1.

Aging changes in the urinary structures

BACKGROUND The kidneys filter the blood and help remove waste and extra fluid from the body. The kidneys also play an important role in controlling the body's chemical balance. As with other organs, kidney function may be slightly reduced with aging. The kidneys are part of the urinary system, which also includes the ureters and the bladder. Bladder control can be affected by muscle changes and changes in the reproductive system. AGING CHANGES As the kidneys age, a number of events occur: y y y The number of filtering units (nephrons) decreases. Nephrons filter waste material from the blood. The overall amount of kidney tissue also decreases. The blood vessels supplying the kidney can become hardened, and the kidneys filter blood more slowly.

Changes in the bladder: y y y The bladder wall changes with age. The elastic tissue becomes tough, and the bladder becomes less stretchy. Muscles weaken, and the bladder may not empty completely when urinating.

In women, weakened muscles can allow the bladder or vagina to fall out of position (prolapse), which can block the urethra. In men, the urethra may become blocked by an enlarged prostate gland. EFFECTS OF CHANGES Under usual conditions, kidney function remains normal in an aging person. Although sometimes they kidneys may function more slowly than those of a younger person. However, illness, medications, and other conditions can affect a kidney's ability to function properly. Changes in the kidneys may affect an elderly person's ability to concentrate urine and hold onto water. Dehydrationoccurs more readily because older people frequently have less of a sense of thirst. Dehydration can also be aggravated if an older person reduces fluid intake in an attempt to reduce bladder control problems. COMMON PROBLEMS Aging increases the risk for urinary disorders, such as: y y Acute kidney failure Chronic kidney failure

y y y

Bladder control issues (urinary incontinence, or leakage or urinary retention, which means you are not able to completely empty your bladder) Bladder infections Other urinary tract infections (UTIs)

UTIs are common, and partly due to incomplete emptying. It is also related to changes in the chemical balance in the urinary tract. Urinary system cancers are more common in the elderly, especially prostate cancer (men) and bladder cancer. In both men and women, urinary changes are closely related to changes in the reproductive system. For example, men may experience problems because of an enlarged prostate (benign prostatic hypertrophy). Women may have vaginal infections (vaginitis) and bladder infections. The aging kidney is more susceptible to adverse drug events. For example, nonsteroidal anti-inflammatory drugs (NSAIDs) and heart medications called ACE inhibitors can cause acute kidney failure failure in some cases. It is important that routine lab tests are done when these medications are used.

2. Aging changes in the female reproductive system As a woman ages, a number of changes take place in the female reproductive system. For women, the cessation of menses (menopause) is an obvious sign of aging. But, it is by no means the only change. A transition period, called the climacteric, lasts for many years before and after a woman's last menstrual period. Information For a woman, aging changes involve hormone levels, physical changes in the woman's entire reproductive tract, and psychological changes. Changes occur in the intricate relationship between the ovarian hormones and those produced by the pituitary gland (in the brain). AGING CHANGES Menopause is a normal part of a woman's aging process. The ovaries stop releasing eggs (ova), and menstrual periods stop. Most women experience menopause around age 50, although it occurs before age 40 in about 8% of women. Prior to menopause, menstrual cycles often become irregular. The ovaries become less responsive to stimulation by follicle-stimulating hormone (FSH) and luteinizing hormone (LH). To try to compensate for the decreased response, the body produces more of these ovary-stimulating hormones for a time. The level of these hormones will eventually decrease. The hormones produced by the ovaries include the different forms of estrogen (including estradiol), progesterone, and androgens (including testosterone). These hormones also decrease around menopause. The ovaries continue to produce small amounts of testosterone and some estrogen. The hormones produced by the pituitary gland are also decreased.

Because hormone levels fall, changes occur in the entire reproductive system. The vaginal walls become less elastic, thinner, and less rigid. The vagina becomes shorter. Secretions become scant and watery. The external genital tissue decreases and thins (atrophy of the labia). In both men and women, reproductive system changes are closely related to changes in the urinary system. EFFECT OF CHANGES Prior to menopause, fertility varies depending on hormone levels. Menopause is said to have occurred when there has been one year without a menstrual period. With menopause, reproductive capacity is lost (the woman can no longer become pregnant). Symptoms that accompany menopause vary in severity. Many of the symptoms are triggered by the hormone changes. Only about 20% to 30% of all women have symptoms that are severe enough that they seek medical attention. Changes occur in the woman's breast tissue at the same time as other reproductive changes. A woman may experience changes in her sex drive (libido) and her sexual response may change, but aging does not prevent a woman from being able to have or enjoy sexual relationships. Most often, things such as availability of a partner, symptoms from vaginal dryness and thinning vaginal walls, and psychological and social factors affect a woman's sexual response more than direct aging changes. COMMON PROBLEMS The pubic muscles lose tone, and the vagina, uterus, or urinary bladder can fall out of position. This is called vaginal prolapse, bladder prolapse, or uterine prolapse, depending on which structure collapses. A prolapse of any of these structures increases the risk of problems such as stress incontinence (urine leakage). Most prolapses can be treated. Irritation of the external genitals can occur (pruritus vulvae). The vaginal walls become thinner and dryer and may become irritated (atrophic vaginitis). Sexual intercourse may become uncomfortable for some women (dyspareunia). There are changes in the levels of normal microorganisms in the vagina, and there is an increased risk of vaginal yeast infections. Similar changes to the bladder and urethra may increase symptoms such as frequency and urgency of urination, and there is an increased risk of urinary tract infection after menopause. Hot flashes, mood disturbances, headaches, and sleep disturbances are also common symptoms that occur during menopause. The causes of these changes are not well understood, but they are also related to the decreasing amount of estrogen produced by the ovaries. Osteoporosis risk is greater in older women. This is caused, in part, by decreased estrogen levels. PREVENTION and TREATMENT Adequate lubrication (with a water-soluble lubricant) can help prevent painful sexual intercourse. A topical estrogen (applied inside the vagina) is sometimes recommended to help maintain the structure of the vaginal tissues. Sexual changes are most frequently related to factors other than simple aging.

Estrogen replacement (such as pills or patches) can prevent or reduce many of the symptoms associated with menopause, including vaginal atrophy and hot flashes. It also decreases the risk of complications such as osteoporosis. However, hormone therapy (HT) may have side effects such as vaginal bleeding, and it has been associated with a somewhat increased risk of breast cancer, stroke, and, under some circumstances, heart disease. Each woman should discuss the pros and cons of estrogen replacement with her own health care provider. 3. Aging changes in the male reproductive system Aging changes in the male reproductive system may include changes in testicular tissue, sperm production, and erectile function. These changes usually occur gradually. Information Unlike women, men do not experience a major, rapid (over several months) change in fertility as they age (like menopause). Instead, changes occur gradually during a process that some people call andropause. Aging changes in the male reproductive system occur primarily in the testes. Testicular tissue mass decreases and the level of the male sex hormone testosterone stays the same or decreases very slightly. There may be problems with erectile function. However, this is a general slowing, rather than a complete lack of function. Fertility: The tubes that carry sperm may become less elastic (a process called sclerosis). The testes continue to produce sperm, but the rate of sperm cell production slows. The epididymis, seminal vesicles, and prostate gland lose some of their surface cells but continue to produce the fluid that helps carry sperm. Urinary function: The prostate gland enlarges with age as some of the prostate tissue is replaced with a scarlike tissue. This condition, called benign prostatic hypertrophy (BPH), affects about 50% of men. This may cause problems with slowed urination, as well as with ejaculation. In both men and women, reproductive system changes are closely related to changes in the urinary system. EFFECT OF CHANGES Fertility varies from man to man, and age is not a good predictor of male fertility. Prostate function is not closely related to fertility, and a man can father children even if his prostate gland has been removed. Some fairly old men can (and do) father children. The volume of fluid ejaculated usually remains the same, but there are fewer living sperm in the fluid. Decreases in the sex drive (libido) may occur in some men. Sexual responses may become slower and less intense. This may be related to decreased testosterone level, but it may also result from psychological or social changes related to aging (such as the lack of a willing partner), illness, chronic conditions, or medications. Aging by itself does not prevent a man from being able to enjoy sexual relationships. COMMON PROBLEMS

Erectile dysfunction (ED) may be a concern for aging men. It is normal for erections to occur less frequently than when a man was younger, and aging men often have less ability to experience repeated ejaculation. However, ED is most often the result of a medical or psychological problem rather than simple aging, and 90% of ED is believed to be of medical rather than psychological origin. Medications (especially those used to treat hypertension and certain other conditions) can cause some men to be unable to develop or maintain enough of an erection for intercourse. Disorders such as diabetes can also cause ED. Erectile dysfunction that is caused by medications or illness is often successfully treated. Talk to your primary health care provider or a urologist if you are concerned about this condition. BPH may eventually interfere with urination. The enlarged prostate partially blocks the tube that drains the urinary bladder (urethra). Changes in the prostate gland make elderly men more likely to have urinary tract infections. Backup of urine into the kidneys (vesicoureteral reflux) may develop if the bladder is not fully drained. If this is not treated, it can eventually lead to kidney failure. Prostate gland infections or inflammation ( prostatitis) may also occur. Prostate cancer becomes more common as men age. It is one of the most frequent causes of cancer death in men. Bladder cancer is also a common cancer in older men. Testicular cancers are possible, but these occur more often in younger men. PREVENTION Many physical age-related changes, such as prostate enlargement or testicular atrophy, are not preventable. Getting treatment for health disorders (such as high blood pressure and diabetes) that lead to changes in urinary and sexual health may prevent later problems with urinary and sexual function. Changes in sexual response are most often related to factors other than simple aging. Older men are more likely to have good sex if they have continued to have sexual activity during middle age. 4. Aging changes in the brain and peripheral system As people age, their brain and nervous system go through natural changes. The brain and spinal cord lose nerve cells and weight. Nerve cells may begin to transmit messages more slowly than in the past. Waste products c4an collect in the brain tissue as nerve cells break down, causing abnormal structures called plaques and tangles to form. A fatty brown pigment (lipofuscin) can also build up in nerve tissue. The breakdown of nerves can affect the senses. You might have reduced or lost reflexes or sensation, leading to problems with movement and safety. Some slight slowing of thought, memory, and thinking seems to be a normal part of aging. Although these changes are natural, many people have misconceptions about the type and extent of these changes. A common myth is that all elderly people become senile. Or, many people blame increased confusion on "getting old" when it may really be caused by an illness.

These changes are not the same in everyone. Some people have many physical changes in their nerves and brain tissue, others have few changes. Some people will have atrophy and plaques, some will have plaques and tangles, and some will have other changes. Furthermore, these changes are not always clearly related to their effects on your ability to think. For example, plaques and tangles are associated with Alzheimer's disease, but some people with the most severe symptoms have fewer plaques and tangles than those who have mild or moderate symptoms. NERVOUS SYSTEM PROBLEMS IN THE ELDERLY Dementia and severe memory loss are NOT normal processes of aging. They can be caused by degenerative brain disorders such as Alzheimer's disease. Delirium can complicate dementia, but is often due to illnesses that are not related to the brain, which can also cause changes in thinking and behavior. For example, almost any infection can cause an older person to become severely confused. Poorly controlled blood sugar (glucose) levels in people with diabetes is another common cause of temporary difficulties with thinking and behavior. Rising and falling glucose levels can interfere with thought. Discuss any significant changes in memory, thought, or ability to perform a task with your health care provider, especially if these symptoms occur suddenly or along with other symptoms. A change in thinking, memory, or behavior is important if it is different from your normal patterns or it affects your lifestyle. PREVENTION There is some evidence that both physical and mental exercise can help maintain thinking abilities. Reading, doing crossword puzzles, and engaging in stimulating conversations -- as well as ordinary physical exercise -- may all help keep your brain as sharp as possible. Such strategies have not been proven, however.