Annals of Long Term Care

Author Affiliations: Dr. Srulevich is a faculty member, Department of Medicine, in the Division of Geriatric Medicine, Crozer-Chester Medical Center, Upland, PA, and Clinical Assistant Professor of Medicine, Temple University School of Medicine, Philadelphia, PA; and Dr. Chopra is Professor of Medicine, Director of Education and Clinical Programs, New Jersey Institute for Successful Aging, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Stratford, NJ.

Introduction

As many as half of all residents in long-term care (LTC) facilities suffer from some type of voiding disorder. A broad array of voiding symptoms such as incontinence, burning, frequency, sense of incomplete bladder emptying, and difficulty in initiating voiding affect the lower urinary tract. The primary focus of this article will be to review the pathophysiology and symptoms of common voiding dysfunctions in the LTC setting, understand how they relate to the underlying disease process, and effectively evaluate and manage acute and chronic conditions. Reasons for voiding dysfunction are often multifactorial and can be related to many overlapping comorbid conditions. Management and treatment options are tailored to relief of symptoms, reducing disease burden, and maintaining quality of life.

Pathophysiology of the Aging Lower Urinary Tract and Relation to Symptoms

The aging lower urinary tract undergoes physiologic changes that can result in increased urinary symptoms, such as urgency, frequency, and a sensation of incomplete emptying, which can manifest as urologic disorders. As aging occurs, overall bladder capacity is reduced and post-void residual volumes can become elevated.1 Age-related morphologic changes in the bladder wall, consisting of a decreased ratio of the area density of smooth muscle to connective tissue, occur in both men and women. In addition, detrusor contractility has been shown to decrease in an age-dependent manner.2 An increase in lower urinary tract symptoms (LUTS) is thus age-related but not sex-specific.3,4 In fact, while initially much lower in men, by the seventh decade the prevalence of urge urinary incontinence (UI) is about equal in both genders.

Approximately half of all persons with symptoms of overactive bladder (OAB) suffer from detrusor overactivity.5 In contrast, voiding symptoms, such as the feeling of incomplete emptying or reduced urinary flow, are similar in both sexes until about age 50, when men demonstrate increased rates of voiding symptoms due to benign prostatic hyperplasia (BPH) and obstructive changes.5 In BPH, age-related prostatic enlargement may encroach upon the anatomic structures and cause obstruction of urine flow through the urethra.

Risk Factors for Voiding Dysfunction in the Geriatric Population

In both men and women, the causes of voiding dysfunction are diverse and can involve numerous organ systems. Acute symptoms always warrant further investigation, and reversible causes such as infection, obstruction, and medication side effects must be considered (Table I). If the symptoms are chronic, as is often the case in the LTC setting, the focus of management is to limit the impact of disease burden. Epidemiological evidence in the geriatric population points to cognitive impairment, constipation, parity, medications, genitourinary surgery, obesity, and cardiovascular disease as risk factors for incontinence.6,7 Gammack6 notes that in frail elderly persons, many of these conditions are already present and may be unmodifiable, so prevention should focus on reducing the impact of chronic disease on these related risk factors.

Older adults often take more medications, which can have deleterious effects on bladder control. Drugs with anticholinergic side effects can reduce bladder emptying and may cause urinary retention. The use of diuretics may complicate the management of incontinence.