DEPARTMENT OF UROLOGY EDUCATION.

COMMON UROLOGICAL PROBLEMS IN GERIATRIC POPULATION

Production Team

Dr Abraham Benjamin - Manager Medical InformaticsMr. Naresh Kumar - Coordinator Medical Informatics

Presentation By Dr.Naveenchandra Acharya MS, MNAMS, DNB, MRCS (UK) Mch (Uro.) PGI.Chandi Consultant Urologist, Chief Andrologist & Micro Surgeon Specialist in Male Infertility and Impotence

The extension of life expectancy is one of the most dramatic achievements of the 20th century

Problems..•Change in dexterity, decreased mobility.

•Altered Mentation, Sleep pattern.

•HTN, stroke, diabetes, Alzheimer's etc.

•decreased drug tolerance.

Physiological Changes

•Aging Bladder: Prostatic enlargement& Bladder instability

•Tendency to excrete more water during night

•Atherosclerotic vessels..poor hemostasis/ED

•Hormonal alterations—impotence & atrophic vaginitis /

recurrent UTIs

Common old age group Urological ailments

• Lower Urinary Tract Symptoms(LUTS): BPH, • Malignancy: Carcinoma prostate ..• Incontinence/overactive bladder• Urinary tract infections • Erectile dysfunction. Affect Quality of life very significantly.

Natural History

• Based on TRUS, the growth of the prostate in these men 40 to 79 years old was estimated to be about 6 ml per decade of life.

•Hesitancy/Weak stream•Urgency, frequency/nocturia.•Retention of urine •Feeling of incomplete voiding.

Ref:- http://www.medicinenet.com/benign_prostatic_hyperplasia/article.htm last accessed on 19/03/10

Mcvary K. BPH:Epidemiology and Co-morbidities. Am J Manag Care. 2006;12:S122-S128)

Benign Prostatic Hyperplasia

Evolving trends in BPH

Treatment Choices in BPH

•Mild Symptoms – Watchful Waiting•Moderate Symptoms – Medical •Severe Symptoms – Surgery - Open / TURP

/LASER prostatectomy •Complications – Surgery(Renal Impairment; Rec. UTIs;Retention; Haematuria; Stones)

Pharmacological management of BPH

Alpha Blockers(Veltam, Dynapress,

Urimax)

5 ARIs(Finast, Dutas)

Mechanism of Action Relax smooth muscle at bladder outlet

Reduce epithelial content of adenoma

Onset of Action 1-3 days At least 3 months

EfficacyEffective in 50% pts Only glands >30-40G

↓AUR 50%

Side EffectsPostural Hypotension,

Aesthenia, Retrograde Ejaculation.

↓Libido/Erection, ↓PSA,

Breast tenderness

•TURP is not as innocuous or successful as many believe – 18% Complication Rate, ~0.5% Mortality

•Mebust et al, J Urol, 1989; 141: 243

•

Ravi M,Singh SK,Mandal AK,Acharya N..Comaprision Of HOLEP And TURP …Urologia internationalis 2009

Laser prostatectomy a suitable choice for aged patient with cardiac comorbdities,big prostate glands(largest gland done with LASER is around 280 gm… in India and 200 gm in our hospital)

Carcinoma Prostate

• Most cases Unfortunately present

in advanced stage

• Very few qualify(<5%) for curative

surgery (Radical

prostatectomy/Radical

Radiotherapy)

In India it’s the medical Oncologist domain

•Hormonal manipulation with LHRH analogues,

•Second line : ketoconazole, Honvan.

•Third line: docetaxel based chemotherapy.

•Calcium, Zoledronic acid supplementation to prevent osteoporosis and skeletal related events.

Agarwal MM, Singh SK, Acharya NC et al. Non-interventional management of

obstructive acute renal-failure in prostate cancer. Can J Urol. 2007

HIFU FOR PROSTATE CANCER

Transient Incontinence

•D-Delirium•I-Infection•A-Atrophic vaginitis•P-Pharmacological•P-Psychological•E-Endocrine•R-Restricted mobility•S-Stool impaction

Incontinence: Aftermaths

•Psychological distress

•Social embarassment

•Disturbed sleep pattern

•Hygienic issues

•Overall Quality of life deterioration

Stress Incontinence

•Females-genital prolapse, atrophic vaginits (post-menopausal changes)

Urge Incontinence

•Detrusor Instability (Aged bladder)

•Parkinsonism/Stroke

•UTI

National Overactive Bladder Evaluation StudySimilar Prevalence among Men and Women

0

5

10

15

20

25

30

35

<25 25-34 35-44 45-54 55-64 65-74 75+

Men

Women

Pre

vale

nce%

Age in Years

Age-Specific Prevalence of OAB*

*Overall prevalence, with and without urge incontinence.

N=5204, women vs men: P=NS. Adapted from Stewart et al. World J Urol. 2003;20:327-336.

Antimuacarinic Receptor Profiles of Individual Agents May Limit Clinical Utility

Side effects of Pharmacotherapy

Dry mouth Blurred vision Constipation & diarrhoea Arrhythmia Retention of urine...Cognitive impairment in elderly patients

Summary of Incontinence Treatment

• Treat underlying factor: UTI,

PARKINSONISM,BPH

• Estrogen supplementation for

atrophic vaginitis

• Antimuscarinic agents for overactive

bladder

• Pelvic muscle exercise: Kegels pelvic

floor dysfunction

Erectile Dysfunction

• The incidence increases significantly with increasing age,

• Decline in testosterone and DHT (ADAMS)

• Testosterone supplementation needed

• Precautions: monitor PSA level, regular DRE

Male Menopause

• Decreased sex drive• Loss of muscle mass• Increased sleepiness• Generalised weakness• Anxiety• Cognitive impairment• Mood swings/depression

ED: An Early Cry For Help

•ED can manifest before other CV symptoms, but it can be silent to the health care provider•Many men will remain silent about ED unless they are asked•Your patients WANT you to bring it upJackson G, et al. Int J Clin Pract. 1999;53:363-368.

Marwick C. JAMA. 1999;281:2173-2174.

Pritzker MR. Proceedings of the American Heart Association. November 7-10, 1999; Atlanta, Ga.

NIH Consensus Development Panel on Impotence. JAMA. 1993;270:83-90.

Options of Management

•PDE-5 Inhibitors

•Injection therapy

•Vacuum Erection Device

•Penile Prosthesis

PDE-5 inhibitors and CVS safety

•Long term PDE-5 inhibitor usage may lead to improvement in endothelial dysfunction and thereby reduce systemic risks too.

•Second Princeton consensus conference – “Sex in some patients and not PDE-5 inhibitors may be dangerous for the heart” Kostis JB. Am J Cardiol 2005;96: 313-321

Vacuum Devices

•Can improve erection

•Messy and user dependent

•Satisfaction varies 35-80%

UTI

• Common problem in

Institutionalized elderly

people

• 10%old M & 20% old F

have bacteuria

• Asymptomatic UTI need

not be treated

CAUSE OF UTI

•Decrease in cell mediated immunity in old age

•Concurrent comorbidities-Diabetes, Parkinsonism

•Inability to empty bladder in Toto- BPH, Cystopathy

•Poor hygiene

Symptomatology

May not exhibit same symptoms

Lethargy, confusion, weakness or new onset incontinence

Close observation of Nursing Home elderly population is key

to management

Urosepsis if not treated early :may lead to hypothermia,

mortality is as high as 40 %

Treatment

Appropriate antibiotics

Intermittent catheterisation

Ostrogen topical supplementation in elderly

females-to enhance local defense mechanism

Cranberry tablets/juice/lactacyd application (for

replenishing lactobacilli store in genital tract)?

Cystoscopy has a role to Play

Acharya N et al..Labial fusion causing pseudoincontinence in an elderly woman. Int J Gynaecol 2007

Psychological issues

Social stigma for incontinence deterrent in seeking for treatment

LUTS/ED considered as normal aging process in elderly people

Limited mental & functional ability which interferes with learning, motivation, and cooperation needed for successful treatment

Concerns in the Forthcoming era

As the proportion of elderly people is on the rise, special emphasis should be laid down on the their needs and suitability

Further research needs to be done in conventional medicines for suitability in geriatric age group

Geriatric medicine should be part of undergraduate and post-graduate teaching curriculum

Superior and Compassionate Care