Editorial – referring to the articles published on pp. 389–422 of this issue

The Boston Area Community Health (BACH) Survey: Urologic and Sexual Symptoms Results or Origins from Physical or Behavioral Conditions

By: François Giulianolowast

European Urology, Volume 52 Issue 2, August 2007, Pages 326-330

Published online: 01 August 2007

Abstract Full Text Full Text PDF (94 KB)

Refers to article:

Measuring the Urologic Iceberg: Design and Implementation of the Boston Area Community Health (BACH) Survey

John B. McKinlay and Carol L. Link

Accepted 6 March 2007

August 2007 (Vol. 52, Issue 2, pages 389 - 396)

Refers to article:

Is Abuse Causally Related to Urologic Symptoms? Results from the Boston Area Community Health (BACH) Survey

Carol L. Link, Karen E. Lutfey, William D. Steers and John B. McKinlay

Accepted 6 March 2007

August 2007 (Vol. 52, Issue 2, pages 397 - 406)

Refers to article:

Beyond the Lower Urinary Tract: The Association of Urologic and Sexual Symptoms with Common Illnesses

Mary P. Fitzgerald, Carol L. Link, Heather J. Litman, Thomas G. Travison and John B. McKinlay

Accepted 6 March 2007

August 2007 (Vol. 52, Issue 2, pages 407 - 415)

Refers to article:

Association between Smoking, Passive Smoking, and Erectile Dysfunction: Results from the Boston Area Community Health (BACH) Survey

Varant Kupelian, Carol L. Link and John B. McKinlay

Accepted 6 March 2007

August 2007 (Vol. 52, Issue 2, pages 416 - 422)

Numerous epidemiologic studies have been performed to identify the prevalence of urologic and sexual conditions. Many of them were United States naturalistic cohorts using national managed care claims databases, which provided the advantages of a sufficiently large sample size, a naturalistic observation, and a nationally representative age distribution. However, the claims data include a population from specific managed care health plans, do not include subjects who do not seek care or use treatment, might be subject to some possible coding errors, and do not generally examine the sequence of comorbidities.

Large community-based prevalence studies, such as the Massachusetts Male Aging Study (MMAS) [1], the Krimpen study [2] and [3], the Multinational Survey of the Aging Male (MSAM) [4], the Prostate Cancer Awareness Week (PCAW) [5], and the Olmsted County and Flint Men's Health studies [6] were extremely useful to the medical community.

  • - The MMAS addressed the important issue of men's health through a cross-sectional survey on health and aging, in men, aged 40–70 yr. This survey was conducted in two waves, with a baseline data collection in 1987–1989 and a follow-up in 1995–1997. A total of 1709 participants were enrolled in the study.
  • - The Krimpel study of male urogenital tract problems and general health status was conducted in 1999 in Dutch men, aged 50–78 yr.
  • - The MSAM-7, a survey of 14,254 men, aged 50–80 yr, was conducted in 2001 to investigate the relationship between lower urinary tract symptoms (LUTS) and sexual problems in aging men.
  • - The PCAW, in 2003, involved 12,679 men screened for prostate cancer. Among them, a total of 6641 men had completed the questionnaires.
  • - The Olmsted County Study (OCS) of urinary symptoms and health status and the Flint Men's Health Study (FMHS) were two large comparable epidemiologic studies of community-dwelling white and black men combined for a total study sample of 2480 men. They also determined the magnitude of racial disparity in LUTS and associated bother.

These community-based prevalence studies are valuable in the estimation of the magnitude of the problem, identification of associated risk factors, and determination of bother in affected individuals. The overall sexual health in aging men is substantially influenced not only by age but also by the severity of their urinary and sexual symptoms after adjusting for the most common known risk factors. Moreover, according to the PCAW and the OCS/FMHS analyses, race/ethnicity appears to constitute a neglected potential risk factor. These data have been often used to project worldwide prevalence of urologic and sexual conditions. However, different communities have unique characteristics that affect the prevalence.

This issue of European Urology includes four articles written by researchers from the New England Research Institute chaired by John McKinlay. The Boston Area Community Health (BACH) [7] study was performed as a response to the US National Institutes of Health consensus panel recommendation. John McKinlay has been working in urologic epidemiology for several decades. The BACH study, conducted during the 2002–2005 period, is a survey on symptoms suggestive of urogenital diseases and conditions. The BACH study will contribute to the epidemiologic understanding of a range of urologic and sexual symptoms by providing prevalence estimates of these latter and their associated risk factors.

The first article [8] describes the need for the study, its aims, its research design, and its field implementation. The understanding of the study's concept is essential. The medical community, urologists and general practitioners, should be familiar with urologic epidemiology to understand how the data are collected, analyzed, and interpreted, as well as to feel comfortable extrapolating results in their own patient population, and consider these results in their individual practice. The BACH survey is built on the urologic epidemiology done over the past years that contributed to the development of scientific knowledge and awareness and to the identification of knowledge gaps.

There is a definite need to have an understanding of urologic and sexual symptoms, of the diagnosed symptoms, but also of the other symptoms, which are never presented for treatment or are presented but receive inappropriate diagnoses and treatment. Most urology research is presently conducted on the relatively small proportion of patients who have access to medical care, who consider symptoms important enough to seek treatment, and who receive an appropriate diagnosis.

The BACH study attempts to measure the true prevalence of urologic symptoms in the general community.

  • The BACH survey may address the limitations of previous studies with a large representative sample, a diversity of ethnicity, an inclusiveness of both men and women and a broad age range.
  • The BACH study was designed to fulfill an ambitious range of methodologic requirements regarding sampling, age distribution, collection of symptoms for representativeness of the general community, and transition to a prospective cohort study.
  • This study involves a randomly selected community-based sample. Its overall design was shaped by three independent variables, age, ethnicity and gender, with equal numbers of men and women, equal numbers of black, Hispanic, and white subjects, and equal numbers of participants by age group. The collected intervening variables are organized into six groups: sociodemographic influences, lifestyles, anthropometrics, health status, and biochemical parameters.
  • The BACH study collected data on urologic and sexual symptoms and comorbidities from validated questionnaires such as the American Urological Association (AUA) symptom index and the abbreviated International Index of Erectile Function (IIEF-5), and also data on health care utilization, including prescribed and over-the-counter medications, reproductive status, and smoking.

The recruited sample included 5506 subjects, 2301 men and 3205 women, and was well balanced across ethnic groups. The completion rate was of 63.4%. Blood samples were obtained from 68% of subjects who completed interviews. The representativeness of the BACH survey of the US community was assessed by comparing the BACH sample with three government-sponsored surveys on many different sociodemographic and health-related variables. It was determined that BACH results could be generalized in the United States.

The collection of urologic symptoms reflects the clinical approach. However, the magnitude of the overlap of symptoms suggestive of different urologic conditions/diseases should be recognized, for example, male frequency, urgency in benign prostatic hyperplasia (BPH) or bladder cancer or urinary tract infection. The availability of a detailed description of the BACH population profile could be of interest to evaluate the representativeness the population involved in clinical trials.

Overall, the BACH study should provide the following: (1) population-based specific prevalence and incidence rates for the major urologic conditions, (2) changes of urologic symptoms across a life span, (3) identification of major risk factors for many urologic symptoms and their implications for one's quality of life, and (4) assessment of the magnitude of unmet urologic needs in the general community, the psychosocial influences, and the use of prescribed and over-the-counter medications.

The second article [9] reports the investigation of the association between a history of sexual, physical, or emotional abuse and LUTS. The article also addresses the issue to which the observed association between abuse and urologic symptoms may be causal.

The World Health Organization (WHO) recognizes child abuse as a major public health problem worldwide. The recent “Study on Violence against Children” [10] provides an understanding of the nature, extent, causes, and consequences of different forms of violence against children—physical, psychological, and sexual—and takes into account the five main settings in which violence takes place. According to this study, around 40 million children, aged 0–14 yr, are abused, will develop physical and behavioral symptoms, and will require health and social care.

In the BACH study, all the three symptoms—frequency, urgency and nocturia—were positively associated with childhood and adolescent/adult sexual, physical, and emotional abuse. However, the severity of the abuses and their association with urologic symptoms might be important and should be examined. The role of corticotropin-releasing factor (CRF) and other neurotransmitters involved in the pathophysiology of these symptoms should be further explored for possibly identifying the neurobiologic support of these disorders and potential new pharmacologic applications that deserve research efforts.

The authors concluded that a strong association exists between abuse and LUTS. They suggested that clinicians should consider the possible contribution of abuse when managing patients who present the symptoms of urinary frequency, urgency, and nocturia.

The third article [11] investigates the relationship between 10 urologic and sexual symptoms and four major illnesses in the large BACH study adult population (n = 5506).

The 10 urologic and sexual symptoms, assessed with validated instruments, were LUTS, painful bladder syndrome (PBS), urinary incontinence (UI), prostatitis, frequency, urgency, nocturia, overactive bladder (OAB), erectile dysfunction (ED), and female sexual dysfunction. The four comorbid illnesses were type 2 diabetes, cardiac disease, hypertension, and depression. The influence of their treatments on urologic and sexual symptoms, not covered in this issue, will also be important to appreciate, for example, nocturia and ED with diuretics or sexual dysfunction with selective serotonin reuptake inhibitors.

Most urologic and sexual symptoms were significantly associated to at least one illness. A stronger association was seen with depression that is consistently associated with all the urologic and sexual symptoms after adjusting for other comorbid illnesses and in the presence of other covariates.

  • This association of urologic symptoms and depression should be reviewed by the leading medical societies responsible for urology for considering new recommendations, such as the two validated questions [12] “During the past month have you been bothered by feeling down, depressed or hopeless?” “During the past month have you often been bothered by little interest or pleasure doing things?” The use of these questions was previously recommended for ED by the International Consultation on Erectile Dysfunction [13].
  • These results confirm the findings of the MMAS in that the probability of ED in men with the most severe depression was approximately 90%, whereas the probability of ED was only 25% in the least depressed group.

To a lesser extent, cardiac disease is also associated with many urologic symptoms such as LUTS, UI, PBS, urgency, OAB, and ED, even after adjustment.

  • The findings of an association of urologic symptoms and cardiac disease is important and should lead to development of experimental and clinical pathophysiologic studies. In addition, it might be of interest to investigate the effect on the lower urinary tract of cardiovascular medications.
  • The association between ED and cardiac disease, previously shown in the longitudinal MMAS [14] and other studies, has been confirmed. However, surprisingly ED was not shown to be significantly associated with hypertension and diabetes. It should be noticed that diabetes, cardiac disease, and hypertension were identified in the BACH study by simply asking the respondents if they had ever been told by health care professionals that they have/had the medical conditions when depression was assessed by a specific questionnaire.

The BACH investigators should consider collecting information on penile curvature abnormalities to estimate the true prevalence of Peyronie's disease.

The fourth article [15] describes data from an analysis performed to confirm the association between ED and smoking, to investigate a dose-response effect, and to assess the association between ED and passive smoking.

Previous studies, including the MMAS, have shown an association between ED, smoking, and cardiovascular disease (CVD), with CVD being the likely pathway between ED and smoking. In the longitudinal MMAS, a higher incidence of ED among both active smokers and individuals exposed to passive smoking was observed; however, a dose-response relationship was not investigated.

In the BACH study, ED and its severity were documented with the IIEF-5. The smoking status (smokers >100 cigarettes in a lifetime), the smoking dose (usual number of cigarettes smoked per day and for how many years), but also the exposure to passive smoking (living on a daily basis with someone smoking) were reported. The age range of the 2301 studied men was 30 to 79 yr with a mean age of 47.6 yr.

An association between ED and smoking was observed with an increased risk of ED with cumulative pack-years of smoking. This dose-response effect of increased severity of ED with increased pack-years of smoking was statistically significant with ≥20 pack-years of exposure after adjusting for major ED risks, such as older age, CVD, and diabetes. There was also an association between ED and passive smoking, but these were small and not statistically significant. The magnitude of the effect of passive smoking was comparable to the 10–19 pack-years of smoking exposure.

The BACH analysis showed and confirmed a significant association between smoking and sexual performance [16]. Nonetheless, smoking also indirectly affects sexual health by increasing the incidence of comorbidities. It would be interesting to show in the longitudinal BACH survey an improvement of ED with smoking cessation to reinforce the current awareness effort.

These four studies constitute the “tip of the iceberg” of the large and comprehensive BACH database. The BACH study is improving our understanding of the epidemiology of a range of urologic and sexual symptoms/conditions. It will likely become the urology epidemiology reference study for the medical community for the coming decade. The generalization of the data to countries beyond the United States is essential and should be determined by appropriate comparisons with non-US surveys.

The ongoing prospective BACH cohort study allows following the population over time to estimate incidence rates, examine early precursors of subsequent disease, and observe the natural course of urologic and sexual symptoms. In addition, the dynamic longitudinal BACH data might help to better understand the importance of the identified associations. In particular, it will provide information about whether treatment of the associated conditions improves urologic and sexual symptoms and affects the quality of life.

The BACH study outcomes stress the fact that urologists should continue to enlarge their global medical approach of male and female patients with urologic symptoms, including the assessment of their psychological status. Such a global approach has been already implemented for ED. The medical community should be made more aware of the importance of urologic symptoms in the management of their patients, both men and women. These results also provide a rationale for giving more room to urology education in the overall medical curriculum and in the continuous medical education of general practitioners.

The authors are to be congratulated for their successful effort. Their communication should stimulate the implementation of a similar survey in Europe and other regions in the world.


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AP-HP, Neuro-Urology–Andrology, Department of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, 104 bd Raymond Poincaré, 92380 Garches, France

Tel. +33147107832; Fax: +33147104443.

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