key: cord-0685947-u6t1azkp
authors: Nabeeh, Hossam; Ibrahim, Ali; Taha, Diaa‐Eldin; Talaat, Mona; Abdelbaky, Tarek M
title: Impact of COVID‐19 pandemic on lower urinary tract symptoms in patients with benign prostatic hyperplasia and predictors of urine retention in such patients
date: 2021-08-26
journal: Low Urin Tract Symptoms
DOI: 10.1111/luts.12407
sha: d9d9fa7bc9fd7f8c7b5e2e445b49560b7e1f319e
doc_id: 685947
cord_uid: u6t1azkp

OBJECTIVES: We assess the effect of coronavirus disease 2019 (COVID‐19) on lower urinary tract symptoms (LUTS) of patients with benign prostatic hyperplasia (BPH). Moreover, we delineate risk factors for urine retention in such patients. METHODS: All COVID‐19 infected males were expeditiously evaluated. All enrolled patients were assessed using the International Prostate Symptom Score (IPSS), uroflowmetry, and pelvi‐abdominal ultrasonography for prostate volume and postvoiding residual urine (PVR) estimation. RESULTS: Fifty patients, who were diagnosed with BPH, were enrolled. The mean age (±SD) was 62.64 ± 7.69. In the pre‐ and post‐COVID‐19 group, the mean (±SD) IPSS was 13.42 ± 4.32 and 26.62 ± 5.77, respectively (P < .001), while PVR was 90.40 ± 32.75 and 185.42 ± 73.42, respectively (P < .001), and maximum flow rate was 14.40 ± 2.75 and 10.74 ± 3.43, respectively (P < .004). After infection with COVID‐19, 13 (26%) patients were managed by urethral catheter fixation owing to urine retention. On bivariate analysis, age, diabetes, large prostate on digital rectal examination, alpha‐blocker monotherapy, microscopic hematuria, positive urine culture, and pre‐COVID‐19 IPSS were significantly correlated with urine retention (P < .001, P = .01, P < .001, P = .06, P < .001, P = .04, and P < .001, respectively). On multivariate analysis, age, pre‐COVID‐19 IPSS, and positive urine culture were the independent predictors of urine retention (P = .05, P < .001, and P = .01, respectively). CONCLUSION: LUTS in BPH patients were significantly affected by COVID‐19. COVID‐19 increases IPSS leading to a change in the treatment modality of BPH. On multivariate analysis, age, pre‐COVID‐19 IPSS, and positive urine culture were the independent predictors of urine retention post COVID‐19 infection.

Lower urinary tract symptoms (LUTS) are a term that covers a variety of symptoms that occur during storing, urination, or after urination categorized by the International Continence Society. 1 LUTS are common in adult men and are often associated with benign prostatic hyperplasia (BPH). 2 The prevalence of BPH increases markedly with age. In autopsy studies, it has been observed that the histological prevalence of the disease also increases with age. 3 After its initial discovery in Wuhan, China, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread throughout the world, and the consecutive coronavirus disease 2019 was declared a pandemic by the World Health Organization (WHO) shortly afterward. 4 As the pandemic is still in an early phase and many symptoms

have not yet been fully described, careful clinical observation is of paramount importance. 5 While infected individuals mostly experience mild symptoms such as fever, upper respiratory tract symptoms, shortness of breath, and diarrhea, 6 or are asymptomatic, 7 in severe cases, pneumonia, multiple organ failure, and death may occur. 8 The most common comorbidities in COVID-19-positive patients are chronic lung disease, diabetes, and hypertension. 9 Rocco et al pointed out the importance of early recognition of symptoms by urologists for proper triage of patients and to prevent missing possible SARS-CoV-2 infection because of an overlap of COVID-19 and classical urological symptoms. Additionally, fever and increased urinary frequency should be considered as important symptoms overlapping with urosepsis in the differential diagnosis of COVID-19 in ambulatory care and emergency rooms. 10 Considering that the COVID-19 pandemic affects older and male patients more, it is obvious that the elderly male population with LUTS will be seriously affected by this pandemic. According to our literature review, no studies evaluate the impact of COVID-19 disease on LUTS in patients diagnosed with BPH.

After institutional board review, a cross-sectional study was carried out between May 2020 and March 2021 in a tertiary hospital. The inclusion criteria were patients who had previously been treated for BPH. Patients who had a history of previous pelvic organ surgery and/or radiotherapy, those with an active urinary system infection, or those with a history of urethral stenosis, and those diagnosed with neurogenic bladder were excluded from the study.

The patients were diagnosed with COVID-19 based on reverse transcription-polymerase chain reaction (RT-PCR) tests of oropharyngeal and nasopharyngeal swabs obtained as per the WHO guidelines.

Informed consent was obtained from all patients, and the institutional ethics committee approved the study.

A pertinent medical history was obtained. The patients were evaluated using the International Prostate Symptom Score (IPSS), pelvi-abdominal ultrasonography with PVR estimation, non-contrast computed tomography (CT) of the chest, uroflowmetry, and laboratory investigations (RT-PCR tests of oropharyngeal and nasopharyngeal swabs, urine analysis, urine culture, kidney function, complete blood count, coagulation profile, serum ferritin, interleukin-6, procalcitonin, d-dimer, C-reactive protein [CRP] , and prostate-specific antigen [PSA]). IPSS before and after COVID-19 infection were compared. The evaluation time was unified on admission, during hospital stay day after day, a month, and 3 months post infection.

Data were analyzed using SPSS 21.0 for Windows (SPSS, USA). Normality tests (Kolmogorov-Smirnov test) were performed to evaluate the distributions of numeric variables. If the distribution of numeric variables was normal, statistical analysis was performed using parametric Student t tests. Mann-Whitney U tests were used to evaluate numerical variables with a skewed distribution. Categorical variables were analyzed using chi-squared or Fisher exact tests. The level of statistical significance was set at 5% (P < .05). A highly significant difference was present if P ≤ .001.

Around 430 COVID-19 patients were screened. All 50 patients, who were diagnosed with BPH, were enrolled. The mean age (±SD) was 62.64 ± 7.69. The mean body mass index ranged from 21.4 to 27.4 kg/m 2 with a mean of 24.11 kg/m 2 . Diabetes, hypertension, cardiac diseases, liver, and chronic kidney disease were present in 54%, 58%, 16%, 12%, and 4% of the studied patients, respectively. Eight patients were on anticoagulant drugs. Prostate volume estimated by ultrasonography ranged from 34 to 110 g with a mean of 64.26 g.

Other patient parameters are shown in Table 1 .

There was a significant increase in IPSS (mean ± SD 26.62 ± 5.77, 25.36 ± 5.86, 25.1 ± 6.3 during hospital stay, at 1 month, and at 3 months, respectively) in comparison with IPSS before infection (13.42 ± 4.32; P < .001). There is a statistically significant change in the IPSS on discharge and its value at 1 month (P < .001). Also, the IPSS 3 months after discharge significantly decreased compared with its level at 1 month (P = .014) ( treatment (alpha-blockers and 5-alpha reductase inhibitors) before infection.

No significant correlations were noticed between COVID-19 laboratory or radiologic parameters and LUTS (Table 1) .

On bivariate analysis, we found that the general condition of the patients evaluated using severity assessment was not associated with urine retention post COVID-19 infection (P = .16). But age, diabetes, large prostate on digital rectal examination, alpha-blocker monotherapy, microscopic hematuria, positive urine culture, and pre-COVID-19 IPSS were significantly correlated with urine retention (P < .001, P = .01, P < .001, P = .06, P < .001, P = .04, and P < .001, respectively). On multivariate analysis, age, pre-COVID-19 IPSS, and positive urine culture were the independent predictors of urine retention after COVID-19 infection (P = .05, P < .001, and P = .01, respectively) ( Table 4 ).

Since the report of the first cases of pneumonia of unknown cause by the WHO at the end of 2019, SARS-CoV-2 and its related disease, COVID-19, has spread rapidly all over the globe. 11

Gender-related COVID-19 mortality is among the most frequently reported epidemiological data. 12 Studies conducted in various countries show that males are more vulnerable to COVID-19 infections, and for this reason, the male gender is considered a poor prognostic factor by some authors. 13 A recent review of current epidemiological studies that gathered data from 59 254 patients from 11 different countries has shown a relationship between the male gender and higher mortality rates. 14 Although the question of why COVID-19 is more common and fatal in men remains a critical question awaiting an answer, recent studies have suggested that one of the reasons for the increased vulnerability of men could be androgen-mediated mechanisms. 15, 16 BPH is one of the common causes of LUTS in older men. Age is the main factor in the development of BPH. Age, pre-COVID-19 IPSS, and positive urine culture were the independent predictors of urine retention post COVID-19 infection.

There is no conflict of interest.

Ali Ibrahim: methodology, idea formulation, and reference collection. Diaa-Eldin Taha: review writing and revision, editing the final draft. Mona Talaat: formal analysis and data collection. Hossam Nabeeh: supervision. Tarek Abdelbaky: data collection and final revision.

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.

Formal consent was signed by the participants for taking part in this research.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Diaa-Eldin Taha https://orcid.org/0000-0003-3295-0505

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Impact of COVID-19 pandemic on lower urinary tract symptoms in patients with benign prostatic hyperplasia and predictors of urine retention in such patients