Management of Incontinence in Patients with Parkinson’s Disease

Management of Incontinence in Patients with Parkinson’s Disease

It is estimated that two-thirds of all patients with PD have some degree of bladder problems ranging from complete inability to empty the bladder (urinary retention) to the more common problem of urinating too often (increased frequency) and to the ability to make it to the bathroom in time (incontinence). Common dysfunctions are bladder overactivity, causing urinary urgency, frequency, and incontinence (unintentional leaking). Getting up at night to use the bathroom (nocturia) is the most prevalently reported non-motor symptom with PD, reported by more than 60%.  Weak voiding is also a common dysfunction. Patients may feel like they must go frequently, but when they go it may take longer than average to void.  Constipation is another common issue that may arise and being constipated can affect medication absorption. Some studies suggest that 80% of people who have Parkinson’s Disease report constipation.

So why do these problems occur in people who have Parkinson’s Disease? As per the Parkinson’s Disease Clinic and Research Center: The bladder is a muscle which gradually expands as urine collects. At the opening, there is a muscle called the sphincter. This muscle is usually closed except when urinating. Both muscles are controlled by the brain. When 1-2 cups of urine have collected in the bladder, the bladder may begin to have small contractions that signal the brain that the bladder is filling up. The brain can suppress the contractions until it is convenient for the person to go to the bathroom. When ready, the brain allows the bladder to contract while the sphincter relaxes. This allows the urine to leave the bladder. In PD, the brain’s control of the sphincter is disturbed. The bladder becomes overactive and wants to empty even when there is just a small amount of urine present. This results in symptoms of urgency, frequency, incontinence, and repeated night-time urination.

Patients with Parkinson’s Disease may also have difficulty eliminating urine.  This can be caused by a sphincter that wants to close when the bladder is ready to empty or by a bladder muscle that is too weak to expel urine. This is a concern because incomplete bladder emptying can cause accumulation of urine and the growth of bacteria. The latter can result in an infection. The symptoms of difficulty eliminating urine include weak urinary stream, dribbling or leaking, and feeling that the bladder has not completely emptied.

Patient should be educated to alert their health care provider is they have any of the following signs:

  1. Leakage of urine 
  2. Inability to urinate when bladder is full – requires immediate attention.
  3. Unusually frequent urination without a proven bladder infection.
  4. Needing to rush to the bathroom or losing urine if you do not “arrive in time.”
  5. Pain related to urination.
  6. Progressive weakness of the urinary stream which may be accompanied by a feeling that the bladder is not emptying completely.

As with any other patient who has been medically screened, treatment should start at the most conservative level. Many of these methods are low risk and can be of significant benefit. A few of these are:

  1. Timed voiding: This involves urinating on a set schedule, gradually extending the time between voiding.
  2. Bladder retraining/urge suppression: Holding the bladder for longer periods of time to allow it to expand back to its previous capacity.
  3. Pelvic Floor Physical Therapy: To include various treatments and approaches, including retaining of the Knack reflex and pelvic floor exercises
  4. Addressing Bladder Irritants: Determining which foods and liquids contribute to the patient’s symptoms. 

Second line of therapy for bladder issues for patients who have Parkinson’s Disease is medical management. Many drugs, such as VESIcare and Ditropan are used to help reduce these symptoms. Mirabegron, which is an oral beta-3 agonist has been showing promising results in treating patients with Parkinson’s Disease who have bladder issues (except those with very high blood pressure).  It is important to weight the potential side-effects, such as dry eyes and mouth, memory issues, constipation, and irritation of the stomach when using these medications.

For those patients whose bladder symptoms are not improved with first- and second-line treatments, surgery may be an option. Some common procedures are:

InterStim: This is a small device, much like a pacemaker, that is implanted just behind the skin of the pelvis. It emits mild electrical pulses that target an area near the sacral nerves and modulates neural activity controlling the bladder. 

Percutaneous tibial nerve stimulation: This is an office procedure that emits electrical stimulation to control bladder function. For this procedure, the patient’s foot is elevated and an acupuncture needle is placed near the near by the ankle (tibial nerve). The impulses travel to the sacral nerve area where bladder function is controlled. 

Botox injections: During this procedure, a small scope is passed inside the bladder. The wall of the bladder is injected with Botox via small needles.

Since urinary problems are common in patients with Parkinson’s Disease, awareness of their existence is the first necessary step for adequate management. People with Parkinson’s Disease should be encouraged to alert their physicians if they are having any issues, especially because effective treatment is often available.

References

1. Sakakibara, Ryuji, et al. “Bladder, Bowel, and Sexual Dysfunction in Parkinson’s Disease.” Parkinson’s Disease, SAGE-Hindawi Access to Research, 2011, www.ncbi.nlm.nih.gov/pmc/articles/PMC3171780/.

2. Wang, C-P, et al. “Early Recognition of Pelvic Floor Dyssynergia and Colorectal Assessment in Parkinson’s Disease Associated with Bowel Dysfunction.” Colorectal Disease : the Official Journal of the Association of Coloproctology of Great Britain and Ireland, U.S. National Library of Medicine, Mar. 2013, www.ncbi.nlm.nih.gov/pubmed/23320499/.

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