Urological problems in old age

The extension of life expectancy is one of the most dramatic achievements of the 20th century. Elderly population, over 65 years, is the fastest growing age group. Rcent Census shows how the age pyramid is showing increase in old age population.






The typical general problems in elderly population are:
• Change in dexterity, decreased mobility : because age related tremors or Parkinsonism/stroke etc.
• Altered Mentation, Sleep pattern: because of age related amnesia
• Comorbidity: HTN, stroke, diabetes, Alzheimer's etc
• Concomitant drug intake: multiple comorbidities
The typical urological problems along with abovesaid general geratric problems are:
• Aging Bladder: Prostatic enlargement& Bladder instability- causing frequency of urination,weak stream ,urgency,nocturia.Nocturia and urgency can be dangerous as the old frail people can have falls and fractures adding to their woes while rushing to the toilets in the night time.Many of Prostatic problems can be treated with medicines avoding the agony.Those people who have severe problems can be easily ttreated surgically with LASER.LASER prostatectomy can offer effective treatment in elderly people with co-morbidities without complications as in routine conventional surgeries.
• Hormonal alterations (age related decline in androgen production):Many people experience erectile dysfunction which they ignore or feel shy to express to doctors passing off as age related problem.Testosterone supplemenation with or without PDE-5 inhibitors help in restoring manhood in may such people.
• Tendency to excrete more water during night: causing nocturnal trips to toilets disturbing a sound sleep.There are nasal sprays available to decrease nocturnal excretion of extra urine.
• Malignancy: Carcinoma prostate : Many western countries have successfully started screening programme(Digital Rectal Examination and Sr PSA) in aged popultation which might result in early detection of cancer and resultant less morbidity.
• Incontinence:Overactive Bladder or weak sphicters because of aging /multiple vaginal births/bladder changes can cause miserable life in females leading to social embarassment. Medications to decrease overactivity or increasing the bladder capacity may reduce the incontinence.Ostrogen topical supplementation in elderly females may enhance local defense mechanism
• Urinary tract infections :Old people may not exhibit same symptoms like dysuria, fever,LUTS like young adults instead they present with lethargy, confusion, weakness or new onset incontinence. Unabated infections if not treated early :may lead to urospepsis with high mortality so Appropriate antibiotics with or without Foley catheterisation/Intermittent catheterisation is the treatment in many patients.Caution has to be exercised when giving antibiotics as the tolerance to antibiotics is always not like young adults.
These are the common urological problems in geriatric population.Many simple measures such as medications for prostate enlargement, antibiotics for infection ,anti-incontinence medications for urine leakage can solve the majority of the issues.Testosterone supplemenation in properly screened aging population can restore not only the erectile dysfunction but feeling of general well being,muscle mass,hemoglobin etc.Challenges in old age are limited mental & functional ability which interferes with learning, motivation, and cooperation needed for successful treatment.So may elderly people suffer in silence.Apart from curing the specific illesses strategies are needed that help to address these psychosocial issues and needs in older patients. As the proportion of elderly people is on the rise, special emphasis should be laid down on the their needs and suitability to treatment.

Penile stress test:window to hearts of men

Many people are hesitant to consult for erectile dysfunction(ED) in their mid 50 s.They think it is a part of ageing.But erectile dysfunction in middle ages can be because of generalised endothelial dysfunction.It could be a presursor of future heart problems.That is the reason many andrologist would call erectile dysfunction as a “wake up call” to coronary artery disease.It has been found that after adjustment for age, ED correlated with the presence of heart disease, hypertension, Diabetes Mellitus, smoking and inversely with protective Lipids(HDL).

Penile erection is caused by a series of actions: relaxation of cavernosal arteries and cavernosal sinuses leads to increased blood flow into the penis, pooling of blood in the sinuses, and an increase in corpus cavernosum pressure.The same NO-cGMP pathway that is critical to erectile function was discovered years earlier as a key endothelium derived dilator of arteries in the systemic, coronary, and
pulmonary vasculatures.In the clinical setting, loss of endothelial NO occurs in the earliest stages of atherosclerosis. In fact, it has been linked to each of the known atherogenic risk factors, such as various forms of dyslipidemia, hypertension, diabetes, cigarette smoking, aging, menopause, hyperhomocystinemia, and a family history of premature atherosclerosis.Although atherosclerosis in its early stages tends to be focal, preferentially localizing to sites of abnormal hemodynamic stresses, loss of endothelium-derived NO in the setting of risk factors is much more generalized and affects nearly all arterial beds, including the arterial blood supply to the penis and the endothelium lining cavernosal sinuses.
Because the arteries supplying penis are smaller than the coronary arteries.So the process causing decereased flow in penile arteries is an harbinger of decreased flow in heart and brain vessels in the future.
So, 57% of men undergoing coronary artery bypass grafting and 64% of men with acute myocardial infarction had preceding ED of some duration. Interestingly, subjects with ED have evidence of endothelial dysfunction in systemic arteries, and an impairment in the NO-cGMP pathway is present before any other evidence of atherosclerotic process is detectable by sophisticated testing. It has been suggested that a deficiency of NO manifests early as ED because erection requires a comparatively large, perhaps 80%, dilation of penile arteries, and hence, this system can ill-afford a loss of NO.Thus, ED, just as endothelial dysfunction, appears to be a sensitive forerunner of atherosclerosis and its complications.

Patient With Multiple Renal And Ureteric Calculi

A 38 year old patient presented with pain in the left flank and fever of 15 days duration.He was a known case of renal stone disease having undergone Percutaneous Nephrolithotomy(PCNL) 5 years back on the same side.

On investigations there were with multiple left renal calculi bulk mainly in lower and middle calyceal groups and multiple lower ureteric stones .He was treated with suitable antibiotic medications till his Urine culture became sterile.
He was then taken up for Ureteroscopy first in view of making him free of ureteric obstruction.With Holmium LASER lithotripsy all stones were pulverised and a 5.5 Fr DJ stent was placed.

Ater a period of 2 days; he was taken up for conventional PCNL.The access was done through posterior-inferior calyx and middle posterior calyx. The complete fluoroscopic and endosocpic clearance was achieved with the use of LASER lithotripsy.

With availability of Holmium LASER as energy medium for stone pulverisation the dwell time in ureter and pelvi-calyceal system has been reduced greatly.It gives us freedom for initially going for Ureteroscopy and rapid stone clearance instead of PCN placement which is done conventionally in Febrile UTI with stones.Thus many complicated stone patients can be tackled in minimun possible sittings without compromising on safety.

Mini PCNL

A 50 year old lady presented with pain in the right flank of 2 years duration.
On investigations there was with right sided staghorn calulcus.



She was taken up for Mini-PCNL.The access was done through posterior-inferior calyx. A J-tip PTFE guide wire was placed in the system.Serial dilatation was done till 15 Fr and 15 Fr Sheath was introduced. The sheath has a offshoot Luer-Lock outflow for reduction of intra-pelvic pressure so as to reduce the incidence of sepsis.A wide angle straight forward telescope 12 ° with angled eyepiece (Karl Storz, Tuttingen, Germany) was used as nephrosocpe.Holmium LASER energy was used as energy for stone dis-integration.









The procedure took 60 minutes and the procedure was completed with the intoduction of small bore nephrostomy tube .The post-operative X-ray showed near total clearance of the calculus.



Stones of the renal pelvis can be treated either by extracorporeal shock wave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). As a low-risk procedure with a longer treatment period, SWL often leads to persistent residual stone fragments, whereas conventional PCNL achieves a higher stone-free rate and allows a shorter treatment period albeit with a somewhat higher surgical risk. To reduce the invasiveness of conventional PCNL, the application of a miniaturised instrument for PCNL (MPCNL) has come in vogue.
Miniature percutaneous (mini-perc) access was first described in the pediatric population by Jackman et al (1997) as an alternative to standard PCNL. Generally, it consists of downsizing to smaller percutaneous access sheaths with the intention of decreasing blood loss, postoperative pain, and the hospital stay in patients undergoing nephroscopic procedures. Feng et al (2001) found that PCNL performed via the mini-perc technique was disadvantageous with regard to visibility and optics compared with PCNL performed through the standard access diameter. Deane and Clayman (2007) published a review on PCNL and concluded that PCNL performed via the mini-perc technique appears to have little value, except in children.
In our experience we have found that mini-PCNL with Holmium LASER application can complete the procedure even in larger stone burden in a reasonable time.The bleeding has been remarkably less than the conventional PCNL.In some cases we can always stage the procedure in the safety of the patient.The post-operative pain and the requirements of the analgesia has been less.As far as visibility is concerned ;as the shearing of renal parenchyma is less during dilatation,the tract bleeding is less so the pelvi-calyceal system most-often is clear.This clarity of vision allows s to use gretaer power Holmium for stone pulverisation and the clearance is rapid.We are a referral centre here in Hyderabad and most often get difficult stagorn calculi but in most of the cases we could clear stones with miniature PCNL without having to resort to a large 28 or 30 Fr tract.

Primary obstructive megaureter with type 3 annular posterior urethral valve

We had a 14- year -old boy presenting with on and off right sided flank pain and recurrent UTIs. His ultrasonography revealed grossly hydronephrotic right kidney with thinned out parenchyma.His renal function tests were normal.




Intravenous Pyelography showed Right Grossly dilated system with dilated tortuous and elongated ureter with delayed excretion.
DTPA scan was done for evaluation of renal function; it showed 15 % relative function on that side with delayed transit.



MCU ruled out the reflux but there was annular constriction at the post urethra suggestive of postrior urethral valve.



The patient was taken up for cystoscopy( with a paediatric scope) and we found annular Type 3 annular valve.This valve got disrupted with cystoscope. The bladder was appearing healthy.(in contrast to what we had imagined)
The patient was taken up for surgery as the kidney was decompensated with obstructive megaureter. The ureter was tapered on lateral side(Hendrens tapering) and with Paquins method the ureter was reimplanted. The bladder was not thickened making the obstructive mega-ureter to be of primary type.
Imaging and intra-operative photographs of the case are are shown.
The interesting point to note that primary obstructive megaureter co-existing with type 3 annular valve is a very rare event and posed dilemma for us.