Can benign prostatic hyperplasia be identified in the primary care setting using only simple tests? Results of the Diagnosis IMprovement in PrimAry Care Trial

AIMS

Diagnosis IMprovement in PrimAry Care Trial (D-IMPACT) was a prospective, multicentre epidemiological study in three European countries to identify the optimal subset of simple tests applied in primary care to diagnose benign prostatic hyperplasia (BPH) in men who spontaneously present with lower urinary tract symptoms (LUTS).

METHODS

Consecutive male patients aged ≥ 50 years who spontaneously attended their regular general practitioner (GP) office with LUTS were eligible for inclusion if they had not previously undergone BPH diagnostic tests or received treatment for BPH. Patients were assessed on three occasions, twice by their regular GP (visits 1 and 2) and once by a urologist (visit 3). The diagnostic accuracy of each variable was determined using the urologists' final BPH diagnosis (at visit 3) as gold-standard. Independent variables analysed were as follows: age; BPH diagnosis performed by GP in visit 1 (yes/no); probability of BPH diagnosis assessed by GP in visit 1; urinalysis (normal/abnormal); prostate-specific antigen (PSA); International Prostate Symptom Score (IPSS); diagnosis of BPH performed by GP in visit 2 (yes/no); and probability of BPH diagnosis assessed by GP in visit 2. Statistically significant variables (p < 0.1) were included in a logistic regression model to identify the best algorithm and describe each test contribution.

RESULTS

The most frequent spontaneously reported LUTS were nocturia and weak urinary stream. BPH study prevalence was 66.0% (95%CI: 62.3-69.5) and 32% of patients were at risk of BPH progression (PSA > 1.5 ng/ml and prostate volume ≥ 30 cm(3)). Among the independent variables analysed, only age, IPSS and PSA showed a statistically significant relationship with BPH diagnosis. In a logistic regression model including age, IPSS, PSA and probability of BPH (based on physical examination and symptoms), positive predictive value (PPV) was 77.1%. Exclusion of BPH probability resulted in a PPV of 75.7%.

CONCLUSIONS

A diagnostic algorithm including only objective variables (age, IPSS and PSA), easily implemented in any GP office, allows GPs to accurately diagnose BPH in approximately three-quarters of patients spontaneously reporting LUTS.

Can simple tests performed in the primary care setting provide accurate and efficient diagnosis of benign prostatic hyperplasia? Rationale and design of the Diagnosis Improvement in Primary Care Trial

Effective treatment of benign prostatic hyperplasia (BPH) improves lower urinary tract symptoms (LUTS) and patient quality of life, and reduces the risk of complications arising from disease progression. However, treatment can only be initiated when men with BPH are identified by accurate diagnostic tests. Current evidence suggests that diagnostic procedures employed by primary care physicians vary widely across Europe. The expected increases in BPH prevalence accompanying the gradual aging of the population, coupled with greater use of medical therapy, mean that general practitioners (GPs) are likely to have an increasingly important role in managing the condition. The GP/primary care clinic is therefore an attractive target location for strategies designed to improve the accuracy of BPH diagnosis. The Diagnosis Improvement in Primary Care Trial (D-IMPACT) is a prospective, multicentre, epidemiological study that aims to identify the optimal subset of simple tests applied by GPs in the primary care setting to diagnose BPH in men who spontaneously report obstructive (voiding) and/or irritative (storage) LUTS. These tests comprise medical history, symptom assessment with the International Prostate Symptom Score questionnaire, urinalysis, measurement of serum levels of prostate-specific antigen and subjective GP diagnosis after completing all tests including digital rectal examination. GP diagnoses and all other tests will be compared with gold-standard diagnoses provided by specialist urologists following completion of additional diagnostic tests. D-IMPACT will establish the diagnostic performance using a non-subjective and reproducible algorithm. An adjusted and multivariate analysis of the results of D-IMPACT will allow identification of the most efficient combination of tests that facilitate accurate BPH diagnosis in the primary care setting. In addition, D-IMPACT will estimate the prevalence of BPH in patients who present spontaneously to GPs with LUTS.

The prevalence of male urinary incontinence in four centres: the UREPIK study

OBJECTIVES

To report the results of the prevalence and health status associated with male urinary incontinence (UI) in a population-based, multicentre study in four countries, and to assess the epidemiology of this condition.

SUBJECTS AND METHODS

A standard questionnaire asking about frequency and amount of urine loss, use of pads and stress incontinence, was used to measure the prevalence of UI among men in four countries (Boxmeer, The Netherlands; Auxerre, France; Birmingham, UK; and Seoul, Korea). Self-reported urinary leakage was also recorded, with details of visits to the doctor for the symptoms. The samples were selected randomly from population registers of men aged 40-79 years, which provided representative samples in each community.

RESULTS

In all, 4979 men responded; from incontinence symptom scores, 7.3% of men aged 40-79 years in Auxerre, 16.3% in Boxmeer, 14.4% in Birmingham and 4.3% in Seoul reported mild to severe UI. On a self-reported question, 14.8% and 14.5% of men in Birmingham and Boxmeer thought that they had urinary leakage, compared with 7.5% and 7.1% of men in Auxerre and Seoul, but typically the reported incontinence was leaking drops of urine a few times a week. Of men with urinary leakage in the three European centres, 25.9% visited the doctor with this problem, compared with only 9.0% of men in Seoul. Of men in the European centres, 5.9% used pads at least occasionally, compared with only 1.6% of men in Seoul. UI was age-related and the reporting of it varied among centres, with 14.4% of men in Birmingham and 12.7% of men in Boxmeer aged 40-49 years reporting mild to severe UI, compared with 5.2% in Auxerre and 1.9% in Seoul. Among men aged 60-69 years the corresponding percentages were 13.7% in Birmingham, 22.6% in Boxmeer, 9.2% in Auxerre and 8.0% in Seoul.

CONCLUSIONS

UI is more common in older men and relatively uncommon among younger men. Some men reported no problems on the symptom questionnaire but replied positively to a direct question. Surprisingly many men wear protective pads at least occasionally as a result of their problem. UI appears to be a problem for men and which remains largely untreated; this may partly be a result of cultural differences.

The association between lower urinary tract symptoms and erectile dysfunction in four centres: the UrEpik study

OBJECTIVE

To report a large-scale multinational investigation of lower urinary tract symptoms (LUTS) and sexual function, designed to investigate the independent association between them, as recent small-scale epidemiological studies suggest an association between benign prostatic hyperplasia and sexual dysfunction; both conditions are strongly associated with age and no study has been able to exclude age as a confounding factor in this relationship.

SUBJECTS AND METHODS

Culturally and linguistically validated versions of standard questionnaires were used to estimate the prevalence of LUTS (using the International Prostate Symptom Score, IPSS) and erectile dysfunction (ED) score (using O'Leary's Sexual Function Inventory) in regions of the UK (Birmingham), the Netherlands (Boxmeer), France (Auxerre) and Korea (Seoul). In each centre, stratified random samples were selected from population registers to provide representative samples of the population of men aged 40-79 years (and their partners) in each community. Direct interviews were held in Seoul and postal questionnaires used in the three European centres. The samples were selected randomly, providing representative samples in each community.

RESULTS

In all, 4800 men and 3674 women responded; the response rates among men were 77% in Boxmeer, 21% in Auxerre, 42% in Birmingham and 65% in Seoul. The overall prevalence of ED for men aged 40-79, estimated as an ED score of 0-4, was 21.1%. There was evidence of a linear increase with age (P < 0.001) and the pattern was very similar in the four centres. From the weighted logistic model, there was evidence of an association between sexual dysfunction, other self-reported diseases and lifestyle. From the ED score, after adjusting for age and country, men with diabetes were more likely to score of 0-4 (odds ratio 1.57, 95% confidence interval 1.09-2.25), as were those with high blood pressure (1.38, 1.09-1.75) and with an IPSS of 8-35 (1.39, 1.10-1.74). For lifestyle, smokers were more likely to score 0-4 (1.54, 1.23-1.92), while physical activity during leisure time was slightly associated with a reduction in the chance of scoring 0-4 (0.87, 0.77-0.99). The analysis gave the same results when repeated using self-reported ED instead of the dichotomised score.

CONCLUSIONS

ED is clearly age-related and a problem for a large proportion of men in the community. It can have a profound impact on the quality of life of the man and on his partner. Were all men with this problem to seek medical help there would be a large burden on healthcare systems. There are cultural and age effects on the assessment of this problem.

The relationship between lower urinary tract symptoms and health status: the UREPIK study

OBJECTIVES

To assess the hypothesis that as lower urinary tract symptoms (LUTS) increase in severity, the impact as measured by the BPH impact index (BII) would also increase.

SUBJECTS AND METHODS

The UREPIK survey collected information on this relationship from men and their partners in the Netherlands, Korea, France and the UK. Culturally and linguistically validated versions of three standard questionnaires, the SF-12, the BII and the International Prostate Symptom Score (IPSS) were used to assess the distribution of symptoms and the impact on health status. Stratified random samples of men aged 40-79 years in each community were recruited. Response rates were 72% in Boxmeer, 28% in Auxerre, 60% in Birmingham and 68% in Seoul. Regression analyses were undertaken on total SF-12, BII and IPSS.

RESULTS

In all, 4800 index men and 3674 women responded; the BII increased with increasing IPSS. The correlation coefficients were; Boxmeer 0.69, Auxerre 0.56, Birmingham 0.60 and Seoul 0.68. For women, the correlations were slightly lower except in Birmingham, at 0.65 (Boxmeer), 0.44 (Auxerre), 0.71 (Birmingham), 0.57 (Korea). BII scores were higher in women than in men with the same level of IPSS. Adjusting for IPSS there was no association between age and BII. There was an association between IPSS quality-of-life (QoL) score and BII; for men the correlation was 0.62 and for women 0.60. Men and women with the same score on the IPSS QoL reported the same bother. Among those with an IPSS of 20-35 women expressed significantly more bother (P < 0.001). The SF-12 scores decreased as the IPSS and the BII increased in both men and women. Furthermore, the SF-12 mental score decreased with increasing symptoms in the partner.

CONCLUSIONS

The relationship between the severity of LUTS and BII was similar in all centres. There is a clear association between the BII and the IPSS QoL question in men and women. The BII discriminates between people who are unhappy about their urinary condition compared with those who are pleased. Although designed for use in men with benign prostatic hyperplasia, the index also appears to be a useful among women. The severity of symptoms of LUTS has an adverse effect on the health status of the individual and his/her partner.

The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study

OBJECTIVE

To evaluate the epidemiology of lower urinary tract symptoms (LUTS) among men and women, as there are significant unanswered questions about the prevalence and impact of LUTS in different populations.

SUBJECTS AND METHODS

A population-based, cross-sectional survey was completed in Boxmeer (the Netherlands), Auxerre (France), Birmingham (UK) and Seoul (Republic of Korea), using culturally and linguistically validated versions of the International Prostate Symptom Score (IPSS). The aim was to estimate the distribution of symptoms of LUTS in men and women. Stratified random samples of men aged 40-79 years in each community were collected. Postal questionnaires were used in Europe and direct interviews in Korea.

RESULTS

In all, 4979 index men and 3790 women were recruited, with age-adjusted response rates among men of 72% in Boxmeer, 28% in Auxerre, 60% in Birmingham and 68% in Seoul. The percentages of men and women with an IPSS of 8-35, indicating moderate to severe symptoms, were, respectively, 20.7 and 18.0 (Boxmeer); 19.2 and 12.6 (Auxerre); 25.1 and 23.7 (Birmingham); 16.2 and 19.9 (Seoul). Among women the relationship between symptoms and age was not as strong as in men. The percentages of men and women with moderate to severe symptoms were by age group, respectively, 10.6, 15.5 (40-49); 19.0, 18.2 (50-59); 30.5, 23.8 (60-69); 40.4, 28.7 (70-79). Among those aged 40-49 the main differences between men and women were in the questions about frequency of urination during the day and holding back urine. Among the older groups men reported more symptoms on all questions apart from urination at night and difficulty in holding back urine, both of which were equally prevalent among men and women.

CONCLUSIONS

The overall prevalence of LUTS was high and showed no marked cultural variation. Prevalence increased with age, with severe LUTS commoner in older men. Women reported similar levels of the symptoms traditionally associated with LUTS in men. In each age group there were no major cultural differences in the frequency of LUTS. There were differences with age between men and women; younger men had a lower prevalence of LUTS than younger women but older men a much higher prevalence than older women. These findings emphasize that the IPSS should be confined to within-patient comparisons and not used as a diagnostic tool. The IPSS performs very similarly regardless of gender.

Post-prostatectomy infection: to treat or not to treat?

A prospective study of bacteriuria in 100 prostatectomies is analysed. The author states that an antibiotic policy which treats only patients with fever, clinical discomfort, or isolated bacteriuria after the first postoperative month does not enhance morbidity, and lowers hospital costs.

Vaso-vesiculography: assessment in andrology and urology

Vasoseminal vasography using the vasopuncture technique is now a safe procedure. However, individual variations and technical pitfalls render interpretation of the images uneasy, even for experienced operators. Its use should be restricted, in andrologic patients, to cases where surgical treatment of azoospermia is contemplated. Normal vasographic patterns in all segments are necessary to undertake operative treatment: patency of ducts-as assessed by injection of dye-does not warrant success of anastomoses in presence of vesicular or ampullar lesions. On the other hand, vasography in urologic patients should gain a wider use, mainly for the diagnosis of malformation or staging of prostatic cancer.

Diagnosis and treatment of renal angiomyolipoma (based on 15 cases). Arguments in favor of conservative surgery (based on 8 cases)

Angiomyolipoma should be suspected when a renal tumor is present especially when the patient is young, the tumor is bilateral, associated with hemorrhagic incidents or if there are multiple tumors in one kidney. When tuberous sclerosis is present the diagnosis is easier and when it is not, arteriography and tomodensitometry are of great help. The benign nature of these tumors is not an argument in favor of nonsurgical treatment. They may sometimes be associated with an authentic malignancy which underlines the necessity of confirming the diagnosis by peroperative examination of a frozen section. When angiomyolipoma is confirmed the surgical treatment of this benign tumor should, in our opinion, be conservative considering the frequency of bilateral disease. This approach is supported by the results published and by our own 8 cases treated by conservative surgery.

[Palliative chemotherapy with 5 FU and CPM in cancer of the prostate with bone metastases resistant to oestrogens. A clinical trial (author's transl)]

The efficacy of an association of cyclophosphamide (CPM) and 5-fluorouracil was studied in 15 patients with prostate cancer not responding to oestrogen therapy, and more particularly its effect on pain due to bone metastases. No objective improvement was noted with this association, but there was a definitite reduction in bone metastases pain in 5 of the patients, with an average remission time of 4 months. Half of the patients had nausea and vomiting, but in spite of this digestive intolerance those patients who obtained pain relief for 4 months considered the treatment to be of positive value. This therapy is recommended only fater the failure of castration, anti-androgens, and oestrogens, together with nitrogen mustard (Estracyt) and corticotherapy.

Etiological aspects and interest of early surgical management of priapism

12 patients have been treated for priapism between March 1973 and September 1977. Etiologic conditions have been found 9 times, leaving only 3 idiopathic priapisms. Treatment of choice consisted of 8 saphenocavernous shunts, achieving detumescence in 7 cases and preserving sexual potency in 5. The precocity of operation seems of no interest to priapism itself but is mandatory to prevent secondary impotence.

[Cis-platinum in the treatment of disseminated testicular neoplasms resistant to classical chemotherapy]

Seven patients with advanced testicular tumors, resistant to existing chemotheurapeutic agents, were treated with a new antitumor agent, the Cisplatinum (associated to mannitol induced hyperdiuresis). There were 3 objective remissions (1 complete and 2 partial). Major toxicity was gastrointestinal. There was little renal and hematologic toxicity in our serie. The drug may have use in combination therapy in advanced non seminomatous testicular tumors.

Composés d'addition de SbF5 avec H2O et HF. Formation d'ions hydronium

A differential thermal analysis study of solutions of SbF5 in H2O and HF has enabled us to determine the thermal treatments required to obtain the stable crystalline phases: SbF5•2H2O, 4SbF5•5H2O, SbF5•H2O, 3SbF5•2H2O, and SbF5•HF•2H2O.The SbF5 adducts were characterized by X-ray powder diagrams.The vibrational spectra of SbF5•2H2O and SbF5•HF•2H2O are consistent with the ionic structures H3O+SbF5OH− and H5O2+SbF6−.The other hydrates are simple donor-acceptor complexes with the structure H2O → SbF5, in which one water molecule is coordinated to the SbF5 and the others are bound by hydrogen bonds to the coordinated water molecule.