Re : Urodynamics in a Community-dwelling Population of Females 80 Years or Older . Which Motive ? Which Diagnosis ?

Urinary dysfunctions such as lower urinary tract symptoms increase with aging (1,2) and the improvement of both diagnosis and treatment may help recover the functional life of these patients. If we take into account the syndrome of frailty in patients older than 80 years, defined as sarcopenia, osteopenia, nutritional changes and factors of illness, a remaining question would be if urodynamic study may improve the accuracy of the LUT dysfunction diagnosis. The authors developed a very interesting paper where they studied the relation between LUT symptoms and urodynamics parameters such as free uroflow and intubated flow, cystometry and urethral pressure profilometry, and final urodynamic diagnosis. They observed that in community population dwelling oldest old females urodynamic study allows to find the causes of treatment failure. However, the majority of the population put forward a decrease in their quality of life often by LUTS developing. The most common complaint was incontinence urinary, often associated with urgency which is the main symptom. The free uroflow obtained in initial moment was low (44%) compared to the second moment (91%). This may have been due to lack of confidence and the uncomfortable procedure that involves this exam. It suggests that in ageing population it is necessary to have a special preparation and adaptation to the environment in order to obtain a safe free uroflow. That, in association with a flow rate may be an interesting tool to evaluate ageing patients with LUTS. Prevalence of DO and DHIC, and occurrence of RRCs during cystometry in older patients was higher compared with younger. The urinary symptoms in this special population may be explained by the oxidative stress in intracellular levels as part of physiologic aging of people (3). In this way, the urodynamic diagnosis may help to treat these patients.


INTRODUCTION
Demographic trends indicate that the most rapidly growing adult population older than 65 years is the sub-group older than 85.Some troublesome problems are reported in the elderly primarily due to a change in lower urinary tract (LUT) function.The evaluation of LUT dysfunction is based on urodynamic investigation which is considered the gold standard.In fact, the use of urodynamics remains debatable, as it is invasive, expensive, time consuming, and frequently it is unhelpful to achieve a final diagnosis.The place of urodynamics in the elderly has been mainly discussed concerning incontinent patients and in the frail and elderly living in a long term care residence (1,2) but less studied in the community-dwelling elderly (3).Guidelines suggest to carry out urodynamics in the elderly after failure of conservative treatment or surgery, and do not recommend urodynamics for frail elders.Often, this procedure is not easy to put into practice as in the case of our urodynamics outpatients clinic where evaluations are performed only when requested by a general practitioner, gynecologist or urologist.
In recent years, more and more elderly females have been referred for evaluation of LUT dysfunction.The major part of this population consists of community-dwelling women who live at home, perform daily tasks, take an active part in society and play sports well into old age.Therefore, the remaining question is the diagnosis of frailty in order to take into account the guidelines.Distinction between ageing, disability and frailty is not clear and the objective measurement of frailty remains to be discussed (4,5).When considering research findings, the prevalence of frailty ranges from 33% to 88% according to the criteria employed (6).Multiple systems must be involved in the frailty definition: sarcopenia, osteopenia, nutritional changes, factors of illness.It has been suggested that older persons who retain the capacity to improve (even a small increase in their gait speed) are therefore not frail (5).
Prevalence of lower urinary tract symptoms (LUTS) and LUT dysfunction increases significantly with ageing.Most urinary problems are multifactorial in origin and are not only the result of the LUT changes with aging (7).Age related changes in the female LUT involve both bladder, impaired contractility or overactivity, and urethra, decreased urethral closure pressure and urogenital atrophy.Some studies have been conducted in order to evaluate the effect of age on the LUT function (8)(9)(10)(11)(12).In fact, these studies seldom concerned the oldest subgroup and were mainly devoted to the role and effects of detrusor overactivity (8,11,12).Taking into account these limitations, our objective was to assess a sizeable population of community-dwelling women, aged 80 years or more, referred for urodynamics in our outpatients' clinic in order to answer to the following questions: why is urodynamics prescribed, what are the patient complaints, what are the urodynamic findings and the urodynamic diagnosis and finally, is urodynamics able to help the physician to achieve a better management of LUTS?

MATERIALS AND METHODS
This was a retrospective study.Among 848 women of all ages referred to our urodynamics outpatient clinic between January 2005 and March 2008, 100 (11.8%) aged 80 years or more (mean age 83.2 years; range 80-93 years) were community-dwelling and able to perform everyday tasks.
This study was conducted in accordance with the declaration of Helsinki.According to the local practice of our Ethics Committee, there is no formal Institutional Review Board approval required for retrospective studies.
Assessment by a physician included detailed medical history and usual medication, physical examination (including neurological and cognitive testing).All patients completed a 2-or 3-day bladder diary and had a urine dipstick test.
Specific evaluation comprised of a history of LUTS being the major complaint in cases of concomitant LUTS, previous medical history of neurological disease (stroke, multiple sclerosis, lumbar injury etc.) or dementia, pelvic floor dysfunction and previous pelvic surgery.Exclusion criteria were complete retention, severe dementia involving failure to understand simple orders or a Mini-Mental State score < 20.One patient with spinal cord injury was excluded from the study.
Quality of life was assessed using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) for incontinent patients and the visual analog scale (VAS) for continent patients.
Urodynamics was performed according to Good Urodynamic Practices (13) with a Laborie's Dorado ® unit.Detailed urodynamic testing included: 1) an initial free uroflow (FF1), 2) a cystometry in the seated position at the medium filling rate of 50 mL/ min with normal saline at room temperature (triplelumen urethral catheter 10F for 67 patients and 7F for 33 patients) and intubated flow (IF), 3) urethral pressure profilometry (UPP) in supine position, empty bladder (before the cystometry) and 200-250 mL filling if incontinent, and 4) a second free uroflow (FF2) if bladder was filled for UPP.
No routine provocative maneuver for detrusor overactivity (DO) was performed during cystometry but coughs were used as quality control of pressure recordings (13).
Studied items were results from uroflows (FF1, FF2 and IF), filling cystometry and UPP, and final urodynamic diagnosis.To be interpretable, a uroflow had to have a urinated volume > 100 mL.
Data are presented as mean ± SD and range.The Wilcoxon signed-rank test was used for comparison of related samples and the Chi 2 test to compare unrelated samples with p < 0.05 considered significant.Statistical analyses were performed using SAS, version 5.0 (SAS Institute, Inc., Cary, NC).

Motive for Urodynamics
Patients' main complaints are summarized in Table-1.Incontinence was the main complaint: 22 urge, 32 mixed and 11 stress.Forty patients had previously received treatment (chemical or surgical) for incontinence in middle age or later as well as for recurrent incontinence or developed urgency.Among these patients, 12 had anticholinergic treatment failure for DO.Other complaints were 16 frequency (≥ 8 voids per 24 hours), 12 dysuria (low stream or hesitancy or straining) or incomplete retention and 1 cystitis (recurrent urinary tract infection and pain during voiding); 6 patients with pelvic organ prolapse had a pre-operative evaluation.
Incidence of incontinence (stress, urge and mixed) was 65.0% close to that of the symptom urgency (urge or mixed incontinence, and frequency) which was evoked by 70.0% of this elderly population.

Previous Medical History
Previous medical history of disease and/or pelvic surgery was obtained by detailed questioning which is summarized in Table-2.

Feasibility of FF and IF
A significant result was the low percentage (44.0%) of interpretable free flow (FF) on arrival (FF1) compared to the percentages of interpretable IF and FF2 (Table -3).

Cystometry
Detrusor overactivity (involuntary detrusor contractions during the filling phase: DO) was found in 45 patients (45%) of whom 15 (33.3 %) had a previous history of neurological disease.
Rhythmic rectal contractions (RRCs) were observed in 29 patients of whom 9 (31.0%) had a history of neurological disease.Among these 29 women, 18 (62%) had DO (7 with a history of neurological disease).

Final Urodynamic Diagnosis
DO was the main diagnosis, found in 45 patients of whom 16 had DHIC; ISD concerned only 25 patients, detrusor underactivity (defined as absence of detrusor contraction during voiding and large PVR) was found in 15, low bladder compliance (∆V/∆p ves less than 20 mL/cm H 2 O) in 5 and normal urodynamic data in 10.In the population for which ISD was not predominant, 15 patients had DO, 5 detrusor underactivity and 2 low bladder compliance.
The Table-1 shows the distribution between main patient complaint and urodynamic diagnosis.
Complaint of urgency (symptom) was found to have a sensitivity of 54.3%, a specificity of 76.7% and a predictive positive value of 84.4% for the detection of DO; complaint of stress or mixed incontinence was found to have a sensitivity of 39.5%, a specificity of 85.9% and a predictive positive value of 68.0% for the detection of ISD.

COMMENTS
A major part (40%) of the studied population had failure of conservative treatment or recurrence of incontinence after surgical cure.These women desired further attempts to correct or manage their incontinence.This condition implies urodynamics for a detailed and objective diagnosis.The other 60% agree to urodynamics as their LUT dysfunction has developed for many years (up to 20 years etc.) and has become a cause of decreased quality of life, or is an acute problem (e.g.incomplete retention after knee or hip surgery).
It is well known that the prevalence of urinary incontinence increases with ageing.In the age range higher than 80 years, the reported rate of incontinence is 35% for community-dwelling women in a questionnaire survey (15) and 82% for institutionalized women (2).We found an intermediate rate of 65% probably due to our recruitment, i.e. women with LUTS whose physicians requested urodynamics.It has been reported that urgency and urge incontinence increase with aging, while if stress incontinence is the main complaint among the women between 25 and 49 years of age it remains a constant complaint in women over 80 (15).In our population, urge and mixed incontinence were the main causes of leakage (54%) and pure stress urinary incontinence was moderately observed (11%).In contrast, urgency appears as the main symptom as it associates frequency and accounts for 70% (as opposed to 42.0% in the group of 748 female patients under age 80 explored during the same period in our laboratory).Urgency is a symptom related to bladder overactivity while DO is only a urodynamic diagnosis.
Acute complaint was only incomplete retention after hip or knee surgery and mainly secondary to hip arthroplasty.
Feasibility of urodynamics in the elderly has been previously demonstrated (2).An unexpected result is the lower percentage of interpretable initial free uroflow (44%) compared with the 60.8% for the group of 748 women under the age of 80; the percentages were similar in the 2 groups for both IF and FF2.Therefore, to be reliable, FF has to be repeated, making certain that the bladder is full enough and taking into account the difficulty for some patients to void in an "unfriendly" environment.
Analysis of filling cystometry shows an increased frequency of DO in this elderly population which is consistent with previous studies (45% as opposed to 23.0% in the population less than 80 years old) but does not explain the complaint of urgency (70%).Hashim and Abrams (16) have found that 44% of women with urgency had DO; in our study 54% of the women who complained of urgency had DO, which is slightly higher.This finding could be related to the decline in central nervous system cholinergic activity occurring with normal aging (17).In addition, we observed a high prevalence of DHIC (low detrusor pressure and high residual volume -35%).This specific association, first described by Resnick and Yalla (18), is characteristic of older patients and is a cause of urinary incontinence in the elderly.However, as this study was retrospective and as urodynamic studies are standardized in our laboratory, no provocative maneuver for DO was performed except for cough for quality control of pressure recordings.
Occurrence of RRCs confirmed the high prevalence of rhythmic rectal contractions in elderly patients (31.8% as compared to 16.5% in the population less than 80 years old).We observed a strong association between RRCs, DO and neurological disease.Despite the small group studied Ozawa et al. have reported a similar result and concluded that RRCs may be regarded as one of the causes responsible for urinary difficulty in the elderly (19).Maximum cystometric capacity was lower than the value reported by Pfisterer et al. (8); this difference could be the consequence of the high incidence of terminal DO in our population.
The mean MUCP value is the value expected for the age; bladder filled, the decrease of the MUCP value implies a lack of adaptation of the sphincter to bladder filling.However, approximately 50 % of the population had at least one measurement (bladder empty or filled) ≤ 30 cm H 2 O.
The main urodynamic diagnosis was DO found in 45 women of whom 38 had suggested LUTS (urge or mixed incontinence, frequency).The second diagnosis, in frequency, was suggested ISD found in 25 women of whom 17 had LUTS (stress or mixed incontinence).That finding is probably the consequence of the association of ISD with a major urodynamic finding such as detrusor overactivity.
Sensitivity, specificity and predictive positive value of urgency for the detection of DO, and stress or mixed incontinence for the detection of ISD are good but not sufficient enough to eliminate urodynamics, mainly to avoid inappropriate new treatment in patients with failure of previous treatment (chemical or surgical).In other patients, who have a number of complaints and who experience great discomfort in daily life, urodynamics should enable the physician to choose the less invasive and quickly effective treatment.
A limitation of our study was that the physician performing the urodynamic investigation was not the physician who originally requested urodynamics.Therefore, our findings can only be considered as advice.A prospective study would be required for a better evaluation of the role played by urodynamics in the management of LUT dysfunction in this specific elderly population.

CONCLUSION
In this population of community-dwelling of elderly females referred by their physician in our urodynamics outpatient clinic, urodynamics primarily allows to find the causes of treatment failure.How-ever, the majority of the population complained of a decrease in their quality of life often due to LUTS which had developed over many years and asked for greater improvement.
The major complaint was incontinence, often associated with urgency which was the main symptom.The low success of FF at arrival suggests that anxiety and an "uncomfortable" environment might play a role in addition to the changes in rate of urine production with ageing.Prevalence of DO and DHIC, and occurrence of RRCs during cystometry increased compared to younger patients.DO and RRCs are frequently a concomitant finding of cystometry.A surprising result was the small group of patients for whom the proposed diagnosis was ISD alone.

Table 2 -
Previous medical history of the studied population.

Table 3 -
Feasibility of free and intubated flows during the urodynamic session.