On Epidemiology: Extrapolations, Foibles, and Fictions.

In this issue of European Urology, Zhang et al [1] present one of the largest epidemiologic evaluations to date of the prevalence of lower urinary tract symptoms (LUTS) in a defined population (in this case a cohort drawn from a single geographic entity). Their research is sound and based on previously established principles for LUTS assessment. Their findings are impressive regarding the presence of LUTS and associated symptoms and (to some degree) bother in this relatively homogeneous population. From the standpoint of research design and epidemiologic quality, this is an outstanding opus. Aswithprior studiesonLUTS, andotherconditions related to the lower urinary tract, concerns arise as to the generalizability andmeaningfulness of these data in relation to human behavior and response to the impact of the condition [2–4]. Per force definitions were chosen and appropriate metrics used for those definitions, as has been done in prior assessments. However, the question again arises as to the importance of the isolated presence of these symptoms in the absence of some assessment of the daily functional impact that the symptoms may or may not produce. Without knowledge of these factors, these prevalencedata,while important, remainunsubstantiatedas to the overall magnitude of the effect. Despite similar data from other studies, treatment-seekingbehavior apparently cannot necessarily be extrapolated from this experience. There may be cultural, societal, and definite personal reasons for the differential between prevalence and care-seeking, which remain distressingly undefined by current experience. The impact of individuals’ assessment of their condition and their need for assistance (medical assessment and care) may be driven by a variety of factors, including concern related to the potential ofmalignancy or other self-perceived comorbidity that is undiagnosed. Another care-seeking driver may be anxiety regarding a process that may be indicative of aging and the associated concern. There is also the simpleworry over a symptom that is unexplained, which prompts individuals to seek a diagnosis to dispel this worry. Unfortunately, epidemiology does not answer these questions, which impose a great onus on practitioners to appropriately manage such patients when they present, including appropriate counseling and education. Perhaps themost fundamental knowledgedeficitwehave is related to the lack of high-quality evidence regarding the natural history of LUTS and other benign conditions of the lower urinary tract. Although community cohort studies have been performed, more data are needed regarding the course individuals may anticipate once symptomatic conditions arise. LUTS may regress, progress, or remain stable, often for reasons that are poorly defined or completely undeterminable [5]. The data from studies such as the above would be much better understood in light of longitudinal assessment in large groups that represent general populations rather than specific research cohorts. Without these data, it is impossible to understand the impact of treatmentseeking behavior on health care systems and health economies. These economic impact data are critical given the paucity of truly substantive morbidities associated with LUTS but the potentially individual symptomatic bother that is disruptive towork andother aspects of personal life. As the median age of the population of developed countries continues to increase, these types of data are significantly consequential given the overt increase in LUTS associated with chronological aging. Recent work on metabolic syndrome and obesity has indicated the strong coexistence of LUTS with these conditions, and modulation of these variables has demonstrated benefit in small groups [6,7]. Perhaps obesity and metabolic syndrome represent the EU RO P E AN URO LOGY 6 8 ( 2 0 1 5 ) 1 1 3 – 1 1 4