Common Urological Issues

In The Elderly Population

Dr.M.G.Rajamanickam
Consultant Urologist
St. Isabels Hospital
Chennai

Urological Diseases
Male
LUTS
Hematuria
Incontinence
ED

Female
Incontinence
Hematuria
LUTS
DUS

maturia

Pre-renal
Renal

Post-renal

Hematuria
Blood in the urine -Dangerous symptomology
Types:
Macroscopic Gross hematuria
Microscopic hematuria (the presence of >3 red blood cells per
high power microscopic field)
Painless or painful
Initial / Terminal / Total
Clots ? If so type of clots?

Timing of Hematuria

Total hematuria
from bladder or upper
tract
Terminal hematuria
bladder neck or prostatic
urethra
Initial hematuria
from urethra

Hematuria

Causes
Urological (surgical)
Nephrological (medical)
1.
2.
3.
4.
5.

Glomerular
Nonglomerular
Blood dyscrasias,
Interstitial nephritis
Renovascular
disease

Hematuria: Common Uro

Causes
1.
2.
3.
4.
5.
6.
7.

Bladder cancer
Kidney cancer
Ureteral cancer
Urethral cancer
Prostate cancer
Stones
Pyelonephritis

8. Cystitis /
Prostatitis
9. BPH
10.Radiation cystitis
11.Chemical cystitis
12.Drug induced
13. Parasitic
infestations

Work up
History esp. drug history (? ASA ? WARFARIN)
Examination
Investigation :

All patients
Urine culture and cytology
Renal US
IVU or computed tomography (CT) scan
Cystoscopy

Urine Cytology
screening for urothelial cancer
Freshly voided postambulant whole
void specimen
Microscopic examination of Pap
stained cells obtained by
centrifugation of an aliquot of urine
(at least 10 mL)

Bladder Cancer
Most common urological cancer
Transitional cell carcinoma (TCC)
Risk factors:
smoking,
dyes used in rubber & cable industry,
phenacetin-containing analgesics
Chronic stones risk for squamous cell
bladder cancer

Bladder Cancer
S/S:
gross & painless hematuria,
Clots and tissue bits
dysuria, frequency, urgency (CIS)

 Diagnosis:
urine for cytology
bladder tumor antigens
USG KUB
CT Urogram

Definite dx by cystoscopy & biopsy

Management
Superficial
TURBT
Post TURBT BcG intravesical

Muscle Invasive
Radical cystoprostatectomy with urinary
diversion
RT (if unwilling)

Management
Extravesical
RT
Neoadjuvant CT folllowed by Radical
cystoprostatectomy with urinary
diversion
Metastatic :
CT RT

Surgery: options
Transurethral resection with fulguration
Laser photocoagulation
Radical cystoprostatectomy with urinary
diversion

Carcinoma Prostate
Adenocarcinoma commonest
More with irritative voiding
symptoms
P/R : hard nodular prostate
Not all nodular prostates are
malignant
Nodular BPH
Infarct
TB
Granulomatous prostatis

DigitalRectalExam
A Central zone
B Fibromuscular zone
C Transitional zone
D Peripheral zone
E Periurethral zone

Seminal Vesicles

Prostate

Sr.PSA
Organ specific not cancer specific
serine protease (33000D)

Normal serum PSA level 0 to 4.0 ng/mL

The value of PSA for cancer detection increased
from 12% to 32% for PSA levels of 4 to 10 ng/mL
and as high as 60% to 80% for levels above 10
and 20 ng/mL
Men with PSA levels greater than 10 ng/mL are
adviced to undergo biopsy
4 -10ng gray zone

FACTORS INFLUENCING THE LEVEL OF PSA

BPH
Prostatitis
Prostate cancer
Prostate manipulation (prostate massage,
prostate biopsy)
Ejaculation
Retention of urine
Elevated serum levels are due to disruption of
cellular architecture within the prostate gland

Evaluation

TRUS + Biopsy
Gleason Grade and Scoring
CT Abdomen and pelvis
MRI Abdomen and pelvis
? MR Spectroscopy
Bone Scan

Management
Depending on the stage and gleasons score
Age and life expectancy
Organ confined disease Radical prostatectomy
(lap/robotic) (nerve sparing)
Extra capsular extension RT Hormonal therapy
Metastatic Disease Hormonal therapy (Androgen
ablation)

Androgen ablation
Surgical - orchiectomy /
adrenalectomy
Medical
Bicalutamide
LHRH Agonist (risk of LH flare)

Urinary Retention
Acute Urinary retention
Chronic Urinary retention

Acute Urinary retention

Painful inability to void, with relief of pain
following drainage of the bladder by
catheterization.

Pathophysiology:
Increased urethral resistance, i.e., bladder
outlet obstruction (BOO)
Low bladder pressure, i.e., impaired bladder
contractility

Acute urinary retention

Causes :

Men:

Benign prostatic enlargement (BPE) due to BPH

Carcinoma of the prostate
Urethral stricture
Prostatic abscess
Stone (bladder neck / urethra)

Women

Pelvic prolapse (cystocoele, rectocoele, uterine)

Urethral stricture;
Urethral diverticulum;
Post surgery for stress incontinence
pelvic masses (e.g., ovarian masses)

Acute urinary retention

Initial Management :
Urethral catheterisation
Suprapubic catheter ( SPC)

Late Management:
Treating the underlying cause

Chronic urinary retention

Obstruction develops slowly, the bladder is
distended (stretched) very gradually over
weeks/months, so pain is not a feature .
Presentation:
Urinary dribbling
Overflow incontinence
Palpable lower suprapubic mass

Etiology
BPH
Diabetic cystopathy
Neurogenic bladder
Parkinosinism
Multiple sclerosis
Spinal cord injury patients

Chronic urinary retention

Usually associated with

Reduced renal function.
Upper tract dilatation

Treatment is directed to renal support.

Bladder drainage under slow rate to avoid
sudden decompression hematuria.
Treatment of cause

Whats LUTS?

LUTS Lower Urinary Tract Symptoms

LUTS is not specific to BPH ->

Not everyone with LUTS has BPH and not everyone
with BPH has LUTS

LUTS
Voiding (obstructive) symptoms

Hesitancy
Weak stream
Straining to pass urine
Prolonged micturition
Feeling of incomplete
bladder emptying
Urinary retention

Storage (irritative or
filling) symptoms

Urgency
Frequency
Nocturia
Urge incontinence

BPH - what causes these symptoms?

Prostate grows with age (androgen

dependent)
Pressure on the urethra restricts urine

Indications for treatment

Obstructive uropathy to renal

impairment

Acute retention of urine

Chronic retention of urine
Urinary tract infection
Bladder stone formation
Urinary incontinence
Hematuria

medication
n

First line of defense against

bothersome urinary
nsymptoms
Manage the condition - dont fix it

Two major types:

(Alpha-1-blocker) - relax the

prostate and provide a larger
urethral reductase
opening (Tamsulosin,
5-alpha
Alfuzosin) - Shrink
inhibitor
the prostate gland
(finasteride, dutas)

possible side effects of

medication
Retrograde
ejaculation
Dizziness
Headache
Fatigue
Loss of sexual drive

SURGICAL PROCEDURES

TURP
Transurethral electro-vaporisation
Transurethral incision
Transurethral laser technique(holmium,KTP)
Balloon dilatation
Prostate stents
Prostatectomy:suprapubic,retropubic,perineal
Laparoscopic

TURP

(transurethral resection of the

prostate)

Gold Standard of care for BPH

Uses an electrical knife to surgically

cut and remove excess prostate tissue
Effective in relieving symptoms and
restoring urine flow

Urinary Incontinence
Affects:
15%-30% living at
home
30% - 35% in acute
care

>50% in RCF
(residential care
facilities)
Nygaard I, et al. JAMA 2008, 300:1311.
Tennstedt S, et al. Am J Epidemiol 2008,
167:390.
Sahyoun NR, et al, Aging Trends 2001(4):1-

Urinary Incontinence
Continence requires:

Adequate mobility
Mentation
Motivation
Manual dexterity
Intact lower urinary tract function

Urinary Incontinence
Medical
Complications

Rashes
Pressure ulcers
UTI
Falls
Fractures

Urinary Incontinence
Psychosocial
complications

Embarrassment
Stigmatisation
Isolation
Depression
Institutionalisation
risk

Urinary Incontinence
AGEING BLADDER CHANGES
Bladder capacity decreases
Bladder compliance decreases
Ability to postpone voiding decreases
Urethral closing pressure decreases in women
Prostate enlarges in men
Involuntary bladder contractions increase
Post-void residual volume increases (50-100ml)
Also:
Increased fluid excretion at night
Age associated sleep disorders
Detrusor muscle changes

Urinary Incontinence
Transient Incontinence
Common e.g.
30% community dwellers
50% of inpatients
D
I
A
P
P
E
R
S

Delirium
Infection
Atrophic Urethritis/vaginitis
Pharmaceuticals
Psychological (rare)
Excessive urine output
Restricted mobility
Stool impaction

Urinary Incontinence
Urinary tract causes of
incontinence:
Detrusor overactivity
Detrusor underactivity
Genuine stress incontinence
(low urethral resistance)
Obstruction
(high urethral resistance)

Urinary Incontinence Evaluation

GOALS:
Investigate and treat transient and
established causes.
Assess patients environment and
support
To detect uncommon but serious
underlying conditions:
Brain lesions
- Spinal cord lesions
- Carcinoma bladder/prostate
- Bladder stones
- Decreased bladder compliance
-

Urinary Incontinence
Drug Treatment of OAB
Anti-cholinergic (antimuscarinics)

Oxybutynin
Solifenacin
Darifenacin
Tolterodine

Best as adjuncts to
bladder drill.
Dose escalation by
titration
Newer ones better

GSI - ISD
Pelvic floor
exercises
Vaginal cones
Urethral plugs
Biofeedback
Duloxetine
Surgery if all fails

Urological Symptoms in
Parkinsons

Frequency
Urgency
Urge incontinence
Nocturia
Weak stream/dribbling
Sensation of incomplete
voiding/Double voiding
ED

Drug Induced

UDE Pattern

Management
PD is slowly progressive for which
only symptomatic treatment is
available.
PD treatment may alter GU function
itself paradoxically.
Treat PD related symptoms
Treat non PD related symptoms
(prostatic enlargement,stress
incontinence)

Diabetes & UI
Detrusor dysfunction uninhibited contractions, cystopathy
Hyperglycemia - osmotic diuresis and polyuria
Medications
Constipation
Functional impairment amputation
Cognitive impairment vascular dementia

Diabetic cystopathy
1.
2.
3.
4.
5.

decreased bladder sensation

decreased bladder contractility
increased bladder capacity
detrusor overactivity
urinary incontinence

What is Erectile Dysfunction

Synonym: Impotence
Inability to attain and maintain an
erection sufficient for satisfactory
sexual performance
Benign
Significant impact on quality of life

Epidemiology
Incidence and prevalence is high
worldwide
Effects up to 52% of men (40-70yrs)
Steep age-related increase.
Complete impotence from 5% of 40yr
olds to 15% of 70yr olds
Only 10-20% solely psychogenic

Risk factors Endothelial

Dysfunction
Surrogate marker for ED:
Sedentary lifestyle
Obesity
Smoking
Hypercholesterolaemia
Metabolic syndrome
Diabetes mellitus

Aetiology

Organic
Hormonal
Anatomical
Drugs
Psychogenic

Organic causes
Vascular factors (CVD,
atherosclerosis, hypertension,
diabetes, hyperlipidemia, smoking,
trauma)
Central causes (Parkinsons, stroke,
MS, tumours, spinal disease/injury)
Peripheral causes (poly-/peripheral
neuropathy, diabetes, alcoholism,
uraemia, pelvic surgery

Drugs

Antihypertensives (beta blockers, diuretics)

Antidepressants (tricyclic and SSRIs)
Antipsychotics (phenothiazines, risperidone)
Anticonvulsants (phenytoin, carbamazepine)
Antihistamines
H2 antagonists (cimetidine, ranitidine)
Recreational drugs (inc tobacco and alcohol)

Management
Main goal: diagnose and treat
underlying cause
Modify reversible causes (lifestyle,
drugs). Men who initiated physical
exercise and weightloss have upto
70% improvement
(note: cycling more than 3 hours per
week may cause dysfunction)

Treatment
Hormonal: testosterone failure give
testosterone
Post-traumatic arteriogenic: surgery
Psychogenic: underlying problem,
sex therapy/counselling,
phosphodiesterase type-5 inhibitors
(sildenafil, tadalafil, vardenafil)

First-line treatment oral therapy

PDE-5 inhibitors
Contraindicated in patients receiving
nitrates, recent stroke/MI, unstable
angina
Sildenafil: 50mg starting dose
Tadalafil: longer half-life, start at 10mg
Vardenafil: more potent effect reduced
by fatty food.
Apomorphine hydrochloride: dopamine
agonist, quick action, sublingual, not
effected by foods

Second line treatments

Intraurethral alprostadil (prostaglandin E1):
Intracavernosal alprostadil: injected, may
cause pain and priapism

Intraurethral Alprostadil (MUSE)

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile

Dysfunction. Oxford: Health Press Limited; 2002 : 55

Intracavernosal Injections

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 53

Alprostadil
BEWARE

Treatment: Vacuum devices

External cylinder, pumping air out
around penis and causing
engorgement
Clinical success rate of 90% (DM)
Work best: motivation, supportive
partner
Adverse effects: pain, petechiae,
bruising, numbness

Vacuum devices

Third-line treatment - Penile

Prostheses
Semi-rigid rods
2 piece inflatable prosthesis
3 piece inflatable prosthesis with abdominal
reservoir
Risks

Infection
Destroys corpora cavernosa
Erosion and extrusion
Mechanical failure

Penile Prosthesis

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