










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Urodynamics, aging, bladder outlet 
obstruction, bladder contractilty, detrusor 
overactivity, bladder compliance

None declared. Received on March 31, 2021 
Accepted on June 5, 2021

Soc Int Urol J.2021;2(5):274–281

DOI: https://10.48083/LQXF2741

274 SIUJ  •  Volume 2, Number 5  •  September 2021 SIUJ.ORG

ORIGINAL RESEARCH

Association of Age With Lower Urinary  
Tract Function in Adult Men Presenting  
for Urodynamics: A Database Analysis
Sanjay Sinha, Lavina Matai

Department of Urology, Apollo Hospitals, Hyderabad, India

Abstract

Background Knowledge regarding lower urinary tract function in adult men could help in making informed 
choices. Few studies have examined the entire spectrum of adult males.

Methods This is a retrospective analysis of all adult men with refractory non-neurogenic urinary symptoms 
presenting to a tertiary center over 9 years. International Continence Society defined indices bladder outlet 
obstruction index (BOOI) and bladder contractility index (BCI) were calculated with established classification. 
Storage abnormality was defined as presence of detrusor overactivity, poor compliance (< 20mL per cm H20) or both. 
Data were analyzed by non-parametric tests using SPSS (version 20.0.0, Armonk NY ) (P < 0.05 significant; 2-tailed). 
Where appropriate, correction for multiple hypothesis testing was applied.

Results A total of 1596 men (range 18 to 91 years, median 51.0 years; IQR 34 to 64 years) were eligible. Median BCI 
and BOOI were 99.5 and 37.0, respectively, and a storage abnormality was noted in 41.7%. On multivariate analysis, 
age was significantly associated with urodynamic findings. While not strictly linear, for each 10 years increase  
in age, on average, the BCI fell 2.4 points and the BOOI increased by 2.4 points. Increasing age was also associated 
with increasing odds of finding a storage abnormality (OR 1.015; 95%CI 1.008 to 1.022; P < 0.001). On post hoc analysis 
(Bonferroni correction), men under 30 years were least likely of any group to show obstruction (30.3%; median  
BOOI 26).

Conclusions Adult men with refractory urinary symptoms show age-associated differences in urodynamic 
findings. An awareness of these trends can help take more informed decisions in clinical care.

Introduction

Age is known to impact all aspects of lower urinary tract function[1]. Knowledge regarding detrusor contractility, 
outlet obstruction and storage abnormality in men of different age groups could help in making more informed 
choices with regard to evaluation and treatment. Men with an underactive detrusor or severe storage abnormality 
show an inferior outcome following prostate surgery[2,3]. The European Association of Urology guidelines 
recommends invasive urodynamics testing before surgery in specified age groups[4]. However, few large studies have 
examined the entire spectrum of adult males, with most excluding either the young or the elderly.

http://SIUJ.org
mailto:drsanjaysinha%40hotmail.com?subject=SIUJ


This is a retrospective database analysis of all adult 
men who presented for urodynamics with a non-neuro-
genic lower urinary tract abnormality to a large volume 
referral center.

Material and Methods
Data pertaining to all adult men with a non-neurogenic 
lower u ri na r y t rac t cond it ion who u nder went 
urodynamics over the last 9 years (May 2011 to February 
2020) were retrieved. Ethics committee approval 
was obtained (AHH‐ACD‐ 001‐ 01‐20). Exclusion 
criteria included prior surgery of the lower urinary 
tract, history of indwelling catheter or intermittent 
catheterization, another lower urinary tract pathology 
such as posterior urethral valves or reflux, neurological 
disease, and primary upper urinary tract pathology such 
as ureteropelvic junction obstruction or urolithiasis 
(except in men with incidental non-obstructive calyceal 
stones); also excluded were men in whom a voiding 
phase evaluation was not feasible (for instance due to 
severe storage abnormality precluding filling) and those 
for whom we had incomplete data.

Urodynamics was performed as per International 
Continence Society (ICS) recommendations[5] using 
a two-catheter technique (both 5F). The peak detrusor 
contraction pressure of the tallest DO was recorded as 
the DO pressure. Compliance was measured from the 
commencement to the end of filling phase. The end fill 
detrusor pressure was recorded as 1cm H20 whenever 
it was ‘0’. Graphs were manually scrutinized to elim-
inate artifacts. When a patient produced a volitional 
contraction but failed to void, the maximum detru-
sor pressure (Pdet.max) was recorded in place of Pdet.Qmax. 
Bladder outlet obstruction index (BOOI) and bladder 
contractility index (BCI) were calculated as per ICS 
guidelines[6]. For patients with a calculated BOOI of ≤ 
0, a value of 0 was recorded. The BOOI and BCI were 
both recorded as ‘0’ in men with acontractility. BCI was 
categorized as 0 (underactive, < 100), 1 (normal, 100 to 
150) and 2 (strong, ≥ 150). BOOI was categorized as 0 
(unobstructed, < 20), 1 (equivocal obstruction, 20 to 40) 
and 2 (unequivocally obstructed, ≥ 40). In the occasional 
patient who voided more than the volume filled, the 
post-void residual (PVR) was recorded as 0 mL.

Non-parametric tests were used since the data were 
not normally distributed on preliminary analysis. SPSS 
(version 20.0.0, Armonk NY ) was used for analysis. The 
data were first analyzed by stratifying age into “age by 
decade” to assess the impact on different urodynamics 
outcome measures. Post hoc analyses were performed 
for the categories of the 3 main urodynamic findings 
BCI, BOOI, and storage abnormality. Multivariate anal-
ysis was performed to assess the independent impact of 
age (un-stratified) on the numerical value of BCI and 
BOOI, as well as the presence of storage abnormality. 
Data for linear regression were presented as estimate of 
change in dependent variable with each unit change in 
independent variable with 95% confidence intervals (CI) 
and P-value.

Results
A total of 3980 adult men with non-neurogenic lower 
urinary tract dysfunction underwent urodynamics 
between May 2011 and February 2020. After exclusions 
(indwelling or intermittent catheterization, 1629; prior 
urinary tract surgery, 264; dialysis or transplantation, 
97; history of congenital lower urinary tract disorder, 
49; voiding phase evaluation not feasible, 20; incomplete 
data, 325), there were 1596 (range 18 to 91 years, median 
51.0 years; IQR 34 to 64 years) evaluable patients.

Urodynamic findings stratified by “age by decade” 
along with univariate analyses are shown in Table  1. 
Presence of detrusor overactivity, abnormal storage, 
and diabetes mellitus, as well as capacity, median BOOI, 
BOOI category, BCI category, Pdet.Qmax, Qmax, and PVR, 
all showed a significant association with age. Detru-
sor overactivity was noted in 524 patients (32.8%) with 
median peak detrusor pressure 33cm H20 (IQR 20 to 55). 
A total of 17.2% of men presented with hydronephrosis 
of at least one kidney.

Numerical value of BCI and BOOI stratified by 
“age by decade” and pressure-f low data are depicted 
in Figures 1 to 3. Intergroup post hoc analysis (crosstab 
chi-square; Bonferroni correction) for association of “age 
by decade” with storage abnormality is shown in Table 2.

Overall, the commonest major urodynamics find-
ing was an underactive detrusor (BCI < 100), noted in 
834 men (52.3%). Unequivocal bladder outlet obstruc-
tion (BOOI ≥ 40) was noted in 725 men (45.4%). Abnor-
mal storage was seen in 665 men (41.7%). Isolated 
obstruction, isolated underactivity, and isolated stor-
age abnormality were noted in 14.2%, 26.8%, and 5.4%, 
respectively.

Multiple regression analyses were performed to 
assess the impact of age on BOOI, BCI, and presence 
of storage abnormality. The overall models to predict 
BOOI, BCI, and storage abnormality were statistically  

Abbreviations 
BCI bladder contractility index
BOOI bladder outlet obstruction index
CI confidence interval
IQR interquartile range
OR odds ratio
PVR post-void residual

275SIUJ.ORG SIUJ  •  Volume 2, Number 5  •  September 2021

Association of Age With Lower Urinary Tract Function in Adult Men Presenting for Urodynamics: A Database Analysis



TABLE 1. 

Urodynamic findings based on “age by decade” along with univariate analyses in adult men  
with refractory lower tract symptoms 

Overall
<30

years
30–40
years

40–50
years

50–60
years

60–70
years

70–80
years

> 80
years

Statistic

n 1596 317 242 226 290 317 176 28

Age, years
Median (IQR)

51.0  
(34.0, 64.0)

25  
(22, 28)

36 
(33, 38)

45 (43, 48)
56 

(53, 58)
65 

(63, 68)
75 

(72, 77)
83 

(82, 84)
P < 0.001

DM (%)
498 

(31.2)
5 

(1.6)
16 

(6.6)
48 

(21.2)
137 

(47.4)
176 

(55.5)
98

 (55.7)
18 

(64.3)
P < 0.001

Detrusor 
overactivity

(%) 

524 
(32.8%)

84 
(26.5)

66 
(27.3)

58 
(25.7)

79 
(27.2)

131 
(41.3)

96 
(54.5)

10 
(35.7)

P < 0.001

C
om

pl
ia

nc
e 

m
l/

cm
 H

20
 (%

)

<10
118 
(7.4)

25 
(7.9)

19 
(7.9)

13 
(5.8)

23 
(7.9)

20  
(6.3)

14 
(8.0)

4 
(14.3)

P = 0.09210–20
186  

(11.7)
41  

(12.9)
32  

(13.2)
17 

(7.5)
24 

(8.3)
47  

(14.8)
20 

(11.4)
5 

(17.9)

≥20
1292 
(81.0)

251 
 (79.2)

191 
(78.9)

196 
(86.7)

243 
(83.8)

250  
(78.9)

142 
(80.7)

19 
(67.9)

Abnormal  
storage (%)a

665 
(41.7%)

119 
(37.5)

94  
(38.8)

71 
(31.4)

102 
(35.2)

154 
(48.6)

108  
(61.4)

17  
(60.7)

P < 0.001

Capacity  
(IQR)

320 
(301, 377)

317  
(303, 361)

333  
(304, 398)

331 
(304, 404)

330 
(302, 392)

314 (266, 
366)

301 
(206, 325)

303 
(197, 318)

P < 0.001

EFP  
(IQR)

6 
(3, 13)

7  
(3, 14)

7  
(3, 13)

6  
(3, 11)

6 
(3, 12)

6 
(3, 13)

6 
(3, 10)

7 
(4, 22)

P = 0.256

BCI  
(IQR)

98.5 
(75.8, 128.0)

95  
(74, 130)

100  
(78, 130)

98  
(70, 131)

102 
(76, 133)

100 
(80, 122)

96 
(79, 115)

87 
(76, 108)

P = 0.356

BOOI  
(IQR)

37.0 
(18.0, 64.0)

26 
(11, 46)

35 
(18, 63)

36 
(17, 66)

42 
(23, 77)

42 
(24, 66)

41 
(23, 63)

41 
(19, 57)

P < 0.001

Pdet.Qmaxb
53 

(39, 78)
46 

(35, 65)
52 

(39, 78)
50 

(35, 83)
58 

(39, 91)
60 

(41, 78)
56 

(44, 74)
52 

(39, 65)
P < 0.001

Qmax
7 

(4, 10)
8 

(5, 12)
7

 (4, 11)
7 

(4, 10)
7 

(3, 9)
7 

(4, 10)
7

(4, 10)
7 

(4, 9)
P < 0.01

PVR
55 

(3, 166)
22 

(0, 122)
44 

(1, 168)
48 

(2, 158)
79 

(7, 191)
68 

(6, 184)
63 

(15,164)
107

(33,144)
P < 0.001

aAbnormal storage was defined as either presence of detrusor overactivity or compliance < 20 mL/cm H20 or both.  
bFor patients who could not void, the Pdet.max was recorded instead of Pdet.Qmax
EFP End fill pressure; Pdet.Qmax: detrusor pressure at maximum flow; Qmax: maximum flow rate.

276 SIUJ  •  Volume 2, Number 5  •  September 2021 SIUJ.ORG

 ORIGINAL RESEARCH



significant. Increasing age was associated with a higher 
BOOI and presence of storage abnormality but a lower 
BCI. Age (−0.240, 95%CI −0.352 to −0.127; P < 0.001) 
and BOOI (0.807; 95%CI 0.765 to 0.849; P < 0.001) but 
not presence of diabetes mellitus or storage abnormal-
ity was associated with BCI. Age (0.241; 95%CI 0.146 to 
0.337; P < 0.001), BCI (0.582; 95%CI 0.552 to 0.613; P < 
0.001) and storage abnormality (10.887; 95%CI 7.869 to 
13.905; P < 0.001) but not diabetes mellitus was associ-
ated with BOOI. Age (OR 1.015; 95%CI 1.008 to 1.022; 
P < 0.001) and BOOI (OR 1.012; 95%CI 1.009 to 1.016; P 
< 0.001), but not diabetes or BCI, were associated with 
presence of storage symptoms.

Discussion
This study showed significant age-associated differences 
on urodynamics evaluation of men presenting with 
refractory lower urinary tract symptoms. Increasing 
age was independently associated with reduced bladder 
contractility (measured by the BCI), increasing degree 
of obstruction (measured by the BOOI), and increasing 
odds of f inding a storage abnormality (detrusor 
overactivity, reduced compliance < 20 mL per cm H20, 
or both). Although not strictly linear, for each 10 years 
increase in age, on average, the BCI fell 2.4 points and 
the BOOI increased by 2.4 points. Increasing decadal 
age was also negatively associated with capacity and 
positively associated with storage abnormality and PVR.

Age (years)

B
CI

18–30 30–40 40–50 50–60 60–70 70–80 80–90

100.0

250

200

100

0

Age (years)

250

200

100

18–30 30–40 40–50

B
O

O
I

0
80–90

50

20.0

150

50–60 60–70 70–80

Pdet.Qmax

53.0

0

Q
m

ax

0

10

20

7.0

30

30

100 200 300 400

FIGURE 1. 

Bladder contractility index values stratified by age in 
box plot

A value over 100 is regarded as normal (horizontal marker 
line). Note the trend of lower values for median BCI with 
each advancing decade beyond the sixth decade.

FIGURE 2. 

Bladder outlet obstruction index values stratified by  
age in box plot

A value under 20 is regarded as unobstructed (horizontal 
marker line). Note the numerically lower median BOOI in 
men in the 18 to 30 years age group. Intergroup analysis 
showed that men in the 18 to 30 age group were least 
likely to show severe obstruction (P < 0.05; Bonferroni 
correction).

FIGURE 3. 

Scatter plot of Qmax versus Pdet.Qmax

The median value for Qmax (7.0 mL per second) and  
median Pdet.Qmax (53 cm H20) are marked by the  
horizontal and vertical marker lines, respectively.

277SIUJ.ORG SIUJ  •  Volume 2, Number 5  •  September 2021

Association of Age With Lower Urinary Tract Function in Adult Men Presenting for Urodynamics: A Database Analysis



The median BCI in adult men was noted to be about 
100 in this study, which is similar to the findings of 
several other studies[7–9]. Underactivity was noted 
in 52.3%, higher than the 11% to 40% reported in a 
review[10]. There was an independent age-associated 
decline in contractility. Literature on the association 
of age and bladder contractility is conflicting[11], but 
others studies have reported a similar association with 
age[7,8,12]. Age can impact bladder contractility by 
several possible mechanisms. These include changes in 
both afferent and efferent neuronal pathways as well as 
the smooth muscle and collagen within the bladder wall 
that might be mediated, at least in part, by ischemia[1]. 
While it is tempting to attribute all these changes simply 
to aging, it is often difficult to resolve whether the obser-
vations are due to disease processes that are increasingly 
common with aging. Older men are also more likely to 
suffer from diabetes. However, diabetes mellitus was 
not independently associated with underactivity in our 
patients (n = 498; 31.2%) when controlled for age. Lack 
of data on duration or control might have blunted our 
ability to identify its impact.

Bladder outlet obstruction was noted in 45.4% of our 
patients with median BOOI 37 (IQR 18 to 64) similar 
to the findings of Rosier et al. (BOOI 37)[12] but some-
what lower than that reported by Oelke et al. (BOOI 44)
[9]. Equivocal obstruction was noted in a further 428 
(26.8%) of men. Age was independently associated 
with the possibility of finding obstruction, which is not 
surprising, given that age is associated with prostate 
size. However, it is instructive to note that a significant 
minority of patients showed no obstruction at all.

Presence of a storage abnormality (detrusor overac-
tivity, poor compliance < 20 mL per cm H20, or both) 
was associated with age. Both detrusor overactivity and 
poor compliance were noted to be more common in the 
elderly, although the latter was not statistically signifi-
cant (Table 1). Overall detrusor overactivity and poor 

compliance were noted in 32.8% and 19.1%, respec-
tively. On multiple regression, presence of bladder outlet 
obstruction was independently associated with pres-
ence of a storage abnormality. In a study of 3357 men,  
detrusor overactivity and poor compliance was noted in 
45% and 7.7%, respectively[7]. An association between 
poor bladder compliance (< 20 mL/cm H20) and older 
age, with a linear reduction for each decade beyond the 
sixth has been noted in another study[13]. Alterations in 
afferent signaling systems and connective tissue matrix 
are important in the pathogenesis of detrusor overac-
tivity and reduced compliance that are often seen with 
aging[14]. These changes might be accelerated by the 
presence of concomitant obstruction[15].

Post hoc analyses of differences based on “age by 
decade” showed interesting sub-trends. The propor-
tion of men with a strong detrusor dropped progres-
sively with age from the sixth decade (Figure 1). The 
proportion of men with a storage abnormality showed 
a progressive increase beyond the age of 60 years, being 
35.2%, 48.6%, 61.4%, and 60.8% in the sixth, seventh, 
eighth and beyond eighth decade, respectively (Table 2).

Men under 30 years of age undergoing urodynamics 
were the least likely of any age group to show obstruc-
tion (30.3%; median BOOI 26), with an additional 
28.7% demonstrating equivocal obstruction (BOOI 20 
to 40). Underactive detrusor was noted in 54.6%. Other 
authors examining young men with refractory urinary 
symptoms with urodynamics have reported different 
findings. A study of 86 men below the age of 45 years 
found obstruction in 62% and an underactive detrusor 
in 10%[16]. This study, however, did not provide the data 
for men under 30 years separately[16]. Rosier et al. found 
a progressive reduction in detrusor contractility, as 
measured by the Watt factor, from the second decade to 
the ninth decade[12]. Young men might demonstrate the 
residual consequences of childhood disorders of lower 
urinary tract function, such as dysfunctional voiding, 

TABLE 2. 

Association between presence of storage abnormality and “age by decade”

Age by decade (years) and number of men with or without a storage abnormality

Storage Abnormality 18–30 30–40 40–50 50–60 60–70 70–80 ≥ 80 Total

No Storage Abnormality 198 148 155 188 163 68 11 931

Abnormal storage 119 94 71 102 154 108 17 665

Abnormal, % 37.5 38.8 31.4 35.2 48.6 61.4 60.7 41.7

Total 317 242 226 290 317 176 28 1596

Storage abnormality defined as detrusor overactivity, poor compliance (<20cm H20), or both.

278 SIUJ  •  Volume 2, Number 5  •  September 2021 SIUJ.ORG

 ORIGINAL RESEARCH



faulty toilet training, or bowel-bladder dysfunction. Of 
note, dysfunctional voiding is a common diagnosis in 
young men with refractory urinary symptoms undergo-
ing urodynamics[17,18].

Maximum flow rate and bladder capacity showed a 
reduction with age, but although statistically significant, 
this was not clinically relevant. However, a concomitant 
increase in residual urine implied progressive reduction 
in voiding efficiency with age. In fact, the effective capac-
ity reduced by about one-third in men above 80 years of 
age compared with those between 18 and 30 years. This 
has implications for storage symptoms such as frequency 
and nocturia.

The European Association of Urology guidelines 
recommend use of preoperative urodynamics testing 
before surgery in men above 80 and below 50 years of 
age with predominant voiding symptoms (both weak 
recommendations), while acknowledging the lack of 
adequate data to support this guidance[4]. Our study 
would suggest that such evaluation might be particularly 
important in men under 30 years of age. Older men show 
a higher prevalence of storage disorders, underactivity, 
and obstruction, but the trends are gradual and notice-
able well before the threshold of 80 years. Of note, men 
above the age of 80 years made up only 1.8% of our study 
population. While universal use of urodynamics has not 
been shown to improve patient outcomes, it is important 
to define subsets of men who might be at higher risk of 
non-obstructive lower urinary tract symptoms[19]. Such 
men might be less likely to have a satisfactory outcome 
after outlet surgery[2].

An important limitation of this study is the lack of 
clinical information with respect to symptoms. The 
method of recording symptoms varied during the study 
period, making it difficult to unify data. Hence, it is 
important to understand the clinical context for this 
group. Patients were typically offered urodynamics only 
when they failed medical management. A total of 17.2% 
had hydronephrosis of at least one kidney at presen-
tation consistent with the refractory nature of their 
symptoms. Men with isolated storage abnormality were 

seldom subjected to urodynamics. Instead, they received 
treatment based on clinical judgment. Consequently, 
only 5.4% of men had an isolated storage abnormality. 
However, as we have reported earlier, presence of stor-
age phase abnormality was associated with an increased 
probability of finding hydronephrosis[20]. The duration 
of symptoms might have impacted bladder function. 
In a study of men with and without outlet obstruction, 
BCI and flow rate reduced, while PVR increased over a 
follow-up of 10 years[21]. However, an earlier publication 
failed to show any change in detrusor contractility with 
time[22], and symptoms are not generally regarded as a 
reliable predictor of the underlying abnormality[23].

The policy with respect to surgery in men with a 
clinical diagnosis of bladder outlet obstruction would 
be expected to impact the findings of this (and simi-
lar studies). While elderly men often undergo surgical 
intervention without urodynamics this is unlikely to 
happen in young men. Therefore, the data for elderly 
men are likely to omit men with unequivocal clinical 
findings suggestive of benign prostatic obstruction (who 
might be expected to have a higher BOOI and BCI). Of 
note, the bias introduced by this is likely to strengthen 
the significance of the lower propensity for finding 
obstruction that we noted in men less than 30 years  
of age.

This database study examined urodynamics find-
ings across the entire spectrum of adult men. While a 
few studies have provided these data, most studies have 
excluded either the young or the elderly.[7,9,24,25]

Conclusions
Examining all men in a single study offers the 
opportunity to apply a uniform yardstick to yield 
comparative data. The conclusions from this study are 
clearly not applicable to the general population of adult 
men. However, they give a clue to anticipated lower 
urinary tract function in adult men with refractory 
lower urinary tract symptoms in whom a urodynamic 
evaluation (and by extension a possible surgical 
intervention) is being contemplated.

279SIUJ.ORG SIUJ  •  Volume 2, Number 5  •  September 2021

Association of Age With Lower Urinary Tract Function in Adult Men Presenting for Urodynamics: A Database Analysis



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Association of Age With Lower Urinary Tract Function in Adult Men Presenting for Urodynamics: A Database Analysis




