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Enlarged prostate: A landmark national survey of its prevalence and impact on US men and their partners

Abstract

This questionnaire-based survey evaluated the frequency and severity of lower urinary tract symptoms (LUTS) and the prevalence of enlarged prostate (EP) diagnosis and its impact on quality of life and spousal relationships among >1000 American men aged >50 years. A quarter of men suffered moderate to severe LUTS and 55% of those consulting a doctor had EP. EP negatively affected patient quality of life and caused relationship strain with spouses. These findings confirm that LUTS and EP are prevalent in the US population, affecting both patient and spouse, and may help in developing management strategies for EP.

Introduction

Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) are significant contributors to the daily practice of urologists and primary care physicians (PCPs). Many symptoms of BPH are the result of a mass-related increase in urethral resistance causing obstruction, and patients often refer to the condition as ‘enlarged prostate’ (EP). Furthermore, EP is a progressive disease in many men, characterized by increasing prostatic enlargement, worsening LUTS, and an increased risk of acute urinary retention (AUR) and EP-related surgical intervention.1, 2, 3, 4

Understanding the likelihood of disease progression and the impact of EP and its associated symptoms on individual men is a crucial component of disease management, particularly as symptoms are incongruous and may be weighted differently by patients and doctors.5 Despite a number of regional population-based studies, few published data are available from US national surveys. Major objectives of this survey were to evaluate the frequency and severity of LUTS among American men, the prevalence of a diagnosis of EP and its impact on quality of life and spousal relationships.

Materials and methods

Study sample and size

Interviews were carried out among a national sample of more than 2000 men aged 50–79 years in the US. These men were taken from a national sample of 17 000 households screened to identify and interview 400 men who had been diagnosed with EP by a doctor and 700 who had not, together with 125 spouses of men who had been diagnosed with EP. Additionally, a national sample of 100 PCPs and 100 urologists were interviewed.

The national samples for the three age cohorts (50–59, 60–69, 70–79 years) and the total sample of men with EP each included approximately 400 respondents for which the maximum expected sampling error would be +5 percentage points at the 95% confidence level. The total national sample of men aged 50–79 years would have an expected sampling error of +2.9 percentage points at the 95% confidence level, if it were proportional. However, this sample was stratified with disproportionate sampling to yield representative subsamples of the three age cohorts. This introduces a design effect into estimates for all men or all men with EP, which may make the variance of specific estimates for these two populations more or less than that expected from simple random sampling.

Interview methodology

The survey was carried out by Schulman, Ronca and Bucuvalas Inc., a national research firm that specializes in health issues. The sample for the survey was obtained using random digit dialing (RDD) of a national sample of residential telephone banks. An adult in the residential household was screened to determine the presence of men aged 50 years in the household. If a man aged 50–79 years was present he was interviewed about EP by telephone. The current frequency and severity of urinary symptoms was measured using the American Urological Association-Symptom Index (AUA-SI) questionnaire, which generates a symptom score defined as mild (0–7), moderate (8–19) or severe (20–35). Any interviewed man with EP was asked if his spouse could also be interviewed. With agreement, this interview was conducted by telephone at a later date. Finally, a sample of urologists (n=100) and PCPs (n=100) who provide direct patient care in an outpatient setting, was identified nationally from the American Medical Association (AMA) or the American Osteopathic Association (AOA). All interviews were carried out by experienced interviewers from a central telephone facility with continuous monitoring for quality control using computer-assisted telephone interviewing. All recruiting and interviewing took place between July and September 2003.

Development and evaluation of the questionnaire

A number of the questions included in the questionnaire come from established scales such as the Health Related Quality of Life (HRQoL-14) index, the Jackson Sleep Scale, the AUA-SI, and the BPH Impact Index. Other questions were drawn from similar or identical measures used in other surveys of chronic disease; for example, the spouse series of questions parallel those used in the survey ‘Beyond Diagnosis: A Landmark Survey on Depression’ and the disease and treatment opinion questions parallel similar items from ‘Asthma in America’ and ‘Irritable Bowel Syndrome in American Women’. Other questions were specific to the treatment and management of EP. Standard demographic questions were also included. The questionnaires were developed after a thorough review of existing published and unpublished studies on EP, and were further reviewed and critiqued by outside medical specialists. The questionnaire consisted of 75 questions for the national sample of men aged 50–79 years, 74 for EP patients, 45 for spouses of men with EP and 58 for PCPs and urologists.

Statistical analyses

Statistical comparison between patient groups and within patient groups for different symptom severities was carried out using a χ2 test. Statistical significance was evaluated at the 0.05 level.

Results

Survey population and demographics

Interviews were carried out among a total national sample of 1203 men aged 50–79 years. Within this sample, a general population sample of 1050 men was interviewed; of these, 266 had previously been diagnosed with EP. A further 153 men with EP were also interviewed, which increased the sample of men with this condition to 419. As planned, 100 PCPs and 100 urologists participated in the survey. Table 1 shows the patient demographics at the time of interview.

Table 1 Patient demographics at the time of interview

Prevalence of urinary symptoms and EP

Among the general population sample of men (n=1050), 30% reported increased urinary frequency in the 12 months before the survey – a higher prevalence than gallstones (1%), kidney trouble (4%), bladder trouble (5%), bowel trouble (8%) and erectile dysfunction (19%), irrespective of the considered cause. Furthermore, 87% of men surveyed reported experiencing at least one urinary symptom in the 30 days before the survey and 25% had suffered moderate to severe symptoms during this timeframe.

The responses to AUA-SI questions 1–7 for all men in the general population sample in the 30 days before the survey are represented in Figure 1. Despite the high prevalence of moderate to severe urinary symptoms in this sample population (25%), 21% had never discussed these symptoms with a doctor (Figure 2). Among those men with moderate to severe symptoms who had consulted a doctor, 55% reported a diagnosis of EP. Of the overall sample population, 25% had been diagnosed with EP and 48% of these men had moderate to severe urinary symptoms. As expected, the prevalence of EP increased with age from 14% of men aged 50–59 years, to 30% of men aged 60–69 years and 44% of men aged 70–79 years. Furthermore, the prevalence of EP with moderate to severe symptoms also increased with age (7% of men aged 50–59 years, 15% aged 60–69 years and 19% aged 70–79 years).

Figure 1
figure1

The prevalence of specific urinary symptoms among men in the general population sample in the 30 days before the survey (n=1050).

Figure 2
figure2

Proportion of men in the general population sample with moderate to severe urinary symptoms who consulted a doctor and received a diagnosis.

EP – risk of AUR and surgery

Almost 20% of men with EP had undergone an EP-related surgical procedure, including laser and microwave surgery, with a similar rate of surgery among men with mild, or moderate to severe urinary symptoms (19 versus 18%, respectively). In both symptom categories the rate of surgery increased with age (Figure 3).

Figure 3
figure3

Proportion of men who have had surgery for EP, by age group (n=419).

Most men (80%) who have had surgery for their EP reported only one such procedure; however, 15% reported two and 5% reported three or more procedures. Almost one quarter (23%) of men who underwent surgery for their EP reported they had suffered problems or complications as a result of the procedure. The most commonly reported complication was urinary incontinence (9%) and others included bleeding (6%), infection (3%), impotence (3%) or ‘something else’ (9%).

In the 12 months before the survey, 3% of men diagnosed with EP required hospitalization and 1% reported having emergency room treatment for their condition. AUR was experienced by 6% of men surveyed with the prevalence highest in the 70–79 year age group. The risk of AUR among men with a diagnosis of EP was significantly greater than that for the overall sample aged 50–79 years, who had not been diagnosed with EP (13 versus 5%, respectively, P<0.05). Furthermore, the risk of requiring surgery as a result of this condition was significantly greater for men with EP compared with those without (25 versus 11%, P<0.05). A higher proportion of those with EP and moderate to severe symptoms (compared with mild) suffered AUR (15 versus 11%, respectively, P>0.05).

EP – burden of disease

Men in the general population sample who had been diagnosed with EP were approximately 1.5–2 times more likely as other men of the same age to rate their current health as only fair or poor (Figure 4). As expected, this rating was greater in men with one or more comorbidities compared with those with no comorbidities (40 versus 14%, respectively, P<0.05). Similarly, the proportion of men who reported activity limitation was greater in men with EP and moderate to severe symptoms compared with those without EP (Figure 5).

Figure 4
figure4

Proportion of men rating their current health as ‘fair’ or ‘poor’.

Figure 5
figure5

Proportion of men reporting current activity limitations as a result of any impairment or health problem.

Approximately 10% of men with EP and mild urinary symptoms aged 50–59 years (7%), 60–69 years (9%), and 70–79 years (12%) agreed that their prostate condition had reduced their quality of life. This increased to 46, 24 and 33%, respectively, in those with EP and moderate to severe symptoms (all P<0.05 for moderate to severe versus mild symptoms).

Impact of EP on spousal relationships

Almost three quarters (74%) of men with EP in the general population sample were married at the time of the survey. A further 12% were married when they were first diagnosed with EP but were no longer married at the time of the survey. The majority stated that the condition had no effect on their spouse (72% for those with mild and 66% for those with moderate to severe symptoms) and this was concordant with the responses given by the majority of spouses (55% reported ‘no effect’). However, when asked about the impact of the condition on specific aspects of their relationship, significant differences were observed. Men with EP and moderate to severe symptoms were more likely than those with mild symptoms to report that their condition caused problems in their marriage, including: lack of physical intimacy; avoidance or withdrawal; a feeling of isolation or distance, anger or conflict; and lack of communication. Spouses of men with EP were more likely than their husbands to report these types of relationship strains, in particular a lack of physical intimacy in their marriage (Figure 6).

Figure 6
figure6

Proportion of men with EP and their spouses reporting specific relationship concerns as a result of a diagnosis of EP.

Discussion

The ‘EP in American men’ survey is the largest and most comprehensive national survey, to date, examining the population prevalence of LUTS and EP and their impact on the patient and his spouse. Data from this survey confirm that LUTS are prevalent among the general population, with approximately 25% of men reporting moderate to severe symptoms. In fact, this may be an underestimate of the actual prevalence of LUTS based on the observation that AUA-SI scores obtained by telephone interview may be up to four points lower than those obtained by self-administration of the questionnaire.6 Data also confirm that EP is the most common diagnosis for moderate to severe urinary symptoms in men aged 50–79 years, although approximately 20% do not consult a doctor. The prevalence of EP in the general population was 25% and, as expected, a clear relationship with increasing age was observed. Considering that self-reporting of EP was required in the present survey, rather than a population-based inclusion, these findings are relatively concordant with those of regional population-based studies. For example, the community-based Olmsted County study showed that 26–48% of men aged 40–79 years reported moderate to severe LUTS.7 Moderate to severe LUTS quantified by symptom scores increased from 13 to 28% in patients aged 40–49 years and >70 years, respectively.8 In a Scottish large-scale community-based study the prevalence of clinical BPH, defined as an EP (>20 ml) in the presence of LUTS and/or a urinary peak flow rate <15 ml/s, increased from 14 to 44% in patients aged 40–50 years and 70–80 years, respectively.9 In addition, community-based data from the municipal authorities of Rotterdam, the Netherlands, showed a prevalence of moderate to severe symptoms of approximately 30% among a population of men aged 55–74 years.10

The present survey data showed that the actual risk of AUR among men with EP was approximately twice that of men of the same age without a diagnosis of EP. This is marginally lower than the findings of the Olmsted County Study in which men with a prostate volume >30 cc had approximately three times the risk of AUR compared with those with smaller prostates.3 In the present survey, the risk of requiring surgery for this condition was 25% among men with EP, a finding that is concordant with other US and UK studies showing that AUR results in prostatectomy in 24–42% of men.11

The burden of EP and LUTS is commonly underestimated, possibly as a result of the benign nature of the disease and the low rates of demand for acute care. However, more than one-third of men with EP and moderate to severe symptoms stated that the condition had reduced their quality of life, and these men were twice as likely to rate their general health as ‘fair’ or ‘poor’ compared with men without EP. Significantly, spouses of men with EP were more likely to report a negative impact on specific aspects of their relationship than men with moderate to severe symptoms, in particular lack of physical intimacy and lack of communication. The lack of communication between men with EP and their spouses may be a factor in the considerable proportion (>20%) of men with moderate to severe symptoms who do not present to a doctor.

If a man with EP considers his symptoms to be a normal part of aging and he is unaware of their impact on his spouse, he may be less inclined to seek treatment. Furthermore, although both men with EP and their spouses commonly report no significant effect of the condition overall, they report a significantly greater impact when asked about specific aspects of their relationship. This suggests that, when a patient presents with symptoms of EP, more detailed questioning is required to fully establish the impact these symptoms are having on the patient himself and his spouse.

As with all surveys, potential limitations of this study include the way in which the questions were worded and the order in which they were asked, interviewer influence and bias, weighting by demographic control data, and how the population was screened. However, although individual questions may not have been validated, all questions employed in the survey were taken from validated questionnaires. Furthermore, with a sample of this size, one can say with 95% certainty that the results have a statistical precision of ±5 percentage points of what they would be if the entire adult population had been surveyed with complete accuracy.

Conclusions

The results of this national US survey confirm the findings of numerous regional population-based studies that LUTS are highly prevalent among the aging male population and that the most common diagnosis is EP. Furthermore, this progressive disease has a significant impact on the quality of life of patients and their spouse, a finding that requires consideration in appropriate management strategies.

References

  1. 1

    Emberton M, Andriole GL, de la Rosette J, Djavan B, Hoefner K, Vela Navarrete R et al. Benign prostatic hyperplasia: a progressive disease of aging men. Urology 2003; 61: 267–273.

    Article  Google Scholar 

  2. 2

    Jacobsen SJ, Girman CJ, Guess HA, Rhodes T, Oesterling JE, Lieber MM . Natural history of prostatism: longitudinal changes in voiding symptoms in community dwelling men. J Urol 1996; 155: 595–600.

    Article  CAS  Google Scholar 

  3. 3

    Jacobsen SJ, Jacobson DJ, Girman CJ, Roberts RO, Rhodes T, Guess HA et al. Natural history of prostatism: risk factors for acute urinary retention. J Urol 1997; 158: 481–487.

    Article  CAS  Google Scholar 

  4. 4

    McConnell JD, Roehrborn CG, Bautista OM, Andriole Jr GL, Dixon CM, Kusek JW et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003; 349: 2387–2398.

    Article  CAS  Google Scholar 

  5. 5

    DuBeau CE, Yalla SV, Resnick NM . Implications of the most bothersome prostatism symptom for clinical care and outcomes research. J Am Geriatr Soc 1995; 43: 985–992.

    Article  CAS  Google Scholar 

  6. 6

    Rhodes T, Girman CJ, Jacobsen SJ, Guess HA, Hanson KA, Oesterling JE et al. Does the mode of questionnaire administration affect the reporting of urinary symptoms? Urology 1995; 46: 341–345.

    Article  CAS  Google Scholar 

  7. 7

    Jacobsen SJ, Girman CJ, Lieber M . Natural history of benign prostatic hyperplasia. Urology 2001; 58: 5–16.

    Article  CAS  Google Scholar 

  8. 8

    Chute CG, Panser LA, Girman CJ, Oesterling JE, Guess HA, Jacobsen SJ et al. The prevalence of prostatism: a population-based survey of urinary symptoms. J Urol 1993; 150: 85–89.

    Article  CAS  Google Scholar 

  9. 9

    Garraway WM, Collins GN, Lee RJ . High prevalence of benign prostatic hypertrophy in the community. Lancet 1991; 338: 469–471.

    Article  CAS  Google Scholar 

  10. 10

    Bosch JL, Hop WC, Kirkels WJ, Schroder FH . The International Prostate Symptom Score in a community-based sample of men between 55 and 74 years of age: prevalence and correlation of symptoms with age, prostate volume, flow rate and residual urine volume. Br J Urol 1995; 75: 622–630.

    Article  CAS  Google Scholar 

  11. 11

    Choong S, Emberton M . Acute urinary retention. Br J Urol Int 2000; 85: 186–201.

    Article  CAS  Google Scholar 

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Correspondence to C G Roehrborn.

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Roehrborn, C., Marks, L. & Harkaway, R. Enlarged prostate: A landmark national survey of its prevalence and impact on US men and their partners. Prostate Cancer Prostatic Dis 9, 30–34 (2006). https://doi.org/10.1038/sj.pcan.4500841

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Keywords

  • health surveys
  • benign prostatic hyperplasia
  • United States
  • epidemiology
  • quality of life

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