Urological problems are extremely common in older adults. The prevalence of many urological disorders increases with advancing age in both men and women. Estimates indicate that approximately 20% of all primary care visits include some type of urological complaint. In fact, the specialty of urology ranks third, behind only ophthalmology and cardiology, in the total annual number of outpatient clinical visits by older Medicare recipients in the United States. These trends hold steady even when stratifying for ages older than either 75 or 85. There is a critical need for more clinicians across all specialties focused on care of older adults. This chapter addresses the evaluation and management of many of the common urological conditions seen in older adults. Several topics relevant to urology are also covered in more detail in other chapters including urinary incontinence (Chapter 27), sexuality and sexual health (Chapter 45), and prostate cancer (Chapter 38).
Hematuria is a common urological condition seen in people of all ages. The condition may be gross or microscopic, and it may be episodic or persistent. Any episode of gross hematuria should be considered abnormal. On microscopic urinalysis, the generally accepted upper limit of normal is zero to three red blood cells per high-powered field. Because it is a common presenting sign for many types of genitourinary pathology, elderly patients with gross or persistent microhematuria should undergo a thorough evaluation including upper urinary tract imaging and cystourethroscopy. The common sources of hematuria in older adults are summarized in Table 26.1. Computed tomography (CT) has become the preferred imaging modality for detection of urological abnormalities in patients with hematuria. If possible, the study should be done both without and with intravenous contrast provided the patient’s baseline renal function is adequate. The noncontrast images are particularly useful to evaluate for stones. After contrast administration, immediate and delayed images are obtained. These help to delineate renal function and anatomy, the course and caliber of the ureters, and the general anatomy of the bladder. Delayed images are useful to identify hydronephrosis and potential ureteral obstruction.
Although larger lesions in the bladder may be identifiable on CT imaging or ultrasound, smaller mucosal lesions may not be evident on these studies. Therefore, cystourethroscopy must be considered an essential part of the complete urological evaluation for hematuria. Bladder cancers, particularly transitional cell carcinomas, usually start in the urothelium and are often visible as papillary lesions on cystoscopy. Carcinoma in situ is a particularly aggressive form of bladder cancer that may initially present with either microscopic or gross hematuria. On cystoscopy, this usually appears as a red, velvety patch in the urothelium. Histological examination of bladder biopsies and cytological examination of either voided urine or bladder washing specimens may be useful to help diagnose bladder malignancies. In the United States, transitional cell carcinoma is the most common form of bladder cancer in older adults, and cigarette smoking is one of the most common risk factors.
Although an episode of gross hematuria can be quite distressing for the patient, emergency evaluation is not usually necessary. The exceptions are patients experiencing clot retention with difficulty passing urine or patients requiring blood transfusions for anemia secondary to the hematuria. Cystourethroscopy with clot evacuation may be required in these cases. If a specific bleeding site is identified, electrocoagulation may be useful. In many cases, a specific source cannot be identified. In cases of persistent gross hematuria, chemical coagulation with bladder infusions of dilute alum or formalin may be required.
In older patients with renal insufficiency, a plain x-ray of the kidneys, ureters, and bladder and renal ultrasound can be performed as the initial imaging evaluation. This should be supplemented with cystourethroscopy and retrograde ureteropyelography to look for abnormalities in the ureters or renal collecting systems. Filling defects may indicate some type of space-occupying lesion such as a stone, tumor, polyp, fungus ball, blood clot, or stricture.
Acute conditions such as urinary tract infection (UTI), prostatitis, or stone passage may be associated with hematuria. Urinalysis should be repeated after these conditions have been treated, and, if hematuria persists, then urological consultation for further evaluation should be obtained. Hematuria is also frequently seen in elderly patients receiving chronic anticoagulation therapy; however, these individuals still require a complete urological evaluation because 15%–20% will be found to have significant underlying genitourinary pathology.
If an older adult patient has persistent microhematuria despite a negative urological evaluation with upper tract imaging, cystourethroscopy, and cytology, then referral to a nephrologist to evaluate for possible glomerular bleeding would be warranted. This is particularly true in patients with a history of either proteinuria or hypertension.
Hematospermia, blood in the ejaculate, is occasionally seen in older men. Although it is most commonly idiopathic and benign, it may be an indication of other underlying genitourinary pathological conditions such as prostatitis or prostate cancer. Bleeding from dilated capillary vessels in the prostate may also cause hematospermia. In some cases, this may be triggered by excessive physical exertion or vigorous sexual activity. Evaluation, including a thorough history taking and physical examination, may help to identify the cause of the condition. Additional tests that may be useful include cystourethroscopy, transrectal ultrasound, prostate biopsy, and determination of prostate-specific antigen (PSA) levels. Oral administration of 5-α-reductase inhibitors may be useful in treatment of hematospermia or hematuria caused by dilation of prostatic capillaries. These medications cause shrinkage of the prostate and can reduce bleeding from these small blood vessels.
Bacteriuria and UTI are among the most common urological diagnoses in older adults. The estimated lifetime risk for development of a UTI in women is greater than 50%, and the associated costs are staggering. In the year 2000, the estimated overall annual expenditures for UTI care in the United States were $2.47 billion for women, and $1.03 billion for men.[5, 6] Epidemiological studies indicate that the incidence and prevalence of UTIs increases with advancing age. Although seen in both sexes, a higher proportion of women are affected, with a ratio of 3:1. Various age-related physiological changes may predispose older adults to UTIs. These include hormonal and vaginal changes associated with menopause, alterations in cognitive function, prostate disease, and changes in bladder physiology.
Asymptomatic bacteriuria should be differentiated from symptomatic UTI. Symptomatic UTIs should be treated in patients of any age. Diagnosis should be confirmed with urinalysis and urine cultures. Determination of drug sensitivity on urine culture is important to ensure that appropriate antibiotic therapy has been administered. This is particularly important given the increased rates of drug resistance seen with many common bacteria. Typical symptoms of acute UTI include fever, dysuria, urinary urgency and frequency, burning with urination, and suprapubic discomfort. Elderly patients may not develop these symptoms because of normal alterations in overall immune status associated with aging. Older adults may exhibit other symptoms resulting from UTI including lethargy, anorexia, or confusion. In elderly patients with new onset of delirium, a urinalysis and urine culture should be checked to determine if a UTI is present.
Antibiotic therapy for acute UTI is usually administered as an oral preparation. Uncomplicated UTI may be treated with simple, low-cost antibiotics such as amoxicillin or ampicillin, nitrofurantoin, or trimethoprim-sulfamethoxazole. In patients who are allergic to these compounds, cephalosporins or doxycycline may be used as second-line therapy. Fluoroquinolones are usually reserved for complicated UTIs including those associated with concomitant stone disease, pyelonephritis, or sepsis. The choice of appropriate antibiotic therapy should of course be guided by the patient’s overall medical condition, renal function status, and the results of the antibiotic sensitivity profile for the specific organism. The duration of therapy generally ranges from three to seven days, and is dependent on a variety of factors including overall complexity of the infection and response to therapy. Intravenous antibiotic therapy may be required in cases of severe infection, pyelonephritis, or urosepsis.
The most common organisms seen in elderly patients with UTI include Gram-negative bacteria such as Escherichia coli, Pseudomonas, Klebsiella, and Proteus. The most common Gram-positive organisms seen in older adults with UTI include Staphylococcus aureus, and Enterococcus. In patients with recurrent, culture-documented UTI, a clinical investigation to search for a nidus of infection is warranted. Common causes of recurrent infection include urolithiasis or other foreign body, chronic urinary retention, and vesicoureteral reflux. Treatment of the underlying condition may lead to resolution or a decrease in the frequency of UTIs.
Asymptomatic bacteriuria is quite common, particularly in elderly women. This is seen both in community-dwelling and institutionalized elders. In a community-based, cross-sectional analysis of 432 people aged 80 or older, 19.0% of the women and 5.8% of the men were found to have asymptomatic bacteriuria. In this study, urinary incontinence, reduced mobility, and systemic estrogen replacement therapy were identified as independent risk factors for asymptomatic bacteriuria in women. There is general consensus that asymptomatic bacteriuria need not be treated with antibiotic therapy.
UTIs associated with systemic bacteremia in elderly patients carry a high risk of morbidity and mortality. In a retrospective study of 191 patients aged 75–105 years with concomitant positive urine and blood cultures, the in-hospital mortality rate was 33%. A variety of factors associated with impaired physical and cognitive function were associated with increased mortality; however, advanced age itself was not identified as a significant risk factor in this particular study. Other studies have confirmed that mental status changes and a history of frequent UTIs may be associated with increased mortality in elderly patients with UTI.
The role of impaired bladder emptying in development of UTI in older adults has been somewhat controversial. Intuitively, it makes sense that increased postvoid residual urine volume may be associated with UTI. The data, however, have been somewhat conflicting on this topic. A recent retrospective analysis of 101 stroke patients admitted for inpatient rehabilitation demonstrated that a finding of two or more postvoid residual urine volumes of 150 mL or more was independently associated with an increased risk of UTI.
Impaired nutritional status may also be associated with an increased propensity for elderly patients to develop UTIs. In a study of 185 hospitalized older adults (mean age 81.6 ± 0.6 years), malnutrition was associated with an increased rate of nosocomial infections, including UTIs.
Indwelling catheterization is clearly associated with an increased risk of UTI in older adults. Intermittent catheterization is preferred, if possible, in patients who have problems with urinary retention. Indwelling catheters should be used only if absolutely necessary. A recently published study examined the rates of UTI observed in a group of 277 elderly patients who had an indwelling urinary catheter placed in the emergency room at the time of hospital admission. Overall, 28% of these patients were diagnosed with a UTI during their hospitalization; however, 69% of these individuals either had a UTI diagnosed in the emergency room or had clinically significant bacteriuria (≥105 organisms/mL) prior to the catheter placement. Therefore, 9% of the patients who had an indwelling catheter placed developed a new UTI during hospitalization.
Several treatments may be helpful to prevent development of UTIs in susceptible older adults. Increased hydration may be helpful to decrease bacterial adherence to the urothelium of the bladder and urethra. Vaginal estrogen replacement may help to prevent development of UTI in postmenopausal women with atrophic vaginitis. Estrogen helps to acidify the vaginal fluid that facilitates growth of Lactobacillus sp., the natural vaginal flora. Lactobacillus is an important component of the natural host–defense mechanism, which helps prevent overgrowth of pathogenic bacteria associated with UTI. The estrogen is administered vaginally to enhance absorption in the vaginal and periurethral tissues. Even in patients already on systemic estrogen therapy, additional vaginal administration may be required to reach appropriate local tissue levels. Administration approximately three times weekly is usually sufficient. Exogenous estrogen administration is typically contraindicated in women with a history of uterine or breast cancer. However, oncologists may permit vaginal estrogen use in select women with a history of breast cancer, particularly if the tumor was estrogen receptor negative.
Cranberries (Vaccinium macrocarpon) have long been considered a preventive agent for UTIs, and consumption of cranberry juice has been associated with decreased rates of UTI in elderly patients. This is most likely because of acidification of the urine and the azo ring chemistry found in the cranberries that prevents bacterial adherence to the urothelium. If patients are going to use cranberry to help prevent UTI, they should be counseled to look for products containing a high percentage of real juice rather than water. Cranberry tablets may be substituted for juice in diabetic patients or those on a reduced calorie diet. However, newer data suggests that cranberry supplementation may not be particularly effective in all older adults patients to prevent UTI, and differences in outcomes may be due to underlying risk of infection.
In general, the use of indwelling urinary catheters should be avoided if at all possible. Indwelling catheters can be associated with significant potential complications including UTIs, urosepsis, and stone formation. Care should be taken to remove the catheter as soon as feasible, and to monitor the patient for signs and symptoms of UTI. With extended time, chronic catheter irritation may lead to squamous metaplasia of the bladder epithelium and squamous cell carcinoma of the bladder.
If chronic indwelling catheter use is required, suprapubic catheter drainage is usually preferred over urethral catheterization. The suprapubic catheter may be easier for caregivers to change and is often more comfortable for patients. In patients who are sexually active, a suprapubic catheter is helpful because it moves the catheter away from the genitals. Chronic urethral catheterization may also lead to urethral or bladder neck erosion and subsequent urinary incontinence. Urinary leakage around an indwelling catheter is usually caused by either catheter blockage or bladder spasms. Gentle irrigation of the catheter with sterile saline can be used to relieve obstruction from urinary sediment. Placement of larger catheters should be avoided because this will only serve to dilate the urethra or suprapubic tract and will not correct the underlying problem. With time, the use of larger catheters may lead to urethral or bladder neck erosion and worsening urinary incontinence. Treatment of urinary incontinence in patients with this type of urethral erosion may be quite difficult and often involves major surgery such as a cystectomy with urinary diversion or augmentation enterocystoplasty with closure of the bladder neck.
Antimuscarinics or other medications for treatment of detrusor overactivity may be useful to diminish bladder spasms. The most common medications used in the treatment of overactive bladder including dosages and potential side effects are listed in Table 26.2. Care should be taken when prescribing these agents in older adults, and the patient and family or caregivers should be instructed to watch closely for any signs of side effects.
Approximately 20% of all adults will develop urinary stone disease at some point in their lives. In general, rates of stone formation and passage do not differ in elderly patients compared with the general population. Patients with a history of stone disease are at significantly increased risk for development of recurrent stone episodes. One of the primary risk factors for stone disease is inadequate hydration, which is often seen in older adults. Epidemiological and health care utilization analysis revealed that Medicare beneficiaries with a diagnosis of stone disease had a 2.5- to 3-fold higher rate of inpatient hospitalization for the condition compared with younger patients. This study also demonstrated that rates of outpatient hospital and office visits for evaluation and treatment of stone disease increased by 29% and 41%, respectively, among Medicare beneficiaries between 1992 and 1998.
Small stones (<5 mm) can often be treated effectively with increased hydration and oral analgesics. In many cases, the stones will pass spontaneously. Administration of oral alpha-blocker medications such as tamsulosin may lead to relaxation of ureteral smooth muscle, which can aid in spontaneous stone passage with peristalsis. Patients are encouraged to collect and strain their urine to capture the stones for chemical analysis. Larger stones often require surgical intervention for treatment. Cystoscopy and ureteral stent placement may be required to bypass an obstructing stone and help relieve renal colic. Indications for stent insertion include upper tract obstruction, particularly with significant urinary infection or bacteriuria, a solitary functioning kidney, underlying renal insufficiency, or intractable nausea, vomiting, or pain. Subsequent surgical treatment may include ureteroscopy with stone fragmentation and removal or extracorporeal shock wave lithotripsy. Percutaneous nephrostolithotomy may be required for large stones in the renal pelvis or calyces. Outcomes for surgical intervention with percutaneous nephrostolithotomy or shock wave lithotripsy are quite favorable for older adults, and overall results are comparable with data from younger patients.
Stone composition may also change with advancing age. Alterations in stone chemistry in older adults may be related to associated changes in vitamin D and calcium metabolism, which can be affected by age-related physiological changes. The overall proportion of uric acid stones also appears to increase with advancing age. This may be related to a progressive defect in urine ammoniagenesis, which is observed with aging, and which leads to a low urinary pH observed in patients who form uric acid stones. In addition, there is evidence that diabetic patients tend to have a higher incidence of uric acid stone production compared with nondiabetics. This may help explain the higher rates of uric acid stone production observed in older adults, who also have a greater tendency to have diabetes mellitus or a history of gout.
Rates of stone recurrence appear to be similar in older adults compared with younger individuals. In a review of 209 stone patients older than 65, calcium oxalate and calcium phosphate were the most common types of stones observed. Elderly patients accounted for 9.6% of the total population in this study; however, the older patients demonstrated a significantly higher rate of uric acid stone formation compared with the younger patients. Hyperuricosuria and hypercalcuria appear to be common in older patients with recurrent stone disease.
The incidence and prevalence of most of the urological malignancies increase with advancing age. In some cases, there may be differences in the type or progression of cancer compared with younger patients. For a more detailed discussion regarding evaluation and management of cancers in older adults, refer to Chapter 38.
Prostate cancer is the most common nonskin cancer diagnosed in men, and the second leading cause of cancer deaths behind lung cancer. It is estimated that approximately 220,800 new cases of prostate cancer will be diagnosed in the United States in 2015, and approximately 27,540 men will die of the disease. The incidence and prevalence of prostate cancer both increase with age. In general, prostate cancer is a slow-growing disease, and many men will die of other comorbid conditions rather than of prostate cancer itself. In patients with clinically organ-confined disease, treatment with curative intent by using either radical prostatectomy or radiation therapy may be utilized. Although there is no specific age limitation, curative treatment is most often considered for those men with a predicted life expectancy of at least 10 additional years. In men with metastatic disease or in those who are not deemed to be surgical candidates, hormonal therapy with androgen deprivation may be used to slow the progression of the disease. For additional information on the evaluation and treatment of prostate cancer in elderly men, refer to Chapter 38.
Routine screening for prostate cancer in elderly men is controversial. In younger men, the American Urological Association recommends screening with an annual serum PSA level and a digital rectal examination. Guidelines suggest starting screening at the age of 50 years, and at 40 years for men considered to be at high risk for prostate cancer. These would include African-American men and those with a family history of prostate cancer. However other groups including the US Preventive Services Task Force do not recommend routine prostate cancer screening. Specific age cut-offs at which to discontinue screening have not been definitively established. In general, routine prostate cancer screening in elderly men with a predicted life expectancy of less than 10 years is not indicated. Decisions to screen for prostate cancer in elderly men should be tailored to each patient’s specific clinical situation with consideration of overall health and other comorbid disease. Targeted diagnostic evaluation, which is conceptually different from screening, may be indicated in select elderly men based on other symptoms and health conditions.
Bladder cancer often presents initially with either gross painless hematuria or persistent microhematuria. In the United States, the most common type of bladder cancer is transitional cell carcinoma. On cystoscopic examination, this usually appears as either a papillary or sessile tumor of the bladder mucosa. Carcinoma in situ is a particularly aggressive form of bladder cancer. Cystoscopically, this typically appears as a velvety red patch in the bladder mucosa. Bladder wash cytology and biopsies are needed to help establish the diagnosis.
Treatment of bladder cancer is dependent on the grade and stage of the tumor. Low-grade tumors that do not invade into the muscular layer of the bladder are usually treated with endoscopic resection. Tumor recurrence occurs in up to 70% of patients, and careful postoperative follow-up is essential for proper treatment. Follow-up consists of repeated cystoscopy and cytology every three months for two years, every four months for two years, every six months for two years, and then annually. Adjuvant therapy with intravesical administration of Bacillus-Calmette-Guérin (BCG) or mitomycin-C may be used to help decrease tumor recurrence. High-grade noninvasive tumors may also be treated with a combination of surgical resection and intravesical chemotherapy.
Invasion of tumor into the muscularis propria is an ominous finding and is associated with a high risk of disease progression. The mainstay of therapy is radical cystectomy in women or cystoprostatectomy in men. This is a major surgical procedure that is associated with significant risk of morbidity and mortality. Recent studies indicate that elderly patients can safely undergo this type of surgery, although the risks and potential benefits need to be carefully considered for each individual patient. Options for urinary diversion include both continent and noncontinent reconstruction procedures. The traditional diversion is an ileal conduit, which is brought to the skin as a urinary stoma. The urine drains continuously into an ostomy bag that is secured directly to the skin. Methods for continent urinary diversion include either a catheterizable internal pouch made of detubularized bowel, which the patient drains several times daily using intermittent catheterization through a stoma in the abdominal wall, or an orthotopic neobladder. The neobladder is also a pouch made of detubularized bowel but it is anastomosed directly to the urethra. The patient voids per urethra to empty the neobladder, although some patients do need to do periodic intermittent catheterization to completely drain the reservoir. Because the orthotopic diversion relies on the external urinary sphincter for continence, many patients experience some urinary leakage particularly during their sleep.
Primary malignant tumors of the urethra are rare and occur more commonly in women than men. Patients usually present with hematuria or difficulty with urination. The tumor is often palpable on bimanual pelvic examination. Cystoscopy and biopsy are used to help confirm the diagnosis. Treatment consists of excision, and possible adjuvant chemotherapy or radiation.
Cancers of the kidney account for approximately 3%–5% of all diagnosed malignancies in both men and women. The most common types of kidney cancer include renal cell carcinomas, which originate in the renal parenchyma, and transitional cell carcinomas, which originate in the transitional epithelium of the renal collecting system. Early treatment is essential to prevent development of metastatic disease beyond the kidney. For renal cell carcinomas, partial nephrectomy using either open or laparoscopic and robotic surgery may be considered if the tumor is amenable to resection to spare as many functional nephrons as possible to preserve renal function. Recent advances in therapeutic methodology have made techniques such as cryotherapy and radio-frequency ablation of renal tumors minimally invasive options for some patients. These types of therapies may be particularly useful in elderly patients who may not be candidates for more invasive surgery, even with laparoscopic or robotic methods. Radical nephrectomy may be required if the tumor is large, if there is involvement of tumor in the renal vein or vena cava, or the tumor is anatomically not amenable to a nephron-sparing approach. The overall health and potential longevity of the patient must be carefully considered in each case.
Nephroureterectomy has been the traditional treatment for transitional cell carcinomas of the renal collecting system. The ureter is removed because the tumor usually involves a field change within the tissue, and subsequent recurrences in the ureter are extremely common (>70%). Nephron-sparing options including endoscopic tumor resection with administration of chemotherapeutic or immunotherapeutic agents into the renal collecting system. These may be viable options in patients who are not candidates to undergo more involved surgery.
Testis cancer is a relatively uncommon malignancy, accounting for approximately 1% of all cancers diagnosed in males.[21, 27] Testis cancers can present at any point in a man’s life, although the types of cancer differ significantly by patient age. In infants and children, yolk sac tumors and embryonal cell carcinomas are the most common. In young men between the ages of 15 and 35 years, testis cancer is actually the most common solid malignancy, and ranks behind only the leukemias and lymphomas in overall incidence. The most common forms of testis cancer in young men include seminomas and nonseminomatous germ cell tumors. In contrast, the most common testicular tumors in elderly men are lymphomas. These tend to be aggressive tumors and are generally managed with systemic chemotherapy or a combination of chemotherapy and radiation. Recurrence is common, occurring in up to 80% of patients. Extranodal recurrence is not uncommon and may involve the central nervous system. Chemotherapy can be useful in some cases of testicular lymphoma.
Prostate diseases are among the most common urological conditions that affect older men. The primary nonmalignant conditions affecting the prostate gland in older men include benign prostatic hyperplasia (BPH) and prostatitis.
The prostate gland secretes fluid that helps form the ejaculate and provides nutrient factors required for the function and survival of sperm. Benign enlargement of the prostate gland typically begins at approximately 40–50 years of age. This enlargement is driven by the presence of serum testosterone. Proliferation of both the stromal and the epithelial components of the prostate gland can occur in cases of BPH. The effect of prostatic enlargement is variable. Some men experience few symptoms; however, many men develop obstructive voiding symptoms including urinary frequency, hesitancy, nocturia, and a slow urinary stream. Nocturia can be particularly bothersome for some men. Data have shown that experiencing two or more episodes of nocturia each night leads to substantial impairment in overall and health-related quality of life. Other men experience chronic difficulty emptying the bladder or acute urinary retention. In some cases, men may also experience irritative voiding symptoms with urinary urgency or urge incontinence. Pain is uncommon unless men have acute urinary retention or need to strain to urinate. Prostate size does not always correlate with symptoms. In fact, some men with relatively small prostate glands have severe symptoms, particularly if the median lobe of the prostate gland is involved. Voiding symptoms associated with BPH can have a significantly negative impact on both overall and health-related quality of life.[31, 32] Fortunately, there are a wide variety of both surgical and nonsurgical therapies for BPH that can be quite effective in relieving these bothersome symptoms. These are outlined in Table 26.3. In addition, quality indicators for evaluation and management of BPH in vulnerable elderly men have recently been established.
|Terazosin (Hytrin)||1–10 mg PO at bedtime (must titrate dose)|
|Doxazosin (Cardura)||1–8 mg PO at bedtime (must titrate dose)|
|Tamsulosin (Flomax)||0.4–0.8 mg PO at bedtime|
|Alfuzosin (Uroxatral)||10 mg PO once daily|
|Finasteride (Proscar)||5 mg PO once daily|
|Dutasteride (Avodart)||0.5 mg PO once daily|
|Transurethral resection of the prostate (TURP)|
|Transurethral incision of the prostate (TUIP)|
|Open suprapubic prostatectomy|
|Open retropubic (nonradical) prostatectomy|
|Minimally invasive therapies|
|Transurethral photovaporization (PVP)|
|Transurethral needle ablation (TUNA)|
|High-intensity focused ultrasound (HIFU)|
|Transurethral microwave thermotherapy (TMT)|