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Original Article: Clinical Investigation

Lower urinary tract symptoms in patients with Niigata Minamata disease: A case–control study 50 years after methyl mercury pollution Noboru Hara,1 Hisashi Saito,2 Kota Takahashi1 and Masayuki Takeda3

1Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, 2Department of Internal Medicine, Kido Hospital, Niigata, and 3Department of Urology, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Yamanashi, Japan

Abbreviations & Acronyms Ctrl = control group IPSS = International Prostate Symptom Score LUTS = lower urinary tract symptoms MeHg = methyl mercury NMD = Niigata Minamata disease group OAB = overactive bladder OABSS = overactive bladder symptom score QOL = Quality of Life

Correspondence: Noboru Hara M.D., Ph.D., Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Asahimachi 1, Niigata 951-8510, Japan. Email: [email protected]

Received 10 June 2012; accepted 8 October 2012. Online publication 19 November 2012

Objectives: To clarify the prevalence of lower urinary tract symptoms and overactive bladder in patients with chronic methyl mercury poisoning. Methods: A total of 151 patients (61 men and 90 women; mean age 72.1 years) with Niigata Minamata disease were enrolled. An age- and sex-matched group of 150 partici- pants was used as control. Patients reported their International Prostate Symptom Score and overactive bladder symptom score. Results: In men, the total, storage and voiding International Prostate Symptom Score scores were higher in the Niigata Minamata disease group than in the control group (10.6 � 7.8 vs 5.0 � 5.0, 4.5 � 3.3 vs 2.4 � 2.4 and 6.1 � 5.1 vs 2.7 � 3.1, respec- tively, P < 0.001 in all). In women, these scores were also higher in the Niigata Minamata disease group than in the control group (8.9 � 7.3 vs 4.0 � 4.0, 4.4 � 3.2 vs 2.8 � 2.4 and 4.5 � 5.0 vs 1.3 � 2.0, respectively, P < 0.001 in all). The prevalence of overactive bladder was more frequent in the Niigata Minamata disease group compared with that in the control group (51.7% vs 26.7%, P < 0.001). In both men and women, the overactive bladder symptom score was higher in the Niigata Minamata disease group than in the control group (4.1 � 3.0 vs 2.4 � 2.9, P = 0.002 and 4.6 � 3.6 vs 2.7 � 2.9, P < 0.001, respectively). The International Prostate Symptom Score and overactive bladder symptom score in the Niigata Minamata disease group were highest in patients aged 60–69 years (P < 0.001 in both), whereas these increased in an age-dependent manner in the control group. Conclusions: Lower urinary tract symptoms and overactive bladder are severe and highly prevalent conditions among patients with methyl mercury poisoning. The higher prevalence of lower urinary tract symptoms among patients aged 60–69 years might be related to the fact that they were exposed to methyl mercury during their childhood/ development.

Key words: lower urinary tract symptoms, methyl mercury poisoning, overactive bladder.

Introduction

Severe neurological disease as a result of exposure to a massive amount of MeHg was first reported in the early 1950s among populations living around the waterfront of Minamata Bay on Kyushu island, Japan.1 This neurological disorder caused by environmental pollution was named Minamata disease after this bay. In 1965, similar conditions of MeHg pollution were also identified around the Agano River area in Niigata City and the neighboring regions of Niigata Prefecture, Japan.2 The case in Niigata has been called Niigata Minamata disease or second Minamata disease. In both cases, the consumption of fish and shellfish contaminated with a high concentration of MeHg represented the primary route of MeHg uptake.1,2 MeHg chloride, a by-product from the acetaldehyde plant of the chemical factory

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International Journal of Urology (2013) 20, 610–615 doi: 10.1111/iju.12001

discharged into the Agano River, was identified as the causa- tive agent of Niigata Minamata disease.3

MeHg poisoning patients were categorized into two clini- cal types: acute and chronic poisoning.4 Adult acute poison- ing caused by the consumption of contaminated fish containing high levels of MeHg is associated with visual impairment, hearing impairment, olfactory disturbance, cer- ebellar ataxia and somatosensory disturbances. Neurologi- cal disorder as a result of chronic poisoning represents somatosensory disturbances, such as a touch threshold increase and increased thresholds of two-point discrimina- tion. To date, numerous studies have underscored the patho- physiology of patients with MeHg poisoning. In contrast, the prevalence of LUTS or OAB in these patients has not been studied, despite recent evidence regarding the rel- evance of sensory afferent excitation to LUTS and OAB in addition to the classical relationship between neurological disorder and urinary dysfunctions.5,6 Indeed, patients with chronic MeHg poisoning frequently report LUTS, such as urinary incontinence and urination difficulty, although their actual condition has not been surveyed. The aim of the present study was to elucidate the epidemiology of LUTS and OAB according to the current International Continence Society (2002) definitions, among patients with Niigata Minamata disease 50 years after MeHg pollution.

Methods

Patients

In the present study, home-bound patients with poor per- formance status were excluded because of their known/ expected urinary incontinence/dysuria and the difficulty in carrying out examinations. In total, 205 patients, who had been diagnosed with Niigata Minamata disease according to the diagnostic criteria,7 were enrolled in the study. They had been diagnosed with Niigata Minamata disease between 1968 and 1997 by a Niigata Minamata disease-certifying physician (HS). The study had a cross-sectional design, and the procedure for the present research project was approved by the Ethics Committee of Kido Hospital. Informed consent was obtained from all patients; the patients were informed of the academic purpose of the study. To specifi- cally examine the influence of chronic MeHg poisoning on LUTS, six patients with a history of bladder/prostate cancer, bladder stone or urinary tract infections were excluded. Patients receiving treatment for lower urinary tract dysfunc- tions, benign prostatic hyperplasia or being managed with a urethral indwelling catheter were excluded. Those who lacked the capacity to give informed consent were also excluded. In the present patient series, no women showed stage 3 or 4 pelvic organ prolapse according to Pelvic Organ Prolapse Quantification system.8 The final study group com- prised 151 patients (Table 1), accounting for 92.1% of all the

eligible Niigata Minamata disease patients. Patients’ ages were distributed equally between men and women (mean 70.6 vs 73.0 years, respectively, P = 0.118). The perform- ance status was good (World Health Organization Perform- ance Status Score zero) in all patients. A total of 144 (95.4%) patients showed distal dominant bilateral sensory disturbance, 88 (58.3%) showed perioral sensory distur- bance, 106 (70.0%) showed ataxia, 64 (42.4%) showed visual constriction, 109 (72.2%) showed hearing impair- ment, 22 (14.6%) showed speech disturbance and 125 (82.8%) showed disequilibrium.

Age- and sex-matched control participants were identified by random sampling from people receiving medical check- ups (Table 1). We consecutively enrolled people who visited our hospitals or associated institutions for the medical check-up/health screening program. Sex and age stratifica- tion was carried out according to the component percentages of sex and age brackets/categories in the Niigata Minamata disease group before applying the exclusion criteria. A total of 150 eligible controls (58 men and 92 women, age mean [range]: 72.0 years [53–89 years]) completed the same ques- tionnaires described below. Sex, age and age category/ bracket were distributed equally between the Niigata Minamata disease and control groups (P = 0.850, P = 0.882 and P = 0.959, respectively). In the control group, 124 (82.7%) and 78 (52.0%) participants reported any storage and voiding symptoms, respectively, and the prevalence of them was equal or higher compared with that in cohorts aged >60 years in a previous population-based study (73.9% and 37.2%, respectively).9

Examinations and questionnaires

Symptom scoring using questionnaires and general and uro- logical examinations were carried out between April and October in 2009 and 2010. The patients filled in the IPSS10

and OABSS5 sheets handed to them when visiting the out- patient clinic for Niigata Minamata disease. Scores of 0 to 7, 8 to 19 and 20 to 35 were regarded as mild, moderate and severe LUTS, respectively. Those with both urgency and a

Table 1 Patients’ characteristics

Niigata Minamata disease group

Mean age at surveillance, years (range)

Total (n = 151) 72.1 (46–87) Male (n = 61) 70.6 (47–85) Female (n = 90) 73.0 (46–87)

Control group Total (n = 150) 72.0 (53–89) Male (n = 58) 70.4 (53–89) Female (n = 92) 73.0 (53–89)

MeHg poisoning and urinary symptoms

total score of 3 or higher were regarded as having OAB. General blood and biochemical examinations, urinalysis, and residual urine volume measurement using an ultrasono- graphic instrument were carried out in all patients with Niigata Minamata disease. Ultrasonographic examinations of the upper and lower urinary tracts were also carried out in patients with any of the following: total IPSS of �8, QOL index of �2, OABSS of �6, any urgency, any incontinence, any dysuria, a residual volume of �50 mL and abnormal urinalysis. Those with microscopic hematuria received a urinary cytological examination; all showed a normal smear.

Statistical analysis

In addition to the c2-test and Fisher’s exact test, the Mann– Whitney U-test was used to compare unpaired parameters between two groups, and Tukey’s honestly significant dif- ference was used for the comparison of values among three or more subgroups. Correlations between parameters were analyzed using Spearman’s rank correlation coefficient analysis (rs). The test was two-sided and P < 0.05 was con- sidered significant. All analyses were carried out using SPSS version 15.0J (SPSS, Chicago, IL, USA) in a Windows- based computer.

Results

IPSS score and QOL index

Table 2 shows the IPSS score and QOL index in the present patient series with Niigata Minamata disease and the control group. The total, storage and voiding scores were higher in

the Niigata Minamata disease group than in the control group (P < 0.001 in all), and the QOL index was also higher in the Niigata Minamata disease group (P = 0.008). Among query items for the storage score, all the scores for pollakisuria, urgency and nocturia in the Niigata Minamata disease group were higher than those in the control group (P = 0.033, P < 0.001 and P < 0.001, respectively). Among query items for the voiding score, all of them were also higher in the Niigata Minamata disease group (P < 0.001 in all; Table 2). In men, the total, storage and voiding scores were higher in the Niigata Minamata disease group than in the control group (10.6 � 7.8 vs 5.0 � 5.0, 4.5 � 3.3 vs 2.4 � 2.4 and 6.1 � 5.1 vs 2.7 � 3.1, respectively, P < 0.001 in all). In women, the total, storage and voiding scores were also higher in the Niigata Minamata disease group than in the control group (8.9 � 7.3 vs 4.0 � 4.0, 4.4 � 3.2 vs 2.8 � 2.4 and 4.5 � 5.0 vs 1.3 � 2.0, respectively, P < 0.001 in all).

In the Niigata Minamata disease group, whereas the storage score was not different between male and female patients (4.5 � 3.3 vs 4.4 � 3.2, P = 0.890), the voiding score was higher in males than in females with a borderline significance (6.1 � 4.5 vs 4.5 � 5.0, P = 0.055). Among query items, the score for a slow stream alone was higher in men than in women (2.1 � 1.9 vs 1.4 � 1.6, respectively, P = 0.016). In men, 24 (39.3%), 29 (47.5%) and eight (13.1%) patients reported a total IPSS of 0–7, 8–19 and 20–35, respectively, and 20 (32.8%), 34 (55.7%) and 7 (11.5%) patients reported a QOL index of 0–1, 2–4 and 5–6, respectively. In women, 47 (52.2%), 35 (38.9%) and eight (8.9%) patients reported a total IPSS of 0–7, 8–19, and 20–35, respectively, and 37 (41.1%), 41 (45.6%) and 12 (13.3%) patients reported a QOL index of 0–1, 2–4 and 5–6, respectively. Using the IPSS, 85 of 90 (94.4%) women and 60 of 61 (98.4%) men reported at least one LUTS.

We additionally analyzed the IPSS score according to age categories (Table 3). In patients/participants aged >80 years, the total IPSS score was similar between the Niigata Minamata disease and control groups (P = 0.206 for the total, P = 0.952 for the storage, P = 0.053 for the voiding and P = 0.200 for the QOL scores/index). Among those aged 70–79 years, these scores were higher in the Niigata Minamata disease group than in the control group except for the QOL index. Among patients/participants aged 60–69 years, these scores were also higher in the Niigata Minamata disease group, and the differences between the two groups were largest in this age category (P < 0.001 in all). In those aged <60 years, these scores were seemingly higher in the Niigata Minamata disease group, but the differences were not significant (Table 3).

OABSS and OAB

Table 4 presents the OABSS and prevalence of OAB in the Niigata Minamata disease and control groups. The OABSS

Table 2 IPSS in the present patient series with Niigata Minamata disease and control group

Niigata Minamata disease group (n = 151)

Control group (n = 150)

P-value

IPSS total 9.6 � 7.5 4.4 � 4.4 <0.001 Storage score 4.5 � 3.2 2.6 � 2.4 <0.001

Pollakisuria 1.5 � 1.5 1.1 � 1.4 0.033 Urgency 1.0 � 1.3 0.5 � 0.9 <0.001 Nocturia 1.9 � 1.3 1.1 � 1.0 <0.001

Voiding score 5.1 � 5.1 1.8 � 2.6 <0.001 Feeling of

incomplete emptying

1.2 � 1.5 0.4 � 0.8 <0.001

Intermittency 1.0 � 1.4 0.2 � 0.7 <0.001 Slow stream 1.7 � 1.8 0.8 � 1.2 <0.001 Straining 1.3 � 1.7 0.3 � 0.8 <0.001

QOL index 2.8 � 1.7 2.3 � 1.3 0.008

Score: mean � SD.

N HARA ET AL.

was higher in the Niigata Minamata disease group than in the control group (4.4 � 3.3 vs 2.6 � 2.9, <0.001). In both men and women, the OABSS was higher in the Niigata Minamata disease group than in the control group (4.1 � 3.0 vs 2.4 � 2.9, P = 0.002 and 4.6 � 3.6 vs 2.7 � 2.9, P < 0.001, respectively).

The prevalence of OAB was more frequent in the Niigata Minamata disease group compared with that in the control group (51.7% vs 26.7%, P < 0.001); in the Niigata Minamata disease group, the fraction of patients with OAB with urinary incontinence (OAB wet) was also higher (36.4% vs 18.7%, P < 0.001). In the Niigata Minamata disease group, 35 male patients (57.4%) met the diagnostic criteria for OAB, and 43 female patients (47.8%) were

regarded as having OAB; 33% of the male and 39% of the female patients had OAB wet.

In the control group, the female OABSS was higher than the male OABSS (P = 0.020), whereas total or subscores of OABSS did not differ between male and female patients in the Niigata Minamata disease group (P = 0.351). According to analyses by age categories, the OABSS in the control group showed an age-dependent increase (60–69 years vs 70–79 years, P = 0.006 and 70–79 years vs >80 years, P = 0.004). In the Niigata Minamata disease group, however, no association was noted between the presence of OAB or the OABSS and age except for the difference between the OABSS of patients aged <60 years (2.6 � 2.5) and 60–69 years (5.8 � 2.9; P = 0.013). We additionally analyzed the OABSS and prevalence of OAB according to age categories, comparing the Niigata Minamata disease and control groups (Table 5). Similar to the IPSS, in patients/participants aged >80 years, the OABSS was com- parable between the Niigata Minamata disease and control groups (P = 0.877), and the prevalence of OAB was not different (P = 0.127). Among those of 70–79 years, the OABSS and prevalence of OAB were higher in the Niigata Minamata disease group than in the control group (P < 0.001 in both). Among patients/participants aged 60–69 years, OABSS and prevalence of OAB were also higher in the Niigata Minamata disease group, and the dif- ferences between the two groups were largest in this age category (P < 0.001 in all). In those aged <60 years, they

Table 3 Comparison of IPSS according to age between the Niigata Minamata disease and control groups

Age <60 years 60–69 years 70–79 years >80 years NMD (n = 14) NMD (n = 39) NMD (n = 67) NMD (n = 31) Ctrl (n = 12) Ctrl (n = 44) Ctrl (n = 62) Ctrl (n = 32)

IPSS total score NMD 6.9 � 8.0 11.4 � 7.2 9.8 � 7.8 6.3 � 5.1 Ctrl 2.8 � 4.0 3.2 � 2.7 4.6 � 4.7 6.3 � 5.1 P-value 0.119 <0.001 <0.001 0.206

Storage score NMD 2.9 � 2.8 5.3 � 3.1 4.4 � 3.5 4.1 � 2.8 Ctrl 1.7 � 2.9 1.8 � 1.6 2.7 � 2.3 4.6 � 4.7 P-value 0.272 <0.001 0.001 0.952

Voiding score NMD 3.9 � 5.8 6.1 � 4.7 5.4 � 5.3 4.1 � 4.7 Ctrl 1.1 � 1.4 1.6 � 1.8 1.9 � 3.0 2.2 � 2.8 P-value 0.119 <0.001 <0.001 0.053

QOL index NMD 2.4 � 1.9 3.2 � 1.2 2.8 � 1.9 2.8 � 1.7 Ctrl 1.3 � 1.2 1.9 � 1.4 2.3 � 1.4 2.3 � 1.3 P-value 0.109 <0.001 0.106 0.200

Score: mean � standard deviation (SD).

Table 4 OABSS in the present patient series with Niigata Minamata disease and control groups

Niigata Minamata disease group (n = 147)

Control group (n = 150)

P-value

OABSS total 4.4 � 3.3 2.6 � 2.9 <0.001 OAB present (n) 78 (51.7%) 40 (26.7%) <0.001 OAB wet present (n) 55 (36.4%) 28 (18.7)% <0.001

Score: mean � SD.

MeHg poisoning and urinary symptoms

were seemingly higher in the Niigata Minamata disease group, but the differences were not significant (Table 5).

Residual urine volume and ultrasonographic findings

In women with Niigata Minamata disease, the residual urine volume was less than 20 mL (mean 1.2 mL), and in men, the mean residual urine volume was 2.3 mL (range 0–74 mL). There was no relationship between the residual urine volume and total or subscores of the IPSS or OABSS in either men or women with Niigata Minamata disease (data not shown). With ultrasonography, none of the patients showed abnormality probably associated with LUTS.

Discussion

More than 60% of the men and approximately 50% of the women with Niigata Minamata disease had moderate (total IPSS of 8–19) to severe (total IPSS of 20–35) LUTS, and more than 95% of them reported at least one LUTS. Even considering their average age of 72 years, the prevalence of LUTS among the Niigata Minamata disease patients was suggested to be high compared with that reported among general populations in both men and women (80.7% of men and 79.3% of women aged >60 years),9,11 although we cannot provide population-based data on LUTS in the prov- ince of Niigata. Instead, we showed that the prevalence of LUTS among patients with Niigata Minamata disease was higher than those in the age- and sex-matched control group (Table 2). Also, the prevalence of OAB was suggested to be higher among those with Niigata Minamata disease (Table 4). Furthermore, OAB patients with Niigata

Minamata disease more frequently reported urinary incon- tinence (Table 4) and severe voiding symptoms, despite low residual urine volume representing a specific observation in patients with Niigata Minamata disease. However, it is unclear from the current results whether the high prevalence of severe LUTS or OAB in Niigata Minamata disease patients was associated with neurogenic lower urinary tract dysfunction. Previous autopsy-based studies showed that MeHg poisoning induces disruptive damage in the nervous system. The damage was most severe in the cerebral and cerebellar cortices.2 The brain stem was affected to a lesser extent, and the influence was least in the spinal cord. Thus, the damage in the cerebral cortex and brain stem might possibly be associated with LUTS in patients with MeHg poisoning.2,12 In contrast, the pathology of peripheral nerves appears to be associated with prolonged duration of the disease, and the sensory nerves are damaged selectively with regeneration in prolonged cases. Most patients in the current series also presented with somatosensory disorders (95.4%), which seemingly does not well explain the high prevalence of LUTS/OAB. Correspondingly, residual urine volume was small or 0 mL in the present patient series. To our knowledge, no study has suggested the relationship between somatosensory disturbance and LUTS/OAB or other lower urinary tract dysfunctions. Thus, a complex mechanism is presumed behind the association between Niigata Minamata disease and LUTS. Interestingly, voiding symptoms were more serious in patients with Niigata Minamata disease, and both genders were affected (P < 0.001 in both; Table 2). Yet, residual urine volume was small, and was dissociated with symptoms. Thus, further neuropathological and uro-neurophysiological examinations are required to elucidate the mechanism of LUTS/OAB, as

Table 5 Comparison of the prevalence of overactive bladder according to age between the Niigata Minamata disease and control groups

Age <60 years 60–69 years 70–79 years >80 years NMD (n = 14) NMD (n = 39) NMD (n = 67) NMD (n = 31) Ctrl (n = 12) Ctrl (n = 44) Ctrl (n = 62) Ctrl (n = 32)

OABSS total NMD 2.6 � 2.5 4.8 � 2.0 4.4 � 3.6 4.6 � 3.4 Ctrl 1.8 � 3.4 1.4 � 1.5 2.6 � 2.8 4.5 � 3.3 P-value 0.491 <0.001 <0.001 0.877

OAB present (n) NMD 5 (35.7%) 25 (64.1%) 36 (53.7%) 12 (40.0%) Ctrl 2 (16.7%) 5 (11.4%) 15 (24.2%) 19 (59.4%) P-value 0.275 <0.001 <0.001 0.127

OAB wet present (n) NMD 2 (14.3%) 16 (41.0%) 27 (40.3%) 10 (33.3%) Ctrl 1 (8.3%) 3 (6.8%) 9 (14.5%) 16 (50.0%) P-value 0.538 <0.001 0.001 0.312

Score: mean � SD.

N HARA ET AL.

well as large epidemiological studies in patients with MeHg poisoning. A study of urodynamics in selected patients is currently underway.

Dissimilar to general populations,10,11 the prevalence of LUTS or OAB did not show an age-dependent increase in patients with Niigata Minamata disease, and the OABSS was not female-leading in them. It is of note that the differ- ence of IPSS and OABSS between the Niigata Minamata disease and control groups was more evident in those aged 60–69 years (Tables 3,5). Also, patients aged less than 60 years had a higher IPSS than those in the control group, although the difference was not significant, most probably because of the small number of patients in this age category. Although the reason why LUTS were more prevalent among patients aged 60–69 years is unclear, it might involve the fact that the patients aged 60–69 years were exposed to high concentrations of MeHg during their childhood/ development. It is known that patients exposed during development/childhood were more severely affected by MeHg poisoning, and many of them had central nervous system disorders.2,13 Although we could not examine the relationship between the severity of neurological symptoms and LUTS because of the absence of the severity categories for Niigata Minamata disease, a recent study showed that the severity of MeHg poisoning based on hair MeHg concen- tration was not necessarily associated with the presence of specific neurological symptoms.14 Environmental pollution caused by MeHg is even now being reported in not only developing countries, but also developed nations,15,16 and clarification of the pathophysiology in patients with MeHg poisoning is still a challenging problem.

In summary, we carried out a case–control study on LUTS and OAB in patients with Niigata Minamata disease 50 years after MeHg pollution. The current study suggested a high prevalence of LUTS and OAB in patients with chronic MeHg poisoning regardless of sex, although further studies are required to clarify its mechanism. LUTS more prevalent among patients aged 60–69 years might involve the fact that they were exposed to high concentrations of MeHg during their childhood/development.

Acknowledgments

The advice and editorial assistance of Dr Gary Myers from the University of Rochester, Rochester, New York, is much appreciated. The authors thank Ms Noriko Sekine, Ms Emiko Sato, Ms Chieko Watanabe, Ms Eiko Honma, and Ms Hiroko Igarashi for their enthusiastic nursing and assistance in data acquisition.

Conflict of interest

None declared.

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MeHg poisoning and urinary symptoms

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