AUA Annual Meeting 2012

ATLANTA – At 15 years after treatment, disease-related quality of life measures appear similar in men with prostate cancer, regardless of whether they had radical prostatectomy or external radiation beam therapy.

The significant differences in sexual, urinary, and bowel function that were apparent in the first 5 years, largely disappeared as time advanced, Dr. Matthew Resnick reported, based on a new subanalysis of men in the Prostate Cancer Outcomes Study.

The convergence of outcomes may not have so much to do with treatment type as it does advancing age, he said at the annual meeting of the American Urologic Association. This is especially apparent in erectile dysfunction, according to Dr. Resnick, a urologic surgeon at Vanderbilt University Medical Center, Nashville, Tenn.

"Age really is the most significant determinant of decline in erectile function over time," he said. "About 50% of men older than 70 have erectile dysfunction."

The Prostate Cancer Outcomes Study (PCOS) enrolled patients from six Surveillance, Epidemiology, and End Results (SEER) tumor registries to examine long-term functional outcomes in men who were diagnosed with prostate cancer between 1994 and 1995.

This subanalysis included 1,655 men aged 55-74 years, who underwent either external beam radiation or radical prostatectomy during that period. They filled out quality of life surveys at baseline, and at 6 months and 1, 2, 5, and 15 years after their diagnosis. Since younger, healthier men may be more likely to have surgery, the authors used a propensity score analysis in an attempt to control for age. Most of the group (70%) underwent radical prostatectomy; 30% had radiation therapy.

Overall, men who had surgery were significantly more likely to experience urinary and sexual dysfunction, while the radiation group was significantly more likely to experience bowel dysfunction.

The differences were most obvious early in the follow-up period. At 2 and 5 years after treatment, men in the surgery group were significantly more likely to report erectile dysfunction than those were those treated with radiation. (odds ratio, 3.46 and 1.96 respectively). By 15 years, this difference had disappeared, however.

Men who had surgery were also significantly more likely to report having no sexual activity at 2 years (OR, 1.83), but at 5 and 15 years, there were no significant differences between the groups.

The surgical group was more likely to report urinary dysfunction compared with the radiation-treated cohort. Having no urinary control was significantly more likely at 2 and 5 years (OR, 6.2 and 5.1 respectively), but not at 15 years. Urine leakage was also significantly more likely in the surgery group at 2 and 5 years (OR, 13.0 and 5.5, respectively), but not at 15 years.

The need for pads to stay dry was significantly more likely at both 2 and 5 years for the surgery group (OR, 26 and 12, respectively). The surgery group was still significantly more likely to need pads at 15 years, although the difference was somewhat attenuated (OR, 4.5).

Not surprisingly, Dr. Resnick said, men in the surgery group were also significantly more likely to report being bothered by their urinary problems at 2 and 5 years, (OR, 6 and 7, respectively), but not at 15 years.

Finally, patients who underwent radiation therapy were more likely to be bothered by bowel dysfunction throughout the follow-up period; by 15 years after treatment, bowel issues were 3.4 times more common among this group.

While more studies on long-term functional outcomes are needed, Dr. Resnick said this information can be helpful in pretreatment decision-making – a time when patients need to weigh the risks of impaired function associated with each treatment paradigm.

"In terms of evaluating the patient up-front, we can use this information to elicit their preferences [for treatment]. That is an important piece of the plan."

The study was funded by the National Cancer Institute. Dr. Resnick had no financial disclosures.

*Headline was revised 07/12/12.

ATLANTA – At 15 years after treatment, disease-related quality of life measures appear similar in men with prostate cancer, regardless of whether they had radical prostatectomy or external radiation beam therapy.

The significant differences in sexual, urinary, and bowel function that were apparent in the first 5 years, largely disappeared as time advanced, Dr. Matthew Resnick reported, based on a new subanalysis of men in the Prostate Cancer Outcomes Study.

The convergence of outcomes may not have so much to do with treatment type as it does advancing age, he said at the annual meeting of the American Urologic Association. This is especially apparent in erectile dysfunction, according to Dr. Resnick, a urologic surgeon at Vanderbilt University Medical Center, Nashville, Tenn.

"Age really is the most significant determinant of decline in erectile function over time," he said. "About 50% of men older than 70 have erectile dysfunction."

The Prostate Cancer Outcomes Study (PCOS) enrolled patients from six Surveillance, Epidemiology, and End Results (SEER) tumor registries to examine long-term functional outcomes in men who were diagnosed with prostate cancer between 1994 and 1995.

This subanalysis included 1,655 men aged 55-74 years, who underwent either external beam radiation or radical prostatectomy during that period. They filled out quality of life surveys at baseline, and at 6 months and 1, 2, 5, and 15 years after their diagnosis. Since younger, healthier men may be more likely to have surgery, the authors used a propensity score analysis in an attempt to control for age. Most of the group (70%) underwent radical prostatectomy; 30% had radiation therapy.

Overall, men who had surgery were significantly more likely to experience urinary and sexual dysfunction, while the radiation group was significantly more likely to experience bowel dysfunction.

The differences were most obvious early in the follow-up period. At 2 and 5 years after treatment, men in the surgery group were significantly more likely to report erectile dysfunction than those were those treated with radiation. (odds ratio, 3.46 and 1.96 respectively). By 15 years, this difference had disappeared, however.

Men who had surgery were also significantly more likely to report having no sexual activity at 2 years (OR, 1.83), but at 5 and 15 years, there were no significant differences between the groups.

The surgical group was more likely to report urinary dysfunction compared with the radiation-treated cohort. Having no urinary control was significantly more likely at 2 and 5 years (OR, 6.2 and 5.1 respectively), but not at 15 years. Urine leakage was also significantly more likely in the surgery group at 2 and 5 years (OR, 13.0 and 5.5, respectively), but not at 15 years.

The need for pads to stay dry was significantly more likely at both 2 and 5 years for the surgery group (OR, 26 and 12, respectively). The surgery group was still significantly more likely to need pads at 15 years, although the difference was somewhat attenuated (OR, 4.5).

Not surprisingly, Dr. Resnick said, men in the surgery group were also significantly more likely to report being bothered by their urinary problems at 2 and 5 years, (OR, 6 and 7, respectively), but not at 15 years.

Finally, patients who underwent radiation therapy were more likely to be bothered by bowel dysfunction throughout the follow-up period; by 15 years after treatment, bowel issues were 3.4 times more common among this group.

While more studies on long-term functional outcomes are needed, Dr. Resnick said this information can be helpful in pretreatment decision-making – a time when patients need to weigh the risks of impaired function associated with each treatment paradigm.

"In terms of evaluating the patient up-front, we can use this information to elicit their preferences [for treatment]. That is an important piece of the plan."

The study was funded by the National Cancer Institute. Dr. Resnick had no financial disclosures.

*Headline was revised 07/12/12.

ATLANTA – At 15 years after treatment, disease-related quality of life measures appear similar in men with prostate cancer, regardless of whether they had radical prostatectomy or external radiation beam therapy.

The significant differences in sexual, urinary, and bowel function that were apparent in the first 5 years, largely disappeared as time advanced, Dr. Matthew Resnick reported, based on a new subanalysis of men in the Prostate Cancer Outcomes Study.

The convergence of outcomes may not have so much to do with treatment type as it does advancing age, he said at the annual meeting of the American Urologic Association. This is especially apparent in erectile dysfunction, according to Dr. Resnick, a urologic surgeon at Vanderbilt University Medical Center, Nashville, Tenn.

"Age really is the most significant determinant of decline in erectile function over time," he said. "About 50% of men older than 70 have erectile dysfunction."

The Prostate Cancer Outcomes Study (PCOS) enrolled patients from six Surveillance, Epidemiology, and End Results (SEER) tumor registries to examine long-term functional outcomes in men who were diagnosed with prostate cancer between 1994 and 1995.

This subanalysis included 1,655 men aged 55-74 years, who underwent either external beam radiation or radical prostatectomy during that period. They filled out quality of life surveys at baseline, and at 6 months and 1, 2, 5, and 15 years after their diagnosis. Since younger, healthier men may be more likely to have surgery, the authors used a propensity score analysis in an attempt to control for age. Most of the group (70%) underwent radical prostatectomy; 30% had radiation therapy.

Overall, men who had surgery were significantly more likely to experience urinary and sexual dysfunction, while the radiation group was significantly more likely to experience bowel dysfunction.

The differences were most obvious early in the follow-up period. At 2 and 5 years after treatment, men in the surgery group were significantly more likely to report erectile dysfunction than those were those treated with radiation. (odds ratio, 3.46 and 1.96 respectively). By 15 years, this difference had disappeared, however.

Men who had surgery were also significantly more likely to report having no sexual activity at 2 years (OR, 1.83), but at 5 and 15 years, there were no significant differences between the groups.

The surgical group was more likely to report urinary dysfunction compared with the radiation-treated cohort. Having no urinary control was significantly more likely at 2 and 5 years (OR, 6.2 and 5.1 respectively), but not at 15 years. Urine leakage was also significantly more likely in the surgery group at 2 and 5 years (OR, 13.0 and 5.5, respectively), but not at 15 years.

The need for pads to stay dry was significantly more likely at both 2 and 5 years for the surgery group (OR, 26 and 12, respectively). The surgery group was still significantly more likely to need pads at 15 years, although the difference was somewhat attenuated (OR, 4.5).

Not surprisingly, Dr. Resnick said, men in the surgery group were also significantly more likely to report being bothered by their urinary problems at 2 and 5 years, (OR, 6 and 7, respectively), but not at 15 years.

Finally, patients who underwent radiation therapy were more likely to be bothered by bowel dysfunction throughout the follow-up period; by 15 years after treatment, bowel issues were 3.4 times more common among this group.

While more studies on long-term functional outcomes are needed, Dr. Resnick said this information can be helpful in pretreatment decision-making – a time when patients need to weigh the risks of impaired function associated with each treatment paradigm.

"In terms of evaluating the patient up-front, we can use this information to elicit their preferences [for treatment]. That is an important piece of the plan."

The study was funded by the National Cancer Institute. Dr. Resnick had no financial disclosures.

*Headline was revised 07/12/12.

ATLANTA – Men with type 1 diabetes might not express an elevated level of prostate specific antigen, even if they have an early prostate cancer, suggest findings from a subanalysis of patients with type 1 diabetes.

In that prospective study, poor glycemic control was associated with decreased PSA levels, irrespective of age or body size, Dr. James Hotaling said during a poster session at the annual meeting of the American Urological Association.

"It’s well known that patients with type 2 diabetes have a decreased risk of prostate cancers as well as lower PSAs," said Dr. Hotaling of the University of Washington, Seattle.

"This lower PSA is thought to stem from a greater volume of distribution because many of these men are overweight or morbidly obese – and some hypothesize that they have lower testosterone because of the obesity and that this contributes to these findings."

Dr. Hotaling and his colleagues sought to determine whether men with type 1 diabetes showed a similar pattern. To do this, they examined data from year 17 of the Epidemiology of Diabetes Interventions and Complications (EDIC) study. EDIC began in 1994 and is the observational follow-up study of 1,441 participants in the earlier Diabetes Control and Complications Trial (DCCT).

PSA concentrations were measured in 627 men during year 17. The investigators stratified the subjects by both age (younger than 40 years, 41-59 years, and 60 years and older) and body mass index (normal, overweight, obese).

The subjects were a mean age of 52 years at the time of PSA measurement. Their mean HbA_1c was 8%, and the mean PSA 0.93 ng/mL.

PSA levels increased with age, from a low of 0.56 ng/mL in the youngest patients to a mean of 1.38 ng/mL in the oldest group.

PSA levels significantly decreased as HbA_1c increased. The mean PSA was 1.05 ng/mL when blood sugar was less than 7.5% and 0.76 ng/mL when blood sugar was above 8.5%.

"Each 10% increase in HbA_1c levels was associated with a PSA reduction of 1.37ng/mL," Dr. Hotaling said. "This association was independent of age and body size."

Our findings suggest that metabolic differences related to diabetes may affect the ability to detect early-stage prostate cancer. This finding also could represent a potentially modifiable risk factor that could be addressed.

The physiologic relationship between hyperglycemia and low PSA is not completely known, he added. "Proposed mechanisms are that hyperinsulinemia and insulin resistance lead to increased estradiol, which causes decreased testosterone and sex hormone–binding globulin, thus leading to a decreased PSA concentration."

EDIC is sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Hotaling reported having no financial disclosures.

ATLANTA – Men with type 1 diabetes might not express an elevated level of prostate specific antigen, even if they have an early prostate cancer, suggest findings from a subanalysis of patients with type 1 diabetes.

In that prospective study, poor glycemic control was associated with decreased PSA levels, irrespective of age or body size, Dr. James Hotaling said during a poster session at the annual meeting of the American Urological Association.

"It’s well known that patients with type 2 diabetes have a decreased risk of prostate cancers as well as lower PSAs," said Dr. Hotaling of the University of Washington, Seattle.

"This lower PSA is thought to stem from a greater volume of distribution because many of these men are overweight or morbidly obese – and some hypothesize that they have lower testosterone because of the obesity and that this contributes to these findings."

Dr. Hotaling and his colleagues sought to determine whether men with type 1 diabetes showed a similar pattern. To do this, they examined data from year 17 of the Epidemiology of Diabetes Interventions and Complications (EDIC) study. EDIC began in 1994 and is the observational follow-up study of 1,441 participants in the earlier Diabetes Control and Complications Trial (DCCT).

PSA concentrations were measured in 627 men during year 17. The investigators stratified the subjects by both age (younger than 40 years, 41-59 years, and 60 years and older) and body mass index (normal, overweight, obese).

The subjects were a mean age of 52 years at the time of PSA measurement. Their mean HbA_1c was 8%, and the mean PSA 0.93 ng/mL.

PSA levels increased with age, from a low of 0.56 ng/mL in the youngest patients to a mean of 1.38 ng/mL in the oldest group.

PSA levels significantly decreased as HbA_1c increased. The mean PSA was 1.05 ng/mL when blood sugar was less than 7.5% and 0.76 ng/mL when blood sugar was above 8.5%.

"Each 10% increase in HbA_1c levels was associated with a PSA reduction of 1.37ng/mL," Dr. Hotaling said. "This association was independent of age and body size."

Our findings suggest that metabolic differences related to diabetes may affect the ability to detect early-stage prostate cancer. This finding also could represent a potentially modifiable risk factor that could be addressed.

The physiologic relationship between hyperglycemia and low PSA is not completely known, he added. "Proposed mechanisms are that hyperinsulinemia and insulin resistance lead to increased estradiol, which causes decreased testosterone and sex hormone–binding globulin, thus leading to a decreased PSA concentration."

EDIC is sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Hotaling reported having no financial disclosures.

ATLANTA – Men with type 1 diabetes might not express an elevated level of prostate specific antigen, even if they have an early prostate cancer, suggest findings from a subanalysis of patients with type 1 diabetes.

In that prospective study, poor glycemic control was associated with decreased PSA levels, irrespective of age or body size, Dr. James Hotaling said during a poster session at the annual meeting of the American Urological Association.

"It’s well known that patients with type 2 diabetes have a decreased risk of prostate cancers as well as lower PSAs," said Dr. Hotaling of the University of Washington, Seattle.

"This lower PSA is thought to stem from a greater volume of distribution because many of these men are overweight or morbidly obese – and some hypothesize that they have lower testosterone because of the obesity and that this contributes to these findings."

Dr. Hotaling and his colleagues sought to determine whether men with type 1 diabetes showed a similar pattern. To do this, they examined data from year 17 of the Epidemiology of Diabetes Interventions and Complications (EDIC) study. EDIC began in 1994 and is the observational follow-up study of 1,441 participants in the earlier Diabetes Control and Complications Trial (DCCT).

PSA concentrations were measured in 627 men during year 17. The investigators stratified the subjects by both age (younger than 40 years, 41-59 years, and 60 years and older) and body mass index (normal, overweight, obese).

The subjects were a mean age of 52 years at the time of PSA measurement. Their mean HbA_1c was 8%, and the mean PSA 0.93 ng/mL.

PSA levels increased with age, from a low of 0.56 ng/mL in the youngest patients to a mean of 1.38 ng/mL in the oldest group.

PSA levels significantly decreased as HbA_1c increased. The mean PSA was 1.05 ng/mL when blood sugar was less than 7.5% and 0.76 ng/mL when blood sugar was above 8.5%.

"Each 10% increase in HbA_1c levels was associated with a PSA reduction of 1.37ng/mL," Dr. Hotaling said. "This association was independent of age and body size."

Our findings suggest that metabolic differences related to diabetes may affect the ability to detect early-stage prostate cancer. This finding also could represent a potentially modifiable risk factor that could be addressed.

The physiologic relationship between hyperglycemia and low PSA is not completely known, he added. "Proposed mechanisms are that hyperinsulinemia and insulin resistance lead to increased estradiol, which causes decreased testosterone and sex hormone–binding globulin, thus leading to a decreased PSA concentration."

EDIC is sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Hotaling reported having no financial disclosures.

ATLANTA – Men younger than age 55 who have served in the U.S. armed forces are almost three times as likely to report urinary incontinence as are their nonmilitary peers.

The association between military service and incontinence remained statistically significant even after investigators controlled for age, medications, and medical comorbidities – including prostate problems, Dr. Alayne Markland said at the annual meeting of the American Urological Society. Additionally, in the youngest group of men, the presence of posttraumatic stress disorder was associated with a threefold increase of any lower urinary tract symptom.

"One implication of this finding is the need for additional screening for men who are members of the armed forces, especially those who are returning from the current wars," said Dr. Markland, an internist at the Birmingham (Ala.) VA Medical Center. "This is something we need to ask about."

Dr. Markland reviewed data from the 2005-2006 and 2007-2008 cycles of the NHANES (National Health and Nutritional Examination Survey). Those cycles included queries about lower urinary tract symptoms, and provided an opportunity for respondents to rate any problems as mild, moderate, or severe.

The survey population included 5,287 men who were older than age 20. Military exposure was assessed by asking whether the respondent had ever served in any branch of the U.S. armed forces.

The investigators divided respondents into three age groups, correlated with the timing of military conflicts in which they might have served: 70 years or older (World War II or the Korean War); 55-59 (Vietnam War); and younger than 55 (Gulf War, Iraq, or Afghanistan). The groupings also allowed some comparison based on health concerns that are known to be associated with each conflict. For example, Vietnam-era vets could have been exposed to the defoliant Agent Orange and have a higher prevalence of diabetes and cancer than exists in the general population. Middle-aged veterans sometimes report Gulf War syndrome, and younger veterans report posttraumatic stress disorder and traumatic brain injury.

Among the entire survey population, the rate of any incontinence was 10%. About a quarter of the respondents reported having some military exposure. The rate of incontinence among these men was 19%, a significant difference.

Urgency was the most common problem, reported by 15% of veterans and 8% of civilians. The rates of stress and mixed incontinence were 4% and 2%, respectively.

Moderate to severe symptoms also were more common among the veterans (19% vs. 3%), whereas 1% of each group reported severe incontinence.

However, Dr. Markland said, when the group was broken down by age, the youngest group was driving the difference. Men aged 55 years and younger were three times more likely to report any urinary incontinence than were the nonmilitary population. The difference remained significant even after investigators controlled for ethnicity, socioeconomic level, body mass index, diabetes, and heart disease.

In another model that included prostate enlargement and cancer, the youngest veterans still had a threefold increase in the risk of incontinence.

Dr. Markland then examined the youngest group more carefully. Their average age was 26 years. Posttraumatic stress disorder was common, affecting 28% of them; 16% of this population reported some form of lower urinary tract problem. In fact, the presence of PTSD was associated with a threefold increase of any lower urinary tract symptom.

The association might be related to adrenergic or anticholinergic medication used to treat PTSD, Dr. Markland said. But even after investigators controlled for this, the youngest veterans had a 20% higher risk of any lower urinary tract symptom.

Because NHANES doesn’t collect any detailed information about military experience, there’s no way to tease out any cause and effect information, she said. But Dr. Christopher Amling, a moderator at the session, suggested that modern war injuries could be playing a part.

"Normally, you would expect to see much higher rates of this among an older population," said Dr. Amling, chief of urology at the Oregon Health and Science University, Portland. "What’s remarkable to me is that this is occurring in this younger population. To me, this suggests something about the recent conflicts – perhaps there is a greater risk of spinal cord or limb injuries."

Or, he said, the difference could be as simple as reluctance among older men to discuss their urinary problems. "Maybe they’re just more embarrassed to say anything about it."

However, Dr. Markland said, younger veterans are returning from the Middle East conflicts with different kinds of injuries than have been seen in past wars.

"Traumatic brain injury is a big issue, and we are still trying to recognize the more subtle presentations of blast injuries."

And, she said, the very armor that protects soldiers may contribute to problems when they survive an injury. "The Kevlar protection shields the thorax and abdomen, so although more people are surviving, we’re seeing many more limbs blown off, as well as TBI. We can keep soldiers from being killed, but anything that injures the brain can cause dysfunctional voiding."

Dr. Markland and Dr. Amling said they had no financial disclosures.

ATLANTA – Men younger than age 55 who have served in the U.S. armed forces are almost three times as likely to report urinary incontinence as are their nonmilitary peers.

The association between military service and incontinence remained statistically significant even after investigators controlled for age, medications, and medical comorbidities – including prostate problems, Dr. Alayne Markland said at the annual meeting of the American Urological Society. Additionally, in the youngest group of men, the presence of posttraumatic stress disorder was associated with a threefold increase of any lower urinary tract symptom.

"One implication of this finding is the need for additional screening for men who are members of the armed forces, especially those who are returning from the current wars," said Dr. Markland, an internist at the Birmingham (Ala.) VA Medical Center. "This is something we need to ask about."

Dr. Markland reviewed data from the 2005-2006 and 2007-2008 cycles of the NHANES (National Health and Nutritional Examination Survey). Those cycles included queries about lower urinary tract symptoms, and provided an opportunity for respondents to rate any problems as mild, moderate, or severe.

The survey population included 5,287 men who were older than age 20. Military exposure was assessed by asking whether the respondent had ever served in any branch of the U.S. armed forces.

The investigators divided respondents into three age groups, correlated with the timing of military conflicts in which they might have served: 70 years or older (World War II or the Korean War); 55-59 (Vietnam War); and younger than 55 (Gulf War, Iraq, or Afghanistan). The groupings also allowed some comparison based on health concerns that are known to be associated with each conflict. For example, Vietnam-era vets could have been exposed to the defoliant Agent Orange and have a higher prevalence of diabetes and cancer than exists in the general population. Middle-aged veterans sometimes report Gulf War syndrome, and younger veterans report posttraumatic stress disorder and traumatic brain injury.

Among the entire survey population, the rate of any incontinence was 10%. About a quarter of the respondents reported having some military exposure. The rate of incontinence among these men was 19%, a significant difference.

Urgency was the most common problem, reported by 15% of veterans and 8% of civilians. The rates of stress and mixed incontinence were 4% and 2%, respectively.

Moderate to severe symptoms also were more common among the veterans (19% vs. 3%), whereas 1% of each group reported severe incontinence.

However, Dr. Markland said, when the group was broken down by age, the youngest group was driving the difference. Men aged 55 years and younger were three times more likely to report any urinary incontinence than were the nonmilitary population. The difference remained significant even after investigators controlled for ethnicity, socioeconomic level, body mass index, diabetes, and heart disease.

In another model that included prostate enlargement and cancer, the youngest veterans still had a threefold increase in the risk of incontinence.

Dr. Markland then examined the youngest group more carefully. Their average age was 26 years. Posttraumatic stress disorder was common, affecting 28% of them; 16% of this population reported some form of lower urinary tract problem. In fact, the presence of PTSD was associated with a threefold increase of any lower urinary tract symptom.

The association might be related to adrenergic or anticholinergic medication used to treat PTSD, Dr. Markland said. But even after investigators controlled for this, the youngest veterans had a 20% higher risk of any lower urinary tract symptom.

Because NHANES doesn’t collect any detailed information about military experience, there’s no way to tease out any cause and effect information, she said. But Dr. Christopher Amling, a moderator at the session, suggested that modern war injuries could be playing a part.

"Normally, you would expect to see much higher rates of this among an older population," said Dr. Amling, chief of urology at the Oregon Health and Science University, Portland. "What’s remarkable to me is that this is occurring in this younger population. To me, this suggests something about the recent conflicts – perhaps there is a greater risk of spinal cord or limb injuries."

Or, he said, the difference could be as simple as reluctance among older men to discuss their urinary problems. "Maybe they’re just more embarrassed to say anything about it."

However, Dr. Markland said, younger veterans are returning from the Middle East conflicts with different kinds of injuries than have been seen in past wars.

"Traumatic brain injury is a big issue, and we are still trying to recognize the more subtle presentations of blast injuries."

And, she said, the very armor that protects soldiers may contribute to problems when they survive an injury. "The Kevlar protection shields the thorax and abdomen, so although more people are surviving, we’re seeing many more limbs blown off, as well as TBI. We can keep soldiers from being killed, but anything that injures the brain can cause dysfunctional voiding."

Dr. Markland and Dr. Amling said they had no financial disclosures.

ATLANTA – Men younger than age 55 who have served in the U.S. armed forces are almost three times as likely to report urinary incontinence as are their nonmilitary peers.

The association between military service and incontinence remained statistically significant even after investigators controlled for age, medications, and medical comorbidities – including prostate problems, Dr. Alayne Markland said at the annual meeting of the American Urological Society. Additionally, in the youngest group of men, the presence of posttraumatic stress disorder was associated with a threefold increase of any lower urinary tract symptom.

"One implication of this finding is the need for additional screening for men who are members of the armed forces, especially those who are returning from the current wars," said Dr. Markland, an internist at the Birmingham (Ala.) VA Medical Center. "This is something we need to ask about."

Dr. Markland reviewed data from the 2005-2006 and 2007-2008 cycles of the NHANES (National Health and Nutritional Examination Survey). Those cycles included queries about lower urinary tract symptoms, and provided an opportunity for respondents to rate any problems as mild, moderate, or severe.

The survey population included 5,287 men who were older than age 20. Military exposure was assessed by asking whether the respondent had ever served in any branch of the U.S. armed forces.

The investigators divided respondents into three age groups, correlated with the timing of military conflicts in which they might have served: 70 years or older (World War II or the Korean War); 55-59 (Vietnam War); and younger than 55 (Gulf War, Iraq, or Afghanistan). The groupings also allowed some comparison based on health concerns that are known to be associated with each conflict. For example, Vietnam-era vets could have been exposed to the defoliant Agent Orange and have a higher prevalence of diabetes and cancer than exists in the general population. Middle-aged veterans sometimes report Gulf War syndrome, and younger veterans report posttraumatic stress disorder and traumatic brain injury.

Among the entire survey population, the rate of any incontinence was 10%. About a quarter of the respondents reported having some military exposure. The rate of incontinence among these men was 19%, a significant difference.

Urgency was the most common problem, reported by 15% of veterans and 8% of civilians. The rates of stress and mixed incontinence were 4% and 2%, respectively.

Moderate to severe symptoms also were more common among the veterans (19% vs. 3%), whereas 1% of each group reported severe incontinence.

However, Dr. Markland said, when the group was broken down by age, the youngest group was driving the difference. Men aged 55 years and younger were three times more likely to report any urinary incontinence than were the nonmilitary population. The difference remained significant even after investigators controlled for ethnicity, socioeconomic level, body mass index, diabetes, and heart disease.

In another model that included prostate enlargement and cancer, the youngest veterans still had a threefold increase in the risk of incontinence.

Dr. Markland then examined the youngest group more carefully. Their average age was 26 years. Posttraumatic stress disorder was common, affecting 28% of them; 16% of this population reported some form of lower urinary tract problem. In fact, the presence of PTSD was associated with a threefold increase of any lower urinary tract symptom.

The association might be related to adrenergic or anticholinergic medication used to treat PTSD, Dr. Markland said. But even after investigators controlled for this, the youngest veterans had a 20% higher risk of any lower urinary tract symptom.

Because NHANES doesn’t collect any detailed information about military experience, there’s no way to tease out any cause and effect information, she said. But Dr. Christopher Amling, a moderator at the session, suggested that modern war injuries could be playing a part.

"Normally, you would expect to see much higher rates of this among an older population," said Dr. Amling, chief of urology at the Oregon Health and Science University, Portland. "What’s remarkable to me is that this is occurring in this younger population. To me, this suggests something about the recent conflicts – perhaps there is a greater risk of spinal cord or limb injuries."

Or, he said, the difference could be as simple as reluctance among older men to discuss their urinary problems. "Maybe they’re just more embarrassed to say anything about it."

However, Dr. Markland said, younger veterans are returning from the Middle East conflicts with different kinds of injuries than have been seen in past wars.

"Traumatic brain injury is a big issue, and we are still trying to recognize the more subtle presentations of blast injuries."

And, she said, the very armor that protects soldiers may contribute to problems when they survive an injury. "The Kevlar protection shields the thorax and abdomen, so although more people are surviving, we’re seeing many more limbs blown off, as well as TBI. We can keep soldiers from being killed, but anything that injures the brain can cause dysfunctional voiding."

Dr. Markland and Dr. Amling said they had no financial disclosures.

ATLANTA – Children who are exposed to secondhand tobacco smoke have an increased risk of urinary urgency, frequency, and incontinence, prospective data from a small study have shown.

Among children with these bladder symptoms, 28% were exposed to tobacco smoke on a daily basis – 13% higher than the overall child exposure rate in New Jersey, Dr. Kelly Johnson said at the annual meeting of the American Urological Association.

In addition to irritating a child’s bladder, childhood exposure to tobacco smoke is directly linked to the development of bladder cancer as an adult, she said in a press briefing.

Dr. Johnson, chief urology resident at the Robert Wood Johnson University Hospital, New Brunswick, N.J., presented prospective data on 45 children, aged 4-17 years, who presented with irritative bladder symptoms – frequency, urgency, and incontinence.

She used the Harvard Children’s Health and the Children’s Neurotoxicant Exposure studies to classify tobacco smoke exposure. The patients’ symptom severity was scored with the Dysfunctional Voiding Scoring System and classified as very mild, mild, Drmoderate, or severe.

About half of the group (21) had very mild or mild symptoms, while the remainder had symptoms scored as moderate or severe.

None of the children with mild scores were exposed to secondhand smoke on a daily basis, and none had mothers who smoked. However, 23% of those with moderate to severe scores had mothers who smoked, and 50% were exposed to smoke in a car on a regular basis.

"On our measures of environmental tobacco smoke exposure, children with greater exposure had significantly higher symptom severity scores than children who weren’t exposed," Dr. Johnson said. "This relationship was particularly striking for the younger children aged 4-10 years old."

Physicians who see children with bladder dysfunction should ask parents about smoke exposure, she advised – not only because of its effect on the current problems, but because of its proven dangers as the child grows up.

"Tobacco smoke contains chemicals that are known bladder irritants in both children and adults, and European studies have shown a strong relationship between adult bladder cancer and childhood tobacco smoke exposure.

The discussion of a child’s urinary symptoms provides a very good opportunity to speak to parents about smoking cessation, she added.

"It’s a teachable moment," that can have a long-lasting positive impact on both the child and the parent. "Unlike other risky behaviors, which affect only the person who engages in them, smoking poses substantial health risks to those not involved in the process," she said.

Dr. Johnson said she had had no relevant financial disclosures.

ATLANTA – Children who are exposed to secondhand tobacco smoke have an increased risk of urinary urgency, frequency, and incontinence, prospective data from a small study have shown.

Among children with these bladder symptoms, 28% were exposed to tobacco smoke on a daily basis – 13% higher than the overall child exposure rate in New Jersey, Dr. Kelly Johnson said at the annual meeting of the American Urological Association.

In addition to irritating a child’s bladder, childhood exposure to tobacco smoke is directly linked to the development of bladder cancer as an adult, she said in a press briefing.

Dr. Johnson, chief urology resident at the Robert Wood Johnson University Hospital, New Brunswick, N.J., presented prospective data on 45 children, aged 4-17 years, who presented with irritative bladder symptoms – frequency, urgency, and incontinence.

She used the Harvard Children’s Health and the Children’s Neurotoxicant Exposure studies to classify tobacco smoke exposure. The patients’ symptom severity was scored with the Dysfunctional Voiding Scoring System and classified as very mild, mild, Drmoderate, or severe.

About half of the group (21) had very mild or mild symptoms, while the remainder had symptoms scored as moderate or severe.

None of the children with mild scores were exposed to secondhand smoke on a daily basis, and none had mothers who smoked. However, 23% of those with moderate to severe scores had mothers who smoked, and 50% were exposed to smoke in a car on a regular basis.

"On our measures of environmental tobacco smoke exposure, children with greater exposure had significantly higher symptom severity scores than children who weren’t exposed," Dr. Johnson said. "This relationship was particularly striking for the younger children aged 4-10 years old."

Physicians who see children with bladder dysfunction should ask parents about smoke exposure, she advised – not only because of its effect on the current problems, but because of its proven dangers as the child grows up.

"Tobacco smoke contains chemicals that are known bladder irritants in both children and adults, and European studies have shown a strong relationship between adult bladder cancer and childhood tobacco smoke exposure.

The discussion of a child’s urinary symptoms provides a very good opportunity to speak to parents about smoking cessation, she added.

"It’s a teachable moment," that can have a long-lasting positive impact on both the child and the parent. "Unlike other risky behaviors, which affect only the person who engages in them, smoking poses substantial health risks to those not involved in the process," she said.

Dr. Johnson said she had had no relevant financial disclosures.

ATLANTA – Children who are exposed to secondhand tobacco smoke have an increased risk of urinary urgency, frequency, and incontinence, prospective data from a small study have shown.

Among children with these bladder symptoms, 28% were exposed to tobacco smoke on a daily basis – 13% higher than the overall child exposure rate in New Jersey, Dr. Kelly Johnson said at the annual meeting of the American Urological Association.

In addition to irritating a child’s bladder, childhood exposure to tobacco smoke is directly linked to the development of bladder cancer as an adult, she said in a press briefing.

Dr. Johnson, chief urology resident at the Robert Wood Johnson University Hospital, New Brunswick, N.J., presented prospective data on 45 children, aged 4-17 years, who presented with irritative bladder symptoms – frequency, urgency, and incontinence.

She used the Harvard Children’s Health and the Children’s Neurotoxicant Exposure studies to classify tobacco smoke exposure. The patients’ symptom severity was scored with the Dysfunctional Voiding Scoring System and classified as very mild, mild, Drmoderate, or severe.

About half of the group (21) had very mild or mild symptoms, while the remainder had symptoms scored as moderate or severe.

None of the children with mild scores were exposed to secondhand smoke on a daily basis, and none had mothers who smoked. However, 23% of those with moderate to severe scores had mothers who smoked, and 50% were exposed to smoke in a car on a regular basis.

"On our measures of environmental tobacco smoke exposure, children with greater exposure had significantly higher symptom severity scores than children who weren’t exposed," Dr. Johnson said. "This relationship was particularly striking for the younger children aged 4-10 years old."

Physicians who see children with bladder dysfunction should ask parents about smoke exposure, she advised – not only because of its effect on the current problems, but because of its proven dangers as the child grows up.

"Tobacco smoke contains chemicals that are known bladder irritants in both children and adults, and European studies have shown a strong relationship between adult bladder cancer and childhood tobacco smoke exposure.

The discussion of a child’s urinary symptoms provides a very good opportunity to speak to parents about smoking cessation, she added.

"It’s a teachable moment," that can have a long-lasting positive impact on both the child and the parent. "Unlike other risky behaviors, which affect only the person who engages in them, smoking poses substantial health risks to those not involved in the process," she said.

Dr. Johnson said she had had no relevant financial disclosures.

ATLANTA – Men in their 40s with a low prostate specific antigen can probably safely delay additional testing for 10-15 years.

Young men with a higher baseline level, however, are twice as likely to develop prostate cancer over the same time period and should probably have their PSA tested at regular intervals, Dr. Christopher Weight said at the annual meeting of the American Urologic Association.

His prospective study of 268 men in their 40s showed that none of the men with a baseline PSA of 1.0 ng/mL or less developed high-risk disease by 10 years and only 3% developed it by 15 years. The findings could provide an effective way to risk-stratify young populations, reducing unnecessary testing and the consequences that sometimes follow it, he said.

"We have to admit that we overdiagnose and overtreat men," Dr. Weight said at a press briefing. "But there is danger in completely throwing out the PSA test. Testing men early can help us identify those who can safely delay additional testing and those who will benefit from more frequent tests."

Dr. Weight, a urology oncology fellow at the Mayo Clinic, Rochester, Minn., turned to the Olmsted County cohort for the study data. Since 1990, most of the residents in the county have received their medical care through the Mayo Clinic and its affiliate centers. A linked health records database provides information for long-term population-based studies.

His analysis included 268 men, all of whom had a baseline PSA drawn sometime during their 40s (median age 45 years). The men also had a transrectal ultrasound and digital rectal exam. They have been followed now for up to 20 years, with a median time of 16 years.

Among the cohort, 192 had a baseline PSA of 1.0 ng/mL or lower and 76 had a level of more than 1.0 ng/mL. There were no significant between-group differences in either family history or the results of the rectal exam.

Over the full follow-up period, men with the lower PSA level had a significantly lower risk of exceeding the age-specific cut points for PSA than did men with the higher levels (10% vs. 50%).

By the end of the follow-up period, there were six incident cases of prostate cancer in the low-PSA group, all of which were low-risk disease. This translated to an incidence rate of 1.6 per 1,000 patient/ years, with a mean of 15 years until diagnosis.

Twice as many men in the high-PSA group developed prostate cancer (12). Of these cases, 10 were low-risk disease and 2 high-risk. This translated into a rate of 8/1,000 patient-years, with a mean of 10 years to diagnosis.

The baseline measurement was fairly predictive of 15-year outcomes, Dr. Weight said. A cutoff of 1.0 ng/mL at the initial test had a sensitivity of 67% and a specificity of 74% for predicting the occurrence of prostate cancer. Changing the cutoff to 0.7 ng/mL on the initial test resulted in a sensitivity of 83% and a specificity of 46%

The results show that this single, early PSA level may be helpful in counseling patients about follow-up, said Dr. Scott Eggener, who moderated the briefing.

"The goals of any test are to identify the cohort of people most likely to benefit, and those people in whom screening can be limited to minimize the potential harms of the test," said Dr. Eggener, director of urology outcomes and translational research at the University of Chicago Medical Center. "If a young man has a very low PSA, we can feel comfortable in recommending that he have another test in several years, somewhat like what’s done with a screening colonoscopy. If the level is higher, this patient probably needs to be followed more frequently."

Neither Dr. Weight nor Dr. Eggener had any financial disclosures.

ATLANTA – Men in their 40s with a low prostate specific antigen can probably safely delay additional testing for 10-15 years.

Young men with a higher baseline level, however, are twice as likely to develop prostate cancer over the same time period and should probably have their PSA tested at regular intervals, Dr. Christopher Weight said at the annual meeting of the American Urologic Association.

His prospective study of 268 men in their 40s showed that none of the men with a baseline PSA of 1.0 ng/mL or less developed high-risk disease by 10 years and only 3% developed it by 15 years. The findings could provide an effective way to risk-stratify young populations, reducing unnecessary testing and the consequences that sometimes follow it, he said.

"We have to admit that we overdiagnose and overtreat men," Dr. Weight said at a press briefing. "But there is danger in completely throwing out the PSA test. Testing men early can help us identify those who can safely delay additional testing and those who will benefit from more frequent tests."

Dr. Weight, a urology oncology fellow at the Mayo Clinic, Rochester, Minn., turned to the Olmsted County cohort for the study data. Since 1990, most of the residents in the county have received their medical care through the Mayo Clinic and its affiliate centers. A linked health records database provides information for long-term population-based studies.

His analysis included 268 men, all of whom had a baseline PSA drawn sometime during their 40s (median age 45 years). The men also had a transrectal ultrasound and digital rectal exam. They have been followed now for up to 20 years, with a median time of 16 years.

Among the cohort, 192 had a baseline PSA of 1.0 ng/mL or lower and 76 had a level of more than 1.0 ng/mL. There were no significant between-group differences in either family history or the results of the rectal exam.

Over the full follow-up period, men with the lower PSA level had a significantly lower risk of exceeding the age-specific cut points for PSA than did men with the higher levels (10% vs. 50%).

By the end of the follow-up period, there were six incident cases of prostate cancer in the low-PSA group, all of which were low-risk disease. This translated to an incidence rate of 1.6 per 1,000 patient/ years, with a mean of 15 years until diagnosis.

Twice as many men in the high-PSA group developed prostate cancer (12). Of these cases, 10 were low-risk disease and 2 high-risk. This translated into a rate of 8/1,000 patient-years, with a mean of 10 years to diagnosis.

The baseline measurement was fairly predictive of 15-year outcomes, Dr. Weight said. A cutoff of 1.0 ng/mL at the initial test had a sensitivity of 67% and a specificity of 74% for predicting the occurrence of prostate cancer. Changing the cutoff to 0.7 ng/mL on the initial test resulted in a sensitivity of 83% and a specificity of 46%

The results show that this single, early PSA level may be helpful in counseling patients about follow-up, said Dr. Scott Eggener, who moderated the briefing.

"The goals of any test are to identify the cohort of people most likely to benefit, and those people in whom screening can be limited to minimize the potential harms of the test," said Dr. Eggener, director of urology outcomes and translational research at the University of Chicago Medical Center. "If a young man has a very low PSA, we can feel comfortable in recommending that he have another test in several years, somewhat like what’s done with a screening colonoscopy. If the level is higher, this patient probably needs to be followed more frequently."

Neither Dr. Weight nor Dr. Eggener had any financial disclosures.

ATLANTA – Men in their 40s with a low prostate specific antigen can probably safely delay additional testing for 10-15 years.

Young men with a higher baseline level, however, are twice as likely to develop prostate cancer over the same time period and should probably have their PSA tested at regular intervals, Dr. Christopher Weight said at the annual meeting of the American Urologic Association.

His prospective study of 268 men in their 40s showed that none of the men with a baseline PSA of 1.0 ng/mL or less developed high-risk disease by 10 years and only 3% developed it by 15 years. The findings could provide an effective way to risk-stratify young populations, reducing unnecessary testing and the consequences that sometimes follow it, he said.

"We have to admit that we overdiagnose and overtreat men," Dr. Weight said at a press briefing. "But there is danger in completely throwing out the PSA test. Testing men early can help us identify those who can safely delay additional testing and those who will benefit from more frequent tests."

Dr. Weight, a urology oncology fellow at the Mayo Clinic, Rochester, Minn., turned to the Olmsted County cohort for the study data. Since 1990, most of the residents in the county have received their medical care through the Mayo Clinic and its affiliate centers. A linked health records database provides information for long-term population-based studies.

His analysis included 268 men, all of whom had a baseline PSA drawn sometime during their 40s (median age 45 years). The men also had a transrectal ultrasound and digital rectal exam. They have been followed now for up to 20 years, with a median time of 16 years.

Among the cohort, 192 had a baseline PSA of 1.0 ng/mL or lower and 76 had a level of more than 1.0 ng/mL. There were no significant between-group differences in either family history or the results of the rectal exam.

Over the full follow-up period, men with the lower PSA level had a significantly lower risk of exceeding the age-specific cut points for PSA than did men with the higher levels (10% vs. 50%).

By the end of the follow-up period, there were six incident cases of prostate cancer in the low-PSA group, all of which were low-risk disease. This translated to an incidence rate of 1.6 per 1,000 patient/ years, with a mean of 15 years until diagnosis.

Twice as many men in the high-PSA group developed prostate cancer (12). Of these cases, 10 were low-risk disease and 2 high-risk. This translated into a rate of 8/1,000 patient-years, with a mean of 10 years to diagnosis.

The baseline measurement was fairly predictive of 15-year outcomes, Dr. Weight said. A cutoff of 1.0 ng/mL at the initial test had a sensitivity of 67% and a specificity of 74% for predicting the occurrence of prostate cancer. Changing the cutoff to 0.7 ng/mL on the initial test resulted in a sensitivity of 83% and a specificity of 46%

The results show that this single, early PSA level may be helpful in counseling patients about follow-up, said Dr. Scott Eggener, who moderated the briefing.

"The goals of any test are to identify the cohort of people most likely to benefit, and those people in whom screening can be limited to minimize the potential harms of the test," said Dr. Eggener, director of urology outcomes and translational research at the University of Chicago Medical Center. "If a young man has a very low PSA, we can feel comfortable in recommending that he have another test in several years, somewhat like what’s done with a screening colonoscopy. If the level is higher, this patient probably needs to be followed more frequently."

Neither Dr. Weight nor Dr. Eggener had any financial disclosures.