Older individuals often have multiple etiologies for their lower urinary tract symptoms (LUTS); i.e., both urologic (U) and neurologic (N) etiologies. Few studies have investigated 'triple disease' (typically one U and two N components) in the LUTS of older adults. Herein, we had specialists from both urology and neurology address triple- and quadruple-etiology disease.

This was a retrospective study with a 12-month recruiting period. We ascertained LUTS by standard questionnaires and bladder diaries. Urodynamics, sphincter EMG, prostate echography, and a neurologic examination were conducted for each patient as well as neuroimaging and neurophysiology examinations when appropriate. The diagnoses of the etiologies were based on published criteria.

We analyzed the cases of 141 older (age >65 years) adults with LUTS referred from both urology (27%) and neurology departments (73%) according to the diagram (Figure). 
The final etiologies were U (n=69, 49%), N (n=136, 96%), and a combination (U and N) (n=77, 55%, overlap counted). The majority of U diagnoses were benign prostatic hyperplasia. The majority of N diagnoses were dementia with Lewy bodies, white matter disease (brain); lumbar spondylosis, and diabetes (peripheral disease). We noted triple-disease etiology in 25% (n=35), increasing with each decade of age (18.2% of sexagenarians, 23.5% of septuagenarians, 39.1% of octogenarians). However, the differences were not significant. (shown in Table and Figure)

The present study is the first to describe LUTS-relevant triple (and quadruple) diseases in older adults at a university hospital. Although there is a significant bias in that this study was from a single center and was limited to patients who underwent urodynamics evaluation, its strengths include the collaboration of urology and neurology departments, which is rather exceptional. In addition, although we analyzed the urodynamic results of our cohort in detail, we had no controls. MIBG myocardial scintigraphy and DAT scans were performed only for patients in whom DLB/PD was suspected; the possibility of false-negative diagnoses of DLB/PD therefore cannot be excluded. We did not have pathology results; thus, the possibility of false-positive results cannot be excluded.
Further, the workup for relevant urodynamic findings is not thorough enough, and there may therefore have been an underdiagnosis of the mechanism of a urodynamic abnormality. Finally, the work-up for N was not thorough enough and there may therefore have been an underdiagnosis of the N etiology in our patients, as seen in one patient with 'undetermined etiology' and two with 'suspected' MSA. Nevertheless, we think that a neuro-urology team is efficient for providing care/management in older adults with LUTS. The management of LUTS in older adults is still a challenge for all urologists, neurologists and geriatric physicians, particularly because large post-void residuals/urinary retention can lead to an emergency in older women. In order to manage LUTS, maximize the quality of life, and prevent life-threatening adverse events in older adults, it is thus advisable to perform collaborative neuro-urological approaches (assessing/untangling the etiologies) in a prospective manner in the future worldwide.

Our results demonstrate that triple disease for LUTS is the most common in octogenarians, and clinicians thus need to untangle LUTS etiologies in order to provide appropriate care and management of older adults.