Behavioral therapies
Timed voiding
Prompted toileting

Assisted toileting

Diet modification (avoid caffeine, alcohol, carbonation, etc.)

Pelvic floor muscle exercises

Urge suppression strategies

Device therapies

Condom catheters (penile sheaths)

Pessaries (intravaginal support devices)

Indwelling catheters (urethral or suprapubic)

Absorbent pads and other products



Antimuscarinic agents a

Darifenacin (time released)

7.5 mg or 15 mg orally once daily

Fesoterodine (time released)

4 mg or 8 mg orally once daily


5 mg two or three times orally daily (maximum daily dose 30 mg)

Oxybutynin (time released)

5 mg, 10 mg, or 15 mg orally once daily

Oxybutynin (transdermal patch)

One patch (3.9 mg daily) topically, changed every 3 days

Oxybutynin (transdermal gel)

One packet topically once daily


1 mg or 2 mg orally twice daily

Tolterodine (time released)

4 mg orally once daily

β-3 Agonist agents b

Mirabegron (time released)

25 mg or 50 mg orally once daily

Surgical therapies

Stress urinary incontinence

Sling cystourethropexy (bladder neck)

Mid-urethral sling

Bladder neck suspensions

Bulking agent injection (bladder neck)

Urgency urinary incontinence

Chemodenervation (botulinum toxin injection)


Augmentation cystoplasty

Urinary diversion

aMain side effects of antimuscarinic agents: dry mouth, dry eyes, constipation, confusion, headache, blurred vision, tachycardia, QT interval prolongation on electrocardiogram, bradycardia and urinary retention

bMain side effects of β-3 agonist agents: hypertension, headache, nausea, dizziness and tachycardia Behavioral Therapies

Behavioral therapies form the mainstay of treatment for UI in most patients. Avoiding dietary components that increase bladder irritation and urinary urgency and frequency can be useful. This includes caffeine, alcohol, highly acidic foods, and carbonated beverages [41]. Fluid restriction is generally not helpful, and can worsen urinary urgency and frequency in some patients due to increased urinary concentration; however, limiting fluids after dinner can reduce nocturia. Timed or scheduled urination can be useful, particularly among those with urinary urgency and urgency UI. Timed voiding is often combined with learning to delay voiding by controlling urge symptoms; this behavioral technique is called ‘urge control’ [42].

Pelvic floor muscle exercises are useful for many patients with stress UI and urgency UI. Patients generally need targeted instruction, and may benefit from working with a physical therapist or nurse for individualized coaching. Such behavioral treatments typically require 3–4 visits to gain confidence in proper techniques and then a periodic review for reinforcement. Older adults using this type of behavioral therapy must be motivated to continue pelvic floor exercise, and understand how to use them at appropriate times. Pelvic floor muscle exercise has been shown to work well in both men and women , and can improve UI more than simple bladder training and timed voiding alone [43, 44]. Device Therapies

Many people use devices such as condom catheters or absorbent pads and products to manage urinary leakage. There are a variety of intravaginal pessaries that can be used for management of stress urinary incontinence (see Chap. 13 Gynecology). Penile clamps for men, or urethral plugs and inserts for women can be used in cases with stress incontinence, particularly with physical exercise or other activities. In general, devices are considered options for management of symptoms rather than definitive treatment of UI. Pharmacotherapies

Medications are widely used for treatment of UI in both younger and older patients but should be initiated only after a trial of behavioral therapy. Most medications are targeted at overactive bladder and are used to treat urinary urgency, frequency, and urgency UI. Most are antimuscarinic, anticholinergic agents which block muscarinic receptors in the bladder and reduce involuntary detrusor contractions. Side effects of this class of medications include urinary retention, constipation, dry mouth, dry eyes, headache, and confusion [45]. Newer agents include beta-3 agonists that also work to reduce bladder overactivity, but avoid the typical anticholinergic effects; side effects for this agent include hypertension, headache, nausea, dizziness, and tachycardia (including atrial fibrillation). The route of administration may be an important consideration, particularly in geriatric patients. Transdermal preparations applied as either a skin patch or gel may be useful in those with swallowing problems. Time-released medications may improve adherence and efficacy. Liquid preparations may also be useful in patients with swallowing difficulties or in those who require use of a feeding tube.

Studies examining use of antimuscarinics in cohorts of older patients have shown efficacy, safety, and tolerability [46, 47]. Using the lowest effective drug dose is recommended, and patients should be monitored carefully and continuously for drug interactions or other adverse effects. Discontinuation of medication due to side effects or limited perceived efficacy is common, and several different medications may need to be tried to find one that works best for an individual patient [4850]. Cost is also a factor when considering medication therapy for elderly patients [51]. Insurance coverage is variable and may differ substantially between medications for a given payment plan. Surgical Therapies

Surgical therapy can be useful for treatment of UI in older adults, particularly if more conservative therapies such as behavioral options or medications have not been successful. In carefully selected patients surgical options improve outcomes for treatment of UI [52]. Age itself should not be the deciding factor of whether someone is a candidate for surgical intervention. Instead, overall health, comorbidity, and goals of care should be the guiding variables [53]. Development of less invasive surgery has increased surgical options for many older adults with UI and other lower urinary tract conditions [54].

Injection of bulking agents at the bladder neck to increase urethral outlet resistance is minimally invasive, and may be effective in elderly women with stress urinary incontinence [55]. A variety of materials have been used for this purpose. Results are generally good, and the procedure offers the advantage of being easily repeatable if needed. This type of therapy may be particularly useful in elderly women with stress UI who may not be good surgical candidates for more involved procedures.

Sling procedures include those that place grafts either under the mid-urethra or the bladder neck. Various graft materials are available including synthetic mesh, autologous fascia, and other biological grafts either from cadaver tissue donors or animal xenografts. Outcomes in carefully selected elderly women are generally good with complication rates similar to those in younger patients [56, 57]. However, other reports suggest that older women may have less overall clinical success with slings, and are at higher risk of complications [58, 59]. Sling procedures for treatment of male stress UI have also been developed, although outcome data specific to elderly men is limited. In men with stress UI, implantation of an artificial urinary sphincter is also an option. Good cognitive status and hand dexterity are needed to correctly operate the device after implantation. In select patients, this therapy can be extremely effective [60].

For patients with urinary urgency, frequency or urgency UI, neuromodulation and chemodenervation are minimally invasive surgical therapies that can help treat symptoms. Neuromodulation uses electrical stimulation of the nerves that control bladder contractility. Sacral neuromodulation is performed by implanting an electrode in the third sacral foramen (S3). This is connected to a programmable generator that provides impulses to the nerve. Success rates up to 83.3 % have been reported in selected elderly patients who underwent stimulator placement [61]. The most common complication is device infection or erosion that may require surgical removal. However, overall complication rates are similar in older and younger patients and age itself should not influence decisions for treatment with this therapy [62, 63]. Chemodenervation of the bladder detrusor muscle is also used for treatment of urgency UI and symptomatic urinary urgency and frequency. The most commonly used agent is onabotulinum toxin A. Studies have demonstrated clinical efficacy and safety even in elderly patients [64]. The main side effect of this treatment is urinary retention which may require clean intermittent catheterization at least temporarily in order to drain the bladder.

In highly select patients, urinary diversion may be considered for treatment of intractable UI. This could include reconstructive procedures with either creation of a urinary stoma such as an ileal conduit, or a continent catheterizable pouch. In some patients, management of a stomal device may be preferable to UI. However, these are major surgical procedures, and care through careful preoperative assessment (see Chap. 3) must be taken to weigh the risks and benefits for a given patient before selecting this type of therapy [65, 66].

18.2 Urinary Catheters

Urinary catheters are sometimes used in the management of urological and non-urological conditions. For example, patients with perineal skin breakdown or sacral pressure ulcers may require temporary indwelling catheter drainage to keep the affected area dry and allow for tissue healing. Temporary urinary catheter drainage is also used after reconstructive surgery with flap placement in order to keep the surgical site dry during healing.

However, in older adults, chronic indwelling catheters should be avoided if at all possible [67]. Indwelling catheters are associated with substantial complications including urinary tract infections, bacterial colonization, urosepsis, and stone formation [68]. Catheters should be removed when feasible, and patients should be monitored for signs or symptoms of infection. Tissue irritation from chronic catheterization can lead to squamous metaplasia of the bladder epithelium, and development of squamous cell carcinoma. If chronic catheter use is needed, suprapubic tube drainage is generally preferred over urethral catheterization. This reduces the risk for urethral and bladder neck erosion. In addition, it is often more comfortable for patients. It may be easier for caregivers to change compared to urethral catheterization, particularly in men, and also gets the catheter out of the genital tract which is beneficial for older adults who remain sexually active.

Persistent urinary leakage around an indwelling catheter is typically due to either bladder spasms or catheter blockage. Irrigation of the catheter with sterile saline can be helpful to relieve obstruction of the tube from urinary sediment. Clinicians should avoid placing larger caliber catheters, which will only serve to dilate the tract and will not solve the underlying problem of detrusor overactivity. If used in the urethra, larger catheters increase the risk of tissue erosion which can lead to severe urinary incontinence and can require advanced surgical reconstruction even bladder removal. Use of antimuscarinic medications to reduce bladder contractions can be very useful in patients who experience urinary incontinence associated with indwelling catheter drainage.

A variety of devices are available to manage urinary leakage including absorbent pads and condom catheters. These are useful for select patients. For example, they can be used when someone wants to participate in social activities that they might otherwise avoid due to UI. Numerous designs are available, and recent improvements have helped enhance odor control, fluid absorbency, and other associated factors [6971]. Condom catheters are useful for men with UI. These disposable devices are designed to surround the penis and are connected to a urinary collection device. They can be particularly helpful for management of bothersome nocturia or if UI prevents men from participating in activities outside their home. Proper sizing and skin hygiene are important to prevent skin irritation or breakdown.

18.3 Urinary Tract Infections and Asymptomatic Bacteriuria

Urinary tract infection (UTI) is one of the most common urologic conditions that occur in older adults. Although both males and females experience UTIs, they tend to be more common in older women. It can sometimes be challenging to differentiate symptomatic UTIs, which need treatment and asymptomatic bacteriuria that does not require antibiotic therapy. Urine cultures are strongly recommended to confirm infection, help identify the associated bacterial organisms, and guide therapy. Antibiotic susceptibility patterns are in constant flux, and it is crucial to identify drug resistance and select appropriate treatment. Although empiric antibiotic therapy may be started based on clinical symptoms and dipstick urine results, antibiotics may need to be changed depending on results of antibiotic susceptibility testing. Catheterized urine samples may be needed if older adult patients have difficulty producing an adequate clean-catch specimen [72].

The most common symptoms of UTI include urinary urgency and frequency, dysuria, bladder pain, and fever. Cloudy and foul-smelling urine are common, but this can also be due to causes other than a UTI. Many older adults may not show these typical symptoms [73]. Instead, they may exhibit ‘atypical symptoms’ including confusion, lethargy, anorexia, agitation, UI, and behavioral changes [74]. Delirium may occur in some patients with UTIs [75]. Upper tract involvement with pyelonephritis or other complex forms of UTI are often associated with comorbidity such as stone disease, diabetes, or anemia [76]. Urosepsis in elderly patients may be serious, and is associated with increased risk of mortality due to decreased physiological reserve. Factors that increase the risk of mortality in older adults with urosepsis include advanced age (≥85 years), hypothermia, severe cognitive impairment, and chronic renal disease [77]. Hospital acquired UTIs are also associated with an increased risk of mortality compare to community acquired infections [78]. Management with fluid resuscitation and appropriate antibiotic therapy is crucial. Fungal UTIs are less common, and tend to occur with advanced age in patients with reduced immune status including those with a prior history of organ transplant on immunosuppressive therapy, those with HIV disease or AIDS, and in those with poorly controlled diabetes . Treatment may require antifungal agents such as fluconazole [79].

In contrast, asymptomatic bacteriuria with or without pyuria is a very common condition in older adults and should not be treated with antibiotics unless there are special considerations such as planned genitourinary surgery. In community dwelling older adults, asymptomatic bacteriuria occurs in about 10 % of men and 10–20 % of elderly women [80, 81]. Extensive data supports that asymptomatic bacteriuria does not require antibiotic therapy [82]. See also Chap. 24 Infection and Immunity in Older Adults for diagnosis and discussion of asymptomatic bacteriuria.

A number of clinical factors increase the risk of UTIs among older adults. Catheter associated UTIs are highly prevalent in acute care hospitals and other inpatient settings [68, 83]. Clean intermittent catheterization can reduce infection rates in patients with retention, and risk is lower compared to chronic indwelling catheter use. Obesity and significant underweight body mass index have both been linked to higher rates of UTI in older patients [84].

Several different therapies have been used to try to prevent UTIs in older adults. Administration of vaginal estrogens can reduce symptomatic UTI rates in elderly women by causing reacidification of the vaginal fluid milieu. This allows growth of Lactobacillus sp., the normal flora in the vagina. These bacteria act as an important host defense by killing bacteria associated with UTIs. Contraindication to vaginal estrogen use includes a personal history of breast or uterine cancer. Ingestion of cranberry juice or cranberry supplements is popular for UTI prevention. Proanthocyandidins in cranberry interact with fructose in bacterial cell walls and potentially prevent adherence of bacteria to the urothelium. However, data on clinical efficacy has been mixed. Recent evidence from a double-blind, randomized, placebo-controlled clinical trial in nursing home residents showed reductions in infection rates, but these statistically significant changes were limited to those with prior high rates of UTI [85]. In general, chronic antibiotic use for prophylaxis should be avoided unless no other options are available. Although it can be useful in select patients, it is also associated with an increased risk of drug resistant bacterial infection which makes treatment more challenging.

Evaluation and treatment of UTIs in nursing homes and other chronic care settings requires special consideration. Differentiation between symptomatic UTIs and asymptomatic bacteriuria can be particularly challenging in this setting, and overuse of antibiotic is common [86, 87]. Drug selection should be guided if possible by local antibiogram data based on local prevalence of specific organisms and resistance patterns [88]. Environmental contamination in nursing home and other chronic care settings may be associated with certain types of infection including methicillin-resistant Staphylococcus aureus (MRSA) [89]. Strict hand-washing and other infection prevention protocols can help to reduce this risk.

The overall costs associated with the evaluation and treatment of UTIs is staggering, and in the USA surpasses the cost of almost all other major genitourinary disorders [90, 91]. The high incidence of UTI certainly contributes, but overtreatment of asymptomatic bacteriuria and care provided in emergency rooms and urgent care centers are also important factors.

18.4 Hematuria

Hematuria is defined as the presence of blood in the urine. This is almost always abnormal, and clinical evaluation is generally indicated to identify potentially serious underlying causes [92]. Common etiologies for hematuria include urolithiasis, malignancies such as kidney cancer or urothelial tumors in the bladder, ureter or kidney, or trauma. Men with severe benign prostatic hyperplasia (BPH) may have bleeding from prostatic capillaries. The use of anticoagulation is common in geriatric patients for treatment of cardiac arrhythmias for stroke prevention. Both normal and supratherapeutic levels of anticoagulation can cause bleeding from a lesion in the urinary tract. All patients with hematuria, including those who develop hematuria after the initiation of anticoagulation, should undergo appropriate clinical evaluation [93]. This includes both cystoscopy and some type of contrast based imaging such as CT urogram or retrograde pyelography.

18.5 Sexual Health

Sexuality and sexual health remain an important part of life for many older adults who wish to remain sexually active if possible [94]. Survey data demonstrates that up to 20–30 % of all older adult men and women remain sexually active well into their 80s [95]. Urologic care providers can help to evaluate and treat sexual health issues in this population. Many common comorbid conditions including diabetes, hypertension, peripheral vascular disease, and heart disease can negatively impact sexual health in geriatric patients. In addition urinary incontinence and treatments for prostate cancer or other malignancies can substantially reduce sexual health in this population [96, 97]. Those with better overall health and less comorbidity tend to remain more sexually active with advancing age [98, 99]. Sexual health changes may also be signs or symptoms of underlying comorbid disease. Frailty has been shown to negatively affect sexual health status, and is associated with multiple changes in both physical and psychosocial domains [100]. Other gynecological disorders such as pelvic organ prolapse or atrophic vaginitis can also impair sexual function in elderly women. Impaired sexual health in older adults is also associated with higher rates of depression and other forms of mental health issues [101, 102].

Partner availability may limit sexual activity, and masturbation may become a primary form of sexual expression for some older people. Other forms of sexual expression may change with aging including a reduction in the emphasis on penetrative sexual activity and increased attention to intimacy with close physical and emotional contact [103]. The living environment may also influence sexual expression, particularly for those living with extended family caregivers or in nursing homes. Increased awareness of sexual health needs has led many nursing homes to work to better accommodate these residents [104]. Inappropriate sexual behavior may be problematic for older adults with cognitive impairment or dementia, and may be particularly challenging for caregivers [105]. Screening and treatment for sexually transmitted diseases may be indicated in some patients depending on sexual activity , and if signs or symptoms of infection are present [106].

A wide variety of therapies are available for sexual health dysfunction in older adults ranging from sexual therapy and counseling, to medications and surgeries designed to improve erectile function in men and sexual response in women. Treatments should be targeted on the patient’s specific goals and outcomes, and should be selected within the scope of overall health and comorbidity. Chapter 22—Endocrinology provides a thorough discussion of the endocrine evaluation and treatment of hormonal deficiencies related to sexual dysfunction.

18.6 Urolithiasis and Stone Disease

Stone disease affects about 20 % of all adults at some point in their lives. Rates of stone formation are similar among older and younger adults, and those with a prior history are at risk for recurrence. Poor hydration status is one of the strongest risk factors for stone formation, and older adults often have a reduced sensation of thirst, or may have difficulty swallowing which can lead to inadequate fluid intake. Recent Medicare data suggest that compared to younger adults, older patients have a 2.5 to 3-fold increased rate of inpatient hospitalization for stone disease [107].

Stone composition may change with age, and older adults more often have uric acid stones compared to younger people [108]. This may particularly affect older patients with diabetes who may have impairments in urinary ammoniagenesis and produce abnormally high levels of uric acid with a low urinary pH [109]. Age-related alterations in vitamin D and calcium metabolism may also affect urolithiasis risk in older adults. Hyperuricosuria and hypercalcuria appear to be common in older patients with recurrent stone disease [110].

Small stones (<5 mm) often pass spontaneously with hydration and oral analgesics. Oral selective alpha-blockers such as tamsulosin may be helpful to enhance ureteral relaxation. Cystoscopy with ureteral stent placement is indicated to bypass the obstruction in cases of larger stones, particularly if the patient experiences intractable nausea, vomiting, or pain. Other indications for ureteral stent insertion include baseline renal insufficiency, a solitary functioning kidney, or significant urinary infection or bacteriuria. Surgical therapy with ureteroscopic stone fragmentation and extraction, extracorporeal shock wave lithotripsy, or percutaneous nephrostolithotomy may be required. The overall success rates for these procedures are similar in geriatric and younger patients [111, 112].

18.7 Benign Prostate Diseases

18.7.1 Benign Prostatic Hyperplasia

One of the most common urologic disorders in aging men is benign prostatic hyperplasia (BPH). Symptoms typically begin around 40–50 years of age [113]. Proliferation of epithelial and stromal elements occurs in response to serum testosterone. The effect of prostate enlargement is variable, and some men have no symptoms while others develop voiding difficulty. Typical symptoms include a decreased urinary stream with urgency, frequency, and nocturia. Severe cases may be associated with acute or chronic urinary retention and incomplete bladder emptying. Prostate size does not necessarily correlate with the degree of symptoms. The voiding symptoms associated with BPH can have a negative impact on overall and health-related quality of life for many men [114]. A useful symptom severity questionnaire is presented in Chap. 8—Tools for Assessment.

There are a variety of treatments available for BPH including both medical and surgical therapies. The most commonly used medications are α-adrenergic antagonists and 5-α-reductase inhibitors (Table 18.2). The α-adrenergic antagonists include terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), and alfuzosin (Uroxatral). These drugs block α-adrenergic receptors in the prostatic urethra and bladder neck. This causes smooth muscle relaxation in these tissues, which in turn reduces outlet resistance. These medications have good overall efficacy [115]. The main adverse effect is orthostatic hypotension, which is more common with the older, less selective agents (terazosin, doxazosin) . These drugs, particularly tamsulosin, may cause the intraoperative ‘floppy iris syndrome’ (leading to potential intraocular surgical complications). Although not generally reversible, the operating ophthalmologist should be made aware of the patient’s use of this agent prior to cataract or other ocular surgery. In addition, intraocular surgery if indicated could be performed before starting the agent [116].

Table 18.2
Medications for treatment of benign prostatic hyperplasia (BPH)

α-Adrenergic antagonist agentsa


Nonselective agents

Doxazosin (Cardura)

1–8 mg orally once daily at bedtime (must titrate dose)

Terazosin (Hytrin)

1–10 mg orally once daily at bedtime (must titrate dose)

Selective agents

Alfuzosin (Uroxatral)

10 mg orally once daily at bedtime

Tamsulosin (Flomax)

0.4 mg or 0.8 mg orally 30 min after the same meal once daily

5-Alpha reductase inhibitor agentsb


Dutasteride (Avodart)

0.5 mg orally once daily

Finasteride (Proscar)

5 mg orally once daily

aMain potential side effects of α-adrenergic antagonist agents: orthostatic hypotension, dizziness (these tend to be more pronounced with the nonselective agents)

bMain side effects of 5-alpha reductase inhibitor agents: decreased libido and erectile dysfunction

The 5-α-reductase inhibitors act by blocking the enzymatic catalysis of the conversion of testosterone into dihydrotestosterone (DHT). Reductions in circulating DHT lead to shrinking of the prostate gland and improvement in urinary outflow. It can take several months for these medications to reach full effect [117]. The two main drugs in this group are finasteride (Proscar) and dutasteride (Avodart). These medications generally work better in men with larger prostate volumes. Potential side effects include decreased libido and development of gynecomastia or breast tenderness. The drugs also cause an approximately 50 % reduction in circulating serum PSA. Prior to initiating these medications, a PSA level can be checked. After initiating a 5-α-reductase inhibitor, measured serum PSA levels should be doubled to estimate the actual PSA level. Several studies suggest that combination therapy with both an α-adrenergic antagonist and a 5-α-reductase inhibitor has better efficacy compared to monotherapy, particularly in men with more severe voiding symptoms or larger prostate glands [118, 119]. However, increased cost and potential side effects need to be carefully considered. Although phytotherapies are popular among older patients with BPH, to date there has been relatively limited research on their efficacy.

Surgical therapy for BPH may be required if medical treatment fails, options including both open and endoscopic procedures. Open suprapubic prostatectomy is typically reserved for patients with very large prostate gland volumes (>100 g). For the majority of men, transurethral surgeries have replaced open surgery and are associated with improved morbidity and good clinical outcomes. Transurethral resection of the prostate (TURP) remains the gold standard to which other forms of surgery are compared. Newer treatments use laser energy to vaporize or resect prostate tissue, or various forms of energy including radiofrequency, high-intensity focused ultrasound, or microwave thermotherapy [120, 121]. These ablate tissues and lead to necrosis and sloughing of affected tissues. Intraurethral prostatic stents have also been used to treat BPH, particularly in men with severe comorbidity who may be poor surgical candidates for even minimally invasive options [122, 123].

Many of the current minimally invasive options for treatment of BPH offer some potential advantages for elderly patients. In some cases, these can be done in an outpatient office setting under local anesthetic or sedation which obviates some of the risks associated with more involved anesthesia. Most have minimal risk of bleeding and can be advantageous for men on anticoagulation therapy.

18.7.2 Prostatitis

The overall prevalence of prostatitis among adult men ranges from 2 to 10 % [124, 125]. Prostate infections are either acute or chronic. The condition tends to occur more commonly in older men, and rates of hospitalization are 2–2.5 times higher in this population compared to younger men [91, 126]. Acute bacterial prostatitis is characterized by rapid onset of symptoms with fever, chills, urinary frequency and urgency, dysuria, and pelvic or perineal pain. Findings may be subtle in older men due to a reduction in overall immune response associated with aging. Physical examination may reveal an enlarged and tender prostate. Care should be taken to avoid vigorous prostate massage as this may lead to urosepsis. Urine cultures are useful to pinpoint the specific organism and guide choice of antibiotics. Inpatient care with intravenous antibiotics may be necessary if the patient is severely ill. If a prostate abscess is identified on CT imaging, surgical drainage is usually indicated. Acute urinary retention often occurs in cases of acute prostatitis and may require suprapubic tube insertion for bladder drainage. Urethral catheterization should be avoided to prevent bacterial seeding and urosepsis. Extended antibiotic therapy (>4 weeks) with an agent which achieves good tissue penetration such as doxycycline or a fluoroquinolone is often required.

Chronic prostatitis is more common than acute prostatitis in elderly men, and is usually associated with urinary urgency, frequency, nocturia, scrotal or perineal pain or referred pain in the low back and suprapubic region [127]. The physical findings are variable and the prostate may or may not be abnormal on rectal examination. Expressed prostatic secretions and urine culture are helpful in diagnosis and guiding therapy. Treatments include targeted antibiotic therapy and dietary modification to avoid urinary irritants such as alcohol, caffeine, or carbonated beverages.

18.8 Genitourinary Cancers

Cancers of the genitourinary tract increase in incidence and prevalence with advancing age. Depending on the type of cancer and the grade and stage, treatment ranges from surgical excision to chemotherapy, radiation therapy, or immunotherapy. Consideration of overall health, quality of life, and goals of care are important, and treatment choices must be made in the context of associated comorbidities. For a discussion of the general approach to the older patient with cancer, please see Chap. 26 Oncology. This section will review selected relevant issues associated with cancer diagnosis and treatment in the older adult population.

18.8.1 Kidney Cancer

Kidney cancers are frequently diagnosed in geriatric patients who have undergone abdominal imaging for other symptoms or conditions. The overall incidence of kidney cancer has been increasing over the past 30 years at a rate of 2–3 % annually [128]. In fact, the largest increases are in patients in their seventh and eighth decades. Age over 75 is a risk factor for more advanced disease, although in older adults with very small tumors, active surveillance is a feasible option, which may obviate the need for invasive surgical therapy [129]. Assessment of underlying comorbidity (see Chap. 3) may be particularly useful to guide therapeutic options for small kidney cancers in older patients [130].

In those who do require surgery, comorbidity is more important than chronological age in overall outcomes from either radical or partial nephrectomy [131, 132]. Outcomes and complications from laparoscopic and robotic partial nephrectomy appear similar to those observed in younger patients [133, 134]. Despite this observation, overall rates of partial nephrectomy in geriatric patients still lag the use in younger people [135]. The exact reasons for this are unclear, but may reflect clinician bias against using these techniques in older or frail (see Chap. 1) individuals. Cytoreductive surgery may be considered in some patients with more advanced disease, although complication rates including need for blood transfusion are higher among older adults [132, 136]. Immunotherapy may be considered, but can be difficult for some older adults to tolerate, particularly if they have associated functional impairments or worse overall performance status. In patients with upper tract urothelial cancers, radical nephroureterectomy may be considered, although the cancer-specific survival in this population >80 years of age is lower than in younger patients [137].

18.8.2 Bladder Cancer

Bladder cancer is one of the most common urologic malignancies, and occurs predominantly in older adults. Prevalence and incidence both increase substantially with advancing age. The primary risk factor is cigarette smoking, although exposure to certain chemicals such as aniline dyes also increases risk. Overall, the median age at diagnosis is >70 years due to the long latency of carcinogen exposure [138]. The most common associated symptom is hematuria. Diagnosis is typically made through a combination of imaging and direct visualization with cystoscopy. Tumor resection is required for tissue diagnosis and to determine the grade and stage of the cancer. It is important to clearly identify whether the tumor is superficial or invades the muscle of the wall of the bladder because this influences selection of therapy. Tumor restaging with repeat resection, especially in cases of incomplete initial resection or where there is a lack of muscularis propria in the sample, can be extremely useful. Adjuvant therapy with intravesical administration of mitomycin C or bacillus-Calmette-Guerin (BCG) may be considered in patients with superficial bladder cancer. However, it has been shown that BCG therapy has a somewhat decreased efficacy in older compared to younger adults [139]. This may be due to diminished immune response with aging.

The standard therapy for muscle-invasive bladder cancer has been surgical treatment with radical cystectomy and urinary diversion. This is one of the most invasive and complex surgical procedures performed in urology. Risk of morbidity and mortality is compounded by the fact that many of these patients have substantial underlying comorbidity and chronic health problems. For example, bladder cancer is frequently linked to a history of cigarette smoking and patients may have lung disorders such as chronic obstructive pulmonary disease (COPD) or restrictive airway disease that puts them at increased anesthetic risk. Despite this fact, multiple studies have demonstrated that with appropriate preoperative planning, intraoperative and postoperative care, radical cystectomy and urinary diversion is safe even in elderly patients [140, 141] Survival benefits have been demonstrated, but must be considered within the overall context of comorbidity and other health issues [142, 143]. There is an increase in perioperative complications in older patients undergoing this procedure, likely due to associated comorbid conditions [144, 145]. Reduced performance status, frailty, and sarcopenia predict complications in patients undergoing radical cystectomy [146, 147]. See Chap. 1 Frailty for information on this important geriatric syndrome.

Bladder sparing surgery in some elderly patients with muscle-invasive cancer using endoscopic resection followed by adjuvant radiation and/or chemotherapy shows similar overall survival to radical surgery in some studies with increased overall time in the hospital [148, 149]. Other studies show worse overall performance status and comorbidity and those who are very elderly tend to have worse outcomes in terms of both overall and cancer-specific survival [150, 151]. The most common indication for radiation therapy in patients with bladder cancer is for treatment of intractable bleeding in those who are not candidates for other surgical intervention [152].

18.8.3 Prostate Cancer

Prostate cancer is one of the most common solid tumor malignancies seen in adult men. This section will selectively focus on issues specific to geriatrics and elderly men. Routine prostate cancer screening is controversial, but most agree that when it is used, screening should generally be discontinued once men have reached 70–75 years of age. This is because use of definitive therapy for prostate cancer with either radical prostatectomy or radiation therapy is generally reserved for men with an estimated remaining life expectancy of at least 10 or more years [153]. Mean life expectancy for men in the USA is approximately 82–84 years. In contrast to screening, targeted diagnostic assessment in selected patients at risk for development of prostate cancer may be useful to guide therapy in light of their overall health status . This may be true even if it is not done with curative intent [154].

Treatment decisions for elderly men with prostate cancer must be made with consideration of overall health and other comorbid conditions. Evaluation of functional status using activities of daily living (ADLs) and instrumental activities of daily living (ADLs) may be useful in this regard [155, 156]. In addition to functional status, information on disease burden and estimated remaining life expectancy can be useful in making clinical decisions in this population. In many cases, prostate cancer is a relatively slow growing and indolent tumor, and many elderly men may die of other conditions such as cardiovascular or pulmonary disease [157, 158]. However, some cases of prostate cancer may be more aggressive and develop into metastatic disease [159, 160].

Treatment of organ-confined prostate cancer includes radical prostatectomy or radiation with either external beam treatment or brachytherapy. While some studies show clinical outcomes equivalent to those in younger men, [161, 162] other studies suggest that elderly men are at higher risk for upgrading or upstaging of disease, biochemical recurrence of disease, urinary incontinence, or sexual dysfunction [163165].

Some clinicians recommend radiation therapy in geriatric patients to avoid the risks associated with radical surgery. However, radiation therapy can be associated with complications including sexual dysfunction, radiation injury to other pelvic organs, or urinary incontinence [166]. Urinary incontinence following radical prostatectomy can have negative effects on quality of life including physical and social activities and mood in elderly men [167, 168]. Although cryotherapy has been suggested as a less invasive option for some men with organ-confined prostate cancer, long-term outcomes of this therapy are unclear [169].

Treatment of metastatic prostate cancer often involves use of hormonal therapy or chemotherapy in order to reduce disease and symptom progression, although they are not used with curative intent. The chemotherapeutic agent docetaxel has increased overall survival in early clinical trials [170]. Androgen deprivation therapy is more commonly used, and is beneficial in many patients although there are risks including cardiovascular disease and diabetes [171]. Because it blocks testosterone production, hormonal therapy is associated with gynecomastia, hot flashes, loss of libido, reduced sexual function, and sarcopenia which is part of the frailty phenotype [172]. Because this therapy is also associated with bone loss [173], men treated with hormonal therapy should be evaluated with imaging for bone disease before and during treatment. Bisphosphonates including alendronate and zoledronic acid slow bone resorption during anti-androgen therapy [174, 175]. The high cost of hormonal treatment may be a barrier for some patients and must be considered when making treatment decisions [176].

18.8.4 Testis Cancer

Primary germ cell tumors are relatively rare in elderly men, and occur most commonly between 15 and 35 years of age. Lymphoma is the most common testicular malignancy seen in the geriatric population [177]. In most cases, this represents a manifestation of systemic disease, and should be evaluated and treated in this context. If geriatric patients do present with a primary germ cell tumor, evaluation and treatment should follow accepted guidelines generally used in younger men. It may be necessary to adjust chemotherapy regimens based on age-related changes in renal hepatic or pulmonary function, or due to other underlying comorbidity. Overall life expectancy following successful treatment approaches that of other elderly men without a history of testis cancer [178].

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Aug 25, 2017 | Posted by in GERIATRICS | Comments Off on Urology

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