Risk behaviours and benign prostatic hyperplasia

Emerging drugs for the treatment of benign prostatic hyperplasia: a 2023 update

INTRODUCTION

Benign prostatic hyperplasia (BPH) is condition that affects over 50% of men as they enter their fifth decade of life, often leading to lower urinary tract symptoms (LUTS). Primary treatment options include alpha blockers, 5-alpha reductase inhibitors, and phosphodiesterase-5 inhibitors. However, these medications can have some side effects, and there is a noticeable dearth of information addressing the long-term use of these medications. Thus, the exploration of all treatment modalities helps ensure patients receive personalized and effective care. Consequently, the primary objective of this review is to identify potential emerging medications for the treatment of BPH.

AREAS COVERED

We conducted an extensive review of articles discussing pharmacotherapy for BPH spanning the last 15 years. Our information gathering process involved Scopus, PubMed-MEDLINE, Cochrane, Wiley Online Library Google Scholar, ClinicalTrials.gov, and the PharmaProjects database. This approach ensures that readers gain an in-depth knowledge of the existing therapeutic agents as well as promising avenues for managing BPH.

EXPERT OPINION

BPH treatment targets a patient's specific constellation of symptoms. Therefore, a broad knowledge base encompassing various treatment options is paramount in ensuring optimal treatment. Looking forward, the emphasis on personalization promises to reshape the landscape of BPH treatment and improve patient outcomes.

The global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Benign prostatic hyperplasia is a common urological disease affecting older men worldwide, but comprehensive data about the global, regional, and national burden of benign prostatic hyperplasia and its trends over time are scarce. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we estimated global trends in, and prevalence of, benign prostatic hyperplasia and disability-adjusted life-years (DALYs) due to benign prostatic hyperplasia, in 21 regions and 204 countries and territories from 2000 to 2019.

METHODS

This study was conducted with GBD 2019 analytical and modelling strategies. Primary prevalence data came from claims from three countries and from hospital inpatient encounters from 45 locations. A Bayesian meta-regression modelling tool, DisMod-MR version 2.1, was used to estimate the age-specific, location-specific, and year-specific prevalence of benign prostatic hyperplasia. Age-standardised prevalence was calculated by the direct method using the GBD reference population. Years lived with disability (YLDs) due to benign prostatic hyperplasia were estimated by multiplying the disability weight by the symptomatic proportion of the prevalence of benign prostatic hyperplasia. Because we did not estimate years of life lost associated with benign prostatic hyperplasia, disability-adjusted life-years (DALYs) equalled YLDs. The final estimates were compared across Socio-demographic Index (SDI) quintiles. The 95% uncertainty intervals (UIs) were estimated as the 25th and 975th of 1000 ordered draws from a bootstrap distribution.

FINDINGS

Globally, there were 94·0 million (95% UI 73·2 to 118) prevalent cases of benign prostatic hyperplasia in 2019, compared with 51·1 million (43·1 to 69·3) cases in 2000. The age-standardised prevalence of benign prostatic hyperplasia was 2480 (1940 to 3090) per 100 000 people. Although the global number of prevalent cases increased by 70·5% (68·6 to 72·7) between 2000 and 2019, the global age-standardised prevalence remained stable (-0·770% [-1·56 to 0·0912]). The age-standardised prevalence in 2019 ranged from 6480 (5130 to 8080) per 100 000 in eastern Europe to 987 (732 to 1320) per 100 000 in north Africa and the Middle East. All five SDI quintiles observed an increase in the absolute DALY burden between 2000 and 2019. The most rapid increases in the absolute DALY burden were seen in the middle SDI quintile (94·7% [91·8 to 97·6]), the low-middle SDI quintile (77·3% [74·1 to 81·2]), and the low SDI quintile (77·7% [72·9 to 83·2]). Between 2000 and 2019, age-standardised DALY rates changed less, but the three lower SDI quintiles (low, low-middle, and middle) saw small increases, and the two higher SDI quintiles (high and high-middle SDI) saw small decreases.

INTERPRETATION

The absolute burden of benign prostatic hyperplasia is rising at an alarming rate in most of the world, particularly in low-income and middle-income countries that are currently undergoing rapid demographic and epidemiological changes. As more people are living longer worldwide, the absolute burden of benign prostatic hyperplasia is expected to continue to rise in the coming years, highlighting the importance of monitoring and planning for future health system strain.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATION

For the Amharic translation of the abstract see Supplementary Materials section.

Lower urinary tract symptoms in patients with small prostates: Smooth muscle proliferation and calcification might be causative factors

OBJECTIVES

The current study is designed to evaluate and compare the histological changes in the surgical samples of prostate taken from patients undergoing transurethral resection of prostate (TURP) for benign prostate hyperplasia (BPH) with different sizes.

METHODS

Prostate surgical tissue samples were obtained from BPH patients undergoing TURP after taking informed consent. Ultrasound measure of prostatic weight and prostate-specific antigen (PSA) levels were obtained from the patients along with other clinical and demographic details. Tissue samples were fixed, processed, sectioned and stained with hematoxylin and eosin and Masson's trichrome to look for histological features, specifically smooth muscle proliferation. Immunohistochemical expression of bone morphogenetic protein (BMP)-2 was recorded to assess the calcification potential.

RESULTS

Fifty-nine surgical samples were obtained from the patients of age range 50-90 years and body mass index (BMI) 15.6-33.3 kg/m² . The range of ultrasound measures of prostate weight was 20-137 g with PSA ranged 1.03-93.3 ng/mL. Patients with small-sized prostate had significant severe smooth muscle proliferation (P < .001). Prostate size/weight had significant positive association with BMI (P < 0.001, r = 0.543) and negative association with BMP-2 (P < 0.001, r = -0.654). Samples with severe smooth muscle proliferation were with increased BMP-2 expression (P < .001) and higher levels of PSA levels (P = 0.004). BMP-2 expression revealed positive significant association with PSA (P < .001, r = 0.432).

CONCLUSION

From this study we conclude that BPH patients with small-sized glands and high PSA levels have increased smooth muscle proliferation and calcification potential causing the symptoms of lower urinary tract symptoms in these patients.

Duration of smoking cessation is negatively associated with the magnitude of chronic prostatic inflammation and storage dysfunction in patients with benign prostatic hyperplasia

OBJECTIVES

To evaluate the impact of smoking and the benefit of smoking cessation on lower urinary tract function and prostatic inflammation in patients with benign prostatic hyperplasia.

METHODS

The medical records of 118 benign prostatic hyperplasia patients who underwent transurethral prostatic surgery between 2006 and 2016 were analyzed. Their smoking history was confirmed. The relationship between smoking and main clinical parameters, International Prostate Symptom Scores, uroflowmetry, pressure flow study, magnitude of prostatic inflammation and the level of serum C-reactive protein was investigated. Furthermore, the relationships between smoking cessation and these clinical parameters were assessed.

RESULTS

The International Prostate Symptom Scores for straining among the non-smokers were significantly lower than those of the smokers (1.71 vs 2.60, P = 0.029). In the pressure flow study, there were negative correlations between the duration of smoking and strong desire to void (correlation coefficient -0.314, P = 0.013), urgency (correlation coefficient -0.349, P = 0.008) and bladder volume at initial detrusor overactivity (correlation coefficient -0.417, P = 0.021). The duration of smoking cessation was negatively correlated with the magnitude of chronic prostatic inflammation (correlation coefficient -0.253, P = 0.027). In the pressure flow study, the duration of smoking cessation was positively correlated with urgency (correlation coefficient 0.286, P = 0.030) and maximum cystometric capacity (correlation coefficient 0.241, P = 0.050).

CONCLUSIONS

Smoking could be a risk factor for the exacerbation of storage dysfunction in benign prostatic hyperplasia patients. Smoking cessation is effective in improving chronic prostatic inflammation and storage dysfunction.

Do Lifestyle Factors Affect Lower Urinary Tract Symptoms? Results from the Korean Community Health Survey

PURPOSE

To evaluate the relationships between lower urinary tract symptoms (LUTS) and lifestyle factors (physical activity, smoking, alcohol consumption, body mass index, and stress) in Korean men.

METHODS

We analyzed the survey results of South Korean men (n=64,439) who were 40 years of age or older among whom interviews were conducted using questionnaires. Trained interviewers performed face-to-face surveys using computer-assisted personal interviewing, the International Prostate Symptom Score (IPSS), and standard questions. We assessed the relationships of lifestyle factors (physical activity, cigarette smoking, alcohol intake, height, weight, and stress) with LUTS.

RESULTS

We observed higher IPSS scores in participants who engaged in no exercise (n=46,008 [71.7%], IPSS=3.19±5.36) than in those who engaged in vigorous physical activity (n=10,657 [17.6%], IPSS=2.28±4.15). Former smokers showed higher total, storage, and voiding symptom IPSS scores than current smokers and nonsmokers. Nondrinkers had higher IPSS scores than current alcohol drinkers. In multivariable logistic regression analysis, we detected no relationship between LUTS and current alcohol drinking in the moderate and severe LUTS groups, using the mild LUTS group as a reference (moderate: 0.91; 95% confidence interval [CI], 0.91-0.91; P<0.001, severe: 0.78; 95% CI, 0.78-0.78; P<0.001). Participants with moderate to severe stress showed higher total IPSS scores than those with no or mild stress (3.38±5.77 vs. 2.88±4.90), with significant relationships between stress and LUTS found in the moderate and severe LUTS groups. In logistic regression analysis, stronger relationships were found for storage and voiding symptoms in the moderate and severe stress groups compared to the mild stress group.

CONCLUSION

A history of smoking, low levels of physical activity, low body mass index, and moderate to severe stress were associated with a greater severity of LUTS. Moderate to severe stress was also related to voiding symptoms. However, there was no association between alcohol intake and LUTS severity.

Metabolic syndrome and smoking are associated with persistence of nocturia after transurethral resection of the prostate

AIMS

The aim of our study was to evaluate the relationship between smoking, metabolic syndrome (MetS) and persistence of nocturia in patients with moderate/severe nocturia (nocturia episodes ≥2), lower urinary tract symptoms (LUTSs), and benign prostatic enlargement (BPE) undergoing transurethral resection of the prostate (TURP).

METHODS

From 2015 onward, a consecutive series of patients with moderate/severe nocturia (nocturia episodes ≥2), LUTS, and BPE undergoing TURP were prospectively enrolled. Medical history, physical examination, and smoking status were recorded. MetS was defined according to Adult Treatment Panel III. Moderate/severe persistent nocturia after TURP was defined as nocturia episodes ≥2. Binary logistic regression analysis was used to evaluate the risk of persisting nocturia.

RESULTS

One hundred two patients were enrolled with a median age of 70 years (interquartile range: 65/73). After TURP, moderate/severe nocturia was reported in 43 of 102 (42%) of the patients. Overall 40 of 102 (39%) patients presented a MetS, and out of them, 23 of 40 (58%) presented a moderate/severe persistent nocturia after TURP ( P = .001). Overall 62 of 102 (61%) patients were smokers, and out of them, 32 of 62 (52%) presented moderate/severe persistent nocturia after TURP ( P = .034). On multivariate analysis, prostate volume, MetS, and smoking were independent risk factors for moderate/severe persistent nocturia after TURP.

CONCLUSION

In our single-center study, MetS and smoking increased the risk of moderate/severe persistent nocturia after TURP in patients with LUTS-BPE. Although these results should be confirmed, and the pathophysiology is yet to be completely understood, counseling smokers and MetS patients about the risk of postoperative persistent nocturia is warranted.

Inflammatory mediators in the development and progression of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the most common urological disease in elderly men. Epidemiological data suggest a causal link between this condition and prostatic inflammation. The prostate is an immune-competent organ characterized by the presence of a complex immune system. Several stimuli, including infectious agents, urinary reflux, metabolic syndrome, the ageing process, and autoimmune response, have been described as triggers for the dysregulation of the prostatic immune system via different molecular pathways involving the development of inflammatory infiltrates. From a pathophysiological standpoint, subsequent tissue damage and chronic tissue healing could result in the development of BPH nodules.

Prostatic inflammation: a potential treatment target for male LUTS due to benign prostatic obstruction

BACKGROUND

The purpose of this narrative review is to evaluate the role of prostatic inflammation as a treatment target for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) and provide an update on the available therapies.

METHODS

An extensive literature search was conducted for studies on established and investigational treatments with anti-inflammatory mechanism of action that has been assessed for the management of male LUTS due to BPO.

RESULTS

Data on phosphodiesterase 5 inhibitors, nonsteroidal anti-inflammatory drugs, vitamin D3 receptor analogs, phytotherapy, statins, and lifestyle changes have been reviewed and analyzed. Preclinical evidence has shown the anti-inflammatory effect of these treatments on prostate. However, there is a wide variation in the degree of mature of each therapy. In addition, there are significant differences between the studies in terms of design, number of patients, and duration of follow-up.

CONCLUSIONS

Several drugs classes have been investigated for their impact on prostatic inflammation and improvement of male LUTS. The reviewed data support the rationale for use of agents that may alter and improve the inflammatory environment in the prostate in men with LUTS, but further high-quality long-term studies are required for the exact positioning of the new drugs in daily practice.

Metabolic syndrome and smoking are associated with an increased risk of nocturia in male patients with benign prostatic enlargement

BACKGROUND

To evaluate the relationship between cigarette smoking, metabolic syndrome (MetS) and nocturia in patients with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE).

METHODS

From 2009 onward, a consecutive series of patients with LUTS/BPE were enrolled. Symptoms were assessed using the International Prostate Symptom Score (IPSS). Age, body mass index (BMI), smoker status, prostate volume (PV), prostate-specific antigen (PSA) levels, fasting glucose levels, triglyceride levels, and high-density lipoprotein levels were recorded. MetS was defined according to Adult Treatment Panel III criteria. Moderate/severe nocturia was defined as nocturnal micturition episodes ≥2.

RESULTS

Overall 492 patients were enrolled with median age and BMI of 68 years (IQR 61/74) and 26.5 kg/m² (IQR: 24/29), respectively. Moderate/severe nocturia was reported in 212 (43.1%) patients. MetS was diagnosed in 147 (29.9%) patients and out of them 89 (60.5%) complained moderate/severe nocturia (p = 0.001). Overall 187 (38%) patients were current smokers and out of them 99 (52%) presented moderate/severe nocturia(p = 0.034). Patients with moderate/severe nocturia were older (p = 0.001) and with larger prostate volume (p = 0.003). On multivariate analysis, age (OR: 1.067 per year, 95% CI: 1.036-1.098; p = 0.001), PV (OR: 1.011 per ml, 95% CI: 1.003-1.019; p = 0.006), MetS (OR: 2.509, 95% CI: 1.571-4.007; p = 0.001) and smoking (OR: 1.690, 95% CI: 1.061-2.693; p = 0.027) were associated with nocturia severity.

CONCLUSIONS

MetS and smoking doubled the risk of moderate/severe nocturia in patients with LUTS and BPE. Assessing smoking and metabolic status in LUTS/ BPE patients is suggested.

Emerging drugs for the treatment of benign prostatic hyperplasia

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common condition affecting over 50% of men as they reach their 5^th decade of life. This leads to a number of sequelae such as lower urinary tract symptoms, urinary retention and a decrease in quality of life. Currently, the available treatments for BPH are alpha blockers and 5-alpha reductase inhibitors. Clinical studies have demonstrated these medical options are effective in alleviating a patient's symptoms, however there are a number of side effects. There is a paucity of information regarding long-term use of these medications. The purpose of this review is to identify potential and emerging medications for the treatment of BPH. Areas covered: Articles used in this review were retrieved from Pubmed, Google and through searching the PharmaProjects database over the last 10 years, giving the reader an in-depth knowledge about the current pharmacological agents available and other potential treatments for BPH. Expert opinion: The new paradigm of BPH treatment depends on addressing a patient's specific constellation of symptoms. This allows to tailor therapy of increasing efficacy and reduce adverse events that our patients have by increasing dosage.

The effect of non-steroidal anti-inflammatory drugs on risk of benign prostatic hyperplasia

BACKGROUND

Inflammation may play a role in pathogenesis of benign prostatic hyperplasia (BPH). However, the role of non-steroidal anti-inflammatory drugs (NSAIDs) as BPH risk factor is unclear. The objective of this study was to examine risk of BPH by NSAID use in a population-based cohort.

METHODS

A total of 74 754 Finnish men without previous BPH at baseline in 1996-1999 were linked to national medication reimbursement database for information on physician-prescribed NSAID purchases during 1995-2009. Information on BPH procedures and diagnoses was obtained from national Care Register for Health Care. Cox regression with adjustment for age and use of cholesterol-lowering, antidiabetic and antihypertensive medication, with NSAID use as time-dependent variable was used to analyse the risk of BPH surgery, medication use, and recorded diagnosis.

RESULTS

Of the subjects 57 707 men (77.2%) used prescription NSAIDs. The risk of BPH was elevated among NSAID users compared to non-users: HR 2.04, 95% CI 1.97-2.10 for BPH medication use, HR 1.59, 95% CI 1.47-1.71 for recorded diagnosis and HR 1.61, 95% CI 1.49-1.74 for surgery. The risk increase correlated with duration of NSAID usage, less with annual dosage. Nevertheless, the risk increase was observed already at short-term and low-dosage use.

CONCLUSIONS

NSAID use is associated with an increased risk of BPH. The association is affected by systematic differences by NSAID use as the risk increase was observed already at short-term use. Nevertheless, the association correlated with duration of use, suggesting that NSAID usage or the conditions indicating it may increase BPH risk.

Risk stratification for benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) represents an important public health problem in ageing men due to frequently associated lower urinary tract symptoms (LUTS), which may impair quality of life. BPH is also a progressive disease, mainly characterized by a worsening of LUTS over time, and in some patients by the occurrence of serious outcomes such as acute urinary retention and need for BPH-related surgery. The management of BPH and LUTS in men should move forward its focus on symptom control only. Indeed, the goals of therapy for BPH are not only to improve bothersome LUTS but also to identify those patients at risk of unfavourable outcomes in order to optimize their management and reduce complications. Risk stratification and tailored treatment should improve the reductions in both symptoms and the long-term consequences of BPH and BPH treatments. To do this, clinicians need to know possible factors that may support the develop of PBH and possible risks due to the BPH itself.

Prostatic vascular damage induced by cigarette smoking as a risk factor for recovery after holmium laser enucleation of the prostate (HoLEP)

Purpose

To evaluate the relationship between prostatic vessel changes induced by cigarette smoking and the perioperative outcome of holmium laser enucleation of the prostate (HoLEP).

Materials and Methods

A total of 268 postoperative patients with benign prostatic hyperplasia (BPH) were prospectively analysed in our department. They were divided into two groups (smokers and non-smokers) according to smoking history. Transrectal colour Doppler ultrasound was performed to evaluate the prostate vascular changes. Pathologically, HE staining, CD31 and CD34 were analysed in prostatic section chips. Furthermore, postoperative outcomes were determined during a 6-month follow-up period.

Results

The preoperative prostate volume was significantly decreased in smoking patients (P = 0.04). CPI was significantly lower in smoking BPH patients (P < 0.01), whereas RI was significantly increased in smokers compared with non-smokers (P < 0.01). Histological assays revealed elevated CD34 in the smoking BPH individuals presenting an increased number of microvessels. The HoLEP duration was increased in smokers. Interestingly, we identified significantly increased overactive bladder syndrome score (OABSS) and decreased Qmax in smoking individuals during the 6-month follow-up with no difference being observed preoperatively. However, no significant difference between the groups was observed for the International Prostate Symptom Score (IPSS).

Conclusions

The significantly lower CPI and higher RI values in smoking BPH patients indicated the presence of considerable vascular damage in these subjects. Moreover, cigarette smoking extended the surgical duration and prolonged the recovery period of overactive bladder (OAB) syndrome. Thus, integrated treatment should be suggested for various BPH individuals.

Smoking and prevalence of nocturia in Japanese patients with type 2 diabetes mellitus: a post-hoc analysis of The Dogo Study

AIMS

No evidence exists regarding the association between smoking status and nocturia among patients with type 2 diabetes mellitus. We evaluated this association among Japanese patients with type 2 diabetes mellitus by post-hoc analysis.

METHODS

Study subjects were 817 Japanese patients with type 2 diabetes mellitus. Study subjects were considered to have nocturia if they answered "once or more" to the question: "Within one week, how many times do you typically wake up to urinate from sleeping at night until waking in the morning?" We used the following three outcomes: (1) nocturia was ≥1 voids per night; (2) moderate nocturia was ≥2 voids per night; and (3) severe nocturia was ≥3 voids per night. Adjustments were made for age, sex, body mass index, hypertension, dyslipidemia, stroke, glycated hemoglobin, current drinking, use of anti-hypertensive agent, use of insulin, use of oral anti-hyperglycemic agent, and diabetic retinopathy.

RESULTS

The prevalence values of one void per night, two voids per night, and three or more voids per night were 39.5%, 27.1%, and 14.8%, respectively. Current smoking was independently inversely associated with severe nocturia compared with never or former smoking; the adjusted PR was 0.47 (95%CI: 0.25-0.89). Among the 443 patients who had ever smoked, compared with former smoking, current smoking was independently inversely related to severe nocturia; the adjusted PR was 0.44 (95%CI: 0.24-0.82).

CONCLUSIONS

In Japanese patients with type 2 diabetes mellitus, current smoking may be independently inversely associated with severe nocturia.

Smoking habits and benign prostatic hyperplasia: A systematic review and meta-analysis of observational studies

Previous studies have warned against the promoting effects of cigarette smoking on benign prostatic hyperplasia (BPH). In contrast, some have argued that smoking confers a protective effect regarding BPH, while others have observed an aggravated effect. Thus, we performed this meta-analysis to determine whether cigarette use is associated with BPH risk.To identify articles from observational studies of relevance, a search was performed concurrent to March 21, 2016, on PubMed, Web of Science, Cochrane, EBSCO, and EMBASE databases. Random-effect model, according to the heterogeneity, was calculated to reveal the relative risks (RRs) and corresponding 95% confidence intervals (CIs).Eight articles were included in this meta-analysis, representing data for 44,100 subjects, of which 5221 (11.8%) had BPH as defined according to the criteria. Seven reports are concerned with analysis between nonsmokers and ex-smokers, in which no significant difference was observed (RR = 0.99, 95% CI 0.94-1.05). Another meta-analysis of 7 studies indicated an observable trend, but without significant difference between groups of nonsmokers and current smokers (RR = 1.17, 95% CI 0.98-1.41). Between groups of heavy (6 articles; RR = 1.02, 95% CI 0.84-1.24) and light smokers (5 articles; RR = 0.90, 95% CI 0.71-1.15), again no significant difference appears. Finally, we combined individuals as never-smokers and ever-smokers and still found no significant difference between the 2 groups of patients (RR = 1.03, 95% CI 0.92-1.15). Sensitivity analysis was displayed and confirmed the stability of the present results.Combined evidence from observational studies shows no significant association between cigarette smoking and BPH risk, either for ex-smokers or for current smokers. The trend of elevated BPH risk from smoking was observed only in current smokers compared with nonsmokers, while marginal significance was observed in comparing ever-smokers with never-smokers in operative patients with BPH.

Association of Alcohol Consumption with Markers of Prostate Health and Reproductive Hormone Profiles: A Multi-Center Study of 4,535 Men in China

Background

The effect of alcohol consumption on prostate health and reproductive hormone profiles has long been investigated and currently, no consensus has been reached. Additionally, large studies focusing on this topic are relatively rare in China.

Purpose

To investigate the association of alcohol consumption with prostate measurements and reproductive hormone profiles in Chinese population; and to examine the relationship between hormone levels and prostate measurements.

Methods

This cross-sectional study included 4535 men from four representative provinces of China. Demographic details, family history of prostate disease, tobacco and alcohol consumption, as well as International Prostate Symptom Score (I-PSS) were collected through a questionnaire. Total prostate specific antingen (total PSA), free PSA, free PSA/total PSA ratio (f/tPSA), and reproductive hormones were measured in serum. Multi-variable regression models were used to test for association of alcohol consumption with markers of prostate health, used to test for association of alcohol consumption with reproductive hormones, and reproductive hormones with markers of prostate health.

Results

Alcohol consumption had no obvious impact on total PSA concentration and I-PSS. Current drinkers had lower level of free PSA (β = -0.11, p = 0.02) and f/tPSA (β = -0.03, p = 0.005), former drinkers also had lower level of free PSA (β = -0.19, p = 0.02) when compared with never drinkers. Lower Luteinizing hormone (LH) (β = -1.05, p = 0.01), sex hormone-binding globulin (SHBG) (β = -4.71, p = 0.01) and higher estradiol (β = 7.81, p = 0.01) was found in current drinkers than never drinkers, whereas higher LH (β = 1.04, p = 0.04) and free testosterone (FT) (β = 0.03, p = 0.02) was detected in former drinkers than never drinkers. Furthermore, LH was positively associated with f/tPSA (β = 0.002, p = 0.006), SHBG was also positively related with free PSA (β = 0.003, p = 0.003) and f/tPSA (β = 0.0004, p = 0.01). Both total testosterone (TT) and FT were inversely related with I-PSS (OR = 0.97, 95% CI, 0.95–0.98; OR = 0.23, 95% CI, 0.11–0.45, respectively).

Conclusions

Alcohol consumption could affect serum free PSA concentration and also f/tPSA ratio, and also acts as an endocrine disruptor on the male reproductive hormone profiles. LH and SHBG were positively related with fPSA and f/tPSA, and higher level of TT and FT may be helpful for improving participants' subjective symptoms.

Prostate Biopsy Markers of Inflammation are Associated with Risk of Clinical Progression of Benign Prostatic Hyperplasia: Findings from the MTOPS Study

PURPOSE

Factors associated with worsening of benign prostatic hyperplasia are not well understood. We measured inflammatory markers from prostate biopsies to study if inflammation is related to clinical progression of benign prostatic hyperplasia.

MATERIALS AND METHODS

We measured inflammatory cell markers CD45, CD4, CD8 and CD68 in transition zone biopsies from 859 men in the MTOPS biopsy substudy. Using novel imaging techniques we quantified amounts of moderate/severe inflammation. Benign prostatic hyperplasia clinical progression was defined as a confirmed 4-point or greater increase in the AUA symptom score from baseline, or the occurrence of urinary incontinence or acute urinary retention. Baseline clinical parameters including concomitant medication use were determined. Kaplan-Meier curves and multivariate Cox proportional hazard models were used to determine the risk of progression.

RESULTS

Inflammation as measured by CD45, CD4 and CD68 increased the risk of clinical progression of benign prostatic hyperplasia. CD4 showed the highest risk where men in the highest tertile of moderate/severe inflammation were at twice the risk of progression compared to men in the lower 2 tertiles combined (HR 2.03, p=0.001). Inflammation was more strongly associated with progression defined by acute urinary retention or incontinence (HR ranging from 2.39 [CD8, p=0.03] to 3.08 [CD4, p=0.01]) than an AUA symptom score increase (CD4, HR 1.86, p=0.01). Men who reported use of nonsteroidal anti-inflammatory drugs or steroids at baseline tended to be at higher risk for progression.

CONCLUSIONS

Although our data show that inflammation increases the risk of progression, our findings suggest that inflammation has a greater role in men who have conditions requiring anti-inflammatory medications.

Physical activity and benign prostatic hyperplasia-related outcomes and nocturia

INTRODUCTION

Benign prostatic hyperplasia (BPH) and its associated lower urinary tract symptoms (LUTS), including nocturia, are extremely common among middle- and older-age American men. Although studies on physical activity (PA) and prevalent BPH-related outcomes suggest that PA may protect against the development of this common condition, only a few studies have examined the relation between PA and incident BPH-related outcomes and LUTS with mixed findings. In addition, although nocturia is the most commonly reported and most bothersome LUTS in men with or without evidence of BPH, few studies have examined the association of PA and nocturia independent of BPH. The purpose of this analysis was to examine the association of PA with BPH-related outcomes and nocturia in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening trial.

METHODS

We examined this association with both prevalent (n = 28,404) and incident (n = 4710) BPH-related outcomes (measured by self-report of physician diagnosis, BPH surgery, finasteride use, and clinical indicators) and nocturia. Poisson regression with robust variance was used to calculate prevalence ratios and relative risks.

RESULTS

PA was weakly positively associated with several prevalent BPH-related outcomes and was strongly inversely associated with prevalent nocturia. In incident analyses, PA was only associated with nocturia. Men who were active ≥1 h·wk(-1) were 13% less likely (95% confidence interval, 2%-22%) to report nocturia and 34% less likely (95% confidence interval, 15%-49%) to report severe nocturia as compared with men who reported no PA. The associations were similar for men with and without additional BPH-related outcomes, except for prevalent nocturia, where the association was stronger for men without other BPH-related outcomes.

CONCLUSIONS

Combined with other management strategies, PA may provide a strategy for the management of BPH-related outcomes, particularly nocturia.

Alcohol is longitudinally associated with lower urinary tract symptoms partially via high-density lipoprotein

BACKGROUND

Previous studies on the association of alcohol consumption with lower urinary tract symptoms (LUTS) have been inconsistent, and none took into account the dynamic nature of LUTS, fluctuating over time. The purpose of the study was to determine the longitudinal association of alcohol consumption with LUTS.

METHODS

We used generalized estimating equations to analyze the longitudinal association of alcohol consumption with LUTS in a longitudinal study of 9,712 healthy men 30 years or older who visited our institution multiple times for routine comprehensive health evaluations, with an average follow-up period of 27.9 months.

RESULTS

Light-moderate alcohol consumption (0.1 to 29 g/d) was associated with decreased likelihood of moderate-severe LUTS, whereas heavy alcohol consumption (≥30 g/d) was associated with increased likelihood of moderate-severe LUTS in a dose-dependent manner. Compared to those with 0 g/d alcohol intake, subjects who drank 0.1 to 9.9, 10 to 19.9, 20 to 29.9, 30 to 39.9, or ≥40 g/d of alcohol were in general significantly associated with moderate-severe LUTS with adjusted odds ratio (95% confidence interval) as follows respectively: 0.94 (0.87 to 1.02), 1.00 (0.91 to 1.09), 0.85 (0.77 to 0.93), 1.08 (0.98 to 1.19), and 1.31 (1.19 to 1.44). However, the protective association of light-moderate alcohol consumption with LUTS was greatly attenuated when serum high-density lipoprotein (HDL) was added to the analysis, specifically for voiding symptoms.

CONCLUSIONS

We show strong evidence there is longitudinal association of alcohol consumption with LUTS. The protective effect of light-moderate alcohol consumption on LUTS is in part modulated by HDL as a confounder, similar to its effect on coronary heart disease.

Older patient perioperative care as experienced via transurethral resection of the prostate (TURP)

This reflective piece takes a holistic approach to an older patient having a transurethral resection of the prostate, commonly known as a TURP. It concentrates on the effects of age and likely comorbidities, and how the care given at each stage--preoperatively, anaesthetically, surgically and postoperatively--by the perioperative team can help to optimise the outcome for the patient. The article offers a critical appraisal of the best evidence available which supports the development of evidence based practitioners.

Epidemiology of lower urinary tract symptoms: emphasis on the status in Korea

A comprehensive and correct understanding of epidemiologic finding about lower urinary tract symptoms (LUTS) is important for several reasons. First, LUTS are highly prevalent in both genders all around the world and are expected to be a major concern to physicians in the near future because of the rapid rise in the elderly population. Second, it is crucial to observe trends in prevalence when national health care policy is established. By using a Medline search with various terms related to LUTS and prevalence, a review of epidemiologic studies was undertaken with an emphasis on the status in Korea. Despite the suggestions made by the International Continence Society, the lack of uniform definitions and the lack of a unified threshold of symptoms are the biggest obstacles in epidemiologic study with regard to LUTS. Most Korean epidemiologic studies on LUTS have been reported since 2000 and reveal that the prevalences of specific clinical conditions, such as LUTS, benign prostatic hyperplasia, overactive bladder, and detrusor underactivity, are in line with prevalences in Western counties. However, the prevalence of nocturia is somewhat different from that in Western countries. Many epidemiologic studies of LUTS have provided us with valuable information and a better understanding of the clinical conditions. Given that the impact of these clinical conditions on quality of life and health care cost will be emphasized more in the near future, more studies on optimal management approaches to LUTS are needed on the basis of this knowledge.

Nonsteroidal anti-inflammatory drugs and prostatic diseases

Prostatic diseases are characterized by increased activity of cytokines, growth factors, and cyclooxygenases- (COX-) 1 and 2. Activation of COX-1 and COX-2 results in increased levels of prostaglandins and the induction of angiogenic, antiapoptotic and inflammatory processes. Inhibition of COX enzymes by members of the widely used nonsteroidal anti-inflammatory drug (NSAID) class of drugs decreases prostaglandin production, and exerts a variety of anti-inflammatory, antipyretic, and antinociceptive effects. While numerous in vitro, in vivo, and clinical studies have shown that NSAIDs inhibit the risk and progression of prostatic diseases, the relationship between NSAIDs and such diseases remains controversial. Here we review the literature in this area, critically analyzing the benefits and caveats associated with the use of NSAIDs in the treatment of prostatic diseases.

Correlation between benign prostatic hyperplasia and inflammation

PURPOSE OF REVIEW

This review aims to evaluate the available evidence on the role of prostatic inflammation in the pathogenesis and progression of benign prostatic hyperplasia (BPH).

RECENT FINDINGS

Although there is still no evidence of a causal relation, accumulating evidence suggests that inflammation may contribute to the development of BPH and lower urinary tract symptoms (LUTS). Inflammatory infiltrates are frequently observed in prostate tissue specimens from men with BPH and the presence or degree of inflammation has been found to be correlated with prostate volume and weight. The inflammatory injury may contribute to cytokine production by inflammatory cells driving local growth factor production and angiogenesis in the prostatic tissue. This proinflammatory microenvironment is closely related to BPH stromal hyperproliferation and tissue remodeling with a local hypoxia induced by increased oxygen demands by proliferating cells which supports chronic inflammation as a source of oxidative stress leading to tissue injury in infiltrating area.

SUMMARY

Although the pathogenesis of BPH is not yet fully understood and several mechanisms seem to be involved in the development and progression, recent studies strongly suggest that BPH is an immune inflammatory disease. The T-cell activity and associated autoimmune reaction seem to induce epithelial and stromal cell proliferation. Further understanding of the role of inflammation in BPH and clinical detection of this inflammation will expand the understanding of BPH pathogenesis and its histologic and clinical progression, allow risk stratification for patients presenting with BPH-related LUTS, and suggest novel treatment strategies.

Lower urinary tract symptoms in relation to region of birth in 95,393 men living in Australia: the 45 and Up Study

PURPOSE

Lower urinary tract symptoms (LUTS) are very common among older men globally, but evidence regarding the relationship between LUTS and country of origin is limited. This study aimed to investigate the relationship between the prevalence of LUTS and region of birth in a large, ethnically diverse population of older men resident in New South Wales, Australia.

METHODS

Data on LUTS, demographic and behavioural factors were collected by postal questionnaire from 2006 to 2009 and analysed for 95,393 men aged 45 and over from the 45 and Up Study, who had not had previous prostate surgery. Logistic regression was used to investigate the association between region of birth and moderate/severe LUTS, ascertained using a modified International Prostate Symptom Score, adjusting for age, income, education, alcohol consumption and smoking.

RESULTS

Overall, 18,530 (19.4 %) men had moderate or severe LUTS. Compared to Australian-born men, prevalence of moderate/severe LUTS was significantly higher in men born in the Middle East & North Africa, Southeast Asia and North America regions (adjusted odds ratios (OR) = 1.43; 95 % CI = 1.23-1.66, OR = 1.25; 1.10-1.42, OR = 1.26; 1.05-1.52, respectively), whereas men from the UK & Ireland had significantly lower prevalence (OR = 0.85; 0.80-0.90). Patterns of association were generally similar for storage- and voiding-related types of LUTS. However, participants born in Sub-Saharan Africa showed a significantly elevated prevalence of moderate/severe voiding symptoms (1.22; 1.03-1.45) but not storage symptoms, compared to Australian-born respondents.

CONCLUSION

The prevalence of LUTS and of specific subtypes of LUTS varies according to region of birth.

Indications for and use of nonsteroidal antiinflammatory drugs and the risk of incident, symptomatic benign prostatic hyperplasia: results from the prostate cancer prevention trial

The authors conducted a cohort study of nonsteroidal antiinflammatory drug (NSAID) use and risk of symptomatic benign prostatic hyperplasia (BPH), using data from 4,735 men without BPH at baseline in the placebo arm of the Prostate Cancer Prevention Trial (1993-2003). Incident BPH (n = 471) was defined as medical or surgical treatment or at least 2 International Prostate Symptom Score (I-PSS) values greater than or equal to 15. Proportional hazards models using time-dependent exposure for NSAID use were employed to estimate covariate-adjusted associations of NSAID-related medical conditions and NSAID use with BPH risk. Arthritis, other inflammation-related musculoskeletal conditions, and headaches were associated with increased BPH risk (hazard ratio (HR) = 1.77 (95% confidence interval (CI): 1.37, 2.29), HR = 1.57 (95% CI: 1.14, 2.17), and HR = 1.40 (95% CI: 1.09, 1.80), respectively). Use of any NSAID, use of aspirin, and use of nonaspirin NSAIDs were associated with significant increases in BPH risk (HR = 1.21 (95% CI: 1.01, 1.46), HR = 1.20 (95% CI: 1.00, 1.45), and HR = 1.34 (95% CI: 1.07, 1.69), respectively). Control for indications for NSAID use, including baseline I-PSS, attenuated the associations slightly, but all became nonsignificant. Among men with no indications for NSAID use, the hazard ratio for any NSAID use was 1.06 (95% CI: 0.82, 1.38). The modest associations of NSAID use with BPH risk in this cohort were probably due to confounding by indication, and NSAID use was not associated with BPH risk.

Relationship of sex hormones and nocturia in lower urinary tract symptoms induced by benign prostatic hyperplasia

OBJECTIVE

The study sought to clarify the relationship between sex hormone levels and lower urinary tract symptoms (LUTS) in patients with benign prostate hyperplasia.

METHODS

Between 2007 and 2010, serum total testosterone (TT), free testosterone, and estradiol were prospectively measured in patients who were transferred to our university hospital. The 924 subjects were divided into two groups. Group I (n = 646) were treated with an alpha blocker only and group II (n = 278) were treated with an alpha blocker + a 5-alpha reductase inhibitor over 3 months before their visit. Clinical conditions were assessed by digital rectal examination, prostate-specific antigen, International Prostate Symptom Score (IPSS), transrectal ultrasonography and maximum urinary flow rate and postvoid residual urine.

RESULTS

The mean age was 69.65 ± 6.56 years. The total IPSS and subscore (storage symptom) was significantly associated with age (p < 0.001/p < 0.05) and the TT level (p < 0.05/p < 0.05). TT level was significantly decreased in patients with ≥ 4 episodes of nocturia. The TT level was significantly related to the presence of severe LUTS (p < 0.05).

CONCLUSIONS

Endogenous testosterone may have a beneficial effect on lower urinary tract function and that a high frequency of nocturia may induce testosterone deficiency.

Benign prostatic hyperplasia: from bench to clinic

Benign prostatic hyperplasia (BPH) is a prevalent disease, especially in old men, and often results in lower urinary tract symptoms (LUTS). This chronic disease has important care implications and financial risks to the health care system. LUTS are caused not only by mechanical prostatic obstruction but also by the dynamic component of obstruction. The exact etiology of BPH and its consequences, benign prostatic enlargement and benign prostatic obstruction, are not identified. Various theories concerning the causes of benign prostate enlargement and LUTS, such as metabolic syndrome, inflammation, growth factors, androgen receptor, epithelial-stromal interaction, and lifestyle, are discussed. Incomplete overlap of prostatic enlargement with symptoms and obstruction encourages focus on symptoms rather than prostate enlargement and the shifting from surgery to medicine as the treatment of BPH. Several alpha antagonists, including alfuzosin, doxazosin, tamsulosin, and terazosin, have shown excellent efficacy without severe adverse effects. In addition, new alpha antagonists, silodosin and naftopidil, and phosphodiesterase 5 inhibitors are emerging as BPH treatments. In surgical treatment, laser surgery such as photoselective vaporization of the prostate and holmium laser prostatectomy have been introduced to reduce complications and are used as alternatives to transurethral resection of the prostate (TURP) and open prostatectomy. The status of TURP as the gold standard treatment of BPH is still evolving. We review several preclinical and clinical studies about the etiology of BPH and treatment options.

Non-steroidal anti-inflammatory drug use and the risk of benign prostatic hyperplasia-related outcomes and nocturia in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

Study Type - Therapy (cohort) Level of Evidence 4. What's known on the subject? and What does the study add? Accumulating evidence suggests that inflammation may contribute to the development of BPH and LUTS. Therefore, it is plausible that anti-inflammatory agents, such as aspirin and other NSAIDs, may reduce the risk of BPH/LUTS, as was observed in a recent analysis of daily aspirin use and BPH/LUTS risk in the Olmsted County Study of Urinary Symptoms and Health Status in Men. The present study, conducted in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, found no association for recent aspirin or ibuprofen use with the risk of BPH/LUTS.

OBJECTIVE

To investigate the relationship between non-steroidal anti-inflammatory drug (NSAID) use and the incidence of benign prostatic hyperplasia (BPH)-related outcomes and nocturia, a lower urinary tract symptom (LUTS) of BPH, in light of accumulating evidence suggesting a role for inflammation in BPH/LUTS development.

PATIENTS AND METHODS

At baseline, participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial completed questions on recent, regular aspirin and ibuprofen use, BPH surgery, diagnosis of an enlarged prostate/BPH, and nocturia. Participants in the intervention arm also underwent a digital rectal examination (DRE), from which prostate dimensions were estimated, as well as a prostate-specific antigen (PSA) test. Only participants in the intervention arm without BPH/LUTS at baseline were included in the analysis (n= 4771). • During follow-up, participants underwent annual DREs and PSA tests, provided annual information on finasteride use, and completed a supplemental questionnaire in 2006-2008 that included additional questions on diagnosis of an enlarged prostate/BPH and nocturia. • Information collected was used to investigate regular aspirin or ibuprofen use in relation to the incidence of six BPH/LUTS definitions: diagnosis of an enlarged prostate/BPH, nocturia (waking two or more times per night to urinate), finasteride use, any self-reported BPH/LUTS, prostate enlargement (estimated prostate volume ≥30 mL on any follow-up DRE) and elevation in PSA level (>1.4 ng/mL on any follow-up PSA test).

RESULTS

Generally, null results were observed for any recent, regular aspirin or ibuprofen use (risk ratio = 0.92-1.21, P= 0.043-0.91) and frequency of use (risk ratios for one category increase in NSAID use = 0.98-1.11, P-trends = 0.10-0.99) with incident BPH/LUTS.

CONCLUSION

The findings obtained in the present study do not support a protective role for recent NSAID use in BPH/LUTS development.

Nonsteroidal antiinflammatory drug use and lower urinary tract symptoms: results from the Boston area community health survey

There is evidence for a role of inflammation in the etiology of lower urinary tract symptoms (LUTS), raising the possibility that use of nonsteroidal antiinflammatory drugs (NSAIDs) may inhibit the development or progression of LUTS. The authors examined the association between use of prescription and over-the-counter NSAIDs and LUTS among 1,974 men and 2,661 women in the Boston Area Community Health Survey (2002-2005). Multivariable-adjusted logistic regression was used to estimate odds ratios and 95% confidence intervals for LUTS, voiding symptoms, storage symptoms, and nocturia. There was no clear association between use of prescription or over-the-counter NSAIDs (compared with no NSAID use) and overall LUTS, voiding symptoms, or nocturia in men or women. However, over-the-counter NSAID use was positively associated with storage symptoms in women (odds ratio = 1.37, 95% confidence interval: 1.03, 1.83), and there was a positive association between over-the-counter NSAID use and overall LUTS among women with a history of arthritis (odds ratio = 2.09, 95% confidence interval: 1.20, 3.64). These results do not provide strong support for an association between NSAIDs and LUTS. However, the associations between over-the-counter NSAID use and certain urologic symptoms, particularly among women with arthritis, and the potential mechanisms involved should be evaluated in future studies.

Dietary patterns, supplement use, and the risk of benign prostatic hyperplasia

It has long been appreciated that a healthy lifestyle plays a critical role in cardiovascular health. It is now apparent that the same is true in the development of benign prostatic hyperplasia (BPH). Prospective cohort data originating from recently published randomized trials on the medical treatment of BPH and prevention of prostate cancer have been invaluable. A growing body of evidence suggests that exercise and the intake of specific macronutrients and micronutrients through regular diet play a beneficial role. Most strikingly, the magnitude of these effects is similar to medical therapies using alpha-blockers and 5-alpha-reductase inhibitors. The use of supplements for prostate disease is a multibillion dollar business in the United States, and supplements are more commonly prescribed than medical therapy in many countries. In contrast to consumption of micronutrients through regular diet, supplemental intake of micronutrients and phytotherapies currently lack evidence to support their efficacy.

The effects of lifestyle factors on the incidence of nocturia

PURPOSE

Cross-sectional studies have shown an association between obesity and nocturia but controversial findings on the relationship between smoking, alcohol and coffee consumption, and nocturia. Prospective studies of the role of lifestyle factors in individuals with nocturia are scarce. We investigated the effects of lifestyle factors on the incidence of nocturia.

MATERIALS AND METHODS

The target population consisted of men who were 50, 60 or 70 years old and residing in Tampere in 1994. A questionnaire was mailed to 3,143 randomly selected men in 1994 and the survey was repeated in 1999 with the 2,837 who were still eligible. The followup sample consisted of 1,580 men with information on nocturia at baseline and 5-year followup. Nocturia was assessed by the Danish Prostate Symptoms Score 1 questionnaire and graded as mild--1 or 2, moderate--3 or 4 and severe--5 or more nightly voids.

RESULTS

Higher body mass index at baseline was associated with an increased incidence of nocturia. Obese men were at 1.6 times (95% CI 1.1-2.4) higher risk for mild nocturia and at 2.3 times (95% CI 1.1-4.7) higher risk for moderate or severe nocturia compared with men who had a normal body mass index. Men who consumed less than 150 gm alcohol per week were at lower risk for moderate or severe nocturia than abstainers (adjusted incidence rate ratio 0.4, 95% CI 0.2-0.8). No statistically significant associations were found for smoking and coffee consumption. The frequency of nocturia at baseline did not increase the incidence of obesity at followup.

CONCLUSIONS

Our findings suggest that obesity increases the risk of nocturia. The link between other lifestyle factors and nocturia is weak or absent.

Nocturia and associated morbidity in a Danish population of men and women aged 60-80 years

OBJECTIVE

To evaluate the association between nocturia and medical diseases, medication, urinary incontinence (UI), recurrent cystitis, smoking, alcohol, parity, hysterectomy, pelvic organ prolapse surgery, UI surgery, and prostate surgery.

SUBJECTS AND METHODS

The previously validated questionnaire the Nocturia, Nocturnal Enuresis and Sleep-interruption Questionnaire was sent to 2000 women and 2000 men aged 60, 65, 70, 75, and 80 years. The population was selected at random from The Danish Civil Registration System.

RESULTS

Using multiple logistic regressions UI and age were significantly associated with nocturia irrespective of severity. Nocturia of > or =1 voids was significantly associated with body mass index (BMI), hypertension, and smoking; and nocturia of > or =2 voids with gender, BMI, diabetes and recurrent cystitis, as well as between nocturia of > or =3 voids and gender, lung disease, diabetes, use of diuretics and recurrent cystitis. Summarising the associations in an ordinal regression analysis UI (odds ratio (OR) 2.17, 95% CI 1.76-2.68), recurrent cystitis (OR 1.97, 95% CI 1.30-2.97) and diabetes (OR 1.89, 95% CI 1.32-1.65) had the strongest associations with nocturia.

CONCLUSIONS

Our results show that various disorders are associated with nocturia. However, the associations are strongly dependent on the severity of the nocturia.

Lipids, lipoproteins and the risk of benign prostatic hyperplasia in community-dwelling men

OBJECTIVE

To examine the associations of serum lipids and lipoproteins with benign prostatic hyperplasia (BPH) in community-dwelling men.

SUBJECTS AND METHODS

This analysis was conducted within the Rancho Bernardo Study, a prospective, community-based cohort study. BPH was defined as a history of prostate surgery for other than cancer, or a medical diagnosis of BPH. Logistic regression modelling, with adjustments for age and stratification by diabetes diagnosis, was used to estimate the odds ratio (OR) of BPH associated with fasting serum concentrations of total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, and the triglyceride to HDL ratio.

RESULTS

Among 531 eligible participants, 259 (48%) reported BPH and 272 (52%) reported no BPH. Men with BPH, with a mean (range) age of 75.8 (76.1-80.1) years, were older than men without BPH , at 72.7 (72.4-74.0) years. There were no significant associations of total cholesterol (P trend, 0.52), HDL cholesterol (0.56), triglycerides (0.30), or triglyceride to HDL ratio (0.13) with the risk of BPH. In a subset analysis in men with diabetes, those in the highest tertile (>133 mg/dL) of LDL cholesterol, compared with those in the lowest tertile (<110 mg/dL), were four times more likely to have BPH (odds ratio 4.00, 95% confidence interval 1.27-12.63, P trend 0.02). These results were not explained by the use of statins.

CONCLUSIONS

In these community-dwelling men, higher serum LDL was associated with a greater risk of BPH among diabetics. These data suggest that diabetic men with increased LDL cholesterol are at greater risk of BPH. This observation is consistent with the concept that cardiac risk factors are involved with the pathogenesis of BPH.

Modifiable risk factors for benign prostatic hyperplasia and lower urinary tract symptoms: new approaches to old problems

PURPOSE

Benign prostatic hyperplasia is generally not regarded as a preventable disease. However, accumulating evidence suggests that modifiable factors may influence the risk of benign prostatic hyperplasia and lower urinary tract symptoms.

MATERIALS AND METHODS

A structured, comprehensive literature review was done to identify modifiable risk factors for benign prostatic hyperplasia and lower urinary tract symptoms among observational studies of older men.

RESULTS

Outcome measures used to define benign prostatic hyperplasia in clinical studies include histological analysis of prostate tissue, radiographically determined prostate enlargement, acute urinary retention, decreased urinary flow rate, pressure flow studies consistent with bladder outlet obstruction, history of benign prostatic hyperplasia surgery, physician diagnosed benign prostatic hyperplasia and American Urological Association symptom score or International Prostate Symptom Score. Factors that potentially increase the risk of benign prostatic hyperplasia and lower urinary tract symptoms include obesity and diabetes. Factors that potentially decrease the risk include increased physical activity and moderate alcohol consumption. Other candidate factors for which clear risk patterns have not yet emerged are dyslipidemia, hypertension, smoking, diet and environment.

CONCLUSIONS

Obesity, diabetes, physical activity and alcohol intake may substantially influence the risk of benign prostatic hyperplasia and lower urinary tract symptoms in older men. Further analyses of these and other potential modifiable risk factors may identify novel interventions for the prevention, diagnosis and treatment of these highly prevalent conditions.

Race/ethnicity, obesity, health related behaviors and the risk of symptomatic benign prostatic hyperplasia: results from the prostate cancer prevention trial

PURPOSE

We examined risk factors for incident symptomatic benign prostate hyperplasia in 5,667 Prostate Cancer Prevention Trial placebo arm participants who were free of benign prostatic hyperplasia at baseline.

MATERIALS AND METHODS

During 7 years benign prostatic hyperplasia symptoms were assessed annually using the International Prostate Symptom Score and benign prostatic hyperplasia treatment was assessed quarterly by structured interview. Total benign prostatic hyperplasia was defined as receipt of treatment or report of 2 International Prostate Symptom Score values greater than 14. Severe benign prostatic hyperplasia was defined as treatment or 2 International Prostate Symptom Score values of 20 or greater. Weight and body circumferences were measured by trained staff and demographic health related characteristics were collected by questionnaire. Cox proportional hazards models were used to calculate the covariate adjusted relative hazards of benign prostatic hyperplasia developing.

RESULTS

The incidence of total benign prostatic hyperplasia was 34.4 per 1,000 person-years. The risk of total benign prostatic hyperplasia increased 4% (p <0.001) with each additional year of age. Risks for total benign prostatic hyperplasia were 41% higher for black (p <0.03) and Hispanic men (p <0.06) compared to white men, and for severe benign prostatic hyperplasia these increases were 68% (p <0.01) and 59% (p <0.03), respectively. Each 0.05 increase in waist-to-hip ratio (a measure of abdominal obesity) was associated with a 10% increased risk of total (p <0.003) and severe (p <0.02) benign prostatic hyperplasia. Neither smoking nor physical activity was associated with risk.

CONCLUSIONS

Black race, Hispanic ethnicity and obesity, particularly abdominal obesity, are associated with increased benign prostatic hyperplasia risk. Weight loss may be helpful for the treatment or prevention of benign prostatic hyperplasia.

Protective association between nonsteroidal antiinflammatory drug use and measures of benign prostatic hyperplasia

In 1990-2002, the authors conducted a population-based cohort study of 2,447 Caucasian men in Olmsted County, Minnesota, to determine whether daily users of nonsteroidal antiinflammatory drugs (NSAIDs) were at lower risk than nondaily NSAID users of developing benign prostatic hyperplasia. Participants completed validated questionnaires during a home visit, including information about daily NSAID use. A random subset of 634 men also participated in a clinical evaluation including transrectal ultrasonography and assessment of serum prostate-specific antigen levels. Examinations and questionnaires were repeated biennially through 2002. Benign prostatic hyperplasia measures included development of moderate/severe urinary symptoms (American Urological Association Symptom Index score >7), low maximum urinary flow rate (<12 ml/second), prostate volume >30 ml, or prostate-specific antigen level >1.4 ng/ml. After adjustment for age, daily NSAID use was inversely associated with onset of moderate/severe urinary symptoms (hazard ratio (HR) = 0.73, 95% confidence interval (CI): 0.64, 0.82), low maximum flow rate (HR = 0.51, 95% CI: 0.43, 0.61), increased prostate volume (HR = 0.53, 95% CI: 0.41, 0.68), and elevated prostate-specific antigen level (HR = 0.52, 95% CI: 0.40, 0.68). In age-specific analyses, inverse associations between NSAID use and urinary measures tended to be stronger in the oldest age groups, although this interaction was statistically significant for only obstructive symptoms and treatment. Results suggest that NSAID use may prevent or delay development of benign prostatic hyperplasia.

Food groups and risk of benign prostatic hyperplasia

OBJECTIVES

To evaluate the role of a wide range of foods on the risk of benign prostatic hyperplasia (BPH), we conducted a case-control study in Italy between 1991 and 2002. Although BPH is an extremely common condition, particularly among older men, its risk factors, including dietary ones, remain largely undefined.

METHODS

Included in the study were 1369 patients younger than 75 years old surgically treated for BPH and 1451 controls younger than 75 years of age who had been admitted to the same hospitals as cases for a wide spectrum of acute, non-neoplastic conditions. A validated and reproducible food frequency questionnaire, including 78 foods and beverages, plus a separate section on alcoholic beverages, was used to assess patients' dietary habits 2 years before diagnosis or hospital admission. Multivariate odds ratios (OR) were obtained after allowance for energy intake and other major potential confounding factors.

RESULTS

A significant trend of increasing risk with more frequent consumption was found for cereals (OR 1.55 for the greatest versus lowest quintile), bread (OR 1.69), eggs (OR 1.43), and poultry (OR 1.39). Inverse associations were observed for soups (OR 0.74), pulses (OR 0.74), cooked vegetables (OR 0.66), and citrus fruit (OR 0.82). No association was observed for milk and yogurt products, coffee and tea, pasta and rice, fish, cheese, row vegetables, potatoes, fruit, or desserts.

CONCLUSIONS

The results of this study suggest a role for dietary habits on the risk of BPH. In particular, a diet rich in cereals and some types of meat and poor in vegetables and pulses may have an unfavorable effect in this Italian population.

Intake of selected micronutrients and the risk of surgically treated benign prostatic hyperplasia: a case-control study from Italy

OBJECTIVE

To analyze the relationship between surgically treated benign prostatic hyperplasia (BPH) and intake of selected micronutrients.

METHODS

A multicentric case-control study was conducted in Italy between 1991 and 2002. Cases were 1369 men with histologically confirmed, surgically treated BPH and controls were 1451 men younger than 75 yr, frequency matched by quinquennium of age and study center, admitted to the hospital for acute nonneoplastic diseases. Information was collected by trained interviewers using a structured validated food-frequency questionnaire. The odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by unconditional multiple logistic regression models.

RESULTS

The risk of BPH significantly decreased with increasing intake of carotene (OR=0.80 for an increment equal to the difference between the 80th and 20th percentile of intake), alpha-carotene (OR=0.83), beta-carotene (OR=0.82), and cis beta-carotene (OR=0.82) and tended to decrease with the intake of vitamin C (OR=0.89) and iron (OR=0.79). The OR tended to increase with the intake of sodium (OR=1.30) and zinc (OR=1.10). No systematic heterogeneity was observed across strata of age, education, and body mass index. No meaningful associations emerged for other antioxidants, such as folic acid, lycopene, lutein/zeaxanthin, vitamin E, vitamin D, nor for retinol.

CONCLUSIONS

Our results suggest a protective effect of carotene on the risk of BPH. The risk tended to decrease also with the intake of vitamin C and iron and tended to increase with the intake of sodium and zinc. Results also indicate that other antioxidants, including folic acid, lycopene, lutein/zeaxanthin, and vitamins D and E, and retinol were not related to the risk for this disease.

Nocturia, depression and antidepressant medication

OBJECTIVE

To assess the possible relationship between treatment with selective serotonin-reuptake inhibitors (SSRIs) and the occurrence of nocturia.

SUBJECTS AND METHODS

An unselected group of adult men and women, living in the city of Ostersund, Sweden, were sent a postal questionnaire containing questions on somatic and mental health, sleep, sleepiness and nocturia. For depression diagnostics, the Major Depression Inventory (MDI) was used. Prescription data on antidepressant drugs were extracted from a register in the county of Jamtland, Sweden.

RESULTS

The questionnaire was completed by 1375 subjects, of whom 609 (44%) were men; the response rate was 69%. Prescription data were available for all respondents. The mean (sd) age of the men and women participating were 48.0 (18.2) and 50.1 (19.1) years, respectively. Two or more nocturnal micturition episodes were reported in 15.6% of the men and 16.5% of the women. In a multiple logistic regression analysis, independent correlates for two or more nocturnal voids vs no more than one were: age 45-59 years vs <45 (odds ratio 2.9; 95% confidence interval 1.9-4.7); age 60-74 vs <45 (6.0; 3.7-9.8); age > 75 vs <45 (13.4; 7.9-22.6); major depression, yes vs no (4.6; 2.8-7.5); and being on treatment with SSRI, yes vs no (2.2; 1.1-4.5). Gender was deleted by the logistic regression model.

CONCLUSION

Major depression has previously been found to be associated with increased nocturnal micturition. In the present study, twice as many men and women treated with SSRIs as those not so treated had two or more nocturnal voids, after adjusting for major depression and age. The implication for the risk of fall injuries is discussed.