Detrusor Overactivity with Impaired Contractility (DOIC) in the Elderly: Challenges in Management

Abstract

Detrusor overactivity with impaired contractility (DOIC) is a complicated and under-evaluated condition of the lower urinary tract. The definition is vague, the etiology is unclear, and the treatment is challenging. However, the prevalence of the condition has increased with the increase in the elderly population. Elderly patients often have multifactorial causes of their voiding problems. Thus, evaluation and treatment should be designed on an individual basis, considering the patient’s physical ability, cognitive function, comorbidities and available supports. The initial approach is to identify and manage the reversible causes. Behavioral modifications and medical treatment can be effective in selected patients. Anticholinergics should be carefully tried with a minimum starting dose, and post-void residuals should be monitored. β3-Adrenergic receptor agonists may be promising as they induce bladder relaxation yet do not block acetylcholine activity during contraction. Αlpha-antagonists can also be effective with or without bladder relaxants. Encouragingly, a study demonstrated the efficacy of combination treatment of anticholinergic drugs and cholinesterase inhibitors in a DOIC model using rats with spinal cord injury. Sacral neuromodulation has proven efficacy in the treatment of refractory overactive bladder and retention. This might be a potential candidate for the treatment of the combined condition of storage and voiding dysfunction. Botulinum toxin can be used in patients with more bothersome and refractory symptoms of detrusor overactivity, rather than voiding symptoms. Patients should be informed of a risk of retention and be willing to do intermittent catheterization. At the moment, there are no treatments for DOIC that are supported by clinical evidence. Further studies are needed to classify patients and to guide treatment plan considering lower urinary tract and beyond lower urinary tract in the elderly with DOIC.