Common urologic problems in the elderly

Prostate cancer, outlet obstruction, and incontinence require special management

Stephen B. Reznicek, MD

VOL 107 / NO 1 / JANUARY 2000 / POSTGRADUATE MEDICINE

CME learning objectives

• To understand the concept of clinically important prostate cancer and know which elderly men need evaluation and which require treatment
• To learn when it is appropriate to refer an elderly woman with urinary incontinence for sophisticated urodynamic studies
• To become familiar with the rules of long-term Foley catheter care

Preview: The three most common and vexing clinical urologic problems in the elderly are prostate cancer and benign outlet obstruction in men and urinary incontinence in women. In this article, Dr Reznicek reviews these entities, with an emphasis on practical management. In addition, he discusses long-term use of catheters in the elderly and presents a pragmatic approach to preventing serious complications.
Reznicek SB. Common urologic problems in the elderly: prostate cancer, outlet obstruction, and incontinence require special management. Postgrad Med 2000;107(1):163-78

As the US population ages, urologic problems are assuming a larger role in primary care medical practices. Physicians are often challenged to solve difficult problems for these patients and their caregivers.

Urologic problems in elderly men

The major urologic problems for elderly men are prostate carcinoma and benign outlet obstruction.

Prostate carcinoma
About 6% of men over 50 years of age harbor clinically significant prostate cancer, and the number rises to about 20% for men over age 75. Between 1987 and 1992, aggressive use of digital rectal examination and prostate-specific antigen (PSA) testing resulted in an 85% increase in the rate of prostate carcinoma detection. The rate then declined by 28% through 1995, suggesting a baseline incidence in the United States of 100 cases per 100,000 men. About 37,000 American men are expected to die of prostate carcinoma in 1999 (1).

Prostate cancer can cause intense local morbidity from obstruction and urinary hemorrhage, as well as significant mortality from lymphatic and axial metastases. Because prostate cancer is so common in elderly men but indolent in a large percentage of cases, the relevant question is, who should be treated? The answer is men with clinically significant prostate cancer (ie, tumor volume >1 cm³) who have a life expectancy of more than 10 years and with whom it is reasonable to discuss a curative option. Men with biologically aggressive cancers that are likely to cause significant morbidity also should be treated.

In light of this answer, prostate cancer screening is generally recommended only for men younger than 75 years who have a life expectancy of 10 years or more. The American Cancer Society and the American Urological Association recommend annual digital rectal examination and serum PSA screening for these men (2). All other elderly men should be evaluated with focused history taking and physical examination. If the history raises a suspicion of prostate cancer or if the digital rectal examination suggests significant prostate cancer (volume >1 cm³), the next steps are serum PSA determination and ultrasound of the prostate with biopsy. Once prostate cancer is diagnosed, bone and computed tomographic scans are reserved for men with a PSA of 10 ng/mL or greater.

Conservative observation (ie, no treatment) is a reasonable treatment option in elderly men with small-volume (<1 cm³), low-grade disease. The 10-year metastasis rate with low-grade prostate cancer (grade I) is 19%. However, the rate rises to 42% with moderate (grade II) lesions and to 74% with poorly differentiated (grade III) carcinoma (3). Overall, 50% to 60% of these patients have progressive disease within 10 years, and between 20% and 63% die of their disease.

Curative treatments (eg, radical prostatectomy, external beam radiation therapy, radioactive seed implantation) are generally used in men who have a greater than 10-year life expectancy and who are healthy enough to undergo treatment. Established nomograms based on clinical stage, PSA level, and tumor differentiation help identify men with localized disease who can expect cure rates between 80% and 90% after surgery alone (4).

Hormonal manipulation is perhaps the most common treatment of prostate cancer in elderly men because of its ease of administration, lack of serious side effects, and overall effectiveness. In the past, hormonal manipulation was primarily used in men with symptomatic metastatic disease. More recently, this approach has been recommended as an alternative to more aggressive therapies in elderly men with clinically significant tumors (5).

Hormonal manipulation can take one of three forms: surgical castration, oral estrogen therapy, and administration of luteinizing hormone-releasing hormone (LHRH) agonists. Side effects common to all of these treatments include hot flashes and the potential loss of sexual performance and libido. Table 1 outlines the advantages and disadvantages specific to each of these treatments.

Table 1. Advantages and disadvantages of hormonal treatment for prostate cancer
Treatment	Advantages	Disadvantages
Surgical castration	Simple outpatient procedure	Surgical risk, not reversible
Oral estrogens	Simple daily oral dose, inexpensive	Risk of exacerbating ischemic heart disease, stroke, deep venous thrombosis, pulmonary emboli
LHRH agonist therapy (leuprolide acetate [Lupron], goserelin acetate [Zoladex])	Nonsurgical, reversible	Expensive ($500/mo); usually given for duration of life
LHRH, luteinizing hormone-releasing hormone.

Because hormonal therapy does not adequately address the issue of adrenal androgen stimulation of prostate cancer, antiandrogens (ie, flutamide [Eulexin], nilutamide [Nilandron], bicalutamide [Casodex]) may be added for patients who show an incomplete response. Antiandrogens are commonly used because of their effect on PSA and clinical response, but no statistically significant difference has been shown in survival rates for men given adjunctive antiandrogen therapy compared with men treated with hormonal manipulation alone.

Intermittent hormonal ablation, consisting of LHRH agonists in combination with antiandrogens, is currently being investigated. This approach capitalizes on multiple cycles of cell regression and may prolong the androgen sensitivity status of the tumor (6). Physical examination and PSA level are used as benchmarks for reinstitution or cessation of therapy. Considerably fewer side effects occur with intermittent ablation, but its overall effectiveness has not yet been established.

Life expectancy, rather than biologic age, is used to guide both detection and treatment of prostate cancer in elderly men. Currently available information suggests that although small, well-differentiated prostate carcinomas can be safely observed, large, poorly differentiated carcinomas require treatment, even in very old patients.

Outlet obstruction
After age 70, about 90% of men have benign prostatic hyperplasia (BPH), but only 15% have clinically significant sequelae. BPH causes 90% of urinary retention in men; myotonic or hypotonic bladder makes up the remainder. Often, the size of the prostate is not proportional to the symptoms it causes, but size is very important in determining treatment. The differential diagnosis of BPH includes prostate cancer, urethral stricture, bladder neck contracture, meatal stenosis, and phimosis--all of which occur more often in elderly than in younger men.

Between the ages of 70 and 79, the 4-year risk of urinary retention in men with BPH is about 8.7% (7). Other significant sequelae of BPH include detrusor instability, infection, stone formation, bladder diverticula, and upper tract dilation with renal insufficiency (figure 1: not shown). As many as 7% of men with acute urinary retention subsequently have myotonic bladder, which often requires intermittent catheterization.

Obstructive symptoms, such as nocturia, a slow urine stream, intermittency, and double voiding, are generally evaluated through focused history taking, an international prostate symptom questionnaire (table 2), and a digital rectal examination, with or without serum PSA testing.

Table 2. International prostate symptom screening questionnaire
	Circle your numerical score for each question below.
1. Over the last month or so, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?	0	1	2	3	4	5
	Not at all	Less than 1 time in 5	Less than half the time	About half the time	More than half the time	Almost always
2. Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?	0	1	2	3	4	5
3. Over the past month or so, how often have you had to urinate again less than two hours after you finished urinating?	0	1	2	3	4	5
4. Over the past month or so, how often have you found that you stopped and started again several times when you urinated?	0	1	2	3	4	5
5. Over the past month or so, how often have you found it difficult to postpone urination?	0	1	2	3	4	5
6. Over the past month or so, how often have you had a weak urinary stream?	0	1	2	3	4	5
7. Over the past month or so, how often have you had to push or strain to begin urination?	0	1	2	3	4	5
Total symptom score = sum of questions 1 to 7 = ______ A score of 10 or less is considered subclinical.
Adapted from Barry MJ, Fowler FR Jr, O'Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 1992;148(5):1549-57.

As part of history taking, it is important to determine if there are any irritative symptoms, such as dysuria, strangury, and hematuria. Cystoscopic examination is essential in these patients because the differential diagnosis includes bladder cancer, stone formation, carcinoma in situ, and interstitial cystitis, as well as BPH.

Drug therapy with oral finasteride (Proscar) or alpha-blocking agents (table 3) is often the treatment choice for BPH. Finasteride (5 mg qd) is most effective in men with large prostates. It is a 5alpha-reductase inhibitor and can shrink the prostate by as much as 20% in volume. In addition, recent studies show that finasteride reduces the risk of acute urinary retention by 50% or more and decreases the need for surgical therapy by the same margin (8).

Table 3. Starting dosages of alpha-blocking agents for managing benign prostatic hypertrophy
Drug	Starting dosage
Tamsulosin hydrochloride (Flomax)	0.4 mg qd
Terazosin (Hytrin)	1 mg qd, adjusted up to 5 mg qd
Doxazosin mesylate (Cardura)	1 mg qd, adjusted up to 4 mg qd
Prazosin (Minipress)	1 mg bid

For men with smaller prostates, alpha blockade may be more effective because of the muscular component of the gland. The newest agent, tamsulosin hydrochloride (Flomax), acts mainly on alpha_1A receptor cells and may cause fewer peripheral vasodilatory symptoms. However, an uncommon but possible side effect is delayed or absent ejaculation. Alpha blockade does not result in prostatic shrinkage; rather, it relaxes the internal sphincter at the bladder neck and prostate.

Surgical management has traditionally been in the form of either transurethral prostatectomy for most men or suprapubic prostatectomy for those with extremely large prostates. Laser prostatectomy, transurethral vaporization of the prostate, microwave hyperthermia, and transurethral needle ablation are gaining acceptance because they can be done in outpatient settings, often under local anesthesia.

Urologic problems in women

Urinary incontinence, which is the most common urologic problem in older women, is responsible, at least in part, for about 50% of nursing home admissions (8). Between 15% and 30% of elderly women who live at home also have problems with incontinence.

Urinary incontinence
Incontinence can be thought of as "storage failure" caused by either sphincteric or detrusor mechanisms. Sphincteric causes include atrophic vaginitis, urethritis, trigonitis, intrinsic sphincter deficiency, and stress urinary incontinence. Detrusor causes are primarily related to detrusor instability but include chronic and acute urinary infection, bladder stone and tumor, and interstitial cystitis.

Pharmacologic agents also can cause urinary incontinence. Use of sedatives can lead to immobility and secondary poor urinary control. Antipsychotic, antidepressant, and antiparkinsonian agents have strong anticholinergic side effects and can cause retention and overflow incontinence. Alpha-blocking drugs can exacerbate intrinsic sphincter deficiency. In addition, diuretics and calcium channel blockers may be troublesome for patients who are in a sensitive compensatory state with incontinence.

Patients with mild to moderate incontinence require a simple evaluation. This consists of focused history taking that determines whether urgency incontinence or stress incontinence is involved. Urinalysis can rule out infection or hematuria. Physical examination should document atrophic vaginitis, significant bladder descensus, and retention.

If urgency incontinence is the primary problem, detrusor instability or atrophic changes due to a low estrogen level are the most likely causes. Treatment can begin with any of the following, alone or in combination: a behavioral bladder drill, a mild anticholinergic agent, or estrogen cream. If stress urinary incontinence is suspected, the first-line treatment is Kegel exercises and use of an estrogen cream.

Local conjugated estrogen therapy is important in this age-group because of endemic estrogen deficiency at the urethra and bladder neck. The simplest treatment is to have the patient apply a small amount of estrogen cream around the urethral meatus each night before going to bed. However, use of estrogen in women who have a history of breast cancer remains controversial.

Patients with severe incontinence and those who do not respond to these simple measures require cystometric studies and determination of leak-point pressure. These sophisticated tests often show one or a combination of the following five conditions: detrusor instability, urethral hypermobility, intrinsic sphincter deficiency, lower urinary tract obstruction, or myotonic bladder (9).

Treatment should be tailored to the cause of incontinence. Detrusor instability may first be managed by bladder drills, during which patients are instructed to restrict fluid intake by about 20% to 30% and to adhere to a strict written and timed voiding protocol. Once the patient has mastered a specific length of time (eg, 90 minutes) between voids, the time is increased by 15 or 30 minutes. Although use of behavioral therapy alone is controversial, it may have the potential to decrease episodes of incontinence by 80% or more (10).

Low-dose anticholinergics can be very helpful as adjunctive treatment when used on an as-needed basis. A low starting dose is important because of the sensitivity of elderly patients to dry mouth, confusion, and other central nervous system effects (table 4).

Table 4. Starting dosages of anticholinergic drugs for women with urinary incontinence
Drug	Starting dosage
Oxybutynin chloride (Ditropan)	2.5 mg bid
Oxybutynin sustained release (Ditropan XL)	5 mg qd
Tolterodine tartrate (Detrol)	2 mg qd
Hyoscyamine sulfate	0.125 mg bid
Propantheline bromide (Pro-Banthine)	7.5 mg bid

In patients who have combined detrusor instability and urethral hypermobility, amitriptyline hydrochloride (Elavil) can be useful because of its anticholinergic effect plus its mild alpha-agonist effect at the level of the bladder neck. Dosage should start at 10 mg twice daily.

Collagen injection therapy, an office procedure, is particularly useful in patients with intrinsic sphincter deficiency. The long-term positive response rate is about 75% (figure 2: not shown). Urethral resuspension procedures (eg, Marshall-Marchetti-Krantz, Burch) and transvaginal urethropexy are useful only in women with isolated urethral hypermobility.

The pubovaginal sling is recommended for severe intrinsic sphincter deficiency or combination urethral hypermobility and intrinsic sphincter deficiency. The sling procedure is quite successful but can cause urinary retention in the elderly and should be used selectively. Use of artificial sphincters is reserved for severe cases.

Management of indwelling catheters

On occasion, long-term catheterization is the only option for patients with intractable incontinence or chronic urinary retention. When an indwelling catheter is needed, special care can reduce the risk of long-term problems (see box below).

Silicone or silicone-coated catheters are recommended because of the lower risk of latex-induced irritability. The smallest catheter (14F or 16F) and the smallest balloon possible (5 mL) should be tried first. A small catheter allows for efflux of natural urethral ductal secretions, and smaller balloons prevent erosion of the bladder neck.

The catheter tubing is attached firmly but without tension to the thigh or the abdomen, and the attachment site is rotated each day. The drainage bag should be emptied at least three times a day, and the catheter and bag should be changed about every 6 weeks.

Obstruction can occur from urinary sediment. Therefore, it may be helpful to acidify the urine with oral vitamin C (500 mg qid). More frequent changes of the catheter or occasional irrigations with 0.25% acetic acid (1 part vinegar to 4 parts water) are necessary in some patients. Bladder spasms can be managed with low-dose anticholinergics (eg, oxybutynin chloride [Ditropan], 5 mg bid).

Routine cultures should not be done on urine from asymptomatic patients with indwelling Foley catheters. All of these patients have bacteriuria, and treatment is not required.

If the patient has a symptomatic urinary tract infection, the first step is to change the catheter and then obtain a culture through the new catheter. Treatment is based on culture results. However, nitrofurantoin (Macrobid, Macrodantin) or fluoroquinolones can be prescribed before culture results are received. These drugs have good uropathogen coverage with low incidence of resistance.

For patients with troublesome chronic infections, various agents (eg, 0.25% acetic acid or gentamicin [80 mg/500 mL isotonic sodium chloride solution]) can be instilled through the catheter and into the bladder in volumes of 2 oz twice a day. To prevent infection, it is useful to flush the drainage tubing each day with hydrogen peroxide. An antibiotic ointment placed around the urethral meatus twice a day makes the catheter interface with tissue more comfortable for the patient and may prevent ascending infection.

Chronic infection caused by the catheter may be secondary to occlusion of natural ductal secretions in the urethra. In addition, significant pain can occur when the catheter irritates the naturally sensitive anatomy. In these cases, a suprapubic catheter may be more comfortable. Suprapubic catheter placement is an outpatient procedure that takes as little as 10 minutes under local anesthesia.

Summary

Urologic problems in elderly patients often require special management that considers life expectancy, general health, and the clinical significance of the disorder. For men with prostate carcinoma or outlet obstruction, new therapies have proliferated in the last 10 years. For elderly women with incontinence, an orderly evaluation process usually results in directed and effective treatment. Finally, long-term use of Foley catheters requires careful attention to detail so that serious problems can be avoided.

References

1. Landis SH, Murray T, Bolden S, et al. Cancer statistics 1999. CA 1999;49(1):8-11
2. Stein B, Lindenmayer JM. Proposed prostate cancer screening recommendations. Medicine and Health/Rhode Island 1997;80(10):343-5
3. Chodak GW. The role of watchful waiting in the management of localized prostate cancer. J Urol 1994;152:1766-8
4. Partin AW, Kattan MW, Subong EN, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. JAMA 1997;277(18):1445-51
5. Medical Research Council Prostate Cancer Working Party Investigators Group. Immediate versus deferred treatment for advanced prostatic cancer: initial results of the medical research council trial. Br J Urol 1997;79:235-46
6. Gleave M, Goldenburg SL, Jones E, et al. Biochemical and pathological effects of eight months of neoadjuvant androgen withdrawal therapy: an update on 125 consecutive patients. (Abstr) J Urol 1997;157(4):390
7. McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. N Engl J Med 1998;338(9):557-63
8. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Clinical practice guideline, Number 2, 1996 update. Publication No. 96-0682, Rockville, MD.
9. Haab F, Zimmern PE, Leach GE. Female stress urinary incontinence due to intrinsic sphincter deficiency: recognition and management. J Urol 1996;156:3-17
10. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women. JAMA 1998;280(23):1995-2000

Checklist for long-term use of indwelling catheters

• Make sure catheter is silicone or silicone-coated
• Use smallest diameter of catheter possible (14F or 16F)
• Use smallest balloon possible (5 mL)
• Rotate attachment site each day
• Empty drainage bag three times a day
• Change catheter and bag every 6 weeks
• Use low-dose anticholinergics for bladder spasms
• Treat obstruction with oral vitamin C or 0.25% acetic acid catheter instillation
• Avoid routine cultures
• Treat only symptomatic urinary tract infections
• Consider suprapubic catheter placement if troublesome complications occur

Presented at a meeting of the Interstate Postgraduate Medical Association, San Diego.

Dr Reznicek is a urologic oncologist, Mercy Hospital, Cadillac, Michigan. Correspondence: Stephen B. Reznicek, MD, Mercy Hospital, 828 Oak St, Cadillac, MI 49601. E-mail: drl@netonecom.net.

Please send technical questions related to the Web site to Ann Harste