ATLANTA – Men younger than age 55 who have served in the U.S. armed forces are almost three times as likely to report urinary incontinence as are their nonmilitary peers.
The association between military service and incontinence remained statistically significant even after investigators controlled for age, medications, and medical comorbidities – including prostate problems, Dr. Alayne Markland said at the annual meeting of the American Urological Society. Additionally, in the youngest group of men, the presence of posttraumatic stress disorder was associated with a threefold increase of any lower urinary tract symptom.
"One implication of this finding is the need for additional screening for men who are members of the armed forces, especially those who are returning from the current wars," said Dr. Markland, an internist at the Birmingham (Ala.) VA Medical Center. "This is something we need to ask about."
Dr. Markland reviewed data from the 2005-2006 and 2007-2008 cycles of the NHANES (National Health and Nutritional Examination Survey). Those cycles included queries about lower urinary tract symptoms, and provided an opportunity for respondents to rate any problems as mild, moderate, or severe.
The survey population included 5,287 men who were older than age 20. Military exposure was assessed by asking whether the respondent had ever served in any branch of the U.S. armed forces.
The investigators divided respondents into three age groups, correlated with the timing of military conflicts in which they might have served: 70 years or older (World War II or the Korean War); 55-59 (Vietnam War); and younger than 55 (Gulf War, Iraq, or Afghanistan). The groupings also allowed some comparison based on health concerns that are known to be associated with each conflict. For example, Vietnam-era vets could have been exposed to the defoliant Agent Orange and have a higher prevalence of diabetes and cancer than exists in the general population. Middle-aged veterans sometimes report Gulf War syndrome, and younger veterans report posttraumatic stress disorder and traumatic brain injury.
Among the entire survey population, the rate of any incontinence was 10%. About a quarter of the respondents reported having some military exposure. The rate of incontinence among these men was 19%, a significant difference.
Urgency was the most common problem, reported by 15% of veterans and 8% of civilians. The rates of stress and mixed incontinence were 4% and 2%, respectively.
Moderate to severe symptoms also were more common among the veterans (19% vs. 3%), whereas 1% of each group reported severe incontinence.
However, Dr. Markland said, when the group was broken down by age, the youngest group was driving the difference. Men aged 55 years and younger were three times more likely to report any urinary incontinence than were the nonmilitary population. The difference remained significant even after investigators controlled for ethnicity, socioeconomic level, body mass index, diabetes, and heart disease.
In another model that included prostate enlargement and cancer, the youngest veterans still had a threefold increase in the risk of incontinence.
Dr. Markland then examined the youngest group more carefully. Their average age was 26 years. Posttraumatic stress disorder was common, affecting 28% of them; 16% of this population reported some form of lower urinary tract problem. In fact, the presence of PTSD was associated with a threefold increase of any lower urinary tract symptom.
The association might be related to adrenergic or anticholinergic medication used to treat PTSD, Dr. Markland said. But even after investigators controlled for this, the youngest veterans had a 20% higher risk of any lower urinary tract symptom.
Because NHANES doesn’t collect any detailed information about military experience, there’s no way to tease out any cause and effect information, she said. But Dr. Christopher Amling, a moderator at the session, suggested that modern war injuries could be playing a part.
"Normally, you would expect to see much higher rates of this among an older population," said Dr. Amling, chief of urology at the Oregon Health and Science University, Portland. "What’s remarkable to me is that this is occurring in this younger population. To me, this suggests something about the recent conflicts – perhaps there is a greater risk of spinal cord or limb injuries."
Or, he said, the difference could be as simple as reluctance among older men to discuss their urinary problems. "Maybe they’re just more embarrassed to say anything about it."
However, Dr. Markland said, younger veterans are returning from the Middle East conflicts with different kinds of injuries than have been seen in past wars.
"Traumatic brain injury is a big issue, and we are still trying to recognize the more subtle presentations of blast injuries."