Non-urological Conditions Research Articles

Nocturia and Blood Pressure Elevation in Adolescents.

Nocturia has been increasingly recognized as a manifestation of various non-urological conditions including hypertension. In adults, blood pressure (BP) elevation has been identified as a robust correlate of nocturia, but such a relationship has not been studied in pediatric populations where nocturia is often attributed to hormonal, sleep, physiological or psychological disorders. Accordingly, this study aimed to determine the relationship between nocturia and BP elevation in adolescents. We prospectively studied 100 patients, aged 10-18 years, recruited from pediatric clinics at our institution. Nocturia (defined as ≥ 1 voids on voiding diary analysis) was present in 45% of the study sample (range: 1-4 voids/night). 37% of subjects self-reported awakening to urinate, and 34% of subjects had BP elevation according to age-dependent thresholds from current Pediatrics guidelines. On multivariate analyses, BP elevation was strongly associated with nocturia determined by both voiding diary (OR 26.2, 95% CI: 6.5, 106.0) and self-report. Conversely, nocturia was associated with increased odds of elevated BP by diary (26.3, 95% CI: 6.5, 106.4) and self-report (OR 8.1, 95% CI: 3.2, 20.5). In conclusion, nocturia appears to be common and is strongly associated with BP elevation in adolescents. These findings suggest that eliciting a history of nocturia holds promise as a simple method of identifying adolescents at risk for hypertension.

WTP4.10 Utility of CT Imaging in a Successful Ambulatory Emergency Surgical Unit

Abstract Aim Drives towards ambulatory management in emergency surgery have resulted in increased availability of urgent imaging to expedite decision making. This review of CT usage aimed to assess frequency of surgical pathology identified, and subsequent management. Methods All acute general surgery referrals to an established ambulatory clinic between 01/01/2021 and 22/07/2022 were included. Information regarding presentation, imaging, and diagnosis were collected in prospectively maintained databases, and subsequently analysed. Results 3154 patients were seen over an 18-month period with a 91.7% successful ambulation rate (n=2938). CT was performed in 577 patients (18.2%); the majority were contrast CT abdomen/pelvis (CTAP, 58.3%, n=331), or CT Kidney/Ureter/Bladder (CTKUB, 40.1%, n=228). The majority of CTAPs were diagnostic (77.0%, 242/331), with 16.0% (n=53) resulting in admission; admission rate for non-diagnostic CTAPs was 4.5% (n=4/89). Subsequent operations occurred in 9.6% (32/331) who underwent CTAP; 5.1% (17/331) underwent emergency operation, urgent ambulatory operations in 3.0% (10/331), and 1.5% (5/331) were listed electively. CTKUBs identified urological pathology in 40.4% (n=92), whilst 7.4% (n=17) identified other pathology. Diagnostic CTKUB led to a 17.5% admission rate (n=17, including 5 non-urological). Conclusion Selective ambulatory CT scanning is a useful adjunct to diagnosis, and admission avoidance. CTKUBs identify lower, but acceptable levels of pathology including non-urological conditions. Judicious use of CT is important to balance resource utilisation, whilst limiting admissions.

Home Blood Pressure Monitoring And Nocturia In Adults.

Although widely viewed as a urological condition, nocturia has been increasingly recognized to accompany various non-urological conditions such as hypertension and blood pressure (BP) elevation on office determination. Home BP monitoring (HBPM) has been shown superior to office-based readings and provides an opportunity to assess potential relationships between nocturia and novel indices derived from multiple BP recordings including BP load, BP variability, and arterial stiffness, which have prognostic significance. We retrospectively studied 103 home BP logs and nocturia frequencies provided by 61 stable cardiology patients ≥ 21 years without medication change. Nocturnal voids ranged from 0 to 5 voids per night, median: 1.5. Nocturia frequency was significantly correlated with home and office systolic BPs and with BP load, but not with diastolic BPs, BP variability or arterial stiffness. On Poisson regression analysis, the estimated prevalence ratio (PR) for home and office systolic BPs were 1.025 (CI: 1.01, 1.04; p < .001) and 1.01 (CI:1.00, 1.02; p = .019), indicating 2.5% and 1% increases in the risk of nocturia per mmHg increases in BP respectively. In conclusion, higher mean home and office systolic BPs are associated with self-reported nocturia frequency with stronger associations seen for home BP measurement. Nocturia frequency appears unrelated to mean home and office diastolic BPs. Nocturia may be related to BP load, (percentage of elevated BP values), but not to BP variability or arterial stiffness. Future prospective studies using HBPM are needed to confirm these findings and to contribute to the understanding of the elevated BP-nocturia link.

A Simple Algorithm to Facilitate Improved Diagnosis of Nocturia

Introduction/Aim: Traditionally, nocturia is considered a bothersome storage symptom, associated with prostatic enlargement. However, nocturia occurs also in a range of urological and non-urological conditions. Some other authors consider nocturia as a disease rather than a symptom. The aim of this article is to present the clinically relevant features of nocturia and to suggest a simple algorithm to facilitate its investigation. Material and Methods: A database and a manual search were conducted in the MEDLINE database of the National Library of Medicine, PubMed, EMBASE, the Cochrane Library and other libraries using the key words “nocturia”, “nocturnal frequency”, “nighttime voiding”, in various combinations with the terms “etiology”, “pathophysiology” “risk factors”, “causes”. We included reviews metanalyses and clinical studies. We considered full-text written papers. Bibliographic information in the selected publications was checked for relevant records not included in the initial search. Results: According to current litterature is a very common condition that affects millions of people worldwide. The rate of people affected increases with age. About 1 in 3 adults over the age of 30 experience nocturia. There is a predominance of female gender among younger patients however occurrence of nocturia is equal between men and women aged 50-59 years. Nocturia occurs in more than 50% of individuals over 60 years of age and the prevalence is greater in men than women. The impact of nocturia in overall health is highly significant. Additionally, to the decrease in quality of life due to the inconvenience that it causes, nocturia can be associated with long-term sleep deprivation and the subsequent exhaustion, mood changes, somnolence, impaired productivity, increased risk of falls and accidents, fatigue, lethargy, inattentiveness, and cognitive dysfunction. Despite its high frequency and significance, nocturia remains under-reported, and under-treated. The most usual reasons explaining the above is the variety of contributing factors and conditions. Conclusions: It is paramount that clinicians are aware of the multiple potential contributing factors in any given patient. A simplified algorithm may help to identify the underlying etiology (such as diabetes or nocturnal polyuria) leading to better treatment outcomes, improved quality of life scores, and substantial symptom resolution.

33] Sacral neuromodulation: Report of initial experience in Kuwait

ObjectiveTo present our 6-year experience with sacral neuromodulation (SNM) since starting implantation in a single centre in Kuwait, as SNM is an established management for several urological and non-urological conditions, and devices and techniques have improved over the past decade.

Knowledge of smoking as a risk factor for disease among urology clinic patients in Australia.

Smoking remains a common habit among the general population. Despite the well-established risks of smoking, relatively few studies have been undertaken to assess the understanding of these risks among the general population. We intended to assess the understanding of smoking as a risk factor for various conditions in a urology outpatient cohort to assess the level of knowledge as well as particular strengths and weaknesses they possess. A four-page questionnaire was distributed among urology outpatients over a 5month period. The questionnaire captured information regarding the knowledge of smoking as a risk factor for various urological and non-urological conditions. Results were collated and stratified according to patient's cancer history as well as smoking status. A total of 112 participants were included in our analytical sample. Our study demonstrated a deficiency in knowledge regarding smoking and urological conditions. When ranked by level of knowledge, four of the bottom five conditions were urological in nature. Furthermore, we found that patients with a personal cancer history demonstrated generally poorer knowledge of smoking as a risk factor compared to patients without a cancer history. Conversely, smokers themselves demonstrated a greater understanding of risks compared to non-smokers. Our study suggests there is much work to be done in the education of patients on the risks of smoking from a urological point of view. We believe more initiative needs to be taken by the specialists treating such patients to achieve an improved level of knowledge.

Identification of low oxygen tolerating bacteria in prostate secretions of cancer patients: aetiological and therapeutic relevance

BackgroundThe sun-sensitive microaerophilic organism Propionibacterium acnes shows linkage with prostate cancer. That circumcision reduces risk of this cancer further supports a role for anaerobes since circumcision reduces the number of anaerobes on the glans penis. A 1988 study linked anaerobes with prostate cancer but considered them to be opportunists in a necrotic tumour. Rediscovering this research led us to revisit the previous hypothesis suggesting that decades of a similar process to that linking Helicobacter pylori (also microaerophilic) to stomach cancer might also be relevant in prostate cancer; and justified this feasibility study to seek evidence to support this hypothesis. MethodsTwo groups of patients were studied: patients with prostate cancer from Barts prostate clinic (active surveillance, n=18) and new referrals with urinary symptoms for investigation through Newham General Hospital (n=21). Urine samples from post-massage examinations were screened with matrix-assisted laser desorption/ionisation time-of-flight (MALDI-TOF) for identification of bacteria grown under anaerobic conditions. Ten preoperative urine samples investigated for non-urological conditions were controls. FindingsAnaerobic organisms were identified in eight (41%) of 18 patients in the active surveillance group, nine (43%) of 21 in the new referral group, and none of ten control samples. In a post-hoc analysis, anaerobes were associated with raised prostate-specific antigen (PSA) (1 [9%] of 11 men with PSA <1·5 vs 16 [57%] of 28 with PSA ≥1·5, p=0·011 [Fisher's exact test]). InterpretationThe numbers of prostate cancers in this series and in similar series in the literature are small (n=27) but the frequency of anaerobes in a comparison with literature control urine samples cultured for anaerobes (n=551) was significantly different (odds ratio 17·8, 95% CI 7·6–42·0). Clearly this needs further investigation in better defined patient and control series. Over several decades anaerobes could be of aetiological significance in prostate cancer and exacerbated by repeated episodes of vitamin D deficiency, thereby explaining linkage with long-term sun exposure but not spot vitamin D concentrations. Success with bacterial vaccines for women with recurrent cystitis suggests potential new approaches to prevent prostate cancer and potentially also cervical cancer in women infected with HPV, given evidence that bacterial vaginosis also involving anaerobes is a known cofactor of cervical cancer. FundingMW received a grant from Barts and The London Charity for purchase of MALDI-TOF equipment (grant reference number 486/1193).

Catheter-based renal denervation as therapy for chronic severe kidney-related pain.

Loin pain haematuria syndrome (LPHS) and autosomal dominant polycystic kidney disease (ADPKD) are the most important non-urological conditions to cause chronic severe kidney-related pain. Multidisciplinary programmes and surgical methods have shown inconsistent results with respect to pain reduction. Percutaneous catheter-based renal denervation (RDN) could be a less invasive treatment option for these patients. Our aim was to explore the change in perceived pain and use of analgesic medication from baseline to 3, 6 and 12 months after RDN. Patients with LPHS or ADPKD, who experienced kidney-related pain ≥3 months with a visual analogue scale (VAS) score ≥ 50/100 could be included. Percutaneous RDN was performed with a single-electrode radiofrequency ablation catheter. RDN was performed in 11 patients (6 with LPHS and 5 with ADPKD). Perceived pain declined in the whole group by 23 mm (P = 0.012 for the total group). In patients with LPHS and ADPKD, the median daily defined dosage of analgesic medication decreased from 1.6 [interquartile range (IQR) 0.7-2.3] and 1.4 (IQR 0.0-7.4) at baseline to 0.3 (IQR 0.0-1.9; P = 0.138) and 0.0 (IQR 0.0-0.8; P = 0.285) at 12 months, respectively. Mean estimated glomerular filtration rate decreased in the whole group by 5.4 mL/min/1.73 m2 at 6 months compared with baseline (P = 0.163). These results suggest that percutaneous catheter-based RDN reduces pain complaints and the use of analgesic medication in patients with LPHS or ADPKD. The present results can serve as the rationale for a larger, preferably randomized (sham) controlled study.

The Interstitial Cystitis/Bladder Pain Syndrome Clinical Picture: A Perspective from Patient Life Experience

IntroductionWe hypothesize that optimal management of interstitial cystitis/bladder pain syndrome requires more personalized data than obtained with symptom questionnaires and standard urological assessment. We used a qualitative approach to develop a best evidence series of questions to explore the total clinical picture in the patient with interstitial cystitis/bladder pain syndrome. MethodsThe methodology of this project included preliminary focus groups, individual patient interviews, content development and validity analyses to develop a series of questions of value to patients with interstitial cystitis/bladder pain syndrome. A new convenience sample of patients with this syndrome completed the series of questions exploring not only pain and urination symptoms, but also other biopsychosocial parameters noted to be of relevance to these patients. ResultsContent of final series of questions addressed pain, urination symptoms, flares and the 10 most important domains impacted by interstitial cystitis/bladder pain syndrome. Further questions addressed thoughts or feelings, attitudes and suicidal ideation. A series of questions addressed how patients cope with and manage their condition. A total of 32 patients with interstitial cystitis/bladder pain syndrome completed the finalized series of questions. Bladder pain and urination symptoms were primary concerns of patients but other domains related to associated nonurological conditions (poor sleep/persistent fatigue, irritable bowel syndrome-like symptoms, low back and general muscle pain, interference/impact [eg sleep, diet, travel, activities, sexual functioning], positive and negative beliefs/attitudes, and coping mechanisms) make up the total clinical picture for each patient. ConclusionsThe biopsychosocial information provided by our patients will better inform the health care professional on how to develop personalized treatment strategies and also individualized patient directed outcomes independent of bladder pain and urination symptoms.

Combination therapies for improved management of lower urinary tract symptoms/benign prostatic hyperplasia.

Several urological and non-urological conditions can contribute to the onset of lower urinary tract symptoms (LUTS), including benign prostatic hyperplasia (BPH), which is one of the main underlying causes in male patients. Six pharmacological classes (alpha-adrenoceptor blockers [ABs], 5alpha-reductase inhibitors [5ARIs], phytotherapeutics, antimuscarinics [AMs], beta3-adrenoceptor agonists and phosphodiesterase type 5 inhibitors [PDE5Is]) are available, alone or in combination, for the treatment of male LUTS. The aim of this review is to summarize the latest evidence on combination medical treatments for male patients with LUTS/BPH. Standard combinations include AB + 5ARI (for patients with increased prostate volume who are at risk for BPH progression); AB + PDE5I (for patients with concomitant erectile dysfunction); and AB + AM or beta3 agonist (for patients with persistent storage symptoms and not at risk for acute urinary retention). Other possible multidrug treatments have been proposed in preliminary studies, but further randomized controlled trials are needed to determine whether these putative strategies will eventually be considered a new standard for patients with LUTS/BPH. The possibility of tailoring BPH treatment according to different patient characteristics and expectations, using two or more drugs, seems a promising path in the field of LUTS/BPH management; however, physicians should consider the risk of increasing costs without proven long-term efficacy with most of these combination treatments.

An Overview of the Management of Male Lower Urinary Tract Symptoms and Benign Prostatic Obstruction

Lower urinary tract symptoms (LUTS) in older men are common and often bothersome, resulting in a significant use of healthcare resources. Symptoms were thought to be secondary to benign prostatic obstruction (BPO) or benign prostatic enlargement (BPE). However, it should be noted that such storage symptoms are also seen in men without enlarged prostates and in women. These symptoms may be caused by detrusor overactivity, non-urological conditions, medications, or lifestyle factors. Management of BPO constitutes to a significant proportion of a urologist’s workload, and will continue to do so with an increasingly ageing population. This review aims to provide an overview of the current understanding of BPE and male LUTS as well as investigations and treatment options. The primary source of data was PubMed, this was searched using Boolean strategies and by scanning a list of related articles. We also examined secondary sources from reference lists of retrieved articles.

Daily Dosing of PDE5 Inhibitors: Where Does it Fit in?

To provide a critical contemporary review of daily PDE5-inhibitor (PDE5-I) use in urological and nonurological conditions. PDE5-Is can be taken up to once a day. However, at present only tadalafil is approved for use in both erectile dysfunction (ED) and benign prostate hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Evolving research in penile rehabilitation, Peyronie's disease, male infertility, pulmonary arterial hypertension, muscular dystrophy and Raynaud's phenomenon shows these therapeutic areas may also benefit from PDE5i therapy. This review examines the role of chronic PDE5 inhibition in ED, BPH-LUTS and other therapeutic targets which may shape our clinical practice in the years to come.

Urologists and the Patient Centered Medical Home

Hopes are high that the delivery system reforms embodied in the patient centered medical home will improve the quality of care for patients with chronic diseases. While primary care physicians, given their training, will likely be the locus of care under this model, there are certain conditions for which urologists are well suited to provide the continuous and comprehensive care called for by the patient centered medical home. To assess the feasibility of the urology based patient centered medical home, we analyzed national survey data. For our measure of medical home infrastructure, we mapped items from the 2007 and 2008 NAMCS (National Ambulatory Medical Care Survey) to the NCQA (National Committee on Quality Assurance) standards for patient centered medical home recognition. We determined the proportion of urology practices in the United States that would achieve patient centered medical home recognition. Finally, we used NAMCS data to estimate the impact of consolidating genitourinary cancer (ie prostate, bladder, kidney and testis) followup care among the current supply of urologists. Nearly three-quarters of urology practices meet NCQA standards for patient centered medical home recognition. At present, primary care physicians spend 9,295 cumulative workweeks providing direct and indirect care to survivors of genitourinary cancers. Off-loading half of this care to urology practices, in the context of the patient centered medical home, would generate an average of 0.73 additional workweeks for each practicing urologist. Urology practices may possess the capacity needed to direct medical homes for their patients with genitourinary cancers. Successful implementation of this model would likely require a willingness to manage some nonurological conditions.

PDE5 Inhibitors in Non-Urological Conditions

Phosphodiesterase type-5 (PDE5) inhibitors are widely used as first-line therapy for erectile dysfunction (ED). Their efficacy and safety combined with an increasing understanding of cyclic guanosine monophosphate (cGMP)-regulated mechanisms, have triggered a number of attempts to determine their effects and potential benefits in non-urological conditions. In recent years, extensive and diverse preclinical and clinical evidence has been made available. PDE5 inhibition has shown collateral benefits for a multitude of risk factors or diseases associated with, or accompanying ED. To date, PDE5 inhibition has been shown to be effective for the treatment of idiopathic pulmonary arterial hypertension and both sildenafil and tadalafil are approved for this indication. However, PDE5 inhibitors appear to have the potential of further expanding their indications. Importantly, accumulating data show that the therapeutic potential extends to the cardiovascular, gastrointestinal, cutaneous and nervous system and that these agents may be beneficial in a multitude of conditions such as Raynaud's phenomenon, heart failure, essential hypertension and stroke. PDE5 inhibitors are a conceptually attractive therapeutic class of agents with pleiotropic effects. The present review discusses recent findings regarding the effects of PDE5 inhibitors on non-urological conditions and highlights current and future clinical applications beyond ED.

Missed Diagnoses by Urologists Resulting in Malpractice Payment

Missed diagnoses are a patient safety concern and they can result in malpractice allegation. The specialist physician may be liable for missed or delayed diagnoses even if an abnormality in the physician area of expertise is ruled out. We approached this largely unstudied area of medical malpractice in an effort to increase physician awareness and identify opportunities for prevention. Working with the Medical Liability Mutual Insurance Company of New York State, we evaluated malpractice claims in urology that were closed with indemnity payment between 1985 and 2004. We identified all such claims resulting from alleged missed or delayed diagnoses by urologists. Claims were divided into 2 main categories based on whether the missed diagnosis was primarily urological, ie testis torsion, or not urological, ie appendicitis. A total of 75 missed diagnosis claims were identified, representing 15% of claims overall. The total indemnity payment for missed diagnosis claims was $32,591,013, which represented 27% of all indemnity payments for the study period. They were divided into 58 missed urological diagnoses and 17 missed nonurological diagnoses. Cancer represented 71% of missed urological diagnoses and 41% of missed nonurological diagnoses. Urological cancer missed diagnosis claims were associated with the highest average indemnity payment of $526,460. The average indemnity payment for missed diagnosis claims was 92% greater than the average indemnity payment for all other claims ($434,546 vs $226,133). An increase in the frequency of missed diagnosis claims closed with indemnity payment and in the amount of payment for missed diagnosis claims were observed during the 20-year study period. Indemnity payments resulting from missed diagnosis claims represent a disproportionately high percent of total indemnity payments (27%) due to a high average payment for such claims. Liability for the urologist resulted from missed diagnoses not only of urological conditions, but also of nonurological conditions.

Unenhanced multidetector CT (CT KUB) in the initial imaging of suspected acute renal colic: evaluating a new service

To evaluate a new imaging pathway for the investigation of patients presenting with suspected acute renal colic. A retrospective review of 500 consecutive cases of suspected acute renal colic was undertaken to evaluate the initial results of a new imaging pathway introduced at our institution, which completely replaced the intravenous urogram (IVU) with unenhanced multidetector CT (CT KUB). The positive rate for urolithiasis was 44% (221/500), the negative rate 46% (229/500) and the rate of other significant findings was 12% (59/500). Female patients had a low positive rate compared with male patients (27.5 versus 57.5%; p<0.001). Urological intervention was required in 28% (61/221) and these patients had a larger average stone size (6.6 versus 3.7 mm; p<0.001) and the stone was located more proximally. Out-of-hours imaging was performed in 37% (186/500), and these patients had a higher positive rate (52 versus 40%; p<0.001). Other findings included a wide range of acute non-urological conditions. The feasibility of replacing the acute IVU with CT KUB in the initial assessment of suspected acute renal colic was demonstrated in the present study. The technique enables rapid diagnosis of urolithiasis, stratification of patients likely to proceed to urological intervention, and prompt diagnosis of a variety of other acute pathological conditions.

Value of Routine Renal and Abdominal Ultrasonography in Patients Undergoing Prostatectomy

To evaluate the frequency of urological and non-urological abnormalities detected on routine renal and abdominal ultrasonography in patients undergoing surgery for benign prostatic hyperplasia (BPH) and to see if they affected the intended decision for prostate surgery. Medical records of 250 patients who underwent open or endoscopic surgery for BPH at Nishtar Hospital, Multan, Pakistan between May 2003 and December 2004 were studied. All patients had abdominal ultrasonography performed during routine preoperative workup. The frequency of urological and non-urological conditions detected on ultrasonography was calculated and the effect of these conditions on the intended decision for prostate surgery was observed. In 102 patients (40.8%) urological and in 8 patients (3.2%) non-urological abnormalities were detected by ultrasonography. Urological conditions detected included uni/bilateral hydronephrosis (34 pts), vesical stones (34 pts), renal cysts (15 pts), renal stones (6 pts), small shrunken kidneys (2 pts), renal tumour (1 pt) and bladder carcinoma (1 pt). Non-urological conditions included gall stones (4 pts), liver abscess (2 pts), hydatid cyst (1 pt) and liver carcinoma (1 pt). The study shows that a sizeable number of patients (44%) had urological and non-urological conditions detected by renal and abdominal ultrasonography. Most patients had benign conditions but three of these patients had potentially life threatening conditions (renal, bladder and hepatic carcinoma) detected by sonography that were unrelated to the prostate. However, in only one patient (0.4%) with bladder carcinoma, surgery for prostate was postponed and bladder tumour was dealt with prior to transurethral resection of prostate (TURP). Various conditions detected by ultrasonography would have been missed if it had not been performed. As ultrasonography is a non-invasive, cost-effective and quite a safe imaging technique, in author's opinion abdominal and renal tract evaluation by ultrasonography should be routinely performed in patients undergoing surgery for BPH.

Three-dimensional imaging of the prostatic urethra--an exciting new tool.

To evaluate the technique of three-dimensional (3-D) ultrasound imaging of the urethra and its application in both research and clinical practice. The study involved 23 patients: 10 with benign prostatic hyperplasia, four with urethral strictures, three post-insertion of prostatic stents, one with bladder neck dyssynergia, three post-transurethral resection of the prostate, and two with non-urological conditions. A transrectal ultrasound scan was initially performed to acquire a series of images of the urethra. These images were then reconstructed into a 3-D format. The 3-D image of the urethra could be rotated on screen and viewed from any angle. The image could also be sliced at any plane to reveal the sectional view. This new tool represents a major advance in imaging techniques and promises to provide new knowledge in understanding the hydrodynamics of the lower urinary tract. The precise geometry of the 3-D urethra will also help in the design of new stents.

Epidemiology of Bladder Emptying Symptoms in Elderly Men

We provide estimates of the prevalence, incidence and remission of difficult bladder emptying symptoms (prostatism) among noninstitutionalized men 60 years old and older living in a community in the United States. The prevalence of 1 or more symptoms of prostatism (hesitancy, straining, weak stream, intermittency or use of a catheter) among men who never had prostatic surgery is 35%. The annual incidence rates during years 1 and 2 of followup were 16.4% and 16.1%, respectively. Remission of symptoms of prostatism also was observed. Of the respondents with severe symptoms at baseline 22.9% were asymptomatic 1 year later. The prevalence of prostatic surgery in this population was 20%. The annual incidence rates during years 1 and 2 of followup were 2.6% and 3.3%, respectively.Urological and nonurological correlates of prostatism are identified. The irritative bladder symptoms are all significantly associated with moderate to severe bladder emptying symptoms (p <0.0005). Nonurological conditions that also are associated with moderate to severe symptoms of prostatism include use of sedatives or tranquilizers, arthritis, poor health status and transient ischemic attacks. These observations are the initial step in documenting and understanding the various symptoms of prostatism, and its application in clinical practice.

Cigarette smoking and bladder cancer

The relation between cigarette smoking and risk of bladder cancer was analysed in a case-control study in Northern Italy of 337 cases of histologically confirmed invasive bladder cancer and 392 controls admitted to the same network of hospitals with acute, non-neoplastic, non-urological conditions. Compared with never-smokers, the multivariate relative risk (RR) was 1.9 (95% confidence interval, CI 1.2–3.1) for ex-smokers and 3.3 (95% CI 2.2–5.0) for current smokers. The risk was directly and significantly related to duration of smoking (RR 3.5 for 30 years or more) and dose (RR 3.9 for 20 cigarettes per day or more), and consistent among strata of sex and age (though the RRs were systematically higher at older ages). Smokers of black tobacco only had a RR of 3.7, compared with 2.6 for smokers of blond cigarettes or mixed types. The interaction between tobacco and several occupations associated with bladder cancer risk fitted an additive rather than a multiplicative model: compared with non-exposed never-smokers, RR was 2.5 for exposed non-smokers, 2.8 for non-exposed smokers and 3.7 for occupationally exposed smokers.