A systematic review of the association between lower urinary tract symptoms and falls, injuries, and fractures in community-dwelling older men

Figures & data

Figure 1. Search strategy for Medline.

Figure 2. Selection process of relevant studies. *Excluding duplicates within databases. †Reasons for exclusion after screening titles and abstracts include off topic (n = 2362), case report (n = 1), letters to editors or opinion papers (n = 10), not community-based (n = 19), study of women (n = 10), and systematic review (n = 6). ‡Reasons for exclusion after assessing full text include younger participants (n = 1), male-specific data not available (n = 9), did not examine the association (n = 4).

Table 1. Characteristics and results of the included studies.

Source	Country	Age	Sample size	Study design	Study factor	Outcome	Period	Association statistic
Stewart, 1992	USA	65+	520	Cross-sectional	Nocturia	Any fall	12 mo	OR = 1.63 (1.00–2.68)
						Any fracture	5 y	OR = 0.69 (0.35–1.34)
Yasumura, 1994	Japan	65–84	366	Cross-sectional	Nocturia	Any fall	12 mo	OR = 2.9 (0.8–10.4)
de Rekeneire, 2003	USA	70–79	1447	Cross-sectional	Incontinence	Any fall	12 mo	OR = 1.5 (1.1–2.0)
Asplund, 2006	Sweden	73.0 ± 6.0 (mean ± SD)	2411	Cross-sectional	Nocturia	Hip fracture	5 y	0 time – 3.1%*
								1 time – 3.2%*
								Twice – 5.2%*
								3 times – 6.8%*
Parsons, 2009	USA	65+	5872	Cohort	Incomplete emptying	Any fall	1 y	RR = 1.19 (1.06–1.33)†
						Recurrent falls	1 y	RR = 1.39 (1.16–1.66)†
					Frequency	Any fall	1 y	RR = 1.17 (1.04–1.33)†
						Recurrent falls	1 y	RR = 1.25 (1.02–1.53)†
					Intermittency	Any fall	1 y	RR = 1.10 (0.98–1.23)†
						Recurrent falls	1 y	RR = 1.26 (1.05–1.51)†
					Urgency	Any fall	1 y	RR = 1.31 (1.17–1.47)†
						Recurrent falls	1 y	RR = 1.59 (1.33–1.89)†
					Weak stream	Any fall	1 y	RR = 1.08 (0.97–1.21)†
						Recurrent falls	1 y	RR = 1.20 (1.10–1.42)†
					Straining	Any fall	1 y	RR = 1.24 (1.06–1.46)†
						Recurrent falls	1 y	RR = 1.60 (1.27–2.02)†
					Nocturia	Any fall	1 y	RR = 1.23 (1.08–1.41)‡
						Recurrent falls	1 y	RR = 1.42 (1.16–1.74)‡
					IPSS score	Any fall	1 y	RR = 1.33 (1.15–1.53)§
						Recurrent falls	1 y	RR = 1.63 (1.31–2.02)§
Nakagawa, 2010	Japan	70+	357	Cohort	Nocturia	Any fracture	5 y	HR = 2.61 (0.76–8.95)
Foley, 2012	UK	70+	2352	Cross-sectional	Incontinence	Any fall	1 y	OR = 1.86 (1.51–2.29)
Frost, 2012	Denmark	60–74	4696	Cohort	Frequency	Any fracture	5.4 y (mean)	HR = 2.05 (1.25–3.36)
						Osteoporotic fracture	5.4 y (mean)	HR = 1.72 (0.81–3.64)
Hedman, 2013	Sweden	75+	471	Cross-sectional	Incontinence	Any fall	1 y	OR = 1.67 (1.13–2.47)

Note: IPSS, International Prostate Symptom Score; OR, odds ratio; RR, relative risk; HR, hazard ratio; mo, months; y, year.

* 5-year incidence by number of nocturnal micturition. †1/2 ≤ of the times relative to never. ‡Severe (20–35 points) relative to mild (0–7). §4–5 times at night relative to 0–1 time.

Table 2. Quality of included studies.

Source	Baseline sample size	Prospective study	Generalizable sampling frame	Random sample	<20% loss to follow-up	Adequate definition of study factor*	Adequate assessment of study factor†	Adequate definition of outcome	Adequate assessment of outcome‡	Adjustment for potential confounders§
Stewart, 1992	520	No	No	No	N.A.	No	No	Yes	No	No
Yasumura, 1994	366	No	Yes	Yes	N.A.	No	No	Yes	No	Yes
de Rekeneire, 2003	1447	No	No	Yes	N.A.	No	No	No	No	Yes
Asplund, 2006	2411	No	Not clear	Yes	N.A.	No	Yes	Yes	No	No
Parsons, 2009	5943	Yes	No	No	Yes	Yes	Yes	No	Yes	Yes
Nakagawa, 2010	357	Yes	Yes	Yes	Yes	No	No	Yes	Yes	No
Foley, 2012	2352	No	Yes	Yes	N.A.	No	Yes	No	No	No
Frost, 2012	4696	Yes	Not clear	Yes	Yes	No	Yes	Yes	Yes	Yes
Hedman, 2013	471	No	Yes	Yes	N.A.	No	Yes	No	No	Yes

*Time frame and frequency of lower urinary tract symptoms should be considered. †Subjective test and self-administered questionnaire are acceptable. ‡Data linkage, falls diary, and more than annual follow-up are acceptable. §Adjusted for other risk factors than age.