Erectile dysfunction in the community: trends over time in incidence, prevalence, GP consultation and medication use--the Krimpen study: trends in ED.

INTRODUCTION: In the general population, erectile dysfunction (ED) is surrounded by a "taboo." Epidemiologists studying this problem have to be aware of the phenomenon of the "tip-of-the-iceberg." AIMS: Our aim is to describe the iceberg phenomenon for ED and their help-seeking behavior in the general population during a period when public interest in ED heightened and waned after the introduction of the drug sildenafil. METHODS: The data were obtained as part of a large longitudinal community-based study, i.e., the Krimpen study. With four rounds of data collection with an approximate 2.1 years interval, the local pharmacists provided data on medication use, whereas abstracts from the medical record and history were provided by the local general practitioners (GPs). The data from the questionnaires were entered into the Krimpen study database but were not communicated to the GPs. MAIN OUTCOME MEASURES: ED: according to the ICS-questionnaire, GP consultation: search of electronic medical dossier for ED or reports from any specialist, use of ED medication as delivered by the pharmacy. RESULTS: The age-standardized prevalence of ED is stable, i.e., around 40%. During the period 1995 to 2000, the incidence increased from 5% to 6.5%, then it stabilizes around 5% per year. The first-time use of ED medication increases exponentially between 1995 and 2000, then it stabilizes at about 3.5% per year. The number of GP consultations by men with ED increases up to 1999, after which it stabilizes at about 1.8% per year. CONCLUSION: We suggest that the availability and awareness of a new pharmacological option induced a change of behavior among GPs and their patients.

No clear association between female hormonal aspects and osteoarthritis of the hand, hip and knee: a systematic review.

OBJECTIVE: Incidence of OA rises steeply in women of age >50 years; the climacteric period for women. The simultaneous occurrence of these events suggests an association between OA and changes in female hormonal aspects. This systematic review studies the assumed association between OA and aspects concerning the fertile period (duration, endogenous hormones, age at menarche/menopause) and the menopause [menopausal status, years since menopause (YSM) and surgical menopause]. METHODS: Medline and EMBASE were searched for articles assessing associations between hand/hip/knee OA and female hormonal aspects. Methodological quality was assessed systematically, and results were summarized in a best-evidence synthesis. RESULTS: Sixteen studies were included in the present study. For most hormonal aspects no association was found. Conflicting evidence was found for an association of age at menarche with Herberden's nodes (HNs) and hand ROA, YSM with knee ROA and ovariectomy with hip OA. An increased risk was seen for low estradiol serum levels in the early follicular phase with incident knee ROA, age at menarche being < or =11 years old with total hip replacement, being post-menopausal and YSM with the presence of HN. A protective effect was seen for age at menopause being > or =52 years with total knee replacement. Evidence level was limited for all. CONCLUSIONS: The assumed relationship between the female hormonal aspects and OA was not clearly observed in this review. The relationship is perhaps too complex, or other aspects, yet to be determined, play a role in the increased incidence in women aged >50 years.

Risk factors for deterioration of erectile function: the Krimpen study.

This report from the Krimpen study explored the relationship between the determinants for worsening of erectile function in the open population. In Krimpen aan den IJssel (a municipality near Rotterdam), all men aged 50-75 years, without cancer of the prostate or the bladder and without a history of radical prostatectomy or neurogenic bladder disease, were invited to participate in June 1995. The response rate was 50%. The follow-up was until June 2004. At baseline a visit to a health centre for the measurement of urinalysis, height, weight and blood pressure was part of the ongoing study. During baseline and at the first follow-up, second follow-up and third follow-up, a self-administered booklet consisting of a compilation of validated questionnaires including the International Continence Society male sex questionnaire was completed. At the urology outpatient clinic, a urological workup was measured. All participants were asked to keep a frequency-volume chart for 3 days. A multivariate Cox-proportional hazard model was constructed to find the determinants of worsening of erectile function, correcting for age. Total follow-up time was 4948 person years consisting of 975 men. During follow-up, 441 events of worsening of erectile function occurred. Multivariate Cox-proportional hazard ratio analyses showed that body mass index (BMI), irritative lower urinary tract symptoms, diabetes mellitus, chronic obstructive pulmonary disease (COPD) and sexual inactivity were determinants with significant hazard ratios. In addition to age, determinants for a deterioration of erectile function based on multivariate longitudinal analyses are BMI, diabetes mellitus, COPD, sexual inactivity and irritative IPSS. The mechanism of various determinants is discussed.

The long-term relationship between a real change in prostate volume and a significant change in lower urinary tract symptom severity in population-based men: the Krimpen study.

OBJECTIVE: We used the database of a longitudinal community-based study to investigate whether real changes in prostate volume (PV) (ie, changes greater than the combination of intra- and interobserver variation of volume measurement) corresponded with significant changes in symptom severity. METHODS: In a community-based study of men aged 50-78 yr, the International Prostate Symptom Score (IPSS) and PV were measured at baseline and at 4.2-yr follow-up. Of 1417 men, 864 completed both rounds. A significant change in IPSS was defined as a change of > or = 4 points. A real change in PV was defined as a percent change of > or = 26%, or an absolute change of > or = 10 cc. RESULTS: After 4.2 yr, about 20% of the men had experienced a significant increase in IPSS and 16-23% had a real increase in PV. The age-adjusted odds ratio for a significant increase in symptom severity, which contrasts men who have a real increase in PV and men who do not show such an increase, is 1.38 (95%CI, 1.05-1.85]. The age-adjusted odds ratio for a significant decrease in symptom severity, which contrasts men with a real increase in PV and those without such an increase, is 1.50 (95%CI, 1.11-2.85). CONCLUSIONS: Benign prostatic hyperplasia can be characterised as a progressive disease in a certain proportion of men older than 50 yr. Men with growing prostates are at a greater risk of symptomatic deterioration. Men who have prostates that do not grow significantly are more likely to improve symptomatically.

Influence of coping styles on quality of life in men with new and increasing lower urinary tract symptoms. The Krimpen Study in community-dwelling men.

OBJECTIVE: The present study aims to determine the influence of coping on quality of life (QOL) in elderly men developing lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: Longitudinal population-based study with a follow-up period of 6.5 years on 1,688 men aged 50-78 years. Data were collected through self-administered questionnaires, including the Sickness Impact Profile (SIP, three domains), Inventory of Subjective Health (ISH), International Prostate Symptom Score (IPSS), and the Utrecht Coping List (UCL). Various physical and urological measurements were completed. Multiple linear regressions were used to determine the change in QOL in men with incident LUTS in relation to coping behavior. RESULTS: Overall no significant association is found between changes in LUTS with a change in QOL. However, a positive change in QOL is significantly associated with a change in LUTS when men use the coping style active problem solving and a negative relation exists with coping style reassuring thoughts. CONCLUSION: Different coping styles have a different impact on the relation between a change in LUTS and a change in generic QOL in community-dwelling elderly men. This makes a future exploration of the clinical treatment possibilities warranted.

Simple case definition of clinical benign prostatic hyperplasia, based on International Prostate Symptom Score, predicts general practitioner consultation rates.

OBJECTIVES: To determine which case-definition of clinical benign prostatic hyperplasia (BPH) has the best predictive value for general practitioner visits for lower urinary tract symptoms (LUTS) suggestive of BPH. The incidence and prevalence rates of general practitioner visits for LUTS were also determined. METHODS: A longitudinal, population-based study from 1995 to 2003 was conducted among 1688 men aged 50 to 78 years old. Data were collected on physical urologic parameters, quality of life, and symptom severity as determined from the International Prostate Symptom Score. Information on health-care-seeking behavior of all participants was collected from the general practitioner (GP) record using a computerized search engine and an additional manual check of the electronically selected files. RESULTS: The incidence and prevalence rate of the men at risk was 19.6% and 14.0%, respectively, and these rates increased with age. For sensitivity and the positive predictive value, the case-definition of clinical BPH as an International Prostate Symptom Score greater than 7 had the best predictive value for GP visits for LUTS within 2 years after baseline. CONCLUSIONS: Because only marginal improvement (greater specificity but lower sensitivity) in the prediction of GP visits for LUTS was possible by adding information on prostate volume and flow, for the prediction of future GP visits for LUTS suggestive of BPH, we suggest that the International Prostate Symptom Score questionnaire be used and that estimation of the prostate volume and flow is not required.

Patient's quality of life and coping style influence general practitioner's management in men with lower urinary tract symptoms: the Krimpen Study.

PURPOSE: To identify patient characteristics associated with general practitioner's (GP) initial treatment decision in men with lower urinary tract symptoms (LUTS) and to test the hypothesis that a different coping style of patients results in different GP behaviour regarding treatment. MATERIALS AND METHODS: A longitudinal, population-based study with a follow-up period of 6.5 years was conducted among 1688 men aged 50-78 years old. Data were collected on quality of life, symptom severity based on the International prostate symptom score (IPSS) and coping. Information on primary care seeking and GP's initial management during 2 years of follow-up of all participants was collected from the general practitioners record. RESULTS: Data were obtained of 68 men, without a history of LUTS, who had a first GP visit for LUTS during the study period. In 54.4% of the cases the GP prescribed medication, independent of symptom severity. In the group of men with a bad disease-specific QOL those with a high passive-reaction-pattern were treated less frequently than those with a low passive-reaction-pattern. CONCLUSION: Findings from this quantitative study are consistent with the hypothesis that different coping styles of patients may result in different GP behaviour regarding treatment. The use of the coping style passive-reaction-pattern has a large influence on GP's initial management in men with LUTS.

Determinants of seeking of primary care for lower urinary tract symptoms: the Krimpen study in community-dwelling men.

OBJECTIVES: To determine which factors predict seeking of primary care among men with lower urinary tract symptoms (LUTS). METHODS: A longitudinal, population-based study with a follow-up period of 6.5 yr was conducted among 1688 men aged 50-78 yr. The following data were collected: prostate volume (using transrectal ultrasonometry), urinary flow rate, ultrasound-estimated postvoid residual urine volume, generic and disease-specific quality of life (QOL), and symptom severity (International Prostate Symptom Score [IPSS]). Information on the seeking of primary care by all participants during 2 yr of follow-up was collected from the general practitioner's (GP) record using a computerised search engine and a manual check of electronically selected files. RESULTS: Prostate volume, postvoid residual volume, IPSS, and social generic QOL are important determinants of first GP consultation in men with LUTS. Measurements (physical urologic parameters) and self-reported items (symptom severity and QOL) contribute almost equally to GP consultation in these men. CONCLUSIONS: Both measurements of prostate volume and postvoid residual urine volume and self-reported information about symptoms or QOL can help to select those who will benefit from medical care and to reassure those men not likely to need help in the near future.

Changes in disease specific and generic quality of life related to changes in lower urinary tract symptoms: the Krimpen study.

PURPOSE: We determined if and to what extent longitudinal changes in lower urinary tract symptoms are related to disease specific and generic quality of life in men. MATERIAL AND METHODS: A longitudinal, population based study with a followup of 4.2 years was done in 1,688 who were 50 to 79 years old. Data were collected through self-administered questionnaires, including the Sickness Impact Profile (3 domains), Inventory of Subjective Health, International Prostate Symptom Score (I-PSS) and Benign Prostatic Hyperplasia Impact Index. Moreover, they completed various physical and urological measurements. Mean I-PSS and quality of life scores at baseline and followup were analyzed for certain subgroups. Multiple linear regression was used to determine the change in quality of life in relation to baseline I-PSS, I-PSS changes between baseline and followup, and age. RESULTS: Although mean I-PSS increased with time, the average generic quality of life improved and almost a third of the men reported better disease specific quality of life. Multiple linear regression revealed that disease specific quality of life was associated with I-PSS at baseline, changes in I-PSS between baseline and followup, and age. However, generic quality of life scores were not associated with these parameters. CONCLUSIONS: Changes in lower urinary tract symptoms severity had little impact on disease specific quality of life in 50 to 79-year-old men or on generic quality of life during the 4.2-year followup.

Loss to follow-up in a longitudinal study on urogenital tract symptoms in Dutch older men.

OBJECTIVE: To describe loss to follow-up (LTFU) in a longitudinal community-based study on urogenital tract dysfunction in older men. PATIENTS AND METHODS: A cohort study of men recruited from a Dutch municipality was performed. A baseline study and two follow-up rounds--all with questionnaires and additional measurements--were performed with, on average, 2.1-year intervals. Baseline characteristics were compared between participants and non-participants in the first and in the second follow-up study. RESULTS: The response rates in the first and in the second follow-up were 78.0 and 80.0%, respectively. Various characteristics were found to be related to LTFU (i.e., more than 5% difference in response rate). Lower urinary tract symptoms were related to LTFU in the first and second follow-up. Sexual dysfunction was related to LTFU only in the second follow-up. Adjustment for confounders yielded odds ratios for the primary outcome variables (lower urinary tract symptoms, sexual dysfunction, and health status) that approximated the value of 1. LTFU according to these variables was different in men with and without other chronic illnesses. CONCLUSIONS: LTFU seems not to be related to the primary outcome variables in this study. Describing response patterns in longitudinal studies is important, especially in studies involving older participants, as often is the case in urological research.

Relation between nocturnal voiding frequency and nocturnal urine production in older men:a population-based study.

OBJECTIVES: To describe the normal values for nocturnal urine production and its determinants, as well as the relation between nocturnal urine production and voiding frequency. METHODS: Data were collected from 1688 men aged 50 to 78 years without bladder or prostate cancer, radical prostatectomy, neurogenic bladder dysfunction, or negative advice from their general practitioner. Measurements included self-administered questionnaires, a 3-day frequency-volume chart, transrectal ultrasonography of the prostate, uroflowmetry, and postvoid residual urine volume measurement. The mean nocturnal urine production was computed from the frequency-volume charts. Linear regression analyses were performed to determine associated factors for nocturnal urine production. Areas under the receiver operating characteristic curves were used to describe the discriminative value of nocturnal urine production on nocturnal voiding frequency. A cutoff value for "increased" nocturnal urine production was defined using logistic regression analysis. RESULTS: The nocturnal urine production was 60.6 mL/hr for the total study population; it increased with age and was significantly higher in men with 24-hour polyuria. Nocturnal urine production was on average higher in men with increased nocturnal voiding frequency, but had only a reasonable discriminative value on nocturnal voiding frequency (areas under receiver operating characteristic curve of 0.71 and 0.76). Nocturnal urine production exceeding 90 mL/hr is suggested as abnormal. CONCLUSIONS: On average, nocturnal voiding frequency is indicative of nocturnal urine production. However, nocturnal urine production is only a modest discriminator for increased nocturnal voiding frequency. Therefore, the use of nocturnal urine production as an explanatory variable for nocturnal voiding frequency in daily practice is of little value.

Normal values and determinants of circadian urine production in older men: a population based study.

PURPOSE: We evaluated circadian urine production and its determinants in a large population based sample of older men. MATERIALS AND METHODS: We collected data on 1,688 men 50 to 78 years old, without radical prostatectomy, prostate or bladder cancer, neurogenic bladder disease or negative advice from their general practitioner, recruited from the population of Krimpen, the Netherlands. Measurements consisted of self-administered questionnaires, including the International Prostate Symptom Score, a 3-day frequency-volume chart, transrectal prostatic ultrasound, uroflowmetry and post-void residual volume. Hourly urine production was determined and urine production day-to-night ratio was calculated from the frequency-volume chart. RESULTS: Men younger than 65 years showed a clear circadian urine production pattern, whereas in older men this pattern was less clear. Smoking, use of diuretic drugs, post-void residual and 24-hour polyuria reinforced the circadian pattern, in favor of daytime urine production. The urine production day-to-night ratio was not associated with prostate enlargement, reduced urinary flow rate, body weight, hypertension, cardiac symptoms, diabetes mellitus, use of antidepressants, cardiac or hypnotic drugs. CONCLUSIONS: Urine production in men younger than 65 years showed a clear circadian pattern in contrast to men older than 65 years. These data can be used as a reference when describing urine production patterns in select populations. In daily practice frequency-volume charts can be used to determine urine production. This method is inexpensive, easy to use and provides valid information on urine production in a natural environment.

Health status and its correlates among Dutch community-dwelling older men with and without lower urogenital tract dysfunction.

OBJECTIVE: To study health status and its correlates in older men with and without lower urogenital tract dysfunction. METHODS: Cross-sectional population-based study on 1688 men aged 50-78 years without bladder or prostate cancer, radical prostatectomy, neurogenic bladder dysfunction or a negative advice from their general practitioner. Data were collected through self-administered questionnaires, including Sickness Impact Profile (SIP, three domains), Inventory of Subjective Health (ISH), International Prostate Symptom Score (IPSS) and International Continence Society (ICS) Male Sex questionnaire, medication use, socio-economic and lifestyle factors. Additional information was collected by measurement of blood pressure, transrectal ultrasonography of the prostate and uroflowmetry. Four health status domains were analyzed using the ISH and three domains of the SIP. Lower urinary tract symptoms (LUTS) were categorised using IPSS, erectile and ejaculatory dysfunction were defined using the ICS questionnaire. RESULTS: All urogenital characteristics and parameters were related to at least two of the health status domains. Multivariate regression analyses yielded that LUTS and cardiac symptoms were associated with suboptimal scores of all four domains. Chronic obstructive pulmonary disease and drugs for abdominal symptoms were related to three domains; erectile and ejaculatory dysfunction, muskuloskeletal or psycho(ana)leptic drugs and marital status to two domains. CONCLUSIONS: The impact of LUTS on health status was equally important as the impact of cardiac symptoms. The impact of sexual dysfunction was smaller than expected. Longitudinal studies are needed to determine how health status and illnesses interact.