Urodynamic Findings and Diagnosis in Aging People 가톨릭의대 성바오로병원 김현우 1

Introduction 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.

Clinical evaluation 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 Basic evaluation 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 Physical examination 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 Further evaluation Generally warranted the diagnosis remains unclear conservative treatment : unacceptable risk or failed Urodynamic evaluation Imaging study Endoscopic examination

URODYNAMICS Urodynimic study indication clinical evaluation does not establish the diagnosis continence is not restored after the reversal of transient causes empirical treatment is ineffective surgery is contemplated ex. BOO : difficult to rule out without urodynamic testing  symptoms and rectally palpated prostate size correlate poorly The aging bladder: morphology and urodynamics. World J Urol 1998 Gediatric incontinence. Urol Clin North Am 1996 Initial evaluation of theh incontinenct patient. J Am Geriatr 1990

URODYNAMICS Simple maneuvers Provocative stress test PVR uroflowmetry 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

URODYNAMICS Uroflowmetry Elderly : UFM may be difficult commonly void small volumes bladder may be empty at the moment of the study (urgency, urge incontinence) mental status may be limiting difficulty voiding in an unfriendly/unfamiliar place BOO UFM : sensitive indicator of voiding dysfunction  promptly need further investigation or avoid extensive urodynamics

URODYNAMICS Uroflowmetry Normal UFM severe voiding symptoms Obstructive UFM (75/man)  PFS : severe BOO UI, obstructive symptoms 80 / DM men Interrupted UFM abdominal straining High RU (300ml)  PFS : DHIC

URODYNAMICS Postvoid residual urine 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 Cystometry Cystometric findings 1. Detrusor overactivity 2. Impaired detrusor function : detrusor underactivity, DHIC 3. Bladder outlet obstruction

URODYNAMICS Cystometry Detrusor overactivity 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 The aging bladder: morphology and urodynamics. World J Urol 1998 The results of prostatectomy: a symptomatic and urodynamic analysis of 152 patients. J Urol 1979

URODYNAMICS Cystometry A 67-year-ole man complaining of frequency, urgency, and UI. (6 months after TURP) 3 episodes of DO accompanied by urge incontinence - treatment anticholinergic medication bladder training

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

Impaired detrusor contractility in community-dwelling elderly presenting with lower urinary tract symptoms. Urology 2007 181 patients (82 men, 99 women). 70 years or older with storage and/or voiding LUTS. urodynamic pressure-flow study IDC  39 (48%) of the 82 men 12 (12%) of the 99 women Prevalence of IDC/DH-IDC was significantly greater in the male population than female. AUR과 indwelling urethral cath. History 있는 사람에서 IDC/DH-IDC 많이 발생. Impaired detrusor contractility in community-dwelling elderly presenting with lower urinary tract symptoms. Urology 2007

Impaired detrusor contractility in community-dwelling elderly presenting 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 75세 이상에서 많이 발생 common mechanism underlying LUTS in the elderly, especially for those with a history of urinary retention and/or urethral catheter placement. Treatment strategies based solely on symptoms can potentially lead to inappropriate pharmacologic therapy and expensive invasive procedures. Relying solely on subjective parameters could be objectionable in the elderly, who are more prone to adverse events and morbidity after pharmacologic or interventional treatment. Impaired detrusor contractility in community-dwelling elderly presenting with lower urinary tract symptoms. Urology 2007

URODYNAMICS Cystometry Detrusor hyperactivity with impaired detrusor contractility (DHIC) 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 Gediatric incontinence. Urol Clin North Am 1996 Initial evaluation of theh incontinenct patient. J Am Geriatr 1990

URODYNAMICS Cystometry A 80-year-ole man complaining of frequency, urgency, and UI Low pressure involuntary detrusor contractions Low flow rate associated with abdominal straining No detectable detrusor contaction  anticholinergic medication should be used cautiously in this patients risk of precipitating urinary retention.

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

The effect of age on lower urinary tract function: a study in women. JAGS 2006 85 ambulatory, community-dwelling female volunteers Max. bladder capacity 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 First desire to void Mean daytime voided volume (voiding diary) Bladder sensation decreased  increasing volumes at first desire to void The effect of age on lower urinary tract function: a study in women. JAGS 2006

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 PdetQmax urethral sphincter function MUCP  age associated loss of striated muscle urge incontinence in old age MUCP Contractile strength The effect of age on lower urinary tract function: a study in women. JAGS 2006

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 G2 G1 G1 : detrusor instability (DI) G2 : impaired contractility(IC) G3 : DI + IC G4 : normal UDS G3 : significantly older than those in the other groups Urodynamic characterization of nonobstructive voiding dysfunction in symptomatic elderly men. J Urol 1999

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

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. highly valuable tool in the investigation of elderly patients with LUTS not always necessary  indicated after excluding potentially reversible conditions outside the urinary tract that may be causing or contributing to the symptoms initial evaluation (incontinent geriatric patients ) : targeted history, P/E, UA, voiding diary, UFM and PVR  the clinician to identify patients who will need more complex urodynamic tests Urodynamic findings in the elderly : may include common diagnosis like BOO and stress urinary incontinence  however, urologic problems often coexist in the elderly, and conditions such as DO and impaired detrusor contractility are common.  e identification of these conditions is necessary to assure accurate prognostic counseling and treatment selection.