Decline of sexual function with age in Japanese men compared with American men--results of two community-based studies.

OBJECTIVES: To investigate the self-reported sexual function of Japanese men aged 40 to 79 years in a community-based study and compare the results to a similarly conducted study in Olmsted County, Minnesota. METHODS: Two hundred eighty-nine Japanese and 2115 American men from the community were queried about ability to have erections when stimulated, sexual drive, and satisfaction with sexual activity using a self-administered questionnaire. RESULTS: Both Japanese and American men showed an age-related decline in erectile function, sexual libido, and sexual satisfaction. In particular, 71% of Japanese men aged 70 to 79 years reported having erections only a little of the time or less when sexually stimulated, and 80% perceived sexual drive once per month or less during the past month. Although more Japanese than American men reported erectile dysfunction and decreased libido, there were no striking differences in self-reported sexual satisfaction between the studies. However, cultural and perceptual differences could play a role in these results, despite attempts to ensure linguistic equivalency in the questionnaires. CONCLUSIONS: Although erectile dysfunction and decreased libido were noted by a greater proportion of Japanese than American men, the self-reported degree of satisfaction was comparable between the studies. Perceptions of elderly male sexual function and its impact on health-related quality of life may differ among races, sites, and countries.

Adverse effects of medications on urinary symptoms and flow rate: a community-based study.

The relationship between urinary symptoms and medication use was investigated in a community-based cross-sectional study involving a random sample of 2115 men 40-79 years of age in Olmsted County, Minnesota. The American Urological Association Symptom Index (AUASI) was generated from a validated self-administered questionnaire. Medication use was assessed by in-person interviews. While 1087 men reported daily medication use, only 136 reported daily use of medications known to affect urinary function adversely, including antidepressants (42), antihistamines (23), and bronchodilators (43). Age-adjusted AUASI scores were higher in men reporting daily use of antidepressants, and the association persisted after additionally adjusting for the Depression and Anxiety subscales of the General Psychological Well-Being Scale (adjusted mean difference, 2.1; 95% confidence interval (CI), 0.5-3.6; p = 0.008). The adjusted AUASI was also higher among men who took antihistamines daily (adjusted mean difference, 2.3; 95% CI, 0.3-4.3; p = 0.03). Lower age-adjusted urinary flow rates occurred with antidepressants, but not with antihistamines or bronchodilators. Clinicians evaluating men for causes of voiding dysfunction in accordance with the Agency for Health Care Policy and Research practice guideline for the diagnosis and management of benign prostatic hyperplasia should be aware that daily use of antidepressants or antihistamines may be associated with AUASI scores that are two to three points higher than in men not taking these medications.

The Pine Ridge-Mayo National Aeronautics and Space Administration telemedicine project: program activities and participant reactions.

OBJECTIVE: To determine the response of participants to the Pine Ridge-Mayo National Aeronautics and Space Administration telemedicine project. DESIGN: We describe a 3-month demonstration project of medical education and clinical consultations conducted by means of satellite transmission. Postparticipation questionnaires and a postproject survey were used to assess the success of the activity. MATERIAL AND METHODS: Patients and employees at the Pine Ridge Indian Health Service Hospital in southwestern South Dakota and employees at Mayo Clinic Rochester participated in a telemedicine project, after which they completed exit surveys and a postproject questionnaire to ascertain the acceptability of this mode of health care. RESULTS: Almost all Pine Ridge and Mayo Clinic participants viewed the project as beneficial. The educational sessions received favorable evaluations, and almost two-thirds of the patients who completed evaluations thought the consultation had contributed to their medical care. More than 90% of the respondents from Pine Ridge and more than 85% of the respondents from Mayo Clinic Rochester said that they would recommend participation in this project to others. More than 90% of respondents from Pine Ridge and 80% of Mayo respondents agreed with the statement that the project should continue. CONCLUSION: These data suggest that a program of clinical consultation services, professional education, and patient education available by telemedicine might be viewed as beneficial.

Association between family history of benign prostatic hyperplasia and urinary symptoms: results of a population-based study.

Baseline measurements for a population-based prospective cohort study were used to assess the association between family history of enlarged prostate and urinary symptoms. Between December 1989 and March 1991, a group of randomly selected men aged 40-79 years from Olmsted County, Minnesota, was administered a previously validated questionnaire that included questions with wording close to that of the American Urological Association's Symptom Index. A detailed family history of an enlarged prostate was obtained by personal interview, and peak urinary flow rates were measured for each participant. Of the 2,119 men, 440 (21 percent) reported a family history of an enlarged prostate. The age-adjusted odds of having moderate or severe urinary symptoms were elevated among those with a family history relative to those without (odds ratio = 1.3, 95 percent confidence interval 1.1-1.7). With simultaneous control for effects of age and worry about urologic function, the odds ratio remained at 1.3 (95 percent confidence interval 1.0-1.6). Furthermore, this risk was greater for men with relatives diagnosed at a younger age (odds ratio = 2.5, 95 percent confidence interval 1.5-4.3). Men with a family history were also 1.3 times as likely to have an impaired peak urinary flow rate. These findings suggest that men with a family history of an enlarged prostate may be at increased risk for development of symptoms and signs suggestive of benign prostatic hyperplasia and that this risk is greater in men with relatives diagnosed at a younger age. Recognition of this association may help to target early interventions and may lead to further clues about the causes of benign prostatic hyperplasia.

Sexual function of men ages 40 to 79 years: the Olmsted County Study of Urinary Symptoms and Health Status Among Men.

OBJECTIVES: Knowledge of male sexual function is somewhat limited because of a lack of current population-based data. This study provides information on sexual function and satisfaction in a population-based sample of men. METHODS: Men aged 40 to 79 years (n = 2115) were selected randomly from the Olmsted County population for the baseline component of a prospective cohort study (the Olmsted County Study of Urinary Symptoms and Health Status Among Men) during 1989-1990. The men completed a self-administered questionnaire that included questions about sexual concerns, performance, satisfaction, drive, and erectile dysfunction. RESULTS: For all five sexual parameters queried, the prevalence of problems and dysfunction increased with age. A comparison of men aged 70 to 79 years with men aged 40 to 49 years suggested that older men were more worried about sexual function (46.6% vs 24.9%), had worsened performance compared with a year ago (30.1% vs 10.4%), expressed extreme dissatisfaction with sexual performance (10.7% vs 1.7%), had absent sexual drive (25.9% vs 0.6%), and reported complete erectile dysfunction when sexually stimulated (27.4% vs 0.3%). Logistic regression analyses suggested that sexual dissatisfaction was significantly associated with erectile dysfunction, decreased libido, and the interaction between erectile dysfunction and libido, but not age. CONCLUSIONS: These population-based cross-sectional data corroborate the previously reported age-related decrease in sexual function. The age-related increase in dissatisfaction could, however, be accounted for primarily by the age-related increase in erectile dysfunction, decreased libido, and the interaction between erectile dysfunction and decreased libido.

Timing of completed suicides among residents of Olmsted County, Minnesota, 1951-1985.

Previous studies of suicide timing may have been biased by incomplete ascertainment of suicides and by delays between the suicidal act and subsequent death. Those potential biases were assessed and minimized in this population-based study by using the unique resources of the Rochester Epidemiology Project in Olmsted County, Minnesota. Using these more accurate data, we confirmed previous reports of no excess suicides on birthdays (+/- 3 days), or during 3 United States national holidays. While most prior reports found excess post-holiday suicides and suicide peaks on Mondays, those findings were not observed in Olmsted County. Because 93% of deaths occurred on the date of the suicidal act, using date of death instead of the actual date of suicide is sufficient for most research purposes.

Natural history of prostatism: relationship among symptoms, prostate volume and peak urinary flow rate.

We describe relationships among symptoms, prostate volume and peak urinary flow rate in an age stratified, community based random sample of white men 40 to 79 years old with no prior prostate surgery, prostate cancer or other conditions known to interfere with voiding. Symptoms were assessed with an instrument comparable to the American Urological Association symptom index. Prostate volume was estimated by transrectal ultrasonography and peak urinary flow rate was measured by a portable device. Subject age was significantly associated with symptom score but accounted for only 3% of its variation, while prostate volume and peak urinary flow rate explained only an additional 10% of the symptom variability. The odds (95% confidence interval) of moderate to severe symptoms increased with age from 1.9 (1.1 to 3.1), 2.9 (1.7 to 5.0) and 3.4 (1.8 to 6.1) for men 50 to 59, 60 to 69 and 70 to 79 years old, respectively, relative to men 40 to 49 years old. Adjusting for age, the odds of moderate to severe symptoms were 3.5 times greater for men with prostatic enlargement (more than 50 ml.) than for men with smaller prostates, while the odds were similarly increased (2.4-fold) for men not achieving a peak urinary flow rate of 10 ml. per second. Estimated odds changed little when other cutoff points were considered for peak urinary flow rate (15 ml. per second) or prostate volume (40 ml.). These results, based on randomly selected white men, suggest a somewhat stronger, albeit modest, relationship among symptoms, prostate size and urinary flow rate than previously reported in clinic based studies. The strength of these relationships is comparable to that found with other diseases.

Cancer screening behaviors and attitudes of women in southeastern Minnesota.

OBJECTIVES: To determine the rates at which women received screening Papanicolaou tests, clinical breast examinations, and mammography and to determine the extent to which these women might be expected to respond to screening recommendations from their physicians. DESIGN: Random-digit-dial telephone interviews conducted in January 1993. SETTING: Fifteen counties in southeastern Minnesota. SUBJECTS: A sample of 1019 women who completed the telephone interview. MAIN OUTCOME MEASURES: Self-reported Papanicolaou test, clinical breast examination, and mammography screening rates, with verification from medical records for a randomly selected subsample of 200 respondents who reported having had a test within 1 year of the interview. RESULTS: For women aged 18 years and older, 60% (95% confidence interval, +/- 3.4%) reported having had a Papanicolaou test within the preceding year. For women 40 years of age and older, 57% (95% confidence interval, +/- 3.5%) reported having had a clinical breast examination in the past year, and 46% (95% confidence interval, +/- 3.6%) reported having had a screening mammogram within 1 year. The verified 1-year Papanicolaou test and mammogram rates were 35% and 33%, respectively. More than 90% of the respondents expressed a willingness to have these tests if their physicians were to advise them that the tests were indicated. However, 53% and 54% of the respondents, respectively, said that they either did not care or did not want their physicians to remind them when they were due for a Papanicolaou test or a mammogram. CONCLUSIONS: Although self-reported screening rates in this population meet Healthy People 2000 goals, verified rates were significantly below target levels. A substantial proportion of women in this population remain ambivalent about participating in cancer detection programs.

The role of community-based longitudinal studies in evaluating treatment effects. Example: benign prostatic hyperplasia.

To determine the appropriateness and effectiveness of medical interventions, it is necessary to understand both the natural history of the conditions the interventions are intended to treat or prevent, and the normal reference ranges of tests used in diagnosis and management. The acquisition of this information through clinic-based studies can yield misleading conclusions owing to selection bias. What appears to be intervention-related variation in outcomes may be variation in the magnitude and form of selection bias. To minimize selection bias, population-based studies are required. Results from the Olmsted County Study of Urinary Symptoms and Health Status Among Men were used to show how a population-based longitudinal study of the natural history of benign prostatic hyperplasia (BPH) can complement research programs of the BPH Patient Outcomes Research Team. Population-based studies of disease natural history are a necessary part of medical outcomes research, and deserve greater emphasis in the medical treatment effectiveness research initiative of the Agency for Health Care Policy and Research.

Do prostate size and urinary flow rates predict health care-seeking behavior for urinary symptoms in men?

OBJECTIVES: To estimate the association between health care-seeking behavior for urinary dysfunction and clinical, physiologic, and anatomic measures of disease. METHODS: A randomly selected sample (n = 475) of men aged 40 to 79 years from Olmsted County, Minnesota, was administered a previously validated questionnaire that assessed the frequency of and bother associated with urinary symptoms and health care-seeking behavior in the past year. Peak urinary flow rates were measured with a standard urometer and prostatic volume was determined by transrectal ultrasound. RESULTS: Overall, 21 of the 475 men (4%) had seen a doctor in the past year for urinary symptoms. Men with moderate to severe symptoms (American Urological Association [AUA] Symptom Scores > 7) were 3.4 times as likely (95% confidence interval [CI] = 1.4, 8.3) to have sought medical care in the past year as men with none to mild symptoms. Men with enlarged prostates (> 40 mL) were 3.9 times as likely to have sought health care (95% CI = 1.6, 9.6), whereas men with depressed peak urine flow rates (< 10 mL/s) were only slightly more likely to have sought health care for urinary symptoms (odds ratio = 2.1, 95% CI = 0.7, 6.5). Overall, 76% of men who had sought medical care had prostatic enlargement, depressed peak urine flow rates, or moderate-severe symptoms (sensitivity). In contrast, only 55% of men who did not seek health care for urinary symptoms in the past year had mild symptoms, normal prostatic volume, and normal peak urine flow rates (specificity). CONCLUSIONS: These data suggest that clinical, physiologic, and anatomic measures of prostatism do not adequately distinguish the men who seek medical care for their urinary symptoms from those who do not. There remain some factor(s) that apparently lead some men with minor disease to seek care and that prevent men with measurable disease from seeking care.

The natural history of prostatism: the effects of non-response bias.

BACKGROUND: In epidemiological studies, non-response may raise the question of generalizability to the target population. Most investigations have not been able to access data that could provide information about the potential impact of non-response bias. METHODS: A 55% response rate was realized at baseline for a prospective cohort investigation of the natural history of benign prostatic hyperplasia in Olmsted County, Minnesota, during 1989-1991 (the Olmsted County Study of Urinary Symptoms and Health Status Among Men). This prompted a preliminary study of potential non-response bias among full participants, partial participants and complete non-responders. The medical diagnostic index maintained by the Rochester Epidemiology Project was used to ascertain the prevalence of specific conditions in the 9 years prior to study inception. RESULTS: The age-adjusted period prevalence rate for benign prostatic hyperplasia (%) was 9.6 (95% confidence interval [CI]: 8.1-11.0) for full participants, 8.2 (95% CI: 5.8-10.6) for partial participants and 5.3 (95% CI: 3.6-6.9) for complete non-responders. Other urologic diagnoses followed the same pattern. However, age-adjusted prevalence rates for general medical examination history and major non-urologic morbidities were decidedly similar across response groups. CONCLUSIONS: These data suggest response may have been driven, in part, by concerns about urologic disease. However, the similarity in non-urologic diagnoses and general medical examinations provide some preliminary reassurance that the 55% response rate did not necessarily compromise generalizability.

Natural history of prostatism: impact of urinary symptoms on quality of life in 2115 randomly selected community men.

OBJECTIVES: To assess the impact of urinary symptoms on health-related quality of life (QoL), including degree of bother, worry, interference with daily activities, psychological well-being, sexual function, and general health in a community-based cohort of men. METHODS: Eligible white men (n = 2115) aged 40 to 79 years who had not undergone previous prostate surgery or had prostate cancer were randomly selected from county residents. These subjects completed a questionnaire, which asked them about frequency and bother of urinary symptoms, interference with daily activities, psychological well-being, worry about urologic disease, sexual functioning, and general health. RESULTS: Men with moderate to severe voiding symptoms reported, on average, four to six times the degree of bother and interference with daily activities and twice the level of worry of men with mild symptoms. Nearly five times the degree of bother and interference was reported for those with mild than with no symptoms. A higher percentage of men with moderate to severe symptoms (26% to 33%) than mild symptoms (< 8%) reported limiting fluids before bed, travel, or driving 2 hours. Receiver operating characteristic curves support the recommended symptom index cutpoint for moderate symptoms (= 8) by differentiating men with and without bother, interference with daily living, or dissatisfaction with urinary condition. CONCLUSIONS: Moderate to severe urinary symptoms have a significant impact on men's lives in terms of degree of bother, worry, interference with daily living, and psychological well-being. The recommended cutpoint on symptom index differentiates men with and without decrement in health-related quality of life.

Effect of several recruitment strategies on response rates at baseline in a prospective cohort investigation. The Olmsted County Study of Urinary Symptoms and Health Status among Men.

Epidemiologic survey response rates were studied in relation to maneuvers introduced to improve acceptance: (a) variation in invitation letters, (b) the use of a brochure with the recruitment mailing, and (c) options for interview location. The baseline population-based survey of a prospective cohort investigation of the natural history of benign prostatic hyperplasia was used. Invitations to participate were mailed to eligible, randomly selected men aged 40 to 79 years from the Olmsted County, Minnesota, population during 1989 to 1991. Of the 3874 men identified, 2119 (55%) participated. Overall, there was no difference in response rate according to invitation characteristics (chi 2(5) = 8.02, P = 0.16). Nevertheless, response rates varied with age (chi 2(7) = 30.9, P < 0.001) and home location (rural versus Rochester city; chi 2(1) = 76.9, P < 0.001). This suggests the innovations used to bolster acceptance did not materially improve response rates. Further, since response rates were highest for men aged 60 to 74 years, men with more symptoms and free time may have joined the cohort more often than others.

Cigarette smoking and prostatism: a biphasic association?

OBJECTIVE: To evaluate the association between cigarette smoking and prostatism in a community-based setting using standardized urinary symptom scores, peak urinary flow rates, and prostatic volume as indicators of disease. METHODS: A population-based cohort of 2,115 Caucasian men aged forty to seventy-nine years from Olmsted County, Minnesota, was administered a previously validated questionnaire that elicited information on frequency of urinary symptoms (approximating the American Urological Association's symptom index), and a detailed history on cigarette smoking, including both amount and pack-years of smoking. Peak urinary flow rates were measured by a standard uroflowmeter (Dantec 1000). The prostatic volume was measured for a subsample of 471 men by transrectal ultrasound. RESULTS: Compared to never-smokers, smokers were less likely to have moderate to severe urinary symptoms (age-adjusted odds ratio 0.82; 95% confidence interval [CI] 0.61 to 1.08). This varied by smoking intensity, however; in men who smoked less than 1 pack a day the age-adjusted odds ratio was 0.53 (95% CI 0.33 to 0.83) and among men smoking 1 to 1.4 packs a day, the odds ratio was 0.87 (95% CI 0.56 to 1.36). For men who smoked 1.5 packs or more a day, the odds ratio was elevated at 1.32 (95% CI 0.84 to 2.07). Smokers were less likely to have peak flow rates less than 15 mL/sec compared with never-smokers (age- and voided volume-adjusted odds ratio 0.48; 95% CI 0.35 to 0.66), or prostatic volume greater than 40 mL (odds ratio 0.54; 95% CI 0.19 to 1.55). CONCLUSIONS: These data from a community-based sample suggest that light or moderate smokers are less likely to have moderate to severe prostatism, whereas heavy smokers are at least as likely to have moderate to severe prostatism compared with never-smokers.

Natural history of prostatism: worry and embarrassment from urinary symptoms and health care-seeking behavior.

OBJECTIVE: To assess the interrelationships among psychosocial symptoms of worry and embarrassment about urinary function, prevalent urinary symptoms, psychological well-being, and health care-seeking behavior in a population-based cohort of men. METHODS: A cohort of 2,119 men aged forty to seventy-nine years, randomly selected from the Olmsted County, Minnesota population between December 1989 and March 1991, were administered a previously validated questionnaire that elicited information about the frequency of urinary symptoms, the degree to which they were perceived as a bother, and if the participant had seen a doctor in the previous twelve months for evaluation of any of these urinary symptoms. Psychological well-being was assessed by a subset of the Psychological General Well-Being Index, and sociodemographic information was also sought. RESULTS: Urinary symptom indices (measured by American Urological Association frequency and bother scores and psychological general well-being subscales) were significantly associated with worry and embarrassment about urinary symptoms in bivariate analyses. Multiple logistic regression analyses demonstrated that men with moderate or severe urinary symptoms or impaired psychological well-being were more likely to be worried or embarrassed about their urinary symptoms than men with mild symptoms. Furthermore, men who were worried about their urinary function were more likely to have sought medical care for their symptoms than men who were not worried. The association between health care-seeking behavior and embarrassment was especially strong among men with little bother associated with their urinary symptoms. CONCLUSIONS: Worry and embarrassment about urinary symptoms reflect quality-of-life issues that appear important in the health care-seeking behavior of men with prostatism. The results underscore findings that prevalent urinary symptoms alone do not determine a man's health care-seeking behavior, and treatment for psychosocial symptoms may be beneficial in some men with symptoms of prostatism.

Correlation between urinary flow rate, voided volume, and patient age in a community-based population.

This investigation is unique in that is the first study to use a large number of randomly chosen men from the community to establish the relationship between: 1) urinary flow rate and voided volume, 2) urinary flow rate and patient age, 3) voided volume and patient age, and 4) the time to achieve peak urinary flow rate and patient age. The results clearly indicate that both the peak and mean urinary flow rate decreases with advancing age. The voided volume also diminishes with increasing age. The time required to achieve the peak urinary flow rate, however, appears to be independent of the patient's age. Irrespective of age, approximately 9 seconds are required to achieve the maximum urinary flow rate. Because the urinary flow rate is dependent upon both the quantity of urine voided and the patient's age, it is necessary to account for the influence of both parameters when establishing the "normal range" for peak urinary flow rate. To this end, nomograms estimating the peak urinary flow rate percentile as a function of voided volume and patient age have been generated and are included in this report. These nomograms, based on a large, randomly selected population, should make peak urinary flow rate a more reliable diagnostic modality for assessing bladder outlet obstruction. They also should be most useful to the practicing clinician when interpreting the results of a peak urinary flow rate determination for a patient presenting with symptoms of prostatism.

Natural history of prostatism: factors associated with discordance between frequency and bother of urinary symptoms.

The objective of this study was to assess the association between frequency and bother of urinary symptoms in a population-based cohort of men and to identify psychosocial factors that are related to reporting heightened or subdued bother relative to symptom frequency. The survey was conducted among men aged forty to seventy-nine years in Olmsted County, Minnesota, the baseline component of a prospective cohort study. Men were queried about the frequency of urinary symptom occurrence and the perceived bother associated with the symptoms. A regression analysis of American Urologic Association (AUA) bother scores on AUA frequency scores demonstrated a tight correspondence (r2 = 0.71). Men with bother scores greater than predicted from their frequency scores were more likely to have sought health care for their urinary symptoms than men whose bother was close to predicted (14 versus 5 percent, respectively). These men with heightened bother were older, poorer, more anxious, and had lower general psychologic well-being scores than the men whose bother was similar to that expected from their reported frequency. Men whose bother was lower than would be expected were less likely to have sought health care for urinary symptoms in the past year (3%) but were of similar age and socioeconomic status as compared with men whose bother was close to expected. These men, however, were more depressed than men whose bother was commensurate with reported frequency. While the men who reported greater bother than expected from their symptom frequency were more likely to have sought medical care for urinary symptoms in the past year, it is not clear whether this greater health-care-seeking behavior is because bother captures an additional component of urologic disease or is a manifestation of psychosocial differences.

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.

Natural history of prostatism: urinary flow rates in a community-based study.

Urinary flow rates were measured in a randomly selected community sample of more than 2,000 men 40 to 79 years old with no history of prostate surgery, prostate cancer or certain other diseases known to interfere with normal voiding. Peak urinary flow rates decreased from a median of 20.3 ml. per second in men 40 to 44 years old to 11.5 ml. per second for men 75 to 79 years old, while voided volumes decreased from a median of 355.5 to 222.5 ml. for the same age ranges. Peak flow rates of less than 10 ml. per second were found in 6% of the men aged 40 to 44 years, increasing to 35% among men aged 75 to 79 years. Urological standards for peak urinary flow rate should be based on community data, and should account for age and voided volume. Our study may serve as the starting point for the development of community-based flow rate normal ranges. Nomograms are given to permit estimating flow rate percentiles as a function of age and voided volume.