Best Practice & Research Clinical Obstetrics & Gynaecology
5Urogenital consequences in ageing women
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
References (141)
- et al.
Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence
Am J Obstet Gynecol
(2005) Overview of pelvic floor disorders
Surg Clin North Am
(2010)- et al.
Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050
Am J Obstet Gynecol
(2011) - et al.
Geriatric gynecology: promoting health and avoiding harm
Am J Obstet Gynecol
(2012) - et al.
Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women
Am J Obstet Gynecol
(2004) - et al.
Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity
Am J Obstet Gynecol
(2002) - et al.
Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects
Am J Obstet Gynecol
(2005) - et al.
Innervation of the female levator ani muscles
Am J Obstet Gynecol
(2002) - et al.
Pathophysiology of pelvic organ prolapse
Obstet Gynecol Clin North Am
(2009) - et al.
Trends in use of surgical mesh for pelvic organ prolapse
Am J Obstet Gynecol
(2013)
Risk factors for mesh/suture erosion following sacral colpopexy
Am J Obstet Gynecol
Risk factors of surgical failure following transvaginal mesh repair for the treatment of pelvic organ prolapse
Eur J Obstet Gynecol Reprod Biol
Factors which influence the short-term success of pessary management of pelvic organ prolapse
Am J Obstet Gynecol
Pelvic floor symptom changes in pessary users
Am J Obstet Gynecol
Patient characteristics that are associated with continued pessary use versus surgery after 1 year
Am J Obstet Gynecol
Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one-year results compared to younger patients
Urology
Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study
Am J Obstet Gynecol
Regret, satisfaction, and symptom improvement: analysis of the impact of partial colpocleisis for the management of severe pelvic organ prolapse
Am J Obstet Gynecol
The association between urinary and fecal incontinence and social isolation in older women
Am J Obstet Gynecol
Urinary incontinence in women
Med Clin North Am
Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse
Obstet Gynecol
Hip fractures, nocturia, and nocturnal polyuria in the elderly
Arch Gerontol Geriatr
Urinary incontinence in the elderly
Clin Geriatr Med
Urodynamics
Crit Care Nurs Clin North Am
Urodynamics: role in incontinence and prolapse: a urology perspective
Urol Clin North Am
Misconceptions and miscommunication among aging women with overactive bladder symptoms
Urology
Botulinum toxin A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review
Eur Urol
Trends in stress urinary incontinence inpatient procedures in the United States, 1979–2004
Am J Obstet Gynecol
An open, multicentre study of NASHA/Dx Gel (Zuidex) for the treatment of stress urinary incontinence
Eur Urol
Urethral bulking: a urology perspective
Urol Clin North Am
Is injection therapy for stress urinary incontinence dead? No
Urology
Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the surgical treatment of female stress urinary incontinence
Eur Urol
The Marlex sling operation for the treatment of recurrent stress urinary incontinence: a 16-year review
Am J Obstet Gynecol
Midurethral slings for stress urinary incontinence: a urogynecology perspective
Urol Clin North Am
Pathophysiology of adult fecal incontinence
Gastroenterology
Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life
Am J Obstet Gynecol
Fecal incontinence in the institutionalized elderly: incidence, risk factors, and prognosis
Am J Med
Fecal incontinence in older women: are levator ani defects a factor?
Am J Obstet Gynecol
General geriatrics and gastroenterology: constipation and faecal incontinence
Best Pract Res Clin Gastroenterol
Outcomes of combination treatment of fecal incontinence in women
Am J Obstet Gynecol
Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation
Clin Gastroenterol Hepatol
Chronic gastrointestinal symptoms in the elderly
Clin Geriatr Med
Age-related changes in the morphology of the myenteric plexus of the human colon
Auton Neurosci
Ageing of the enteric nervous system
Mech Ageing Dev
Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia
Gastroenterology
Surgical treatment of patients with constipation and fecal incontinence
Gastroenterol Clin North Am
Urinary tract infections in the elderly
Clin Geriatr Med
Urinary tract infection in patients with acute coronary syndrome: a potential systemic inflammatory connection
Am Heart J
Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital
Am J Infect Control
The demographics of pelvic floor disorders: current observations and future projections
Am J Obstet Gynecol
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