With Progression of Benign Prostatic Hyperplasia Symptoms and Serious Adverse Events Among Men Using Drug Therapy

IMPORTANCE

Benign prostatic hyperplasia (BPH) in older men can cause lower urinary tract symptoms (LUTS), which are increasingly managed with medications. Frailty may contribute to both symptom progression and serious adverse events (SAEs), shifting the balance of benefits and harms of drug therapy.

OBJECTIVE

To assess the association between a deficit accumulation frailty index and clinical BPH progression or SAE.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Medical Therapy of Prostatic Symptoms trial, which compared placebo, doxazosin, finasteride, and combination therapy in men with moderate-to-severe LUTS, reduced urinary flow rate, and no prior BPH interventions, hypotension, or elevated prostate-specific antigen. Enrollment was from 1995 to 1998, and follow-up was through 2001. Data were assessed in February 2021.

EXPOSURES

A frailty index (score range, 0-1) using 68 potential deficits collected at baseline was used to categorized men as robust (score ≤0.1), prefrail (score 0.1 to <0.25), or frail (score ≥0.25).

MAIN OUTCOMES AND MEASURES

Primary outcomes were time to clinical BPH progression and time to SAE, as defined in the parent trial. Adjusted hazard ratios (AHRs) were estimated using Cox proportional hazards regressions adjusted for demographic variables, treatment group, measures of obstruction, and comorbidities.

RESULTS

Among 3047 men (mean [SD] age, 62.6 [7.3] years; range, 50-89 years) in this analysis, 745 (24%) were robust, 1824 (60%) were prefrail, and 478 (16%) were frail at baseline. Compared with robust men, frail men were older (age ≥75 years, 12 men [2%] vs 62 men [13%]), less likely to be White (646 men [87%] vs 344 men [72%]), less likely to be married (599 men [80%] vs 342 men [72%]), and less likely to have 16 years or more of education (471 men [63%] vs 150 men [31%]). During mean (SD) follow-up of 4.0 (1.5) years, the incidence rate of clinical BPH progression was 2.2 events per 100 person-years among robust men, 2.9 events per 100 person-years among prefrail men (AHR, 1.36; 95% CI, 1.02-1.83), and 4.0 events per 100 person-years among frail men (AHR, 1.82; 95% CI, 1.24-2.67; linear P = .005). Larger point estimates were seen among men who received doxazosin or combination therapy, although the test for interaction between frailty index and treatment group did not reach statistical significance (P for interaction = .06). Risk of SAE was higher among prefrail and frail men (prefrail vs robust AHR, 1.81; 95% CI, 1.48-2.23; frail vs robust AHR, 2.86; 95% CI, 2.21-3.69; linear P < .001); this association was similar across treatment groups (P for interaction = .76).

CONCLUSIONS AND RELEVANCE

These findings suggest that frailty is independently associated with greater risk of both clinical BPH progression and SAEs. Older frail men with BPH considering initiation of drug therapy should be counseled regarding their higher risk of progression despite combination therapy and their likelihood of experiencing SAEs regardless of treatment choice.

[EFFICACY AND SAFETY OF 25 AND 50 μg DESMOPRESSIN ORALLY DISINTEGRATING TABLETS IN NOCTURIA DUE TO NOCTURNAL POLYURIA IN JAPANESE MALE PATIENTS]

(Purpose) To conduct a prospective study on the efficacy and safety of desmopressin for nocturnal polyuria. (Materials and methods) We selected 51 Japanese men, aged ≥50 years, with complaints of nocturia and a nocturnal polyuria index of ≥0.33. We administered 25 or 50 μg desmopressin (Minirinmelt Orally Disintegrating Tablet^®), once daily at bedtime. We evaluated the nighttime urinary frequency and urine volume, nocturnal polyuria index, time to the first urination after falling asleep, and International Prostate Symptom Score (IPSS) at baseline and at 4, 8, and 12 weeks after administration. In addition, they underwent clinical examinations and blood tests at 1, 4, and 12 weeks to evaluate the safety of the drug. (Results) We observed a decrease in the nighttime urinary frequency and urine volume, and nocturnal polyuria index, increased prolonged time to the first urination after falling asleep, and improved IPSS at and after 4 weeks, compared to baseline data. Furthermore, the drug remained effective even at 12 weeks for all parameters. We observed adverse events in 31.3% of the patients. The incidence of hyponatraemia was particularly high in 15.7% of the patients. Those with a lower serum sodium level and lesser body weight at baseline were more likely to develop hyponatraemia. (Conclusion) Desmopressin was identified as a potential drug for the treatment of nocturnal polyuria. However, hyponatraemia, an important adverse event, resulted in treatment discontinuation in several patients. A sodium level lower than the normal level and low body weight at baseline were the risk factors for hyponatraemia.

Evaluation and treatment of urinary incontinence in the aging male

Risk of urinary incontinence (UI) increases with age and can have detrimental effects on patients and caregivers. UI should not be considered a normal part of aging and warrants a comprehensive evaluation. Treatment of UI in the aging male requires special consideration, particularly when it comes to comorbid conditions and potential side effects of intervention. The aim of this review is to discuss the evaluation of, risk factors for, and management of UI in the aging male.

Synchronous genitourinary lichen sclerosus signals a distinct urinary microbiome profile in men with urethral stricture disease

PURPOSE

Alterations in the urinary microbiome have been associated with urological diseases. The microbiome of patients with urethral stricture disease (USD) remains unknown. Our objective is to examine the microbiome of USD with a focus on inflammatory USD caused by lichen sclerosus (LS).

METHODS

We collected mid-stream urine samples from men with LS-USD (cases; n = 22) and non-LS USD (controls; n = 76). DNA extraction, PCR amplification of the V4 hypervariable region of the 16S rRNA gene, and sequencing was done on the samples. Operational taxonomic units (OTUs) were defined using a > 97% sequence similarity threshold. Alpha diversity measurements of diversity, including microbiome richness (number of different OTUs) and evenness (distribution of OTUs) were calculated and compared. Microbiome beta diversity (difference between microbial communities) relationships with cases and controls were also assessed.

RESULTS

Fifty specimens (13 cases and 37 controls) produced a 16S rRNA amplicon. Mean sample richness was 25.9 vs. 16.8 (p = 0.076) for LS-USD vs. non-LS USD, respectively. LS-USD had a unique profile of bacteria by taxonomic order including Bacillales, Bacteroidales and Pasteurellales enriched urine. The beta variation of observed bacterial communities was best explained by the richness.

CONCLUSIONS

Men with LS-USD may have a unique microbiologic richness, specifically inclusive of Bacillales, Bacteroidales and Pasteurellales enriched urine compared to those with non-LS USD. Further work will be required to elucidate the clinical relevance of these variations in the urinary microbiome.