VOIDING DYSFUNCTION IN ELDERLY PATIENTS

Voiding dysfunction in elderly patients is not a uniform disease entit y. Diseases of the cerebrospinal system, metabolic imbalances, detruso r degeneration and bladder outlet obstruction or sphincter impairment can all result in disabilities such as urinary retention and/or urinar y incontinence. Although the urodynamic pattern of an uninhibited neur opathic bladder resulting from a poorly functioning corticoreticular s ystem may seem to be normal in these elderly subjects, many of them ha ve lost control of the micturition reflex: the warning to void occurs suddenly at full bladder capacity, and the abrupt sensation that urina tion is imminent cannot be controlled appropriately. Classifying these symptoms under a simple common denominator, such a detrusor instabili ty can be misleading, because the therapeutic approach in these patien ts should be more highly differentiate. Detrusor overactivity may be s ymptomatic and associated with curable diseases of the lower urinary t ract, such as bladder outlet obstruction, urinary tract infection or b ladder cancer. On the other hand, some of the underlying causes of so- called idiopathic detrusor overactivity have been disclosed recently b y Elbadawi et al. (1993), relating detrusor impairment to detrusor deg eneration characterized morphologically by a dysjunction pattern. In t his setting, it cannot be overemphasized that better knowledge of the underlying disease will result in more successful treatment of the voi ding disability in such patients. Urinary incontinence in elderly pati ents is not always due to an incompetent urinary sphincter, and urinar y retention in this age group is not always the result of a bladder ou tlet obstruction. Before contemplating any surgical intervention in th ose elderly patients with urinary retention or urinary incontinence, a ge-related dysfunc tion of the lower urinary tract must be excluded an d the diagnostic work-up should include, in particular, underlying med ical, psychological, neurogenic and degenerative disorders. Bladder dy sfunction is especially common in elderly people, and an effective app roach to the problem should focus research and treatment on the impact that normal ageing has on the lower urinary tract. Therefore urologis ts should keep in mind the importance of this rather large-scale, if u nrewarding, problem in our ageing population.