The Multiple System Atrophy Coalition hosted a two-day conference in late October on various aspects of MSA, which is a disorder similar to Parkinson’s disease (PD). MSA is called an atypical parkinsonism disorder. 

One of the talks, presented by Dr. Michael Guralnick, a urologist at Froedtert Hospital in Milwaukee, focused on urinary frequency, urgency, and incontinence. These are bladder symptoms of both MSA and PD.

The speaker detailed a three-tiered management approach to an over-active bladder – behavior modification (including pelvic floor therapy), medication, and procedural (such as nerve stimulation and Botox injections). Similarly, Dr. Guralnick detailed a three-tiered management approach to urinary dysfunction – behavior modification (including pelvic floor therapy), medication, and procedural (such as nerve stimulation, Botox injections, and prostate surgery). Catheters were also addressed. All of this talk applies to PD, MSA, and other atypical parkinsonism disorders.

To watch this webinar, go here and click “Register Now.” Follow the instructions and email link, then return to the conference website. If you are logged in, you can access this link to view the recording.

Dr. Guralnick’s talk begins at timestamp 26:20.

Stanford Parkinson’s Community Outreach has a webpage with lots of resources on urinary issues in PD.

I listened to this presentation and am sharing a summary of the talk below. 

– August Besser

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“MSA and the Bladder” – Lecture Notes

Speaker: Dr. Michael Guralnick, urologist at Froedtert Hospital in Milwaukee, Wisconsin.

Conference Host: Multiple System Atrophy Coalition

October 24, 2020

Summary by August Besser, Stanford Parkinson’s Community Outreach

Urinary Tract Anatomy

• The two kidneys make urine and send the urine down to the bladder
• The bladder is emptied through the urethra
• Prostate in males
• The bladder muscle (detrusor) is analogous to a car’s engine
• The urethral sphincter muscle is analogous to a car’s brake

The Bladder has Simple Functions:

• Urine storage (hold it in): the bladder muscle relaxes and the sphincter muscle contracts
• Urine emptying/voiding: the bladder muscle contracts and the sphincter muscle relaxes
• The nervous system’s control of the urinary tract is complex and still not fully understood

Adult Neurogenic Lower Urinary Tract Dysfunction (ANLUDT)

• Nervous system is like the circuitry in your house and the bladder and sphincter are appliances (e.g., microwave and toaster)
• Pathology in the nervous system (brain, spinal cord, nerves) can result in abnormal functioning of the bladder and sphincter

Urine Storage Dysfunction (aka Overactive Bladder)

• Urinary frequency: influenced by urine output- fluid intake, edema (ankle swelling), diuretic medication
• Urinary urgency
• Urinary incontinence (accidental wetting): bed wetting and urge incontinence

Urinary Emptying/Voiding Dysfunction

• Weak (underactive) bladder
• Urethral obstruction
  • Voiding difficulty: weak stream and straining
  • Retained urine in bladder: risk for infection (UTI), kidney stones, or kidney dysfunction. Leads to frequent urination (the bladder is always partly full).

MSA Affects the Brain and Spinal Cord

• Lower urinary tract symptoms are very common in MSA
  • Affect >90% of patients
  • May precede onset of other neurologic and orthostatic symptoms
  • May progress with time
• Urine storage dysfunction and/or emptying dysfunction

How Are Patients Assessed?

• Symptom assessment and physical exam. Questionnaires.
• Urine testing. Rule out infection/blood.
• Bladder scanner (ultrasound). Assess emptying.
• Bladder diary/wet pad tests. Assess urine production, urinary frequency, incontinence.
• Urodynamic testing

3-Tiered Management of Overactive Bladder

• Behavior modification/pelvic floor therapy
• Medication
• Procedural

Behavior Modification/Pelvic Floor Therapy

• ·      Fluid management
  •  Avoid excessive urine production
    • Appropriate intake/timing of fluids
    • Management of leg edema/swelling: timed diuretics, compressive stockings, afternoon lie downs
    • Treat sleep apnea
  • Avoid bladder irritants
• Manage constipation
• Pelvic floor therapy
  • Kegels
  • Physical therapy: biofeedback and electrical stimulation
• Bladder retraining
  • Timed urination (prompted)
  • Delayed urination

Bladder Irritants

• Alcoholic beverages, including beer and wine
• Citrus juices and fruits
• Highly spiced foods
• Carbonated beverages (e.g., soft drinks)
• Caffeine (coffee, tea, chocolate)
• Sugar, honey
• Milk/milk products
• Corn syrup
• Artificial sweetener
• Smoking

Overactive Bladder Medications

• Oxybutynin, Tolterodine, Solifenacin, etc.: All roughly equivalent in efficacy (improve urine holding)
• Some cause more side effects
  • Dry mouth
  • Constipation
  • Blurred vision
  • Potential for cognitive problems (e.g. memory); especially oral Oxybutynin

Procedural Management

• Nerve stimulation (technically not approved for neurogenic bladder)
  • Tibial aka PTNS
  • Sacral aka InterStim
• Botulinum toxin injection into bladder (Botox)

CAUTION

• Medications and some procedures that reduce bladder hyperactivity (to improve urine storage) have the potential to worsen bladder emptying. Akin to taking foot off of gas pedal.
• This could force a compromise between urine storage and emptying. Some patients require catheterization to empty their bladders if they take OAB medications or use Botulinum toxin injections to improve urine storage.

3-Tiered Management of Urine Emptying Dysfunction

• Behavior modification/pelvic floor therapy
• Medication
• Procedural

Medications for Emptying Dysfunction

• Relax sphincter: Tamsulosin, Sildosin, Alfuzosin
• Shrink prostate: Finasteride, Dutasteride
• Strengthen bladder (rarely used): Bethanecol

Procedures to Improve Emptying

• Nerve stimulation: sacral neuromodulation aka InterStim
• Botulinum toxin (Botox) injection into sphincter
• Prostate surgery

Prostate Surgery and MSA

• Used to relieve urinary symptoms in BPH patients with enlarged prostates that obstruct the urethra
• Generally, in MSA the prostate is not the cause of urinary symptoms (it’s a neurological condition affecting the bladder and sphincter)
• Prostate surgery doesn’t necessarily improve bladder emptying and carries a significant risk for urinary incontinence in MSA patients

Catheters

• Can help manage both urinary storage (incontinence) and emptying dysfunctions
• Indwelling vs intermittent vs external
• Can have downsides: bladder irritation, urinary infection, urinary stones

Intermittent (Self) Catheterization

Advantages: No need to carry drainage bag, less irritation/infection than indwelling

Disadvantages: needs to be done multiple times a day, potential for infection, discomfort/difficulty with insertion

Indwelling (Foley) Urethral Catheter

• Advantages: Simplifies bathroom habits, may lessen incontinence (balloon plugs urethra)
• Disadvantages: irritation of bladder, infection, stones, urethral trauma/erosion

Suprapubic Catheter

• Advantages: Avoids urethra (no trauma), may be more comfortable, less infection, larger catheter size drains better
• Disadvantages: skin irritation (especially if obese), can leak urine per urethra, requires minor surgical procedure

External Catheter

• Manages urinary incontinence (not urinary retention)
• Can be worn as needed
• Less infection than indwelling catheters
• Need to have adequate bladder emptying
• May not stay on well if penis retracts into fat

Keys to Keeping Catheters “Happy”

• High fluid intake: at least 2-3 liters per day (irrigation might be needed)
• Change catheter regularly: at least every 4 weeks for indwelling catheters; new catheter each time for intermittent catheters
• More frequent emptying is better than less frequent for intermittent catheterization
• Don’t force it- avoid trauma to urethra