aging urinary tract
TRANSCRIPT
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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