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Urologic Diseases Research Updates
Spring 2010

Lower Urinary Tract Symptoms in Men Associated with Metabolic Syndrome Photo montage of a blood pressure meter, a hand holding a blood glucose meter, and a man’s shadow with a piece of graph paper in the background.

Men with mild to severe lower urinary tract symptoms (LUTS) are more likely to have metabolic syndrome (MetS)-a constellation of cardiovascular disease risk factors-than men without them, according to an analysis of data collected by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)-funded Boston Area Community Health (BACH) survey.

"These findings have important diagnostic and management implications. Patients who present with components of metabolic dysfunction should be routinely queried with respect to urological function," wrote Varant Kupelian, Ph.D., a research scientist at the New England Research Institutes, Watertown, MA, and co-authors in their report about the analysis, which appeared in the August 2009 issue of The Journal of Urology.

Interestingly, the prevalence of MetS was just as high among men with mild LUTS as it was among men with severe LUTS. Men with no LUTS had the lowest prevalence of MetS, but MetS prevalence quickly increased with increasing LUTS. The researchers scored LUTS severity using the American Urological Association Symptom Index (AUASI). See the table below for a description of the AUASI questionnaire.


Chart showing the American Urological Association Symptom Index questionnaire. The first four questions ask about voiding symptoms: “Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?”; “During the past month or so, how often have you found you stopped and started again several times when you urinated?”; “During the past month or so, how often have you had a weak urinary stream?”; and “During the past month or so, how often have you had to push or strain to begin urination?”. The last three questions ask about storage symptoms: “During the past month or so, how often have you found it difficult to postpone urination?”; “During the past month or so, how often have you had to urinate again less than two hours after you finished urinating?”; and “Over the past month, how many times per night did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?”. Answer options for questions one to six are “Not at All,” worth 0 points; “Less than 1 time in 5,” worth one point; “Less than half the time,” worth two points; “About half the time,” worth three points; “More than half the time,” worth four points; and “Almost always,” worth five points. Answer options for the last question are “None,” worth zero points; “1 time,” worth one point; “2 times,” worth two points; “3 times,” worth three points; “4 times,” worth four points; and “5 times,” worth five points. [D]


MetS components include abdominal obesity, high blood pressure, high cholesterol, high triglycerides, and diabetes. Scientists believe these frequently comorbid conditions may stem from a common underlying cause. For the current analysis, MetS was defined as the presence of three or more MetS components.

Line graph showing the association of the metabolic syndrome (MetS) with lower urinary tract symptoms (LUTS). LUTS severity, on a scale of 0 to 35, is plotted on the X axis. MetS prevalence is plotted on the Y axis. The graph designates no symptoms as total LUTS scores from zero to 1, mild symptoms as total LUTS scores from 2 to 7, moderate symptoms as LUTS scores from 8 to 19, and severe symptoms as LUTS scores from 20 to 35. According to the graph, only about 20 percent of men without LUTS had MetS, but 30 percent or more of men with mild, moderate, and severe LUTS had MetS. [D]
MetS prevalence was similar among men with mild, moderate, and severe LUTS.

BACH

Funded by the NIDDK, the BACH is a population-based epidemiological survey of urologic symptoms, such as pelvic pain, prostatitis, and sexual dysfunction, among men and women ages 30 to 79. From 2002 to 2005, BACH researchers interviewed study participants, asking extensive questions about health history; lifestyle; use of tobacco, alcohol, and medications, including diabetes medications; and level of income and education. They recorded participants' hip and waist circumference, height, weight, and blood pressure and collected blood for the analysis of cholesterol and triglycerides.

When LUTS were grouped as either "voiding" or "storage" symptoms, the researchers found that mild or worse voiding symptoms-incomplete emptying of the bladder, weak urine stream, intermittency (starting and stopping a urine stream), and straining to urinate-were significantly associated with MetS; however, storage symptoms were not. Urgency (the urgent need to urinate), frequency of urination, and nocturia (waking during the night to urinate) were grouped as storage symptoms. When researchers analyzed LUTS individually, they found that incomplete emptying, intermittency, and nocturia were all independently associated with increased odds of MetS.

LUTS are common among men. Between 26 and 46 percent of men ages 40 to 79 have moderate to severe LUTS. For years, scientists thought LUTS in men were principally related to the bladder and benign prostatic hyperplasia(BPH). But recent data pointing to associations between LUTS and chronic illnesses, such as heart disease and diabetes, have fostered the hypothesis that factors outside the bladder and prostate play an important role.

"This community-based cohort study confirms the results of prior analyses linking the metabolic syndrome to an increased risk of LUTS, and adds to a growing body of evidence supporting robust associations of modifiable risk factors-obesity, diabetes, and diet-with LUTS and BPH," wrote J. Kellogg Parons, M.D., an assistant professor at the University of California, San Diego, in a companion editorial.

Diabetes and LUTS

Diabetes was associated with more significant increases in LUTS than any of the other four components of MetS. Chronic hyperglycemia, or high blood glucose, resulting from diabetes is known to damage peripheral nerves.

In their report, the researchers suggest that the increase in voiding but not storage symptoms associated with MetS may be due to a phenomenon seen in animal studies that show that hyperglycemia selectively increases cell death of pelvic parasympathetic neurons but has little effect on sympathetic neurons.

"Such an unbalanced loss of autonomic neurons might induce an oversupply of sympathetic tone compared to parasympathetic efferent activity resulting in increased bladder neck obstruction and reduced bladder power, which combined might produce an increase in obstructive symptoms as noted," wrote Kupelian and colleagues.

The authors urged additional studies aimed at understanding the common pathophysiology of LUTS and MetS.

The National Kidney and Urologic Diseases Information Clearinghouse, an information dissemination service of the NIDDK, has fact sheets and easy-to-read booklets about urologic diseases. For more information or to obtain copies, visit www.urologic.niddk.nih.gov.


NIH Publication No. 10-5743
April 2010

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The National Kidney and Urologic Diseases Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

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