Curr Bladder Dysfunct Rep (2014) 9:350–363 DOI 10.1007/s11884-014-0261-8 GERIATRIC BLADDER DYSFUNCTION (G GHONIEM, SECTION EDITOR) Role of Urodynamics in the Evaluation of Elderly Voiding Dysfunction Ayman Mahdy & Gamal M. Ghoniem Published online: 14 September 2014 # Springer Science+Business Media New York 2014 Abstract Voiding dysfunction is a common condition in the MUI Mixed urinary incontinence elderly that can affect both men and women. Due to the age- NPH Normal pressure hydrocephalus associated changes in the lower urinary tract, voiding dys- PFME Pelvic floor muscle exercise function in the elderly is usually complex and multifactorial, PCa Prostrate cancer necessitating more objective testing sometimes. In this chap- PD Parkinson disease ter, we will focus on the role of urodynamics in the setting of PMC Pontine micturition center voiding dysfunction in the elderly. The term voiding dysfunc- PFS Pressure flow studies tion will be used to refer both to storage and obstructive lower PVR Postvoid residual urinary tract symptoms. RP Radical prostatectomy SUI Stress urinary incontinence TBI Traumatic brain injury Keywords Urodynamics . Geriatric . Elderly . Voiding UTIs Urinary tract infections dysfunction UUI Urgency urinary incontinence UI Urine incontinence Abbreviations VLPP Valsalva leak point pressure AD Alzheimer dementia VUR Vesicoureteral reflux AUA American urological association VUDS Videourodynamics BOO Bladder outlet obstruction CVA Cerebrovascular accident DHIC Detrusor hyperactivity with impaired contractility DO Detrusor overactivity Introduction DU Detrusor undercontractility ICS International continence society The elderly is defined by the World Health Organization (WHO) IPSS International prostate symptom score as the chronological age of 65 years. With the advances in ISD Intrinsic sphincter deficiency medical care, the elderly is expected to be a growing sector of LUTS Lower urinary tract symptoms our patients’ population. The number of individuals aging MS Multiple sclerosis 65 years or more has increased by 140 million between 1975 MSA Multiple system atrophy and 1995, accounting for 6 and 7 % of the world’spopulations, respectively. This age group is projected to comprise 10 % of the A. Mahdy (*) world population by 2025 [1]and20%oftheAmericanpopu- Division of Urology, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0589, Cincinnati, OH 45267, lation in 2030 [2]. Furthermore, those over the age of 85 years are USA the fastest growing segment of the elderly population in the USA, e-mail: [email protected] and the number of individuals 80 years and older will rise from 9.3 million in 2000 to 19.5 million in 2030 [3]. G. M. Ghoniem Department of Urology, University of California Irvine, 333 City With this increase in the elderly population, we, the urolo- Blvd. West, Ste 2100, Orange, CA 92868, USA gists, expect a parallel increase in the geriatric patients’ Curr Bladder Dysfunct Rep (2014) 9:350–363 351 volumes in our practice. In 2006, the elderly patients repre- Video-urodynamics can also help identify the level of BOO sented 48 % of the urology outpatient visits. This is the highest especially in women [5]. rate between surgical subspecialties, exceeded only by oph- When bladder function is weak, different terms have been thalmology and only with a narrow margin [4]. use. These include the following: impaired bladder contractil- There is no specific standard definition of voiding dysfunc- ity (IC), detrusor under contaractility (DU), and more recently tion but the condition can be broadly classified to obstructive detrusor underactivity (DU).Detrusorundercontractility lower urinary tract symptoms (LUTS), storage LUTS, and urine (DU) is defined by the International Continence Society incontinence (UI). LUTS in the elderly are usually multifacto- (ICS) as “detrusor contraction of reduced strength and/or rial. In men, aging is usually associated with benign prostatic duration, resulting in prolonged bladder emptying and/or a hyperplasia (BPH), a condition that per se can cause LUTS. In failure to achieve complete bladder emptying within a normal women, aging is usually associated with some degree of pelvic time span”[6]. There are no standardized cutoff urodynamic organ prolapse (POP) and vaginal atrophic changes, two con- values that define DU. Chung et al. used a maximum flow rate ditions that can also predispose to LUTS. In both men and of ≤15 ml/s and detrusor pressure of Qmax of <20 cm H2O to women, the bladder collagen/elastin ratio changes, again lead- define DU in their study of male patients who had radical ing to bladder functional changes and hence LUTS. prostatectomy [7•]. DU should be differentiated from “AD” Furthermore, the elderly with LUTS may also encounter one which is defined by the ICS as “one that cannot be demon- or more of other age-related disease conditions that affect the strated to contract during urodynamic studies.” lower urinary tract function. These disease conditions may Both DU and AD are common urodynamic findings in the include mental, cognitive, and/or physical impairments that geriatric population. In a study of 449 women, Valentini et al. may predispose to different forms of voiding dysfunction. found predominance of impaired detrusor contractility and These factors together turn the evaluation of LUTS in the high PVR in patients 75–93 years old compared to younger elderly a multifactorial and complicated process. In this set- age groups [8]. The elderly are more predisposed to fecal ting, urodynamics may provide an invaluable objective tool to impaction, impaired mobility, and use of multiple medications further characterize and guide the management of LUTS in the that can affect the detrusor function [9]. Furthermore, detrusor elderly. The value of urodynamics, however, should be function was shown to decline with age. This is probably weighted against the invasiveness of the procedure and the related to the normal detrusor muscle changes with aging with need for urethral catheterization with possible subsequent decreased smooth muscle concentration and increased colla- infection, pain, or urethral trauma. In this chapter, we will gen deposition. DU tends to be more in men than women. In a discuss the role of urodynamics in the geriatric voiding dys- study of urodynamic testing in 1179 patients 65 years of age or function with specific focus on certain disease conditions that older, Jeong et al. reported DU in 40.2 % in men and 13.3 % in can affect the lower urinary tract in the elderly. women. The rates of DU in this study were found to increase with age in both genders [10]. Obstructive LUTS Detrusor Hyperactivity with Impaired Contractility or Detrusor Overactivity with Detrusor Undercontractility Obstructive LUTS occur during the voiding phase of the micturition cycle. Some of the obstructive LUTS are per- More commonly observed in the elderly, detrusor hyperactiv- ceived by patients at the beginning of micturition (urinary ity with impaired contractility (DHIC) is the urodynamic hesitancy), during micturition (weak stream, intermittent finding of detrusor overactivity (DO) during the filling and stream), or at the end of micturition (postvoid dribbling and DU during the emptying phases of urodynamic study (Fig. 1). sense of incomplete bladder emptying). This may progress to This is usually accompanied with high PVR. Clinically, the acute or chronic urine retention. Obstructive LUTS are com- patients usually have mixed storage and obstructive LUTS. mon in the elderly and can be related to bladder and/or bladder Elderly patients with urge incontinence were found to have outlet. Bladder-related obstructive LUTS include detrusor increased detrusor contraction than those with DHIC [11]. We undercontractility (DU) and acontractile detrusor (AD). suggest to replace the old term (DHIC) with this newer term Bladder outlet-related obstructive LUTS on the other hand (detrusor overactivity with detrusor undercontractility refer to bladder outlet obstruction (BOO). Differentiation of (DODU)) to facilitate understanding and avoid confusion. the two entities, during urodynamic studies, can significantly In addition to the diagnostic value of urodynamics in affect treatment decision making and outcome. The addition differentiation between BOO and DU, urodynamics may pro- of imaging studies during video-urodynamics may provide vide additional data that can affect treatment plan and help some useful anatomic data. The use of fluoroscopy during with appropriate patient counseling before surgery. Lewis the study can diagnose concomitant vesicoureteral reflux et al. retrospectively reviewed the charts of 87 of men with (VUR) and/or bladder diverticulum secondary to BOO. urine retention presumed to be secondary to BPH. The 352 Curr Bladder Dysfunct Rep (2014) 9:350–363 Fig. 1 Detrusor hyperactivity with impaired contractility. Urodynamic filling cystometry, she developed detrusor overactivity (DO) with urine tracing of filling cystometry and pressure flow studies in an 86-year-old leakage at a filling volume of 90 ml. She also leaked with cough (CL) female with insensible urinary incontinence accompanied with urinary with cough leak point pressure of 60 cm H2O at 150 ml. During voiding, frequency, urgency, increased daytime voiding frequency, and nocturia. she urinated 75 ml with maximum flow rate of 4 ml/s (red arrow) and a Patient also reported sense of incomplete bladder emptying and weak Pdet at Qmax of 3.3 cm H20 (blue arrow). She also showed