대한배뇨장애요실금학회지 J Korean Continence Soc 2008;12:27-35 원저 대사증후군에서남성하부요로증상관련위험요인분석 이화여자대학교의과대학비뇨기과학교실, 내과학교실 1, 예방의학교실 2 이하나 정우식 심봉석 홍영선 1 박혜숙 2 Analysis of risk factors associated with male lower urinary tract symptoms in the metabolic syndrome Ha Na Lee, Woo Sik Chung, Bong Suk Shim, Young Sun Hong 1, Hye Sook Park 2 From the Department of Urology, Internal Medicine 1, and Preventive Medicine 2, School of Medicine, Ewha Womans University, Seoul, Korea Puropose: The purpose of this study was to evaluate the relationship between lower urinary tract symptoms (LUTS) and the metabolic syndrome in the elderly male. Material and methods: The metabolic syndrome group of 348 patients (64.4±8.6 years old) and the control group of 150 patients (66.0±7.0 years old) were included in the study. The voiding factors, such as International Prostate Symptom Score (IPSS), quality of life score, prostate volume, maximal urine flow rate, residual urine volume, and prostate-specific antigen (PSA) were investigated. Waist circumference, blood pressure, fasting glucose, HDL-cholesterol, triglyceride were measured for the evaluation of the metabolic syndrome. Results: Waist circumference (β=0.025, p<0.001), systolic (β=0.004, p<0.05) and diastolic blood pressure (β=0.006, p<0.05) were positively correlated with prostate volume. In the logistic regression analysis of voiding factors according to metabolic syndrome factors, the patients who have central obesity (Odds ratio [OR]=2.931), central obesity and hypertension (OR=3.598), central obesity and diabetes (OR=2.508), hypertension and low HDL-cholesterolemia (OR=2.326), central obesity, hypertension and diabetes (OR=3.083), central obesity, hypertension and low HDL cholesterolemia (OR=3.440) represented a significantly increased age-adjusted risk of benign prostatic enlargement (25g or more). OR of symptomatic benign prostatic hyperplasia (BPH) was 3.178 in the patients with cental obesity, and 2.381 in the patients with both central obesity and hypertension. Conclusions: In male elderly, the metabolic syndrome was closely related with LUTS and its main risk factor was central obesity, represented as waist circumference. (J Korean Continence Soc 2008;12:27-35) Key Words: Risk factors, Metabolic syndrome, Lower urinary tract symptoms 접수일자 : 2008 년 3 월 18 일, 수정일자 : 2008 년 4 월 23 일, 채택일자 : 2008 년 5 월 4 일교신저자 : 심봉석, 이대목동병원비뇨기과, 서울시양천구목동 911-1 우 158-710 Tel: 02-2650-5157, Fax: 02-2654-3682, E-mail: bonstone@ewha.ac.kr Vol. 12, No. 1, 2008 27
이하나 정우식 심봉석 홍영선 박혜숙 서론최근식습관및생활방식의급격한서구화로인하여우리나라에서도허혈성심질환이나관상동맥질환등심혈관계질환으로인한사망률이 1990년인구십만명당 10.4명에서 2000년 21.5명으로 2배이상증가하였다 (1). 이러한심혈관계질환의위험요인으로는나이, 흡연, 고혈압, 고LDL 콜레스테롤혈증, 저HDL 콜레스테롤혈증, 고혈당, 비만, 신체적비활동, 혈액응고이상등이밝혀져있는데 (2,3), 대사증후군은이러한심혈관계질환및제 2형당뇨병의위험인자들즉, 비만, 지질대사이상, 또는내당능장애, 고혈압의군집질환군으로, 이는인슐린저항성을공통적인특징으로하며심혈관계질환의발생및사망률과밀접한관련성이있다 (4,5). 대사증후군은그자체가질병이기도하지만심혈관및뇌혈관질환뿐아니라비뇨기과적으로하부요로증상을유발하고진행을촉진하는것으로알려져있다 (6,7). 전립선비대증및이와관련된하부요로증상으로대표되는노년기남성의배뇨장애는노화가직접관련되며, 고혈압이나당뇨병과같은만성질환과연관성이있고실제노인들의상당수에서동시에발생하고있어이두가지질환군사이에연관성이있는것으로추정된다. 이에저자들은노년기남성에서나타나는배뇨증상의위험요인으로대사증후군의연관가능성과그정도를알아보고자, 대사증후군에서대사증후군의각요소와배뇨장애요소들간의관련성에관해분석하였다. 2. 연구방법 1) 대사증후군의정의대사증후군의진단기준은국제당뇨연맹의 2005년정의에따라서복부비만 ( 허리둘레 90cm) 을가지고있으면서아래나열된요소중두가지이상을가진경우로하였다. (1) 고중성지방혈증 : 150mg/dL 또는치료중, (2) 저 HDL-콜레스테롤혈증 : 40mg/dL 또는치료중, (3) 고혈압 : 수축기혈압 130mmHg 혹은이완기혈압 85mmHg, 또는치료중, (4) 공복고혈당 : 공복혈당 100mg/dL, 또는제 2형당뇨병진단 2) 배뇨장애요소와대사증후군요소의평가배뇨장애요소의평가를위해국제전립선증상지수 (International Prostate Symptom Score; IPSS) 와삶의질점수 (quality of life), 전립선용적, 최대요속 (maximal flow rate), 잔뇨량, 혈청전립선특이항원 (prostate-specific antigen; PSA) 을조사하였고, 대사증후군진단기준에근거하여, 대사증후군요소인허리둘레, 혈압, 공복혈당, HDL-콜레스테롤, 중성지방을조사하였다. 3. 통계분석 대상및방법 1. 연구대상 2004년 3월부터 2007년 3월까지본원비뇨기과, 내분비내과및종합검진센터에내원하여검사한결과대사증후군의조건에부합하는 50세이상 65세이하남자환자 348명과건강한대조군남성 150명을대상으로하였다. 환자들은대사증후군에대한내과적치료나진단되지않은부분에대한예방적처치는하지않았고, 배뇨장애에대한처치를받은경우는제외하였다. 통계분석은 SAS 프로그램 (version 9.0) 을사용하였다. 대사증후군환자군과대조군간의대사증후군요소와배뇨장애요소의비교는 Student's t-test (unpaired) 를이용하였고, 배뇨장애요소간의상관관계는피어슨상관분석 (Pearson correlation) 으로분석하였다. 대사증후군요소와배뇨장애요소간의상관분석으로선형회귀분석 (linear regression) 을사용하여각대사증후군요소의증감에따라배뇨장애요소의통계학적유의한변화가있는지를알아보았으며, 대사증후군요소에따라각기준값이상의배뇨장애를나타낼상대적위험도 (odds ratio) 를로지스틱회귀분석 (logistic regression) 을사용하여분석하였는데, 하부요로증상인자의기준값은 IPSS 11점, 삶의질점수 4점, 전립선용적 25g과 40g 을기준으로하였고, 최대요속은 15ml/sec와 10ml/sec, 배뇨후 28 대한배뇨장애요실금학회지
대사증후군에서남성하부요로증상관련위험요인분석 잔뇨량은 20ml와 50ml, PSA 2.5ng/dl와 4.0ng/dl를기준으로하여분석하였다. 허리둘레는 94cm를기준으로나누어추가분석하였고, 전립선용적과최대요속, 잔뇨량, PSA 값의분포가한쪽으로치우쳐져있어이를정규분포화하기위해모두로그 (log) 변환하여분석하였다. 이중에서도잔뇨가 0인경우는 1을더하여로그변환하였으며, 모든통계학적유의수준은 p값이 0.05 미만인경우로하였고, p값이 0.05 이상이고 1.00 미만인경우경계성유의수준으로판단하였다. 11.0±4.4ml/sec, 잔뇨는 29.1±34.3ml로, 모든요소에서대조군보다악화된소견을보였다 (Table 1). 대사증후군환자에서평균 IPSS 점수를부분항목별로보았을때불완전배뇨감항목의평균점수는 2.67±1.74점이고, 빈뇨항목은 2.71±1.61점, 단속뇨항목은 2.47±1.59점, 요급항목은 2.03±1.42점이었고, 약뇨항목는 2.94±1.72점, 배뇨지연항목은 2.10±1.71점, 야간뇨항목은 2.24±1.52점으로약뇨가가장악화되어있었다 (Figure 1). 결 과 2. 배뇨장애요소간의상관관계 1. 연구대상자들의일반적특성대사증후군의조건에부합한연구대상자는 348명 ( 평균나이 64.4±8.6세 ) 이었고, 대조군은 150명 ( 평균나이 66.0±7.0 세 ) 이었다. 대사증후군환자들의평균허리둘레는 94.5±5.2 cm, 평균수축기혈압은 138.0±14.3mmHg, 평균이완기혈압은 79.5±9.7mmHg 이었으며, 평균 HDL 콜레스테롤은 44.2±4.2 mg/dl, 평균 TG는 158.4±113.3mg/dl 이었다. 배뇨장애요소는대사증후군에서는평균 IPSS 17.2±4.4점, QoL 3.9±1.2점이었고, 평균전립선용적은 32.8±17.1g 이었으며평균최대요속은 대사증후군환자의배뇨장애요소간의상관관계에서잔뇨과 IPSS (r=0.216, p=0.005), PSA와전립선용적 (r=0.575, p<0.0001), PSA와잔뇨 (r=0.151, p=0.050) 는통계학적으로의미가있는양의상관관계를보였으며, 최대요속과 IPSS (r=-0.240, p=0.002), 잔뇨와최대요속 (r=-0.274, p=0.0003) 은음의상관관계를보였다 (Table 2). 3. 대사증후군유무에따른배뇨장애평가항목비교 1. 선형회귀분석 Table 1. Comparison of the metabolic characteristics and the lower urinary tract symptoms between the metabolic syndrome group and the control group. Mean ± SD * Metabolic syndrome (n=348) Control (n=150) p-value Age (year) 64.4±8.6 66.0±7.0 0.138 Systolic BP (mmhg) 138.0±14.3 122.9±13.7 0.039 Diastolic BP (mmhg) 79.5±9.7 74.5±7.1 0.001 Serum glucose (mg/dl) 114.9±29.8 97.1±12.1 <0.001 Waist circumference (cm) 94.5±5.2 84.35±7.13 <0.001 Triglyceride (mg/dl) 158.4±113.3 105.1±17.5 <0.001 HDL-cholesterol (mg/dl) 44.2±4.2 46.2±11.8 0.002 Prostate volume (g) 32.8±17.1 21.3±4.7 0.002 IPSS 17.2±4.4 8.0±4.8 <0.001 QoL score 3.9±1.2 2.7±1.5 0.002 Maximal flow rate (ml/sec) 11.0±4.4 20.5±8.1 0.004 Residual urine (ml) 29.1±34.3 16.5±10.7 <0.001 * SD: standard deviation, BP: blood pressure, HDL cholesterol: high density lipoprotein cholesterol, IPSS: International Prostate Symptom Score, QoL: quality of life Vol. 12, No. 1, 2008 29
이하나 정우식 심봉석 홍영선 박혜숙 5 4 3 2 1 2.67 2.71 2.47 2.03 2.94 2.1 2.24 0 Residual urine sensation Frequency Intermittency Urgency Weak stream Hesitancy Nocturia Figure 1. Mean scores of each items of International Prostate Symptom Score; most severe symptom was weak stream, followed by frequency. Table 2. Correlation among the lower urinary tract symptoms in the patients with metabolic syndrome * IPSS logprov logqmax logrv logpsa IPSS r 1.00-0.0049-0.240 0.220-0.006 p value 0.526 0.002 0.005 0.939 logprov r -0.049 1.00-0.0546 0.113 0.575 p value 0.526 0.482 0.146 <0.0001 logqmax r -0.240-0.0545 1.00-0.274-0.074 p value 0.002 0.482 0.0003 0.343 logrv r 0.220 0.113-0.274 1.00 0.151 p value 0.005 0.146 0.0003 0.050 logpsa r -0.006 0.575-0.074 0.151 1.00 p value 0.939 <.0001 0.343 0.050 * Adjusted for age, p<0.05, IPSS: International Prostate Symptom Score, logprov: log transformation of prostate volume, logqmax: log transformation of maximal flow rate (Qmax), logrv: log transformation of residual volume, logpsa: log transformation of PSA, r: correlation coefficient 대사증후군요소들이배뇨장애각요소들에영향을줄수있는지를알고자선형회귀분석을시행한바, 이완기혈압 1mmHg 증가시 IPSS 0.208점이증가하였으나 (β=0.208, p=0.003), 다른대사증후군요소들과는상관관계가없었다. 최대요속과잔뇨량, 삶의질은대사증후군의모든요소들과상관관계가없었고, PSA는허리둘레로측정한복부비만과 양의상관관계가있었다 (β=0.029, p=0.023) (Table 3). 전립선용적은허리둘레 (β=0.025, p<0.0001) 와수축기혈압 (β=0.004, p=0.036), 이완기혈압 (β=0.006, p=0.049) 과양의상관관계가있었다. 허리둘레가 1cm 증가시전립선용적의로그변환값이 0.0246 증가하였고, 수축기혈압 1mmHg 증가시는전립선용적의로그변환값이 0.004 증가하였다 (Table 3). 30 대한배뇨장애요실금학회지
대사증후군에서남성하부요로증상관련위험요인분석 Table 3. Linear regression analysis for the lower urinary tract symptoms according to the metabolic syndrome Variable β S.E. 95% CI Pr > t IPSS WAIST -0.060 0.127-0.311 0.192 0.640 SBP 0.029 0.047-0.064 0.121 0.543 DBP * 0.208 0.069 0.073 0.344 0.003 Glucose 0.014 0.022-0.030 0.057 0.540 Triglyceride 0.003 0.006-0.009 0.014 0.611 HDL-cholesterol 0.034 0.059-0.082 0.150 0.564 logprov WAIST * 0.025 0.005 0.014 0.035 <.0001 SBP * 0.004 0.002 0.0003 0.009 0.036 DBP * 0.006 0.003 0.00003 0.012 0.049 Glucose -0.0008 0.001-0.003 0.001 0.422 Triglyceride -0.00001 0.000-0.0005 0.0005 0.964 HDL-cholesterol * -0.005 0.003-0.010 0.0002 0.060 logpsa WAIST * 0.029 0.013 0.004 0.054 0.023 SBP 0.006 0.005-0.003 0.015 0.181 DBP 0.011 0.007-0.003 0.025 0.121 Glucose -0.002 0.002-0.006 0.002 0.378 Triglyceride 0.0006 0.0006-0.0006 0.002 0.329 HDL-cholesterol -0.004 0.006-0.016 0.008 0.486 WAIST: waist circumference 94cm, SBP: systolic blood pressure 130mmHg, DBP: diastolic blood pressure 85mmHg, glcose: fasting plasma glucose 100mg/dl, triglyceride: triglyceride 150mg/dl, HDL_chol: HDL cholesterol 40mg/dl, logprov: log transformation of prostate volume, logpsa: log transformation of PSA, S.E: standard error, β : regression coefficient, * P-value<0.05 2. 다변량회귀분석대사증후군의요소들간에도상호간의영향을줄수있음을고려하여다변량분석을시행한바, IPSS는이완기혈압과양의상관관계가있었고 (β=0.277, p=0.003), 중성지방은경계성의의수준으로양의상관관계가있었다 (β=0.012, p=0.088). 전립선용적은허리둘레와양의상관관계가있었고 (β=0.018, p=0.005), 잔뇨량은저 HDL-콜레스테롤과상관관계가있었다 (β=0.014, p=0.030). 3. 로지스틱회귀분석가. 배뇨장애단일요소에대한상대위험률 (Table 4) 대사증후군구성요소와배뇨장애평가항목들을각각기준값을바탕으로범주화하여대사증후군요소를가진군이그렇지않은군에비해배뇨장애의범주에포함될위험률을분석하였다. IPSS와삶의질점수, 잔뇨량은통계학적인의미있는결과가나타나지않았다. (1) 전립선용적전립선용적 25g을기준으로하였을때, 허리둘레가 94cm 이상인군은 94cm 이하인군에비해전립선용적이 25g 이상일위험률이 2.931배로높았다. 94cm 이상의허리둘레와고혈압을동시에가진군에서그렇지않은군에비해전립선용적 25g 이상위험률이 3.598배였으며, 복부비만과고혈당을가진군에서는상대위험률이 2.508배였다. 복부비만과고혈압, 고혈당을모두가진군에서는그렇지않은 Vol. 12, No. 1, 2008 31
이하나 정우식 심봉석 홍영선 박혜숙 Table 4. Odds ratio and their 95% confidence intervals (CIs) from logistic regression analysis of the voiding factors according to factor combinations of metabolic syndrome Prostate Volume25 Prostate Volume40 Qmax 15 PSA 2.5 OR 95% CI OR 95% CI OR 95% CI OR 95% CI wc 2.931 * 1.421 6.046 2.082 * 1.074 4.036 0.741 0.326 1.687 3.961 * 1.586 9.894 bp 1.066 0.440 2.584 1.433 0.573 3.583 2.874 * 1.070 7.722 1.579 0.421 5.924 glc 0.867 0.409 1.838 0.860 0.419 1.766 1.082 0.421 2.777 0.871 0.339 2.237 tg 0.766 0.389 1.510 0.599 0.305 1.176 0.648 0.282 1.487 1.184 0.497 2.820 hdl 1.796 0.922 3.497 1.310 0.687 2.497 0.682 0.304 1.533 1.168 0.502 2.718 wc-bp 3.598 * 1.621 7.988 2.052 * 1.028 4.094 1.180 0.494 2.814 3.136 * 1.281 7.675 wc-glc 2.508 * 1.140 5.517 2.001 0.985 4.064 0.594 0.255 1.382 3.089 * 1.298 7.350 wc-tg 1.042 0.449 2.421 1.012 0.438 2.341 0.847 0.313 2.295 3.197 * 1.182 8.649 wc-hdl 2.149 0.928 4.978 1.877 0.879 4.004 0.702 0.283 1.746 2.562 * 1.040 6.313 bp-glc 0.857 0.431 1.703 0.938 0.481 1.831 1.495 0.648 3.448 1.113 0.460 2.691 bp-tg 0.810 0.394 1.665 0.874 0.427 1.786 1.167 0.468 2.911 1.574 0.644 3.845 bp-hdl 2.326 * 1.123 4.816 1.521 0.781 2.966 1.137 0.480 2.690 1.356 0.575 3.200 glc-tg 0.930 0.426 2.031 0.549 0.245 1.230 1.105 0.418 2.922 0.976 0.351 2.719 glc-hdl 1.254 0.591 2.662 1.221 0.588 2.536 0.729 0.307 1.731 1.023 0.399 2.622 tg-hdl 0.848 0.385 1.868 0.526 0.229 1.212 0.433 0.175 1.072 0.876 0.294 2.609 OR: odds ratio, CI: confidence interval, IPSS: International Prostate Symptom Score, QoL: quality of life, Prostate Volume25: prostate volume 25g, Prostate Volume40: prostate volume 40g, Qmax 15: maximal flow rate 15ml/sec, RV 20: residual urine volume 20ml, PSA 2.5: prostate specific antigen 2.5ng/dl, wc: waist circumference 94cm, bp: systolic blood pressure 130mmHg or diastolic blood pressure 85mmHg, glc: fasting plasma glucose 100mg/dL, tg: triglyceride 150mg/dL, hdl: HDL cholesterol 40mg/dL * statistically significant 군에비해전립선용적이 25g 이상일위험률이 3.083배였으며, 복부비만과고혈압, 저 HDL-콜레스테롤혈증이있는군에서는 3.440배의상대위험률을나타냈다. 전립선용적 40g 을기준으로하였을때, 허리둘레가 94cm 이상인군은 94cm 이하인군에비해전립선용적이 40g 이상일위험률이 2.082 배로높았고, 복부비만과고혈압을동시에가진군은그렇지않은군에비해전립선용적 40g 이상일위험률이 2.052 배였다. (2) 최대요속최대요속을 15ml/sec 기준으로하였을때, 고혈압이있는군은없는군에비해최대요속이 15ml/sec 이하일위험률이 2.874배였다. (3) PSA PSA를 2.5ng/dl 기준으로하였을때, 허리둘레가 94cm 이상인군은 94cm 이하인군에비해 PSA가 2.5ng/dl 이상일위험률이 3.961배높았다. 복부비만과고혈압, 복부비만과고혈당, 복부비만과고지혈증, 복부비만과저 HDL-콜레스테롤혈증을가진군은각각상대위험도가 3.136, 3.089, 3.197, 2.562로높았으며, 복부비만과고혈압, 고혈당을모두가진군과복부비만과고혈압, 고지혈증을모두가진군은그렇지않은군에대한상대위험도가 2.990, 2.981였다. 나. 증상적전립선비대증에대한상대위험률 (Table 5) 배뇨장애평가항목들중최대요속 15ml/sec 이하, 전립선용적 25g 이상, IPSS 9점이상의요소를모두가진경우를증상적전립선비대증으로정의하고 (12), 대사증후군요소를가진군이그렇지않은군에비해이러한기준을충족할수있는위험률을구하였다. 대상환자중증상적전립선비대증으로분류되어진환자수는 194명 (55.7%) 이었는데, 허리둘 32 대한배뇨장애요실금학회지
대사증후군에서남성하부요로증상관련위험요인분석 Table 5. Odds ratio and their 95% confidence intervals (CIs) from logistic regression analysis of symptomatic benign prostatic hyperplasia according to factor combination of metabolic syndrome OR 95% CI wc 3.178 * 1.282 7.878 bp 2.013 * 1.232 2.727 glc 1.050 0.512 2.154 tg 0.447 0.229 0.875 hdl 0.847 0.449 1.598 wc-bp 2.381 * 1.026 4.220 wc-glc 1.249 0.619 2.518 wc-tg 0.622 0.275 1.410 wc-hdl 1.188 0.558 2.529 bp-glc 1.397 0.720 2.709 bp-tg 0.819 0.406 1.651 wc-bp-glc 1.672 0.778 3.593 wc-bp-tg 0.962 0.384 2.408 wc-bp-hdl 1.994 0.829 4.792 wc-glc-tg 0.562 0.214 1.475 wc-glc-hdl 0.892 0.365 2.181 wc-tg-hdl 0.529 0.193 1.450 bp-glc-tg 0.873 0.348 2.188 bp-glc-hdl 0.992 0.445 2.209 bp-tg-hdl 0.628 0.241 1.635 glc-tg-hdl 0.319 0.103 0.993 wc-bp-glc-tg 0.748 0.244 2.286 wc-bp-glc-hdl 1.289 0.458 3.630 wc-bp-tg-hdl 0.940 0.282 3.139 wc-bp-glc-tg-hdl 0.320 0.078 1.315 bp-glc-tg-hdl 0.373 0.086 1.610 wc-bp-glc-tg-hdl 0.400 0.069 2.326 symptomatic benign prostatic hyperplasia was defined as Qmax<15ml/sec and Prostate Vol >25g and IPSS>9 Number of this category were 194 patients (55.7%). OR: odds ratio, CI: confidence interval, wc: waist circumference 94cm, bp: systolic blood pressure 130mmHg or diastolic blood pressure 85mmHg, glc: fasting plasma glucose 100mg/dL, tg: triglyceride 150mg/dL, hdl: HDL-cholesterol 40mg/dL, * statistically significant 레가증가된복부비만을가진군은상대위험률이 3.178으로가장높았고, 복부비만과고혈압을모두가진군은그 렇지않은군에비해위의세가지요소를모두가진증상적전립선비대증을나타낼위험률은 2.381 이었으며, 고혈압만있는군의상대위험률은 2.013 이었다. 고찰대사증후군은인슐린저항성을공통된특징으로한심혈관계질환의발생및사망과관련된질환의군집으로 (8), 대사증후군이있는사람은그렇지않은사람에비해심혈관계질환은 2배, 제 2형당뇨병은 4배증가하며 (9), 심혈관계또는관상동맥질환으로인한사망률도 2.9-4.2배증가한다 (10). 1923년스웨덴의의사인 Kylin이처음으로고혈압, 고혈당및고요산혈증의 3가지대사질환의군집성 (clustering) 개념을처음으로주장하였고, 이후에도 1947년 Vague가소위남성형비만으로알려진상체비만의유형이제 2형당뇨병과각종심혈관질환등의대사이상과흔히연관된다는사실을발표한바있다 (11). 1988년 Reaven (4) 은심혈관계질환의위험인자인이상지방혈증, 비만, 고혈압, 인슐린저항성에따른내당능장애등의군집성을 'X 증후군 (Syndrome X)' 혹은 인슐린저항성증후군 이라고명명하였으며, 1998년 WHO에서는 대사증후군 으로정의하고실제적인진단기준을제시하였으며, 2001년 National Cholesterol Education Program Adult Treatement Pannel III (NCEP-ATP III) 에서진단적편이성과임상적응을고려한기준을발표하였고, 가장최근에는국제당뇨연맹에서허리둘레를중심으로 2005년에제시한새로운기준이현재널리쓰이고있다 (12). 미국의경우대사증후군의유병률이 2.4-43.5% 로매우다양하게보고되고있고 (13), 국내에서도 20세이상인구에서 21.5% 의높은이환율을보이고있다 (14). 대사증후군의기본병태생리는인슐린매개성포도당흡수의장애로인한인슐린저항성에의해이차적으로발생한고인슐린혈증으로알려져있다 (4,5,15). 인슐린저항성이나고인슐린혈증은시상하부의교감신경계활성을조절하는배쪽내측핵 (ventromedial nucleus) 에영향을미쳐혈중및조직내카테콜아민 (cathecholamine) 을증가시키는작용을하며 (16), 말초교감신경계도자극하여교감신경활성도를증가시킨다 (17). 이렇게활성도가증가된교감신경계는교감신경의분포가많은장기에영향을미치게되는데, 전립선및방광경부에도작용하여하부요로에서는배뇨증상을일으킨다. 전립선비대증으로인한하부요로증상의기전은방광 Vol. 12, No. 1, 2008 33
이하나 정우식 심봉석 홍영선 박혜숙 경부및전립선부위에많이분포되어있는교감신경계의과활성때문으로알려져있다 (18). 복부비만은전립선비대증의병인중의하나로생각되는에스트로겐과안드로겐의비율변화를일으켜서전립선의비대를촉진하여배뇨증상을악화시킨다. 복부비만은혈청내에스트로겐과인슐린을증가시키고, 성호르몬결합글로불린과자유테스토스테론을감소시킨다 (19). 성호르몬결합글로불린의감소는전립선내로의안드로겐과에스트로겐의진입을증가시키고, 전립선내부로진입한안드로겐은안드로겐수용체와결합하여전립선을증식시켜하부요로증상을악화시킨다 (19). 또한비만으로인해증가된인슐린은전립선의증식에중요한역할을하는인슐린양성장인자-1의수용체와결합하여전립선의증식에관여하고, 교감신경계를과활성화하여하부요로증상을악화시킨다 (19). 본연구는복부비만의지표를국제당뇨연맹에서제시한허리둘레로사용하였고, 한국인의기준치가없기때문에중국인기준치를적용하였는데 (12), 복부비만이대사증후군요소중배뇨증상과가장연관이있었다. 고혈압환자에서보이는고카테콜아민혈증은방광배뇨근의수축과관련이있는요추천골천수에영향을미쳐빈뇨와야간뇨를일으키고, 전립선및방광경부의평활근긴장도를증가시켜방광출구폐색을초래하기도한다 (20). 45 세이상중년및노인을대상으로한국내연구에의하면남녀모두에서대사증후군의유병률에가장큰영향을미치는것은혈압과허리둘레로나타났다. 그러므로대사증후군유병률을낮추기위해서는혈압과허리둘레의관리에역점을두어야한다 (21). 동맥경화증등의순환기계질환은방광의혈류를감소시켜부교감신경계의만성변형을초래한다. 부교감신경계의만성변형은배뇨근의부교감신경자극반응을저하시켜배뇨근의수축력을약화시키면서이와관련된배뇨장애를일으킨다 (22). 2006년 Kim 등 (23) 이시행한대사증후군과남성배뇨장애의연관성에대한연구에의하면대사증후군환자군에서대조군에비해모든배뇨요소들이악화되어있는것으로나타났고, 대사증후군을가진전립선비대증환자들이대사증후군이없는전립선비대증환자들에비해체중과 BMI, 혈당, 혈중중성지방, 그리고 PSA 수치가높고, HDL 콜레스테롤수치가낮았다. 또한전립선연평균성장속도도대사증후군을가진전립선비대증환자들에서의미있게증가하였다 (24). 본연구에서는대사증후군의일부요소는노년기남성하부요로증상의가장중요한요소인전립선의비대와밀접한관계가있으며, 가장큰영향을미치는것은허리둘레로측정한복부비만이었다. 그러나전립선의크기는환자가주관적으로느끼는증상점수나삶의질과는연관성을보이지는않았다. 본연구의결과복부비만과고혈압이같이있을경우전립선용적을비롯한하부요로증상발현에가장영향미치므로복부비만과고혈압에대한관리가하부요로증상의치료및예방에기여할것으로생각한다. 결론본연구에서는대사증후군의여러요소중허리둘레로측정한복부비만과고혈압이하부요로증상과연관성이있었다. 그러므로대사증후군으로진단된환자에서는대사증후군의처치와함께하부요로증상을진단하여적절한치료가병행되어야할것이다. References 1) Korea National Statistical Office. 2000 Annual report on the cause of death statistics. 2001 2) Wilson PW, D Ahostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97: 1837-47 3) Fluster V, Pearson TA. 17th Nethesda 27th Bethesda Conference. Matching the intensity of risk factor management with the hazard for coronary heart disease events. J Am Coll Cardiol 1996;27:957-1047 4) Reaven GM. Banting lecture 1988. Role of the insulin resistance in human disease. Diabetes 1988;37:1595-607 5) DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care 1991;14:173-94 6) Hellmich M, Evers T, Kubin M, Merchant S, Lehmacher W, Engelmann U, et al. Development and validation of a risk score for somatic erectile dysfunction: combined results from three cross-sectional surveys. Eur Urol 2005; 48:495-502 7) 김재헌, 심봉석, 홍영선. 전립선비대증에서대사증후군 34 대한배뇨장애요실금학회지
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