MDNews - Cleveland-Akron-Canton

++++++++++++++++++++++++++++++++ +++ +++ ++++++++++++++++++++++++++++++++ CARING FOR THE ELDERLY + + ages 70+. Although the detailed path of physiology of OAB is not well understood, it is clear that aging, menopause, diabetes and increased BMI are signifi cant risk factors. In a majority of cases, the over activity happens both during the day and night. However, there are patients whose incontinence is an issue during sleep. As a part of the aging process, the amount of urine excretion increases proportionately at night. This would add to the frequency of urination and the urinary inconti- nence. A number of studies, including a recent study sponsored by the National Institutes of Health, have indicated that the prevalence of urinary incontinence is on the rise. Between 2001 and 2007 only, there was an additional 5% increase in the prevalence of urinary incontinence. Although OAB and bladder control problems affect both men and women, it appears that women constitute the larger portion of the affected population. Over the past several decades, a num- ber of effective treatment options have been introduced to successfully treat OAB. The treatment options range from pharmacological agents that affect the bladder selectively to recent introduction of Botox injection into the bladder. In a smaller percentage of cases, OAB can be treated by placement of a neuromodulator. Despite the common prevalence of OAB the other causes of symptoms of fre- quency, urgency and urgent continence that may require immediate attention, need to be ruled out. Superfi cial bladder tumor, urinary tract infections, bladder stones, or other acute inflammatory conditions could present themselves Geriatric Urology O By Firouz Daneshgari, MD VERACTIVE BLADDER (OAB) or urinary incontinence is a common condition affecting more than 50% of women as OAB. Therefore in screening for OAB, these causes should be ruled out. Algorithm for treatment of OAB will constitute a urine analysis cyctoscopy or urodynamics if indicated and initiation of an oral or patch medication. The majority of the available phar- maceutical agents function through the antimuscranic function. If the patient cannot tolerate the medication or has unwanted side affects such as dry mouth, blurry vision, or change in mental status, the use of Botox (Botulium A) toxin has been shown in Level I evidence to be effective for treatment of both dry OAB or overactive bladder associated with urinary incontinence. Currently the use of Botox for OAB is not FDA approved, this treatment is offered as an off label treatment in urology subspecialty clinics. Case Study: Urinary Tract Infection or Asymptomatic Bacteriuria? An 87 year old female presents with recurring issue of positive urine dip stick in her routine checkup with her primary care physician. The dip stick is positive for leukstrase and positive for blood. The PCP refers the patient to a urology specialist for the condition due to concern that a prescription of antibiotics, more than six times over the last two years, may create additional medical problems. During the patient's presentation at the urologist's offi ce, the following question was asked: Did the patient have any additional symptoms were present with the positive urine dipstick such as frequency of urination, urgency, or burning while urinating? Following a complete physical exam, including a pelvic exam, the urologist discussed that simple positive urine dipstick or even presence of bacteria in the bladder at the elderly age, is not always indication of urinary tract infection. The presence of bacteria in the urine (bacturia) and lack of any symptoms (asymptomatic) is a known phenomenon and occurs in more than 30% of women above the age of 65. The causes for Asymptomatic Bacturia (AB) are far from clear. In the absence of other contributing factors such as presence of pelvic organ prolapse, which would indicate improper emptying of the bladder, or simple inability of the bladder to empty itself completely (impaired contractility), it appears that AB is a refl ection of the bladder remodeling that occurs during the geriatric years — very similar to a situation that occurs in diabetes or neurogenic bladder. It appears that the bladder's ability to rid of bacteria decreases as the bladder ages. In the absence of bothersome symptoms, such as frequency/urgency or burning, simple presence of bacteria, and especially if the count is less than 10 to the 5th colonies per mL, it could simply be observed and not treated with antibiotics. However, if there is an associated symptom or presentation of atypical symptoms, such as confusion, changes in mental status, lack of appetite or nausea, these should be taken seriously in association with a presence of bacteria in the urine. In the presence of such conditions, an active treatment route should be implemented. Dr. Firouz Daneshgari is a urologist and fellowship trained in female pelvic medicine and reconstruction surgery. He is the director of the University Hospitals Urology Institute. He is also the Lester Persky Professor and chairman or the Department of Urology at Case Western Reserve University School of Medicine. n NOVEMBER-DECEMBER 2011 MDNEWS.COM MD NEWS Cleveland-Akron-Canton | 17

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