Myths and treatment tips for Parkinson's disease urinary issues
Who is Dr. Jalesh Panicker?
Dr. Panicker works as a Consultant Neurologist in the specialty of uro-neurology at The National Hospital for Neurology and Neurosurgery, and he is a Reader at the Institute of Neurology of University College London (UCL), Queen Square, London. He has a specialist interest in Uro-Neurology and Pelvic neurology and his primary interest has been understanding the neural control of the bladder and how it is affected following neurological diseases such as Parkinson’s. He is actively involved in clinical research, supported by external grants from funders such as Parkinson’s UK. We had the good fortune to sit down with him and pick his brain about everything important about the bladder and Parkinson’s.
Jalesh Panicker MD
Myth #1: Bladder issues are rare in people with
Parkinson’s Disease
The results of studies exploring different non-motor symptoms in Parkinson's disease strongly suggest that bladder problems are very common. Nearly 70% of individuals report urinary symptoms and these issues can have an immense impact on quality of life and can contribute in a significant way to health-related costs. Watch this video below from Dr. Indu Subramanian’s interview with Dr. Panicker on wHolistic.
Myth #2: Most persons with Parkinson’s have the
same types of bladder issues
The most common type of bladder problem has been difficulties in holding urine. As a result, individuals are unable to hold urine for sufficient lengths of time and this results in an increased frequency to urinate in the day and night. Individuals may need to rush to the toilet (called urinary urgency) and this may sometimes lead to incontinence. Additionally, individuals may report problems with urination such as difficulties in starting their urinary stream, known as urinary hesitancy, a weak and interrupted urinary stream and, occasionally, may also experience retention of urine. Difficulties in urination are not as noticeable as problems with holding urine, and some individuals may unknowingly leave behind urine in their bladder after urinating. This is known as the post-void residual volume, and as a routine should be measured through a simple bedside ultrasound scan. Holding back a significant quantity of urine in the bladder after urinating can increase the risk for developing urinary tract infections.
Myth #3: Waking up at night to urinate is not
related to my Parkinson’s disease
Waking up at night with the need to urinate, known as nocturia, can occur in nearly 60% of individuals with Parkinson's disease. This can result from either a small sized bladder or result from overactivity of the muscle lining the bladder wall called the detrusor (the medical term is detrusor overactivity), or it can occur from increased production of urine in the night (known as nocturnal polyuria). The assessment of nocturia may nececitate filling in a 3-day diary so that we can better understand the frequency of urination and volumes of urine voided. You may also need to undergo a test of bladder function called urodynamics. Having ankle swelling (called pedal edema), medical conditions such as diabetes, heart failure or obstructive sleep apnoea, and alsosome types of medications such as diuretics can increase the chances for developing nocturia.
Myth #4: Parkinson’s Disease has nothing to do
with my bladder problems
Signals from the brain may control bladder function, and dopamine plays an important role through exerting an inhibitory effect on the bladder reflex. When dopamine levels decrease in Parkinson's disease, there may be a loss of control over the reflex meaning that the bladder is no longer inhibited (blocked) and may take on a “life of its own." Once it takes on a life of its own it may begin to misbehave. It is likely that alterations in other chemicals in the brain may also contribute to the bladder problems in Parkinson's.
There may be of course other causes for bladder symptoms in individuals with Parkinson's and therefore it is important to investigate symptoms before concluding that they are Parkinson's related.
Myth #5- There is no hope for helping my bladder
problems related to Parkinson’s disease- so I
won’t bother to tell my care providers about my
symptoms
There are actually many treatments available for the bladder issues in Parkinson’s, so you should definitely speak to your doctor about your bladder symptoms. You may be asked to undergo some tests to help understand whether bladder problems are related to Parkinson's or not related. A bedside or clinic based ultrasound scan to measure the amount of urine left in the bladder after urinating should be performed to measure the post-void residual urine.
There is also a role for regulating the type of fluids consumed, as well as for performing pelvic floor exercises. Medications can help to calm the bladder, specifically symptoms of urinary urgency, frequency and incontinence. These pills help relax the bladder and thereby allow urine to be held by the bladder. An example of a pill are antimuscarinic agents such as solifenacin or tolterodine, and another example is mirabegron. Your doctor will assess whether you are suitable for using pills before giving you a prescription. Many times these medications are not possible because the risks outweigh the benefits (e.g. inducing confusion or constipation).
Tibial nerve stimulation has recently been shown to be helpful and safe for managing bladder symptoms, and there is some preliminary evidence to suggest that this may be useful in individuals with Parkinson's.
Another treatment that may be possible is botulinum toxin (Botox) injections. This treatment works by blocking signals from the brain to the muscles so that they no longer communicate effectively with each other. Injecting botulinum toxin into the muscle lining the bladder wall (the detrusor muscle) has been shown to relax this muscle and thereby help with an overactive bladder. Large studies have revealed that botulinum toxin is effective in treating the overactive bladder, specifically those due to neurological disorders such as multiple sclerosis and spinal cord injury, however and unfortunately there are a few studies that have shown this treatment to be effective in Parkinson's. This treatment has a risk in that some individuals may not be able to empty their bladder completely after the injections and this could temporarily lead to other issues such as urinary tract infections.
To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonBedside and https://www.tourettetreatment.com/
He also serves as the Medical Director for the Parkinson’s Foundation.
To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.