Aging Urinary Tract

7/30/2019 Aging Urinary Tract

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The Ageing Lower

Urinary Tract

Dr. Adrian Wagg

Division of Geriatric Medicine

Department of Medicine


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Expressions of interest

Funding from Astellas, Pfizer and GSK for research,sponsorship to meetings, lectures

Funding from CIHR, BUPA, HQIP, DH for research


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The Brain lavatory axis

Mobility, dexterity, co-morbidity,habit, adaptation

Physiology, pathophysiology,

Cognition, co-morbiditieswhite matter lesionsbrakes off , habit, adaptation

M

edication


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UI as a Geriatric Syndrome

Multiple risk factors, across multiple organ systems and domains

UI

Modulating factor

UI

RF 1

RF 2

Tinetti et al11995; Inouye et al, 2007

Young Elderly


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0

5

10

15

20

25

30

35

0 1 2 3

Age group

%

(95%C

I)Nocturia (2 times/night)

Urgency

Frequency

UUI

MUI

SUI

Symptom prevalence and age

60

Men

European Urology Volume 50, Issue 6, December 2006, Pages 1306-1315


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0

5

10

15

20

25

30

35

40

0 1 2 3

age group

%

(95%CI)

Nocturia (2 times/night)

Urgency

Frequency

UUI

MUI

SUI

Symptom prevalence and age

60

Women

European Urology Volume 50, Issue 6, December 2006, Pages 1306-1315


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Prevalence and Severity of Urinary Incontinence by Sex and AgeGroup

Perry S et al. J Public Health Med 2000; 22(3):427-34.

Females

0

5

10

15

20

25

30

35

40-49 50-59 60-69 70-79 80+

Age group (years)

Prevalence%

Monthly and slight

Monthly and damp

Monthly and wet

Monthly and soaked


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Prevalence and Severity of Urinary Incontinence by Sex and AgeGroup

Males

0

5

10

15

20

25

30

35

40-49 50-59 60-69 70-79 80+

Age group (years)

Prevalen

ce%

Monthly and slight

Monthly and damp

Monthly and wet

Monthly and soakedPerry S et al. J Public Health Med 2000; 22(3):427-34.


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What makes incontinence more likely in older

people?

Changes in LUT physiology

Increased prevalence of LUT disease

Impact of co-existent disease

Impact of treatments

.ability to compensate


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Ageing and the lower urinary tract - whatsnormal?

56 elderly subjects - comprehensive urodynamic

assessment and CT /MRI (26)

Normal UDS in 18% (PVR < 250mL)

Detrusor Instability commonest diagnosis

DI seen as commonly in unobstructed as

obstructed men

Obstruction with and without symptoms equally

common in the men


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Normal bladder architecture


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Susset J G, Servot-Viguier D, Lamy F,Madernas P, Black R. Collagen in155 human bladders. Invest Urol1978;16:204-206

Collagen


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Changes in matrix

Increase in collagen in association with greaterage collagen: muscle >53% and infiltration ofsmooth muscle bundles

Similar increase in response to ischaemia

Similar changes in addition to detrusor

hypertrophy in detrusor smooth muscle in responseto outflow tract obstruction


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Normal innervation

Ch i i ti


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Changes in innervation

Linear loss of acetylcholinesterase containing nerves in

association with greater age

Mean nerve/mm2 muscle measured by light

microscopy related to subject age

Mean nerve profiles/mm2 of

detrusor measured by e.m

p


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Yoshida M, Miyamae K, Iwashita H, Otani M, Inadome A. Management of detrusor

dysfunction in the elderly: changes in acetylcholine and adenosine triphosphaterelease during aging. Urology. 2004;63:17-23.


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Contractile function as measured

by Q* in association with age

Age-related fall in women p


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Bladder capacity

Maximum bladder capacity falls in association withgreater age

Functional capacity also falls

There is a greater urinary frequency

Saito M, Kondo A, Kato T, Yamada Y. Frequency-volume charts:Comparison of frequency between elderly and adult patients. Br JUrol 1993; 72: 38-41


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Maximum bladder capacity by decade of

life(median and 95% CI)

0

100

200

300

400

500

600

20-

30

30-

40

40-

50

50-

60

60-

70

70-

80

80-

90

90+

Age group

Volume(mL)

n=78n=185

n=332 n=262 n=184n=199

n=130n=11

Collas DM, IntUrogynecol J

1996; 7: 24-29.


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Voiding Function

Both sexes void less successfully in laterlife

Larger residual volumes (50-150mL)

Increased incidence of incompleteemptying (men > women)


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Median (95%CI) maximum flow rate for men and womenin relation to greater age

Women and men, p


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Residual volumes

Malone-Lee J G. Br J Urol 1993; 72: 873-880.


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Bladder Sensation

There is a decreased sensation of bladder filling inassociation with ageing.

Studies of sensation in association with studies ofcerebral perfusion have demonstrated decreased

perfusion of right insula Griffiths 2007


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Sensation


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The decreased sensation and decreasedbladder capacity may conspire to give an

elderly person less time to reach thelavatory.


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Urge in older v younger men

-50

0

50

100

150

200

R1 R2

The interval was (medianand 95%CI) 5 (4 5) and 3

(3 5) minutes in oldermen. The intervals werestatistically significantlydifferent (W=31294.5,p


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Urethral Function

Lower urethral pressures found in both sexes in association

with increased age The urethra becomes less compliant and able to resist

pressure

Increased stiffness of urethra and bladder in association with

increased age - observed clinically as reduced compliance.Women with USI show reduced stiffness of the urethra


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Urethral Function

Loss of striated muscle cells in association with greater age

Strasser H, Tiefenthaler M, Steinlechner M, Bartsch G, Konwalinka G. Urinary incontinence in the elderlyand age-dependent apoptosis of rhabdosphincter cells. Lancet 1999;354:918-9


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No incontinence stress urinary incontinence

Maximum urethral closure pressure is lower in

association with greater age

r= -0.4, p=0.03


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From Haubensak 1975

Resting urethral pressure with age

and sex, measured by UPP

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8

Decade of life

Urethralpressure(mmHg)

males

females


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Detrusor overactivity

In both sexes, detrusor overactivity is associated with lower

bladder capacities with advancing age.

Sensation of filling in older people with DO is increased

Contraction strength is decreased compared to younger

people with DO

Urethral resistance is increased


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Median and interquartile ranges for Q star in

women with and without detrusor overactiv ity

0

20

40

60

80

100

120

10 20 30 40 50 60 70 80

Ag e (by decade)

Qs

tar(mL

/s)

non- DO

DO


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In women with pure stress incontinence, these pressures are lower

Detrusor pressures at urethral

opening and closure in women with

detrusor overactivity or stress

incontinence(medians and 95% CI)

0

10

20

30

40

0 2 4Detrusorp

ressure(cm

pdet.clos

pdet.open

DO


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In women with detrusor overactivity, there is an increase in urethralresistance

Pdet.open for stable and overactive

bladders in w omen under and over

the age of 70.

Medi an and 95%CI

0

5

10

15

20

25

30

35

40

45


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Nocturnal frequency / polyuria

- mechanisms

Loss of renal concentrating ability Kirkland J L, Lye M, Banerjee AK. Patterns of urine flow and

electrolyte excretion in healthy elderly people. Brit Med J1983; 287:1665-1667

loss of diurnal ADH / ANP secretion Asplund R, Aberg H. Diurnal variation in the levels of

antidiuretic hormone in the elderly J Intern Med 1993; 229:

131

increase in GFR when supine

N t l f / l i


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Nocturnal frequency / polyuria

- mechanisms

dependent oedema

reduced bladder capacity in late life

co-existent disease

other reasons for waking


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Physiological changes which predispose to increased

nocturnal urinary frequency

Increased 24h urine volume output Increased urinary frequency

Reduction in the ability of the kidney to concentrate urine Delayed diuresis in response to a fluid load Alteration in the circadian rhythm of ADH secretion Increased level of Na secretion by night

h f


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Other factors

the elderly with nocturia have a higher 24-hour urineproduction than age matched controls with no nocturia.

Nocturics also produce a higher proportion of their daily urineoutput at night

h b i


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Protect the brain

Studies in the community-dwelling elderly link structural whitematter changes in the brain with

mobility impairment

cognitive impairment

urinary urgency

urinary incontinence

Elderly individuals with greater white matter hyperintensity burden

also show increased prevalence of detrusor overactivity anddifficulty maintaining continence on urodynamic studies

J Gerontol A Biol Sci Med Sci 2009;64A; 8:902-909J . Neurol. Neurosurg. Psychiatry 1999; 67, 658660.

C l l f h bl dd


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Central control of the bladder

Sacral afferentinput

Sacral efferentoutput

Pons

PAG

cerebellum

hypothalamus

thalamusAnteriorcingulate

gyrus

insula

Pre frontal

PAG

Kavia,

DasGupta,F

owler2005

P t t th b i


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Protect the brain

Right frontal and inferior frontal WMH associatedwith UI severity OR: 1.05 (1.00-1.77)

UI associated with WMH in:

Cingulate gyrus OR 1.52 (1.01-2.3)

UI severity associated with WMH in

Anterior corona radiata

UI bother associated with WMH in: Anterior corona radiata

J Gerontol A Biol Sci Med Sci 2009;64A; 8:902-909

Th B i


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The Brain

Blue: Areaswhere theresponse tobladder fillingdiminished with

increased age


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Brain response to bladder filling during self-reported urgency showedsignificant activations in a cluster of frontal regions, including medial andsuperior frontal gyri as well as right inferior frontal gyrus adjacent to rightinsula, dorsolateral prefrontal cortex and cerebellum

Aging Urinary Tract

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