INDICATION OF SURGERY IN

GERIATRIC BLADDER PROBLEM :

AN UROLOGICAL PERSPECTIVE

Dr. Tjahjodjati, dr, SpB, SpU(K)

KSM Urologi RS Dr Hasan Sadikin/FK Unpad
Bandung
 GERIATRICS
• Geriatrics: older pople
• Geriatric syndrome: multifactorial, and shared risk factors—including older
age, cognitive impairment, functional impairment, and impaired mobility—
were demonstrated across the common geriatric syndromes of pressure
ulcers, INCONTINENCE, falls, functional decline, and DELIRIUM.

Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric Syndromes: Clinical, Research and Policy Implications of a Core Geriatric Concept
. J Am Geriatr Soc. 2007 May; 55(5): 780–791.
AGING PROCESS IN ELDERLY
 AGING BLADDER

•Detrusor contractility

•Bladder capacity

•Ability to withhold voiding

oDetrusor overactivity

oPostvoid residual

Elbadawi A. World J Urol 1998;16(suppl 1):S10-S34

 PROBLEM URINARY SYMPTOMS IN ELDERLY

• INCONTINENCE
• LOWER URINARY TRACT SYMPTOMS
• URINARY TRACT INFECTION
• MALIGNANCY : PROSTATE CANCER, BLADDDER CANCER
 URINARY INCONTINENCE IN
ELDERLY
• Urinary incontinence is defined by the International Continence Society as
INVOLUNTARY URINARY LEAKAGE
• It affects more than a fifth of people aged over 85 years
• Burdens to the patients as well as to the caregiver:
• damage to skin
• urinary tract infections
• an increased risk of falls
• avoidance of going far from home
• feeling of alienation.

Abrams P, Cardozo L, M Fall. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the
International Continence Society. Neurourol Urodyn 2002;21:167-78.
Thirugnanasothy S, Managing urinary incontinence in older people. BMJ 2010;341:c3835
 About 2 millions suffer from this silent epidemic

30-60 % community-dwelling
 older women

EPIDEMIOLOGY  10-35 % community-dwelling

older men

Over 50 % institutionalized older

 adult

Prevalence increases with age

 and disability

Anger et all (2006). The prevalence of urinary incontinence among community dwelling adult women: Results from the National Health and Nutrition Examination Survey. The Journal of
Urology, 175(2), 601-604.
Melville et all (2005). Urinary incontinence in US women: A population-based study. Archives of Internal Medicine, 165(5), 537-542
Vaughan et all. (2011). Urinary incontinence in older adults. The Mount Sinai Journal of Medicine, 78(4), 558-570. doi: 10.1002/msj.20276
 ETIOLOGY IN ELDERLY
• Multifactor , depend on type incontinence
• Coexisting cerebrovascular accident
• Bladder outlet obstruction secondary to benign prostatic hypertrophy (BPH)
• Delirium- and confusion-related incontinence

Shah D, Badlani G. Treatment of Overactive Bladder and Incontinence in Elderly. Reviews in Urology. 2002 Vol 4 Suppl 4
 TYPE OF URINARY INCONTINENCE
Stress—Involuntary urinary leakage on effort or exertion, sneezing, or
coughing

The most
Urge—Involuntary leakage accompanied by or immediately
common type in
preceded by urgency
elderly

Mixed—Involuntary leakage associated with urgency and also with

exertion, effort, sneezing, or coughing

Overflow—Leakage owing to bladder outflow obstruction of any

cause resulting in large post-void residual volume

Functional—Incontinence resulting from an inability to reach or use

the toilet in time (for example, poor mobility, cognitive impairment)
 ETIOLOGY OF URINARY
INCONTINENCE IN ELDERLY
Stress Incontinence
Functional

Urge Overflow

Mixed
Mobility and
communication
Pelvic floor problem
weakness Middle aged BPH,
Neurological women with neurogenic
disturbances fluctuating
oestrogen bladder
ETIOLOGY OF INCONTINENCE
• DeMaagd GA, Davenport TC. Management of Urinary Incontinence. 2012;37:6.
 TREATMENT OF URINARY
INCONTINENCE IN ELDERLY

Before initiate Consider:

treatment
- Comorbidities
- current medication use
- life expectancy
- preferences for care
- goals of care
 TREATMENT OF URINARY
INCONTINENCE IN ELDERLY
caffeine restriction, fluid manipulation if patients
Behavioral modification
have excessive fluid intake, and bladder retraining

Pelvic Muscle Floor Training (PMFT), electrical

Physiotherapy Treatment stimulation

Medication Antimuscarinics, B3 Agonist, Botulinum toxin

Neuromodulation

Surgery Treatment
 SURGERY INDICATION
• 1. Behavioral and/or medical treatment failure
• 2. Impair daily activity / quality of life
• 3. Family wishes
 SURGERY TREATMENT

very little remains know about surgical

treatment of UI in frail elderly patients 
SURGERY AS LAST RESORT

Morbidity and mortality of UI surgery appear

Consider:
to be similar to major noncardiac surgical - RISK AND BENEFIT
procedures FOR THE PATIENTS!!

URODYNAMIC STUDY  MUST BE DONE

BEFORE SURGERY
 INDICATION OF SURGERY

• OVERFLOW INCONTINENCE :
1. BPH : - recurrent urinary retention
- recurrent urinary tract infection
- bladder stone
- recurrent haematuria
- renal failure due to bph
- bladder diverticulae
Treatment : TURP
2. STRICTURE URETRAE ------- treatment : internal uretrotomy, resection
anastomosis uretra

3. URETHRAL STONE -------- surgical removal stone

• URGE INCONTINENCE : depend on etiology

a. not respon to medical theraphy
b. impair daily and quality of life
Treatment : botox injection, sacral neuromodulation, bladder augmentation,
urinary diversion
• STRESS INCONTINENCE :
1. not respond to medical treatment
2. impair quality of life
Treatment : Artificial urethral sphincter
Transvaginal Tape/ Transobturator Tape
 SURGICAL TREATMENT
 
Periurethral Bulking Agents
Urethral bulking agents are
suitable for patients with
moderate SUI due to intrinsic
sphincter deficiency or for
patients where the risks of a
midurethral sling would be
considered too great

Slings Artificial Urethral Sphincters
Midurethral slings are Artificial urethral
the most common sphincter is the gold
surgical option offered standard for surgical
to treat urinary treatment of male
incotinence urinary incotinence
 SURGICAL TREATMENT IN
GERIATRIC INCONTINENCE

Periurethral bulking agents Urethral slings Artificial urethral spinchters

thank you!