Genitourinary Emergencies in Older Adults





Older adults are frequently seen in the emergency department for genitourinary complaints, necessitating that emergency physicians are adept at managing a myriad of genitourinary emergencies. Geriatric patients may present with acute kidney injury, hematuria, or a urinary infection and aspects of how managing these presentations differs from their younger counterparts is emphasized. Older adults may also present with acute urinary retention or urinary incontinence as a result of genitourinary pathology or other systemic etiologies. Finally, genital complaints as they pertain to older adults are briefly highlighted with emphasis on emergent management and appropriate referrals.


Key points








  • Asymptomatic bacteriuria in older adults is common. It is frequently misdiagnosed and inappropriately treated.



  • Urinary tract infections in geriatric patients are more likely to be complicated, caused by a multidrug-resistant organism, and require a longer course of treatment.



  • Urinary incontinence has a broad differential; emergent conditions include urinary tract infections, spinal cord pathology, and delirium.



  • Abuse of older adults is under-recognized, whether in the form of neglect, physical abuse, or sexual abuse.



  • Microscopic hematuria should not be dismissed and should always be referred for outpatient follow-up.




Introduction


Older adults comprise 15% of the US population and are expected to reach 21% in 2040. With this population growth comes a more pronounced use of emergency care, necessitating a thorough understanding of the unique considerations of this age group. Many genitourinary (GU) complaints, such as retention, incontinence, pelvic organ prolapse, and urinary tract infections (UTIs), are more likely to occur in older adults. However, older adults may be less likely to seek care for GU complaints, and when they do, they are less likely to receive evidence-based care. Older adults’ emergency department (ED) visits may further be complicated by acute or chronic cognitive impairments limiting the ability to obtain an adequate history, shame or embarrassment related to the sensitive nature of GU complaints as well as challenges associated with the fast-paced nature of EDs themselves. Moreover, several life-threatening conditions may masquerade as benign genital complaints, as summarized in Box 1 .



Box 1

Life-threatening conditions presenting as urogenital complaints





  • Emphysematous pyelonephritis



  • Incarcerated hernia



  • Necrotizing fasciitis (Fournier’s gangrene)



  • Renal infarction



  • Testicular torsion




Background


Pertinent History


Sexual history


Clinician questions should avoid assumptions of heterosexuality or abstinence when discussing a geriatric patient’s sexual behavior ; lesbian, gay, bisexual, and transgender people make up 5% to 10% of the population overall and 25% of patients in their 80s are sexually active. One approach to start the conversation with the patient may be to ask, “Are you currently satisfied with your sexual activity?” Follow-up questions regarding gender identity, sexual orientation, number of partners, frequency and type of activity, penile implants, hormone replacement, and medications can ensue. Lesbian, gay, bisexual, and transgender older adults are less likely to divulge their sexual history to health care providers for fear of discrimination and refusal of care, especially given that they grew up in a time when their behavior was considered pathologic.


Medications


Polypharmacy is common among older adults and may contribute to acute urologic complaints. Older adults presenting to the ED should have their medications reviewed (prescribed, over the counter, and recreational) for iatrogenic causes of their presentation, specifically for medications with peripheral alpha-1 blockers and anticholinergic properties. Medications used to treat menopausal symptoms or erectile dysfunction may not be thought of as “medications” and should be specifically inquired about as well.


Mistreatment and abuse


Older adults should be screened for elder abuse, especially those with cognitive or physical impairment. The most common type of mistreatment is neglect, such as improper toileting, poor hygiene, and delay in seeking care, and should raise a red flag for further inquiry.


Pertinent Physical Examination


Evaluating a patient with a GU complaint should include abdominal palpation to detect a distended bladder as well as abdominal masses and chaperoned genital and rectal examinations. All patients with irritative voiding symptoms should be offered a genital examination, because they may not recognize the presence of genital culprit for their symptoms or be too embarrassed to disclose it to the physician. Fecal impaction, prostate enlargement or tenderness, perineal sensation, and abnormal sphincter tone should be elicited on rectal examination. Positioning a patient in a manner that allows adequate GU examination and visualization of the perineum, such as the lithotomy position, may be logistically challenging and uncomfortable for older adult patients and require the assistance of other health care team members. Patients suspected to have a hernia or pelvic organ prolapse should be examined while standing, if possible. A neurologic examination is essential to identify spinal cord abnormalities and peripheral neuropathy. Signs of physical or sexual abuse may be uncovered while performing a physical examination and should be addressed immediately. Logistical difficulties should not deter the physician from performing a thorough examination.


Urinary tract pathology


Acute Kidney Injury


Older adults are susceptible to acute kidney injury (AKI) given that renal blood flow decreases by 10% every decade after the age of 50, especially in patients with hypertension and chronic heart disease. When compared with those without AKI, patients with AKI are more likely to be older, have underlying chronic kidney disease, progress to end-stage renal disease, and have increased mortality, especially in the setting of sepsis or heart failure. ,


Older adults with renal failure are more likely than younger adults to present with vague concerns and report symptoms of weakness, dizziness, or feeling tired and generally unwell. Questions regarding urine color and output, uremic symptoms (such as nausea, vomiting, and headache), and fluid overload are important. Physical examination ranges from unremarkable to signs of dyspnea with rales, disorientation, and an ill appearance.


Serum creatinine is the most commonly used laboratory value to estimate kidney function. However, the levels can be confounded by volume overload, low body weight, and a decrease in production during acute illness, particularly in older adults. Calculating the creatinine clearance by taking into account the patient’s weight and age is a more reliable estimate for renal function than serum creatinine alone.


An investigation of the cause of the AKI requires consideration of prerenal (hypovolemia), renal (intrinsic renal injury), and postrenal (obstruction at any level along the urinary tract) etiologies, which may occur concurrently or independently. For example, AKI in the setting of sepsis may be due to exposure to nephrotoxic drugs, diminished renal flow secondary to inflammation from sepsis, hypovolemia, or underlying renal disease.


The managing the underlying cause of AKI improves symptoms and may resolve the injury. Treatment for AKI in older adults does not generally differ from that in younger patients, with some exceptions. Comorbidities such as diastolic heart failure require frequent reassessment during fluid resuscitation to avoid fluid overload. Ethical considerations and shared decision making are necessary before starting a life-altering treatment such as dialysis.


Hematuria


Hematuria may be visible (gross) or seen only on urinalysis (microscopic); the latter is commonly found incidentally during an evaluation for other complaints. A confirmation of the origin of any hematuria may require a physical examination and potentially a straight catheterization, because many patients reporting hematuria actually have a vaginal or rectal source of their bleeding. The timing of bleeding relevant to urination can give clues regarding its potential urinary source, as outlined in Fig. 1 .




Fig. 1


The timing of hematuria.


Infection and anticoagulation are common causes of gross hematuria in older adults. With advancing age, more worrisome etiologies should be considered, such as aortic dissection with extension into the renal vasculature, renal vein thrombosis, urinary tract tumors, or acute tubular necrosis. Myoglobinuria resulting from rhabdomyolysis should be considered in the differential of “blood in the urine” as well.


The etiology of the bleeding determines disposition and treatment. Benign prostatic hyperplasia (BPH) causing significant bleeding and hemodynamic instability is an indication for emergent intervention such as transurethral resection of the prostate. , Asymptomatic microscopic hematuria is commonly due to BPH or urologic malignancy. Older adults, particularly current or former smokers, have a high risk of malignancy and should follow up with urology.


Urinary Retention


Acute urinary retention (AUR) is the inability to voluntarily void and can lead to infection, hydronephrosis, and renal failure. Comorbidities and polypharmacy can alter the presentation in older adults; AUR is often associated with fecal impaction, delirium, and constitutional symptoms. AUR affects up to 10% of men in their 70s and one-third of men in their 80s. BPH is the most common cause of AUR in older males and age is the greatest risk factor for BPH. Obstructive symptoms such as frequency, nocturia, and dribbling of urine affect 25% of men by age 60 years and 45% by age 85. However, it is prudent to avoid anchoring on BPH in older men and consider other causes of AUR such as acute prostatitis, especially in the presence of additional symptoms such as fever.


There are few published data addressing occurrence rates and treatment of AUR in women. The most common causes of AUR in women are detrusor underactivity, obstruction (such as bladder masses and pelvic organ prolapse), or iatrogenic (gynecologic surgery). Causes of AUR in both sexes are summarized in Box 2 . A list of medications causing retention is in Box 3 .



Box 2

Causes of AUR in males and females

Data from : Serlin DC, Heidelbaugh JJ, Stoffel JT. Urinary Retention in Adults: Evaluation and Initial Management. Am Fam Physician . 2018;98(8):496-503.





  • Bladder cancer or stones



  • Infection



  • Medication side effects



  • Neurogenic bladder secondary to chronic diseases (eg, diabetes, peripheral neuropathy)



  • Spinal compression



  • Trauma (bladder, hip, pelvis, or urethra)



  • Urethral stricture




Box 3

Medications causing urinary retention

Data from : American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc . 2019;67(4):674-694; Curtis LA, Dolan TS, Cespedes RD. Acute Urinary Retention and Urinary Incontinence. Emerg Med Clin North Am . 2001;19(3):591-620.





  • Anticholinergics



  • Antidepressants



  • Antihistamines



  • Antiparkinsonian agents



  • Antipsychotics



  • Muscle relaxants



  • Nonsteroidal anti-inflammatory drugs



  • Over-the-counter cold medications



  • Sympathomimetics




Draining a distended bladder provides pain relief and should be done immediately unless contraindications exist, such as a recent urologic procedure. Rapid emptying of an enlarged bladder has been reported to cause a vagal response, resulting in temporary hypotension and/or hematuria; however, studies show neither is common nor clinically significant. , When a precipitating cause of AUR can be identified, such as infection, constipation, or medication, it should be rectified and a spontaneous voiding trial performed. The optimal timing for a voiding trial is unclear ; it is reasonable to attempt spontaneous voiding while in the ED and discharge the patient with an indwelling catheter if voiding fails. Men with BPH may be started on alpha blockers in the ED; alpha blockers before removal of the catheter increase the success rate of voiding. , In contrast, there are few data for the benefit of alpha blockers in treating female urinary retention. Alpha blockers may cause hypotension and are best taken at bedtime. Follow-up in three days improves outcomes and reduces complications.


The postvoid residual (PVR) is the amount of urine retained in the bladder after a voluntary void and can be an objective measure of urinary retention. Clinically significant PVR volume is unclear; it is highly dependent on the clinical context and may range from 100 to 500 mL. Asymptomatic individuals should be followed up in the primary care setting for the development of symptoms, especially those without prior history of elevated PVR volumes. Symptomatic patients with an elevated PVR or those with obstructive complications require an urgent urology referral. Hospitalization is indicated when AUR precipitates or exacerbates comorbid medical conditions or is associated with acute renal failure, urosepsis, malignancy, or spinal cord compression.


Urinary Incontinence


Discerning the acuity of urinary incontinence is necessary, because 20% of older adults in the community have some element of urinary incontinence at baseline, a percentage that increases to 75% in residents of long-term care facilities. There are different types of incontinence and more than one type may coexist ( Table 1 ). Urge incontinence is more common in the older population. However, stress and mixed incontinence have similar frequencies in younger and older women. The differential diagnosis of acute incontinence is broad, encompassing GU, neurologic, and pharmacologic causes. , A helpful mnemonic for the differential of acute incontinence is DIAPERS, summarized in Table 2 . The disposition and management depend on the underlying etiology.



Table 1

Different types of urinary incontinence

Data from: Nitti VW, Blaivas JG. Urinary incontinence: Epidemiology, pathophysiology, evaluation, and management overview. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell’s Urology, ed 9. Philadelphia: WB Saunders Co; 2007: 2046; and Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary incontinence in women. JAMA . 2017;318(16):1592.
























Type Definition Cause
Urgency incontinence Involuntary urinary loss with a sensation of urgency Idiopathic; systemic neurologic condition
Stress incontinence Involuntary urinary loss with activities that increase intra-abdominal pressure (eg, exertion, sneezing, coughing) Abnormal urethral closure; repetitive increase in intra-abdominal pressure.
Mixed incontinence A combination of urgency and stress incontinence Any of the causes above
Overflow incontinence Incomplete urinary bladder emptying from detrusor underactivity or areflexia Systemic neurologic conditions; urethral obstruction


Table 2

Differential diagnosis of acute urinary incontinence: the DIAPERS mnemonic

Adapted from : Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary incontinence in women. JAMA . 2017;318(16):1592; and Resnick NM. Initial evaluation of the incontinent patient. J Am Geriatr Soc . 1990;38(3):311-316.



























Causes of Acute Urinary Incontinence
D Delirium
Dementia
Diabetes (neurogenic bladder, hyperglycemia)
I Infection (UTI)
Inflammation
A Atrophic vaginitis
P Pharmacology (eg, anticholinergics, alpha agonists, calcium channel blockers)
E Excessive urine output (eg, excessive intake, diuretics)
R Restricted mobility
S Stool impaction
Sacral nerve root pathology

Abbreviation: UTI, urinary tract infection.


Urinary tract infections


Older adults are more likely than their younger counterparts to have a UTI, have a more complicated course, and require a longer course of antibiotics. In addition to frailty, many factors may predispose older adults to a worsened outcome and are summarized in Table 3 .



Table 3

Factors predisposing older adults to complicated UTIs ,



















Risk Factor Example
Anatomic and structural abnormalities


  • Urinary tract calculi



  • Urinary tract tumor (including prostate)



  • Extraurinary tumors compression ureters or bladder



  • Urethral stricture



  • Pelvic floor prolapse (eg, uterine prolapse, cystocele)



  • Benign prostatic hypertrophy

Functional abnormalities


  • Urinary retention



  • Urinary incontinence



  • Neurogenic bladder



  • Postmenopausal estrogen deficiency

Instrumentation and foreign bodies


  • Urethral catheterization (including Foley catheter placement)



  • Cystoscopy



  • Transurethral surgery



  • Stent placement



  • Lysis of calculi



  • Penile implant

Systemic factors


  • Immunocompromise



  • Renal transplant



  • Single kidney



Clinical Presentation


Similar to their younger counterparts, UTIs in older adults can affect any location along the urinary tract. Older adults are less likely to have flank pain with pyelonephritis and may present with gastrointestinal or pulmonary symptoms. As with all infections, older adults are less likely to have a fever or leukocytosis, even in the presence of bacteremia. Older adults are more likely to have chronic GU symptoms and the acuity of presenting symptoms must be clarified. , Eliciting symptoms can be challenging in residents of long-term care facilities, especially those with catheters. , Consensus-based recommendations on clinical presentations suggestive of a UTI in this population are presented in Table 4 . These criteria have not been validated in the ED and should not substitute for the clinician’s judgment.


Jul 11, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Genitourinary Emergencies in Older Adults
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