A: It is important to obtain a comprehensive history as multiple factors may contribute to urinary symptoms and incontinence in the older patient. While ­bladder outlet obstruction with overactive bladder is a common diagnosis in the older patient, there are many other factors that may contribute in this patient. The presence of congestive cardiac failure/possible diuretic therapy could lead to frequency and nocturia symptoms. Previous radiotherapy for pelvic tumor could cause fibrosis and reduced bladder capacity. Major pelvic surgery (anterior resection) could result in injury to the pelvic efferent nerves to the bladder causing impairment of bladder emptying.

A: Urinalysis/urine culture, PSA, and serum electrolytes and creatinine which were normal. However, the urinary tract ultrasound (see Chap. 3) showed normal kidneys with a post-void residual of 250 ml (Fig. 6.1).

A: LUTS with elevated residual in an older patient suggests the presence of BOO with some bladder decompensation, but there may be underlying detrusor pathology from previous radiotherapy and pelvic surgery leading to a hypocontractile bladder.

A: The presence of an elevated residual urine suggests that there is some decompensation of bladder function, and the patient was commenced on alpha-blocker therapy with tamsulosin. It is important to assess social and functional issues and discuss goals of management with the patient prior to commencing medical therapy (see Table 6.2). Residual measurements should be repeated to confirm that there is indeed incomplete bladder emptying as there is considerable void to void variation (Ref. Chap. 3) (Tips 6.1).

A: Urodynamics can helpful in the elderly to guide management and avoid the risks of adverse effects associated with empiric prescription of multiple medications. It is well known that urinary symptoms do not always correlate of the urodynamic diagnosis. Urodynamics are generally well tolerated in geriatric patients with adequate cognition and mobility, but risks and benefits should be considered for each patient.

A: Detrusor hyperactivity with impaired contractility (DHIC) is a condition increasingly recognized in the elderly. On urodynamics, DHIC is characterized by low-pressure involuntary detrusor contractions during bladder filling and reduced detrusor contractility during voiding resulting in incomplete bladder emptying. Pathophysiology is poorly understood, and the condition is often mistaken as bladder outlet obstruction (BOO) or overactive bladder. Currently, there is a paucity of data on the clinical management of DHIC.

Management strategies are formulated on the basis of symptomatic complaints, urodynamic findings, complications, and patient tolerability. If urinary symptoms are minimally bothersome, it can be managed conservatively with adjustments to fluid intake, prompted voiding, bladder retraining, and continence appliances. If the symptoms are predominantly related to detrusor overactivity, a trial of low-dose anticholinergic medication can be initiated. If symptoms are more related to impaired bladder emptying, alpha-blockers may be considered to decrease outlet resistance or added in combination with a low-dose anticholinergic medication. In select patients, TURP can be considered. Clean intermittent catheterization or indwelling catheters can be a suitable way to manage elevated post-void residuals especially if associated with complications such as recurrent infections or intractable incontinence.

A: In this patient who is quite bothered by his symptoms with evidence of bladder decompensation, anticholinergics would be contraindicated. Surgery to reduce outlet resistance can improve bladder emptying in this group of patients, and he elected to have a laser TURP given the need for ongoing anticoagulation (Tips 6.2).