Military Exposure and Urinary Incontinence among American Men

Transcription

1 Military Exposure and Urinary Incontinence among American Men Camille P. Vaughan,*, Theodore M. Johnson II, Patricia S. Goode, David T. Redden, Kathryn L. Burgio and Alayne D. Markland From the Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center (CPV, TMJ, PSG, DTR, KLB, ADM), Birmingham, Alabama and Atlanta, Georgia, Division of General Medicine and Geriatrics, Department of Medicine, Emory University (CPV, TMJ), Atlanta, Georgia, and Center for Aging (PSG, KLB, ADM) and Schools of Public Health (DTR) and Medicine (PSG, DTR, KLB, ADM), University of Alabama at Birmingham, Birmingham, Alabama Purpose: We examined the association between military exposure and urinary incontinence in American men. Materials and Methods: Data from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008 were merged to include 5,297 men 20 years old or older. The question, Did you ever serve in the Armed Forces of the United States? (yes/no) was used to assess military exposure. Urinary incontinence was categorized as any or moderate/severe urinary incontinence vs none. Because the impact of military exposure varied by age, multivariate logistic regression models were used to estimate the OR and 95% CI stratified by 3 age groups, including 55 or less, 56 to 69 and 70 years or greater. Analysis was adjusted for race/ethnicity, education, body mass index, self-reported health status, number of chronic conditions, depression and prostate conditions, the latter in men 40 years old or older. Results: Overall 23% of male respondents reported military exposure. Men with military exposure were more likely to report any urinary incontinence (18.6% vs 10.4%) and moderate/severe urinary incontinence (9.0% vs 3.1%, each p <0.001) than men without military exposure. After multivariate adjustment in men 55 years old or younger those with military exposure had 3 times greater odds of urinary incontinence (OR 3.28, 95% CI 1.38e7.77). Military exposure did not increase the odds of urinary incontinence in men 56 to 69 years old (OR 0.97, 95% CI 0.44e2.18), or 70 years old or older (OR 0.91, 95% CI 0.55e1.50). Conclusions: Prior military exposure was associated with moderate/severe urinary incontinence in American men 55 years old or younger even after controlling for known risk factors. Case finding is warranted for urinary incontinence in younger men with a history of military service. Key Words: urinary bladder, veterans, urinary incontinence, male, public health Abbreviations and Acronyms LUTS ¼ lower urinary tract symptoms UI ¼ urinary incontinence Accepted for publication July 11, Study received National Centers for Health Statistics ethics review board approval. Supported by Veterans Health Administration Rehabilitation Research and Development Career Development Awards (CDA-2) B6126-W (ADM) and Vaughan 1 IK2 RX (CPV). The United States Department of Veterans Affairs had no role in the collection, analysis and interpretation of the data or the manuscript preparation, review or approval. The conclusions expressed by the authors do not necessarily reflect the opinions of the United States Department of Veterans Affairs or the author affiliated institutions. * Correspondence: Atlanta Veterans Affairs Medical Center, 1670 Clairmont Rd., Mailstop: 11B, Decatur, Georgia (telephone: , extension 3710; FAX: ; camille.vaughan@emory.edu). Financial interest and/or other relationship with Astellas and Kimberly-Clark. Financial interest and/or other relationship with Pfizer, Ferring, Vantia and Johnson & Johnson. Financial interest and/or other relationship with Pfizer and Astellas. IN the United States men who are veterans are known to have significantly worse health status than men in the civilian population. 1 Certain conditions that are highly prevalent in the veteran population, such as depression, posttraumatic stress disorder, prostate cancer and neurological disease, are also often associated with LUTS. 2 4 In 1 study the urinary symptom burden was not higher in the veteran population than in the /14/ /0 THE JOURNAL OF UROLOGY 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Vol. 191, , January 2014 Printed in U.S.A. j 125

2 126 MILITARY EXPOSURE AND URINARY INCONTINENCE AMONG AMERICAN MEN civilian population. 5 However, that study relied on administrative claims data, which could be a significant limitation because of the lower coding use in the Veterans Affairs (VA) single payer health system compared to the civilian, largely fee-forservice system. Also, most adults who experience urinary symptoms do not report UI to their provider. 6 NHANES represents a population based sample of American adults who completed validated urinary symptom questionnaires in select years as well as an assessment of self-reported military service. We examined the association of military exposure with any UI and moderate/severe UI in men. Because the impact of exposure could vary across military conflicts of different eras, we also assessed whether the association between military service and UI varied by age. MATERIALS AND METHODS NHANES Sample The NHANES program consists of cross-sectional health surveys performed by the National Center for Health Statistics of the Centers for Disease Control and Prevention ( NHANES provides estimates of the health status of the population of the United States by selecting a nationally representative sample of the noninstitutionalized population using a complex, stratified, multistage, probability cluster design. NHANES oversampled individuals 60 years old or older along with black, Mexican-American and low income white individuals to provide more reliable estimates of these groups. The National Centers for Health Statistics ethics review board approved the protocol and all participants provided written informed consent. Procedures Participants were interviewed at home and then underwent standardized physical examination, including measurement of height and weight, and a private interview at a mobile examination center. The interview included questions on LUTS for all participants 20 years old or older. Men 40 years old or older were also asked questions related to prostate conditions during this private interview. Military exposure was self-reported as a positive or negative response to the question, Did you ever serve in the Armed Forces of the United States? To define UI severity we analyzed responses from the validated 2-item Incontinence Severity Index, which measures incontinence volume and frequency. Responses to the 2 questions are multiplied to obtain a severity score of 1 to 12 with a score of 3 or greater categorized as moderate/severe UI. 7 Moderate/severe UI corresponds to at least weekly leakage or monthly leakage of volumes more than only drops regardless of the type of UI. Among men who responded negatively to the stress and urge UI questions other incontinence was defined by a positive response to the question, During the past 12 months, have you leaked or lost control of even a small amount of urine without an activity like coughing, lifting or exercise, or an urge to urinate? Positive responses to the stress as well as the urge UI questions defined mixed UI. These definitions are consistent with International Continence Society definitions. 8 For prostate conditions the response to the question, Have you ever been told by a doctor or health professional that you had an enlarged prostate gland? defined benign prostate hyperplasia. The response to the question, Have you ever been told by a doctor or health professional that you had prostate cancer? identified those who had had prostate cancer. Age was categorized into 3 groups chosen to correspond to the age of veterans who served in specific wartime eras, including 1) 55 years old or youngerdveterans of recent conflicts, including the Gulf War, 2) 56 to 69 years olddvietnam conflict veterans and 3) 70 years old or olderdkorean War and World War II veterans. In interviews done in the household participants self-reported race/ethnicity, which was then categorized as nonhispanic white, nonhispanic black, Hispanic (including Mexican-American) and other/mixed race/ ethnicity. Given the difference in some LUTS according to racial/ethnic differences among men, 9,10 nonhispanic white men were compared to all other racial/ethnic groups. Education was categorized as at least some level of high school education, including a General Education Development equivalent, or more than high school. The poverty income ratio, an indicator of socioeconomic status that uses the ratio of income to the family poverty threshold set by the United States Census Bureau, was categorized as less than 1dbelow the poverty threshold, 1 to less than 2d1 to 1.9 the poverty threshold, or 2 or greaterd2 or more the poverty threshold. From body measurement data the body mass index was calculated as weight in kg divided by height in m 2 and categorized as less than 25.0dunderweight/normal weight, 25.0 to 29.9doverweight and 30.0 or moredobese. 11 Data on disease status was ascertained by the question, Has a doctor or other health professional told you that you had [disease]? In addition to hypertension, we also examined 5 disease categories identified as leading causes of death or morbidity in a prior NHANES analysis, including arthritis, cerebrovascular accident, chronic lower respiratory tract disease (self-reported emphysema, chronic bronchitis or asthma), coronary heart disease (coronary disease, angina or myocardial infarction) and diabetes mellitus (receiving insulin and/or diabetic pills). 12 Participants were then categorized based on the cumulative number of chronic disease categories reported (none, 1, 2, 3, 4 or more). Self-described general health status was defined by the response to the question, Would you say that in general your health is excellent, very good, good, fair, or poor? Responses were aggregated into 2 categories, that is excellent, very good or good health vs fair or poor health. Depression was assessed in a private interview at the mobile examination center using the validated Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 yields a score of 0 to In this analysis a score of 10 or greater was used to define major depression.

3 MILITARY EXPOSURE AND URINARY INCONTINENCE AMONG AMERICAN MEN 127 Statistical Analysis All analysis was calculated using StataÒ 12.0, which incorporates the design effect, appropriate sample weights, and stratification and clustering of the complex NHANES sample design. 14 Sample weights adjusted for unequal probabilities of selection and nonresponse. For this analysis we defined any UI as mild, moderate or severe symptoms. The Pearson chi-square test, including the appropriate sampling weights, was used to assess the association of UI with demographic and medical characteristics, which were selected based on the potential to impact UI or confound the association between UI and military exposure. These characteristics were race/ethnicity, education, body mass index, self-reported health status, 15 number of chronic conditions, depression and prostate conditions, the latter in men 40 years old or older. Estimates with a relative SE of greater than 30% were identified as statistically unreliable and not included in the final model. Multivariate logistic regression models were constructed using variables from bivariate analysis that showed statistically significant associations with UI (p <0.1). To test whether the effect of military exposure on UI (dependent variable) varied by age we introduced the interaction term, age decade military experience. To better understand the joint associations between UI and military exposure by age the data set was stratified into 3 age groups, including 55 or less, 56 to 69 and 70 years or greater. Separate weighted multivariate models were then constructed for each age group. Weighted multivariable models included race/ethnicity, education, body mass index, self-reported health, comorbid conditions and depression. Multivariate models including prostate conditions were analyzed separately because they only included men 40 years old or older. Only prostate enlargement was included in the 40 to 55-year age group due to the few primary sampling units and low prevalence of prostate cancer. The POR and 95% CI were obtained from the multivariate models with statistical significance considered at p <0.05. RESULTS Two of the 5,297 men 20 years old or older had missing data on military exposure and 621 had missing data on UI, leaving 4,674 available for analysis. The overall rate of reported military exposure was 22.8%, including 11.4% in men 55 years old or younger, 45.0% in men 56 to 69 years old and 68.5% in men 70 years old or older. Men with any UI and moderate/severe UI had several notable differences compared to men without UI (supplementary table, Those with UI were more likely to be older, report a history of military exposure, have a higher body mass index (any UI only) and report worse self-rated health. Men with UI were also more likely to have a positive screening test for depression, 4 or more comorbid conditions, a previous diagnosis of prostate enlargement and a previous diagnosis of prostate cancer (p <0.005). Overall, men with military exposure had a higher prevalence rate of any UI (18.6% vs 10.4%) and of moderate/severe UI (9.0% vs 3.1%, each p <0.001). Figure 1 shows the UI prevalence rate by severity in men with vs without military exposure in the 3 age groups. When comparing prevalence rates between age groups, men 70 years old or older were more likely to have UI regardless of a military exposure history. Of the age groups only men in the youngest age group (20 to 55 years) with military exposure had an increased prevalence of UI compared to men without military exposure (p <0.001). Of all men with UI the reported type of UI (urgency, stress, mixed or other) did not differ between those with and without military exposure (fig. 2). Urgency UI was the most common UI type reported by all men (fig. 2). Because adding an interaction term to the multivariate model indicated a significant difference in the association of military exposure and UI based on age group, we performed stratified analysis. The significant association between military exposure and UI persisted in the youngest age group (model 1, POR 3.8, 95% CI 1.7e8.4) but not in the middle or oldest age groups (see table). When limiting multivariate analysis to men 40 years old or older to allow for the inclusion of prostate conditions (model 2), benign prostate hyperplasia affected the odds of UI in the youngest age group (POR 3.3, 95% CI 1.4e7.8, see table). No significant change was noted in the other age groups when prostate conditions were added. DISCUSSION In this population based sample of American men self-reported military service was associated with UI. However, our assessment of interaction and adjustment for potential confounders revealed that the relationship between military service and UI was only significant in younger men (age 55 years or less). These results suggest that efforts directed toward UI case finding are important, particularly among younger male veterans, whom many practitioners may not consider at high risk for UI because of age. Findings should also stimulate further research on specific exposures or injuries common in recent military conflicts that could account for the variability across age groups. While all types of UI were reported by men who reported military service, urgency UI was the most prevalent type. Urgency UI is also the most commonly reported type of UI in the general population of men. 16 Studies in civilian and military populations suggest that traumatic brain injury is associated with urinary symptoms, particularly urgency UI and detrusor instability. 17,18 Traumatic brain injury is a well recognized combat related injury in more recent military conflicts. Information on traumatic brain injury was not included in

4 128 MILITARY EXPOSURE AND URINARY INCONTINENCE AMONG AMERICAN MEN Figure 1. UI prevalence and severity in age categories of men with and without military exposure. Blue bars indicate mild UI. Red bars indicate moderate UI. Green bars indicate severe/very severe UI. Asterisk indicates Pearson chi-square test for difference in each age category. NHANES. Recent studies also suggest that veterans with Gulf War illness experience autonomic dysfunction, including urinary symptoms. 19 Additional research is needed to assess whether the prevalence of traumatic brain injury or Gulf War illness in younger veterans could be a factor related to the increased prevalence of UI in this group. Military exposure was 4 to 6 times more common in men older than 55 years. This difference is likely the effect of drafting by the Selective Service System from 1948 to However, after assessing potential confounding factors military exposure was not associated with UI in men older than 55 years. The association also did not vary based on self-reported prostate cancer, which is a service connected Multivariable models of association of military exposure with moderate to severe UI in American men by age Model (age) No. Pts OR (95% CI) p Value Figure 2. UI types in American men with (red bars) and without (blue bars) military exposure. No statistically significant difference was noted between groups for each UI type. Model 1: , (1.71e8.4) (0.46e2.52) or Greater (0.63e1.52) 0.93 Model 2 (prostate enlargement/ca): , (1.38e7.77) (0.44e2.18) or Greater (0.55e1.50) 0.72

5 MILITARY EXPOSURE AND URINARY INCONTINENCE AMONG AMERICAN MEN 129 condition in veterans with Agent Orange exposure in the Vietnam military conflict. 2 However, UI remains a highly prevalent condition in men with a history of military service in these age groups with 20% of those 56 to 69 years old and 30% of those 70 years old or older reporting UI. While military exposure may not be as significant a factor as age, practitioners should query all older patients on bothersome urinary symptoms. The current study has strengths not found in a previous study of urinary symptom prevalence in the United States using health care encounter data from the VA health care system. 5 In NHANES urinary symptoms were self-reported using a validated questionnaire, in contrast to being determined by diagnostic codes, which could underestimate symptom prevalence. 20 Missing data on the primary exposure of military service and UI outcome were sparse with less than 15% missing. Using a large sample with a significant proportion of men who reported military service (almost a quarter of the sample) allowed for multivariate comparisons between men with and without military exposure. There are some limitations of our study. Because NHANES is a cross-sectional study, causality cannot be ascertained. Military exposure is a self-reported item that could not be verified in this de-identified data set. Additional data, such as duration of service or combat vs noncombat status, are not available in NHANES. The accuracy of NHANES self-reported data on medical conditions has some variability but is considered moderately accurate for prostate cancer. 21 Information on prior treatment for UI or other LUTS is not available in NHANES. Lastly, NHANES excluded institutionalized individuals, thereby limiting the generalizability of these results beyond community dwelling men. CONCLUSIONS These results show that military service is associated with UI in American men 55 years old or younger. While many practitioners may not consider screening for UI in this age group, veterans of recent military conflicts should be queried about UI, particularly urgency UI. Including urinary symptom questionnaires in the assessment of military personnel returning from deployment could help determine whether the variation in the relationship between military exposure and UI by age group is explained by combat related exposure during specific conflicts. REFERENCES 1. Rogers WH, Kazis LE, Miller DR et al: Comparing the health status of VA and non-va ambulatory patients: the Veterans Health and Medical Outcomes Studies. J Amb Care Manag Soc Amb Care 2004; 27: Chamie K, DeVere White RW, Lee D et al: Agent Orange exposure, Vietnam War veterans, and the risk of prostate cancer. Cancer 2008; 113: Li B, Mahan CM, Kang HK et al: Longitudinal health study of US 1991 Gulf War veterans: changes in health status at 10-year follow-up. Am J Epidemiol 2011; 174: Toomey R, Kang HK, Karlinsky J et al: Mental health of US Gulf War veterans 10 years after the war. Br J Psychiatry 2007; 190: Anger JT, Saigal CS, Wang M et al: Urologic disease burden in the United States: veteran users of Department of Veterans Affairs healthcare. Urology 2008; 72: Burgio KL, Ives DG, Locher JL et al: Treatment seeking for urinary incontinence in older adults. J Am Geriatr Soc 1994; 42: Sandvik H, Seim A, Vanvik A et al: A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour padweighing tests. Neurourol Urodyn 2000; 19: Abrams P, Chapple C, Khoury S et al: Evaluation and treatment of lower urinary tract symptoms in older men. J Urol 2009; 181: Fitzgerald MP, Litman HJ, Link CL et al: The association of nocturia with cardiac disease, diabetes, body mass index, age and diuretic use: results from the BACH survey. J Urol 2007; 177: Burgio KL, Johnson TM 2nd, Goode PS et al: Prevalence and correlates of nocturia in community-dwelling older adults. J Am Geriatr Soc 2010; 58: DuBeau C, Kuchel G, Johnson TM II et al: Incontinence in the frail elderly. Presented at International Consultation on Incontinence, Paris, France, July 5-8, Weiss CO, Boyd CM, Yu Q et al: Patterns of prevalent major chronic disease among older adults in the United States. JAMA 2007; 298: Kroenke K, Spitzer RL and Williams JB: The PHQ-9: validity of a brief depression severity measure. J Gen Int Med 2001; 16: Vaughan CP, Endeshaw Y, Nagamia Z et al: A multicomponent behavioural and drug intervention for nocturia in elderly men: rationale and pilot results. BJU Int 2009; 104: Johnson TM, Kincade JE, Bernard SL et al: The association of urinary incontinence with poor self-rated health. J Am Geriatr Soc 1998; 46: Markland AD, Goode PS, Redden DT et al: Prevalence of urinary incontinence in men: results from the National Health and Nutrition Examination Survey. J Urol 2010; 184: Giannantoni A, Silvestro D, Siracusano S et al: Urologic dysfunction and neurologic outcome in coma survivors after severe traumatic brain injury in the postacute and chronic phase. Arch Phys Med Rehab 2011; 92: Keller JJ, Liu SP and Lin HC: Traumatic brain injury increases the risk of female urinary incontinence. Neurourol Urodyn 2013; 32: Haley R, Charuvastra E, Shell W et al: Cholinergic autonomic dysfunction in veterans with gulf war illness: Confirmation in a population-based sample. JAMA Neurol 2013; 70: Sohn MW, Zhang H, Taylor B et al: Prevalence and trends of selected urologic conditions for VA healthcare users. BMC Urol 2006; 6: Bergmann M, Byers T, Freedman DS et al: Validity of self-reported diagnoses leading to hospitalization: A comparison of self-reports with hospital records in a prospective study of American adults. Am J Epidemiol 1998; 147: 969.