Lower urinary tract symptoms in men and women without underlying disease causing micturition disorder: a cross-sectional study assessing the natural history of bladder function

Classification of Bladder Emptying Patterns by LSTM Neural Network Trained Using Acoustic Signatures

(1) Background: Non-invasive uroflowmetry is used in clinical practice for diagnosing lower urinary tract symptoms (LUTS) and the health status of a patient. To establish a smart system for measuring the flowrate during urination without any temporospatial constraints for patients with a urinary disorder, the acoustic signatures from the uroflow of patients being treated for LUTS at a tertiary hospital were utilized. (2) Methods: Uroflowmetry data were collected for construction and verification of a long short-term memory (LSTM) deep-learning algorithm. The initial sample size comprised 34 patients; 27 patients were included in the final analysis. Uroflow sounds generated from flow impacts on a structure were analyzed by loudness and roughness parameters. (3) Results: A similar signal pattern to the clinical urological measurements was observed and applied for health diagnosis. (4) Conclusions: Consistent flowrate values were obtained by applying the uroflow sound samples from the randomly selected patients to the constructed model for validation. The flowrate predicted using the acoustic signature accurately demonstrated actual physical characteristics. This could be used for developing a new smart flowmetry device applicable in everyday life with minimal constraints from settings and enable remote diagnosis of urinary system diseases by objective continuous measurements of bladder emptying function.

Seasonal changes in occurrence and severity of lower urinary tract symptoms-Tampere Aging Male Urologic Study (TAMUS)

OBJECTIVES

To determine if lower urinary tract symptoms (LUTS) involve seasonal variation and how this affects the severity of LUTS.

METHODS

A total of 3163 men aged 50 to 70 years were mailed a questionnaire on urinary symptoms. The overall response rate was 65.3% (2064 out of 3163 men). The men were asked whether their urinary symptoms showed variation in degree of difficulty according to time of year and if yes, when LUTS were the worst and the mildest. Ten different LUTS were evaluated with four response options for the severity of symptoms. Mean symptom scores and the proportions of symptomatic men were evaluated according to the presence of seasonal changes in different symptoms.

RESULTS

Overall, 17.1% of men reported seasonal variation in severity of LUTS, older men more frequently than younger men. Worse LUTS during winter were reported by 81% of the men reporting seasonal variation, and 93% reported that LUTS were relieved in summer. More seasonal variation was reported by men with comorbidities (stroke, neurological disease) and those with medical treatment for LUTS or operative treatment for benign prostatic hyperplasia. Men with more severe LUTS were more likely to report seasonal changes.

CONCLUSIONS

One out of six men reported seasonal changes in LUTS, with winter worsening and summer relieving the symptoms. Men with seasonal variation in LUTS had more severe LUTS in all 10 symptom groups that were investigated.

Change of Detrusor Contractility in Patients with and without Bladder Outlet Obstruction at Ten or More Years of follow-up

To analyze the change of detrusor contractility by investigating urodynamic characteristics with long term follow-up. This study retrospectively reviewed 166 lower urinary tract symptoms patients without bladder outlet obstruction (BOO) and 63 patients with BOO who underwent repeated urodynamic studies at the first time and more than 10 years later. The urodynamic parameters, bladder contractility index (BCI), and BOO index (BOOI) were compared before and after. As time goes by, detrusor pressure at maximum flow rate (PdetQmax) significantly decreased and post-void residual (PVR) volume significantly increased in both men and women. Full sensation, urge sensation, voided volume, and BCI significantly decreased. We also compared men with and without BOO, PdetQmax, maximum flow rate (Qmax), voided volume, and BCI all significantly decreased in both groups without difference. PVR increased greater in men with BOO after >10 years significantly (p = 0.036). Women with detrusor overactivity (DO) under antimuscarinic showed no significant BCI change compared to patients without DO (p = 0.228). Detrusor contractility decreases in men and women after >10 years of follow-up. However, this finding suggests that patients with BOO or DO under adequate medical treatment, detrusor contractility is not aggravated over 10 or more years of follow-up.

Changes in urination according to the sound of running water using a mobile phone application

Objective

The sound of running water (SRW) has been effectively used for toilet training during toddlerhood. However, the effect of SRW on voiding functions in adult males with lower urinary tract symptoms (LUTS) has not been evaluated. To determine the effect of SRW on urination in male patients with LUTS, multiple voiding parameters of uroflowmetry with postvoid residual urine (PVR) were assessed according to the presence of SRW played by a mobile application.

Methods

Eighteen consecutive male patients with LUTS were prospectively enrolled between March and April 2014. Uroflowmetry with PVR measured by a bladder scan was randomly performed once weekly for two consecutive weeks with and without SRW in a completely sealed room after pre-checked bladder volume was scanned to be more than 150 cc. SRW was played with river water sounds amongst relaxed melodies from a smartphone mobile application.

Results

The mean age of enrolled patients and their mean International Prostate Symptom Score (IPSS) were 58.9 ± 7.7 years (range: 46–70) and 13.1 ± 5.9, respectively. All patients had not been prescribed any medications, including alpha-blockers or anti-muscarinic agents, in the last 3 months. There was a significant increase in mean peak flow rate (PFR) with SRW in comparison to without SRW (15.7 mL/s vs. 12.3 mL/s, respectively, p = 0.0125). However, there were no differences in other uroflowmetric parameters, including PVR.

Conclusions

The study showed that SRW from a mobile phone application may be helpful in facilitating voiding functions by increasing PFR in male LUTS patients.

Calcium Antagonists Use and Its Association with Lower Urinary Tract Symptoms: A Cross-Sectional Study

Background

Lower urinary tract symptoms (LUTS) have been reported amongst the side effects of calcium antagonists (CA). CAs act on the bladder by affecting the ability of the detrusor muscle to create enough contractile force to overcome obstruction to normal voiding. We aimed to determine the relationship between CA use and LUTS in general medical inpatients.

Methods and Findings

In this cross-sectional study we recruited 278 medical inpatients (including 85 CA users) aged ≥40 (72.1±13.7) years. LUTS was assessed using the International Prostate Symptoms Score (IPSS) questionnaire. A Logistic regression model using a ‘backwards-elimination’ strategy was used to identify variables associated with LUTS and for calculating the adjusted odds ratios and the 95% confidence intervals (CI). After adjusting for other risk factors and drugs, patients on amlodipine/nifedipine and diltiazem/verapamil (compared to non-users) were more likely to suffer from severe LUTS [Males: 12.45(CI: 1.57–98.63) and Females: 7.75(CI: 0.94–63.94)] and moderate-to-severe LUTS [Males: 17.43(CI: 2·26–134.39) and Females: 47.8(CI: 6.22–367.37)]. Patients on felodipine/lercanidipine were less likely to suffer from either severe or moderate-to-severe LUTS. Further, 19 (22.4%) CA-users were on treatment for LUTS compared to 18 (9.3%) of the non-users group, p = 0.003. Both male and female CA-users were three times more likely to be on alpha-blockers than non-users, p<0.001. CA-users were more likely to have undergone urinary tract-related surgery (Males: two times, p = 0.07 and females: nine times, p = 0.029). The study was limited by the fact that a causal relationship could not be established between CA use and LUTS.

Conclusions

Our results demonstrate an association between CA use and an increasing severity of LUTS. They also demonstrate that CA-users are more likely to have medical or surgical treatment for LUTS. However, these CA’s effects on LUTS vary, and the use of highly vascular selective agents does not appear to pose significant risk.

Association between Lower Urinary Tract Symptoms and Vascular Risk Factors in Aging Men: The Hallym Aging Study

Purpose

The aim of this study was to investigate the relationship between lower urinary tract symptoms (LUTS) and risk factors for vascular diseases in a population-based cohort study, the Hallym Aging Study (HAS).

Materials and Methods

Among the 1,520 participants in HAS, 280 men aged more than 50 years, who underwent detailed health evaluations, including health-related questionnaires, evaluations of their medical history, and various life style factors, as well as clinical measurements, were included in the study. Vascular risk factors used in the present study including hypertension, diabetes mellitus, hyperlipidemia, and smoking and were assessed by medical history and clinical measurements. LUTS were assessed by validated questionnaires, the International Prostate Symptom Score (IPSS), and the relationship between LUTS and vascular risk factors was investigated.

Results

Of the 280 men, 175 (62.5%) had moderate/severe LUTS (IPSS>7) and 260 (93%) had one or more vascular risk factors. The IPSS was similar in those with no (11.6±9.7) and one or two (11.5±8.5) vascular risk factors, but increased to 15.1±9.3 in those with 3 or more vascular risk factors (p<0.05). The multiple logistic regression analysis, controlling for age and body mass index (BMI) showed that men with 3 or more vascular risk factors were 3 times more likely to have moderate/severe LUTS than men without vascular risk factors (p<0.05).

Conclusions

Men with risk factors for vascular diseases are more likely to have LUTS and these findings suggest that vascular risk factors play a role in the development of LUTS.

Incontinence and detrusor dysfunction associated with pelvic organ prolapse: clinical value of preoperative urodynamic evaluation

INTRODUCTION AND HYPOTHESIS

We examined how preoperative urodynamic findings are related to the urinary problems following surgical repair of pelvic organ prolapse (POP).

METHODS

The clinical records of 87 women who underwent surgery for POP were reviewed retrospectively. Preoperatively, cough stress test and urodynamic testing, including pressure-flow study, were performed with prolapse reduction. Postoperative evaluation included uroflowmetry, postvoid residuals, and symptom assessment using questionnaires.

RESULTS

A cough stress test with simple filling was sufficient for diagnosis of occult stress urinary incontinence (SUI). The presence of detrusor overactivity was a good predictor of postoperative persistence of urgency and urge urinary incontinence. Postvoid residuals (PVR) largely increased immediately after surgery, but usually recovered within 1 month. Poor detrusor contractility was the best predictor of large PVR occurrence.

CONCLUSIONS

Preoperative urodynamic evaluation of SUI and detrusor function was useful for predicting postoperative urinary conditions in POP patients. Its cost-effectiveness remains to be examined.

Psychometric analysis of international prostate symptom score for female lower urinary tract symptoms

OBJECTIVES

Although the International Prostate Symptom Score (IPSS) has often been used for female lower urinary tract symptoms (FLUTS), the psychometric properties of IPSS for FLUTS have not been studied. We investigated the reliability and validity of IPSS for FLUTS.

METHODS

Two samples were prepared. Sample A consisted of 227 women and 455 men who consulted a hospital doctor and sample B consisted of 519 women and 419 men who consulted a general practitioner. Eighty-nine percent of participants completed all IPSS items and quality of life index. Cronbach's alpha coefficients and Spearman's rho were calculated for reliability and validity assessment, respectively. A factor analysis was also conducted to explore the underlying structure.

RESULTS

Significant differences were found in age and each IPSS item score between the 2 samples. Cronbach's alpha of IPSS in women was approximately 0.8 in both samples, comparable to that in men. The relatively high Spearman's rho among most of IPSS voiding items and among most storage items and low Spearman's rho among most of the different categories described indicated good convergent and discriminant validity. The factor analysis showed 2 components in IPSS for FLUTES. The first was consistently related to IPSS items 1, 3, 5, and 6 and the second was related to IPSS items 2, 4, and 7. In men, however, IPSS item 4 comprised different components between samples A and B.

CONCLUSIONS

Although the subject background somewhat affects the psychometric properties, the IPSS can be relevant when used to examine women, as well as men.

Diagnosis and treatment of lower urinary tract symptoms in the elderly by general practitioners

AIM

We investigated the diagnosis and treatment of lower urinary tract symptoms (LUTS) by general practitioners (GPs) according to the Practical Manual for LUTS Evaluation and Treatment in the Elderly For GPs.

METHODS

Using the manual, 14 GPs determined LUTS severity using the International Prostate Symptom Score, Quality of Life Index, post-void residual urine volume and the International Consultation on Incontinence Questionnaire-Short Form, then evaluated utilization of the frequency volume charts and other examinations to treat LUTS and assessed treatment effectiveness.

RESULTS

This study included 52 men (aged 71 +/- 9 years) and 37 women (73 +/- 9). Voiding symptoms were more frequent in men but storage symptoms occurred similarly in both sexes. The overall severities of LUTS were similar between sexes. Of 36 men and 27 women who were treated, water restriction for polyuria and nocturnal polyuria was recommended for 17 men and 14 women, bladder training for six women, and pelvic floor exercise for three men and 16 women as behavioral therapy. Of 27 men and 25 women whose treatment effectiveness was assessed by GPs, effectiveness was judged as "fairly good" or greater in 20 men (74%) and 23 women (92%). Eleven men (40%) and 20 women (80%) were satisfied with their treatment.

CONCLUSION

It is suggested that GPs can provide high-quality LUTS practice when they follow the manual and use the recommended tools for evaluation and monitoring.

Chapitre C - Troubles vésico-sphinctériens et sclérose en plaques

Multiple sclerosis (MS) is a neurological disease characterized by multiple demyelinating lesions disseminated throughout the central nervous system (nerve conduction block). The management of these patients requires a perfect knowledge of the natural history of the disease. In this article, the authors review the literature to identify the most frequent voiding disorders observed in this disease and then study the diagnostic and therapeutic modalities and the optimal modalities of follow-up in these patients, in view of the risk of various urological complications.

Impact of Lower Urinary Tract Symptoms on Quality of Life Using Functional Assessment Cancer Therapy Scale

OBJECTIVES

To assess the impact of lower urinary tract symptoms (LUTS) on general quality-of-life (QOL) measures in an outpatient setting.

METHODS

A total of 1546 male patients aged 51 years or older and scoring more than 11 in the International Prostate Symptom Score completed the general version of the Functional Assessment Cancer Therapy, the Benign Prostatic Hyperplasia Impact Index, and additional questions. Previous prostatic surgery and neurourologic conditions were exclusion criteria, but the use of urologic medication was not.

RESULTS

LUTS and QOL were significantly related to age, with older patients presenting with more symptoms and worse QOL. In addition, the results showed negative correlations between LUTS and QOL. The division of the severity groups according to the International Prostate Symptom Score showed that patients from the severe group reported significantly worse QOL compared with the moderate group. The 32% variance in the FACT-G was explained by the International Prostate Symptom Score items, controlling for age. Nocturia combined with incomplete bladder emptying were the strongest predictors of QOL.

CONCLUSIONS

LUTS have considerable impact on the general well-being of the patient. Combined with age, they can explain up to 30% of the variance in QOL. Nocturia and incomplete emptying are the most troublesome symptoms.

The Association Between Vascular Risk Factors and Lower Urinary Tract Symptoms in Both Sexes

OBJECTIVES

To test the potential role of atherosclerosis in the development of lower urinary tract symptoms (LUTS), we investigated the association between vascular risk factors and LUTS in both sexes.

METHODS

Men and women participating in a health screening project completed the International Prostate Symptom Score (IPSS). In parallel all individuals underwent a detailed health investigation with assessment of diabetes mellitus, hypertension, hyperlipidemia, and nicotine use.

RESULTS

A total of 1724 men (52.3+/-9.1yr, mean+/-standard deviation; IPSS: 6.3+/-4.3) and 812 women (56.0+/-9.9 yr; IPSS: 5.2+/-4.9) entered the study. A total of 62.5% (n=1077) of men had no vascular risk factor, 32.1% (n=554) one, and 5.4% (n=93) two or more; the corresponding figures for women were 64.7% (n=525), 30.7% (n=249), and 4.7% (n=38). In men, the IPSS was identical in those with no (6.2+/-4.1) and one (6.2+/-4.4) vascular risk factor yet increased to 7.7+/-5.5 (+24.2%) in those with two or more risk factors (p=0.01). In women, the IPSS increased from 4.8+/-4.6 in those with no vascular risk factor to 5.7+/-5.3 (+18.7%) with one and 7.0+/-5.7 (+45.8%) with two or more factors (p=0.05).

CONCLUSIONS

Our data suggest that vascular risk factors play a role in the development of LUTS in both sexes. This observation opens new aspects in our understanding of the pathogenesis of LUTS and warrants future studies.

Older women and men with urinary symptoms

The aim was to compare urinary symptoms and their influence on daily life among elderly (75+) women and men in a sample that previously had reported difficulties controlling urine (urine incontinence (UI)) and/or other urinary symptoms (OU). A further aim was to find underlying structures of urinary symptoms and to identify symptoms that had an impact on seeking medical help and need of help in daily activities (dependency). In total, 771 persons (352 men and 419 women) over 75 years answered a questionnaire, addressed to those (n=1881) who in a previous population-based study had reported having symptoms of UI and/or OU using the Bristol Female Lower Urinary Tract Symptoms (BF-LUTS) questionnaire and International Continence Society male (ICSmale) questionnaire. The groups with UI, OU, women and men reported similar symptoms of frequency, day and night, as well as influence on social life, and avoidance of places and situations due to the urinary symptoms although they differed in storage and voiding symptoms. Feeling incomplete emptying of bladder differed between the UI, OU, and mixed symptoms (MS) groups but not between genders. Of the whole sample, 43.3% had sought medical help. Factor analysis of similar questions in BF-LUTS and ICSmale questionnaire resulted in the factors labeled voiding, storage, pain, frequency, and daily life. Predictors of the urinary symptoms for needing help in daily activities were frequent micturition day and night (OR 3.2) when aged was controlled for. Influence on daily life (OR 2.5), storage symptoms (OR 2.2), and pain symptoms (OR 2.1) predicted seeking medical help. The results show that urinary symptoms are equally bothersome among men and women. There is a need to encourage elderly to seek medical help and to obtain treatment or alleviations for symptoms that give most bother and indicate dependency, such as frequent micturition day and night and difficulties to reach the toilet in time without leakage.

Do atherosclerosis and chronic bladder ischemia really play a role in detrusor dysfunction of old age?

OBJECTIVES

To determine whether atherosclerosis-induced chronic pelvic ischemia plays a role in the pathogenesis of aging bladder dysfunction.

METHODS

Old (70 weeks of age), apolipoprotein E gene knockout (APOEKO) mice, known to develop atherosclerosis spontaneously were used. A group of 70-week-old C57B mice were used as controls. The mice were killed and bladder smooth muscle strips obtained for in vitro contractile force determinations. The maximal contractions in response to 110 mM KCl, 10(-5) M bethanechol, and resting muscle tone were compared. The abdominal aortas and iliac arteries were harvested from the mice, and computerized image analysis was used to determine the percentage of surface area of atherosclerosis in each mouse.

RESULTS

Although the APOEKO mice had massive atherosclerosis of the abdominal aortas and iliac arteries (lesion surface area +/- SEM 15.93% +/- 3.02%, n = 4), the control mice (n = 5) had no atherosclerosis at all. No statistically significant difference was found in detrusor function (KCl 0.48 +/- 0.11 versus 0.49 +/- 0.05, bethanechol 0.11 +/- 0.02 versus 0.13 +/- 0.04, tone 0.063 +/- 0.019 versus 0.07 +/- 0.004, respectively) between the APOEKO mice (n = 6) and the control mice (n = 6).

CONCLUSIONS

Pelvic atherosclerosis caused no statistically significant changes in bladder smooth muscle contractile responses to bethanechol, KCl, or resting tone. The difference between these and previously reported results may have been a result of the more gradual onset of atherosclerosis in our model, which better mimics pelvic organ ischemia in the elderly.

A Cross-Sectional Study of the International Prostate Symptom Scores Related to Age and Gender in Dutch Adults Reporting No Voiding Complaints

OBJECTIVE

To determine the IPSS in a selected population reporting no voiding complaints.

SUBJECTS AND METHODS

1143 adults without voiding complaints were included. They were divided over both sexes and all decades. All subjects filled out questionnaires including the IPSS. Statistical analysis was aimed at relating the IPSS to age and gender.

RESULTS

The IPSS in both sexes shows a gradual significant increase in consecutive age groups. Men in the third age decade have a mean score of 2.8, while men older than 70 years of age have a score of 7.0. In women these scores are 4.0 and 5.6 respectively. The increase is about equally caused by storage and voiding scores. The items addressing weak stream in men and nocturia and urgency in men and women are the major factors causing the correlation with age. Nearly 17% of all subjects have moderate symptom scores and 1% has severe scores.

CONCLUSION

In both adult men and women reporting no voiding complaints the IPSS increases with age. This rise is more prominent in males.

Overactive Bladder in the Elderly

Overactive bladder (OAB) is a common condition characterised by the symptoms of urinary frequency and urgency, with or without urge incontinence and nocturia. The prevalence of OAB increases markedly with age in both men and women. OAB can have a detrimental effect on physical functioning and psychological well-being, as well as significantly reducing quality of life. Antimuscarinic therapy -- with or without behavioural therapy -- represents the most common treatment for patients with OAB. Several antimuscarinic agents are currently available for the treatment of OAB in adults, including oxybutynin, tolterodine, trospium chloride, darifenacin and solifenacin. The antimuscarinics all appear to exert their clinical effect through inhibition of the bladder muscarinic receptors, but they vary both in structure and in their functional profile. While efficacy has been demonstrated in adult populations (including patients >65 years of age), few studies have been reported specifically in a geriatric population, and antimuscarinics are often underutilised in the elderly despite the marked increase in the prevalence of OAB in this age group. One explanation for this apparent underuse of an effective treatment option may be concerns about the frequency of anticholinergic adverse events, such as dry mouth; the likelihood of detrimental CNS effects, including cognitive impairment and sleep disturbances; and the potential for harmful interactions with existing pharmacotherapy. When selecting an antimuscarinic agent for the management of an elderly patient presenting with OAB, in addition to considering evidence of clinical efficacy and tolerability, issues of safety specific to an older population should be borne in mind. In particular, the likelihood of detrimental CNS effects should be considered, including cognitive impairment and sleep disturbances, secondary to anticholinergic load. Oxybutynin and tolterodine have both been associated with cognitive adverse events and effects on sleep architecture and quality. In contrast, trospium chloride and darifenacin do not appear to be associated with cognitive adverse events and trospium chloride does not negatively affect sleep architecture or quality. Biotransformation by the cytochrome P450 (CYP450) system is an important step in the activation or elimination of a large number of drugs, including oxybutynin, tolterodine, darifenacin and solifenacin, raising the possibility of clinically relevant and potentially serious drug interactions. In elderly patients, such interactions are of particular relevance given the potential for declining activity of certain members of the CYP450 family combined with decreased hepatic blood flow, which can reduce first-pass metabolism and thus the bioavailability of drugs metabolised via this route. Of the antimuscarinic agents used to treat OAB, only trospium chloride is not extensively metabolised in the liver by the CYP450 system and is excreted largely as the active parent compound in the urine. This paper provides an overview of the pathophysiology of OAB and reviews current approaches to achieving a differential diagnosis and selecting appropriate treatment for the older patient. The pharmacology and clinical effects of current medication for the treatment of OAB symptoms in patients defined by the OAB pharmacology literature as 'elderly' are also reviewed.

Overexpression of epithelial sodium channels in epithelium of human urinary bladder with outlet obstruction

OBJECTIVES

To examine whether the epithelial sodium channel (ENaC) is expressed in the human urinary bladder and how its expression changes in association with outlet obstruction. Detrusor instability occurs in association with bladder outlet obstruction. The increase of afferent activity is one of the possible mechanisms for this detrusor instability. The ENaC expressed in mammals has been implicated in various mechanosensory functions.

METHODS

Specimens of urinary bladder mucosa were obtained from 9 controls and 9 patients with bladder outlet obstruction verified by the International Prostate Symptom Score, prostate volume, and urodynamic tests. In 7 patients with outlet obstruction, involuntary detrusor contraction was demonstrated. The expression and localization of ENaC proteins was examined using immunofluorescent staining. The quantification of ENaC gene expression was assessed by real-time reverse transcriptase-polymerase chain reaction.

RESULTS

The alpha-ENaC, beta-ENaC, and gamma-ENaC proteins were expressed in human urinary bladder epithelium with outlet obstruction, and the alpha-ENaC and gamma-ENaC proteins were virtually unstained in the control bladders. Alpha-ENaC, beta-ENaC, and gamma-ENaC mRNA were detected in 1, 6, and 4 of 9 control bladders, respectively. Each ENaC mRNA was clearly present in all obstructed bladders. The expression levels of each subunit in the obstructed bladders were significantly greater than those in controls. The quantified ENaC expression correlated significantly with the storage symptom score.

CONCLUSIONS

The ENaC expressed in the bladder epithelium might be implicated in the mechanosensory transduction in the bladder afferent pathways, thereby inducing detrusor instability by outlet obstruction.

[Urodynamic phenomena in the aging bladder]

Lower urinary tract symptoms increase with age in both sexes and are a major problem in the elderly due to the medical and bio-psycho-social consequences involved. Lower urinary tract dysfunctions in the elderly are generally multifactorial in origin and are classifiable to a large extent by age and pathology related changes. Urodynamic findings should never be interpreted without considering the medical history, bladder diary, clinical examination and other findings. Age related changes involve a decrease of voided volume and urinary flow and an increase in overactive bladder symptoms and post void residuals. Consequently, decreased maximum bladder capacity, terminal detrusor overactivity and detrusor overactivity with impaired contractile function are typically found in the elderly. Patients with terminal detrusor overactivity are well treated by bladder training and timed voiding, sometimes combined with anticholinergic drugs, whereas patients with phasic detrusor overactivity are often good candidates for non-invasive electrical neuromodulation.