Urodynamics: Focus On the Geriatric Patient

Christine Koops; Leslie S. Wooldridge

Disclosures

Urol Nurs. 2017;37(3):127-142. 

In This Article

Abstract and Introduction

Abstract

The focus of this article is on indications for urodynamics, detailed description, and definition of each component of urodynamic testing, along with common urodynamic findings often seen in the elderly. Precautions to take when working with older adults are discussed. The correlation of study findings with real patient cases is identified along with options for a plan of care.

Introduction

Lower urinary tract symptoms (LUTS) in older adults are very common. These symptoms include urinary frequency, urgency, incontinence, dysuria, nocturia, and retention. The pathophysiology of these issues varies as well. Etiology can be obstructive, nonobstructive, or a combination. These symptoms can have a detrimental impact on quality of life. According to the EPIC study, the largest population-based survey to assess LUTS in five countries, storage symptoms, including any type of incontinence, reported a prevalence of 10.4% in men over age 60 years and 19.3% of women over 60 years. In addition, voiding symptoms in general were noted in 37.2% of men and 24.6% of women over 60 years of age (Irwin et al., 2006). Mahdy and Ghonium (2014) reported that 15% to 50% of older adults, as well as up to 40% of nursing home residents, are affected by urinary incontinence. The economic burden of overactive bladder (OAB) along with urge urinary incontinence in 2007 was $65.9 billion, with projected costs of $76.2 billion in 2015 and $82.6 billion in 2020 (Coyne et al., 2014). This represents a staggering economic burden in the United States.

As adults age, so do their bladders. Most bladders develop a decreased capacity, decreased compliance, and weaker contractility as they age. Conditions such as Parkinson's disease, dementia, cerebral vascular accident, spinal stenosis, degeneration of the spine, and other neurological diseases, which are more prevalent in the geriatric population, can lend to a more complicated urological diagnosis (Berni & Cummings, 2004). Nocturnal output also tends to increase with age (Elbadawi, Hailemariam, Yalla, & Resnick, 1997). All of these changes can result in mixed problems that can present in different ways, resulting in a challenge for the older adult patient to articulate.

There are also gender differences. In women, there are more persistent urgency symptoms along with decreased detrusor contractility (Shin, On, & Kim, 2015). In older women, peri-genital estrogen becomes depleted. Estrogen receptors in the vagina, pelvic floor, bladder, and urethra are no longer being nourished by estrogen. Consequently, vaginal tissues become dry and atrophic, pelvic floor muscles weaken, and bladder urgency can become a problem (Robinson & Cardozo, 2011). In men, prostates eventually enlarge (Glazener et al., 2011), which can subsequently cause obstruction, irritative symptoms, and difficulty voiding and urinary retention. A large multinational study revealed that 45.3% of men aged 70 to 80 years have moderate to severe LUTS (Rosen et al., 2003). The prevalence of LUTS increases as men age, including both storage and voiding symptoms (Kuo, 2007).

The diagnostic evaluation of all urologic diseases should begin with an extensive medical history that includes a current medication list and a physical examination. The physical examination should include a pelvic examination for females and prostate examination for males, abdominal examination, urinalysis, urine culture (if appropriate), and measurement of post-void residual (PVR), along with a uroflow (Rosier et al., 2016). Voiding diaries can be one of the most useful assessment tools, especially with patients who have a difficult time articulating their symptoms. A three-day record that includes voiding times, voided volumes, leakage episodes, and amount and type of fluid intake would be ideal (Bright, Cotterill, Drake, & Abrams, 2012; Jimenez-Cidre et al., 2015). Unfortunately, compliance with this type of request can be a challenge for many patients, particularly those who might be confronted with memory, vision, dexterity, or mobility difficulties. Additional assessment tools could include questionnaires and various other tests (see Table 1). In some cases, diagnosis and initial treatment plans can be determined after computation of these data, but in cases where there are still questions about specific urinary tract functions that need to be answered, urodynamics should be considered as a next step (Al-Zahrani & Gajewski, 2016).

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