Genitourinary Medicine

The ageing genitourinary system

Changes in women

Oestrogen levels fall following menopause (usually around age 50) leading to vaginal epithelium atrophy, decreased vaginal lubrication, and acidification and greater vulnerability to vaginal and urinary infection
The uterus and ovaries atrophy
The vagina becomes smaller and less elastic

Hormone replacement therapy improves menopausal symptoms but has other serious adverse effects that severely limit its use (see

‘Hormone replacement therapy and the menopause’, p.448).

Changes in men

There are gradual changes in anatomy and function, but no sudden change in fertility, and most older men remain fertile
Testicular mass and sperm production fall as does semen quality
The prostate gland enlarges and fibroses—benign prostatic hypertrophy (BPH)—but the volume of ejaculate remains similar
Erection becomes less sustained, less firm, and the refractory period between erections lengthens. However, severe erectile dysfunction, ie inability to sustain an erection sufficient to have sexual intercourse, is usually the result of pathology or drug treatment rather than ageing itself
Testosterone levels remain stable or decrease slightly. In a minority, more severe falls are seen and hypogonadism may become symptomatic, manifesting as fatigue, weakness, osteoporosis, muscle atrophy, declining sexual function, and impaired cognition

Testosterone replacement may be considered in those with low hormone levels and symptoms. This may have symptomatic benefit, but risks serious side effects (eg rising haematocrit, prostatic hypertrophy). Low doses (delivered by patches or injection) may reduce this risk, but monitoring is probably needed. There are no good-quality long-term trials of replacement therapy.

Changes in both sexes

Cross-sectional studies show much reduced frequency of sexual behaviour of all kinds in older people. However, longitudinal studies show much smaller changes, suggesting that many changes are due to cohort effects, eg changes in the prevailing social environment during early adulthood.

Other factors include physical and psychological illness (eg arthritis, depression), reduced potency, social changes (eg lack of a partner due to bereavement). Most of these factors are modifiable.

Further reading

Read J. (2004). Sexual problems associated with infertility, pregnancy, and ageing. BMJ 329: 559-61.

HOW TO … Examine the older female genital system

This is an important part of the assessment for symptoms such as postmenopausal bleeding, urinary incontinence and symptoms of prolapse. Approach tactfully—many older women will not be keen on pelvic examination.

Proceed as follows:

Reassure the patient and position for examination—the standard position with the patient on her back and the legs spread may not be possible with hip disease; consider rolling the patient onto her side, drawing up the knees and inspecting from this position
Inspect the external genitalia, looking for atrophy, erythema, infection, and abrasions. Severe prolapse may be immediately apparent
Ask the patient to bear down, which may reveal smaller degrees of prolapse
Perform a vaginal examination, remembering to use plenty of lubrication. Begin with a single digit if the vaginal opening is tight
Some rectocoeles are only detected by bimanual examination of the vagina and rectum
Use a speculum if available and tolerated

Benign prostatic hyperplasia: presentation

BPH is characterized by non-malignant enlargement of the prostate gland and an increase in prostatic smooth muscle tone. The resulting bladder outlet obstruction leads to lower urinary tract symptoms (LUTS; ‘prostatism’).

Prostatism affects 25-50% of men over 65 years, although the histological changes of BPH are even more common—almost universal in those >70. The natural history is variable—some deteriorate, some stay the same, and some improve, even without treatment.

Assessment

Symptoms

LUTS are variable, and may be mostly either:

Obstructive. Weak stream, straining, hesitancy, nocturia, acute retention, or chronic retention with overflow incontinence
Irritative. Frequency, dysuria, urgency, and urge incontinence

Other presentations include haematuria (the prostate is hypervascular), UTI, and renal failure secondary to hydronephrosis. Obstructive symptoms may be worsened by drugs, eg sedating antihistamines. Tricyclic antidepressants may improve irritative symptoms, but worsen obstruction.

Scoring systems (see Box 19.1) can help determine symptom severity, track progression, and response to treatment.

Investigations

Tests may help confirm the diagnosis, exclude other pathology, and identify complications:

Urinary flow rate confirms obstruction, but is rarely needed
Blood glucose to exclude diabetes, a common cause of urinary symptoms
U,C+E (renal failure)
Urinalysis (infection, haematuria)
USS renal tract (hydronephrosis, high residual volume (see Box 20.1)
PSA. Consider this, especially if the prostate is irregular. However, testing is not mandatory, and in general should be guided by the patient’s views, after a discussion of risks and benefits of further investigation and treatment (see ‘Prostatic cancer: presentation’, p.514 and ‘Prostate-specific antigen’, p.516)
Cystoscopy and USS. If haematuria is detected, to exclude renal and bladder cancer

Box 19.1 International prostate symptom score (IPSS)

This is a well-validated, widely used assessment tool that can be either self-administered, or given as part of a structured assessment by a health professional. Aggregate scores from the seven questions to give a total score range of 0-35 (Table 19.1):

0-7 Mildly symptomatic
8-19 Moderately symptomatic
20-35 Severely symptomatic

Table 19.1 International prostate symptom score

	Not at all	<1 time in 5	Less than half the time	About half the time	More than half the time	Almost always
Incomplete emptying. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?	0	1	2	3	4	5
Frequency. Over the past month, how often have you had to urinate again<2hr after you finished urinating?	0	1	2	3	4	5
Intermittency. Over the past month, how often have you found you stopped and started again several times when you urinated?	0	1	2	3	4	5
Urgency. Over the past month, how difficult have you found it to postpone urination?	0	1	2	3	4	5
Weak stream. Over the past month, how often have you had a weak urinary stream?	0	1	2	3	4	5
Straining. Over the past month, how often have you had to push or strain to begin urination?	0	1	2	3	4	5
	None	1 time	2 times	3 times	4 times	5 times or more
Nocturia. Over the past month, many times did you most typically get up to urinate, from the time you went to bed until the time you got up in the morning?	0	1	2	3	4	5

Benign prostatic hyperplasia: treatment

Treatment choice is influenced by patient preference, severity of symptoms, presence of complications, and fitness for surgery.

Conservative measures

‘Watchful waiting’ is reasonable if symptoms are mild or moderate and complications absent. Reassure the patient. Reassess clinically and check renal function at 6-12 monthly intervals. Advise reduction in evening fluid intake; stop unnecessary diuretics. The main risk is acute urine retention (1-2% per year).

Herbal preparations

These are widely used by patients, bought ‘over the counter’; always ask about non-prescription remedies. The most widely used is saw palmetto (Serenoa repens) extract, and there is some evidence that it works, especially in milder disease, perhaps acting as a 5-α-reductase inhibitor (see

‘Drugs’, p.512). PSA levels may therefore be reduced.

Drugs

Suitable for mild, moderate, or severe symptoms without complications, especially if patient preference is strong. Patients with more severe symptoms benefit most. Two drug classes may help:

α-adrenergic blockers (‘α-blockers’ eg doxazosin, terazosin, tamsulosin). They relax prostatic smooth muscle, increasing urine flow rates

and reducing symptoms in days. Side effects are common: the most important are hypotension, especially orthostatic hypotension, and syncope. Use cautiously, starting with low dose (eg doxazosin 1mg od, increased in 1mg increments at 2-week intervals to 4mg). Exercise great caution if prescribed with diuretics or other vasodilators, if there is a past history of syncope, and in the frail. Tamsulosin may be more prostate-selective than other α-blockers and may have fewer circulatory side effects
5-α-reductase inhibitors (eg finasteride). These inhibit prostatic testosterone metabolism, reducing prostatic size. Benefit occurs slowly (months) and is most likely if the prostate is large (>40mL); those with mild enlargement benefit little or not at all. Side effects are uncommon but include erectile dysfunction (<5%), gynaecomastia, and loss of libido. Given the absence of cardiovascular side effects, 5-α-reductase inhibitors may be a better option in the frail older person. PSA levels fall by ˜50%, so double the observed value to give an indication of prostate cancer risk
Combination treatment. There is no evidence that this is more effective than monotherapy. If there is no significant benefit with one drug class, switch to another, or consider surgery

α-Blockers, prostatism, and hypertension

Many men have symptoms of prostatism and are also hypertensive. α-blockers can be an attractive option as the one drug may treat both. However, the evidence for α-blockers in the treatment of hypertension is inferior than that for several other drug classes. Assess the impact on each problem separately, and consider prescribing the most appropriate treatment for each individual condition. See

‘HOW TO … Use anti-hypertensives in a patient with comorbid conditions’, p.271.

Surgery

More effective than drugs or ‘watchful waiting’, but side effects are more common and usually irreversible. Indicated if:

Symptoms are moderate or severe (with patient preference)
There are complications (recurrent UTI or haematuria, renal failure)
A trial of drug treatment has failed

Transurethral resection of the prostate (TURP). The (gold-) standard procedure. Success rates are >90%. Adverse effects include retrograde ejaculation (most), erectile dysfunction (5-10%), incontinence (1%) and death (<1%). 10% need further surgery within a few years.

Newer procedures. Several have been developed. They are generally less invasive and probably have fewer adverse effects, but long-term outcome data are less good. Local availability and expertise are limited. For example:

Transurethral incision. of the prostate (TUIP). Effective in those with smaller prostate glands. Low incidence of side effects
Transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA). These newer systems are well tolerated, and require only local anaesthesia in an outpatient setting. However, some are time-consuming and difficult to learn, long-term results are less well known, and availability varies locally

Open prostatectomy is reserved for very large glands and where other interventions are needed, eg removal of bladder stones. It is very effective, but comorbidity is higher.

Urinary catheterization

Urinary catheterization is an option where:

Symptoms are severe, or significant complications have occurred (eg retention)
Surgical mortality and morbidity would be high
Drug treatment has not been tolerated, or is unlikely to be effective

A long-term catheter may be required if the patient fails a trial (or trials) without catheter.

Prostatic cancer: presentation

A very common cancer in men, much more so with age: median age at diagnosis is over 70. However:

Most die with tumour rather than because of it
Most are asymptomatic, or have only obstructive symptoms
Many tumours do not progress, even without treatment

This leads to difficult management decisions, especially in older people, where life expectancy for other reasons may be low, and expensive, unpleasant or risky treatments may not be worthwhile.

Assessment

Predictors of an adverse disease course (symptoms, local progression, metastases and death) include more advanced stage (TNM classification) and histological grade (eg Gleason score: see

‘Gleason score’, p.514).