In April 2022, the American Parkinson Disease Association (APDA) Massachusetts Chapter hosted a webinar with urologist Dr. Linda Ng on bladder issues in PD. Dr. Ng identified common bladder symptoms, broken into two categories – storage and voiding. She described quality-of-life impacts that bladder symptoms can have, including limiting physical activity, causing a loss of self esteem, limiting and planning travel around toilet accessibility, and absences from work. And Dr. Ng discussed potential behavioral, medical, and surgical solutions. To treat bladder issues, Dr. Ng recommends visiting a urologist.
According to Dr. Ng, the bladder has two major functions. One is to provide storage for urine and the second is to void the liquid. As capacity is reached, a nerve signal is sent to the brain to trigger the need to urinate and to coordinate the contractions needed to void. People with PD have bladder function issues because fluctuations in dopamine levels directly affect bladder muscles and nerves. PD is also thought to impact the nerve pathway between the bladder and the area of the brain that controls bladder function.
Because of the abnormal nerve signals, the bladder may start to contract too early, leading to incontinence.
In an office visit, the urologist will perform a physical exam and urinalysis, and may perform other tests such as a post-void residual ultrasound, cystoscopy, prostate sizing, and urodynamic testing. Once the correct diagnosis is reached, the problem can be treated through behavioral, medical and possible surgical management.
Behavioral modifications for an overactive bladder include decreasing fluid intake, timed voiding, bladder retraining, and avoiding bladder irritants. If these modifications alone do not fix the issue, medications are used. The most common medications are anticholinergic drugs with antimuscarinic activity. Studies have shown that anticholinergic drugs can cause cognitive decline, so Dr. Ng recommends beta3-adrenergic agonists that do not have memory or cognitive side effects. If medication does not relieve symptoms, alternative management options such as pelvic floor physical therapy, Botox, and sacral neuromodulation may be used. If none of the above alleviates the symptoms, pads, diapers, or condom catheters are available.
There are also treatment options for voiding dysfunction. Alpha blockers and pelvic floor physical therapy can help with urinary hesitancy. Obstructed voiding through benign prostatic hyperplasia can be managed with surgery. Finally, an underactive bladder can be treated with intermittent catheterization.
The question-and-answer session at the end of the webinar is also worth reviewing. This question and answer, in particular, caught my attention:
Question: People with PD have constipation issues. Can that cause problems with an overactive bladder?
Answer: Yes, because the intestines and colon sit directly on the bladder, so when you are frequently constipated, that can exert external pressure on the bladder itself, which can also cause the sensory nerves in the bladder to send premature messages to the brain that you need to urinate.
For more information on bladder issues, see this Stanford Parkinson’s Community Outreach page:
The webinar recording can be viewed here on the APDA YouTube channel
Please see below for notes on the April webinar.
Regards,
Joëlle Kuehn
“Understanding bladder issues in PD” – Webinar notes
Speaker: Linda Ng, MD, urologist, Boston Medical Center
Webinar Host: American Parkinson Disease Association Massachusetts Chapter
Webinar Date: April 19, 2022
Summary by: Joëlle Kuehn, Stanford Parkinson’s Community Outreach
Normal bladder:
- 2 major functions: provide storage and emptying (voiding) the liquid
- Storage:
- Normal bladder capacity is 300-500 cc (1.5 – 2 cups)
- As capacity is reached, nerve signal is sent to the brain to trigger the need to urinate
- Normal compliance: should be elastic, and no matter how much the volume changes, the pressure in the bladder should remain low
- An overactive bladder can develop when the nerve signals send prematurely to the brain before capacity is reached
- Voiding:
- Bladder contracts once patient has reached the bathroom or is ready to void
- Bladder contraction is coordinated with urinary sphincter relaxation
- Requires contraction of adequate strength
- Problems in voiding develop when patients cannot contract their bladders with adequate strength, meaning bladders are underactive
- Other problem: bladder starts to contract but the urinary sphincter does not relax at the same time like it is supposed to
Bladder and PD bladder:
- People with PD have bladder issues because fluctuations in dopamine levels directly affect bladder function
- Fluctuations in dopamine levels (dopamine D1-GABAergic direct pathway) affect the bladder muscles and nerves
- PD is also thought to impact the nerve pathway between the bladder and the area of the brain that controls bladder function.
- Because of aberrant nerve signals, the bladder may start to contract before you are trying to urinate, meaning you may have incontinence
Common urinary symptoms:
- Storage symptoms (overactive bladder/OAB)
- Urgency (33-54%)
- Frequency (16-36%):
- Frequency is too high if have to void more than 8 times in a 24 hour period
- Normal voiding should be every 2-3 hours with normal drinking
- If you drink more liquid, of course you void more which is normal, but if you void more with normal amounts of drinking, it is considered overactive
- Urge incontinence: You have the urge but the bladder starts contracting and voiding before you can sit down
- Nocturia (>60%): Most difficult storage symptom to treat
- Voiding symptoms (17-27%):
- Urinary hesitancy:
- Have the strong urge to urinate, but when you get there, the stream doesn’t initiate right away
- Due to sphincter not relaxing when the bladder starts to contract
- Poor stream
- Straining to urinate
- Sense of incomplete emptying: Just urinated but feel that there’s more urine in the bladder
- Urinary hesitancy:
Nocturia:
- Common symptom and very difficult to treat because it is multifactorial, because it is also a symptom of other health conditions that coexist in patients with PD
- Symptom of overactive bladder
- Symptom of benign prostatic hyperplasia (BPH)
- Can be seen in patients with excessive urine production (nocturnal polyuria). Seen in people with sleep apnea or diabetes
- Can be a symptom of circadian rhythm disturbances regulated by Arginine vasopressin (AVP) and melatonin. Makes patients more hyper alert at night (sleep is not as deep), so they are more aware of their bladders being full
Other Genitourinary / Urology symptoms – Sexual dysfunction:
- Decrease in libido
- Erectile dysfunction
- Important to have the partner present so that they can bring up these issues
- Can be treated with phosphodiesterase inhibitors (ex. Viagra) or other methods
Bladder issues impact on quality of life:
- Physical: Limitations on or cessation of physical activity
- Psychological:
- Guilt / depression
- Loss of self esteem
- Fear of:
- Being a burden
- Lack of bladder control
- Urine odor
- Social:
- Reduction in social interaction
- Limiting and planning travel around toilet accessibility
- Domestic:
- Requirements for specialized underwear, bedding, can be embarrassing and costly
- Special precautions with clothing
- Occupational:
- Absence from work
- Decreased productivity
- Sexual: Avoidance of sexual contact and intimacy
What to expect at an office visit:
- General history / physical exam
- Urinalysis to look for things like blood in the urine
- Post-void residual: scan bladder with ultrasound after voiding. Tells how much urine is left in bladder after just voided
- Voiding diary: What types of fluid they are taking in
- Possible prostate sizing: If suspecting benign prostatic hyperplasia
- Possible cystoscopy
- Possible urodynamic testing
Urodynamic evaluations and tests:
- Storage phase:
- Cystometrogram (CMG): like an EKG but for your bladder, electrical tracing the signals from the bladder to the brain, there shouldn’t be any signals until the bladder is full
- Parameters measured by a CMG:
- Sensation
- Volume at first sensation of bladder filling, first desire to void, normal desire to void, and strong desire
- Bladder capacity
- Detrusor overactivity:
- Involuntary bladder contractions
- Urge incontinence
- Voiding phase:
- Uroflowmetry:
- Voiding into a funnel that allows the cc’s per second of urine to be recorded)
- Measurement of rate of urine flow over time
- Pressure-flow study:
- Measures how much squeeze/pressure the bladder is able to generate
- Allows bladder outlet obstruction (BPH) to be differentiated from detrusor underactivity
- Electromyography (EMG patch):
- Looks at what the sphincter is doing
- Measures the electrical activities of the striated urinary sphincter through an electrode generally applied around the anus
- During normal voiding, EMG activity is quieted before initiation of detrusor contraction
- Uroflowmetry:
Actions/behavioral modifications if a patient is diagnosed with an overactive bladder:
- Decreased fluid intake:
- Especially at night
- Recommendation is 64oz of fluid per day
- Recommend more water
- Bladder retraining
- Timed voiding: Using a clock to tell you when to void instead on waiting for the urge to void
- Avoid bladder irritants such as caffeine, alcohol, acidic foods, carbonated beverages, and other bladder irritants
Medical Management of OAB:
- If behavioral modifications alone do not fix the issue, there are medications
- Most common treatments are anticholinergic drugs with antimuscarinic activity
- Eight anticholinergic drugs are available, all with different dose formulations, and delivery systems:
- Darifenacin, Fesoterodine, Solifenacin, Ooxybutynin (oral, transdermal, gel), Tolterodine, Trospium
- Trospium is the only one that doesn’t cross the blood-brain barrier
- There are studies showing that with the other 7 drugs, long-term use can lead to memory impairment which is already a concern in PD patients
- Beta3-adrenergic agonists are now available, and have not been linked to memory issues
Side effects of anticholinergics:
- Should not be used in patients with urinary retention, gastric retention, or uncontrolled narrow-angle glaucoma
- Dry mouth was the most frequently reported adverse event, others include headache, constipation, nausea, and dry eyes
- Recent studies suggest that long term use can cause cognitive decline and dementia
Beta3 agonists:
- No anticholinergic side effects
- Increase bladder capacity by relaxing the detrusor smooth muscle
- Mirabegron (Myrbetriq):
- Hypertension is a potential side effect, so need to monitor blood pressure
- 25mg and 50mg dosing
- Vibegron (Gemtesa):
- No significant changes in BP
- 75mg dosing
Alternative management of OAB:
- Biofeedback/pelvic floor physical therapy (PFPT)
- Deep brain stimulation (indirect)
- Botulinum toxin injection to they bladder (Botox)
- Percutaneous tibial nerve stimulation (PTNS)
- Sacral neuromodulation/InterStim:
- Implantable device for sacral nerve electrical stimulation
- A 2019 study with 20 patients, 7 patients reported an over 50% improvement
- Conclusion: outcome inferior to non-neurogenic patient
- If OAB symptoms decrease by at least 50%, an implantable pulse generator is inserted subcutaneously into the buttock
What happens when behavioral, medical, and alternative therapies aren’t effective?
- Pads or diapers
- Condom catheters for male patients
Management of voiding dysfunction:
- Urinary hesitancy:
- Alpha blockers (Tamsulosin, Alfuzosin)
- Pelvic floor physical therapy
- Obstructed voiding (BPH):
- Surgical management – surgery
- Underactive bladder:
- Possibly increased with progression of disease
- Intermittent catheterization:
- Patient uses a catheter every 4-6 hours to empty their bladder themselves, but only offered if they have the manual dexterity needed to do so
- Subprapubic catheter vs indwelling foley
Question and Answer:
Question: How do I make an appointment with a urologist that understands PD if my neurologist does not address bladder symptoms?
Answer: Depending on insurance, some insurances allow patients to self-refer, so they can call the urologist office directly requesting an appointment. Otherwise they can ask their neurologist or primary care physician for a referral. Some specialize in their field of neurourology who have further training, and neurologists or primary care physicians can look up urologists who have those specific credentials.
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Question: Why are urinary tract infections common in Parkinson’s?
Answer: When patients develop an underactive bladder, it leaves old urine in the bladder. This can lead bacteria to grow which in turn can lead to urinary tract infections. If they are common for patients, I will often do the urodynamic testing to see how well they are emptying their bladders and hopefully there is a treatment we can offer the patient.
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Question: How long should you try new medications for bladder before you know if it’s working or not working?
Answer: I usually have my patients trial medications for about 2 months.
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Question: People with PD have constipation issues. Can that cause problems with an overactive bladder?
Answer: Yes, because the intestines and colon sit directly on the bladder, so when you are frequently constipated, that can exert external pressure on the bladder itself, which can also cause the sensory nerves in the bladder to send premature messages to the brain that you need to urinate.
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Question: How does an enlarged prostate impact PD bladder issues?
Answer: The prostate sits at the base of the bladder, so if the bladder is already weakened from PD, that patient will have more difficulty emptying their bladder because they have two sources, a weak bladder and an obstructive source.
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Question: What is the natural course of OAB if left untreated?
Answer: It is all about quality of life with an overactive bladder. In general, it tends to worsen with time as the nerves worsen.
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Question: How does a daily dose of hydrochlorothiazide (HCTZ) affect these treatments?
Answer: That is a diuretic. A diuretic will cause your kidneys to produce more urine, so if getting up at night frequently to urinate is a problem, I often recommend that patients not take their HCTZ in the evening hours.
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Question: Is Tamsulosin taken just before bedtime a good option for frequent urination?
Answer: It can be. It is a muscle relaxant, so if some of the symptoms are due to not emptying the bladder in entirety because of the slow sphincter, then it would work. If you don’t have any sphincteric issues or BPH, then it is less effective as a drug for the bladder alone, it won’t work on the bladder at all.
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Question: How long does Botox last, and how often do you need to have it done?
Answer: Botox for the average patient lasts about 6-8 months, but it depends per person and is good to stick to a schedule.
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Question: What is Noctura and how effective is it?
Answer: It is an effective medication for patients who feel that the nighttime waking up is due to excessive urine production. It works on a feedback symptom. The main risk of taking it is that it can cause sodium levels to plummet, so sodium levels need to be monitored.
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Question: Is there a specific diaper brand you recommend?
Answer: Not really, it’s kind of a trial and error if pads or diapers work. Try a few different types and find what they are most comfortable with. Some patients ask for a prescription so that insurance covers it.
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Question: Does melatonin help, and which dose?
Answer: Melatonin is usually recommended and prescribed by a neurologist, and I’ve seen many different doses. It is a medication with low side effects and low risks so I recommend they discuss it with a neurologist.
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Question: Can the condom catheter be used for all-day control?
Answer: Yes it can be used all day. Depending on how active you are it may come off, so usually patients ask for 2 a day.