Body mass index, waist-to-hip ratio, and metabolic syndrome as predictors of middle-aged men's health

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1 Originl Article - Sexul Dysfunction/Infertility pissn eissn Body mss index, wist-to-hip rtio, nd metbolic syndrome s predictors of middle-ged men's helth Jung Hyun Prk *, In-Chng Cho 1,*, Yoo Seok Kim 1, Soon Ki Kim 1, Seung Ki Min 1, So Shin Kye Deprtments of Fmily Medicine nd 1 Urology, Ntionl Police Hospitl, Seoul, Kore Purpose: There is no reported evidence for n nthropometric index tht might link obesity to men s sexul helth. We evluted the bility of n nthropometric index nd the symptom scores of five widely used questionnires to detect men s helth problems. We determined the predictive bilities of two obesity indexes nd other clinicl prmeters for screening for lower urinry trct symptoms nd sexul dysfunction in middle-ged men. Mterils nd Methods: A totl of 1,910 middle-ged men were included in the study. Prticipnts underwent detiled clinicl evlution tht included recording the symptom scores of five widely used questionnires. The prticipnts body mss index nd wist-to-hip rtio were determined. Serum prostte-specific ntigen, urinlysis, testosterone, estimted glomerulr filtrtion rte, evlution of metbolic syndrome, nd trnsrectl ultrsonogrphy were ssessed. Results: By use of logistic regression nlysis, ge nd totl prostte volume were independent predictors of lower urinry trct symptoms. Metbolic syndrome ws the only significnt negtive predictive fctor for chronic prosttitis symptoms. Age nd metbolic syndrome were independent predictive fctors for erectile dysfunction. Wist-to-hip rtio hd sttisticlly significnt vlue for predicting erectile dysfunction. Conclusions: Our dt showed tht totl prostte volume is significnt predictor of lower urinry trct symptoms, nd centrl obesity hs predictive bility for erectile dysfunction. Metbolic syndrome ws the only significnt negtive predictive fctor for chronic prosttitis-like symptoms. The mngement of correctble fctors such s wist-to-hip rtio nd metbolic syndrome my be considered preventive modlities ginst the development of men s helth problems. Keywords: Body mss index; Lower urinry trct symptoms; Metbolic syndrome X; Physiologicl sexul dysfuntion; Wist-hip rtio This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. INTRODUCTION With ge, men experience decreses in importnt helth indictors like muscle mount, physicl ctivity, nd sexul drive. Furthermore, lower urinry trct symptoms (LUTS) re highly prevlent in mles, nd it hs been clerly shown tht the prevlence of LUTS increses with ge [1]. The incidence of erectile dysfunction (ED) lso increses with ge, s does the incidence of crdiovsculr disese risk fctors, such s hypertension, obesity, nd Received: 28 Jnury, 2015 Accepted: 23 Februry, 2015 Corresponding Author: So Shin Kye Deprtment of Fmily Medicine, Ntionl Police Hospitl, Songi-ro 123, Songp-gu, Seoul , Kore TEL: , FAX: , E-mil: soskye@nph.go.kr *These uthors contributed eqully to this study nd should be considered co-first uthors. c The Koren Urologicl Assocition,

2 Obesity-relted indices nd men s helth dibetes. Additionlly, ED hs significnt negtive impct on qulity of life (QoL). Stisfction with sexul life nd the existence of LUTS severely ffect men's QoL nd plgue middle-ged men's helth [2]. Numerous studies hve ssessed QoL in men with LUTS, benign prosttic hyperplsi (BPH), nd ED, but n estimtion of middleged men's helth in comprison to other comprehensive clinicl prmeters hs not been reported previously in Kore. Questionnires re one of the most commonly used techniques for collecting helth-relted informtion in clinicl studies becuse of their ese nd simplicity [3]. The Interntionl Prostte Symptom Score (IPSS) questionnire is used worldwide to mesure LUTS [1]. To evlute vrious voiding symptoms, perinel or suprpubic pin, nd sexul disturbnce, The Ntionl Institutes of Helth Chronic Prosttitis Symptom Index (NIH-CPSI) is used to ssess chronic prosttitis (CP)/chronic pelvic pin syndrome [4]. The ndrogen deficiency in ging mles (ADAM), premture ejcultion dignostic tool (PEDT), nd Internl Index of Erectile Function-5 (IIEF- 5) questionnires re used worldwide to evlute men's sex lives [5]. By using these five questionnires to evlute detiled clinicl problems, we proposed to reserch severl fctors ffecting middle-ged men's generl helth. We evluted the reltionship of vrious clinicl prmeters tht re relted to men's generl helth nd the symptom scores of five widely used questionnires for detecting men's helth problems. We determined the predictive bilities of two obesity indexes nd other clinicl prmeters for screening for LUTS nd sexul dysfunction in middle-ged men. We believe tht this study my not only provide clerer figure of the suffering cused in middle-ged men's QoL, but lso widen the public's understnding of middle-ged men's generl helth. MATERIALS AND METHODS 1. Study design Between Mrch nd September 2013, totl of 1910 helthy Koren men ged 40 to 59 yers who prticipted in helth exmintion were included. The subjects grew up in vrious cities nd were recruited from our institution. All men underwent detiled clinicl evlutions by use of the IPSS, NIH-CPSI, ADAM, IIEF-5, nd PEDT questionnires. Anthropometric mesurements, including height, weight, nd wist circumference, were determined. Blood nd urine smples were obtined for serum prostte-specific ntigen (PSA) nd testosterone mesurement between 0700 nd The estimted glomerulr filtrtion rte (egfr) ws clculted nd metbolic syndrome (MetS) ws evluted. The egfr ws clculted by using the bbrevited four-vrible Modifiction of Diet in Renl Disese eqution [6]: GFR=186.3 (serum cretinine) (ge) (0.742 if femle) (1.210 if blck) MetS ws defined by using the criteri estblished by the Ntionl Cholesterol Eduction Progrm-Adult Tretment Pnel III published in 2005 [7]. MetS ws dignosed when t lest three of the following criteri were present: (1) wist circumference greter thn 90 cm or body mss index (BMI) higher thn 25 kg/m 2, (2) systolic blood pressure 130 mmhg or greter or distolic blood pressure 85 mmhg or greter or use of ntihypertensive mediction, (3) fsting blood sugr greter thn 110 mg/ dl or self-reported dibetes mediction use, (4) triglyceride greter thn 150 mg/dl, nd (5) high-density lipoprotein cholesterol less thn 45 mg/dl or use of lipid mediction [7]. Therefter, ll of the prticipnts underwent digitl rectl exmintion (DRE) to screen for prostte enlrgement or nodules suggesting prostte cncer. Next, trnsrectl ultrsound (TRUS) ws performed nd ultrsonogrphic inspection of the prostte ws performed in ech subject by using 3.5-MHz trnsducer (Voluson 730, Generl Electronic, Milwukee, WI, USA). Prostte volume ws mesured by using the prostte ellipsoid formul, multiplying the lrgest nteroposterior (height, H), trnsverse (width, W), nd cephlocudl (length, L) prostte dimeters by (HxWxLxπ/6) by using TRUS [8]. BMI ws clculted s the weight (kg) divided by the squre of the height (m), nd wist-to-hip rtio (WHR) ws determined s the wist circumference divided by the hip circumference [9]. Wist circumference ws mesured by plcing tpe mesure snugly t the horizontl level between the subcostl mrgin nd pelvic brim [10]. Exclusion criteri included presence of pyuri (white blood cells>5 on urinlysis), the presence of neurogenic bldder dysfunction, confirmed prostte cncer, history of recurrent urinry trct infections or bldder stones, or ny other history of lower urinry trct disorder influencing urintion. In ddition, individuls who used medictions ffecting prostte growth, such s nti-ndrogens nd 5-α-reductse inhibitors, or who hd bnorml findings on the DRE were excluded from the study. 387

3 Prk et l 2. Sttisticl nlysis T-tests were conducted to compre the differences in men's generl helth scores ccording to other prmeters, such s PSA, testosterone level, egfr, nd totl prostte volume (TPV). Chi-squre or Fisher exct test were conducted to compre the differences in mens' generl helth scores ccording to MetS, obesity, nd centrl obesity. The results were expressed s men±stndrd devition or proportion vlues. nd multivrite logistic regression nlyses were performed for ech group to determine the significnce of ge, PSA, testosterone, egfr, nd TPV s predictors of men's helth problems. The results were considered sttisticlly significnt when p<0.05. Sttisticl nlyses were performed by using SPSS ver (SPSS Inc., Chicgo, IL, USA). 3. Ethics sttement The study protocol ws pproved by the Institutionl Review Bord in Ntionl Police Hospitl (Seoul, Kore; IRB registrtion number hr-008). Informed consent ws obtined from ech ptient. RESULTS 1. Ptient chrcteristics Among 1,910 prticipnts, 1,899 ptients completed urologicl nd psychitric evlutions nd did not meet the previous exclusion criteri. The medin ge of the ptients ws 53 yers, nd the medin vlues of BMI nd WHR were 24.8 kg/m 2 nd 0.93, respectively. BMI ws ctegorized into two groups: nonobese (<24.8 kg/m 2 ) nd obese ( 24.8 kg/m 2 ) becuse 24.8 kg/m 2 ws the medin vlue in the helthy volunteers. We lso divided the ptients into two groups by their WHR, either bove or below 0.93, the medin vlue in the helthy volunteers. The dt on the ptients ges, serum PSA levels, nd testosterone levels nd the results of the nthropometric mesurements re summrized in Tble 1. In ddition, the medin scores on the IPSS, NIH-CPSI, ADAM, IIEF-5, nd PEDT re summrized in Tble Differences in men's generl helth score ccording to vrious prmeters We exmined men's generl helth by using severl clinicl prmeters, including obesity-relted prmeters. To nlyze differences in men s generl helth ccording to vrious clinicl prmeters, we divided the five questionnire groups into two subgroups ech depending on the degree of symptom severity (Tble 2). In this study, moderte to severe LUTS ws defined s n IPSS score 8, nd the group with moderte to severe LUTS hd reltively greter TPV thn did the group with no or mild LUTS (p=0.001). Other clinicl prmeters were not significntly different between the two groups divided by severity of LUTS. NIH-CPSI ws defined s score over 14, nd inversely, those men showed lower prevlence of MetS (p=0.023) thn did men in the group with no or mild CPSI. Other clinicl prmeters, including obesityrelted prmeters, did not differ significntly between the two groups divided by severity of NIH-CPSI. To evlute the sex life of the ptients, we divided the subjects by IIEF-5 score. ED ws defined s score less thn 12. In this study, the group with moderte to severe ED showed reltively higher prevlence of MetS (p=0.012) nd centrl obesity (mesured by WHR 0.93) (p<0.001). There were no sttisticlly significnt differences in other clinicl prmeters between the two groups divided ccording to the severity of their IIEF-5 scores. For the two remining questionnires, ADAM nd PEDT, there were no significnt differences between subgroups. Tble 1. Ptient chrcteristics (n=1,899) Vlue Age (y) 53.0 ( ) prostte-specific ntigen (ng/ml) 0.72 ( ) Testosterone (ng/ml) 4.58 ( ) egfr (ml/min/1.73 m 2 ) ( ) Body mss index (kg/m 2 ) 24.8 ( ) Totl prostte volume (cm 3 ) 24.0 ( ) Wist-to-hip rtio 0.93 ( ) Interntionl Prostte Symptom Score 10 (6 16) CPSI 7 (4 13) ADAM 34 (26 44) IIEF-5 18 (13 22) Premture ejcultion dignostic tool 7 (4 11) Metbolic syndrome 636 (33.5) Hypertension history 392 (20.7) Dibetes history 162 (8.5) Dyslipidemi history 57 (3.0) Vlues re presented s medin (interqurtile rnge) or number (%). egfr, estimted glomerulr filtrtion rte; CPSI, the Ntionl Institutes of Helth Chronic Prosttitis Symptom Index; ADAM, ndrogen deficiency in ging mles questionnire; IIEF-5, Interntionl Index of Erectile Function

4 Obesity-relted indices nd men s helth Tble 2. Differences in men s generl helth score ccording to vrious prmeters Severity PSA (ng/ml) TT (ng/ml) IPSS CPSI ADAM IIEF-5 PEDT 0.92± ± ± ±1.40 egfr (ml/min/1.73 m 2 ) 99.42± ±16.12 TPV (cm 3 ) 23.6± ±7.0 MetS 253 (34.7) 383 (32.8) Obesity by BMI 355 (49.7) 527 (46.6) Centrl obesity by WHR 436 (59.7) 715 (61.2) p-vlue ± ± ± ± ± ± ± ± (34.7) 104 (28.4) 717 (48.2) 165 (46.2) 938 (61.2) 213 (58.2) p-vlue ± ± ± ± ± ± ± ± (32.6) 283 (34.7) 508 (48.5) 374 (46.9) 650 (60.0) 501 (61.4) p-vlue ± ± ± ± ± ± ± ± (32.2) 136 (39.4) 719 (47.4) 163 (49.5) 912 (58.7) 239 (69.3) p-vlue < ± ± ± ± ± ± ± ± (32.7) 257 (34.7) 541 (47.9) 341 (47.6) 696 (60.1) 455 (61.5) p-vlue Vlues re presented s men±stndrd devition or number (%). PSA, prostte-specific ntigen; TT, totl testosterone; egfr, estimted glomerulr filtrtion rte; TPV, totl prostte volume; MetS, metbolic syndrome; BMI, body mss index; WHR, wist-to-hip rtio; IPSS, Interntionl Prostte Symptom Score; CPSI, the Ntionl Institutes of Helth Chronic Prosttitis Symptom Index; ADAM, ndrogen deficiency in ging mles questionnire; IIEF-5, Interntionl Index of Erectile Function-5; PEDT, premture ejcultion dignostic tool. Tble 3. Logistic regression nlyses predicting moderte to severe LUTS (IPSS 8) Multivrite p-vlue OR 95% CI p-vlue OR 95% CI Age < PSA Testosterone egfr TPV MetS (non-mets vs. MetS) BMI WHR LUTS, lower urinry trct symptoms; IPSS, Interntionl Prostte Symptom Score; OR, odds rtio; CI, confidence intervl; PSA, prostte-specific ntigen; egfr, estimted glomerulr filtrtion rte; TPV, totl prostte volume; MetS, metbolic syndrome; BMI, body mss index; WHR, wist-tohip rtio. 3. Fctors influencing LUTS We evluted the predictive vlue of severl fctors for moderte to severe LUTS by looking t IPSS scores over 7. Multiple logistic regression nlyses reveled tht ge nd totl TPV were independent predictors of moderte to severe LUTS in the multivrite nlysis (p=0.001, odds rtio [OR], 1.034; 95% conf idence intervl [CI], ; p=0.010, OR, 1.019; 95% CI, ; respectively) (Tble 3). 4. Fctors influencing CP symptoms We evluted the predictive vlue of severl fctors for moderte to severe CP-like symptoms by NIH-CPSI scores over 14. As determined by logistic regression nlysis, MetS ws the only significnt negtive predictive fctor for moderte to severe CPSI scores (p=0.022; OR, 0.747; 95% CI, ) (Tble 4). 5. Fctors influencing symptoms relted to ndrogen deprivtion in ging mles We evluted the predictive vlue of severl fctors for moderte to severe ging mle's symptoms by ADAM scores over 36. Multiple logistic regression nlyses reveled tht ge ws the only significnt independent predictor for moderte to severe ADAM score (p=0.018; OR, 1.024; 95% CI, 389

5 Prk et l Tble 4. Logistic regression nlyses predicting moderte to severe CP-like symptoms (CPSI 15) p-vlue OR 95% CI Age PSA Testosterone egfr TPV MetS (non-mets vs. MetS) BMI WHR CP, chronic prosttitis; CPSI, Ntionl Institutes of Helth Chronic Prosttitis Symptom Index; OR, odds rtio; CI, confidence intervl; PSA, prosttespecific ntigen; egfr, estimted glomerulr filtrtion rte; TPV, totl prostte volume; MetS, metbolic syndrome; BMI, body mss index; WHR, wist-to-hip rtio. Tble 5. Logistic regression nlyses predicting moderte to severe ging mle s symptoms (ADAM 37) p-vlue OR 95% CI Age PSA Testosterone egfr TPV MetS (non-mets vs MetS) BMI WHR ADAM, Androgen Deficiency in Aging Mles questionnire; OR, odds rtio; CI, confidence intervl; PSA, prostte-specific ntigen; egfr, estimted glomerulr filtrtion rte; TPV, totl prostte volume; MetS, metbolic syndrome; BMI, body mss index; WHR, wist-to-hip rtio. Tble 6. Logistic regression nlyses predicting moderte to severe erectile dysfunction (IIEF-5 11) Multivrite p-vlue OR 95% CI p-vlue OR 95% CI Age < < PSA Testosterone egfr TPV MetS (non-mets vs MetS) BMI WHR , IIEF-5, Interntionl Index of Erectile Function-5; OR, odds rtio; CI, confidence intervl; PSA, prostte-specific ntigen; egfr, estimted glomerulr filtrtion rte; TPV, totl prostte volume; MetS, metbolic syndrome; BMI, body mss index; WHR, wist-to-hip rtio ). There were no significnt predictive fctors except ge (Tble 5). Aging definitely cuses lte-onset hypogondism. 6. Fctors influencing ED The degree of ED ws considered moderte to severe when the score on the IIEF-5 questionnire ws 11 or lower. The logistic regression nlysis showed tht ge nd MetS were independent predictive fctors for moderte to 390

6 Obesity-relted indices nd men s helth severe ED in the multivrite nlysis (p<0.001, OR, 1.121; 95% CI, ; p=0.036, OR, 1.323; 95% CI, ; respectively). WHR hd sttisticlly significnt vlue for predicting moderte to severe ED in the univrite nlysis (p=0.016; OR, ; 95% CI, , ) (Tble 6). Thus, higher ge, existence of MetS, nd centrl obesity mesured by WHR hd predictive bility for ED. DISCUSSION Becuse QoL hs improved in recent yers, more ttention is being pid to diseses tht influence QoL rther thn to only life-thretening diseses. LUTS, ED, nd premture ejcultion re such diseses tht ffect QoL in elderly men. To further our understnding bout the seriousness of middle-ged men's helth, we ssessed the severity of men's urinry trct symptoms, sexul function, nd premture ejcultion by using vlidted questionnires. Over the pst decdes, mny different groups hve investigted the influence of obesity on the development of BPH nd LUTS with conflicting results. Most of these groups concluded tht overll obesity, bdominl obesity, nd WHR cn increse the risk of BPH nd LUTS, t lest to some degree [11]. In our study, to minimize the effect of comorbidity by senility, the ge of ptients ws confined to 40 to 59 yers, representing middle-ged men. A totl of 1899 helthy Koren men ged 40 to 59 yers were included, nd the ge rnge ws selected becuse it encompssed the ged most closely ssocited with prosttitis nd ED. The outcomes of this study included severl interesting findings tht deserve further explntion. First, we showed tht clinicl prmeters including obesity-relted prmeters did not differ significntly between the groups divided by IPSS, NIH-CPSI, IIEF-5, ADAM, nd PEDT scores, except for TPV nd MetS. Our results indicted tht the group with moderte to severe LUTS hd reltively greter TPV. Second, the group with moderte to severe NIH-CPSI scores hd lower prevlence of MetS. Third, ccording to IIEF-5, the group with moderte to severe ED showed reltively higher prevlence of MetS nd centrl obesity s mesured by WHR. Fourth, we showed tht ge nd TPV were ssocited with more severe LUTS. Fifth, MetS ws the only significnt negtive predictive fctor for moderte to severe CPSI scores. We could not find definite reson for the negtive reltionship between MetS nd CP-like symptoms in our study. However, we suspect tht effects of dietry nd helthy behviors could be importnt issues in this reltionship. Brtoletti et l. [12] suggested tht CP/chronic pelvic pin syndrome (CPPS) is multifctoril disese. Cigrette smoking, high-clorie diet with low fruit nd vegetble consumption, constiption, slow digestion, sexul reltionship with more thn one prtner, nd coitus interruptus were more likely in ptients with CP/CPPS thn in controls [12]. In ddition, Zhng et l. [13] reported tht higher leisure-time physicl ctivity ws ssocited with lower risk of CP/CPPS. Ptients dignosed with MetS often give lot of ttention to their eting hbits nd lifestyle. The significnce of behvior-induced CPlike symptom reduction is still unknown. Further studies re needed to better chrcterize the etiopthogenesis in individuls to define the optiml pproch to dignosis nd tretment. Sixth, we reveled tht ge ws the only significnt independent predictor for moderte to severe ADAM scores. Finlly, we reveled tht ging, the existence of MetS, nd centrl obesity mesured by WHR hd predictive bility for ED. Interestingly, we found no evidence tht higher BMI in middle ge is ssocited with n incresed risk of LUTS, ED, or other relted men's helth concerns. In contrst, WHR ws strongly nd independently relted to ED. Overll, there re cler dvntges of using WHR; it is convenient nd simple to mesure nd n esy metric in dignosing not only the sequele normlly ssocited with MetS, but lso voiding dysfunction [10]. WHR my therefore be both useful nd importnt s mesure of success for possible future tretment options for ptients with ED. Active reduction of wist circumference vi tretment of MetS in ddition to tretment of pelvic inflmmtion nd ischemi my led to durble nd mteril improvement in ED. Other studies hve lso shown tht weight loss significntly improves insulin sensitivity, erectile function, nd testosterone levels in men [10]. To our knowledge, this is first study simultneously ssessing severl clinicl prmeters including obesityrelted prmeters nd the five questionnires for ssessing middle-ged men's helth. We studied lrge number of subjects in popultion-bsed study, nd there re few Asin studies in which more thn 1,500 subjects were nlyzed. This is the first lrge-scle study of Koren middle-ged men using the five vlidted questionnires. The number of ptients in this study ws lrge enough to chieve representtion of middle-ged men. Although severl studies hve shown n ssocition of LUTS nd obesity, there re few studies regrding the effects of the five vlidted questionnires representing men's urinry 391

7 Prk et l symptoms nd sexul function ccording to severl clinicl prmeters [11]. Our dt showed medin vlues nd severl functionl sttus indexes of middle-ged Koren men. However, our study hd severl specific limittions. Although the five questionnires tht we used were vlidted, studies bsed on questionnires hve limittions in tht they do not include bsic disese development nd limited informtion cn be obtined, prticulrly regrding dignostics. Becuse we only used the five questionnires to ssess LUTS nd sexul function, we lcked the detiled medicl nd socil history of the ptients. Another limittion of this study ws tht the dt were cross-sectionl nd did not provide informtion regrding the temporl cuse-effect reltionship between the clinicl prmeters nd middle-ged men's generl helth. The bseline demogrphics of the men enrolled in this study were not fully inspected or rndomized; thus, the bseline comorbidity of ech ptient my hve ffected the ptients' responses to the questionnires. Becuse this study consisted of dt from single institution, there my be potentil selection bis s well. In the future, locl popultion-bsed studies nd rndomized controlled trils will be needed. Despite these limittions, it is meningful tht this study showed reltionship of severl clinicl prmeters with middle-ged men's generl helth in popultion-bsed study. CONCLUSIONS Our dt showed tht TPV is significnt predictor of LUTS, nd our results indicted tht ge nd TPV were ssocited with the severity of LUTS symptoms. MetS ws the only significnt negtive predictive fctor for CPlike symptoms. It is suggested tht ptients with MetS re not prone to CP-like symptoms. Aging definitely cuses lte-onset hypogondism. Also, we showed tht ging, the existence of MetS, nd centrl obesity mesured by WHR hd predictive bility for ED. WHR is convenient nd simple mesurement, so it my therefore be useful nd importnt s mesure of success for future tretment. CONFLICTS OF INTEREST The uthors hve nothing to disclose. ACKNOWLEDGMENTS This work ws supported by Koren Ntionl Police Hospitl grnt. 392 REFERENCES 1. Irwin DE, Milsom I, Kopp Z, Abrms P, Artibni W, Herschorn S. Prevlence, severity, nd symptom bother of lower urinry trct symptoms mong men in the EPIC study: impct of overctive bldder. Eur Urol 2009;56: Cyn S, Bozlu M, Cnpolt B, Akby E. The ssessment of sexul functions in women with mle prtners complining of erectile dysfunction: does tretment of mle sexul dysfunction improve femle prtner's sexul functions? J Sex Mritl Ther 2004;30: Kim JH, Doo SW, Yng WJ, Song YS. Homogeneity mong the koren interntionl prostte symptom score questionnires used in rel prctice. Koren J Urol 2013;54: Scheffer AJ. Clinicl prctice. Chronic prosttitis nd the chronic pelvic pin syndrome. N Engl J Med 2006;355: Rosen RC, Riley A, Wgner G, Osterloh IH, Kirkptrick J, Mishr A. The interntionl index of erectile function (IIEF): multidimensionl scle for ssessment of erectile dysfunction. Urology 1997;49: Levey AS, Stevens LA, Schmid CH, Zhng YL, Cstro AF 3rd, Feldmn HI, et l. A new eqution to estimte glomerulr filtrtion rte. Ann Intern Med 2009;150: Jeong JH, Kim ET, Kim DK. Assocition of metbolic syndrome nd benign prostte enlrgement in young Koren mles. Koren J Urol 2011;52: Kim W, Jung JH, Kng TW, Song JM, Chung HC. Clinicl effects of discontinuing 5-lph reductse inhibitor in ptients with benign prosttic hyperplsi. Koren J Urol 2014;55: Byun HK, Sung YH, Kim W, Jung JH, Song JM, Chung HC. Reltionships between prostte-specific ntigen, prostte volume, nd components of metbolic syndrome in helthy Koren men. Koren J Urol 2012;53: Lee RK, Chung D, Chughti B, Te AE, Kpln SA. Centrl obesity s mesured by wist circumference is predictive of severity of lower urinry trct symptoms. BJU Int 2012;110: Kim GW, Doo SW, Yng WJ, Song YS. Effects of obesity on prostte volume nd lower urinry trct symptoms in Koren men. Koren J Urol 2010;51: Brtoletti R, Ci T, Mondini N, Dinelli N, Pinzi N, Pvone C, et l. Prevlence, incidence estimtion, risk fctors nd chrcteriztion of chronic prosttitis/chronic pelvic pin syndrome in urologicl hospitl outptients in Itly: results of multicenter cse-control observtionl study. J Urol 2007;178: Zhng R, Chomistek AK, Dimitrkoff JD, Giovnnucci EL, Willett WC, Rosner BA, et l. Physicl ctivity nd chronic prosttitis/chronic pelvic pin syndrome. Med Sci Sports Exerc 2015;47:

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