L’urodynamique permet-elle une meilleure compréhension des troubles mictionnels des patientes de plus de 80 ans ?

25 mars 2018

Auteurs : F.A. Valentini, B.G. Marti, G. Robain
Référence : Prog Urol, 2018, 4, 28, 230-235




 




Introduction


Population ageing is a phenomenon affecting the entire planet. It is the result of better management and early detection of health problems, and lifestyle improvement. The population over 60 years old is the fastest growing on. In France, people over 80 years represent 5.8% of the population (3.76 millions), 65% (2.44 millions) of whom are women [1].


One significant consequence is an increasing number of women older than 80 years complaining of lower urinary tract symptoms (LUTS); this increase is mostly due to the awareness of the consequences on daily life of LUT dysfunction (LUTD) [2, 3, 4, 5, 6]. More and more elderly women live at home, perform daily tasks, take an active part in society and play sport.


Another characteristic of that older population is that a better management of neurological disease induces a not negligible sub-population with that clinical condition [7].


Normal age related changes are observed in the structure of both detrusor and urethra. Consequences are an increased occurrence in storage symptoms (frequency, urgency, nocturia) and in voiding symptoms (hesitancy, complete or incomplete retention, incomplete voiding) [8].


Storage symptoms are the most common complaint and detrusor overactivity (DO) the more frequent evoked cause [9]. However, LUT symptoms and urodynamic diagnosis do not necessarily correlate [10] as combination of storage and voiding dysfunction is frequently observed in older people as in detrusor hyperactivity with impaired contractility (DHIC) [11, 12]. This lack of correlation between symptoms and diagnosis may also result from multifactorial conditions: co-morbidities, polymedication and its side effects.


Moreover, despite the old age and the increasing number of co-morbidities, urodynamic study is currently performed to diagnose the cause of LUTS.


Our purpose was to evaluate the contribution and usefulness of urodynamics to the diagnosis and management of LUTD in an oldest female population.


Materials and methods


Retrospectively, a database comprising 169 urodynamic studies of consecutive women, aged≥80 years old (83.8±3.4 years) range [80-93 years], with symptoms and signs of lower urinary tract dysfunction was used for analysis. These women were referred for urodynamic assessment, some for advice about previous or recommended treatment, others, only for urodynamic diagnosis of LUTD by their referring physician.


Sub-populations were respectively 124 non-neurological (mean age 83.8±3.4 years) and 45 neurological (mean age 83.5±3.2 years) women. Age range was the same in the whole population and in each sub population. Non-neurological women had no past history of neurological disease and normal neurological examination before urodynamic, neurological women had known neurological disease. Each file comprised demographic data, medical history, bladder diary for three days, medications, urodynamic parameters and diagnosis, and proposed management.


Exclusion criteria were advanced cognitive impairment (MMSE≤20) and/or severe mobility impairment (inability to settle on the urodynamic table). All women were mobile and cooperated for urodynamics.


Urodynamics was performed according to good Urodynamic Practices [13] with a Laborie's Dorado® unit. Detailed urodynamic testing included the following sequence: an initial free uroflow (FF1), a cystometry in the seated position at the medium filling rate of 50mL/min with normal saline at room temperature (triple-lumen urethral catheter 7F) and intubated flow (IF), urethral pressure profilometry (UPP) in supine position, empty bladder (before the cystometry) and 200-250mL filling if continent, and a second free uroflow (FF2) if bladder was filled for UPP.


Urodynamic diagnosis was based on results of the whole sequence of tests according with ICS criteria. All recordings were reviewed independently by 2 investigators specialist in urodynamic. Good agreement occurred in up to 89% of the files. In the remaining 11%, an additional interpretation was made jointly to reach a single conclusion. When no symptoms were reproduced during the assessment, the conclusion was "normal" or non-contributive.


Data are presented as mean±standard deviation (SD) and range. Analysis of variance (Anova) was used to compare unrelated samples. Statistical analysis was performed using SAS, version 5.0 (SAS Institute, Inc., Cary, NC, USA). All statistical results were considered significant at P <0.05.


This study was conducted in accordance with the Declaration of Helsinki. According to the local practice of Ethics Committee, there is no formal Institutional Review Board approval required for retrospective studies.


Results


Non-neurological population


Mean co-morbidities (Table 1) were 2.5 per woman, mainly cardiovascular (57.4%), endocrinology (43.6%), musculo-skeletal (40.4%), previous pelvic surgery (30.8%) and cognitive impairment (29.9%). Charlson score and CIRS (Cumulative Illness Rating Scale) appear in Table 1. Parity was 2.1±1.8.


Complaints (Table 2) were 80 incontinence (of which 18 stress incontinence, 36 mixed incontinence and 26 urgency incontinence), 22 frequency, 16 incomplete retention or dysuria. Six women had evaluation before surgery for prolapse.


Twenty-one patients (17.9%) had failure of previous treatment: 4 recurrent incontinence after surgery, 17 insufficient improvement by local oestrogen therapy or anticholinergic.


Urodynamic diagnosis (UD) (Table 3) was categorized as normal (non-contributory, 31N), detrusor overactivity (39 DO), detrusor underactivity (27 DU, including 6 DHIC) and intrinsic sphincter deficiency (27 ISD).


The best indicators for UD (Table 4a) were:

first desire (B1) increased in DU vs. N (P =0.0003), vs. DO (P <0.0001) and in ISD vs. N (P =0.0384) and vs. DO (P <0.0001);
functional bladder capacity (FBC) increased in DU vs. N (P =0.0170) and vs. DO (P <0.0001) and decreased in DO vs. N (P =0.0003) and vs. ISD (P <0.0001);
post void residual volume (PVR) increased in DU vs. ISD (P =0.0016), vs. N (P =0.0066) and vs. DO (P <0.0001), and decreased in DO vs. N (P =0.0017) and vs. ISD (P =0.0137);
voiding time (t mic ) increased in DU vs. DO (P =0.0065).


Maximum flow rate (Q max ) and detrusor pressure at Q max (P det.Qmax ) were not significant indicators.


During the first free uroflow the only diagnosis indicator was t mic , greatly reduced in DO (12.6±6.3 s) vs. N (21.6±12.1 s) P =0.0145, vs. ISD (25.5±19.7 s) P ≤0.0065 and vs. DU (33.4±24.5 s) P <0.0001.


There were 94 (75.8%) treatment proposals which were based on UD for DO, DU and ISD, and on the main complaint when UD was "N".


Anticholinergics were proposed for 35 patients (37.2%) of whom 27 (77.1%) had DO diagnosis. Physiotherapy was recommended for 19 (20.1%) patients of whom 12 (63.1%) had ISD. Local estrogen therapy was prescribed for 11 women (11.7%) with atrophic vaginitis. Indication of surgical treatment for urogenital prolapse or severe ISD was confirmed for 8 women. Prompted voidings or self-catheterization were advised for 11 (11.7%) women of whom 8 had DU diagnosis. Watchful waiting was proposed to 8 (8.5%) patients.


Among the 21 (16.9%) women with previous treatment, 6 changes were proposed (including 4 discontinuation of anticholinergics: 2 for prompted voidings and 2 due to ISD diagnosis).


Neurological population


Mean co-morbidities (Table 1) were 3.1 per woman, mainly cardiovascular (44.4%), endocrinology (38.8%), musculo-skeletal (55.5%) and previous pelvic surgery (55.5%), cognitive impairment (38.8%). Neurological condition was the consequence of cerebrovascular accident (15), degenerative disorder (19) and spinal cord injury (11). Charlson score and CIRS appear in Table 1. Parity was 1.8±1.2.


Complaints (Table 2) were 24 incontinence (of which 2 stress incontinence, 11 mixed incontinence and 11 urgency incontinence), 4 frequency, 16 incomplete retention or dysuria.


Eight women (17.8%) had failure of previous treatment: recurrent incontinence after surgery (2), insufficient improvement by local estrogen therapy (1) or anticholinergic (3) and difficulties to carry out self-catheterization (2).


Urodynamic diagnosis (UD) (Table 3) was categorized as normal (non-contributory, 9N), detrusor overactivity (13 DO), detrusor underactivity (19 DU including 6 DHIC) and intrinsic sphincter deficiency (4 ISD).


The best indicators for UD (Table 1b) were:

first desire (B1) increased in DU vs. N (P =0.0499) and vs. DO (P =0.0010);
functional bladder capacity (FBC) increased in DU vs. N (P =0.0086) and vs. DO (P <0.0001) and in N vs. DO (P =0.0019);
post void residual volume (PVR) increased in DU vs. N (P <0.0001) and vs. DO (P <0.0001).


Maximum flow rate (Q max ), detrusor pressure at Q max and voiding time (t mic ) were not significant indicators.


During the first FF the only diagnosis indicator was PVR, greatly increased in DU (180±128mL) vs. N (52±59mL) P =0.0016 and vs. DO (43±54mL) P =0.0004.


There were 35 (77.7%) treatment proposals. Prompted voiding or self-catheterization were advised in 11 patients (31.4%) based on DU diagnosis, and anticholinergics in 7 among 13 women (20.0%) with DO diagnosis. Clean intermittent catheterization was only proposed to 2 patients with incomplete retention. Watchful waiting was proposed to 6 (17.1%) patients.


Among the 8 (17.7%) women with previous treatment, 1 change was noticed which was discontinuation of anticholinergics.


Discussion


Prevalence of LUTS and associated LUTD increase with ageing [2]. The fastest growing group in age in the whole population is people over 60 years and the improvement of health implies a large increase of the number of women over 80 years [1]. As these women hope for a good quality of life, they ask for the best management of their urinary problems. Overactive bladder is the more frequently evoked cause of dysfunction in elderly. AUA/SUFU guideline for treatment of overactive bladder in elderly is, in first-line behavioral therapies (bladder control strategies, pelvic floor muscle training, and lifestyle modifications). However an empirical anticholinergic therapy is often used [14]; this treatment can also be introduced when behavioral therapies are insufficient. The effects of anticholinergics on the lower urinary tract are thought to be mediated by the M2 and, mostly, M3 subtypes. However side effects (dry mouth, constipation, and blurred vision) do not be underestimated, and especially cognitive impairment via M1 receptors when the passing of the blood-brain barrier. To prescribe anticholinergic therapy for elderly subject needs to take into account co-morbidities and associated treatments to minimize adverse events and the practitioner must give priority to agents which do not pass the blood-brain barrier.


Thus the first question that arises is the usefulness of urodynamic assessment to clarify the diagnosis and to propose the best management. It is well known that LUTS poorly correlate with diagnosis [9, 10, 15] but for a significant percentage of women, urodynamics is considered normal although they express a complaint. As an example, among the 31 non-neurological women with urodynamic diagnosis "N", 14 complained of urgency incontinence.


The second question results from the growing importance of a sub population of women with a neurological condition: is there a difference in the role of urodynamics? Some authors think that urodynamic studies should be performed in elderly patients with significant LUTS and coexisting neurologic disease [4].


To start the discussion, significant differences are brought to the fore when comparing populations with and without neurological condition. These differences may be the cause of different management.


In neurological women occurrence of comorbidities is higher (3.1 vs. 2.5) and incidence of pelvic surgery more frequent (55.5% vs. 30.8%). The main complaint is significantly different: incontinence in non-neurological group (64.5% vs. 53.3%) and incomplete retention or dysuria in neurological one (35.5% vs. 12.9%). High number of comorbidities and high occurrence of retention are reasons for avoiding anticholinergics which have known side effects, especially in frailty patients [16].


Looking at urodynamic assessment, the best indicators for urodynamic diagnosis are not very different in the two populations. The only significant difference is observed during free uroflow: increased post void residual volume in neurological population and decreased voiding time in non-neurological one.


Whatever the neurological condition, the percentage of women with previous treatment and who are referred for urodynamics because of a failure of this treatment is similar (slightly higher in neurological women).


Urodynamic DO is the most common diagnosis in both sub-populations but DHIC is more frequent in the neurological one; in DHIC significant detrusor underactivity may be present [17]. That last condition explains why anticholinergics are less frequently proposed compared to prompted voiding or self-catheterization.


An interesting result is the frequency of ISD in the non neurological group. This is consistent with the known decrease of urethral function with ageing [18] and probably associated with important performance of daily tasks and sport. According with urodynamic diagnosis treatment proposals are conservative treatment (physiotherapy (56.5%), local estrogen, prompted voiding) or watchful waiting or surgery.


Looking at previous treatments, the significant changes are discontinuation of anticholinergics after urodynamics diagnosis of ISD or DU. That result highlights the risk of empirical anticholinergic therapy [19, 20] while it may prevent invasive investigations.


The last point to be discussed is the role of urodynamics when the urodynamics assessment is diagnosed normal. In non-neurological women the treatment is then based on the main complaint and a regular follow-up is suggested, while in neurological women where that situation is not frequent it is suitable to demonstrate a possible detrusor under activity.


Limitation of this study is the retrospective analysis. Our study concerns only a community-dwelling population which constitutes a bias of recruitment. In addition, the studied population includes women referred to our urodynamic laboratory for evaluation of LUTS; some patients had previous treatment and our contribution is urodynamic diagnosis and some proposals but there is not follow up.


Conclusion


Usefulness of urodynamics to manage LUT dysfunction in women older than 80 years is greatly dependent on their neurological status. In non-neurological women it is indisputable but proposed treatment needs to take into account existing co-morbidities. In neurological women the main usefulness is to confirm DU and to propose the best management in order to avoid complete retention.


Contributors


FA Valentini: project development, manuscript writing/editing, data collection.


BG Marti: project development, manuscript writing/editing.


G Robain: data collection.


Disclosure of interest


The authors declare that they have no competing interest.



Acknowledgments


We would like to thank Charlotte Marti for rereading the english manuscript.



Appendix A. Supplementary data


L'urodynamique permet-elle une meilleure compréhension des troubles mictionnels des patientes de plus de 80 ans ?

(107 Ko)
  




Table 1 - Frequency of main co-morbidities observed vs. neurological status and co-morbidity scores (Charlson and CIRS).
  Non-neuro (n =124)  Neuro (n =45) 
No. Co-morbidities/pt  2.3  3.1 
Cardiovascular  57.40%  44.40% 
Endocrine  43.60%  38.80% 
Musculo-squeletal  40.40%  55.50% 
Previous pelvic surgery  30.80%  50.50% 
Cognitive impairment  29.90%  38.80% 
Charlson (+age)  2 (6)  3 (7) 
CIRS  4 



Légende :
In bold: important results.



Table 2 - Main complaint vs. neurological status. One women with neurological condition had bladder pain.
  Non-neuro (n =124) 
Neuro (n =44) 
Incontinence  80  64.50%  24  53.30% 
18 SI-22.5%    2 SI-8.3%   
36 MI-26 UI    11 MI-11 UI   
45.0%-32.5%    45.8%-45.8%   
Frequency  22  17.70%  8.80% 
Incomplete retention, dysuria  16  12.90%  16  35.50% 
Pre-op POP  4.60% 



Légende :
In bold: important results.



Table 3 - Urodynamic diagnosis vs. neurological status.
  Non-neuro (n =124) 
Neuro (n =45) 
Normal (Non-contributory)  31  25.00%  16.70% 
Detrusor overactivity  45  36.30%  19  42.20% 
(6 DHIC)    (6 DHIC)   
13.30%    31.50%   
Detrusor underactivity  21  16.90%  13  28.80% 
Intrinsic sphincter deficiency  27  21.70%  8.80% 



Légende :
In bold: important results.



Table 4 - Urodynamic parameters during intubated flow and contribution to urodynamic diagnosis.
  B1 (mL)  FBC (mL)  PVR (mL)  Q max (mL/s)  P det.Qmax (cm H2 O)  t mic (s) 
4a. Non-eurological population             
N =31  148±95  360±132  221±179  11.2±7.5  16.7±8.6  52.1±42.1 
DO=39  105±64  236±109  94±118  10.4±4.4  22.5±14.0  40.4±30.9 
DU=21  240±128  449±184  343±181  7.8±3.3  24.2±21.5  77.7±72.4 
DHIC=            
ISD=27  200±70  396±100  197±168  11.4±4.8  14.8±10.1  52.1±21.8 
4b. Neurological population             
N = 178±91  391±39  240±153  12.0±5.6  7.3±1.0  48.3±31.9 
DO=13  137±74  231±99  138±77  7.7±4.5  25.7±18.0  33.5±13.5 
DU=13  292±138  532±111  522±109       
DHIC=            
ISD= 173±36  514±139  493±169  11 



Légende :
In bold: important results.


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