URINARY PROBLEMS

IN ELDERLY
Hendra Herman
FK UNJA
RSUD RADEN MATTAHER
Jambi
Urinary Incontinence

“ The involuntary loss of urine which is objectively

demonstrable and a social or hygienic problem ”

The International Continence Society

Hunskaar, et.al., Int Urogynecol J, 2000
 Bladder Anatomy

• Hollow, distensible, muscle organ

 Reservoir of urine
• Capacity ~600 mL
• Desire ~200 mL
• Normal void ~300 mL

 Organ of excretion
• Behind symphysis pubis
• Female – against anterior wall of
uterus
• Trigone
• Sphincter
Physiology

• Sympathetic nerve cause relaxation

• Parasympathetic nerve induce or
initiate voiding
Types of Urinary Incontinence

• Transient or reversible UI (Acute)

• Established or Persistant UI (Chronic)
• Urge UI
• Stress UI
• Mixed UI
• Overflow UI
• “Functional” UI
Reversible causes of UI

• D - Delirium or Drugs

• R - Restricted mobility

• I - Infection, impaction

• P - Polyuria
Persistent

Stress

CAUSES OF Urge/
Overflow PERSISTANT
UI OAB

Functional
Stress UI

The complaint of involuntary

leakage with effort or exertion
or on sneezing or coughing

Sudden increase in
abdominal pressure

Urethral pressure

Abrams P et al. Urology. 2003;61:37-49.

Urge UI

The complaint
of involuntary
leakage
accompanied by
or immediately
preceded by
urgency Involuntary detrusor
contractions

Urethral pressure

Abrams P et al. Urology. 2003;61:37-49. Ouslander J. N Engl J Med. 2004;350(8):786-799.

Overactive bladder

• Includes urinary urgency with or without urge

incontinence, urinary frequency, and nocturia
• Associated with involuntary contractions of the
detrusor muscle
Mixed UI

The complaint of
involuntary
leakage associated
with urgency and
also with exertion, Sudden increase in
effort, sneezing, abdominal pressure

or coughing Involuntary detrusor

contractions

Urethral pressure

Abrams P et al. Urology. 2003;61:37-49. Chaliha C et al. Urology. 2004;63:51-57.

 •Urethral blockage
Overflow •The Bladder is not able
to empty properly

Neurogenic/Atonic

Obstruction
Functional Incontinence

• Immobility
• Diminished vision
• Aphasia
• Environment
• Psychological
Aging Changes

• Decreased bladder capacity

• Reduced voiding volume
• Reduced flow rates
• Increased urine production at night

• * Nordling, J Experimental Gerontology, 2002, 37:991

Risk Factors for UI

• Impaired mobility
• Depression
• Stroke
• Diabetes
• Parkinson’s Disease
• Dementia (moderate to severe)
• 1/3 have multiple conditions
• FI, Obesity, CHF, Constipation, TIAs, COPD, Chronic cough,
Impaired mobility & ADLs
Consequences of UI

• Cellulitis, Pressure ulcers, UTI

• Falls with fractures
• Sleep deprivation
• Social withdrawal, depression
• Embarrassment (50%), interference with activities
•  Caregiver burden, contributes to institutionalization
• Costs > $16 billion
Basic Evaluation of UI

• History: Bladder diary

• Physical examination, especially Genitourinary and Neurological

• Bladder stress test

• Postvoid residual

• Urinalysis, urine culture if indicated

• Ureum, creatinine, fasting glucose

Referral Criteria

 Recurrent urinary tract infections

 Hematuria
 Elevated postvoid residual or other
evidence of possible obstruction

 Recent gynecological or urological

surgery or pelvic radiation

 Failed treatment of stress or urge UI

Others Diagnostic Tools

• USG
• Cystogram
• Cystoscopy
• Urodinamic study
Benign Prostatic Hyperplasia (BPH) and
Prostate Cancer

• Both are included in ten most diagnosed diseased in men over 50

YO
• Cases are increase due to change in dietary
• Cases are increase due to increase in elderly population
Top 10 Diagnosed Diseases
in Men Age ≥ 50 Years
1-year prevalence (%)
(n = 963,452 person-
Rank Disease years)
Coronary Artery
1 51.3
Disease/Hyperlipidemia
2 Hypertension 45.2
3 Diabetes Mellitus Type 2 17.5
4 Enlarged Prostate 13.5
5 Osteoarthritis 13.3
6 Arrhythmias 8.8
7 Cataract 8.6
8 Gastroesophogeal reflux disease 8.4
9 Bursitis 8.0
10 Prostate Cancer 7.8
Issa MM et al. Am J Manag Care. 2006;12(suppl):S83–S89.
 Epidemiology

• The prevalence of BPH can be calculated on the basis of :

• Histologic criteria (autopsy prevalence)
• Clinical criteria (clinical prevalence).
• No men younger than 30 had evidence of BPH, prevalence rose with each
age group, peaking at 88% in men in their 80s.
• The prevalence increases in the fourth decade of life, reaching nearly 100%
in the ninth decade.
• Age-specific autopsy prevalence is similar in all populations (regardless of
ethnic and geographic origin)

( Moore, 1943 ; Swyer, 1944 ; Franks, 1954 ; Karube, 1961 ; Harbitz and Haugen, 1972 ;
Pradhan and Chandra, 1975 ; Holund, 1980 ; Berry et al, 1984 ; Carter and Coffey, 1990 ).
 Lower Urinary Tract Symptoms (LUTS)

Obstructive Symptoms Irritative Symptoms

• Hesitancy
• Urgency
• Weak stream
• Frequency
• Straining to pass urine
• Nocturia
• Prolonged micturition
• Urge incontinence
• Feeling of incomplete bladder
emptying
• Urinary retention

Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

Pathophysiology

(Roehrborn CG et al, 2007)

Etiology • The precise molecular etiology of this hyperplastic
process is uncertain.
• The observed increase in cell number may be due to:
• Epithelial and stromal proliferation or
• Impaired programmed cell death leading to cellular
accumulation.
• Androgens, estrogens, stromal-epithelial interactions,
growth factors, and neurotransmitters may play a role

(Roehrborn CG et al, 2007)

Etiology • The development of BPH requires an intact
androgen signaling pathway, but androgens to do
not cause the disease.
• The hyperplastic process caused by imbalance
between cell death and cell proliferation
• Paracrine and autocrine growth factors seem to
be the primary factors --- stimulate or inhibit
stromal and epithelial growth.
• Inflammation, common in BPH specimens, may
play a role in the pathogenesis
• BPH can have a familial inheritance
(Roehrborn CG et al, 2007)
( Rohrborn CG et l, 2007)
 The therapeutic hormonal aspect of BPH

• BPH treatment options

• Watchful waiting
• Drugs:
• Alpha adrenergic blockers
• 5-alpha reductase Inhibitors
• Combination therapy
• Surgical therapy:
• TURP, Minimal invasive surgical therapy, Open
(Roehrborn CG et al, 2007)
TURP Removes Tissue

• Opens bladder neck

• Create Cavity
• Improvement in
symptoms
• Less impotence
Prostate Cancer

• Most common non-skin cancer in men

• Second leading cause of cancer death in U.S. men
• About 25% of prostate cancers are thought to be
clinically significant

Campbell-Walsh UROLOGY, 9th edition

Comprehensive Textbook of Genitourinary Oncology, 3rd edition
Trends in Incidence Rates for Selected Cancers by Sex, United
States, 1975 to 2010

Jemal et al. Cancer statistics, 2014. CA cancer J clin, 2014 Mar-Apr;61(2):133-4.

Presentation

• Most patients are asymptomatic

• Diagnosed due to elevated PSA or abnormal DRE
• Advanced cancer may present with bone pain, unintentional
weight loss, hematuria, worsening LUTS, urinary retention,
hydronephrosis, LE weakness/leg numbness/difficulty with
ambulation

Campbell-Walsh UROLOGY, 9th edition

Comprehensive Textbook of Genitourinary Oncology, 3rd edition
Screening

• Controversial
• Does PSA-based screening lead to decrease in risk of death from
prostate cancer?
• Advantages
• May prolong survival and save lives
• Save men from long painful death with little effective treatments available
(costs?)
• Disadvantages
• Overdiagnosis which leads to Overtreatment
• Potential decrease in QOL from treatment (costs?)
Campbell-Walsh UROLOGY, 9th edition
Comprehensive Textbook of Genitourinary Oncology, 3rd edition
Diagnosis

• PSA not perfect and can only be used to define risk of prostate
cancer NOT diagnosis
• No universally accepted threshold value
• Decision to biopsy based on many different criteria (age, overall
health, PSA velocity, PSADT, FH, race, etc…)

Campbell-Walsh UROLOGY, 9th edition

Indications for Prostate Biopsy

• Suspicious DRE
• Age, ethnicity, +FH
• Abnormal total PSA

Campbell-Walsh UROLOGY, 9th edition

When to Perform Imaging to Evaluate for
Metastatic Disease
• Bone scan
• Indicated: PSA>20, Gleason score ≥8, Bone pain
• Pelvic CT/MRI
• Indicated: PSA>20, Gleason score ≥8
• Newer data suggests fused PET/CT with 11C- Acetate may
be much better at detecting microscopic +LN

Campbell-Walsh UROLOGY, 9th edition

Oyama et al. 11C-Acetate PET imaging of prostate
Cancer: detection of recurrent disease at PSA
relapse. 2003. J Nuc Med. 44; 549
Dying With PCa is Not Pleasant

• Incontinence
• Sexual dysfunction
• Bone pain, fractures
• Metabolic syndrome
• Hormone Rx – induced dementia
• Urinary symptoms, bleeding
• Cachexia
Treatment options for Localized Prostate Cancer

• Active Surveillance
• Surgery
• Radiation
• Cryoablation

Campbell-Walsh UROLOGY, 9th edition

Comprehensive Textbook of Genitourinary Oncology, 3rd edition
 Treatment • Hormonal
options for • Chemotherapy
Advance • Combined
Prostate Cancer

Campbell-Walsh UROLOGY, 9th edition

Comprehensive Textbook of Genitourinary Oncology, 3rd edition
ERECTILE DYSFUNCTION

Definition
The inability to attain and/or maintain an erection sufficient for
satisfactory sexual performance.

Persistent 3 months
Remember, both partners in a relationship are affected.

National Institute of Health. JAMA. 1993

Prevalence
• 20 – 30 million in USA

• > 150 million worldwide

• The risk increases with age

40%
30%
Minimal ED
20%
Moderate ED
10% Complete ED
0%
40 years 70 years
Massachusetts Male Aging Study. J Urol. 1994
 Periaqueductal Grey
Midbrain
Visual, auditory and
olfactory cerebral
afferents

Medial Preoptic Area

Paraventricular Nucleus
Hypothalamus

Mucosal sensory receptors

(Krause finger Corpuscle)
Physiology
Smooth muscle relaxation
Relationship between endothelial dysfunction-related risk
factors in vascular diseases & ED

National Institutes of Health. JAMA. 1993

Lue TF. N Engl J Med. 2000
Classification of ED

• Organic (most common, 70%)

• Vascular
• Hormonal
• Neurological
• Medications
• Psychogenic
• Mixed psychogenic and organic
IIEF-5 6 bulan terakhir
Bagaimana kepercayaan anda untuk
1
Sangat rendah
2
Rendah
3
Sedang
4
Baik
5
Sangat baik
mencapai dan mempertahankan
ereksi?
Ketika ereksi dengan stimulasi seksual, Hampir tidak Kurang dari Setengah Lebih dari Hampir
seberapa sering ereksi anda cukup pernah/tidak setengahnya setengah selalu/selalu
keras untuk penetrasi? pernah

Selama hubungan seksual, seberapa Hampir tidak Kurang dari Setengah Lebih dari Hampir
sering anda dapat mempertahankan pernah/tidak setengahnya setengah selalu/selalu
ereksi setelah penetrasi? pernah

Selama hubungan seksual, seberapa Sangat-sangat Sangat sulit Sulit Tidak terlalu Tidak sulit
sulit anda mempertahankan ereksi sulit sulit
hingga selesai hubungan?

Seberapa sering hubungan seksual Hampir tidak Kurang dari Setengah Lebih dari Hampir
anda memuaskan? pernah/tidak setengahnya setengah selalu/selalu
pernah
5-Item International Index of Erectile
Function (IIEF-5).

• ED Classification according IIEF-5 Score:

• Severe (5-7),
• Moderate (8-11),
• Mild – Moderate (12-16),
• Mild (17-21),
• No ED (22-25).
Clinical Evaluation for ED (Physical Examination)

• Blood pressure
• Cardiac, thyroid, testicular, prostate examination
• Penile anatomical abnormalities
• Gynecomastia
• Exercise treadmill test (if cardiac risk factors are present)
Erection Hardness Score

EUROPEAN UROLOGICAL ASSOCIATION

Clinical Evaluation for ED (Laboratory)

• Fasting glucose
• HbA1C
• Fasting lipid profile
• Blood chemistry
• Serum testosterone
• Hemogram

Additional test (optional):

• ECG
Treatment of ED

• Treat reversible causes

• Lifestyle modification (weight loss, tobacco cessation, exercise)
1st line • PDE-5 inhibitor

• Intracavernous injection
• Medicated Urethral System for Erection
2nd line • Vacuum erection device

• Surgical prosthesis
• Some men respond to hormonal therapy, penile revascularization
3rd line or sex therapy
First line Therapy

Heidelbaugh, Am Fam Phycisian 2010

 First Line Therapy
Vacuum constrictions device
Second Line Therapy
Intracavernous injection
Second Line Therapy
Medicated Urethral System for Erection
Third Line Therapy

• Maleable penile prosthesis

Third Line Therapy

• Inflatable penile prosthesis

TERIMA KASIH