URODYNAMICS
IN WOMEN FROM MENOPAUSE TO OLDEST AGE: WHAT MOTIVE? WHAT DIAGNOSIS?
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Neurourology
Vol. 37 (1):
100-107, January - February, 2011
doi: 10.1590/S1677-55382011000100013
FRANÇOISE A. VALENTINI, GILBERTE ROBAIN, BRIGITTE G. MARTI
ER6 - Universite Pierre et Marie Curie (FAV, GR), Paris, France and Department of Physical Medicine and Rehabilitation (FAV, GR, BGM), Hopital Charles Foix, Ivry-sur-Seine, France
ABSTRACT
Purpose:
To analyze age-associated changes as a motive for urodynamics and urodynamic
diagnosis in community-dwelling menopausal women and to discuss the role
of menopause and ageing.
Materials and Methods: Four hundred and
forty nine consecutive menopausal women referred for urodynamic evaluation
of lower urinary tract (LUT) symptoms, met the inclusion criteria and
were stratified into 3 age groups: 55-64 years (A), 65-74 years (B), and
75-93 years (C). Comprehensive assessment included previous medical history
and clinical examination. Studied items were motive for urodynamics, results
of uroflows (free flow and intubated flow) and cystometry, urethral pressure
profilometry, and final urodynamic diagnosis.
Results: The main motive was incontinence
(66.3%) with significant increase of mixed incontinence in group C (p
= 0.028). Detrusor function significantly deteriorated in the oldest group,
mainly in absence of neurological disease (overactivity p = 0.019; impaired
contractility p = 0.028). In the entire population, underactivity predominated
in group C (p = 0.0024). A progressive decrease of maximum urethral closure
pressure occurred with ageing. In subjects with no detrusor overactivity
there was a decrease with age of detrusor pressure at opening and at maximum
flow, and of maximum flow while post void residual increased only in the
C group.
Conclusion: In our population of community-dwelling
menopausal women, incontinence was the main motive for urodynamics increasing
with ageing. A brisk change in LUT function of women older than 75 years
underlined deterioration in bladder function with a high incidence of
detrusor hyperactivity with or without impaired contractility while change
in urethral function was progressive. Effect of ageing appears to be predominant
compared to menopause.
Key
words: ageing; women; LUTS; urodynamics
Int Braz J Urol. 2011; 37: 100-7
INTRODUCTION
Lower
urinary tract (LUT) dysfunction is a major cause of reduced quality of
life in the ageing population. For women the postmenopausal period has
significantly increased and is now up to one third or more of the total
lifespan. LUT function is affected by estrogen
withdrawal and ageing. A major consequence of estrogen withdrawal is urogenital
atrophy with possible contribution to urinary symptoms such as frequency,
urgency and incontinence (1). Ageing is associated with a progressive
decrease in autonomic innervation and of detrusor contractility (2,3).
Some studies have focused on identifying the effects of menopause and
ageing (4-6) on lifestyle. In spite of a reported significant trend for
increased prevalence of symptoms with ageing, none of these studies have
identified causes.
Despite the fact that many patients avoid
discussing their problems, postmenopausal women constitute a large population
who undergo urodynamics for lower urinary tract symptoms (LUTS) and urodynamics
is considered as the best tool for the evaluation of patients with LUTS.
Some authors (7) have concluded that female
bladder and urethral function deteriorate throughout adult life, whether
or not detrusor overactivity (DO) is present. In a previous study (8)
we analyzed the motive for urodynamics and the urodynamic diagnosis in
a population of community-dwelling elderly females (80+ years); we showed
that incontinence was the main motive and DO the main diagnosis.
Our objectives in this study were to extend
our analysis to a large population of postmenopausal community-dwelling
women referred as outpatients for evaluation of LUTS and to consider the
relationships between menopause and ageing on the changes in the motive
of referral and in LUT function.
MATERIALS AND METHODS
The
population consisted of 449 consecutive women, community-dwelling, aged
= 55 years who underwent urodynamics for LUTS in our outpatient urodynamics
clinic between January 2005 and March 2008. Patients were stratified in
3 age groups: 55-64 years (A, short-term menopause), 65-74 years (B, middle-term
menopause), and 75-93 years (C, long-term menopause). The lowest age group
(55 years) was set so that the women were all postmenopausal (in France,
the mean age of menopause is 50.1 years). This retrospective study was
conducted in accordance with the declaration of Helsinki. The local practice
of our Ethics Committee does not require a formal institutional review
board approval for retrospective studies.
Urodynamics investigations were performed
according to Good Urodynamic Practices (GUP) (9) using the Laborie’s
Dorado® unit. Detailed urodynamic session included one initial free
uroflow (FF1), cystometry and pressure-flow study (PFs) in a seated position,
urethral pressure profilometry (UPP) in supine position, bladder empty
before cystometry and bladder filled (according with the functional bladder
capacity) after PFs and then a second FF. Cystometry
was performed with a 7F triple-lumen urethral catheter. Bladder was filled
with saline at room-temperature at a medium filling rate of 50 mL/min.
Abdominal pressure was recorded using a punctured intra-rectal balloon
catheter.
Pressures were zeroed to atmosphere with
the transducers placed at the level of the upper edge of the symphisis
pubis.
No routine provocative manoeuvres for DO
were performed but according to GUP coughs were used as quality control
of pressure recordings (9).
All patients had an evaluation including
medical history and usual medication, bladder diary for at least 48 hours
including voiding times and voided volumes during day and night-time,
physical examination and dipstick urinalysis.
Specific evaluation comprised of a history
of LUTS, previous history of neurological disease (stroke, multiple sclerosis,
lumbar injury, etc.) or dementia, pelvic floor status and previous pelvic
surgery. Patients with LUTS due to a specific physiopathology (complete
spinal cord injury) were excluded, as well as those who were unable to
perform the standardized protocol for complete retention (no FF and PFs
were possible) or severe dementia (involving failure to understand simple
orders or Mini Mental State < 20).
Two physicians independently assessed urodynamics;
good agreement occurred in up to 95% of the files. In the remaining 5%,
a third interpretation was carried out jointly to agree on a single conclusion.
Studied items were motive for urodynamics, feasibility of uroflows (FF
and PFs), detrusor behavior during filling cystometry, UPP and final urodynamic
diagnosis. Feasibility of uroflows was defined by a voided volume higher
than 100 mL. To analyze the detrusor behavior during filling cystometry,
an additive stratification was used with the following parameters: age
(A,B,C), without neurological disease (I) or with (II) (was verified that
previous pelvic surgery did not lead to significant difference).
Quality of life was assessed using the ICIQ-UI-SF
questionnaire for incontinent patients (10) and visual analog scale (VAS)
for continent patients.
Statistical Analysis
Data are presented as mean ± SD and range. The Wilcoxon signed rank test was used for comparison of related samples, analysis of variance and the chi-square test to compare unrelated samples. Statistical analysis was performed using SAS, version 5.0 (SAS Institute, Inc., Cary, NC). All statistical results were considered significant at p < 0.05.
RESULTS
Population
The
3 sub-groups were homogeneous in terms of numbers of patients: A = 137,
B = 155, C = 157. Mean age was 59 ± 3 years in A, 70 ± 3y
in B and 81 ± 4 years in C.
Oral or transdermal hormone replacement
therapy (HRT) was respectively taken by 11 (8.0%) women in A and 29 (18.8%)
in B; in C, 15 women (9.6%) received estrogen locally.
Motive for Urodynamics
Table-1 lists the motive for urodynamics by age-groups. Incontinence was the main motive, evoked by 298 (66.3%) patients. Mixed incontinence increased with ageing with a significant difference between groups A and C (p = 0.028).
ICIQ-SF score (maximum 21) and VAS score
(maximum 10) are detailed in Table-2.
Previous History
Previous
history of medical disease or/and pelvic surgery was obtained by detailed
questioning, and is listed in Table-3.
One hundred and sixteen (25.8%) patients
had a previous history of neurological disease (A = 35; B = 36; C = 45)
and 151 (33.6%) had undergone previous pelvic surgery (A = 56; B = 54;
C = 41).
Eleven patients were referred for pre-operative
evaluation of pelvic organ prolapse (POP); POP grade 2-3 was revealed
during urogenital examination in 31 additional patients (A = 9; B = 13;
C = 9).
Feasibility of the Tests
The percentage of interpretable initial FF was significantly higher in age-group B (A = 57.8%; B = 69.3%; C = 47.5%) while there was not a significant difference between the age groups for both interpretable PFs (A = 64.2%; B = 56.1%; C = 56.4%) and FF at end of the session (A = 94.6%; B = 94.8%; C = 97.2%).
Cystometry (Table-4)
Detrusor
overactivity (involuntary detrusor contraction during the filling phase,
DO) (9-11) and its subset detrusor hyperactivity with impaired contractility
(DHIC) (12) were found in a total of 142 patients (32%) with a significant
increase in group C: 43% vs. 23% A & 30% B (p = 0.0004); detrusor
underactivity (impaired detrusor contraction leading to prolonged voiding
time and high residual volume) (DUA) (9) was found in 62 patients (14%)
with also a significant increase in C (p = 0.0024). Normal detrusor behavior
significantly decreased in c (p = 0.005).
In sub-group I (333 patients without neurological
disease) the detrusor behavior was normal in 194 (58.2%) with only a significant
difference between subgroups I-B and I-C (p = 0.044). DO and DHIC significantly
increased in subgroup I-C (respectively p = 0.019 and 0.028) but the increase
in DUA was not significant.
In subgroup II (116 patients with neurological
disease) the detrusor behavior was normal in 33 (28.4%). DO was found
in 46 (39.6%), DHIC in 15 (12.9%) and DUA in 20 (17.2%). There was no
significant difference between the 3 age groups regarding DO: II-A (45.7%),
II-B (36.1%) and II-C (37.7%). An increase in DHIC and DUA in subgroup
II-C was observed.
Functional bladder capacity (FBC) did not
change significantly with age but depended on DO (Table-5). Some other
voiding parameters were modified in DO patients: pdet.op and pdet.Qmax
increased, the voiding time decreased, except in group A, and PVR was
lower in group C. In the DO population, pdet.op was higher than pdet.Qmax.
Uroflow Parameters (Table-6)
Maximum flow rate diminished with age whether measured during FF or PFs, and was significantly lower during PFs. The decrease was independent of DO. Post void residual (PVR) significantly increased only in group C.
UPP (Table-7)
Maximum
urethral closure pressure (MUCP) decreased steadily with age remaining
in the range of the “theoretical” value which is bladder filled
(110 - age) ± 20% in cm H2O (13).
MUCP was non significantly higher in continent
patients either with bladder empty or bladder filled, but was significantly
lower bladder filled vs. bladder empty in incontinent whatever the age
and incontinent in group B.
Urodynamic Diagnosis
Detrusor
hyperactivity (DO or DHIC) was the main urodynamic diagnosis increasing
significantly in group C: 68/157 (43%) vs. 38/137 (27%) (A) and 36/155
(23%) (B) (p = 0.0004) whatever the neurological status. DO was significantly
more frequent (p = 0.007) in the age-group C (28%) vs. A (23%) and B (15%)
and DHIC increased with ageing: 4% in A, 8% in B and 15% in C.
DUA was predominant in the oldest group
34/157 (22%) compared with 14/137 (10%) (A) and 14/155 (9%) (B). That
dysfunction was associated with an incompetent sphincter in 2 A patients,
5 B and 14 C.
Intrinsic sphincter deficiency (ISD) was
predominant in B 56/155 (36%) vs. A 34/137 (25%) or C 38/157 (24%).
Low bladder compliance (= 20 mL/cm H2O)
was predominant in group B: 10 women of which 9 were without neurological
disease.
Normal urodynamic tests were observed in
31 (22%) A patients, 24 (15%) in B and 18 (11%) in C.
Various or uncertain diagnoses were more
frequent in A (16%) and B (14%) than in C (6%).
COMMENTS
This
study was retrospective and therefore has its own limitations. However,
we used a standardized protocol for urodynamics and all files contain
the same items. The population is representative of community-dwelling
women with urinary disorders and age-groups are homogeneous in the number
of patients.
In our postmenopausal population, urinary
incontinence (UI) was the main motive for urodynamics with a percentage
variation between 61.3 and 68.8. These values, above the estimated prevalence
of urinary incontinence in middle-aged and older women (4), resulted from
our recruitment, i.e. women referred for evaluation of LUT dysfunction.
In the general population many patients avoid discussing problems related
to incontinence, lowering the recorded percentages. Prevalence of urinary
incontinence during the menopausal transition has been reported with a
variation from 8% to 56%; nevertheless, evidence that menopause is an
independent factor in the prevalence of incontinence remains lacking (4).
Mixed UI increases with ageing, probably
due to the association of a decreased urethral sphincter function and
occurrence of detrusor overactivity.
urge incontinence does not vary significantly with age. On the other hand,
stress incontinence appears as slightly predominant in age-group B in
patients who take oral or transdermal HRT (or who have taken it five to
ten years after menopause); this is consistent with the findings of Steinauer
et al. (14) who report an increased risk for stress incontinence in women
taking HRT.
Quality of life scores show that the impact
of LUT dysfunction remains stable with age.
Achievement of interpretable tests, requiring
a “comfortable” environment and some relaxation is often difficult
at the beginning of the session.
As previously reported (7) FBC does not
diminish with age and is smaller, with no variation with age, in DO subjects.
There are some surprising results as the
sub-group B differs from the others in terms of normal detrusor behavior,
low occurrence of DO and low bladder compliance. One plausible explanation
may by the higher incidence of stress incontinence in this group.
DO increases with age regardless of a history
of neurological disease or previous pelvic surgery. In the entire DO population,
pdet.op is higher than pdet.Qmax which may imply a common finding of an
incomplete sphincter relaxation at the onset of flow.
DHIC, is a common condition in frail elderly
individuals (12), and DUA increases in the same way; these two latter
behaviors lead respectively to UI with high PVR and to chronic retention.
The decrease of detrusor contractility with ageing can be related to the
decrease in caveolae, bladder weight and smooth muscle density with age
(3).
For a complaint consistent with bladder
overactivity (urge or mixed incontinence, frequency) similar percentage
(near 85%) in DO plus DHIC is found in the 3 age-groups. Qmax, pdet.op
and pdet.Qmax all decline with age in women without DO. This observation
is consistent with previous studies which show age-associated deterioration
of the detrusor contractility (15,16). However, decreased contractility
allows an effective emptying except in the oldest age-group where PVR
increases.
MUCP decreases with age, a result consistent
with previous studies (7); with the bladder filled, the values are in
the range of the “theoretical values” (13). Perucchini et
al. (17) reported that this decrease could be the reflect of the association
with age of a loss of striated muscle in the female urethra.
In incontinent women, the decrease observed
between bladder empty and bladder filled demonstrates a lack of adaptation
of the urethral sphincter to bladder filling. This behavior could be the
explained by both sphincter sarcopenia and impaired pelvic floor.
An unexpected and unexplained finding is
the significant decrease of MUCP bladder filled in continent women of
the middle age-group.
For a complaint consistent with an impaired
sphincter function (stress or mixed incontinence), a lower urethral closure
pressure than expected for age was found in only 52.6% (A), 57.4% (B)
and 62.7% (C).
Urodynamic diagnosis was found in a high
percentage (90% or more) of the 3 age groups.
Abnormal detrusor behavior appears as the
main final diagnosis with specific changes according to ageing. In the
oldest women without neurological disease, a significant increase of DO,
DHIC was observed; the increase of DUA was not considered significant.
The incidence of DHIC and DUA in this age group is more likely related
to decreased pdet.op and pdet.Qmax leading to an increased PVR.
In all groups, complaint of stress and urge
incontinence was respectively associated with ISD and detrusor hyperactivity
(DO or DHIC). Mixed incontinence was associated with ISD in age-groups
B and C and with detrusor hyperactivity in C.
One final question: Can the responsibility
of the changes in LUT function be attributed to the normal ageing process
or to menopause?
Although menopause has been shown to be
associated with urinary incontinence, evidence for it being an independent
factor in the prevalence of urinary incontinence and bladder dysfunction
remains lacking. In our population, menopause and ageing could be considered
as independent factors as the percentage of women taking HRT is insignificant.
Brisk changes in LUT function occurred in the oldest group while for the
two other age groups (A and B) changes were progressive. Note that the
change in urethral function is progressive with ageing. Therefore, if
the role of menopause can be considered in younger and middle age, we
propose that the role of ageing is predominant with a strenuous expression
in advanced age as it mainly implies the detrusor which is less dependent
on estrogens.
CONCLUSION
In our community-dwelling population of menopausal females urinary incontinence remains the main motive for urodynamics and there is an increasing complaint of urgency with ageing. The lack of adaptation of the sphincter to bladder filling could explain the complaint of incontinence. The role of ageing clearly results from deterioration in bladder function leading to DO, DHIC and DUA in the oldest group. Due to the brisk changes in detrusor function between the middle and the oldest age groups the role of ageing appears to predominate. Further studies are needed to search for a better understanding of the neural control of micturition in ageing women and to better define the conditions leading to impaired detrusor function in the oldest age groups.
CONFLICT OF INTEREST
None declared.
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____________________
Accepted after revision:
June 26, 2010
_______________________
Correspondence address:
Dr. Françoise A. Valentini
Université Pierre et Marie Curie (Paris 6)
4 Place Jussieu, 75005 Paris, France
Fax: + 33 1 4959-4697
E-mail: favalentini@gmail.com