1. 1. Kim JH, Park JY, Oh MM, Lee JG, Kwon SS, Bae JH. Treatment satisfaction with low-dose tamsulosin for symptomatic benign prostatic hyperplasia: results from a multicentre cross-sectional survey. Int J Clin Pract. 2012 Dec; 66(12):1209-15. 2. National Air Pollutants Emission 2010. National Institute of Environmental Research in Ministry of Environment, Korea. 3. Telemetering system measures the emissions of 5 criteria air pollutants (i.e., PM10, ozone [O3], CO, sulfur dioxide [SO2], and nitrogen dioxide [NO2]) via 311 air pollution measurement networks set up in 97 local cities and districts (http://www.airkorea.or.kr). The Association between Air Pollution and Benign Prostatic Hyperplasia Sung Ryul Shim, M.P.H., Ph.D. Korea University Introduction Aims Patients & Methods Results Discussion References Contact Information Sung Ryul Shim, M.P.H., Ph.D. sungryul.shim@gmail.comsungryul.shim@gmail.com I have no potential conflicts of interest to report The prevalence of BPH increases exponentially with age and varies by geography. Large geographic differences in BPH prevalence may be related to genetic, lifestyle, and environmental factors. However, little is known about the role of environmental factors in benign tumors associated with BPH. Therefore, we focused on air pollution as an environmental factor affecting BPH and attempted to explain the regional differences in BPH prevalence in relation to air pollution. To determine whether air pollution was associated with BPH. The present study used data from two large population studies: a community-based interview survey and a university hospital outpatients-based interview survey 1. Both studies were conducted in male subjects aged 50 years and older who provided consent for the questionnaire surveys and voluntarily expressed their intention to participate. In order to enhance the validity of the International Prostate Symptom Score (IPSS), both studies excluded patients who had undergone urological surgery that could affect the IPSS, who had received any treatment for BPH or prostate cancer, and who were taking or had taken any drug for these conditions. The present study covered 9 major areas of South Korea, with a total of 56 institutions and 1,734 participants in those areas(Fig 1). This study attempted to determine the mean emissions of air pollutants using the National Air Pollutants Emission (NAPE) 2010 report 2 and the telemetering system 3 established by the National Institute of Environmental Research within the Korean Ministry of Environment. The mean International Prostate Symptom Score was 16.16 ± 7.98, 17.58 ± 7.28, and 18.58 ± 8.50 in the low-, medium- and high-level area groups, respectively, according to the emission of air pollutants per capita on the basis of the NAPE report, and the differences between the groups were statistically significant (P <0.01; table 1). In order to examine the risk for BPH due to air pollution substances, we analyzed logistic regression models for each substance. The NAPE data showed that the risk of BPH increased as the overall concentration of air pollutants increased, and in particular, nitrogen oxides (NOx) and sulfur oxides (SOx) were significantly associated with a dose-dependent increased risk of BPH (NOx: odds ratio [OR], 1.729; 95% confidence interval [CI], 1.252–2.388 for the high-level areas; SOx: OR, 1.356; 95% CI, 1.071–1.716 and 2.022, 1.421- 2.877 for the medium-level and high-level area groups, respectively)(Table 2). Air pollutants (i.e., NOx, SOx, carbon monoxide, total suspended particles, particle matter less than 10 μm in diameter, volatile organic compounds, and ammonia) as environmental factors increase estrogen levels that can affect prostate development and lead to permanent developmental effects such as malignant neoplasm of the urinary tract, which in turn will affect the development of benign tumors such as BPH. Accordingly, the differences in such associations with air pollutants emission could explain variations in BPH prevalence among geographic areas. Table 1. IPSS of area groups according to National Air Pollutants Emission 2010 Area groupsNOx Criteria * Provincen(1,734)IPSS † Low< 10 Daegu, Daejeon, Seoul, Gwangju 873 16.16±7.98 Medium10 – 20Incheon, Gyeonggi, Busan674 17.58±7.28 ‡ High> 20Gangwon, Ulsan187 18.58±8.50 ‡ IPSS, international prostate symptom score. * NOx; kg/year/person, National Air Pollutants Emission. † P <0.01 for ANOVA. ‡ same letters indicate no statistical significance based on Duncan multiple comparison. Table 2. ORs and 95% CIs of air pollutants for BPH in NAPE and TMS NAPE*OR95% CITMS † OR95%CI Model (SOx) <1Ref.<0.006Ref. 1-101.3561.071-1.7160.0061.6031.194-2.152 >102.0221.421-2.877>0.0061.2180.837-1.773 Model (NOx) <10Ref.<0.021Ref. 10-201.1460.926-1.4170.021-0.0290.8670.622-1.209 >201.7291.252-2.388>0.0290.5380.387-0.748 Model (CO) <13Ref.<0.5Ref. 13-201.0870.864-1.3660.50.6290.464-0.853 >201.6691.216-2.290>0.50.6430.466-0.887 Model (PM10) <1Ref.<48Ref. 1-101.8471.109-3.07448-540.9490.736-1.225 >101.5271.053-2.214>540.7710.575-1.034 Model (VOC)Model (O 3 ) <13Ref.<0.021Ref. 13-200.9650.780-1.1930.021-0.0231.3831.095-1.747 >201.7631.055-2.946>0.0231.8831.463-2.422 Model (NH 3 ) <1Ref. 1-50.8550.677-1.081 >51.5561.135-2.134 OR, odds ratio of logistic regression analysis. CI, confidence interval. BPH, benign prostatic hyperplasia. * National Air Pollutants Emission, kg/year/person, 2010. National Institute of Environmental Research in Ministry of Environment. † Telemetering System, ppm/year(SOx, NOx, CO, O 3 ) ㎍ / ㎥ /year(PM10), 2010. National Institute of Environmental Research in Ministry of Environment. Models adjusted for age. Dependent variable: mild and moderate 0 / severe 1. Conclusion This study is the first in the world to demonstrate the association between air pollution and BPH. These findings demonstrate increased risks of BPH among men exposed to higher concentrations of air pollution. However, we suggest that our findings not be interpreted to mean that air pollution might be a causal factor, should the association with air pollution be confirmed.