1. Urodynamic Findings and Diagnosis in Aging People
가톨릭의대 성바오로병원
김현우 1

2. 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.

3. 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

4. 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.

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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.

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

13. 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% %
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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.