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1.  Tolterodine extended release in the treatment of male oab/storage luts: a systematic review 
BMC Urology  2014;14:84.
Overactive bladder (OAB)/ storage lower urinary tract symptoms (LUTS) have a high prevalence affecting up to 90% of men over 80 years. The role of sufficient therapies appears crucial. In the present review, we analyzed the mechanism of action of tolterodine extended-release (ER) with the aim to clarify its efficacy and safety profile, as compared to other active treatments of OAB/storage LUTS.
A wide Medline search was performed including the combination of following words: “LUTS”, “BPH”, “OAB”, “antimuscarinic”, “tolterodine”, “tolterodine ER”. IPSS, IPSS storage sub-score and IPSS QoL (International Prostate Symptom Score) were the validated efficacy outcomes. In addition, the numbers of urgency episodes/24 h, urgency incontinence episodes/24 h, incontinence episodes/24 h and pad use were considered. We also evaluated the most common adverse events (AEs) reported for tolterodine ER.
Of 128 retrieved articles, 109 were excluded. The efficacy and tolerability of tolterodine ER Vs. tolterodine IR have been evaluated in a multicenter, double-blind, randomized placebo controlled study in 1529 patients with OAB. A 71% mean reduction in urgency incontinence episodes was found in the tolterodine ER group compared to a 60% reduction in the tolterodine IR (p < 0.05). Few studies evaluated the clinical efficacy of α-blocker/tolterodine combination therapy. In patients with large prostates (prostate volume >29 cc) only the combination therapy significantly reduced 24-h voiding frequency (2.8 vs. 1.7 with tamsulosin, 1.4 with tolterodine, or 1.6 with placebo). A recent meta-analysis evaluating tolterodine in comparison with other antimuscarinic drugs demonstrated that tolterodine ER was significantly more effective than placebo in reducing micturition/24 h, urinary leakage episodes/24 h, urgency episodes/24 h, and urgency incontinence episodes/24 h. With regard to adverse events, tolterodine ER was associated with a good adverse event profile resulting in the third most favorable antimuscarinic. Antimuscarinic drugs are the mainstay of pharmacological therapy for OAB / storage LUTS; several studies have demonstrated that tolterodine ER is an effective and well tolerated formulation of this class of treatment.
Tolterodine ER resulted effective in reducing frequency urgency and nocturia and urinary leakage in male patients with OAB/storage LUTS. Dry mouth and constipation are the most frequently reported adverse events.
PMCID: PMC4230346  PMID: 25348235
Lower urinary tract symptoms; Overactive bladder; Storage LUTS; Tolterodine; Urge incontinence; Frequency; Nocturia
2.  The Prevalence of Lower Urinary Tract Symptoms in Korean Men Aged 40 Years or Older: A Population-Based Survey 
The aim of this study was to evaluate the prevalence of lower urinary tract symptoms (LUTS) among Korean men aged ≥40 years.
We performed a population-based, cross-sectional door-to-door survey on a geographically stratified random sample of men aged ≥40 years. All respondents were asked about the presence of individual LUTS using a questionnaire based on 2002 International Continence Society definitions. For comparison, we also defined nocturia as two or more nocturnal micturitions per night. The International Prostate Symptom Score (IPSS) questionnaire was used to assess LUTS severity.
Responses from 1,842 subjects were analyzed. The overall prevalence of LUTS was 83.4%. Storage LUTS (70.1%) were more prevalent than voiding (60.4%) or postmicturition LUTS (38.3%). When nocturia was defined as two or more nocturnal micturitions per night, voiding symptoms became most prevalent (storage, 39.7%; voiding, 60.4%; and postmicturition, 38.3%). More than 90% of our population described the severity of their urinary symptoms as moderate (8-19) or severe (20-35). The prevalence and severity of LUTS increased with age.
LUTS are highly prevalent among Korean men, and its prevalence increases with age. Increased public awareness and a larger number of treatment options are needed to appropriately manage symptoms and their consequences.
PMCID: PMC4180162  PMID: 25279239
Lower urinary tract symptoms; Prevalence; Epidemiologic studies
3.  Influence of Type of Nocturia and Lower Urinary Tract Symptoms on Therapeutic Outcome in Women Treated With Desmopressin 
Korean Journal of Urology  2013;54(2):95-99.
To investigate the type of nocturia and concomitant voiding dysfunction (VD) and the effect of desmopressin treatment on nocturia in women.
Materials and Methods
We reviewed 84 women who experienced more than 2 nocturia episodes as recorded on a pretreatment frequency volume chart and who were treated with desmopressin. All patients underwent history taking, physical examination, urinalysis, International Prostate Symptom Score assessment, completion of a urinary sensation scale, and completion of a 3 day frequency volume chart. Nocturia was divided into nocturnal polyuria (NP), reduced nocturnal bladder capacity (RNBC), and mixed type. After treatment with desmopressin, a reduction in nocturia of over 50% compared with baseline was regarded as effective.
Among 84 women, the most common concomitant VD was overactive bladder (OAB, 60.7%). NP was observed in 70.2% (59/84) of the women, RNBC in 7.1% (6/84), and mixed type in 22.6% (19/84). After medication with desmopressin, 73 women (86.9%) showed a significantly reduced number of nocturia episodes (1.4±1.5) compared with baseline (3.7±1.3, p<0.05). Eleven women (13.1%) did not show improvement. Of the 73 women who showed improvement, 41 women showed a reduction of more than 50% over baseline, and these women had a lower baseline urgency grade.
In the majority of women, nocturia coexisted with other VD such as OAB. Treatment with desmopressin effectively reduced the nocturia. However, other lower urinary tract symptoms (LUTS) such as urgency may reduce the effect of desmopressin. Therefore, consideration of concomitant LUTS seems to be necessary to increase the treatment effect of desmopressin on nocturia in women.
PMCID: PMC3580312  PMID: 23549374
Deamino arginine vasopressin; Lower urinary tract symptoms; Nocturia; Women
4.  Association of overactive bladder and C-reactive protein levels. Results from the Boston Area Community Health (BACH) Survey 
Bju International  2011;110(3):401-407.
To investigate the association between overactive bladder (OAB) and C-reactive protein (CRP) in a population-based sample of men and women.
Epidemiological survey of urological symptoms among men and women aged 30–79 years. A multi-stage stratified cluster design was used to randomly sample 5503 adults from the city of Boston. Analyses were conducted on 1898 men and 1854 women with available CRP levels.
The International Continence Society defines OAB as ‘Urgency with or without urge incontinence, usually with frequency and nocturia.’ OAB was defined as: (1) urgency, (2) urgency with frequency, and (3) urgency with frequency and nocturia.
Odds ratios (OR) and 95% confidence intervals (95% CI) of the CRP and OAB association were estimated using logistic regression.
Prevalence of OAB increased with CRP levels in both men and women.
In men, adjusted ORs (95% CI) per log10(CRP) levels were 1.90 (1.26–2.86) with OAB defined as urgency, 1.65 (1.06–2.58) with OAB defined as urgency and frequency, and 1.92 (1.13–3.28) with OAB defined as urgency, frequency and nocturia.
The association was more modest in women with ORs (95% CI) of 1.53 (1.07–2.18) for OAB as defined urgency, 1.51 (1.02–2.23) for OAB defined as urgency and frequency, and 1.34 (0.85–2.12) for OAB defined as urgency, frequency and nocturia.
Results show a consistent association of increasing CRP levels and OAB among both men and women.
These results support our hypothesis for the role of inflammation in the development of OAB and a possible role for anti-inflammatory agents in its treatment.
PMCID: PMC3325364  PMID: 22176817
C-reactive protein; epidemiology; inflammation; overactive bladder
5.  Dietary Macronutrient Intake and Lower Urinary Tract Symptoms in Women 
Annals of epidemiology  2011;21(6):421-429.
To examine associations between macronutrient and total energy intakes with lower urinary tract symptoms (LUTS) in women.
Cross-sectional analysis of 2,060 women aged 30–79 years in the population-based Boston Area Community Health Survey (2002–2005). Data were collected by validated food frequency questionnaire and in-person interviews. Outcomes for multivariate logistic regression were moderate-to-severe total LUTS, storage, voiding, and post-micturition symptoms.
Greater total energy intake was positively associated with LUTS, specifically among women with lower waist circumferences (<76 cm, P=0.005, pinteraction=0.01). Increased saturated fat intake was associated with post-micturition symptoms (Quintile 5 vs. 1, OR 3.94, 95% CI 1.57, 9.89, ptrend =0.04). High protein intake was positively associated with storage symptoms (ptrend =0.03), particularly nocturia. No consistent associations were observed for carbohydrate, monounsaturated or polyunsaturated fat intakes.
Among women with low waist circumferences, high total daily calorie intake was associated with moderate-to-severe LUTS. While greater saturated fat intake was linked to post-micturition symptoms, the possibility that post-micturition symptoms in women represent more extensive or severe conditions should be explored in future research. These novel results indicate that dietary contributors to LUTS in women are distinct from those in men and may depend on symptom subtype and body size.
PMCID: PMC3090524  PMID: 21421330
Diet; Energy intake; Nutrition; Urination disorders; Lower urinary tract symptoms; Urinary tract; Fatty acids; saturated; Dietary fats; Dietary proteins
6.  Prostatic hyperplasia is highly associated with nocturia and excessive sleepiness: a cross-sectional study 
BMJ Open  2012;2(3):e000505.
The objective of this study is to assess the impact of nocturia on sleep in patients with lower urinary tract symptoms (LUTS)/benign prostatic enlargement (BPE) (nocturia≥2).
Cross-sectional survey.
798 urologists and general practitioners randomly selected from the overall population of urologists and general practitioners of every French region.
A total of 2179 LUTS/BPE men (aged 67.5±7.5 years old) were recruited.
Primary and secondary outcome measures
Validated patients' self-administered questionnaires were used to assess the severity of LUTS/BPE (the International Prostate Symptom Score), sleep characteristics (sleep log) and sleep disorders (the International Classification of Sleep Disorders (ICSD-2) and the DSM-IV). Sleepiness was assessed with the Epworth Sleepiness Scale (ESS). The volume of 24 h diuresis (1500 ml) was measured.
Participants had on average 2.9±0.9 nocturia episodes (three or more episodes in 67%) and the International Prostate Symptom Score of 15.8±5.7; 60.9% complained of insomnia according to the ICSD-2, 7.9% of restless leg syndrome and 6.4% of obstructive sleep apnoea. 32.3% had excessive sleepiness (ESS >10) and 3.1% severe excessive sleepiness (ESS >16). Insomnia was mainly nocturnal awakenings with an average wake after sleep onset of 89±47 min. The number of episodes of nocturia per night correlated significantly with wake after sleep onset and ESS but not with total sleep time and sleep latency.
Nocturia is significantly associated with sleep maintenance insomnia and sleepiness in men with BPE.
Article summary
Article focus
Complaint of nocturia and its links with excessive sleepiness.
Assessment of the impact of nocturia on sleep.
Key messages
By being disruptive to sleep, the nocturia episodes affected sleep efficiency and quality.
The number of nocturia episodes was associated with an increased sleepiness in men with benign prostatic hyperplasia.
Strengths and limitations of this study
This is a cross-sectional study. It would have been more convincing to compare our subjects to a similar group of older people with no benign prostatic hyperplasia. However, our study focused on the frequency of insomnia and on the correlates between benign prostatic hyperplasia and insomnia.
PMCID: PMC3367152  PMID: 22649170
7.  A Survey on Lower Urinary Tract Symptoms (LUTS) Among patients with Benign Prostatic Hyperplasia (BPH) in Hospital Universiti Sains Malaysia (HUSM) 
Patients with Benign Prostatic Hyperplasia (BPH) commonly presents with lower urinary tract symptoms (LUTS), which can be of obstructive symptoms such as hesitancy, incomplete voiding, post void dribbling or of irritative symptoms such as urgency, frequency and nocturia. Various recent studies indicate that nocturia is a very important and bothersome lower urinary tract symptom especially among patients with Benign Prostatic Hyperplasia (BPH). The aims of the study was to determine the frequency of common urinary symptoms among patients with BPH in HUSM as well as to evaluate the extent of bothersomeness of each and every symptom to these patients. This study too was aimed at evaluating the success of TURP in resolving pre operative LUTS. This was a questionnaire-based survey using a validated ICSBPH model whereby patients with BPH were selected and quizzed personally by an investigator. A subset of patients who had undergone TURP were further questioned regarding their satisfaction with the procedure. When nocturia is defined as waking up at night once or more to pass urine, the prevalence of nocturia was about 90%, but only 1 in 6 patients considered this is a very serious symptom. Even if the definition was changed to waking up twice or more, the prevalence is still quite high at over 80%. Urgency were noted in half of the patients, but only a quarter of them consider it a serious problem. 1 in 5 patients experienced significant leak and almost all consider it serious. About one third of the studied population had to be catheterized due to urinary obstruction and interestingly only about half of them considered it as a very serious event. Overall, a great majority of these patients considered suffering from these urinary symptoms for the rest of their life as very devastating. This study conclude that although the prevalence of nocturia was high among BPH patients, but it was not considered serious by majority of them. In fact, LUTS in our BPH patients did not differ much from BPH patients elsewhere. On the whole, TURP resolved most of the LUTS effectively.
PMCID: PMC3442630  PMID: 22993495
Survey; lower urinary tract symptoms; benign prostatic hyperplasia; nocturia; bothersomeness
8.  What Is the Most Bothersome Lower Urinary Tract Symptom? Individual- and Population-level Perspectives for Both Men and Women 
European Urology  2014;65(6):1211-1217.
No study has compared the bothersomeness of all lower urinary tract symptoms (LUTS) using a population-based sample of adults. Despite this lack of evidence, investigators have often cited their LUTS of interest as the “most bothersome” or “one of the most bothersome.”
To compare the population- and individual-level burden of LUTS in men and women.
Design, setting, and participants
In this population-based cross-sectional study, questionnaires were mailed to 6000 individuals (18–79 yr of age) randomly identified from the Finnish Population Register.
Outcome measurements and statistical analysis
The validated Danish Prostatic Symptom Score questionnaire was used for assessment of bother of 12 different LUTS. The age-standardized prevalence of at least moderate bother was calculated for each symptom (population-level burden). Among symptomatic individuals, the proportion of affected individuals with at least moderate bother was calculated for each symptom (individual-level bother).
Results and limitations
A total of 3727 individuals (62.4%) participated (53.7% female). The LUTS with the greatest population-level burden were urgency (7.9% with at least moderate bother), stress urinary incontinence (SUI) (6.5%), nocturia (6.0%), postmicturition dribble (5.8%), and urgency urinary incontinence (UUI) (5.0%). Burden from incontinence symptoms was higher in women than men, and the opposite was true for voiding and postmicturition symptoms. At the individual level, UUI was the most bothersome for both genders. Although the response proportion was high, approximately a third did not participate.
Both men and women with UUI report moderate or major bother more frequently than individuals with other LUTS. At the population level, the most prevalent bothersome symptoms are urgency, SUI, and nocturia.
Patient summary
Urinary urgency was the most common troubling symptom in a large population-based study; however, for individuals, urgency incontinence was the most likely to be rated as bothersome.
Take Home Message
Population-based study assessing bother of individual lower urinary tract symptoms (LUTS) found the highest age-standardized prevalence for bothersome urgency. However, among individuals affected by LUTS, urgency incontinence was the most likely to cause significant bother. LUTS were generally well tolerated across ages and genders.
PMCID: PMC4018666  PMID: 24486308
Age factors; Bothersomeness; Definition; Lower urinary tract symptoms; Overactive bladder; Prevalence; Sex; Urinary incontinence; Urination disorders; Voiding dysfunction
9.  Characterization of overactive bladder in women in a primary care setting 
Overactive bladder (OAB) represents a disorder with overall increasing prevalence in the American population. However, gender-specific characteristics of OAB and how it relates to the general practitioner are not well described. We sought to determine the distribution and characteristics of OAB in women in a primary care setting.
Self-administered questionnaires were distributed to patients visiting a family medicine outpatient center. The modified questionnaire included eight questions on evidence of lower urinary tract symptoms (LUTS, OAB-validated 8-question screener [OAB-V8]), two questions on stress urinary incontinence, and one question on incomplete emptying. The questionnaire included demographic characteristics and relevant medical and surgical history. Body mass index was calculated based on weight and height. Chi-square test and risk ratio analysis were used to analyze the relationship between OAB and other independent variables.
Of 1025 questionnaires administered, 386 were completed. Patients ranged from 16 to 97 years, the majority were African American (78.2%), and 49.7% were premenopausal while 50.3% were postmenopausal. OAB was present in 46.4% of premenopausal women and 41.7% of postmenopausal women. OAB was significantly associated with overweight status (body mass index 25.0–29.9, P = 0.042) and obesity (body mass index ≥30, P < 0.001). Overall, obese women were twice as likely to have OAB (relative risk = 1.99, 1.31–3.04) than women with normal weight. OAB was not shown to correlate with race, cigarette use, history of hysterectomy, or parity.
OAB was evident in 44% of all female patients surveyed, which is much higher than previously reported estimates. In addition, overweight women were more likely to have OAB. Increased awareness of OAB in the primary care setting should be considered for women’s general health.
PMCID: PMC3818934  PMID: 24198633
overactive bladder; incontinence; women; primary care
10.  The Urologist's View of Male Overactive Bladder: Discrepancy between Reality and Belief in Practical Setting 
Yonsei Medical Journal  2010;51(3):432-437.
In order to gain insight into the physicians' awareness of and attitude towards management of overactive bladder (OAB) in males, we performed a nationwide survey of the current strategies that urologists use to diagnose and manage OAB in male patients.
Materials and Methods
A probability sample was taken from the Korean Urological Association Registry of Physicians, and a random sample of 289 Korean urologists were mailed a structured questionnaire that explored how they manage benign prostatic hyperplasia (BPH).
A total of 185 completed questionnaires were returned. The consent rate in the survey was 64.5%. Eighty-one (44%) urologists believed that of all males with lower urinary tract symptoms (LUTS), 20% or more had OAB and 72 (39%) believed that 10-20% had OAB. Half of the urologists surveyed believed that the most bothersome symptom in male OAB patients was nocturia. Seventy-three percent of respondents reported that they prescribed alpha blockers with anticholinergics for first line management, while 19% of urologists prescribed alpha blocker monotherapy but not anticholinergics for OAB patients. Though acute urinary retention (AUR) was considered the anticholinergic adverse event of most concern, the most frequently observed adverse event was dry mouth (95%).
The present study provides insights into urologist views of male OAB. There is a discrepancy between the awareness of urologists and actual patterns of diagnosis and treatment of male OAB. This finding indicates the need to develop further practical guidelines based on solid clinical data.
PMCID: PMC2852801  PMID: 20376898
Overactive bladder; physician's practice patterns; bladder outlet obstruction; benign prostatic hyperplasia; anticholinergics
11.  Men's Lower Urinary Tract Symptoms Are Also Mental and Physical Sufferings for Their Spouses 
Journal of Korean Medical Science  2009;24(2):320-325.
Lower urinary tract symptoms (LUTS) in men may have an adverse effect on spouse health-related quality of life (HRQL), and these effects are probably influenced by cultural and perceptional differences. This study was conducted to explore the impact of LUTS in Korean men on their spousal HRQL in relation to symptom severities and other demographic parameters. A total of 130 spouses, whose husbands had a nocturia, frequency of greater than once per night, who shared a bed with their husbands, and accompanied husbands at consultation, were subsequently enrolled and asked to complete a structured questionnaire. Almost all spouses (98%) suffered one or more inconveniences that affected HRQL to some degree. Sleep disturbance was rated to be most inconvenient. The sleep disturbances were significantly correlated with nocturia frequency and husband co-morbidity. Husband's LUTS caused partners to feel fatigued (62%), embarrassed (79%), concerned about the possibilities of cancer (69%) and surgery (81%), sexual life deteriorated (58%), and dissatisfied, unhappy, or terrible (36%). Spouse's perception on HRQL was found to be well correlated with husband's quality of life. Men with LUTS need to understand that their LUTS is also mental and physical sufferings for their spouses.
PMCID: PMC2672136  PMID: 19399278
Lower Urinary Tract Symptom; Prostate; Spouse, Quality of Life
12.  Prevalence and factor association of premature ejaculation among adult Asian males with lower urinary tract symptoms 
Prostate International  2015;3(2):65-69.
To determine the prevalence of premature ejaculation (PE) among adult Asian males presented with lower urinary tract symptoms (LUTS) and characterize its association with other clinical factors.
A cross-sectional study was conducted at a tertiary medical center to determine the prevalence of PE among adult male participants with LUTS during the Annual National Prostate Health Awareness Day. Basic demographic data of the participants were collected. All participants were assessed for the presence and severity of LUTS using the International Prostate Symptom Score (IPSS), and for the presence of PE using the PE diagnostic tool. Digital rectal examination was performed by urologists to obtain prostate size. LUTS was further categorized into severity, storage symptoms (frequency, urgency, and nocturia), and voiding symptoms (weak stream, intermittency, straining, and incomplete emptying) to determine their association with PE. Data were analyzed by comparing the participants with PE (PE diagnostic tool score ≥11) versus those without PE, using the independent t test for continuous data, Mann–Whitney U test for ordinal data, and Chi-square test for nominal data. The statistical significance was set at P < 0.05.
A total of 101 male participants with a mean ± standard deviation age of 60.75 ± 10.32 years were included. Among the participants, 33% had moderate LUTS, and 7% severe LUTS. The most common LUTS was nocturia (33%). The overall prevalence of PE was 27%. There was no significant difference among participants with PE versus those without PE in terms of age, marital status, prostate size, or total IPSS score. However, significant difference between groups was noted on the level of education (Mann–Whitney U, z = −1.993, P = 0.046) where high educational status was noted among participants with PE. Likewise, participants with PE were noted to have more prominent weak stream (Mann–Whitney U, z = −2.126, P = 0.033).
Among the participants consulted with LUTS, 27% have concomitant PE. Educational status seems to have an impact in the self-reporting of PE, which may be due to a higher awareness of participants with higher educational attainment. A significant association between PE and weak stream that was not related to prostate size suggests a neuropathologic association.
PMCID: PMC4494636  PMID: 26157771
Factor association; Lower urinary tract symptoms; Premature ejaculation
13.  Systematic Review and Meta-analysis of Candidate Gene Association Studies of Lower Urinary Tract Symptoms in Men☆ 
European Urology  2014;66(4):752-768.
Although family studies have shown that male lower urinary tract symptoms (LUTS) are highly heritable, no systematic review exists of genetic polymorphisms tested for association with LUTS.
To systematically review and meta-analyze studies assessing candidate polymorphisms/genes tested for an association with LUTS, and to assess the strength, consistency, and potential for bias among pooled associations.
Evidence acquisition
A systematic search of the PubMed and HuGE databases as well as abstracts of major urologic meetings was performed through to January 2013. Case-control studies reporting genetic associations in men with LUTS were included. Reviewers independently and in duplicate screened titles, abstracts, and full texts to determine eligibility, abstracted data, and assessed the credibility of pooled associations according to the interim Venice criteria. Authors were contacted for clarifications if needed. Meta-analyses were performed for variants assessed in more than two studies.
Evidence synthesis
We identified 74 eligible studies containing data on 70 different genes. A total of 35 meta-analyses were performed with statistical significance in five (ACE, ELAC2, GSTM1, TERT, and VDR). The heterogeneity was high in three of these meta-analyses. The rs731236 variant of the vitamin D receptor had a protective effect for LUTS (odds ratio: 0.64; 95% confidence interval, 0.49–0.83) with moderate heterogeneity (I2 = 27.2%). No evidence for publication bias was identified. Limitations include wide-ranging phenotype definitions for LUTS and limited power in most meta-analyses to detect smaller effect sizes.
Few putative genetic risk variants have been reliably replicated across populations. We found consistent evidence of a reduced risk of LUTS associated with the common rs731236 variant of the vitamin D receptor gene in our meta-analyses.
Patient summary
Combining the results from all previous studies of genetic variants that may cause urinary symptoms in men, we found significant variants in five genes. Only one, a variant of the vitamin D receptor, was consistently protective across different populations.
Take Home Message
Despite >70 publications, the evidence for associations between any specific genetic polymorphism and male lower urinary tract symptoms (LUTS) remains weak. In pooled analyses, only the rs731236 variant of the vitamin D receptor has moderate epidemiologic credibility as a risk factor for LUTS.
PMCID: PMC4410299  PMID: 24491308
Benign prostatic hyperplasia; BPH; Genetics; Genomics; Lower urinary tract symptoms; LUTS; Incontinence, male; Overactive bladder
14.  Ramelteon combined with an α1-blocker decreases nocturia in men with benign prostatic hyperplasia 
BMC Urology  2013;13:30.
Nocturia is defined as waking one or more times during the night due to the urge to void. Recently, the effectiveness of several sedatives and analgesics for nocturia has been reported. We herein investigated the effects of ramelteon, an antioxidant and sleep inducer, on nocturia unresponsive to α1-blocker monotherapy in males with lower urinary tract symptoms (LUTS) as a pilot study.
Subjects were 19 patients who had LUTS suggestive of benign prostate hyperplasia, received α1-blockers (tamsulosin, silodosin, or naftopidil), and continued to have two or more episodes of nocturia per night before starting ramelteon. Ramelteon at 8 mg once daily for one month was added to the α1-blocker. A self-administered questionnaire including the International Prostate Symptom Score (IPSS), quality of life (QoL) index, Overactive Bladder Symptom Score (OABSS), and Nocturia Quality-of-Life Questionnaire (N-QOL) were assessed before and one month after starting ramelteon.
The mean score on IPSS question 7 (nocturia) decreased significantly from 2.88 before starting ramelteon to 2.41 one month after starting the medication (P = 0.03). The mean total OABSS decreased significantly from 6.31 to 5.38 (P = 0.03), and the mean for OABSS question 2 (nighttime frequency of nocturia) also significantly decreased from 2.63 to 2.13 (P = 0.01). The mean total N-QOL score did not change significantly. Two patients had dizziness; the remaining patients had no adverse drug-related events.
Ramelteon in combination with an α1-blocker could be a treatment option for reducing nocturia in men with BPH.
PMCID: PMC3687682  PMID: 23758651
Ramelteon; Melatonin; Nocturia; Benign prostate hyperplasia; α1-blocker
15.  A prospective study of obesity and incidence and progression of lower urinary tract symptoms 
The Journal of urology  2013;191(3):715-721.
We prospectively evaluated the association between adiposity and risk of lower urinary tract symptoms (LUTS) incidence and progression in the Health Professionals Follow-up Study (HPFS).
Materials and Methods
Participants reported their current height and weight and their weight at age 21 at baseline, a year later their waist and hip circumferences, and then every two years their weight. Periodically, participants completed the International Prostate Symptom Score (IPSS) survey and reported surgery or medication use for LUTS. We used Cox proportional hazards regression to estimate the multivariable-adjusted association between adiposity and LUTS incidence and progression. The incidence analytic cohort (n=18,055) were men without LUTS at baseline. Men entered the progression analytic cohort (n=6,461) when they first experienced LUTS.
Risk of LUTS (n=4,088) increased with increasing body mass index (BMI ≥35 vs 23-<25 kg/m2: HR=1.61; 95% CI 1.31–1.99, p-trend<0.0001), waist circumference (>42 vs ≤33 in: HR=1.39, 95% CI 1.19–1.63, p-trend<0.0001), and weight gain from age 21 (≥50 lbs vs stable weight: HR=1.31, 95% CI 1.17–1.46, p-trend=<0.0001). Risk of LUTS progression (n=1,691) increased with BMI (≥35 vs 23-<25 kg/m2: HR=1.44, 95% CI 1.04–2.00, p-trend=<0.0001), weight gain from 21 years of age (≥50 lbs vs stable weight: HR=1.35, 95% CI 1.14–1.60, p-trend=<0.0001), and waist circumference (>42 vs ≤33 in: HR=1.32, 95% CI 0.95–1.85, p-trend=0.005).
Men with higher total and abdominal adiposity or who gained weight were more likely to develop LUTS or experience progressive LUTS. Our findings support that obesity may be an important target for LUTS prevention and intervention.
PMCID: PMC4164218  PMID: 24076306
Lower urinary tract symptoms; obesity; men
16.  Current role of treatment in men with lower urinary tract symptoms combined with overactive bladder 
Prostate International  2014;2(2):43-49.
Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are highly prevalent in older men. The storage subcategory of LUTS is synonymous with overactive bladder (OAB) syndrome, which is an empirical diagnosis. Traditionally, alpha-blockers are widely prescribed to manage the LUTS of BPH, although storage symptoms may persist in many men despite treatment. Therefore, because therapies that target the prostate often fail to alleviate storage symptoms, they may not be the appropriate therapy for OAB. In past years, most physicians appeared to give more weight in elderly men to voiding symptoms than to storage symptoms and to be more concerned with initial treatment with anticholinergics for males with storage symptoms. Considering the recent increase in data on the efficacy and safety of combination treatment with alpha receptor antagonists and antimuscarinic agents, the standard pharmacologic treatment of patients with LUTS combined with OAB should be an alpha receptor antagonist and an antimuscarinic agent. Beta-3 adrenoreceptor agonists may also potentially be useful for the treatment of male LUTS combined with OAB.
PMCID: PMC4099395  PMID: 25032191
Prostatic hyperplasia; Overactive urinary bladder; Pharmacology
17.  Relationship between Lifestyle and Health Factors and Severe Lower Urinary Tract Symptoms (LUTS) in 106,435 Middle-Aged and Older Australian Men: Population-Based Study 
PLoS ONE  2014;9(10):e109278.
Despite growing interest in prevention of lower urinary tract symptoms (LUTS) through better understanding of modifiable risk factors, large-scale population-based evidence is limited.
To describe risk factors associated with severe LUTS in the 45 and Up Study, a large cohort study.
Design, Setting, and Participants
A cross-sectional analysis of questionnaire data from 106,435 men aged ≥45 years, living in New South Wales, Australia.
Outcome Measures and Statistical Analysis
LUTS were measured by a modified version of the International Prostate Symptom Score (m-IPSS). The strength of association between severe LUTS and socio-demographic, lifestyle and health-related factors was estimated, using logistic regression to calculate odds ratios, adjusted for a range of confounding factors.
Overall, 18.3% reported moderate, and 3.6% severe, LUTS. Severe LUTS were more common among men reporting previous prostate cancer (7.6%), total prostatectomy (4.9%) or having part of the prostate removed (8.2%). After excluding men with prostate cancer or prostate surgery, the prevalence of moderate-severe LUTS in the cohort (n = 95,089) ranged from 10.6% to 35.4% for ages 45–49 to ≥80; the age-related increase was steeper for storage than voiding symptoms. The adjusted odds of severe LUTS decreased with increasing education (tertiary qualification versus no school certificate, odds ratio (OR = 0.78 (0.68–0.89))) and increasing physical activity (high versus low, OR = 0.83 (0.76–0.91)). Odds were elevated among current smokers versus never-smokers (OR = 1.64 (1.43–1.88)), obese versus healthy-weight men (OR = 1.27 (1.14–1.41)) and for comorbid conditions (e.g., heart disease versus no heart disease, OR = 1.36 (1.24–1.49)), and particularly for severe versus no physical functional limitation (OR = 5.17 (4.51–5.93)).
LUTS was associated with a number of factors, including modifiable risk factors, suggesting potential targets for prevention.
PMCID: PMC4198085  PMID: 25333345
18.  Commonly-used antihypertensives and lower urinary tract symptoms: Results from the Boston Area Community Health (BACH) Survey 
Bju International  2011;109(11):1676-1684.
To examine differences in the prevalence of lower urinary tract symptom (LUTS) among users of five common antihypertensive (AHT) classes compared to non-users, adjusted for LUTS risk factors in a large, representative sample.
Subjects and Methods
Data were from the Boston Area Community Health Survey, a population-based study of community-dwelling male and female (30–79y) residents of Boston, MA for whom prescription drug information was collected (2002–2005). The urologic symptoms of storage, voiding, and nocturia were assessed using interviewer-administered questionnaires and the American Urologic Association Symptom Index. This analysis was conducted among 1,865 participants with an AHT indication. Associations of angiotensin-converting enzyme inhibitors, beta blockers, calcium channel blockers (CCBs), loop and thiazide diuretics with the three groups of LUTS were estimated using odds ratios (ORs) and 95% confidence intervals (CIs) from multivariate logistic regression (referent group=untreated hypertension). Overlap in use was accounted for using monotherapy and combination therapy exposure categories.
Among women, monotherapy with CCBs was associated with increased prevalence of nocturia (OR=2.65, 95% CI: 1.04–6.74) and voiding symptoms (OR=3.84, 95% CI: 1.24–11.87); these results were confined to women aged <55. Among men of all ages, positive associations were observed for thiazides and voiding symptoms (monotherapy OR=2.90, 95% CI: 1.17–7.19), and loop diuretics and nocturia (combination therapy OR=2.55, 95% CI: 1.26–5.14).
Results are consistent with the hypothesis that certain AHTs may aggravate LUTS. The presence of new or worsening LUTS among AHT users suggests review of medications and consideration of a change in AHT class.
PMCID: PMC3249016  PMID: 21951754
urination disorders; antihypertensive agents; epidemiology
19.  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 
BJU international  2012;110(7):1050-1059.
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).
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 ratio for one category increase in NSAID use = 0.98–1.11, P-trends = 0.10–0.99) with incident BPH/LUTS.
The findings obtained in the present study do not support a protective role for recent NSAID use in BPH/LUTS development.
PMCID: PMC3382045  PMID: 22429766
aspirin; benign prostatic hyperplasia; ibuprofen; lower urinary tract symptoms; non-steroidal anti-inflammatory drugs
20.  Serenoa repens monotherapy for benign prostatic hyperplasia (BPH): an updated Cochrane systematic review 
BJU international  2012;109(12):1756-1761.
To estimate the effectiveness and harms of Serenoa repens monotherapy in the treatment of lower urinary tract symptoms (LUTS) consistent with benign prostatic hyperplasia (BPH).
Materials and methods
We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and other sources through to January 2012 to identify randomised trials.
Trials were eligible if they randomised men with symptomatic BPH to receive Serenoa repens extract monotherapy for at least 4 weeks in comparison with placebo, and assessed clinical outcomes and urodynamic measurements.
Our primary outcome was improvement in LUTS, based on change in urological symptom-scale scores.
In all, 17 randomised controlled trials (N = 2008) assessing Serenoa repens monotherapy (typically 320 mg/day) vs placebo met inclusion criteria, although only five reported American Urological Association Symptom Index (AUASI) or International Prostate Symptom Scores (IPSS). Trial lengths ranged from 4 to 72 weeks. The mean age of all enrolees was 64.3 years and most participants were of White race. The mean baseline total score was 14 points, indicating moderately severe symptoms. In all, 16 trials were double blinded and adequate treatment allocation concealment was reported in six trials.
In a meta-analysis of three high quality long-to-moderate term trials (n = 661), Serenoa repens therapy was no better than placebo in reducing LUTS based on the AUASI/IPSS (weighted mean difference [WMD] −0.16 points, 95% confidence interval [CI] −1.45 to 1.14) or maximum urinary flow rate (Qmax; WMD 0.40 mL/s, 95% CI −0.30 to 1.09). Based on mostly short-term studies, Qmax measured at study endpoint were also not significantly different between treatment groups (WMD 1.15 mL/s, 95% CI −0.23 to 2.53) with evidence of substantial heterogeneity (I2 58%).
One long-term dose escalation trial (72 weeks) found double and triple doses of Serenoa repens extract did not improve AUASI compared with placebo and the proportions of clinical responders (≥ 3 point decrease in the AUASI) were nearly identical (43% vs 44% for Serenoa repens and placebo, respectively) with a corresponding risk ratio of 0.96 (95% CI 0.76–1.22).
Long-term, Serenoa repens therapy was no better than placebo in improving nocturia in one high-quality study (P = 0.19). Pooled analysis of nine short-term Permixon® trials showed a reduction in the frequency of nocturia (WMD −0.79 times/night, 95% CI−1.28 to −0.29), although there was evidence of heterogeneity (I2 76%)
Adverse events of Serenoa repens extracts were few and mild, and incidences were not statistically significantly different vs placebo. Study withdrawals occurred in ≈10% and did not differ between Serenoa repens and placebo.
Serenoa repens therapy does not improve LUTS or Qmax compared with placebo in men with BPH, even at double and triple the usual dose.
Adverse events were generally mild and comparable to placebo.
PMCID: PMC3513282  PMID: 22551330
Serenoa repens; benign prostatic hyperplasia; phytotherapy; systematic review
21.  A study of bladder dysfunction in women with type 2 diabetes mellitus 
Diabetes mellitus has been associated with an earlier onset and increased severity of urologic diseases that often result in debilitating urologic complications. Diabetic bladder dysfunction refers to a group of bladder symptoms occurring in patients with diabetes mellitus ranging from bladder over activity to impaired bladder contractility.
Bladder dysfunction is an under evaluated issue in women with diabetes. Aim of our study was to investigate prevalence of bladder dysfunction and its relation with other chronic complications of diabetes in women with type 2 diabetes.
Materials and Methods:
In a hospital-based cross sectional study, a cohort of women with type 2 diabetes mellitus who had lower urinary tract symptoms (LUTS) were enrolled. We used the American Urological Association Symptom Index (AUA-SI) to assess the severity of LUTS and the Indevus Urgency Severity Scale (IUSS) to assess presence of overactive bladder (OAB). Age-BMI- matched controls that did not have diabetes but had lower urinary tract symptoms were also studied and compared with women with type 2 diabetes. Urodynamic evaluation was done in willing patients.
LUTS attributable to bladder dysfunction were reported in 67% of women with type 2 diabetes after exclusion of other causes. Out of them, 36% had moderate to severe LUTS (total AUA-SI score >7). Prevalence of OAB was 53%. Urodynamic evaluation revealed presence of stress urinary incontinence in 48% patients and changes of detrusor over activity and detrusor under activity in 23% and 11% patients, respectively. Among the chronic complications of diabetes, peripheral neuropathy, nephropathy, and presence of metabolic syndrome were significantly associated with moderate to severe LUTS and OAB.
Bladder dysfunction is a highly prevalent complication in women with diabetes. Chronic complications of diabetes especially neuropathy, nephropathy, and presence of metabolic syndrome are important predictors of bladder dysfunction.
PMCID: PMC4138915  PMID: 25143916
Type 2 diabetes; lower urinary tract symptoms; bladder dysfunction; diabetic cystopathy
22.  The Impact of Lower Urinary Tract Symptoms on Quality of Life, Work Productivity, Depressive Symptoms, and Sexuality in Korean Men Aged 40 Years and Older: A Population-Based Survey 
To examine the impact of lower urinary tract symptoms (LUTS) on health-related quality of life (HRQoL) in Korean men aged ≥40 years.
A population-based, cross-sectional door-to-door survey was conducted among men aged ≥40 years. Individuals with LUTS were defined as men reporting at least one LUTS using 2002 International Continence Society definitions. Structuredquestionnaires were used to assess several dimensions of HRQoL, including generic health status (EuroQoL-five-dimensions questionnaire), work productivity (work productivity and activity impairment questionnaire), depressive symptoms (center for epidemiologic studies depression scale), and sexual health (sexual satisfaction and erectile dysfunction). The impact of LUTS was assessed by comparing several dimensions of HRQoL among men with and without LUTS.
Of the 1,842 participants, 1,536 (83.4%) reported having at least one LUTS. The prevalence of LUTS increased with age (78.3% among those aged 40–49 years to 89.6% among those aged 60 years or older). Those with LUTS reported a significantlylower level of generic health status and worse work productivity compared with those without LUTS. Significantly more individuals with LUTS reported having a higher level of major depressive symptoms compared with those without LUTS.Those with LUTS reported worse sexual activity and enjoyment, and were significantly more likely to have erectile dysfunction than those without LUTS.
LUTS seem to have a substantial impact on several dimensions of HRQoL in Korean men aged ≥40 years.
PMCID: PMC4490313  PMID: 26126442
Lower Urinary Tract Symptoms; Quality of Life; Epidemiologic Studies
23.  Are commonly-used psychoactive medications associated with lower urinary tract symptoms? 
Lower urinary tract symptoms (LUTS) such as urinary frequency and urgency are bothersome and associated with reduced quality-of-life. Atypical antipsychotics (AAPs) have been implicated in increasing the risk of urinary incontinence. In a large community-based sample of men and women, we examined the associations of AAP use and selective serotonin reuptake inhibitor (SSRIs) use with LUTS.
Data were collected (2002–2005) from a generalizable sample of Boston, MA, USA residents aged 30–79 (N=5503). LUTS were assessed using the American Urologic Association Symptom Index (AUA-SI). The prevalence of clinically-significant LUTS was estimated using a cutoff AUA-SI score of 8+ to indicate moderate-to-severe symptoms. Confounder-adjusted odds ratios (ORs) and 95% confidence intervals (CI) were calculated from multivariate logistic regression to estimate the associations for psychoactive drugs used in the previous month (SSRIs, AAPs, both) and LUTS.
Among women, AAP users had a higher prevalence of LUTS (46.2%) compared to SSRI users (23.5%) and those with depressive symptoms not using SSRIs or AAPs (26.3%). Corresponding prevalence estimates among men were 32.7%, 29.8%, and 33.3%. In multivariate models, AAP use was significantly associated with LUTS among women when used either with SSRIs (OR=2.72, 95%CI:1.45–5.10), or without SSRIs (OR=3.05, 95%CI:1.30–7.16) but SSRI use without AAP use was not associated with LUTS, compared to non-users without depressive symptoms. No associations were observed among men.
In our study, AAPs but not SSRIs were associated with increased prevalence of LUTS among women only. Further prospective research is needed to determine time sequence and cause-and-effect.
PMCID: PMC3538827  PMID: 22138718
antipsychotic agents; antidepressive agents; urination disorders; pharmacoepidemiology; epidemiology
24.  The Effect of Benign Lower Urinary Tract Symptoms on Subsequent Prostate Cancer Testing and Diagnosis 
European urology  2013;63(6):1021-1027.
Lower urinary tract symptoms (LUTS) are common and have been associated with the subsequent diagnosis of prostate cancer (PCa) in population cohorts.
To determine whether the association between LUTS and PCa is due to the intensity of PCa testing after LUTS diagnosis.
Design, setting, and participants
We prospectively followed a representative, population-based cohort of 1922 men, aged 40–79 yr, from 1990 until 2010 with interviews, questionnaires, and abstracting of medical records for prostate outcomes. Men were excluded if they had a previous prostate biopsy or PCa diagnosis. Self-reported LUTS was defined as an American Urological Association symptom index score >7 (n = 621). Men treated for LUTS (n = 168) were identified from review of medical records and/or self report. Median follow-up was 11.8 yr (interquartile range: 10.7–12.3).
Outcome measurements and statistical analysis
Associations between self-reported LUTS, or treatment for LUTS, and risk of subsequent prostate biopsy and PCa were estimated using Cox proportional hazard models.
Results and limitations
Fifty-five percent of eligible men enrolled in the study. Men treated for LUTS were more likely to undergo a prostate biopsy (hazard ratio [HR]: 2.4; 95% confidence interval [CI], 1.7–3.3). Men younger than 65 yr who were treated for LUTS were more likely to be diagnosed with PCa (HR: 2.3, 95% CI, 1.5–3.5), while men aged >65 yr were not (HR: 0.89, 95% CI, 0.35–1.9). Men with self-reported LUTS were not more likely to be biopsied or diagnosed with PCa. Neither definition of LUTS was associated with subsequent intermediate to high-risk cancer. The study is limited by lack of histologic or prostate-specific antigen level data for the cohort.
These results indicate that a possible cause of the association between LUTS and PCa is increased diagnostic intensity among men whose LUTS come to the attention of physicians. Increased symptoms themselves were not associated with intensity of testing or diagnosis.
PMCID: PMC3637922  PMID: 23313032
25.  Correlation between Nocturia and Sleep: A Questionnaire Based Analysis 
Korean Journal of Urology  2010;51(11):757-762.
This study evaluated the effectiveness and quality of sleep (QoS) in adult patients with nocturnal lower urinary tract symptoms (LUTS) including nocturia and nocturnal polyuria.
Materials and Methods
A total of 102 patients with nocturia and daytime LUTS were enrolled in this study. All patients completed a questionnaire that included the International Prostate Symptom Score (IPSS), quality of life score (QoL), overactive bladder questionnaire (OABq), and a sleepiness index. The sleepiness index was measured with the Korean Beck Depression Inventory (K-BDI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Berlin Questionnaire (BQ), and the International Restless Legs Syndrome Study Group (IRLSSG). Statistical analyses included the Student's t-test and chi-square test. Differences were considered significant at a p-value of less than 0.05.
Nocturia during sleep was experienced by 68 (66.7%) out of 102 patients. There was no significant association between the nocturia- and the sleep-related scales, but with multiple regression analysis for sex and age, the K-BDI score (p=0.05), IPSS score (p=0.05), and OABq (p=0.02) were significantly higher in patients who woke up to void during sleep. A total of 57 (55.9%) patients diagnosed with overactive bladder with nocturia had severe daytime sleepiness on the ESS questionnaire (p=0.019) and more urgency symptoms on the IPSS questionnaire (p=0.007).
Patients with nocturia had a greater risk of being depressive and felt sleepier during the daytime. LUTS including nocturia and sleep quality closely affected each other. Therefore, clinicians should consider patients' LUTS and sleep problems or QoS as well to provide more satisfying outcomes.
PMCID: PMC2991572  PMID: 21165195
Nocturia; Quality of life; Sleep disorders

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