Parkinsons Disease And Incontinence: What Is The Link
Parkinsons is a degenerative disorder of the central nervous system. It is caused by the loss of nerve cells, which contain a chemical called dopamine. Many people understand Parkinsons Disease to only cause delayed movement and impaired balance.In reality, Parkinsons Disease is much more complex. It can affect a persons ability to do things people take for granted. One of the key problems people with Parkinsons can experience is incontinence. Studies have shown prevalence statistics ranging from 27% to 85% for urinary symptoms in Parkinsons patients.
Bowel Incontinence: Another Embarrassing Casualty Of Pd
Fecal Incontinence is where you lose control of your bowels. This blog post explains the primary cause of this in Parkinsons disease. Problems reaching the toilet in time because of mobility, abdominal bloating or cramping compound the problem. Dr. De León has included a check list of things to help minimize occurrences and embarrassment, even to the point of surgery, if necessary.
Hypothalamic Neurons And Dopamine In Men
Among the 3 types of erection, reflexive erection requires an intact sacral cord, particularly the intermediolateral cell columns. Pathology studies have shown that involvement of the IML nucleus is common in MSA, whereas it is uncommon in PD. Therefore, reflexive erection can be affected in patients with MSA. In patients with a supra-sacral spinal cord lesion, reflexive erection might be preserved, whereas psychogenic erection is severely disturbed because of a lesion in the spinal pathways to the sacral cord. Libido and erection are thought to be regulated by the hypothalamus; particularly the medial preoptic area and the paraventricular nucleus . Electrical or chemical stimulation in the MPOA/PVN evoked erection and mating behaviors in experimental animals, both of which were abolished by destruction of these areas. Somatosensory inputs from the genitalia ascend in the anterior spinal cord, and project to the MPOA/PVN via the thalamic nuclei. Erotic visual inputs from the retina are thought to reach the MPOA via the mamillary body. Recent neuroimaging studies have shown that penile stimulation or watching pornography activated these areas in humans . NPT seems to be regulated by the hypothalamic lateral preoptic area .
Toilet Habits And Constipation In Parkinsons Disease
Suggestions for good toilet habits include:
- Go to the toilet as soon as you feel the urge to pass a bowel motion. Hanging on can contribute to constipation.
- Use the correct posture on the toilet to help you pass a bowel motion place your elbows on your knees, bulge out your stomach, straighten your spine and put your feet on a footstool.
- Avoid holding your breath and dont strain when you are on the toilet. Allow yourself plenty of time.
- Use a warm washcloth pressed against your back passage or gently massage with one or two fingers to help to relax the muscles.
- Talk to your doctor or pharmacist about medicines to help soften your bowel motions.
Parkinson’s Disease And Voiding Dysfunction
In this 54-minute webinar, urologist Dr. Sidney Radomski explains how voiding function is affected by Parkinsons disease in both men and women. He discusses how an enlarged prostate contributes to voiding problems and management options of voiding dysfunction for those with Parkinsons disease and MSA.
Circadian Rhythm Disturbances And Nocturia
The suprachiasmatic nucleus of the hypothalamus controls the circadian rhythm by regulating melatonin release from the pineal gland in response to the environmental light/dark cycle. Neurodegeneration and cell death occurring in PD has been shown to affect structures involved in circadian rhythm control, such as the hypothalamus. It has been shown that mice overexpressing -synuclein exhibit a reduced SCN firing rate, potentially weakening their ability to communicate neural and hormonal signals from the central clock. Sleep disturbances are common in PD,- and alterations in the circadian rhythm have been demonstrated in PD, even at the early stages.,
In health, there exists a circadian rhythm for urine production, and, as a result, roughly less than 25% of 24-hour urine is produced during the night. This is thought to be mediated through release of AVP and melatonin and is known to be affected with aging. Production of urine is influenced by the circadian regulation of sodium and free water handling. Diurnal release of hormones are regulated through the pituitary and increased plasma levels of arginine vasopressin at night. A loss of this diurnal response has been observed in otherwise elderly healthy individuals reporting NP. A loss of circadian regulation of urine production results in limited reabsorption of free water and diuresis. Reduced AVP secretion is linked not only to nocturnal polyuria,, but also to nocturnal enuresis.
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 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.
Addressing Practical Aspects Of Eating And Drinking
Some people with Parkinsons have problems chewing and swallowing. This can make it difficult to eat a diet with plenty of fibre. A speech and language therapist can give advice about this. Ask your GP, specialist or Parkinsons nurse for a referral. If it takes a long time to eat and your meal goes cold, eat smaller portions and go back for seconds that have been kept warm. You can also get special plates that keep your meals hot the Disabled Living Foundation has more information.
An occupational therapist will also be able to give you some tips and practical advice.
Treatment Of Bowel Dysfunction In Pd
3.4.1. Dietary Fibers
Although it is not certain whether exercise may facilitate bowel habit in PD, in the healthy population, moderate exercise is reported to shorten mouth-to-anus transit time and improve overall wellbeing . Water content is an important determinant to make stools normal or hard . PD patients are reported to have reduced water intake . Diet and laxatives are the first-line treatment for constipation . Dietary fibers such as psyllium produced an improvement in stool consistency and an increase in stool frequency in healthy population and PD . Polyethylene glycol 3350 , or bulking and highly hydrophilic agent polycarbophil , improve constipation in PD.
3.4.2. Cholinergic Drugs
A prior report has shown that pyridostigmine bromide, an acetylcholinesterase inhibitor, is effective in the amelioration of constipation in PD .
3.4.3. Dopaminergic Drugs
Levodopa and Other Dopaminergic Agonists
3.4.4. Dopaminergic Blockers
3.4.5. Serotonergic Drugs
3.4.6. Other Drugs
Although prior reports have indicated the effectiveness of motilides , neurotrophin-3 and colchicine on constipation in PD, their use remains limited. Type A botulinum toxin injection into the puborectalis muscle and biofeedback ameliorates anismus in PD.
How Is Parkinsons Linked To Incontinence
People with Parkinsons disease are more likely to have incontinence because messages going from their brain to their bladder can be interrupted. This is due to Parkinsons being triggered by having fewer nerve cells which contain dopamine this is a chemical messenger which helps you to have coordinated movement.
As a result of this, the bladder will contract when its not even particularly full, meaning that your loved one may not have time to get to the toilet before urine leakage occurs.
The types of urinary incontinence most often experienced by those with Parkinsons will be nocturia and urge incontinence. It is also common for people with Parkinsons to suffer from bowel incontinence.
Sexual Dysfunction In Parkinsons Disease
People with PD may experience sexual dysfunction, including loss of desire, inability to orgasm, erectile dysfunction in men, decreased lubrication in women, or pain with intercourse in women. Some studies have found that sexual dysfunction may occur in 60-80% of men and women with PD. Older patients with PD have more sexual dysfunction than younger patients, although sexual dysfunction is also greater in older adults who do not have PD. In addition to age, conditions such as diabetes, hypertension, and depression can factor into sexual dysfunction.3,4
There are several factors that can lead to sexual dysfunction in people with PD. In addition to the motor symptoms of PD, which may create practical barriers to engaging in sexual activity, non-motor symptoms like depression, anxiety, or sleep disturbances can also impact a persons sex drive. Many people with PD express dissatisfaction with their sexual life.3,5
Some people with PD who are treated with dopamine agonists develop impulse control disorders, like hypersexuality. Hypersexuality can lead to unusual or increased sexual behavior, which may have devastating effects on relationships. Changing medications or reducing the dose of medication can help, and people who experience any side effects such as impulse control disorders should bring it to the attention of their doctor.3
Fluids For Constipation In Parkinsons Disease
Be guided by your doctor, but general suggestions include:
- Try to drink six to eight glasses of fluid every day. Water is best, but you can also include fluid in the form of soup, juice, tea and coffee.
- Limit drinks that cause dehydration such as alcohol, tea and coffee.
- Spread your drinks throughout the day.
Strategies For Managing Nocturia In Pd
Despite the high prevalence of nocturia and impact on QoL, treatment options for managing this problem are currently limited and are often poorly tolerated or ineffective in PD. Guidance on nocturia treatment is limited, and most treatment options are derived from guidance around general management of urinary symptoms in neurological patients., ,
Extraenteric Nervous System And Dopamine
Whereas small intestine and ascending colon are innervated by the vagus nerves originating in the medulla, extraenteric innervation of descending colon, sigmoid colon, and rectum primarily shares that of the LUT . LUT and LGIT perform the similar function of storage and emptying. However, there are also profound differences with regard to physiology . In addition, while the LUT requires intact neuraxis for storage and emptying , it has not been entirely clear to what extent LGIT needs extra-ENS.
The basal ganglia modulate the bowel motility , with the main action apparently being inhibitory . However, under stress conditions, facilitatory responses were also observed . Although the connection is not fully clarified, bowel function seems to be modulated by the higher brain structures . Most areas activated in functional neuroimaging by bowel distention strikingly overlap the area activated by bladder distention .
Prevalence Of Nocturia In Pd
Questionnaire based studies generally report a high prevalence of nocturia, with figures ranging between 76% and 86%,, though one study reported a prevalence of only 34.6%. In a study of 115 PD patients using a questionnaire on pelvic organ functions, Sakakibara et al. reported nocturia in 53% of men and 63% of women with PD.
Nocturia has been reported in 34.6% of PD patients using a semistructured interview in 1,072 consecutive patients with PD in the large, multicentric PRIAMO study.
This apparent variability in prevalence between studies could be put down to several factors, including differences in the demographic features of the cohort of patients being studied, and the occurrence of medical comorbidities. LUT symptoms are more prevalent with advancing disease and were most frequent in patients at H & Y stage 4 to 5 with a reported prevalence of around 90%. Moreover, the term nocturia has been applied differently in studies and the prevalence varies according to the definition being used. The International Continence Society made an attempt to standardize the definition of nocturia in 2002 and, based on a consensual approach, put forward the complaint that the individual has to wake at night one or more times to void.
Causes Of Constipation In Parkinsons Disease
The ways in which Parkinsons disease can increase the risk of constipation include:
- lack of dopamine in the brain impairs control of muscle movement throughout the body. Bowel muscles can become slow and rigid
- uncoordinated bowel motions the bowel muscles may be weak and unable to contract, or they may clench instead of relaxing when trying to pass a motion
- eating problems dietary fibre containing insoluble fibre adds bulk to your bowel motions and can help prevent constipation. However, if a person with Parkinsons disease finds it difficult to chew or swallow, they may avoid eating fibrous foods
- drinking problems you need water to plump up the dietary fibre in your bowel motions. Swallowing difficulties may discourage a person with Parkinsons disease from drinking enough fluids
- sedentary lifestyle lack of exercise slows the passage of food through your intestines. Parkinsons disease reduces muscle control, so lack of exercise is common
- medications many different medications can cause constipation. Medications used in the treatment of Parkinsons disease may slow bowel movements or cause a decrease in appetite.
Treatment Of Bladder Dysfunction In Pd
2.4.1. Dopaminergic Drugs
It is possible that levodopa and other antiparkinson medication may affect bladder function in PD. Aranda and Cramer studied the effects of 38mg apomorphine injection on the storage function in 2 de novo PD patients, and found that the bladder capacity increased. They gave oral levodopa to one of the patients, and the bladder capacity increased. We compared the frequency of bladder dysfunction in de novo PD and PD with levodopa. In that study, LUTS was less frequent than in the treated group . In another study, after 3 months of treatment with levodopa, the storage urodynamic parameters were slightly improved in de novo PD .
2.4.2. Cholinergic Drugs
Anticholinergics are generally used as a first-line treatment for overactive bladder. However, it is important to balance the therapeutic benefits of these drugs with their potential adverse effects. When the dose of drug increases, postvoid residuals may appear . Dry mouth and constipation are common . Cognitive adverse events by anticholinergics are a concern particularly in the elderly. For example, trihexyphenidyl and oxybutynin have been shown to have central side effects . Factors contributing to the central effects of drugs may include blood-brain barrier penetration . Among the factors of BBB penetration, diffusion is facilitated by lipophilicity . Particularly in elderly patients who have hallucinations or cognitive decline , anticholinergics should be used with extreme caution.
Evaluating And Treating Urinary Issues In Parkinson’s Disease Multiple System Atrophy And The Other Atypical Parkinsonism Disorders
In this hour-long webinar, neuro-urologist Ekene Enemchukwu, MD focuses on urinary incontinence, overactive bladder, urinary retention, and other urinary issues in PD, MSA, and the atypical parkinsonism disorders. Following the presentation, moderator Candy Welch, Brain Support Networks MSA caregiver support group leader, asks Dr. Enemchukwu many questions submitted by webinar participants.
Neural Control Of Erection: Normal Erection In Men
Sexual dysfunction is not uncommon in PD . Studies have shown that sexual dysfunction has great significance in relation to quality-of-life measures. However, the detailed mechanism of sexual dysfunction in PD has not been well known.
The genital organ primarily shares lumbosacral innervation with the lower urinary tract. Erection is a vascular event ; occurring secondarily after dilatation of the cavernous helical artery and compression of the cavernous vein to the tunica albuginea . Helical artery dilatation is brought about by activation of cholinergic and nitrergic nerves; this activation facilitates nitric oxide secretion from the vascular endothelium. Ejaculation is brought about by contraction of the vas deferens and the bladder neck, in order to prevent retrograde ejaculation, by activation of adrenergic nerves . Sexual intercourse in healthy men can be divided into 3 phases : desire , excitement and erection, and orgasm, seminal emission from the vas deferens, and ejaculation from the penis. Erection can be further classified into 3 types by the relevant stimulation: psychogenic erection , reflexive erection , and nocturnal penile tumescence sleep). Morning erection is considered the last NPT in the nighttime.
Treatment Modalities For Sexual Dysfunction In Parkinsons Disease
Given the high prevalence of SD in patients with PD, physicians and other healthcare providers should discuss and treat sexual health issues as an integral part of treating the disease. In all instances, drug regimens should be reviewed for possible effects on sexual function. Sexual education, counselling and specific suggestions about therapeutic methods are important, and should be provided by the treating physician.
In a newly diagnosed patient with PD the possible enhancing influence of dopaminergic treatment on sexuality should be discussed with both partners. The improved libido in the male PD patient may be unwelcome, as the elderly spouse has already settled in a situation of not being bothered. The emergence of hypersexuality in the treated PD patient is, as a rule, drug induced, and modification of treatment is helpful. Profound loss of libido in the well-treated PD patient may call for an endocrinological consultation if it causes distress.
In a newly diagnosed PD patient who present with SD, the dopaminergic drugs should be introduced first, and their effect followed up. Occasionally, the SD will also improve. Difficulties with the motor aspects of the sexual activity may be overcome by counselling and appropriate timing of dopaminergic treatment. Poor lubrication in the female patient with PD may be helped by lubricants; urge incontinence during coitus by previously emptying the bladder and treating the overactive bladder.
Does Parkinsons Cause Incontinence
I have recently been diagnosed with Parkinsons Disease and am shocked to see I am experiencing heavy leaks..during the day AND night. Im finding it difficult to know when my bladder is full, which is leading to urine overflowing during the day!! I wasnt told this would happen!! I am new to this.. what do I do?? How do I choose a product? Im not sure I want to talk to a Doctor and would rather get an answer on here. Im a 50 year old male.
ll Edward,
Parkinsons Disease is a common cause of incontinence. Bladder problems occur due to Parkinsons affecting the nerves that control bladder emptying. Parkinsons can also affect your ability to reach the toilet quickly before leakages. Painkillers commonly used for Parkinsons such as codeine and anticholinergics prescribed for tremor can even cause incontinence.
You describe your leaks as heavy, therefore more protection is needed for you than an incontinence pad. Either protective pants or an all-in-one brief will be suitable for you. Belted all-in-one products are ideal if you are less mobile or immobile and would like a product that is easy to put on and off. They have velcro fastenings for fast removal and will keep you dry for longer than other product options.
You can read our blog on overflow incontinence symptoms for more information on the condition.
Take care and do not hesitate to ask other questions!
Treatment Of Sexual Dysfunction In Pd
4.4.1. Male Sexual Dysfunction
Dopaminergic Drugs
It is possible that levodopa and other antiparkinson medication may affect sexual function in PD. However, it is not entirely clear to what extent levodopa ameliorates sexual dysfunction in PD. In contrast, subcutaneous apomorphine injection is used to ameliorate fluctuating symptoms in PD. It has also been used to treat erectile dysfunction in the general population and in patients with PD , although the dose is different . Apomorphine is thought to stimulate dopamine D2 receptors, and activate oxytocinergic neurons in the PVN. Nausea is a common side effect of this drug. Cabergoline and pergolide are also reported to improve sexual dysfunction in PD. In contrast, pathological hypersexuality may occur together with or without delirium , which is attributed to the dopamine dysregulation syndrome in this disorder. DBS in the STN has produced either improved sexual wellbeing or transient mania with hypersexuality in patients with PD.
Phosphodiesterase-5 Inhibitors
When dopaminergic drugs did not help, phosphodiesterase-5 inhibitors, for example, sildenafil, vardenafil, and so forth, become the first line treatment in PD . These drugs inhibit nitric oxide degradation and facilitate smooth muscle relaxation in the cavernous tissue. When treating PD patients with postural hypotension, these drugs should be prescribed with extreme caution .
Other Drugs
4.4.2. Female Sexual Dysfunction
How Is Neurogenic Bladder Diagnosed
A doctor will do an exam and may order several tests of the nervous system and the bladder to diagnose neurogenic bladder: These include:
- Urodynamic studies: These bladder function tests measure how much urine the bladder can hold, the pressure within the bladder, how well urine flows, and how well the bladder empties when it is full. Special sensors may be placed on the skin near the urethra or rectum to see if the muscles and nerves in those parts of the body are working properly.
- Cystoscopy: The doctor may perform this procedure to examine the inside of the bladder and urethra with the use of a small telescope .
- X-rays
Urinary Problems In Parkinson’s Disease
Parkinsons disease has many features that have little or nothing to do with movement. Among these non-motor symptoms are problems with the autonomic nervous system the part of the nervous system that controls automatic bodily functions, such as heart rate, blood pressure, sweating, sexual function and both gastrointestinal and urinary function. These symptoms are often among the most serious and complex issues faced by people with PD.
Unlike bowel dysfunction , which often occurs before Parkinsons movement symptoms, urinary dysfunction is not typically a problem until the later stages of the disease.
Parkinsons Disease And Your Bladder
Many diagnosed with Parkinsons disease experience urinary tract issues. A Michigan Medicine urologist discusses treatment options for patients to consider.
Anne Pelletier-Cameron, M.D., often jokes to her patients that shes a female plumber of the lower urinary tract. On a more professional note, however, shes a urologist in the Michigan Medicine Department of Urology.
In this role, Pelletier-Cameron treats patients with a variety of lower urinary tract symptoms. Some of her patients have been diagnosed with Parkinsons disease, a progressive nervous system disorder that impacts movement. But the breakdown of nerve cells that characterize Parkinsons disease can also cause non-movement symptoms, including bladder issues.
Half of all women and 17% of men will experience urinary incontinence, or the inability to hold urine, she says, noting that for Parkinsons disease patients, those numbers escalate.
Many of my PD patients end up having other bladder problems, including issues with urgency and frequency, says Pelletier-Cameron. Nocturia, or the need to urinate many times during the night, is also common, along with difficulty in emptying the bladder.
The bladder is very complicated, says Pelletier-Cameron. It needs to be big enough to store urine so you can go about your life without having to empty your bladder every 10 minutes. It also needs to store urine at low pressure and squeeze at the right time to make sure the urine doesnt back up to the kidneys.
Medical Comorbidities And Nocturia
Concomitant urological pathologies may also contribute to reduced nocturnal bladder capacity. Patients with PD may develop storage dysfunction as a result of benign prostate enlargement, which is common in the age group prevalent for PD and may cause nocturia and nocturnal polyuria. Often urodynamic studies are required to evaluate the relative contribution of bladder outlet obstruction. Other urological pathologies include malignancy of the bladder, bladder stones, interstitial cystitis, and pelvic organ prolapse or from stress incontinence. Urinary tract infection can lead to urinary frequency and may exacerbate nocturia.
The treatments used to manage PD may, in themselves, influence LUT symptoms. The effects of levodopa on LUT symptoms are inconsistent, however, and worsening of symptoms have been reported in some studies whereas improvement has been reported in others., , It has been suggested that during acute administration, l-dopa may cause worsening of symptoms, but is known to ameliorate the first sensation of bladder filling on long-term administration. Dopamine receptor agonists have been reported to promote storage in a study using bromocriptine. In another study, a change from bromocriptine to pergolide lessened nocturia. Apomorphine was reported to increase bladder capacity. DBS may have variable effects on LUT dysfunction, though an improvement in nocturia has generally been noted.-