Urodynamic Findings and Diagnosis in Aging People

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김현우

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LUTS is a major problem in the elderly population and increase with age

30% of patients in nurseries : placed there because of urinary incontinence

multiple comorbidities

make it difficult to determine which changes are related to aging alone and which

are related to disease.

Introduction

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Geriatric patients

- mental and physical disabilities

- must be individualized.

Unrelated to a urologic etiology

DIAPPERS !!

Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological factors,

Excess urine output, Restricted mobility, Stool impaction

Clinical evaluation

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focused history : comorbid conditions, medications

targeted physical examination urinalysis/urine culture PVR voiding diary (2-3 days, patient or caregiver)

needed for accurate diagnosis leading to appropriate conservative treatment.

Clinical evaluation

Basic evaluation

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women

pelvic examination genital prolapse, atrophic vaginitis, urethritis.

provocative stress testing SUI

rectal exam stool impaction

integrity of the sacral innervation

enlarged prostate : BOO

Clinical evaluation

Physical examination

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Generally warranted

the diagnosis remains unclear

conservative treatment : unacceptable risk or failed

Urodynamic evaluation

Imaging study

Endoscopic examination

Clinical evaluation

Further evaluation

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① clinical evaluation does not establish the diagnosis

② continence is not restored after the reversal of transient causes

③ empirical treatment is ineffective

④ surgery is contemplated

ex. BOO : difficult to rule out without urodynamic testing

symptoms and rectally palpated prostate size correlate poorly

URODYNAMICS

The aging bladder: morphology and urodynamics. World J Urol 1998Gediatric incontinence. Urol Clin North Am 1996Initial evaluation of theh incontinenct patient. J Am Geriatr 1990

Urodynimic study indication

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Provocative stress test PVR uroflowmetry

URODYNAMICS

Simple maneuvers

Elaborate (complex) tests

Cystometry Cystourethrography UPP Leak-point pressure PFS Test of detrusor contractility Electromyography Videourodynamic, ambulatory urodynamics

The aging bladder: morphology and urodynamics World J Urol 1998

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Elderly : UFM may be difficult

① commonly void small volumes

② bladder may be empty at the moment of the study (urgency, urge incontinence)

③ mental status may be limiting

④ difficulty voiding in an unfriendly/unfamiliar place

BOO UFM : sensitive indicator of voiding dysfunction

promptly need further investigation

or avoid extensive urodynamics

URODYNAMICS Uroflowmetry

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URODYNAMICS Uroflowmetry

Normal UFM

severe voiding symptoms Obstructive UFM (75/man)

PFS : severe BOO

UI, obstructive symptoms 80 / DM menInterrupted UFM abdominal straining High RU (300ml)

PFS : DHIC

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PVR : indicates inefficient voiding (detrusor contractility, BOO) No standard maximal PVR volume

< 50 ml : empirically considered normal

> 100 ml : abnormal

not establish a definite diagnosis of obstruction or detrusor hypocontractility

to monitor the progression of the disease with a known BOO.

URODYNAMICS Postvoid residual urine

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Cystometric findings

1. Detrusor overactivity

2. Impaired detrusor function : detrusor underactivity, DHIC

3. Bladder outlet obstruction

URODYNAMICS Cystometry

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the most common dysfunction major cause of urinary incontinence 25-75% of patients with LUTS obstruction : one cause of detrusor instability

69% 31%

relief of prostatic obstruction

URODYNAMICS Cystometry

Detrusor overactivity

The aging bladder: morphology and urodynamics. World J Urol 1998 The results of prostatectomy: a symptomatic and urodynamic analy-sis of 152 patients. J Urol 1979

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A 67-year-ole man complaining of frequency, urgency, and UI. (6 months after TURP)

URODYNAMICS Cystometry

- 3 episodes of DO - accompanied by urge incontinence

- treatment anticholinergic medication bladder training

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URODYNAMICS Cystometry

Detrusor underactivity

contraction of reduced strength ± duration

- prolonged bladder emptying and/or a failure to achieve complete bladder emptying - urinary retention, poor urinary stream, incontinence

symptomatic elderly men : 23-73% etiology DU

frail female nursing home residents (87.6 years) : IDC/DH-IDC 45%

Resnick et al. Neurourol Urodyn 1996

female patients referred for UDS 19% (39/206) hypocontractile bladder

Groutz et al. Urology 1999

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181 patients (82 men, 99 women). 70 years or older with storage and/or voiding LUTS. urodynamic pressure-flow study

Impaired detrusor contractility in community-dwelling elderly pre-senting with lower urinary tract symptoms. Urology 2007

IDC 39 (48%) of the 82 men 12 (12%) of the 99 women

Impaired detrusor contractility in community-dwelling elderly presenting with lower urinary tract symptoms. Urology 2007

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Impaired detrusor contractility in community-dwelling elderly pre-senting with lower urinary tract symptoms. Urology 2007

IDC, with or without DH common mechanism underlying LUTS

especially history of urinary retention and

urethral catheter placement

recommended urodynamic studies

before deciding on additional treatment

Impaired detrusor contractility in community-dwelling elderly presenting with lower urinary tract symptoms. Urology 2007

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commonly present in frail elderly persons with incontinence

UDS of 94 incontinent nursing home residents

DHIC was the most common UDS finding (1/3)

symptoms : predominantly related to bladder overactivity

urodynamic findings higher PVR detrusor instability (up to 50% ) not capable of effective detrusor contractions no signs of bladder obstruction or sphincteric abnormalities

URODYNAMICS Cystometry

Gediatric incontinence. Urol Clin North Am 1996Initial evaluation of theh incontinenct patient. J Am Geriatr 1990

Detrusor hyperactivity with impaired detrusor contractility (DHIC)

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A 80-year-ole man complaining of frequency, urgency, and UI

Low pressure involuntary detrusor contractionsLow flow rate associated with abdominal strainingNo detectable detrusor contaction

anticholinergic medication should be used cautiously in this patients risk of precipitating urinary retention.

URODYNAMICS Cystometry

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URODYNAMICS Pressure-flow study

Bladder outlet obstruction

enlargement of prostate gland (BPH) voiding problems in elderly male weak stream, hesitancy … uncommon diagnosis in women second most common cause in older men combined with detrusor overactivity, impaired detrusor contractility, or both incontinence overflow incontinence due to urinary retention

The aging bladder: morphology and urodynamics. World J Urol 1998

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The effect of age on lower urinary tract function: a study in women. JAGS 2006

Max. bladder capacity

First desire to void

Mean daytime voided volume (voiding diary)

85 ambulatory, community-dwelling female volunteers

The effect of age on lower urinary tract function: a study in women. JAGS 2006

Bladder capacity

does not diminish with age but smaller with DO common belief that bladder capacity shrinks with age maybe to DO rather than to aging itself

Bladder sensation

decreased increasing volumes at first desire to void

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The effect of age on lower urinary tract function: a study in women. JAGS 2006

Contractile strength

PdetQmax

MUCP

The effect of age on lower urinary tract function: a study in women. JAGS 2006

Detrusor contractility

detrusor contraction strength detrusor pressure at maximum flow maximum flow rate progressive deterioration of detrusor function

urethral sphincter function

MUCP age associated loss of striated muscle urge incontinence in old age

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Urodynamic characterization of nonobstructive voiding dysfunction in symptomatic elderly men. J Urol 1999

- urodynamic abnormalities associated with symptomatic nonobstructive voiding dysfunction- 193 men, relationship between age and type of dysfunction

G3 : significantly older than those in the other groups

Urodynamic characterization of nonobstructive voiding dysfunction in symptomatic elderly men. J Urol 1999

G1 : detrusor instability (DI)G2 : impaired contractility(IC)G3 : DI + ICG4 : normal UDS

G3

G2

G1

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Urodynamic characterization of nonobstructive voiding dysfunction in symptomatic elderly men. J Urol 1999

Maximum isometric detrusor contraction pressure and age not significantly correlated

Weak correlation between bladder compliance and age

Urodynamic characterization of nonobstructive voiding dysfunction in symptomatic elderly men. J Urol 1999

- Max. flow rate, bladder compliance, symptom score not different among 4 groups

- Treatment of nonobstructived cases based on symptoms (?) lead to inappropriate pharmacological therapy and unsuccessful clinical outcomes

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Take home message

Initial evaluation

- targeted history, P/E, UA, voiding diary, UFM and PVR

- clinician to identify patients need more complex urodynamic tests

Urodynamic study

- indicated after excluding potentially reversible conditions causing or

contributing to the symptoms

Urodynamic findings

- may include common diagnosis (BOO , SUI)

- coexist DO and impaired detrusor contractility

- identification of these conditions is necessary to assure accurate

prognostic counseling and treatment selection.