In April 2022, PMD Alliance hosted a webinar with Erica Vitek, occupational therapist (OT), who addressed urinary issues in Parkinson’s disease (PD) including normal bladder function, pelvic floor muscle exercises, and how to support bladder health. She also delved into practical lifestyle changes that can improve bladder function, and resources for incontinence. Erica explained some terms such as mixed incontinence, neurogenic bladder, nocturia, and overflow incontinence.
Urinary issues or incontinence is extremely common in PD with recent studies showing that about 70% of those with PD experience urinary and bladder difficulties. The most common issues are the urgency and frequency of going to the bathroom.
According to Erica, another common complaint is having to go to the bathroom at night time, which disrupts sleep. A common PD symptom that arises due to night time urination urges is mobility issues. The PD medications may or may not work precisely at night and hence getting up and moving at night is also not advisable. Getting up and moving at night also introduces the risk of falling in low lighting situations.
Lastly, coughing, laughing, and sneezing might cause urinary leakage. Sometimes the urge to go to the bathroom is so extreme that even adjusting your clothes before getting up to go might be too much stress on the bladder and may cause a bit of leakage. In some people, the whole bladder might release on the way to the restroom.
This webinar was recorded, and is accessible on the PMD Alliance YouTube channel.
For more resources on PD incontinence and blog, please see these Stanford Parkinson’s Community Outreach webpages:
My notes from the webinar are below.
“Uncovering urinary issues” [in Parkinson’s Disease] – Webinar notes
Webinar Host: PMD Alliance
Webinar Date: April 20, 2022
Speakers: Erica Vitek, OT, Aurora Sinai Medical Center, Wisconsin
Summary by: Sheela Sakariya, Stanford Parkinson’s Community Outreach
A condition in which a combination of urgency of sensation to go to the bathroom and having a little bit of leakage. Sometimes people have leakage at night time while in bed.
A condition in which the bladder is really full and overflows because you have not gotten up to go to the bathroom.
This is a general term for anyone who has lower urinary tract dysfunction or impairment related to the neurologic condition. Dopamine plays a role in bladder control hence, the condition is related to the neurology of the brain. When a person has less dopamine or damage in the brain cells and impacts the bladder, it’s called neurogenic bladder. Essentially, it’s the damage to the nervous system that’s interrupting the signals from the nerves to the bladder.
When we age, the hormone that is supposed to produce less urine at night starts diminishing. So, we do tend to produce more urine at night generally as part of the natural aging process. If you wake up more than one time each night to go to the bathroom, you may have nocturia. Sleep disruption from having to urinate during the night can impact your quality of life.
About 1 in 3 adults over the age of 30 experience nocturia. The rate of people affected increases with age. It can be caused by a lifestyle habit or an underlying health problem.
Nocturia can be caused by:
- Polyuria: when your body makes too much urine in a 24-hour period
- Nocturnal polyuria: when your body makes too much urine during the night
- Bladder storage problems: when your bladder doesn’t store or release urine well
- Mixed nocturia: when more than one of these problems are happening
Diuretics both stimulate your bladder and increase the amount of urine produced by your body. These can temporarily create conditions that lead to urinary incontinence in some people, particularly those who have another contributing risk factor. Physicians tend to tell you to take these pills in the morning so it does not disrupt the night time sleep routine.
Urinary issues and causes
Urinary issues or incontinence are extremely common in PD and some recent studies state that about 70% individuals with PD experience urinary and bladder difficulties. The most common issue is the urgency of going to the bathroom coming on more and more than it used to before as well as more frequency of urination. In addition, the amount of urine is very small compared to before.
Another common complaint is going to the bathroom at night time which disrupts sleep and also brings up mobility issues when the medications may or may not be working. Getting up and moving at night also introduces the risk of falling in low lighting situations.
Lastly, coughing, laughing, and sneezing might cause urinary leakage, as well as when the urge comes on very quickly and so intensively that even adjusting your clothes to go to the bathroom might be too much stress on the bladder and may cause a bit of leakage. Some people with PD experience more than a bit of leakage where the whole bladder might release all the urine on the way to the restroom.
Incontinence at night
As a therapist, we would like to find out some measurements:
- Use a measuring hat which will help me (as a therapist) understand how much urine comes out during the day vs night.
- How often do you need to urinate
- How many urges do you have during the day/night
What is normal:
- Bladder can hold about 1-2 cups of urine (2 cups is the maximum)
- Average urination should be about 10 ounces
- Lot of people with PD have only about 3 ounces per urination and is extremely common
- 6-8 times going to the bathroom during the day is normal
- 0-1 times at night
Strategies for night time incontinence in PD
Fluid shifting: getting more fluids during the day time and in the earlier hours of the day. Around 64 ounces of fluids per day between waking time and 3:30 pm. Only 6 ounces of fluid during dinner, and only sips after that for medication. That can really help retrain the bladder to be filled during the day and bathroom frequency to increase during the day and decrease at night
Other nighttime management options: pure wick (catheter like device) for females; condom catheter for males; men’s liberty for males
Pelvic floor exercise in PD
Your pelvic floor is the magical muscle group that prevents all your organs from falling right out the bottom of your body. It contracts and relaxes when you use the restroom. These two muscles work together with the rest of your core to stabilize and support the spine. Physiotherapists, doctors and nurses know that exercising the pelvic floor muscles can help you to improve your bladder control with PD.
When done correctly, these exercises can build up and strengthen these muscles and so help you to control your bladder and bowel. The muscles of the pelvic floor are kept firm and slightly tense to stop leakage of urine from the bladder and wind or feces from the bowel. When you pass water or have a bowel motion the pelvic floor muscles relax. Afterwards, they tighten again to restore control. The muscles actively squeeze when you laugh, cough, lift or sneeze to help prevent any leakage.
Men vs women experience in PD incontinence
Men and women experience very similar symptoms for incontinence in PD. The major difference is estrogen plays a more dominant role for females especially in menopause and post menopuase. During menopause when the estrogen levels are down, the tissues in the pelvic area tend to be reduced. That’s very close to the urethra where the urine comes out of the bladder. So, women might have additional opportunities to use estrogen cream prescribed by a doctor to help with bladder issues as well as urinary tract infections.
Question and answer session
Question: Is it unusual to go to the bathroom 6-8 times a night?
Answer: Yes, it should be 0-1 times a night. Six times a night is way too much and needs to be addressed. That definitely impacts your sleep and should be addressed immediately.
Question: How should I take my pills if I reduce water intake after 6pm?
Answer: You have to take your pills, so you have to drink some water. I might suggest taking your pills with applesauce or something that helps with your pills instead of fluids. Taking your pills with something that does not have as much liquid but can also help you swallow can be beneficial for night time incontinence.
Question: When I cough, sneeze, or laugh, it’s not a little bit of leakage, it’s a lot. Is that normal with PD?
Answer: I highly recommend doing pelvic floor muscle therapy. Pelvic floor is a muscle that helps to support all organs of the pelvis. The pelvic floor muscle can be trained just as any other muscle in the body to have a better reaction with those coughs/sneezes. We can also create an exercise program to strengthen that muscle.
Question: Would botox injections help with incontinence in PD?
Answer: Botox is becoming very popular with PD and incontinence. The botox procedure would be done by a urologist and they would place the injections throughout the bladder muscle. It’s a temporary solution that kills off the bladder nerves and gives the bladder the ability to stretch and store more urine into it. These injections have to be repeated for it to be effective.
Question: Will artificial intelligence (AI) have any play in PD incontinence?
Answer: In the future, I am not sure how much AI will have influence in the diagnostics and treatment of physical conditions such as incontinence in PD. We know there are 200 different subtypes of PD, and even the smartest physicians will not be able to formulate, change, and learn individualized treatment for each subtype. So some form of AI will be helpful in how we plan, develop, and improve our approach towards precision medicine.
Question: How does muscle strength help with incontinence?
Answer: Muscle strength is a great way to improve bladder control. A combination of botox and floor pelvic exercise which will build muscles is a great way to improve your bladder and incontinence issues. A lot of medications help with PD, but a lot of people with PD cannot tolerate taking those medications due to other side effects, hence exercise is a great option.
Question: Can you speak about the long term use of catheters to solve the incontinence problem?
Answer: The recommendation is not to use long term catheters if possible as the risk of infections increases significantly. In addition, nursing care needs to be involved like a home care nurse needs to come to your house and change it regularly. I rarely see anyone using a catheter full time.