- Email: [email protected]
Prevalence of Lower Urinary Tract Symptoms in Male Aborigines and Non-aborigines in Eastern Taiwan
ORIGINAL ARTICLE
Prevalence of Lower Urinary Tract Symptoms in Male Aborigines and Non-aborigines in Eastern Taiwan Hann-Chorng Kuo* Background/Purpose: Lower urinary tract symptoms (LUTS) are highly prevalent in men. The relationship of LUTS with socioeconomic level has not been investigated in Asian people. This study investigated the prevalence of LUTS in men and between aborigines and non-aborigines in eastern Taiwan, and their association with demographic, socioeconomic and behavioral characteristics. Methods: A survey of LUTS in adult male community residents of Hualien district was conducted in 2006. LUTS were assessed using questionnaires for the International Prostate Symptom Score (IPSS) and Quality of Life Index (QoL-I). The prevalence of each bothersome LUTS, moderate LUTS (IPSS > 8) and impaired QoL (QoL-I > 4) were compared between aborigines and non-aborigines. The association between the prevalence of LUTS and socioeconomic status was also compared between the two groups. Results: There were 196 aborigines (32%) and 419 non-aborigines (68%) who completed the questionnaires. Nocturia was the most common LUTS in aboriginal and non-aboriginal men. The prevalence of moderate LUTS increased with age (p < 0.001) in men overall. Significantly higher prevalence rates of frequency (11.7% vs. 7.2%, p = 0.044) and nocturia (31.1% vs. 19.8%, p = 0.002) were found in aborigines than non-aborigines. However, there was no significant difference in the prevalence of moderate LUTS (12.8% vs. 8.8%, p = 0.220) or impaired QoL (24.3% vs. 19.9%, p = 0.088) between aborigines and nonaborigines. The higher prevalence of frequency and nocturia in aborigines was associated with significantly lower educational and economic levels, which were also associated with a higher prevalence of alcohol drinking, betel quid chewing and cigarette smoking. Conclusion: Nocturia was the most common LUTS in community dwelling aboriginal and non-aboriginal adult males. A low socioeconomic level was associated with a higher prevalence rate of moderate LUTS and impaired QoL, especially in aborigines. [J Formos Med Assoc 2008;107(9):728–735] Key Words: aborigines, epidemiology, lower urinary tract symptoms
Lower urinary tract symptoms (LUTS) are highly prevalent in men. The overall prevalence of LUTS is estimated to be 18.7–40% and increases with age, but it does not differ by sex or race/ethnicity.1,2 In men over 65 years old, the prevalence of one or more troublesome LUTS that affect daily life is estimated to be 48%.3 A 5-year longitudinal study
of men over 45 years old has found that LUTS showed no change in 19%, worsened in 50%, and improved in 31%.4 The most important risk factor for the development of LUTS is age, and there is also a trend for a higher International Prostate Symptom Score (IPSS) in men with elevated blood pressure and large waist size.5 A longitudinal study ©2008 Elsevier & Formosan Medical Association
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Department of Urology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan. Received: January 6, 2008 Revised: March 16, 2008 Accepted: March 25, 2008
728
*Correspondence to: Dr Hann-Chorng Kuo, Department of Urology, Buddhist Tzu Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan. E-mail: [email protected]
J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
of black American men has found that about 25% of those older than 60 years have a measurable progression in LUTS severity over time.6 Most previous epidemiologic studies of LUTS have been performed in Western countries. The reported prevalence rates of 14–59% in Asian countries are similar to those in Western countries.7 Few studies of LUTS prevalence have been performed in aborigines and other minority populations. The prevalence, severity and dissatisfaction with LUTS increases with age and severity is associated with poorer health in old people.8 The racial disparity found in the prevalence rate of LUTS may be caused by sociocultural differences in reporting symptom morbidity.2 In an American study, black men had a higher prevalence rate of LUTS but were less bothered by these symptoms compared with white men.2 However, high income was inversely associated with LUTS and with obstructive and irritative symptoms in African-American men.9 The causes of this disparity might include lower levels of alertness to LUTS and less impact from LUTS on quality of life (QoL) in people from lower socioeconomic groups. In Taiwan, there are nine main aboriginal tribes that comprise approximately one seventh of the total population. In general, their health status, evaluated by life expectancy, mortality rate and prevalence and incidence of various diseases, is worse than that of the rest of the general Taiwanese population.10 In the Hualien district of eastern Taiwan, aborigines and non-aborigines live together in a proportion of about one to three. The educational, socioeconomic and living environments are quite different between aborigines and non-aborigines. Aborigines have a lower education level, lower family income and live in rural or mountainous areas. Previous studies have shown that the general health status of aboriginal adolescents is inferior to that of nonaborigines.11 The lifestyles of aborigines are also quite different from that of non-aborigines. The prevalence rate of betel quid chewing is 46.1% in aborigines. Betel quid chewing is closely associated with obesity, alcohol consumption and cigarette smoking.12 J Formos Med Assoc | 2008 • Vol 107 • No 9
This prospective study was conducted to investigate the prevalence of LUTS in aborigines and non-aborigines in eastern Taiwan (Hualien district). In addition, the prevalence of LUTS and their association with education level, family income and other characteristics, including physical exercise, alcohol consumption, betel quid chewing and cigarette smoking were also investigated. The results of this study may provide useful information about the prevalence of LUTS in different ethnic populations living in the same district.
Methods A survey of LUTS in community dwelling adult males in Hualien district was conducted in 2006. Individuals without previous or current urologic diseases were randomly selected and interviewed using structured questionnaires for LUTS. The proportion of aboriginal and non-aboriginal subjects enrolled was based on the proportion of residents from these groups in the Hualien district. Data collected included age, body weight, body height, education level, family income, betel quid chewing, alcohol consumption, cigarette smoking, and physical exercise. The history of LUTS treatment and intention to seek treatment were also recorded. All study subjects were classified according to their socioeconomic levels and behavioral patterns. Men with an educational level of up to senior high school were considered to have a low educational level. Family income of less than NT$30,000 per month (equivalent to the monthly income of a hard working college graduate) was considered as a low income. Men with alcohol consumption equivalent to more than one can of beer per day, chewing more than 10 betel quids per day, cigarette smoking of more than 10 pieces per day were considered as having a habit. Subjects were considered to have frequent physical exercise if they performed at least one physical activity (jogging, running, biking, mountain climbing) per week. 729
H.C. Kuo
Table 1. Demographic characteristics of aborigines and non-aborigines* Aborigines (n = 196)
Non-aborigines (n = 419)
p
48 ± 25 170 ± 15.5 71 ± 10.5 56 (28.6) 74 (37.8) 81 (41.3) 68 (34.7) 161 (82.1) 138 (70.4)
53 ± 23 163 ± 13.1 69.5 ± 8.4 37 (8.8) 76 (18.1) 123 (29.4) 185 (44.2) 215 (51.3) 184 (43.9)
0.163 0.004 0.154 < 0.001 < 0.001 0.002 0.016 < 0.001 < 0.001
Age (yr) Body height (cm) Body weight (kg) Betel quid chewing Alcohol consumption Cigarette smoking Physical exercise Education (up to senior high school) Family income (≤ NT$30,000/mo) *Data presented as mean ± standard deviation or n (%).
The LUTS assessment was based on the questionnaires of the IPSS and Quality of Life Index (QoL-I). Seven items on storage and empty symptoms were graded from 0 to 5, which represented non-symptomatic to very frequently encountered symptoms. QoL-I was graded from 0 to 6, which represented the subject’s characterization of none to major concern about their LUTS.13 Only grades of > 3 for the individual LUTS were considered as bothersome and clinically relevant. IPSS was measured and a score > 8 was considered to indicate moderate LUTS. A QoL-I > 4 was considered to indicate a significantly impaired QoL. Data obtained from interviewer and self-administered questionnaires were stratified by 20-year age groups. The prevalence of each bothersome LUTS, an IPSS > 8, or QoL-I > 4 was also compared between male aborigines and non-aborigines. The correlation of age with LUTS, IPSS and QoL-I was calculated and compared between aborigines and non-aborigines. Finally, the association of individual LUTS, IPSS > 8 and QoL-I > 4 with educational level, family income and other characteristics were compared between the two groups. The χ2 test and Pearson’s correlation were used for statistical analysis. A value of p < 0.05 was considered statistically significant.
Results A total of 675 male residents were randomly selected for interview. After excluding men with 730
previous prostatectomy, treatment for pre-existing urologic disease, or prostate cancer, 615 (91%) participants completed the structured intervieweradministered questionnaire. There were 196 aborigines (32%) and 419 non-aborigines (68%) who completed the questionnaires. The mean age of these subjects was 48 ± 25 years and 53 ± 23 years for the aborigines and non-aborigines, respectively. Non-aborigines had a higher body height than aborigines but the body weight was similar in the two groups. Aborigines had a higher prevalence of alcohol consumption, betel quid chewing, cigarette smoking, lower educational level, lower economic level, and less frequent physical exercise than non-aborigines (Table 1). In the overall group, the most prevalent symptom was nocturia (23.4%), followed by frequency (8.6%), residual urine sensation (8.5%), intermittency (7.6%), slow stream (5.2%), straining to void (4.2%) and urgency (3.6%). Moderate LUTS (IPSS > 8) was noted in 10.1% of subjects in the overall group and an impaired QoL (QoL-I > 4) in 22.9%. The prevalence rates of individual bothersome LUTS, moderate LUTS and impaired QoL in aborigines and non-aborigines are shown in the Figure. Significantly higher prevalence rates of frequency (11.7% vs. 7.2%, p = 0.044) and nocturia (31.1% vs. 19.8%, p = 0.002) were found in aborigines than non-aborigines. However, there was no significant difference in the prevalence of moderate LUTS or impaired QoL between aborigines and non-aborigines. J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
p = 0.002 31.1
35 Non-aborigines Aborigines
30
p = 0.088 24.3
Percentage
25 19.8
20 15 10
p = 0.220 12.8
p = 0.044 p = 0.181 10.2 7.6
11.7 7.2
p = 0.204 9.2 6.9
p = 0.146 p = 0.400 6.0 4.1 3.6 3.3
5
19.9
8.8 p = 0.546 4.3 4.1
≥ oL -I Q
IP
SS
≥
4
8
ria tu oc N
re st ow Sl
St r to aini vo ng id
am
y nc ge Ur
Re
sid se ual ns ur at in io e n Fr eq ue nc y In te rm itt en cy
0
Figure. Prevalence of bothersome lower urinary tract symptoms (LUTS), moderate LUTS (IPSS > 8) and impaired quality of life (QoL-I > 4) in male aborigines and non-aborigines.
In the overall 615 men, moderate LUTS were found in five (4.4%), 20 (8.1%), 23 (11.4%) and 14 (26%) of men aged < 30, 30–50, 51–70 and > 70 years old, respectively. The prevalence of moderate LUTS increased with age (p < 0.001) in men overall. The prevalence of moderate LUTS significantly increased with age in non-aborigines and had an increasing trend in aborigines. The prevalence of individual LUTS increased with age in non-aborigines but not in aborigines, except for nocturia, which increased with age in both groups. Although impaired QoL was found in 22.9% of the overall group, there was no association between impaired QoL and increasing age in either the aboriginal or non-aboriginal group (Table 2). Table 3 shows the association of alcohol consumption, betel quid chewing, cigarette smoking and social economic differences with the prevalence of LUTS in aborigines and non-aborigines. Aborigines with the habits of alcohol consumption, betel quid chewing and cigarette smoking had a significantly higher prevalence of symptoms of intermittency, residual urine sensation, nocturia, moderate LUTS and impaired QoL than J Formos Med Assoc | 2008 • Vol 107 • No 9
non-aborigines with the same substance use patterns. In the overall group, lower educational level was significantly associated with a higher prevalence of moderate LUTS (p < 0.001), frequency (p < 0.001), intermittency (p < 0.001), urgency (p = 0.006), slow stream (p = 0.005), straining to void (p = 0.001), and nocturia (p < 0.001). Lower educational level was associated with a significantly higher prevalence of frequency, nocturia, moderate LUTS and impaired QoL in aborigines than in non-aborigines. In the overall group, only the prevalence rates of urgency (p = 0.024) and nocturia (p < 0.001) were significantly associated with a lower economic level. A lower family income was associated with a higher prevalence of urgency (5.6% vs. 1.4%, p = 0.004) and nocturia (31.4% vs. 14.7%, p < 0.001) than a higher income was. Aborigines with a lower family income had a higher prevalence of daytime frequency, nocturia and impaired QoL than non-aborigines with a lower family income, while the prevalence of other LUTS in these groups was not associated with differences in income. 731
H.C. Kuo
Table 2. Age-related lower urinary tract symptoms presentation in aborigines and non-aborigines* Age (yr) < 30
30–50
51–70
> 70
p
Frequency
A NA
5 (11.6) 1 (1.4)
8 (10.5) 11 (6.5)
10 (14.7) 8 (6.0)
0 10 (22.2)
0.597 < 0.001
Urgency
A NA
2 (4.7) 0
3 (3.9) 0
3 (4.4) 6 (4.5)
0 8 (17.8)
0.932 > 0.001
Intermittency
A NA
3 (7.0) 0
7 (9.2) 8 (4.7)
7 (10.3) 11 (8.2)
1 (11.1) 10 (22.2)
0.942 < 0.001
Slow stream
A NA
2 (4.7) 0
2 (2.6) 4 (2.4)
3 (4.4) 10 (7.5)
0 11 (24.4)
0.845 < 0.001
Straining to void
A NA
2 (4.7) 0
2 (2.6) 4 (2.4)
2 (2.9) 7 (5.2)
2 (22.2) 7 (15.6)
0.041 < 0.001
Residual urine sensation
A NA
4 (9.3) 2 (2.9)
5 (6.6) 9 (5.3)
11 (16.2) 11 (8.2)
0 10 (22.2)
0.187 0.001
Nocturia
A NA
6 (14.0) 4 (5.7)
22 (28.9) 17 (10.0)
30 (44.1) 37 (27.6)
3 (33.3) 25 (55.6)
0.050 < 0.001
IPSS > 8
A NA
4 (9.3) 1 (1.4)
9 (11.8) 11 (6.5)
10 (14.7) 13 (9.7)
2 (22.2) 12 (26.6)
0.688 < 0.001
QoL-I > 4
A NA
9 (20.9) 19 (27.1)
13 (17.1) 41 (24.1)
16 (23.5) 30 (22.4)
1 (11.1) 12 (26.7)
0.706 0.870
*Data presented as n (%). A = aborigines; NA = non-aborigines; IPSS = International Prostate Symptom Score; QoL-I = Quality of Life Index.
The prevalence of alcohol consumption, betel quid chewing and cigarette smoking was significantly higher in aborigines than in non-aborigines. These behaviors were associated with a higher prevalence rate of individual LUTS, moderate LUTS and impaired QoL in the overall group. Aborigines with these substance use patterns also had higher prevalence rates of nocturia, intermittency, residual urine sensation, as well as moderate LUTS and impaired QoL than non-aborigines. Frequent physical exercise was reported by 253 men (41.1%), including 185 non-aborigines and 58 aborigines. Frequent physical exercise was inversely associated with impaired QoL (p = 0.01) in both aborigines and non-aborigines, but had no association with the prevalence of any individual LUTS or the existence of LUTS of moderate severity. Among the 62 men with moderate LUTS, 12 (19.4%) had been treated for their LUTS while 50 (80.6%) had not been treated. However, 45 732
men (72.6%) expressed a desire to receive medical treatment for their bothersome LUTS in the future.
Discussion This is believed to be the first study to investigate the prevalence of LUTS in community dwelling male aborigines and non-aborigines in eastern Taiwan. Aborigines had higher prevalence rates of nocturia and frequency than non-aborigines, which might be related to their significantly lower educational level, lower economic level, and association with a higher prevalence of alcohol consumption, betel quid chewing and cigarette smoking. Frequency and nocturia are the two most common reported bothersome LUTS.3 In the BACH survey of LUTS, nocturia was reported by 28.4% of people, increased with age, had a J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
Table 3. Relationship of lower urinary tract symptoms and demographics between aborigines and non-aborigines* Alcohol consumption
Betel quid chewing
Cigarette smoking
Education (up to senior high school)
Economic (≤ NT$30,000/mo)
Frequency
A NA p
9 (39.1) 4 (13.3) 0.033
7 (30.4) 1 (3.3) 0.009
10 (43.5) 6 (20) 0.062
19 (82.6) 17 (56.7) 0.042
18 (78.3) 14 (46.7) 0.019
Urgency
A NA p
3 (37.5) 2 (14.3) 0.309
3 (37.5) 0 (0) 0.036
4 (50) 3 (21.4) 0.182
7 (87.5) 9 (64.3) 0.255
6 (75) 12 (85.7) 0.456
Intermittency
A NA p
7 (38.9) 2 (6.9) 0.010
5 (27.8) 1 (3.4) 0.025
9 (50) 2 (17.2) 0.020
16 (88.9) 19 (65.5) 0.072
13 (72.2) 15 (51.7) 0.139
Slow stream
A NA p
3 (42.9) 5 (20.0) 0.224
2 (28.6) 0 (0) 0.042
5 (71.4) 5 (20) 0.019
4 (57.1) 18 (72) 0.376
4 (57.1) 14 (56) 0.649
Straining to void
A NA p
2 (25) 3 (16.7) 0.498
1 (12.5) 0 (0) 0.308
2 (25) 3 (16.7) 0.498
7 (87.5) 12 (66.7) 0.274
6 (75) 10 (55.6) 0.312
Residual urine sensation
A NA p
11 (55) 5 (15.6) 0.004
8 (40) 2 (6.3) 0.004
12 (60) 6 (18.8) 0.003
17 (85) 20 (62.5) 0.074
15 (75) 17 (53.1) 0.099
Nocturia
A NA p
25 (41) 12 (14.5) < 0.001
20 (32.8) 7 (8.4) < 0.001
28 (45.9) 25 (30.1) 0.039
56 (91.8) 58 (69.9) 0.001
51 (83.6) 50 (60.2) 0.002
IPSS > 8
A NA p
11 (44) 5 (13.5) 0.009
8 (32) 0 (0) < 0.001
14 (56) 6 (16.2) 0.001
22 (88) 24 (65) 0.038
19 (76) 21 (57) 0.099
QoL-I > 4
A NA p
16 (41) 17 (16.7) 0.003
12 (30.8) 7 (6.9) 0.001
20 (51.3) 29 (28.4) 0.010
31 (79.5) 50 (49.0) 0.010
27 (69.2) 45 (44.1) 0.006
*Data presented as n (%). A = aborigines; NA = non-aborigines; IPSS = International Prostate Symptom Score; QoL-I = Quality of Life Index.
higher prevalence in the minority population, and was associated with increasing body mass index, type II diabetes and cardiac disease.14 A recent study showed that increasingly severe LUTS was associated with a low QoL.15 Another study has found that the prevalence of LUTS and erectile dysfunction (ED) significantly increased with age, and the presence of LUTS and QoL impairment due to LUTS was an independent risk factor for the presence of ED.16 Nocturia was the most prevalent LUTS in this study. This result is in accordance with previous LUTS surveys in Europe and Japan.17,18 Yu et al J Formos Med Assoc | 2008 • Vol 107 • No 9
also reported a high prevalence rate of nocturia in Taiwanese people, and found that nocturia had a more significant QoL impact when the patient had two or more episodes per night. Men experience a greater impact from nocturia than women, particularly in the bother/concern domain.19,20 Nocturia has multiple attributable factors and increases with age. In this study, we found that alcohol consumption, betel quid chewing and cigarette smoking were all associated with a higher prevalence of nocturia. Aborigines in Taiwan usually have these three substance use habits together. Men with these habits might have 733
H.C. Kuo
increased water intake that results in diuresis, which might lead to a high urine output at night and cause nocturia. Low educational and economic levels were associated with the prevalence of moderate LUTS and impaired QoL, which suggests that low socioeconomic level in men might have an effect on sensory disorders of the urinary tract. A previous study has shown that moderate to severe LUTS is significantly associated with increased odds of having clinically relevant depressive symptoms.21 Individuals with low socioeconomic and educational levels, as in the aborigines in our study, are at increased risk of depressive illness. In Taiwan, aborigines have a lower health status than non-aborigines because of a lack of local hospital and medical consultation in their area of residence. The high prevalence rates of nocturia and moderate LUTS might also reflect a higher prevalence of depressive symptoms in this minority population. This community survey included only men without previous urological disease, and only a symptom score of > 3 was defined as a bothersome LUTS. The low prevalence rate of urgency (3.6%) indicated that the prevalence of bothersome overactive bladder in these community dwelling adult males was not as high as previously reported.22,23 Meanwhile, the low prevalence rates of slow stream (5.2%) and straining to void (4.2%) suggested that the prevalence of LUTS caused by benign prostatic hyperplasia was also low. As in previous reports from Asian countries,18,23 most of the men with moderate LUTS in the present study did not seek medical treatment, although they felt an impaired QoL because of bothersome LUTS. This suggests the need for more health education in this community. Nocturia was the most common symptom in community dwelling aborigines and nonaborigines in Taiwan. The prevalence of LUTS increased with age in the overall group and in both aborigines and non-aborigines. A low socioeconomic level was associated with higher prevalence rate of moderate LUTS and impaired QoL, especially in aborigines. 734
References 1. Kupelian V, Wei JT, O’Leary MP, et al. Prevalence of lower urinary tract symptoms and effect on quality of life in a racially and ethnically diverse random sample: the Boston Area Community Health (BACH) Survey. Arch Intern Med 2006;166:2381–7. 2. Sarma AV, Wei JT, Dunn RL, et al. Comparison of lower urinary tract symptom severity and associated bother between community-dwelling black and white men: the Olmsted County Study of Urinary Symptoms and Health Status and the Flint Men’s Health Study. Urology 2003; 61:1086–91. 3. Pinnock C, Marshall VR. Troublesome lower urinary tract symptoms in the community: a prevalence study. Med J Aust 1997;167:72–5. 4. Temml C, Brossner C, Schatzl G, et al. Prostate Study Group of the Austrian Society of Urology. The natural history of lower urinary tract symptoms over five years. Eur Urol 2003;43:374–80. 5. Haidinger G, Temmel C, Schatzl G, et al. Risk factors for lower urinary tract symptoms in elderly men. For the Prostat Study Group of the Austrian Society of Urology. Eur Urol 2000;37:413–20. 6. Sarma AV, McLaughlin JC, Jacobsen SJ, et al. Longitudinal changes in lower urinary tract symptoms among a cohort of black American men: the Flint Men’s Health Study. Urology 2004;64:959–65. 7. Li MK, Garcia LA, Rosen R. Lower urinary tract symptoms and male sexual dysfunction in Asia: a survey of ageing men from five Asian countries. BJU Int 2005;96:1339–54. 8. Taylor BC, Wilt TJ, Fink HA, et al. Prevalence, severity, and health correlates of lower urinary tract symptoms among older men: the MrOS study. Urology 2006;68:804–9. 9. Joseph MA, Harlow SD, Wei JT, et al. Risk factors for lower urinary tract symptoms in a population-based sample of African-American men. Am J Epidemiol 2003;157: 906–14. 10. Ko YC, Liu BH, Hsieh SF. Issues on aboriginal health in Taiwan. Gaoxiong Yi Xue Ke Xue Za Zhi 1994;10:337–51. 11. Chen MY, James K, Liao J. Health issues of aboriginal female adolescents in Taiwan. J Adv Nurs 2004;47:401–7. 12. Lin CF, Wang JD, Chen PH, et al. Predictors of betel quid chewing behavior and cessation patterns in Taiwan aborigines. BMC Public Health 2006;6:271. 13. Cockett A, Aso Y, Denis L, et al. Recommendation of the International Consensus Committee concerning: 1. Prostate symptom score and quality of life assessment. In: Cockett ATK, Khoury S, Aso Y, et al, eds. Proceedings of the 2nd International Consultation on Benign Prostatic Hyperplasia (BPH), 1993. Jersey: Scientific Communications International, 1994:553–5. 14. Fitzgerald MP, Litman HJ, Link CL, et al; BACH Survey Investigators. The association of nocturia with cardiac
J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
15.
16.
17.
18.
disease, diabetes, body mass index, age and diuretic use: results from the BACH survey. J Urol 2007;177:1385–9. Robertson C, Link CL, Onel E, et al. The impact of lower urinary tract symptoms and comorbidities on quality of life: the BACH and UREPIK studies. BJU Int 2007;99: 347–54. Ponholzer A, Temmel C, Obermayr R, et al. Association between lower urinary tract symptoms and erectile dysfunction. Urology 2004;64:772–6. Irwin DE, Milson I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006;50:1306–14. Homma Y, Yamaguchi O, Hayashi K; Neurogenic Bladder Society Committee. Epidemiologic survey of lower urinary tract symptoms in Japan. Urology 2006;68:560–4.
J Formos Med Assoc | 2008 • Vol 107 • No 9
19. Yu HJ, Chen TH, Chie WC, et al. Prevalence and associated factors of nocturia among adult residents of the Matsu area of Taiwan. J Formos Med Assoc 2005;104:444–7. 20. Yu HJ, Chen FY, Huang PC, et al. Impact of nocturia on symptom-specific quality of life among community-dwelling adults aged 40 years and older. Urology 2006;67:713–8. 21. Wong SY, Hong A, Leung J, et al. Lower urinary tract symptoms and depressive symptoms in elderly men. J Affect Disord 2006;96:83–8. 22. Yu HJ, Liu CY, Lee KL, et al. Overactive bladder syndrome among community-dwelling adults in Taiwan: prevalence, correlates, perception, and treatment seeking. Urol Int 2006;77:327–33. 23. Moorthy P, Lapitan MC, Quek PL, et al. Prevalence of overactive bladder in Asian men: an epidemiological survey. BJU Int 2004;93:528–31.
735
Prevalence of Lower Urinary Tract Symptoms in Male Aborigines and Non-aborigines in Eastern Taiwan Hann-Chorng Kuo* Background/Purpose: Lower urinary tract symptoms (LUTS) are highly prevalent in men. The relationship of LUTS with socioeconomic level has not been investigated in Asian people. This study investigated the prevalence of LUTS in men and between aborigines and non-aborigines in eastern Taiwan, and their association with demographic, socioeconomic and behavioral characteristics. Methods: A survey of LUTS in adult male community residents of Hualien district was conducted in 2006. LUTS were assessed using questionnaires for the International Prostate Symptom Score (IPSS) and Quality of Life Index (QoL-I). The prevalence of each bothersome LUTS, moderate LUTS (IPSS > 8) and impaired QoL (QoL-I > 4) were compared between aborigines and non-aborigines. The association between the prevalence of LUTS and socioeconomic status was also compared between the two groups. Results: There were 196 aborigines (32%) and 419 non-aborigines (68%) who completed the questionnaires. Nocturia was the most common LUTS in aboriginal and non-aboriginal men. The prevalence of moderate LUTS increased with age (p < 0.001) in men overall. Significantly higher prevalence rates of frequency (11.7% vs. 7.2%, p = 0.044) and nocturia (31.1% vs. 19.8%, p = 0.002) were found in aborigines than non-aborigines. However, there was no significant difference in the prevalence of moderate LUTS (12.8% vs. 8.8%, p = 0.220) or impaired QoL (24.3% vs. 19.9%, p = 0.088) between aborigines and nonaborigines. The higher prevalence of frequency and nocturia in aborigines was associated with significantly lower educational and economic levels, which were also associated with a higher prevalence of alcohol drinking, betel quid chewing and cigarette smoking. Conclusion: Nocturia was the most common LUTS in community dwelling aboriginal and non-aboriginal adult males. A low socioeconomic level was associated with a higher prevalence rate of moderate LUTS and impaired QoL, especially in aborigines. [J Formos Med Assoc 2008;107(9):728–735] Key Words: aborigines, epidemiology, lower urinary tract symptoms
Lower urinary tract symptoms (LUTS) are highly prevalent in men. The overall prevalence of LUTS is estimated to be 18.7–40% and increases with age, but it does not differ by sex or race/ethnicity.1,2 In men over 65 years old, the prevalence of one or more troublesome LUTS that affect daily life is estimated to be 48%.3 A 5-year longitudinal study
of men over 45 years old has found that LUTS showed no change in 19%, worsened in 50%, and improved in 31%.4 The most important risk factor for the development of LUTS is age, and there is also a trend for a higher International Prostate Symptom Score (IPSS) in men with elevated blood pressure and large waist size.5 A longitudinal study ©2008 Elsevier & Formosan Medical Association
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Department of Urology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan. Received: January 6, 2008 Revised: March 16, 2008 Accepted: March 25, 2008
728
*Correspondence to: Dr Hann-Chorng Kuo, Department of Urology, Buddhist Tzu Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan. E-mail: [email protected]
J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
of black American men has found that about 25% of those older than 60 years have a measurable progression in LUTS severity over time.6 Most previous epidemiologic studies of LUTS have been performed in Western countries. The reported prevalence rates of 14–59% in Asian countries are similar to those in Western countries.7 Few studies of LUTS prevalence have been performed in aborigines and other minority populations. The prevalence, severity and dissatisfaction with LUTS increases with age and severity is associated with poorer health in old people.8 The racial disparity found in the prevalence rate of LUTS may be caused by sociocultural differences in reporting symptom morbidity.2 In an American study, black men had a higher prevalence rate of LUTS but were less bothered by these symptoms compared with white men.2 However, high income was inversely associated with LUTS and with obstructive and irritative symptoms in African-American men.9 The causes of this disparity might include lower levels of alertness to LUTS and less impact from LUTS on quality of life (QoL) in people from lower socioeconomic groups. In Taiwan, there are nine main aboriginal tribes that comprise approximately one seventh of the total population. In general, their health status, evaluated by life expectancy, mortality rate and prevalence and incidence of various diseases, is worse than that of the rest of the general Taiwanese population.10 In the Hualien district of eastern Taiwan, aborigines and non-aborigines live together in a proportion of about one to three. The educational, socioeconomic and living environments are quite different between aborigines and non-aborigines. Aborigines have a lower education level, lower family income and live in rural or mountainous areas. Previous studies have shown that the general health status of aboriginal adolescents is inferior to that of nonaborigines.11 The lifestyles of aborigines are also quite different from that of non-aborigines. The prevalence rate of betel quid chewing is 46.1% in aborigines. Betel quid chewing is closely associated with obesity, alcohol consumption and cigarette smoking.12 J Formos Med Assoc | 2008 • Vol 107 • No 9
This prospective study was conducted to investigate the prevalence of LUTS in aborigines and non-aborigines in eastern Taiwan (Hualien district). In addition, the prevalence of LUTS and their association with education level, family income and other characteristics, including physical exercise, alcohol consumption, betel quid chewing and cigarette smoking were also investigated. The results of this study may provide useful information about the prevalence of LUTS in different ethnic populations living in the same district.
Methods A survey of LUTS in community dwelling adult males in Hualien district was conducted in 2006. Individuals without previous or current urologic diseases were randomly selected and interviewed using structured questionnaires for LUTS. The proportion of aboriginal and non-aboriginal subjects enrolled was based on the proportion of residents from these groups in the Hualien district. Data collected included age, body weight, body height, education level, family income, betel quid chewing, alcohol consumption, cigarette smoking, and physical exercise. The history of LUTS treatment and intention to seek treatment were also recorded. All study subjects were classified according to their socioeconomic levels and behavioral patterns. Men with an educational level of up to senior high school were considered to have a low educational level. Family income of less than NT$30,000 per month (equivalent to the monthly income of a hard working college graduate) was considered as a low income. Men with alcohol consumption equivalent to more than one can of beer per day, chewing more than 10 betel quids per day, cigarette smoking of more than 10 pieces per day were considered as having a habit. Subjects were considered to have frequent physical exercise if they performed at least one physical activity (jogging, running, biking, mountain climbing) per week. 729
H.C. Kuo
Table 1. Demographic characteristics of aborigines and non-aborigines* Aborigines (n = 196)
Non-aborigines (n = 419)
p
48 ± 25 170 ± 15.5 71 ± 10.5 56 (28.6) 74 (37.8) 81 (41.3) 68 (34.7) 161 (82.1) 138 (70.4)
53 ± 23 163 ± 13.1 69.5 ± 8.4 37 (8.8) 76 (18.1) 123 (29.4) 185 (44.2) 215 (51.3) 184 (43.9)
0.163 0.004 0.154 < 0.001 < 0.001 0.002 0.016 < 0.001 < 0.001
Age (yr) Body height (cm) Body weight (kg) Betel quid chewing Alcohol consumption Cigarette smoking Physical exercise Education (up to senior high school) Family income (≤ NT$30,000/mo) *Data presented as mean ± standard deviation or n (%).
The LUTS assessment was based on the questionnaires of the IPSS and Quality of Life Index (QoL-I). Seven items on storage and empty symptoms were graded from 0 to 5, which represented non-symptomatic to very frequently encountered symptoms. QoL-I was graded from 0 to 6, which represented the subject’s characterization of none to major concern about their LUTS.13 Only grades of > 3 for the individual LUTS were considered as bothersome and clinically relevant. IPSS was measured and a score > 8 was considered to indicate moderate LUTS. A QoL-I > 4 was considered to indicate a significantly impaired QoL. Data obtained from interviewer and self-administered questionnaires were stratified by 20-year age groups. The prevalence of each bothersome LUTS, an IPSS > 8, or QoL-I > 4 was also compared between male aborigines and non-aborigines. The correlation of age with LUTS, IPSS and QoL-I was calculated and compared between aborigines and non-aborigines. Finally, the association of individual LUTS, IPSS > 8 and QoL-I > 4 with educational level, family income and other characteristics were compared between the two groups. The χ2 test and Pearson’s correlation were used for statistical analysis. A value of p < 0.05 was considered statistically significant.
Results A total of 675 male residents were randomly selected for interview. After excluding men with 730
previous prostatectomy, treatment for pre-existing urologic disease, or prostate cancer, 615 (91%) participants completed the structured intervieweradministered questionnaire. There were 196 aborigines (32%) and 419 non-aborigines (68%) who completed the questionnaires. The mean age of these subjects was 48 ± 25 years and 53 ± 23 years for the aborigines and non-aborigines, respectively. Non-aborigines had a higher body height than aborigines but the body weight was similar in the two groups. Aborigines had a higher prevalence of alcohol consumption, betel quid chewing, cigarette smoking, lower educational level, lower economic level, and less frequent physical exercise than non-aborigines (Table 1). In the overall group, the most prevalent symptom was nocturia (23.4%), followed by frequency (8.6%), residual urine sensation (8.5%), intermittency (7.6%), slow stream (5.2%), straining to void (4.2%) and urgency (3.6%). Moderate LUTS (IPSS > 8) was noted in 10.1% of subjects in the overall group and an impaired QoL (QoL-I > 4) in 22.9%. The prevalence rates of individual bothersome LUTS, moderate LUTS and impaired QoL in aborigines and non-aborigines are shown in the Figure. Significantly higher prevalence rates of frequency (11.7% vs. 7.2%, p = 0.044) and nocturia (31.1% vs. 19.8%, p = 0.002) were found in aborigines than non-aborigines. However, there was no significant difference in the prevalence of moderate LUTS or impaired QoL between aborigines and non-aborigines. J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
p = 0.002 31.1
35 Non-aborigines Aborigines
30
p = 0.088 24.3
Percentage
25 19.8
20 15 10
p = 0.220 12.8
p = 0.044 p = 0.181 10.2 7.6
11.7 7.2
p = 0.204 9.2 6.9
p = 0.146 p = 0.400 6.0 4.1 3.6 3.3
5
19.9
8.8 p = 0.546 4.3 4.1
≥ oL -I Q
IP
SS
≥
4
8
ria tu oc N
re st ow Sl
St r to aini vo ng id
am
y nc ge Ur
Re
sid se ual ns ur at in io e n Fr eq ue nc y In te rm itt en cy
0
Figure. Prevalence of bothersome lower urinary tract symptoms (LUTS), moderate LUTS (IPSS > 8) and impaired quality of life (QoL-I > 4) in male aborigines and non-aborigines.
In the overall 615 men, moderate LUTS were found in five (4.4%), 20 (8.1%), 23 (11.4%) and 14 (26%) of men aged < 30, 30–50, 51–70 and > 70 years old, respectively. The prevalence of moderate LUTS increased with age (p < 0.001) in men overall. The prevalence of moderate LUTS significantly increased with age in non-aborigines and had an increasing trend in aborigines. The prevalence of individual LUTS increased with age in non-aborigines but not in aborigines, except for nocturia, which increased with age in both groups. Although impaired QoL was found in 22.9% of the overall group, there was no association between impaired QoL and increasing age in either the aboriginal or non-aboriginal group (Table 2). Table 3 shows the association of alcohol consumption, betel quid chewing, cigarette smoking and social economic differences with the prevalence of LUTS in aborigines and non-aborigines. Aborigines with the habits of alcohol consumption, betel quid chewing and cigarette smoking had a significantly higher prevalence of symptoms of intermittency, residual urine sensation, nocturia, moderate LUTS and impaired QoL than J Formos Med Assoc | 2008 • Vol 107 • No 9
non-aborigines with the same substance use patterns. In the overall group, lower educational level was significantly associated with a higher prevalence of moderate LUTS (p < 0.001), frequency (p < 0.001), intermittency (p < 0.001), urgency (p = 0.006), slow stream (p = 0.005), straining to void (p = 0.001), and nocturia (p < 0.001). Lower educational level was associated with a significantly higher prevalence of frequency, nocturia, moderate LUTS and impaired QoL in aborigines than in non-aborigines. In the overall group, only the prevalence rates of urgency (p = 0.024) and nocturia (p < 0.001) were significantly associated with a lower economic level. A lower family income was associated with a higher prevalence of urgency (5.6% vs. 1.4%, p = 0.004) and nocturia (31.4% vs. 14.7%, p < 0.001) than a higher income was. Aborigines with a lower family income had a higher prevalence of daytime frequency, nocturia and impaired QoL than non-aborigines with a lower family income, while the prevalence of other LUTS in these groups was not associated with differences in income. 731
H.C. Kuo
Table 2. Age-related lower urinary tract symptoms presentation in aborigines and non-aborigines* Age (yr) < 30
30–50
51–70
> 70
p
Frequency
A NA
5 (11.6) 1 (1.4)
8 (10.5) 11 (6.5)
10 (14.7) 8 (6.0)
0 10 (22.2)
0.597 < 0.001
Urgency
A NA
2 (4.7) 0
3 (3.9) 0
3 (4.4) 6 (4.5)
0 8 (17.8)
0.932 > 0.001
Intermittency
A NA
3 (7.0) 0
7 (9.2) 8 (4.7)
7 (10.3) 11 (8.2)
1 (11.1) 10 (22.2)
0.942 < 0.001
Slow stream
A NA
2 (4.7) 0
2 (2.6) 4 (2.4)
3 (4.4) 10 (7.5)
0 11 (24.4)
0.845 < 0.001
Straining to void
A NA
2 (4.7) 0
2 (2.6) 4 (2.4)
2 (2.9) 7 (5.2)
2 (22.2) 7 (15.6)
0.041 < 0.001
Residual urine sensation
A NA
4 (9.3) 2 (2.9)
5 (6.6) 9 (5.3)
11 (16.2) 11 (8.2)
0 10 (22.2)
0.187 0.001
Nocturia
A NA
6 (14.0) 4 (5.7)
22 (28.9) 17 (10.0)
30 (44.1) 37 (27.6)
3 (33.3) 25 (55.6)
0.050 < 0.001
IPSS > 8
A NA
4 (9.3) 1 (1.4)
9 (11.8) 11 (6.5)
10 (14.7) 13 (9.7)
2 (22.2) 12 (26.6)
0.688 < 0.001
QoL-I > 4
A NA
9 (20.9) 19 (27.1)
13 (17.1) 41 (24.1)
16 (23.5) 30 (22.4)
1 (11.1) 12 (26.7)
0.706 0.870
*Data presented as n (%). A = aborigines; NA = non-aborigines; IPSS = International Prostate Symptom Score; QoL-I = Quality of Life Index.
The prevalence of alcohol consumption, betel quid chewing and cigarette smoking was significantly higher in aborigines than in non-aborigines. These behaviors were associated with a higher prevalence rate of individual LUTS, moderate LUTS and impaired QoL in the overall group. Aborigines with these substance use patterns also had higher prevalence rates of nocturia, intermittency, residual urine sensation, as well as moderate LUTS and impaired QoL than non-aborigines. Frequent physical exercise was reported by 253 men (41.1%), including 185 non-aborigines and 58 aborigines. Frequent physical exercise was inversely associated with impaired QoL (p = 0.01) in both aborigines and non-aborigines, but had no association with the prevalence of any individual LUTS or the existence of LUTS of moderate severity. Among the 62 men with moderate LUTS, 12 (19.4%) had been treated for their LUTS while 50 (80.6%) had not been treated. However, 45 732
men (72.6%) expressed a desire to receive medical treatment for their bothersome LUTS in the future.
Discussion This is believed to be the first study to investigate the prevalence of LUTS in community dwelling male aborigines and non-aborigines in eastern Taiwan. Aborigines had higher prevalence rates of nocturia and frequency than non-aborigines, which might be related to their significantly lower educational level, lower economic level, and association with a higher prevalence of alcohol consumption, betel quid chewing and cigarette smoking. Frequency and nocturia are the two most common reported bothersome LUTS.3 In the BACH survey of LUTS, nocturia was reported by 28.4% of people, increased with age, had a J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
Table 3. Relationship of lower urinary tract symptoms and demographics between aborigines and non-aborigines* Alcohol consumption
Betel quid chewing
Cigarette smoking
Education (up to senior high school)
Economic (≤ NT$30,000/mo)
Frequency
A NA p
9 (39.1) 4 (13.3) 0.033
7 (30.4) 1 (3.3) 0.009
10 (43.5) 6 (20) 0.062
19 (82.6) 17 (56.7) 0.042
18 (78.3) 14 (46.7) 0.019
Urgency
A NA p
3 (37.5) 2 (14.3) 0.309
3 (37.5) 0 (0) 0.036
4 (50) 3 (21.4) 0.182
7 (87.5) 9 (64.3) 0.255
6 (75) 12 (85.7) 0.456
Intermittency
A NA p
7 (38.9) 2 (6.9) 0.010
5 (27.8) 1 (3.4) 0.025
9 (50) 2 (17.2) 0.020
16 (88.9) 19 (65.5) 0.072
13 (72.2) 15 (51.7) 0.139
Slow stream
A NA p
3 (42.9) 5 (20.0) 0.224
2 (28.6) 0 (0) 0.042
5 (71.4) 5 (20) 0.019
4 (57.1) 18 (72) 0.376
4 (57.1) 14 (56) 0.649
Straining to void
A NA p
2 (25) 3 (16.7) 0.498
1 (12.5) 0 (0) 0.308
2 (25) 3 (16.7) 0.498
7 (87.5) 12 (66.7) 0.274
6 (75) 10 (55.6) 0.312
Residual urine sensation
A NA p
11 (55) 5 (15.6) 0.004
8 (40) 2 (6.3) 0.004
12 (60) 6 (18.8) 0.003
17 (85) 20 (62.5) 0.074
15 (75) 17 (53.1) 0.099
Nocturia
A NA p
25 (41) 12 (14.5) < 0.001
20 (32.8) 7 (8.4) < 0.001
28 (45.9) 25 (30.1) 0.039
56 (91.8) 58 (69.9) 0.001
51 (83.6) 50 (60.2) 0.002
IPSS > 8
A NA p
11 (44) 5 (13.5) 0.009
8 (32) 0 (0) < 0.001
14 (56) 6 (16.2) 0.001
22 (88) 24 (65) 0.038
19 (76) 21 (57) 0.099
QoL-I > 4
A NA p
16 (41) 17 (16.7) 0.003
12 (30.8) 7 (6.9) 0.001
20 (51.3) 29 (28.4) 0.010
31 (79.5) 50 (49.0) 0.010
27 (69.2) 45 (44.1) 0.006
*Data presented as n (%). A = aborigines; NA = non-aborigines; IPSS = International Prostate Symptom Score; QoL-I = Quality of Life Index.
higher prevalence in the minority population, and was associated with increasing body mass index, type II diabetes and cardiac disease.14 A recent study showed that increasingly severe LUTS was associated with a low QoL.15 Another study has found that the prevalence of LUTS and erectile dysfunction (ED) significantly increased with age, and the presence of LUTS and QoL impairment due to LUTS was an independent risk factor for the presence of ED.16 Nocturia was the most prevalent LUTS in this study. This result is in accordance with previous LUTS surveys in Europe and Japan.17,18 Yu et al J Formos Med Assoc | 2008 • Vol 107 • No 9
also reported a high prevalence rate of nocturia in Taiwanese people, and found that nocturia had a more significant QoL impact when the patient had two or more episodes per night. Men experience a greater impact from nocturia than women, particularly in the bother/concern domain.19,20 Nocturia has multiple attributable factors and increases with age. In this study, we found that alcohol consumption, betel quid chewing and cigarette smoking were all associated with a higher prevalence of nocturia. Aborigines in Taiwan usually have these three substance use habits together. Men with these habits might have 733
H.C. Kuo
increased water intake that results in diuresis, which might lead to a high urine output at night and cause nocturia. Low educational and economic levels were associated with the prevalence of moderate LUTS and impaired QoL, which suggests that low socioeconomic level in men might have an effect on sensory disorders of the urinary tract. A previous study has shown that moderate to severe LUTS is significantly associated with increased odds of having clinically relevant depressive symptoms.21 Individuals with low socioeconomic and educational levels, as in the aborigines in our study, are at increased risk of depressive illness. In Taiwan, aborigines have a lower health status than non-aborigines because of a lack of local hospital and medical consultation in their area of residence. The high prevalence rates of nocturia and moderate LUTS might also reflect a higher prevalence of depressive symptoms in this minority population. This community survey included only men without previous urological disease, and only a symptom score of > 3 was defined as a bothersome LUTS. The low prevalence rate of urgency (3.6%) indicated that the prevalence of bothersome overactive bladder in these community dwelling adult males was not as high as previously reported.22,23 Meanwhile, the low prevalence rates of slow stream (5.2%) and straining to void (4.2%) suggested that the prevalence of LUTS caused by benign prostatic hyperplasia was also low. As in previous reports from Asian countries,18,23 most of the men with moderate LUTS in the present study did not seek medical treatment, although they felt an impaired QoL because of bothersome LUTS. This suggests the need for more health education in this community. Nocturia was the most common symptom in community dwelling aborigines and nonaborigines in Taiwan. The prevalence of LUTS increased with age in the overall group and in both aborigines and non-aborigines. A low socioeconomic level was associated with higher prevalence rate of moderate LUTS and impaired QoL, especially in aborigines. 734
References 1. Kupelian V, Wei JT, O’Leary MP, et al. Prevalence of lower urinary tract symptoms and effect on quality of life in a racially and ethnically diverse random sample: the Boston Area Community Health (BACH) Survey. Arch Intern Med 2006;166:2381–7. 2. Sarma AV, Wei JT, Dunn RL, et al. Comparison of lower urinary tract symptom severity and associated bother between community-dwelling black and white men: the Olmsted County Study of Urinary Symptoms and Health Status and the Flint Men’s Health Study. Urology 2003; 61:1086–91. 3. Pinnock C, Marshall VR. Troublesome lower urinary tract symptoms in the community: a prevalence study. Med J Aust 1997;167:72–5. 4. Temml C, Brossner C, Schatzl G, et al. Prostate Study Group of the Austrian Society of Urology. The natural history of lower urinary tract symptoms over five years. Eur Urol 2003;43:374–80. 5. Haidinger G, Temmel C, Schatzl G, et al. Risk factors for lower urinary tract symptoms in elderly men. For the Prostat Study Group of the Austrian Society of Urology. Eur Urol 2000;37:413–20. 6. Sarma AV, McLaughlin JC, Jacobsen SJ, et al. Longitudinal changes in lower urinary tract symptoms among a cohort of black American men: the Flint Men’s Health Study. Urology 2004;64:959–65. 7. Li MK, Garcia LA, Rosen R. Lower urinary tract symptoms and male sexual dysfunction in Asia: a survey of ageing men from five Asian countries. BJU Int 2005;96:1339–54. 8. Taylor BC, Wilt TJ, Fink HA, et al. Prevalence, severity, and health correlates of lower urinary tract symptoms among older men: the MrOS study. Urology 2006;68:804–9. 9. Joseph MA, Harlow SD, Wei JT, et al. Risk factors for lower urinary tract symptoms in a population-based sample of African-American men. Am J Epidemiol 2003;157: 906–14. 10. Ko YC, Liu BH, Hsieh SF. Issues on aboriginal health in Taiwan. Gaoxiong Yi Xue Ke Xue Za Zhi 1994;10:337–51. 11. Chen MY, James K, Liao J. Health issues of aboriginal female adolescents in Taiwan. J Adv Nurs 2004;47:401–7. 12. Lin CF, Wang JD, Chen PH, et al. Predictors of betel quid chewing behavior and cessation patterns in Taiwan aborigines. BMC Public Health 2006;6:271. 13. Cockett A, Aso Y, Denis L, et al. Recommendation of the International Consensus Committee concerning: 1. Prostate symptom score and quality of life assessment. In: Cockett ATK, Khoury S, Aso Y, et al, eds. Proceedings of the 2nd International Consultation on Benign Prostatic Hyperplasia (BPH), 1993. Jersey: Scientific Communications International, 1994:553–5. 14. Fitzgerald MP, Litman HJ, Link CL, et al; BACH Survey Investigators. The association of nocturia with cardiac
J Formos Med Assoc | 2008 • Vol 107 • No 9
LUTS in male aborigines
15.
16.
17.
18.
disease, diabetes, body mass index, age and diuretic use: results from the BACH survey. J Urol 2007;177:1385–9. Robertson C, Link CL, Onel E, et al. The impact of lower urinary tract symptoms and comorbidities on quality of life: the BACH and UREPIK studies. BJU Int 2007;99: 347–54. Ponholzer A, Temmel C, Obermayr R, et al. Association between lower urinary tract symptoms and erectile dysfunction. Urology 2004;64:772–6. Irwin DE, Milson I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006;50:1306–14. Homma Y, Yamaguchi O, Hayashi K; Neurogenic Bladder Society Committee. Epidemiologic survey of lower urinary tract symptoms in Japan. Urology 2006;68:560–4.
J Formos Med Assoc | 2008 • Vol 107 • No 9
19. Yu HJ, Chen TH, Chie WC, et al. Prevalence and associated factors of nocturia among adult residents of the Matsu area of Taiwan. J Formos Med Assoc 2005;104:444–7. 20. Yu HJ, Chen FY, Huang PC, et al. Impact of nocturia on symptom-specific quality of life among community-dwelling adults aged 40 years and older. Urology 2006;67:713–8. 21. Wong SY, Hong A, Leung J, et al. Lower urinary tract symptoms and depressive symptoms in elderly men. J Affect Disord 2006;96:83–8. 22. Yu HJ, Liu CY, Lee KL, et al. Overactive bladder syndrome among community-dwelling adults in Taiwan: prevalence, correlates, perception, and treatment seeking. Urol Int 2006;77:327–33. 23. Moorthy P, Lapitan MC, Quek PL, et al. Prevalence of overactive bladder in Asian men: an epidemiological survey. BJU Int 2004;93:528–31.
735