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Urogenital consequences in ageing women

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Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman's life span and contribute to pelvic floor disorders. Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. The exact mechanisms and pathophysiological processes by which ageing affects pelvic floor and lower urinary and gastrointestinal tract anatomy and function are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor. Other conditions associated with ageing that may co-exist, such as changes in mental status, can result in different types of pelvic floor dysfunction (e.g. functional incontinence). Pelvic organ dysfunction may be associated with significant morbidity and affect quality of life. These groups of patients often pose difficult diagnostic and therapeutic dilemmas owing to complex medical conditions and concurrent morbidities. In this chapter, we summarise the current evidence on the management of pelvic floor disorders, with emphasis on elderly women and the associations between the ageing process and these disorders. Clinicians with an understanding of the affect of ageing on the pelvic floor and lower urinary and gastrointestinal tract anatomy and function, and the complex interplay of other comorbidities, will be able to investigate, diagnose and treat appropriately there women. A holistic approach may result in substantial improvements in their quality of life.

Introduction

Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman's life span to contribute to pelvic floor disorders (PFDs). Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. In most cases, PFDs co-exist, making multidisciplinary assessment and treatment essential.1 Although age is a well-known factor affecting pelvic floor and lower urinary and gastrointestinal tract anatomy and function, the exact mechanisms and pathophysiological processes are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor.

Although pelvic organ disorders may result in significant morbidity and can be life altering, they rarely affect woman's overall physical health or life expectancy. The purpose of any treatment should be symptom relief and restoration of normal pelvic anatomy and function. Decisions about diagnostic and therapeutic interventions, however, should ensure that the expected anatomical, functional, and quality-of-life improvements should outweigh risks of morbidity and complications of the treatment.2

Increased life expectancy, women's awareness of pelvic floor health, disorders with associated quality of life considerations, and the development of various treatment modalities over the past few decades, are factors that have resulted in an ever-increasing demand and usage of healthcare resources in this field. The estimated demand for consultations for PFDs is anticipated to increase by 30% by the year 20303; women undergoing stress urinary incontinence surgery will increase by 47.2%; and those who will have surgery for pelvic organ prolapse will increase from 166,000 in 2010 to 245,970 in 2050 in the USA.4

In women with frailties, multiple comorbidities, or cognitive dysfunction, the primary aim should be to optimise quality of life. Thus, decisions for treatment modalities require a thorough assessment of the woman's condition, and a recognition that some women may be too frail to undergo interventions with surgical and anaesthetic risks.5

Section snippets

Pelvic organ prolapse

Age, body mass index, and higher vaginal parity, are the most common risk factors for pelvic organ prolapse (POP). Studies from the Women's Health Initiative, which included women in the USA aged between 50 and 79 years, reported a prevalence of any degree of prolapse (grades 1–3) based on examination to be 41.1%.6, 7 The prevalence of cystocele was 24.6–34.3%, rectocele 12.9–18.6%, and uterine prolapse 3.8–4.2%. Among 1000 women who presented for an annual gynaecological examination, every

Urinary incontinence

Urinary incontinence can result in psychosocial difficulties, including low self-esteem, sexual dysfunction, social isolation, and loneliness.30

In elderly women especially, urinary incontinence may have associated medical complications, and some investigators consider it as a marker for an increased mortality rate in some cases.31 Many elderly women accept it as a normal part of ageing, and they do not seek help earlier than an average of 4 years.32

Geriatric incontinence evaluation begins with

Urinary urgency incontinence

Urinary urgency incontinence (UUI) can be caused by involuntary bladder contractions or poor bladder compliance that results from loss of the viscoelastic features of the bladder. It is most commonly idiopathic; however, it is associated with advancing age, and cognitive and neurological impairment. Moreover, aetiology, pathophysiology, and rationale of different treatments in elderly people with urinary urgency incontinence, is poorly understood, making communication and appropriate

Stress urinary incontinence

Stress urinary incontinence is caused by increased intra-abdominal pressure that exceeds the urethral pressure.52 Urethral hypermobility or intrinsic sphincter deficiency affect the continence mechanism.

Anal incontinence

Most studies report a significant effect of age on risk of fecal incontinence.64, 65 Fecal incontinence is a debilitating condition,66 yet the underlying mechanisms are still not fully understood.64 In institutionalised patients, fecal incontinence may be a marker of declining health and increased mortality.67 Immobility and dementia preclude patients from reaching the toilet in time, and are important associated factors of fecal incontinence.

Fecal incontinence is more common in women with

Chronic constipation

Constipation and laxative use is highly prevalent among elderly people,77 particularly among those who are institutionalised. Studies suggest a prevalence of about 50% of nursing-home residents using daily laxatives.78 Severe constipation is seen most commonly in women; elderly women having two to three times higher rates than their male counterparts,79 mainly because of colonic transit and PFD.

The altered mechanical properties, structural changes, and control of the pelvic floor in elderly

Urinary tract infections

Urinary tract infections are the most common bacterial infections among older people. More than 50% of women sustain a UTI in their lifetime, and about 10% of women have an episode annually.93 It can range from asymptomatic to symptomatic, to even life-threatening urosepsis. It can also be uncomplicated in women with normal genitourinary tract, or complicated, in women with functional or structural abnormalities.94 Urinary tract infections are a principal cause of falls among nursing-home

Sexual function

Sexual function may be affected by various factors associated with the ageing process. Mucosal atrophy, scars, a short or narrow vagina, or a contracted pelvic floor, can result in sexual pain. Lack of physical sexual response can also result in discomfort and pain.

During menopause, different changes take place, and sexual health may be affected. Fear of leakage and use of pads can lead to decreased frequency of sexual activity. Coital incontinence with its two forms leaking with penetration

Conclusion

Ageing in women can have multifactorial implications on the urogenital and lower gastrointestinal tract, with different effects on anatomy, function and quality of life. Multidisciplinary input is of paramount importance in the management of women with complex disorders and comorbidities. Cognitive function, mobility and physical status, concomitant medication, perioperative care, and appreciating the uncertainty of the recovery time are factors that should be taken into account in decision

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