Bladder Dysfunction in Aging Populations

Introduction

Due to advances in public health, nutrition and medicine, significant gains were made in life expectancy during the 20th century. Currently, the worldwide average life expectancy for all individuals is 67 years, with women generally living longer than men, 69 years vs. 65 years, respectively. However, in developed countries, life expectancy for both genders often exceeds these estimates, resulting in a significant population of individuals in their 70’s and beyond. Though many remain relatively healthy as they age, a considerable number will develop medical conditions that place them at greater risk of physical disability, hospitalisation and death. Such individuals may be classified as the “frail elderly”, though this term is losing favor.

Symptoms

Older adults, both female and male, experience the same lower urinary tract symptoms (LUTs) as adults of all ages, including urinary incontinence, overactive bladder (i.e., urgency, urgency incontinence, frequency, or nocturia) and impaired emptying. The prevalence of incontinence and overactive bladder symptoms increases with age. It is believed that both physiologic changes in the lower urinary tract and alterations in central neurolgical control mechanisms contribute to LUTs in aging. These age-related changes include impairment in central signalling, diminished detrusor muscle strength, loss of oestrogen effect in women and reduction in blood flow and vascularity as well as loss of muscle mass in the urethra. In men, prostatic obstruction may play a significant role.

Comorbidities compound the intrinsic factors that contribute to incontinence. Dementia, instability due to fall risk or dizziness, as well as diminished vision and hearing are all independently associated with incontinence. Diabetes mellitus, in particular, leads to many types of LUTs, from detrusor overactivity to atonic bladder, to frequency secondary to polyuria. Impaired mobility may also result from diabetes (i.e., from neuropathy or lower extremity amputation) and could impair toilet access.

Mobility disorders may also lead to functional incontinence. That is, even if the mechanisms for maintaining continence are intact, difficulty in reaching the toilet in time to empty the bladder will render the patient incontinent. Moreover, when patients suffer cognitive impairment or psychiatric illness, they may not respond to normal voiding signals and, therefore, do not exhibit normal toileting activity.

Finally, older individuals are often prescribed multiple medications, many of which may cause LUTs. Numerous agents such as opiates, antimuscarinics and antipsychotics may cause constipation and retention of urine. Diuretics produce polyuria which, in turn, may lead to frequency and urinary incontinence.

Assessment

Preliminary screening of elderly patients to evaluate functional decline and health deterioration may be accomplished using the Vulnerable Elders Survey (http://www.rand.org/health/projects/acove/survey.html). In-office evaluation should involve a detailed history covering the time course and nature of the LUTs, their severity and the resultant effects on the patient’s quality of life using ICQ-SF and Urogenital Distress Inventory (UDI) or Incontinence Impact Questionnaire (IIQ). Information about how the individual manages LUTs at home, including use and type of absorbent products, should be elicited. All medical comorbidities and medications must be documented. Some older patients may be unable to impart such history, so the contributions of caretakers or family members may be essential to obtaining this information, particularly that related to medications, proximity to toileting facilities and eating and drinking habits.

The physical exam should be focused on the abdomen and pelvis with particular attention to distension as a sign of urinary retention and genital excoriation indicative of chronic exposure to moisture. Atrophic changes and prolapse in women and prostatic characteristics in men should be assessed. Sometimes urine leakage is demonstrated during the exam, providing a clue as to the nature of any incontinence, e.g. as with the cough stress test.

In addition to neurological screening, it may be useful to perform a formal test of cognitive function such as the Abbreviated Mental Test score or Mini Mental State examination. A Barthel score to assess functioning in the activities of daily living can also be helpful in determining the course of action for treatment.

A urine analysis should be performed to rule out infection, proteinuria, glucosuira, or other underlying pathology. Haematuria, whether microscopic or visible, always requires additional evaluation. An upper tract imaging study as well as a cystoscopic examination can help to determine if an occult disease process is contributing to a patient’s symptoms.

A bladder diary including information about bowel movements for a 3-day period can be extremely helpful in determining causes of LUTs as well as recommending therapy. Unfortunately, the cognitive impairments in some elderly patients often preclude their collecting the necessary data; however, a surrogate can gather this information. Complex urodynamic testing is not routinely necessary or desirable in a frail patient, but a urinary flow rate and measurement of post-void residual urine volume should be performed.

Treatment

Often multimodality therapy is required to optimise voiding function in older adults. Treatment may range from behavioural interventions to judicious use of medication to surgery. Current literature clearly supports the safety and efficacy of surgical treatment in geriatric patients with appropriate preoperative optimisation and precautions. Successful treatment frequently leads to enormous gains in quality of life as well as benefits to overall health.

Initially, symptomatic urinary tract infection should be treated in affected older adults. Topical oestrogen therapy should be considered in appropriate female patients, as this may be useful in prevention of UTIs in this population. Any genitourinary lesions that may be contributing to the individual’s complaints should be addressed.

Behavioural interventions are considered the mainstay of the treatment of LUTs. They may include prompted or timed voiding, reduction in fluid intake or avoidance of bladder irritants. Also included in this category are various efforts at increasing elders’ access to a toilet such as convenient placement of a commode.

Pharmacologic therapy in men often begins with alpha blockade for the treatment of prostatic obstruction. In elderly men with very large glands or who are not felt to be candidates for prostatic surgery, a 5-alpha reductase inhibitor may be added to the regimen. Treatment with antimuscarinic agents is often a “double-edged sword”, as these medications enhance urinary control while potentially causing dry mouth, constipation, cognitive impairment and urinary retention. Certain antimuscarinic agents that do not cross the blood brain barrier to a significant degree may be preferred in older adults, though actual trials in frail geriatric subjects are scarce. It is necessary to exercise caution in administering these agents to those individuals who have baseline dementia.

When there are clear anatomic abnormalities significantly contributing to LUTs in frail older adults and the anatomic derangements are amenable to surgical correction, surgery should be offered. Urodynamic testing may be necessary before contemplating surgery for urinary incontinence. Preoperative optimisation and postoperative precautions to prevent delirium contribute significantly to good outcomes.

Conclusion

LUT disorders can result in severe disability and social withdrawal in elderly people. It is therefore essential that those caring for such individuals proactively identify those at risk or who have lower urinary tract symptoms and ensure proper evaluation and treatment. The treatment of LUT disorders in frail older adults should be individualised and multimodal intervention is commonly required. Given advancements in anaesthesia, perioperative care and surgical techniques, surgical therapies should be offered to appropriate patients. When geriatric patients receive such attentive care, the effects of LUT disorders on overall health and well-being can be minimised.

References

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