It is well recognized that the population of the United States is changing, as the proportion of older adults grows dramatically. Because disorders of the genitourinary system are particularly common in older adults, the specialty of urology will be significantly affected by these trends. Research is critically needed to provide data that will allow a better understanding of the unique nature of urologic disease in the older adult. This information will affect diagnostic and treatment interventions for older adults, particularly the role of urologic surgical therapy.

A comprehensive literature search was performed to identify literature relevant to geriatric urology. The search was conducted on the National Library of Medicine's PubMed database. The period covered was from 1985 to March 19, 2001. Older literature was included if it provided important historical or other unique information. Newer literature cited for some topics was added during manuscript revision, and results from searches for kidney and bladder neoplasms were also added. Several guidelines and consensus reviews regarding the evaluation and management of urinary incontinence, prostatic disease, and other genitourinary disorders provided pertinent information on the diagnosis and treatment of urologic conditions in older adults that was also extracted for this review.

  The search was limited to the English language, human subjects, and an age delineation of 65 years and older. The following six topics were initially searched: prostate disease, renal transplantation, sexual dysfunction, stone disease, urinary incontinence, and urinary tract infections.

  For the prostate, the search strategy combined terms for prostate radiology and surgery with terms for prostate diseases and procedures, age factors, postoperative care, outcomes, length of stay, functional status, and complications. This search resulted in 1519 references.

  For renal transplantation, the search strategy combined the term kidney transplantation with the terms for age factors and postoperative course, along with the terms reject, tissue donor, cadaveric donor, and patient selection. This search resulted in 1530 references.

  For sexual dysfunction, the search strategy used the terms hormone replacement therapy, testosterone, aged, sexual dysfunctions, sex disorders, libido, penile erection, and impotence. This search resulted in 1318 references.

  For stone disease, the search strategy combined the terms lithotripsy, urinary calculi, kidney calculi, and nephrostomy with the terms for age factors, postoperative care, outcomes, length of stay, functional status, and complications. This search resulted in 633 references.

  For urinary incontinence, the terms used were urinary incontinence, aged, and age factors combined with postoperative care, prognosis, outcome, length of stay, predict, forecast, recovery, functional status, and postoperative complications. This search retrieved 1042 items.

  For urinary tract infections, the search strategy was simply for the terms urinary tract infections and aged. It elicited 1132 references.

Background and Epidemiology

The epidemiology of incontinence in the geriatric population has been closely examined. Urinary incontinence is a very common disorder among older adults; it is estimated that between 15% and 35% of community-dwelling adults in the United States aged 60 or over suffer from urinary incontinence. ¹ The overall prevalence increases with age in both men and women. A recent survey of 10,458 community-dwelling men in Sweden revealed a linear relationship between the prevalence of urinary incontinence and age. ² The overall prevalence of urinary incontinence was found to be 6.1% at 65 years, 9.6% at 75 years, 21.8% for those between 85 and 89, and 28.2% for those aged 90 years and over. A similar study in a cohort of 7949 older women with a mean age of 76.9 ± 5.0 years revealed that 41% reported urinary incontinence, with 14% suffering from daily incontinent episodes. ³ This latter study found the prevalence of urinary incontinence to be strongly associated with age, using multivariate regression analysis (odds ratio [OR] 1.3 per 5 years, 95% CI [confidence interval] 1.2 to 1.5). The authors also found that some common conditions associated with aging are strongly correlated with increased incontinence; these include prior hysterectomy, obesity, history of stroke, chronic obstructive pulmonary disease, diminished gait speed, and poor overall health. This finding supports prior studies that have also demonstrated the relationships between urinary incontinence and other chronic disorders associated with increasing age. ⁴

  Urinary incontinence can have significant negative impact on self-esteem and has been associated with increased rates of depression. ^5,6 Incontinence also affects social aspects of quality of life and activities of daily living. ^7,8 It may result in increased dependence on caregivers. Survey data suggest that at least 50% of homebound older adults suffer from urinary incontinence. ⁹ Those who are incontinent demonstrate significant impairments in social interaction. ¹⁰

  Incontinence has been identified as one of the major risk factors that in the United States leads to nursing-home admission, and this relationship has been extensively studied. Using data from the Longitudinal Study on Aging, Coward et al learned that incontinent people in less urbanized or populous areas are more at risk for nursing-home admission than are those in more populous areas. ¹¹ A relative lack of community support services may explain this finding. Other geriatric syndromes that are associated with urinary incontinence can significantly increase the risk of functional dependence. In particular, cognitive impairment and gait abnormalities have been linked to increased rates of both isolated urinary incontinence and combined urinary and fecal incontinence. ^12,13 Tinetti et al demonstrated a strong association between urinary incontinence and an increased risk of falls. ¹⁴ Seidel et al looked at the relationship between cognition and continence status in an attempt to predict discharge placement after inpatient rehabilitation. ¹⁵ They found that analysis of continence and cognitive status at the time of admission to rehabilitation services allows prediction of continence status at discharge that could impact placement decisions.

  Even those who are continent at the time of admission to a nursing home have been shown to be at significantly increased risk for the development of urinary incontinence. The estimated incidence of new-onset urinary incontinence in nursing-home residents is approximately 27% per year. ¹⁶ However, age itself has not been identified as a risk factor. In a review of 434 nursing-home residents, Palmer et al identified incontinent episodes or poor behavioral adjustment within 2 weeks of admission, male gender, dementia, or impaired mobility within 2 months as significant risk factors for chronic incontinence in nursing-home residents. ¹⁷

Although urinary incontinence has been operationally defined in a variety of ways, the central feature is considered to be the involuntary loss of urine. This may be either acute or chronic. Urinary incontinence that is acute in onset is often transient and is typically caused by nonurologic factors such as fecal impaction, delirium, or polypharmacy. Correction of the underlying problem often leads to resolution of the urinary incontinence.

  There are a variety of forms of chronic urinary incontinence, including stress incontinence, urge incontinence, overflow incontinence, and functional incontinence. Mixed patterns are very common. Determining the type of urinary incontinence an individual has is critically important because type influences the choice and success of a given therapy. Surgical therapies are commonly used to treat stress incontinence and selected patients with urge incontinence.

  Stress incontinence is caused by a decrease in outlet resistance at the level of the bladder neck. Leakage occurs when the pressure in the bladder exceeds the outlet closure pressure. Patients describe episodes of incontinence with activities that increase intra-abdominal pressure, such as coughing, sneezing, or laughing. This may be caused by either urethral hypermobility or intrinsic sphincter deficiency. Research has suggested that apoptosis of the rhabdosphincter cells may be one of the primary causes of sphincteric dysfunction in older adults. ^19,20

  Urge incontinence is typically caused by overactivity of the detrusor muscles in the bladder wall. Abnormal contractions during bladder filling lead to a sensation of urgency, and if strong enough, these contractions may cause urinary leakage. Urge incontinence is often associated with neurologic disorders, such as prior stroke.

  Overflow incontinence is caused by an inability to completely empty the bladder with each voiding attempt. This is often caused by poor detrusor contractility and may be associated with chronic conditions such as diabetes mellitus and some neurologic disorders. Patients typically describe constant dribbling incontinence caused by leakage from the full bladder. Sensation is often diminished, and patients may not sense an elevated postvoid residual volume.

  A unique form of incontinence in the elderly population is detrusor hyperactivity with impaired contractility. ²¹ This is essentially a combination of urge and overflow incontinence. In these cases, the bladder demonstrates abnormal contractions with filling but diminished contractile function during the voiding effort. It is particularly common in frail elderly persons.

  Functional incontinence refers to loss of independent urinary control caused by other functional limitations, such as diminished mobility or cognition. Common causes of mobility limitations include arthritis and gait disturbances. Urinary incontinence seen in people with dementia is often functional in origin.

The evaluation of the patient with urinary incontinence must begin with a detailed history and physical examination. This provides the most valuable information for diagnosis and therapeutic planning. However, a variety of other techniques have been developed, ranging from validated survey instruments to predictive algorithms and sophisticated urodynamic tests. Although these tools are widely employed in the evaluation of the incontinent patient, few studies have examined their utility specifically for the older adult. ^22,23

  A large number of both self- and interviewer-administered survey instruments have been designed to assess types and degrees of urinary incontinence. However, there is no clear consensus about which instruments are best or should be used particularly in the geriatric population. One study demonstrated that brief questionnaires may be inaccurate and tend to correlate poorly with urodynamic findings in older adults. ²⁴

Biobehavioral Therapies. A variety of biobehavioral therapies have been developed to address urinary incontinence, including bladder retraining, pelvic floor muscle exercises, and prompted or assisted voiding routines. These conservative therapies are usually recommended as first-line treatment options, particularly for geriatric patients. ^25,31 Although they have been shown to be effective in general, few have been studied in elderly persons. ³² In addition, interpretation and generalization is often difficult because many studies include a heterogeneous population with various forms of urinary incontinence. ³¹

  Wyman et al performed a randomized clinical trial comparing bladder training with scheduled toileting, pelvic floor muscle exercises, and a combination of the two techniques; their subjects were 204 women with a mean age of 61 ± 10 years who were suffering from stress or urge incontinence, or both. ³³ After a 12-week intervention program, the group using the combined treatments was found to have significantly fewer incontinent episodes than did groups using either technique alone. However, at 3-month follow-up, there was no significant difference between groups, suggesting that enrollment in a structured intervention program may be more important than the exact protocol. In a single-arm trial, Publicover and Bear examined the utility of scheduled voiding with weekly clinician counseling. ³⁴ In a group of 19 women aged 64 to 88 years (mean age 75.2), they found that behavioral intervention significantly reduces the number of urinary incontinent episodes during treatment and at 6-month follow-up. The causes and types of incontinence were not defined in this study.

  Prompted voiding techniques have also been developed and used successfully with nursing-home residents. ³⁵ Ouslander et al demonstrated an overall response rate of 41% in a cohort of 191 elderly incontinent nursing-home residents (mean age 84.5 years) who underwent a prompted toilet training program. ³⁶ These researchers found that the overall wet percentage went from 26.7% to 6.4% and was sustained at 9.6% after 9 weeks.

Future studies need to include standardized operational definitions for urinary incontinence, a clear separation of the types of incontinence included in the study population, and requirements for patient inclusion and exclusion.

  Although a number of survey instruments are currently used to evaluate patients with incontinence, few have been developed or validated for use in older adults. In the area of diagnostic evaluation, there is a need to better define the role of formal urodynamic testing, including videourodynamics in the assessment of older patients with urinary incontinence. This is particularly important for those considered as surgical candidates.

  Urinary incontinence and pelvic organ prolapse often coexist in older women. Additional research on the diagnosis and management of prolapse in older women is needed, particularly to help define the role of surgical therapy in this population.

  Several sets of clinical guidelines have been developed for the evaluation and management of urinary incontinence. Formal outcomes research is needed to identify the utility of these guidelines in both institutionalized and community-dwelling older adults.

  Although there has been some research examining the association between urinary incontinence and other chronic health conditions in older adults, more work is needed to better understand these complex interactions. Examination of the relationship between urinary incontinence and other functional impairments, such as cognitive and physical limitations, will be particularly important. Urinary incontinence is commonly associated with chronic neurologic conditions, such as stroke, Parkinson's disease, multiple sclerosis, and Alzheimer's disease. The urologic implications of these disorders, particularly for rehabilitation outcomes, are still relatively poorly understood. In addition, there is a need for additional work on the urologic outcomes in geriatric patients with spinal cord injuries.

  Research on behavioral techniques and pharmacotherapy for urinary incontinence must include older adult subjects. Ideally, these treatments should be analyzed for evidence of age-related effects. Studies should also include a variety of subjects, including community-dwelling older adults and people residing in assisted-living and long-term-care environments.

  Studies regarding surgical therapy for urinary incontinence should examine outcomes, including potential complications in older adults. Although short-term studies are necessary to begin this work, long-term data will be required to fully evaluate the risks and benefits of anti-incontinence surgeries in older patients. Ideally, this would include 5- to 10-year follow-up with both subjective and objective outcomes measures. Standard surgical techniques, such as injection of bulking agents at the bladder neck, bladder neck suspension procedures, pubovaginal sling cystourethropexy, and artificial urinary sphincter placement, need to be examined in older patient populations in a prospective fashion, with an appropriate length of follow-up.

  New anti-incontinence surgical techniques are being developed for both men and women. Many of these procedures are minimally invasive, and they have the potential to offer good clinical outcomes with less surgical risk. However, they need to be studied in comparison with currently accepted procedures. Prospective randomized trials that include older adults in a subgroup analysis would be the ideal. Innovative surgical techniques for urge incontinence such as sacral nerve stimulator implantation also need to be studied in a prospective fashion in this patient population.

Urol 2 (Level B): Studies are needed to establish the validity of new and existing survey instruments to assess the types and degrees of urinary incontinence in older adults.

Urol 3 (Level B): Systematic prospective cohort or case-control studies are needed to determine whether urodynamic and imaging techniques are associated with better outcomes in urinary incontinence in older patients.

Urol 4 (Level A): Depending on the results of studies of the impact of urodynamic and imaging techniques on outcomes (Urol 3), the effect of particular urodynamic or imaging studies on the accuracy of diagnosis and outcomes of treatment should be assessed in randomized controlled trials.

Urol 5 (Level A): Further randomized controlled trials are needed to test the efficacy and safety of both new and established anticholinergic drugs for the management of urinary incontinence in older adults.

Urol 6 (Level A): Randomized controlled trials with large numbers of subjects will be required to determine whether acupuncture or other complementary therapies have a significant beneficial effect in treating urge or mixed urinary incontinence in older patients.

Urol 7 (Level A): The bladder neck suspension and sling procedures have been proven effective in older women studied an average of 17 months after surgery. Prospective cohort studies with longer-term follow-up periods are needed to determine whether these procedures have sustained longevity.

Urol 8 (Level B): Prospective cohort studies are needed to explore the factors that identify which elderly patients will do better with early surgical intervention than with more conservative treatment options.

Urol 9 (Level A): Performing randomized controlled trials to extend the studies of factors that identify appropriate candidates for early surgery for incontinence could lead to the development and validation of predictive models useful for guiding treatment decisions for various types of urinary incontinence in older patients (see also Key Research Questions in Geriatric Urology, end of chapter).

UTIs and asymptomatic bacteruria are common in older adults, particularly those in long-term-care settings. Although there is consensus that symptomatic infections should be treated with antibiotics, the implications of recurrent infections and asymptomatic bacteruria on long-term morbidity and mortality outcomes are more controversial. In a prospective cohort study of 1491 women, Abrutyn et al did not find UTI to be a risk factor for mortality. ⁵² In contrast, they did find age and poor self-reported health status to be significant predictors of mortality. However, a previous longitudinal cohort study of 1148 men and women reported by Nordenstam et al did demonstrate a significant increase in 5-year mortality for men with bacteruria. ⁵³ The similar finding in women disappeared when those with indwelling catheters were excluded from the analysis. In contrast, Nicolle et al reported no significant survival difference between men with and without asymptomatic bacteruria. ⁵⁴

  Bacteruria has been shown to be a transient phenomenon in older adults. Monane et al performed a prospective observational study on 61 women. ⁵⁵ Subjects included both community-dwelling persons and long-term-care residents. The researchers found asymptomatic bacteruria to be present in 20% of all urine samples and in one third of all subjects over 6 months of follow-up. Variation was seen on a month-by-month basis, with frequent spontaneous alterations in positive and negative specimens.

  These data support the consensus that asymptomatic bacteruria in the older adult does not usually warrant initiation of antibiotic therapy. In a randomized trial of antibiotic treatment for 50 institutionalized elderly women (mean age 83.4 ± 8.8 years) with asymptomatic bacteruria, Nicolle et al found no short-term benefits to be associated with therapy. However, they did identify increased long-term risks, including reinfection with resistant organisms. ⁵⁶ Similarly, Ouslander et al found that treating asymptomatic bacteruria in institutionalized elderly women does not improve rates of chronic urinary incontinence. ⁵⁷

  Bacteruria is also commonly associated with chronic indwelling catheter use and typically does not require treatment. However, UTIs associated with short-term catheterization of less than 2 weeks in older adults should be addressed. In a prospective randomized controlled trial, Harding et al examined the role of antibiotic therapy in a group of 119 women with catheter-acquired UTIs ⁵⁸ and found that infections resolve spontaneously more often in younger women than in those aged 65 years or older (89% versus 62%;P < .001). They also found that single-dose antibiotic therapy is generally effective, although more so in the younger women.

  Raz et al examined the risk factors associated with recurrent UTI in a case-control study of 149 postmenopausal women referred for evaluation and treatment of UTIs. ⁵⁹ Compared with the 53 age-matched control subjects, the case subjects tended to have at least one of three common urologic conditions believed to predispose them to infection: urinary incontinence (41% versus 9%, P < .001), cystocele (19% versus 0%, P < .001), and elevated postvoid residual urine volume (28% versus 2%, P < .001). Age was not identified as a significant risk factor in this study.

  Two studies have shown the prevalence of UTI in hip fracture patients to be approximately 23% to 25%. ^60,61 Catheterization was not found to be a significant risk factor. However, female gender, prior history of UTIs, poor general medical health, and delay in operative treatment of the fracture were found to be predictors of UTI. The identification and treatment of UTIs in this patient population are also important to help prevent potential infection of implanted orthopedic prostheses.

  Vaginal estrogen replacement has long been a mainstay of therapy for the prevention of recurrent UTIs in postmenopausal women. ⁶² Many patients find cream-based preparations messy and uncomfortable. A recent randomized open, parallel study by Eriksen revealed good response to an estrogen-impregnated vaginal device (Estring). ⁶³ Its use has not been studied in a geriatric population; however, improved satisfaction could lead to increased adherence by older patients.

  Cranberry juice and other cranberry preparations have long been used as prophylactic treatments for recurrent UTIs. It is hypothesized that cranberries contain compounds that prevent bacterial adhesion to the urothelium. Studies support the prophylactic use of cranberry products, particularly in institutionalized older adults. ⁶⁴ Avorn et al performed a randomized, double-blind, placebo-controlled trial with 153 older women (mean age 78.5 years). ⁶⁵ Consumption of 300 mL of cranberry juice each day was found to reduce the odds of clinically significant bacteriuria (≥ 10⁵ organisms) with associated pyuria to 42% of that seen in the control subjects (P = .004). In another study, Kontiokari et al compared consumption of cranberry-lingonberry juice, Lactobacillus GG, and placebo in a group of 150 women previously diagnosed with acute Escherichia coli UTIs. ⁶⁶ They found a 20% reduction in the absolute risk of recurrent UTI (defined as a urine culture with ≥ 10⁵ colony-forming units of bacteria) for the women who drank the juice in comparison with the control group (P = .023, 95% CI = 3% to 36%). The recurrence rate for those who consumed Lactobacillus did not differ from that of the control group in this series.

  Most research on UTIs in older adults has examined patient risk factors and the bacteriology associated with infection. Studies are often confusing because they lack detailed information on what constitutes an infection. The definition of asymptomatic bacteruria is especially a problem. Future research studies must clearly state the inclusion and exclusion criteria used for subject selection.

Urol 11 (Level B): The natural history and potential risks of urinary tract infection or asymptomatic bacteruria and forms of preventive therapy warrant further study (see Key Research Questions in Geriatric Urology, end of chapter).

Urol 12 (Level A): Research on new antibiotic agents for the treatment of urinary tract infection should include randomized controlled trials specifically designed to assess the safety and efficacy of these drugs in geriatric patient populations.

BPH is caused by a proliferation of the stromal components of the prostate, typically beginning after age 40 and leading to functional obstructive changes. The development of lower urinary tract voiding symptoms in men appears to be related to this hyperplastic aging process. In a cross-sectional analysis of 1557 men (mean age 51.3 years, range 40 to 96), Haidinger et al found that increasing age is an independent risk factor for onset of symptoms. ⁶⁷ Other studies have supported this finding but suggest that age does not influence the outcome of subsequent surgery for BPH. ⁶⁸ Interestingly, symptoms such as urinary urgency and frequency have also been found to be correlated with increasing age in women, but outlet obstruction is uncommon. In a prospective cohort analysis of 2280 men followed for almost 25 years, the development of obstructive voiding symptoms such as urgency, frequency, hesitancy, decreased force and caliber of urinary stream, and nocturia was found to be highly predictive of the need for prostate surgery, and the risk varies significantly by age. ⁶⁹ These authors found that men aged 62 to 68 years are more likely than their younger counterparts to require surgery.

  Over the past 15 years there has been a general shift from surgical to medical therapy as the preferred initial treatment for most patients with BPH. The development of safe, clinically effective pharmacologic agents, including α₁-adrenoceptor antagonists such as doxazosin, terazosin, and tamsulosin, and 5-α-reductase inhibitors such as finasteride, has led to a decline in rates of surgery for BPH. ^70-72 Breslin et al reviewed a series of 1822 BPH patients in a single private practice between July 1, 1987 and June 30, 1991 and determined that the rate of surgery dropped from 28% in the first year of the study to 8% in the last year. ⁷³ This matches the timing of the increased acceptance and use of pharmacotherapy for the treatment of BPH. In a review of the Medicare database, Holtgrewe identified a 30% decline in surgery for BPH despite an increase in the number of older men enrolled in the program. ⁷⁴

  Phytotherapy has recently gained popularity as a medical treatment option for BPH. Several compounds have been used, including Pygeum africanum, Hypoxis rooperi, and Serenoa repens. There have been few randomized controlled trials of these types of agents, and research is complicated by the lack of standardization in the preparation of most of these compounds. A recent meta-analysis by Wilt et al examined data from 18 trials involving 2939 men. ⁷⁵ They found an improvement in obstructive urinary symptoms with many different phytotherapy preparations. However, most studies have limited follow-up of less than 1 year, and none targeted geriatric patients. ⁷⁶

  Despite the increase in the use of pharmacotherapy for the treatment of BPH, some patients ultimately require surgical intervention. Several studies support the fact that surgical therapy for BPH, such as transurethral resection of the prostate (TURP), is generally well tolerated even by elderly patients. A study by Concato et al revealed that, after adjusting for age and severity of comorbidity, there is no difference in 5-year mortality between older men undergoing TURP and those undergoing open surgery. ⁷⁷ Ibrahim et al also showed that there is no increase in morbidity or mortality with advancing patient age for men undergoing surgery for BPH. ⁷⁸ Improvements in surgical technique have decreased operative times and the associated risks, such as hyponatremia due to absorption of large volumes of irrigation fluid used in surgery. ⁷⁹ In a retrospective analysis of 229 men between the ages of 80 and 97, Ilkjaer et al found that overall outcomes from TURP are excellent. ⁸⁰ In this study, the perioperative mortality rate was 2%, and complications such as UTI or bleeding occurred in 21%. These data match historical control data on younger subjects. ⁷⁹ In long-term follow-up (range 6 to 16 years), the overall satisfaction rate was excellent, at 86%. In a separate retrospective population-based study of 621 men undergoing TURP for treatment of BPH, Pientka et al found that age is not a risk factor for perioperative morbidity or mortality. ⁸¹ This was found to be true for both those with and without significant underlying comorbidities.

  Alterations in sexual function have been reported after TURP for treatment of BPH. However, age may also influence these clinical outcomes. In an analysis of postpro-statectomy sexual adjustment in 72 men aged 50 to 79 years (mean age 65 years), Libman et al found age to be a significant risk factor for postoperative erectile dysfunction. ⁸²

Age has clearly been identified as a risk factor for the development of prostate cancer. Early detection is possible in most cases by the use of a combination of serum prostate-specific antigen (PSA) testing and digital rectal examination. The American Cancer Society currently recommends annual screening examination using the combination of PSA and digital rectal examination for men aged 50 and over who have a life expectancy of at least 10 years. ⁸⁶ Men in high-risk groups, including black Americans and those with a first-degree relative with prostate cancer, should begin screening at 40 to 45 years of age.

  Using data from the Baltimore Longitudinal Study of Aging, Carter et al have reported that biennial testing in older men may provide similar results in terms of cancer detection at a significant cost savings. ⁸⁷ The age at which annual prostate cancer screening may be suspended is much more controversial. Most urologists agree that patients need an estimated 10-year life expectancy to justify definitive therapy for localized prostate cancer, such as radical prostatectomy or radiation therapy. The median current life expectancy for men in the United States who have reached age 65 is estimated to be approximately 82 years. Therefore, one could argue to continue screening with annual PSA and rectal examination into the mid-70s for many men. However, this has not been adequately examined. It is currently recommended that the risks and benefits of screening and the possible need for treatment be discussed with elderly men prior to making decisions about screening. ^88,89

  PSA levels appear to correlate directly with increasing age, and some authors have argued for the use of age-adjusted normal ranges for interpretation of results. ⁹⁰ However, other authors disagree. In a study of 773 men, Catalona et al found that age-specific PSA cutoffs enhance specificity but lack appropriate sensitivity. ⁹¹ They found that 20% to 60% of cancer in men aged 60 and over would have been missed with the use of age-specific PSA norms.

  Age may also influence the choice of treatments for prostate cancer. Many urologic surgeons are reluctant to perform radical prostatectomy on patients aged 70 years and over. However, recent literature suggests that projected life expectancy may be a more useful diagnostic criterion for surgical selection than patient age alone. ⁹² However, the best methods to establish projected life expectancy have not been definitively established. It has been shown that surgical therapy is generally well tolerated by elderly men if they are carefully selected and screened for comorbid disease. ^93,94 However, this must be balanced with data that identify increased age at the time of diagnosis as a strong predictor of a decreased probability of surgically curable prostate cancer. ⁹⁵

  Age also appears to affect patient choices about treatment options. In a study using a convenience sample of 163 men seen at an urban Veterans Affairs Medical Center, Mazur and Merz found that patients were willing to trade off complications from surgery for increased potential cancer survival. ⁹⁶ Mean patient age was 65.2 years (range 35 to 84). Overall, 62% of the patients were willing to accept a 100% chance of postoperative urinary incontinence and 83% were willing to accept a 100% chance of erectile dysfunction for better 5-year survival. Age influences the results; older subjects are less willing to accept complications for increased survival. In a similar trial, these authors also reported that older patients are more willing to accept expectant management than radical surgery. ⁹⁷ These results were found to be influenced by age within the context of pre-existing urologic conditions. Subjects with current urinary dribbling or incontinence or sexual dysfunction were found to be much more likely to prefer expectant management over surgery.

  Outcomes and complications may differ with patient age. Kerr and Zincke reported a significantly higher rate of postoperative urinary incontinence in elderly men after radical prostatectomy. ⁹⁸ They compared outcomes from 191 men aged 55 years or younger at the time of surgery with 51 men who were aged 75 years or older. In this retrospective cohort analysis, 16% of the elderly patients but only 3% of the younger patients reported significant urinary incontinence (P = .001). A large population-based study of Medicare claims data for 101,604 men revealed that there is an increase in 30-day mortality after radical prostatectomy that is associated with age (< 0.5% for men aged 65 to 69 years, and approximately 1% for men aged 75 years and older). ⁹⁹

  Disease-free survival may also be influenced by patient age at the time of surgery. In a retrospective study of 489 consecutive men treated with radical prostatectomy, öbek et al reported that age may be an independent prognostic factor for the risk of biochemical recurrence. ¹⁰⁰ At a mean follow-up of 25.4 months, 12% of those 70 years or younger but 25% of older men were found to demonstrate rising PSA levels (P = .01). The researchers also found that younger age is associated with a longer time to recurrence (P < .02).

  The effects of surgical intervention for localized prostate cancer on general and disease-specific quality of life can be substantial. In a cross-sectional analysis of 528 managed-care enrollees, Litwin et al found significant impairment in health-related quality of life for men who underwent radical prostatectomy. ¹⁰¹ This was found to occur even after adjusting for age and pre-existing urinary and sexual dysfunction. Stanford et al reported similar results in a population-based longitudinal cohort of 1291 men who underwent radical prostatectomy with 24-month follow-up. ¹⁰² Patients aged 65 to 74 years constituted 40.9% of subjects, and 2.8% were between ages 75 and 79. Urinary and sexual dysfunction side effects were found to be more common in the older men and to lead to a decrease in quality of life.

  Changes in quality of life have also been reported in men with metastatic prostate cancer. Hormonal manipulation with either surgical or medical androgen ablation is commonly used in the treatment of these men. Litwin et al reported that there is no significant difference in health-related quality of life in elderly men (mean age 71.2 to 75.4 years) treated with orchiectomy and those receiving pharmacologic agents for androgen ablation. ¹⁰³ Survival data have historically been equivalent between these treatment options.

Although there has been a large amount of research on prostate diseases, including both BPH and prostate cancer, relatively few studies have targeted geriatric patients. The greatest advances have come in the understanding of the pathophysiology of prostate disorders and the relationship to the normal aging process. Currently, there is a strong focus on the molecular biology of prostate disease and possible preventive therapies. Studies of new technology, such as gene therapy for BPH and prostate cancer, should include prospective research with older men.

  Pharmacotherapy for BPH has certainly changed the initial approach to this disorder for most patients. As new, more uroselective products are developed for the treatment of BPH, they must be tested for safety and efficacy in older men. Phytotherapy is becoming quite popular, and additional research is needed to better understand the pharmacologic mechanisms of these products. Randomized placebo-controlled trials will be needed to establish outcomes data, particularly for older adults.

  Research has established the safety and efficacy of TURP surgical therapy for BPH, even in quite elderly men. Research on new, less invasive surgical techniques needs to examine clinical outcomes, including complications, in older men. Results must be compared with the current gold standard, TURP, and studies should ideally be randomized. Future research on both surgical and nonsurgical therapies for BPH must also include an analysis of cost and the impact on health-related quality of life.

  The optimal treatments for localized and metastatic prostate cancer in elderly men remain controversial. The biological nature of prostate cancer is unique in that it is generally a slow-growing tumor. Therefore, it will be critical that future clinical research studies include adequate long-term follow-up of at least 5 to 10 years.

  A large amount of research has focused on the role of screening for prostate cancer by the use of PSA testing and rectal examination. It is now widely accepted that patients should have a projected life expectancy of at least 10 years to be considered for definitive treatment of localized prostate cancer with either radical prostatectomy or radiation therapy. Most research on life expectancy is population based. However, in order to use this 10-year clinical criterion, we need to develop better models for prediction of life expectancy for individuals. There is also no clear consensus regarding when routine screening in older men may be discontinued. Studies to identify the risks and benefits of continued screening, including potential costs and complications from screening and treatment, will be needed to answer this question. Decision-analysis models that include patients' desires regarding evaluation and treatment may be helpful in this regard.

Urol 14 (Level A): Randomized trials in elderly men are needed to compare minimally invasive surgical therapies for benign prostatic hyperplasia with the gold standard procedure, transurethral resection of the prostate.

Urol 15 (Level A): Randomized controlled trials are needed to compare outcomes of early transurethral resection of the prostate with outcomes of initial medical therapy followed by subsequent transurethral resection of the prostate when clinically necessary.

Urol 16 (Level B): Prospective cohort studies and decision-analysis models are needed to identify the characteristics that predispose an older patient with benign prostatic hyperplasia to benefit from early transurethral resection of the prostate (see Key Research Questions in Geriatric Urology, end of chapter).

Urol 17 (Level B): Because screening for prostate cancer is so widespread, it may be very difficult to design a randomized controlled trial comparing prostate-specific antigen screening with rectal examination alone, using risks, benefits, and costs as outcome measures. Therefore, the decision as to when to stop routine screening for prostate cancer in elderly men may depend on prospective cohort studies.

Urol 18 (Level A): Because there is so much uncertainty regarding the best treatment plan for localized or locally metastatic prostate cancer, it is justified and indeed necessary to design randomized clinical trials in large populations of elderly men, with subgroup analyses, to examine the effects of clinical characteristics on treatment decisions.

Bladder cancer and renal malignancies, including both renal cell carcinomas and transitional cell carcinomas of the upper urinary tract, are more common in older than in younger adults. However, the natural history, pathophysiology, and long-term treatment outcomes of these disorders have not been extensively studied in older adults.

  Transitional cell carcinoma is the most common malignant tumor of the urinary bladder in the United States. Superficial tumors are usually treated by endoscopic resection. However, the overall recurrence rate is up to 70%, and long-term surveillance is recommended to identify recurrent disease. Adjuvant intravesical chemotherapy or immunotherapy with Bacillus-Calmette-Guerin is commonly used to treat recurrences. In contrast, the standard treatment for muscle-invasive bladder cancer is radical cystectomy and urinary diversion. This major surgery may be associated with significant risk of perioperative morbidity and mortality. Research has shown that radical cystectomy with urinary diversion can be safely performed in elderly patients; however, the long-term outcomes have not been assessed. ^104-107 In particular, the effects of such major surgery on activities of daily living, instrumental activities of daily living, and overall rehabilitation status in older adults have not been clearly identified. The efficacy of less invasive forms of surgical therapy, including partial cystectomy or aggressive endoscopic resection with adjuvant radiation or chemotherapy, has not been studied in older adults.

  Renal and adrenal malignancies, particularly small, incidentally detected tumors, are also more common in older adults. However, the natural history of these types of tumors, particularly in elderly patients, needs additional study. ¹⁰⁸ Renal and adrenal tumors are often chemo- and radioresistant. Traditional surgical therapies for these types of tumors include radical nephrectomy, nephroureterectomy, or adrenalectomy. Newer, less invasive techniques such as laparoscopic surgery, cryotherapy, and nephron-sparing surgery have been used in older adults and may offer the promise of reduced morbidity. ¹⁰⁹

Urol 20 (Level A): Predictive outcomes models to identify who would most benefit from the various forms of therapy for bladder and renal malignancies need to be developed and validated (see Key Research Questions in Geriatric Urology, end of chapter).

The prevalence of sexual complaints increases with age. Panser et al conducted a population-based cross-sectional study of 2115 men and found that, in comparison with men aged 40 to 49 years, older men (70 to 79 years) are more worried about their overall sexual function (24.9% versus 46.6%) and report that they experienced worse actual performance over the past year. ¹¹⁰ The older men also have rated higher levels of dissatisfaction, decreased libido, and impaired erectile function. However, in a multivariate analysis, age itself was not found to be an independent predictor of the results. On the basis of survey results from a convenience sample of 1680 men in different geographic locations, Jφnler et al confirmed that the prevalence of erectile dysfunction increases with age. ¹¹¹ In an analysis of data from the Massachusetts Male Aging Study, Johannes et al reported the crude incidence rate for erectile dysfunction to be 25.9 cases per 1000 man-years (95%CI = 22.5 to 29.9). ¹¹² The incidence increases significantly with increasing age, with 12.4, 29.8, and 46.4 cases per 1000 man-years for men in their 40s, 50s, and 60s, respectively. They also found that other risk factors for erectile dysfunction include lower education as well as comorbid disease, such as diabetes mellitus, heart disease, and hypertension.

  Diabetes and use of hydrogen-blocker medications for the treatment of gastric acidity and reflux were found to be significant risk factors for erectile dysfunction (relative risk [RR] for both, 2.3) in a cross-sectional survey study of older men by Helgason et al. ¹¹³ They also identified prostate cancer as a significant risk factor (RR 1.9). However, they did not conclude that age itself is a risk factor. Despite these increases in the prevalence of sexual dysfunction, older men remain interested in sexual function and activity. ¹¹⁴ A similar trend has been documented in a small convenience survey of older men residing in long-term-care facilities. ¹¹⁵ Sexual dysfunction in older adults has been associated with a decreased quality of life and mental health impairment, including depression. ^116-118

Several studies have presented early data to suggest that most sexual dysfunction in older adults is related to the effects of other chronic comorbid diseases rather than normal aging alone. ¹²⁶ The most common associated disorders include hypertension, diabetes mellitus, atherosclerosis, and other diseases of the cardiovascular system. ^127-131 Associated changes in penile vasculature lead to impairment of penile blood flow and subsequent erectile dysfunction. Sexual dysfunction related to impaired penile blood flow is also a side effect of many antihypertensive medications, particularly those containing Β-blockers.

  Chronic pain is associated with an increased rate of sexual dysfunction and may be associated with the concomitant increase in depressive symptoms in chronic pain patients. ¹³² Similarly, patients with end-stage renal disease on peritoneal dialysis display increased rates of sexual dysfunction, depression, and impaired quality of life. ¹³³ Gastrointestinal and urinary diversion surgeries are common in older adults for treatment of bladder and bowel cancers. Ostomy patients typically report poorer quality of life and limitations in sexual function than do patients without a stoma. ^134-136 These changes are often caused by impaired body image and lack of knowledge about techniques to improve sexual function despite these handicaps.

  Studies of the relationship between sleep apnea and sexual dysfunction have provided conflicting data. Karacan and Karatas examined 22 men with sleep apnea (mean age 54, range 27 to 73) and found that erectile function improved in one third of the men with use of continuous positive airway pressure. ¹³⁷ However, Schiavi et al did not find sleep apnea to be a significant risk for erectile dysfunction in a similar cohort of 70 men aged 45 to 75 years. ¹³⁸

  Neurologic disorders are very common in older adults, and in retrospective cohort studies several have been associated with impaired sexual function. Stroke appears to be a cause of significant sexual dysfunction in both men and women. ¹³⁹ Right hemispheric stroke appears to cause greater impairments than left hemispheric stroke. ¹⁴⁰ It must also be remembered that any sexual dysfunction will affect both the individual patient and his or her partner(s). ¹⁴¹ Parkinson's disease is also associated with sexual dysfunction. In a cohort study of 50 subjects (mean age 67.3 years) with evidence of autonomic nervous system dysfunction, Koller et al found a 70% rate of sexual impairment. ¹⁴²

Research on sexual function and dysfunction in older adults has focused primarily on basic physiology and pathophysiology. The general associations between chronic disorders such as diabetes mellitus and vascular disease have been identified, but more work will be needed to examine these complex relationships. The development of new diagnostic and therapeutic options must include prospective analysis of utility in older adults. Potential side effects of therapy must be carefully examined. For example, currently used oral medications have potential interactions with other drugs that may lead to cardiovascular complications. Critical outcomes analysis in older persons will be needed to determine safety and efficacy of new products.

  The physiology of sexual function and dysfunction in older women is very poorly understood. Research is critically needed to better understand this basic biology in order to develop effective treatment modalities. Cost and quality-of-life research is also needed regarding sexuality in both older men and women.

Urol 22 (Level B): Time series (before-and-after) studies may be sufficient to assess the effect of sildenafil on sexual function of women aged 65 to 74, 75 to 84, and 86 years and older.

Urol 23 (Level B): Time series (before-and-after) studies may be sufficient to assess the effect of sildenafil on sexual function of men aged 65 to 74, 75 to 84, and 86 years and older.

Urol 24 (Level B): Prospective clinical series are needed to examine the use of intracavernosal injections, vacuum erection devices, and penile prostheses by men who are nonresponsive to sildenafil or are ineligible to use it.

Urinary tract stone disease is one of the most common disorders treated by the urologist. It is estimated that approximately one in every five individuals will experience an episode of urolithiasis at some point in life. The risk factors and symptoms associated with the development and passage of urinary stones are the same in older and younger persons. Swallowing difficulties and fear of increased incontinence are common in older adults and may cause decreased fluid intake, which can increase the propensity for stone production.

  Very few studies have examined the surgical management of stone disease in geriatric patients. Extracorporeal shock-wave lithotripsy (ESWL) has become a popular form of effective, minimally invasive therapy, especially for stones in the renal collecting system and upper ureter. Kramolowsky et al reviewed the utility of ESWL as a function of age. ¹⁵⁰ They examined a cohort of 789 consecutive patients undergoing ESWL for treatment of stones in the upper urinary tract. Of these patients, 96 (12%) were aged 70 or over, with a mean age of 75 (range 70 to 93). A total of 905 treatment procedures were performed, of which 107 procedures were in the older group. No significant differences were identified between the groups with regard to treatment-related complications, length of postoperative hospitalization, or clinical efficacy. The need to perform secondary procedures to render patients stone-free was similar in the groups (12.5% older, 13% younger).

  Newer forms of minimally invasive surgical therapy for stone disease have revolutionized the care of patients with urolithiasis. Surgical procedures include retrograde ureteroscopic stone extraction and percutaneous nephrostolithotomy. Many of these procedures also use lithotripsy technology such as ultrasound, electrohydraulic shock-wave therapy, and holmium laser energy.

End-stage renal disease (ESRD) is a common clinical problem with a variety of causes, and the prevalence increases with increasing age. Although chronic peritoneal or hemodialysis is effective therapy for ESRD, renal transplant is often the preferred form of therapy because of better survival and overall and disease-specific quality of life. ¹⁵¹ The incidence rates for ESRD have more than doubled for most age groups over the past decade. ¹⁵² In fact, the incidence for those aged 75 and over has increased by a factor of 2.4 times. In 1996 in the United States, 73,000 new ESRD cases were identified, and 46% of these patients were aged 65 years or over. ¹⁵³ ESRD has important implications for overall quality of life. Beusterien et al reported significant impairment in essentially all quality-of-life domains, with ESRD patients scoring lower than those with congestive heart failure or clinical depression. ¹⁵⁴ In an analysis of Medicare claims data for almost 43,000 transplants, Whiting et al demonstrated a significant cost savings for transplant over chronic dialysis even when quality of life was not figured into the cost-equation models. ¹⁵⁵

Studies on data from the United Network for Organ Sharing have suggested that overall graft survival from donors aged 55 and over is approximately 10% lower than for grafts from younger donors. However, results depend largely on how graft survival is defined. Many studies combine perioperative deaths with other causes of graft loss. Other research examines outcomes more critically, using biochemical parameters.

  Shimmura et al examined predonation creatinine clearance for living related donors and found no significant differences in graft survival that are based on this parameter. ¹⁵⁷ Hayashi et al suggested that graft survival from living related older donors is most likely due to the fact that no preservation or significant cold ischemia time is required for these transplants. ¹⁵⁸ They also pointed out that follow-up in the living related older donor (age > 66) revealed no significant changes in postoperative serum creatinine in comparison with younger historical controls. In a retrospective cohort analysis of extreme-age donors (< 10 or > 60 years old), Ferraresso et al reported actuarial graft survival at 1 and 4 years of 90% and 87% in kidneys from older living related donors. These figures are statistically equivalent to historical controls. ¹⁵⁹

  There is continued controversy over whether older kidney grafts should be used exclusively for older recipients. In a retrospective cohort study using biochemical parameters, Vianello et al found that grafts from persons of "high donor age" (50 to 66 years) had lower survival than did grafts from younger persons. ¹⁶⁰ They concluded that when kidneys from donors aged 50 years and over are used, they should probably be given to recipients with an estimated life expectancy of no more than 10 to 15 years. However, a more recent retrospective analysis of 509 transplants challenges this conclusion. ¹⁶¹ These investigators compared results stratified by both donor and recipient age. This study was unique in that it considered age as a continuous rather than a categorical variable. They found that the age of both the donor and recipient independently influences the overall graft survival rates when results are censored for deaths. They found no interaction between these variables, which suggests that trying to match the ages of donors and recipients may not be necessary.

  Chronic organ rejection does not appear to differ on the basis of the age of the graft donor. In a retrospective cohort analysis comparing graft survival from 112 older living related donors (55 to 81 years) with that from 87 younger donors (< 45 years), Kumar et al found no difference in overall graft survival between the groups. ¹⁶² In addition, they found no difference in graft function, using biochemical parameters, including serum creatinine or glomerular filtration rate. However, they did identify a significantly higher rate of acute graft rejection in kidneys obtained from the older donors.

Although it has been well documented that older adults can successfully undergo kidney transplantation for renal replacement therapy, statistics on graft survival usually show lower success in older adults than in younger recipients. However, the method used to define graft loss is important for analysis and interpretation. Most studies include perioperative deaths as a graft loss. However, in a retrospective cohort analysis comparing 206 recipients aged 60 years or over with 1640 younger recipients, Doyle et al found no significant differences in graft survival when death is censored as a cause of graft loss. ¹⁶⁴ In fact, graft loss in older adults appears to be due more to perioperative mortality than to other factors. ¹⁶⁵

  The primary risk factor for perioperative mortality in older renal transplant recipients appears to be concomitant cardiopulmonary disease. In a small retrospective analysis of 26 kidney recipients aged 60 years or over, Schulak et al found that both overall patient and graft actuarial survivals are influenced by the presence of cardiovascular comorbidity. ¹⁶⁶ Low-risk patients had 1- and 3-year graft and patient survival rates of 91% and 84%, respectively, but high-risk patients had survival rates of 67% and 58%. Their findings are supported by data reported by Tesi et al in an analysis of 1222 consecutive transplants. ¹⁶⁷ They found that underlying cardiovascular disease was the leading cause of death in both older and younger recipients.

  The presence of underlying cardiovascular disease certainly influences patient selection for transplant. In a sociodemographic cohort analysis of 4118 subjects started on dialysis between 1986 and 1987, Gaylin et al found cardiovascular disease to be the most predictive parameter of who received a transplant. ¹⁶⁸ This suggests that potential recipients are being well screened to help maximize clinical outcomes.

There has been a large amount of research on renal transplantation for the management of ESRD in older adults. Most of this work has focused on the use of kidneys from older donors for younger recipients. More recent studies have examined the ability to perform transplants in older recipients. As surgical techniques for renal harvest and transplant improve, these methods will need to be studied in older adult populations. Laparoscopic donor nephrectomy for living related kidney donors has recently gained widespread attention as a minimally invasive technique. As transplant surgeons continue to push the age limits for donation, this technique will need to be examined in older adults.

Urol KQ1: Research is needed to better define the pathophysiology and natural history of the most common genitourinary disorders affecting older adults. These include but are not limited to urinary incontinence, urinary tract infection, prostate diseases, urologic malignancies, sexual dysfunction, stone disease, and renal failure and transplantation.

Hypothesis-generating: Basic science and clinical studies are recommended to examine these issues, particularly the impact of common comorbid illnesses that may influence genitourinary health, for example, diabetes mellitus, hypertension, and chronic neurologic conditions. Large-scale cohort studies, well-designed case-control studies, and community-based research techniques are needed to develop this baseline knowledge.

Hypothesis-testing research that is based on this improved understanding of genitourinary disorders in older adults should then be conducted. Randomized therapeutic trials with appropriate operational definitions and adequate longitudinal follow-up should be developed to identify the most effective surgical and nonsurgical treatment options for each of these conditions.

Urol KQ2: Research is needed to develop and validate predictive models to identify appropriate candidates for early surgical or other more active therapies for urologic disorders versus appropriate candidates for an initial trial of more conservative treatment options.

Hypothesis-generating research: For most urologic conditions that affect older adults, a range of treatment options are available, including conservative nonsurgical therapies, biobehavioral treatments, pharmaco-therapy, or surgical interventions. There is a perceived general tendency to favor initial trials of conservative therapy in older adults. Research is needed to determine whether delay in treatment may make subsequent surgical intervention more difficult or less successful. Conversely, it is possible that a planned course of preoperative nonsurgical therapy may potentially improve subsequent surgical outcomes. In addition, models to determine what preoperative evaluation techniques best influence outcomes should be developed. For example, which patient undergoing treatment for urinary incontinence would most benefit from formal urodynamic evaluation? Ideally, these models should be created on the basis of findings from randomized controlled clinical trials of diagnostic evaluations and treatments outlined in Urol KQ1, above.

Hypothesis-testing research to determine the validity and reliability of these predictive models will then be required. This will involve prospective cohort studies and clinical trials of these models.

Urol KQ3: Research is needed to analyze the longitudinal outcomes of various urologic therapies, including potential risks, benefits, and costs.

Hypothesis-generating research: The genitourinary disorders that affect older adults are diverse, and each presents unique diagnostic dilemmas and treatment challenges. Large-scale, prospective cohort studies and randomized controlled clinical trials will be needed to identify the impact of the information gained from work on Urol KQ1 and Urol KQ2. Emphasis should be placed on risks and benefits associated with health-related quality of life, improvement or preservation of functional capacity, and costs. The development of cooperative databases from multiple clinical centers will help to facilitate this type of outcomes research.

Hypothesis-testing research using randomized controlled trials will subsequently be required to demonstrate the clinical utility and longevity of these therapies. It will be critically important for these studies to be designed with a sufficient follow-up interval to document the durability of outcomes.

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