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Voiding Dysfunction in Institutionalized Elderly Men: The Influence of Previous Prostatectomy
0022-534 7/83/1301-0258$02.00/0
Vol. 130, August Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
VOIDING DYSFUNCTION IN INSTITUTIONALIZED ELDERLY MEN: THE INFLUENCE OF PREVIOUS PROSTATECTOMY MARTIN BARKIN, * DAN DOLFIN, SENDER HERSCHORN, RICHARD COMISAROW RORY FISHER
AND
From the Division of Urology, Sunnybrook Medical Center, Toronto, Ontario, Canada
ABSTRACT
Voiding problems, either retention or incontinence, affect a majority of institutionalized elderly patients. Although impaired cerebral function is the dominant cause, those patients who had undergone prior transurethral prostatectomy were more vulnerable to the development of voiding dysfunction than those who had not. Moreover, the elimination of obstruction by prostatectomy did not produce the expected shift from indwelling catheterization to condom drainage. There were 233 men in the long-term wards of K Wing, a chronic facility funded by the government for veterans who require institutional care. Evaluation of these patients by history, physical examination, chart review and nurse interview revealed that only 89 (37 per cent) had normal voiding, 75 (32 per cent) were on permanent indwelling catheter drainage, 52 (22 per cent) required a formal collection device and 17 (9 per cent) were incontinent. Aside from the significant social and nursing consequences of this high level of voiding dysfunction there also were many profound medical consequences. Virtually all of the patients on indwelling catheterization and more than half of those on condom drainage had urinary tract infection. In addition, 21 cystolitholapaxies were required as a result of catheter-induced bladder stones and 8 orchiectomies were done as a result of catheter-induced epididymitis. The patients were elderly (mean age 76 ± 12 years, range 55 to 97 years) and more than two-thirds were regarded as having some form of dementia (table 1). Furthermore, 81 patients also had neurological disorders that affected voiding function adversely (table 2) and others had associated disabilities that impaired rehabilitation severely (28 amputees, 7 bilateral amputees and 12 blind patients). Dementia was the single most important predisposing factor to this high incidence of voiding dysfunction. 1- 3 Only 32 per cent of 155 demented patients had normal voiding function compared to 48 per cent of 78 nondemented patients (p <0.02) (part A of figure). Surprisingly, however, a second factor emerged from this study. A total of 64 patients had undergone transurethral prostatectomy before hospitalization. The percentage of demented patients among those who had and had not undergone prior transurethral prostatectomy was the same (65 per cent). Most patients had achieved normal voiding function after transurethral prostatectomy for a varying interval. However, when they were evaluated as part of this study normal voiding function occurred in only 26 per cent of the patients who had undergone prior transurethr.al resection compared to 42 per cent of those who had not (part B of figure). This difference (p <0.05) suggested that as the conditions that lead to voiding dysfunction, either retention or incontinence, develop those patients who have undergone prior transurethral prostatectomy are somewhat more vulnerable than those who have not. If a previous transurethral prostatectomy predisposes the elderly demented man to severe voiding dysfunction, this dysfunction should be of a type that is managed more readily by an external collecting device, rather than an indwelling catheter. Accepted for publication December 10, 1982. * Requests for reprints: Division of Urology, Sunnybrook Medical Center, 2075 Bayview Ave., Suite 1039, Toronto M4N 3M5, Ontario, Canada.
However, in both groups the percentage of patients managed by condom drainage was the same (part C of figure). In other words, just as many patients who had never undergone transurethral prostatectomy could be managed by an external collecting device as those who had undergone such surgery previously. TABLE
1. Frequency of appearance of diagnoses reflecting impaired
cerebral function in 165 patients Frequency Dementia (unspecified) Senile dementia Alzheimer's disease Organic brain syndrome Cerebral atrophy Cerebral infarct with dementia Epilepsy with dementia Brain tumor Parkinson's disease with dementia Huntington's disease chorea Cerebral arteriosclerosis Alcoholism with dementia Severe personality disorder Total
TABLE 2.
52 15 10 18 4 4 8
11 11 2
61 10 7 213
Frequency of appearance of major neurological disease other than dementia in K Wing patients Frequency
Multiple sclerosis Cerebellar degeneration Transverse myelitis Hemiplegia Hemiparesis Paraplegia/quadriplegia Spinal cord disease Amyotrophic lateral sclerosis Guillain-Barre syndrome Total
13 1 1 30 13
15 6
1 1 81
DISCUSSION AND CONCLUSIONS
It is clear that the elderly man who requires institutional care is severely disabled. Brain deterioration affects the majority of these patients, and other neurological and miscellaneous disabilities compound the problem. Such patients are predisposed markedly to voiding dysfunction. Previous transurethral surgery appears to accentuate this predisposition. The effects of prior surgery on continence are well known. Transurethral prostatectomy disrupts some of the continence mechanisms at the bladder neck and within the prostatic urethra. 4 The remaining intrinsic and extrinsic mechanisms at the level of the membranous and supramembranous urethra are, under normal circumstances, sufficient to maintain continence. Under the 258
VOIDING DYSFUNCTION IN INSTITUTIONALIZED ELDERLY MEN
circumstances prevailing in our patients not are these mechanisms insufficient but bladder function generally is disrupted.5 If continence were the only problem then most of these patients should have been managed by external collection devices rather than indwelling catheterization. Since this was not the case, either the indications for placement of a long-term indwelling catheter were inappropriate or other voiding factors were operative. Without appropriate urodynamic assessment it is not possible to determine which factor is responsible. Accordingly, it is recommended that all patients with dementia or a major neurologic disorder should be evaluated by urodynamic testing before transurethral prostatectomy.
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REFERENCES
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1. Castleden, C. M., Duffin, H. M. and Asher, M. J.: Clinical and
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0
DEMENTED NO. = 155 100
NON-DEMENTED NO. = 78
2. 3.
B
4.
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urodynamic studies in 100 elderly incontinent patients. Brit. Med. J., 282: 1103, 1981. Hilton, P. and Stanton, S. L. R.: Assessing elderly incontinent patients. Brit. Med. J ., 282: 1706, 1981. Willington, F. L.: Incontinence in the Elderly. New York: Academic Press, 1977. Mayo, M. E. and Ansell, J. S.: Urodynamic assessment of incontinence after prostatectomy. J. Urol., 122: 60, 1979. Eastwood, H. D.: Urodynamic studies in the management of urinary incontinence in the elderly. Age Ageing, 8: 41, 1979.
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EDITORIAL COMMENT
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PREV. TURP NO. 47
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A, dementia and voiding dysfunction results show that 48 per cent of patients without dementia have normal voiding compared to only 32 per cent of demented patients. Dementia is significant factor in voiding dysfunction in institutionalized elderly men (p <0.02). B, only 26 per cent of patients who had undergone previous transurethral prostatectomy had normal voiding compared to 42 per cent of patients without this history. Since there were equal proportions of demented patients in both groups history of prostatectomy was significant predisposing factor to voiding dysfunction in elderly men (p <0.05). C, there is no discernible shift to form of voiding dysfunction that could be managed by external appliance in patients who have undergone previous prostatectomy. Equal proportions of patients in both groups were managed by catheter and condom drainage.
The authors not surprisingly have found that elderly men in a nursing home often are incontinent. A prior transurethral resection did not make patient management any easier and seemed to be related to an increased incidence of incontinence. There are a number of questions raised by this study that will need to be answered. Why are a substantial percentage of demented patients continent if dementia is the leading cause of incontinence in the elderly? What are the urodynamic findings in patients after transurethral resection compared to those who had never undergone transurethral resection and how are these findings related to incontinence? The answers will require detailed urodynamic study but will help us to manage this difficult problem in an increasingly aged population. Edward J. McGuire Department of Urology Yale University School of Medicine New Haven, Connecticut
Vol. 130, August Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
VOIDING DYSFUNCTION IN INSTITUTIONALIZED ELDERLY MEN: THE INFLUENCE OF PREVIOUS PROSTATECTOMY MARTIN BARKIN, * DAN DOLFIN, SENDER HERSCHORN, RICHARD COMISAROW RORY FISHER
AND
From the Division of Urology, Sunnybrook Medical Center, Toronto, Ontario, Canada
ABSTRACT
Voiding problems, either retention or incontinence, affect a majority of institutionalized elderly patients. Although impaired cerebral function is the dominant cause, those patients who had undergone prior transurethral prostatectomy were more vulnerable to the development of voiding dysfunction than those who had not. Moreover, the elimination of obstruction by prostatectomy did not produce the expected shift from indwelling catheterization to condom drainage. There were 233 men in the long-term wards of K Wing, a chronic facility funded by the government for veterans who require institutional care. Evaluation of these patients by history, physical examination, chart review and nurse interview revealed that only 89 (37 per cent) had normal voiding, 75 (32 per cent) were on permanent indwelling catheter drainage, 52 (22 per cent) required a formal collection device and 17 (9 per cent) were incontinent. Aside from the significant social and nursing consequences of this high level of voiding dysfunction there also were many profound medical consequences. Virtually all of the patients on indwelling catheterization and more than half of those on condom drainage had urinary tract infection. In addition, 21 cystolitholapaxies were required as a result of catheter-induced bladder stones and 8 orchiectomies were done as a result of catheter-induced epididymitis. The patients were elderly (mean age 76 ± 12 years, range 55 to 97 years) and more than two-thirds were regarded as having some form of dementia (table 1). Furthermore, 81 patients also had neurological disorders that affected voiding function adversely (table 2) and others had associated disabilities that impaired rehabilitation severely (28 amputees, 7 bilateral amputees and 12 blind patients). Dementia was the single most important predisposing factor to this high incidence of voiding dysfunction. 1- 3 Only 32 per cent of 155 demented patients had normal voiding function compared to 48 per cent of 78 nondemented patients (p <0.02) (part A of figure). Surprisingly, however, a second factor emerged from this study. A total of 64 patients had undergone transurethral prostatectomy before hospitalization. The percentage of demented patients among those who had and had not undergone prior transurethral prostatectomy was the same (65 per cent). Most patients had achieved normal voiding function after transurethral prostatectomy for a varying interval. However, when they were evaluated as part of this study normal voiding function occurred in only 26 per cent of the patients who had undergone prior transurethr.al resection compared to 42 per cent of those who had not (part B of figure). This difference (p <0.05) suggested that as the conditions that lead to voiding dysfunction, either retention or incontinence, develop those patients who have undergone prior transurethral prostatectomy are somewhat more vulnerable than those who have not. If a previous transurethral prostatectomy predisposes the elderly demented man to severe voiding dysfunction, this dysfunction should be of a type that is managed more readily by an external collecting device, rather than an indwelling catheter. Accepted for publication December 10, 1982. * Requests for reprints: Division of Urology, Sunnybrook Medical Center, 2075 Bayview Ave., Suite 1039, Toronto M4N 3M5, Ontario, Canada.
However, in both groups the percentage of patients managed by condom drainage was the same (part C of figure). In other words, just as many patients who had never undergone transurethral prostatectomy could be managed by an external collecting device as those who had undergone such surgery previously. TABLE
1. Frequency of appearance of diagnoses reflecting impaired
cerebral function in 165 patients Frequency Dementia (unspecified) Senile dementia Alzheimer's disease Organic brain syndrome Cerebral atrophy Cerebral infarct with dementia Epilepsy with dementia Brain tumor Parkinson's disease with dementia Huntington's disease chorea Cerebral arteriosclerosis Alcoholism with dementia Severe personality disorder Total
TABLE 2.
52 15 10 18 4 4 8
11 11 2
61 10 7 213
Frequency of appearance of major neurological disease other than dementia in K Wing patients Frequency
Multiple sclerosis Cerebellar degeneration Transverse myelitis Hemiplegia Hemiparesis Paraplegia/quadriplegia Spinal cord disease Amyotrophic lateral sclerosis Guillain-Barre syndrome Total
13 1 1 30 13
15 6
1 1 81
DISCUSSION AND CONCLUSIONS
It is clear that the elderly man who requires institutional care is severely disabled. Brain deterioration affects the majority of these patients, and other neurological and miscellaneous disabilities compound the problem. Such patients are predisposed markedly to voiding dysfunction. Previous transurethral surgery appears to accentuate this predisposition. The effects of prior surgery on continence are well known. Transurethral prostatectomy disrupts some of the continence mechanisms at the bladder neck and within the prostatic urethra. 4 The remaining intrinsic and extrinsic mechanisms at the level of the membranous and supramembranous urethra are, under normal circumstances, sufficient to maintain continence. Under the 258
VOIDING DYSFUNCTION IN INSTITUTIONALIZED ELDERLY MEN
circumstances prevailing in our patients not are these mechanisms insufficient but bladder function generally is disrupted.5 If continence were the only problem then most of these patients should have been managed by external collection devices rather than indwelling catheterization. Since this was not the case, either the indications for placement of a long-term indwelling catheter were inappropriate or other voiding factors were operative. Without appropriate urodynamic assessment it is not possible to determine which factor is responsible. Accordingly, it is recommended that all patients with dementia or a major neurologic disorder should be evaluated by urodynamic testing before transurethral prostatectomy.
100 L
A z
75 _
0 I--
er: ::i 1-
u
50 _
~ ...J <(
:2'
er: 0
25 _
z
259
REFERENCES
··il!l·!lm,--------...i.---
1. Castleden, C. M., Duffin, H. M. and Asher, M. J.: Clinical and
r,,.,...,.,.,.,_,...,.i,·..,··..
0
DEMENTED NO. = 155 100
NON-DEMENTED NO. = 78
2. 3.
B
4.
75
5.
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z
urodynamic studies in 100 elderly incontinent patients. Brit. Med. J., 282: 1103, 1981. Hilton, P. and Stanton, S. L. R.: Assessing elderly incontinent patients. Brit. Med. J ., 282: 1706, 1981. Willington, F. L.: Incontinence in the Elderly. New York: Academic Press, 1977. Mayo, M. E. and Ansell, J. S.: Urodynamic assessment of incontinence after prostatectomy. J. Urol., 122: 60, 1979. Eastwood, H. D.: Urodynamic studies in the management of urinary incontinence in the elderly. Age Ageing, 8: 41, 1979.
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EDITORIAL COMMENT
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PREV. TURP NO. 47
i'IO TURP NO. = 97
A, dementia and voiding dysfunction results show that 48 per cent of patients without dementia have normal voiding compared to only 32 per cent of demented patients. Dementia is significant factor in voiding dysfunction in institutionalized elderly men (p <0.02). B, only 26 per cent of patients who had undergone previous transurethral prostatectomy had normal voiding compared to 42 per cent of patients without this history. Since there were equal proportions of demented patients in both groups history of prostatectomy was significant predisposing factor to voiding dysfunction in elderly men (p <0.05). C, there is no discernible shift to form of voiding dysfunction that could be managed by external appliance in patients who have undergone previous prostatectomy. Equal proportions of patients in both groups were managed by catheter and condom drainage.
The authors not surprisingly have found that elderly men in a nursing home often are incontinent. A prior transurethral resection did not make patient management any easier and seemed to be related to an increased incidence of incontinence. There are a number of questions raised by this study that will need to be answered. Why are a substantial percentage of demented patients continent if dementia is the leading cause of incontinence in the elderly? What are the urodynamic findings in patients after transurethral resection compared to those who had never undergone transurethral resection and how are these findings related to incontinence? The answers will require detailed urodynamic study but will help us to manage this difficult problem in an increasingly aged population. Edward J. McGuire Department of Urology Yale University School of Medicine New Haven, Connecticut