Benign prostatic hyperplasia: effects on quality of life and impact on treatment decisions.
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Adult↗
Biomedical subjects
W M Garraway
Publications and source records attributed to W M Garraway.
Prostatism and the burden of benign prostatic hyperplasia on elderly men.
All men aged 40-79 years registered with two group general practices in Central Scotland were enumerated. Four hundred and ten men (249 in the working age group 40-64 years and 161 in retirement ages 65-79 years satisfied predetermined criteria for clinical benign prostatic hyperplasia (BPH) of prostatic weight > 20 g in the presence of urinary dysfunction and without evidence of malignancy. Despite a higher prevalence of BPH among the retirement group (428/1000) compared with men of working ages (202/1000), there were virtually no statistically significant differences between the two groups in terms of annoyance and interference in daily living activities caused by urinary dysfunction, frequency of urinary symptoms, or medical consultations for BPH. Although elderly men with BPH changed their lifestyle as a result of urinary dysfunction, only a low proportion of them disclosed their difficulties to a doctor. Increased education of the public and health care professionals about the nature and magnitude of the problem of BPH in elderly men is required.
Activities of Daily Living↗
Use of a 7-day diary for urinary symptom recording.
A cohort of 254 men, aged 40-79 years, was followed up at 1 year in a community-based survey of benign prostatic hyperplasia. Immediately after completing a questionnaire about the occurrence of 12 urinary symptoms over the previous month, the men were invited to keep a prospective diary asking about the same symptoms over 7 consecutive days in order to assess the amount of day-to-day variation in symptoms and to examine to what extent the findings reflected those of the retrospective questionnaire. The majority of men reported minor degrees of daily fluctuations in symptoms. Only modest correlations existed between the diary mean and maximum score for each symptom and the corresponding retrospective questionnaire score. Where repeated assessments of urinary symptom status are considered necessary a prospective diary may be more appropriate than a retrospective questionnaire.
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Consultation patterns in a community survey of men with benign prostatic hyperplasia.
BACKGROUND: The Stirling benign prostatic hyperplasia natural history group have previously reported a prevalence of this condition of 255 per 1000 in a community study of 1610 men aged 40-79 years. AIM: It was decided to examine the consultation patterns of men with benign prostatic hyperplasia in greater detail. METHOD: All participating men were invited to complete a previously validated lifestyle questionnaire including questions on consultations with their general practitioner during the previous year and previous history of prostatic problems. The men who had a urinary symptom score greater than 11, or who had a urinary flow rate of less than 15 ml per second were examined by transurethral ultrasonography for prostate size. RESULTS: Of 364 men with benign prostatic hyperplasia, 89% had not consulted their doctor about urinary symptoms in the year prior to the study. Men with moderate to severe urinary symptoms were six times more likely to have consulted their doctor than those with mild symptoms. Moderate to severe symptoms and greater interference with daily living activities were both associated with a greater likelihood of consultation, independent of age. Of all the men in the study referred to the specialist clinic for assessment of prostate size by transurethral ultrasonography, two thirds were referred because of low urinary flow rate and one third because of high urinary symptom scores. The reported consultation data showed a reverse ratio of one third of those consulting having a low urinary flow rate and approximately two thirds having urinary symptoms. CONCLUSION: While mass screening is unjustified, there is a need for patient education about benign prostatic hyperplasia in general and the recognition of declining strength of urinary flow as a symptom of benign prostatic hyperplasia and not of ageing alone. Furthermore, evaluation of primary care use of urinary flowmeters and the development of local protocols are suggested as elements of a case finding strategy for benign prostatic hyperplasia based on patient led consultation.
Adult↗
Impact of benign prostatic hyperplasia on general well-being of men.
Little is known about the impact of benign prostatic hyperplasia (BPH) on the general well-being of men with this condition. All men aged 40-79 years registered with a group general practice were enumerated. BPH was defined as enlargement of the prostate gland of equivalent weight > 20 g in the presence of symptoms of urinary dysfunction and/or a urinary peak flow rate < 15 ml/s, without evidence of malignancy. Four hundred and ten men (20% of those who participated) satisfied these criteria. The proportion of men with a negative feeling of well-being was higher in men with BPH than in men who did not have BPH. The difference was consistent for all aspects of well-being (anxiety, depression, self-control, vitality, being worried or being bothered by illness). Men with BPH had a higher level of bothersomeness attributed to urinary symptoms, and more interference in selected daily living activities caused by urinary dysfunction. These were related to worry or concern over urinary function and prostate cancer, together with a higher level of embarrassment caused by urinary dysfunction, compared with men who did not have BPH. Patients' feelings of well-being should be taken into account in the clinical management of BPH.
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Similar levels of urological symptoms have similar impact on Scottish and American men--although Scots report less symptoms.
Urinary symptoms and the extent to which they interfere with living activities were compared in 2 community-based investigations that enrolled men 40 to 79 years old who were randomly sampled from Olmsted County, Minnesota (2,119) and the Forth Valley of Scotland (1,385). Both investigations included symptom questions with wording that is nearly identical to that of the American Urological Association (AUA) symptom index. Following AUA scoring conventions we grouped scores into mild (AUA score 0 to 7), moderate (score 8 to 19) and severe (score 20+) categories. Minnesota men had symptoms that were more frequent, more bothersome and caused greater interference with living activities than did Scottish men of comparable age (p < 0.0002). However, within each symptom score category, the extent to which symptoms interfered with living activities was essentially the same in both populations. Although there appear to be important differences in urinary symptom prevalence between Scotland and Minnesota, the AUA symptom index provides a consistent measure of the extent to which urinary symptoms interfere with living activities in both populations. These findings support use of the AUA symptom index in the diagnostic evaluation of men with benign prostatic hyperplasia.
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Prostatic surgery for benign prostatic hyperplasia: meeting the expanding demand.
We describe changes in the pattern of surgery for benign prostatic hyperplasia (BPH) in Scotland between 1971 and 1989. The data are based on an analysis of routinely collected Scottish hospital in-patient statistics for primary prostatic operations on men with a diagnosis of BPH (ICD Code 600.0). Primary operation age-adjusted rates for BPH increased from 8.9 to 15.8 per 10,000 male population from 1971 to 1989. This was accompanied by a reduction in bed day use for BPH surgery from 49,500 bed days in 1971 to 36,000 in 1989. Case fatality for all surgery for BPH also fell steadily and can no longer be regarded as a relevant measure of prostatectomy outcome. Virtually all surgical intervention is now transurethral resection (TUR), forming 94% of surgery for BPH in 1989 compared with only 32% in 1971. The increase in surgical procedures carried out for BPH has been greater in younger age groups. If the pattern of increasing surgical intervention in the management of BPH over the past few years continues and there is an increased demand for treatment, and if the reported demographic changes occur, there will be a need for an additional 9 new consultant urologists in Scotland by 2001. Even if present operation rates hold steady, population changes alone will produce enough work for 2 more urologists.
Age Factors↗
Follow-up of a cohort of men with untreated benign prostatic hyperplasia.
A cohort of 266 men with untreated benign prostatic hyperplasia (BPH) identified in a community-based survey were followed for a period of 1 year. Although the overall prevalence of urinary symptoms increased during the year, substantial within-subject variation in urinary symptomatology occurred, with up to a quarter of men reporting urgency and dribbling to have improved whilst one third of men reported other urinary symptoms to have deteriorated. Levels of bothersomeness caused by urinary symptoms did not show much change during the period of follow-up. An overall increase of 19% in urinary peak flow which was also consistent across all age groups was present at 1 year compared with baseline, even after adjusting for increased urinary void volume. A slow progression in the extent to which interference with selected activities of daily living by urinary dysfunction occurred. This was greater in men of working age (40-64 years), compared with men of retirement age (65-79 years). A longer period of observation is required in order to determine the extent to which a consistent pattern of urinary symptomatology exists in untreated BPH, as well as whether interference with daily living activities continues to progress over time.
Activities of Daily Living↗
Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly men.
To assess the importance of benign prostatic hyperplasia on activities of daily living, a cross-sectional survey of 1627 men aged 40-79 years (representing a 65% response rate) registered with two health centres in central Scotland was carried out, using a urinary symptom questionnaire and uroflowmetry to identify men more likely to have benign prostatic hyperplasia. The condition was defined as a prostate gland of more than 20 g in the presence of symptoms of urinary dysfunction and/or a peak flow rate of less than 15 ml s-1, without evidence of malignancy. Transrectal ultrasonography was used to measure the volume (and by inference weight) of prostate glands. A total of 410 men satisfied the criteria for benign prostatic hyperplasia. Overall, 51% of men with benign prostatic hyperplasia reported interference with at least one of a number of selected activities of daily living as a result of urinary dysfunction, compared with 28% of men who did not have this condition. In 17% of men of working age (40-64 years) with benign prostatic hyperplasia, this interference occurred most or all of the time for at least one activity of daily living compared with only 3% of men in the same age group who did not have this condition. If the criteria of unmet need for treatment of benign prostatic hyperplasia constitutes interference by urinary dysfunction most or all of the time in at least one activity of daily living, then the findings of this survey suggest that a substantial number of middle aged and elderly men living in the United Kingdom may be in need of assessment and treatment for this condition.
Activities of Daily Living↗
High prevalence of benign prostatic hypertrophy in the community.
There is a strong suspicion among urologists that the prevalence of benign prostatic hyperplasia is higher than has been reported in clinical retrospective and necropsy studies. To find out the prevalence in one community all men aged 40-79 years registered with a group general practice were invited to complete a urinary symptom questionnaire and to undergo uroflowmetry. 705 men (77% of those eligible) participated. 214 men (84% of those invited) with signs and symptoms of prostatic dysfunction subsequently underwent transrectal ultrasonography (TRUS) for assessment of the volume (and by inference weight) of their prostates. The prevalence rate of benign prostatic hypertrophy (BPH), defined as enlargement of the prostate gland of equivalent weight greater than 20 g in the presence of symptoms of urinary dysfunction and/or a urinary peak flow rate less than 15 ml/s and without evidence of malignancy, was 253 (95% CI 221-285) per 1000 men in the community, rising from 138 per 1000 men aged 40-49 years to 430 per 1000 men aged 60-69 years. Thus apparently well men have a much higher frequency of BPH than was previously thought to be the case.
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The quality of health services research in medical practice in the United Kingdom.
STUDY OBJECTIVE: The aim was to determine the scope and quality of published health services research concerned with medical practice in the United Kingdom. DESIGN: Scope of health services research was reviewed in articles published in 41 medical and public health journals in 1985. In random sample of 60 papers stratified by study design, 18 key research parameters were assessed for the quality of reporting and application in the studies. MAIN RESULTS: Over 80% of the research described in 246 articles was carried out by clinicians, mostly without acknowledged epidemiological or statistical assistance. More than half the studies were descriptive and only 17% were trials. In studies of hospital services, 4% covered long term care, in contrast to 67% concerned with inpatient care. One third of studies were conducted in general practice but only 10% of these included an assessment of clinical outcome. Important research parameters were often not reported; for example, response rates were missing in 52% of the studies, and comparability of cases and controls was not stated in 42% of relevant studies. Major inadequacies were found in the conduct of research, particularly in the selection of controls, allowance for confounding factors, objectivity of measurements, application of statistical tests, and conclusions reached. CONCLUSIONS: Published health services research concerned with medical practice in the United Kingdom is often conducted by clinicians without expert assistance. The quality of reporting and methods employed are deficient in many respects. Short training courses and other initiatives are required to enhance the quality of health services research in medical practice.
Epidemiologic Methods↗
Hypertension management and stroke recurrence in a community (Rochester, Minnesota, 1950-1979).
The purposes of this study were to determine the trend in stroke recurrence over time and the effect of the prestroke blood pressure and management of hypertension on stroke recurrence in 1,680 incidence cases of stroke in residents of Rochester, Minnesota. Recurrent, primarily ischemic, stroke occurred in 267 cases. Stroke recurrence rates did not change during the 30-year period 1950-1979, in contrast to the decline in initial stroke incidence rates during this time. The overall stroke recurrence rates were less than 5%/yr, with cumulative rates of 5.7%, 19.3%, and 28.8% at 1, 5, and 10 years, respectively. Neither level of blood pressure before the first stroke nor management of hypertension had any apparent effect on stroke recurrence rates throughout the follow-up.
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The changing pattern of hypertension and the declining incidence of stroke.
We studied whether changes in recognition and control of hypertension could be detected in the population of Rochester, Minn, from 1950 to 1979, a period in which a major decrease in the incidence rate of stroke was observed. Prevalence of diastolic blood pressure greater than or equal to 105 mm Hg fell 26% and 70% in men and women, respectively, between 1950 to 1959 and 1970 to 1979. Prevalence of pressures greater than or equal to 95 mm Hg decreased 5% in men and 58% in women. Increasing control of hypertension had an almost inverse linear relationship with the decreasing incidence of stroke in women, but the incidence of stroke in men did not decrease until ten years after improvement in the control of blood pressure began. We conclude that improvements in the detection and control of hypertension contributed to the declining incidence of stroke and that differences in management of hypertension could account for the difference between men and women in the trend of stroke decline.
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Motor function after stroke.
Two hundred and eighty-seven patients who had survived an acute stroke for up to one week after admission to hospital were examined for loss of motor function in the arm and leg. There was a highly significant difference in problem-solving, spatial neglect, communication and postural function between those with significant motor loss and those without. There was no significant difference in memory impairment. Significant loss in motor power had a bad prognosis for functional outcome, length of stay in hospital and survival. If recovery was to occur, it had done so by eight weeks.
Cerebrovascular Disorders↗
Neurologic examination in stroke rehabilitation: adequacy of its description in clinical textbooks.
Medical textbooks were reviewed to establish how well they presented those aspects of examination of the nervous system which are important in stroke rehabilitation. In addition, information was sought concerning such factors as the presence of instructions for the examiner and patient, grading and interpretation of results, and the importance of observer variation which can influence results of periodic neurologic examination of stroke patients. Study results demonstrated that the description of the neurologic examination which should be used in stroke rehabilitation was often incomplete and poorly defined. Material provided little interpretation for the physical signs which might be found. Factors which might influence results of periodic examination of the nervous system in stroke patients received little attention. There is an urgent need to develop a standardized form of clinical examination to meet the needs of practitioners who assess neurologic status in stroke rehabilitation.
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Primary intracerebral hemorrhage: impact of CT on incidence.
From 1975-1979, the incidence of primary intracerebral hemorrhage (PIH) increased in Rochester, MN, when compared with a previously decreasing incidence. Judging from patients with PIH who were alert at diagnosis, we estimated that 24% of the hemorrhages in earlier years had been mislabeled as infarction. The 30-day survival rate increased from 8% in 1945-1974 to 44% in 1975-1979. The incidence rate was about 45% higher in patients receiving anticoagulant treatment than in those who did not. The increased incidence rate and improved survivorship were attributed to more frequent identification of small PIH by CT.
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The dichotomy of myocardial and cerebral infarction.
The Mayo Clinic medical record linkage and indexing system was used to examine changes in incidence and case fatality of myocardial infarction (MI), sudden unexpected death (SUD), and cerebral infarction (CI). The average annual age and sex adjusted incidence rates for MI (including SUD) and CI declined by 14% and 55%, respectively, between 1950-54 and 1975-79. The decline in the incidence of MI was due to a reduction in sudden unexpected death (SUD), greatest in younger persons. 30-day case fatality after MI declined from 50% to 35% during this period.
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