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July2010 Vol.47 Issue:      3 (Supp.) Table of Contents
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Idiopathic Parkinson's Disease: Lower Urinary Tract Dysfunctions and Urodynamic Abnormalities

Ehab S. Mohammed1, Maged M. Ragab2

 

Departments of Neurology­­1, Urology2, Tanta University; Egypt

 



ABSTRACT

Background: Although the motor symptoms of idiopathic Parkinson's disease (IPD) are well defined, several studies have established that the non motor symptoms of IPD are common and occur across all stages of IPD, underestimated, unrecognized and  untreated. Objectives: The aim of this study is to evaluate the urinary symptoms at different stages of IPD severity and its relation to urodynamic parameters. Methods: This study was conducted on 49 patients with probable IPD (according to Hoehn and Yahr staging of IPD severity, 4, 10, 29, 5, 1 cases were classified as stages 1 to 5 respectively) to evaluate their urinary symptoms using international prostate symptom score and urodynamic tests. Results: In this study, the most prevailing urinary symptom in IPD is nocturia (77.5%) followed by urgency (36.7%) and frequency (32.6%). Urodynamic tests revealed detrusor hyperreflexia in 33 patients (67.3%), hyporeflexia in 6 patients (12.2%) and 10 (20.4%) patients with normal detrusor function.The pathological urodynamic parameters, initial void desire volume and maximum bladder capacity were correlated significantly with disease severity and irritative symptoms index score meanwhile obstructive symptoms index score had no significant correlation with any of urodynamic parameters nor disease severity. Total IPSS symptoms score was significantly correlated with quality of life score. The mean of urodynamic parameters did not differ in IPD patients who did or did not receive anticholinergic or dopaminergic drugs. Conclusion: Urinary dysfunctions are common in IPD and deteriorate progressively with the disease severity. Detrusor hyperactivity is the most common urodynamic abnormality found in IPD patients. The irritative urinary symptoms significantly affect quality of life of IPD patients. [Egypt J Neurol Psychiat Neurosurg.  2010; 47(3): 381-386]

 

Key Words: Parkinson's disease, Urodynamic parameters, International Prostate Symptom Score

 

Correspondence to Ehab S. Mohammed. Department of neurology, Tanta University, Egypt.

Tel: +20473245258. Email:ehab_metwally70@yahoo.com





INTRODUCTION

 

Idiopathic Parkinson's disease (IPD) is a movement disorder associated with loss of dopaminergic neurons in the substantia nigra and the development of Lewy bodies. A reduction in normal striatal dopamine levels of 80% or more results in the cardinal symptoms of IPD, namely bradykinesia, rigidity, rest tremor and postural instability1. Although the motor symptoms of Parkinson’s disease are well defined, the non-motor features of this disorder are under-recognized and, consequently, undertreated. Non-motor symptoms and their management have been recognised by the UK National Institute for Clinical Excellence as an important unmet need in IPD2. Results from a recent international survey show that up to 62% of non-motor symptoms of PD, such as apathy, pain, sexual difficulties, bowel, urinary incontinence, and sleep disorders might remain undeclared to health-care professionals because patients are either embarrassed or unaware that the symptoms are linked to IPD3.

Results from early studies suggested that urinary dysfunction (UD) affects between 37% and 70% of individuals with IPD4. However, many of these studies may have overestimated the prevalence of UD since they were published prior to the recognition of multiple system atrophy (MSA) as a separate disease entity. In addition, many studies recruited patients with symptomatic bladder dysfunction from tertiary referral centers. The use of non-validated questionnaires and the inclusion of patients with other forms of parkinsonism such as cerebrovascular parkinsonism may have led to further bias5. More recent studies, using accepted diagnostic criteria for IPD, have found the prevalence of UD to be between 27% and 39%. When compared to a control group the relative risk of bladder symptoms in IPD is 2-fold6.

The aim of this work is to evaluate the urinary symptoms at different stages of IPD severity and its relation to urodynamic tests.

 

PATIENTS AND METHODS

 

This study was conducted on 49 patients with probable IPD7 attending Neurology and Urology departments, Tanta University Hospital for evaluations of the lower urinary tract symptoms. All patients were subjected to, history taking including International Prostate Symptom Score (IPSS)8, general and neurological examinations, including classification of the IPD into 5 stages of the Hoehn & Yahr disability stages9. The IPSS questionnaire was administrated to each patient by one of us to help the patient to understand the questionnaire. All men underwent digital rectal examinations and pelvic ultrasonography to exclude prostatic hyperplasia.

All patients (49 patients), 31 male patients and 18 female patients, their age ranged from 56-73 years (mean 63.73±7.21 years) and their duration of illness was 4-11 years (mean 7.81±3.27 years) were subjected to urodynamic studies.

According to Hoehn and Yaher classification of Parkinson's disease disability stage, we had 4, 10, 29, 5, 1 patients distributed into stages 1 to 5 respectively. The number of patients in stage 3 was higher than other stages; this may be due to few lower urinary symptoms in early stage of the disease and severe motor and psychiatric symptoms that affect daily life activities in advanced stages. Antiparkinsonian drugs received by the patients were levodopa (41 patients), dopamine agonists (39 patients) and anticholinergic (24 patients).

 

Statistical Analysis

       Data are presented as mean±SD. Analysis was performed with SPSS statistical package version 12 (SPSS, USA). For statistical purpose the disease severity stages were divided into mild (stages 1 and 2 H & Y), moderate (stage 3 H & Y) and severe (stages 4 and 5 H & Y).

 

RESULTS

 

Lower urinary tract symptoms:

The most frequent symptoms of lower urinary tract dysfunctions were symptoms due to filling phase disorder which include nocturia (77.5%), urgency (36.7%) and frequency (32.6%) (Table 1).

 

The IPSS index scores:

The total IPSS scores and irritative index scores were correlated significantly with disease severity while obstructive index scores did not (Table 2). Also, there was significant correlation between total IPSS score and quality of life score (Table 3).

 

Urodynamic parameters:

In this study, we found 33 (67.3%) patients with detrusor hyperreflexia,6 (12.2%) patients with hyporeflexia, 10 (20.4%) patients with normal detrusor function (Table 4). Initial void desire volume and maximum bladder capacity(urodynamic parameters associated with filling phase) were correlated with disease severity while detrusor pressure and post-void residual urine (urodynamic parameters associated with voiding phase) did not (Table 5). There was significant correlation between irritative symptoms score index and initial void  desire volume and maximum bladder capacity meanwhile the obstructive symptoms score index had no significant relations with any of urodynamic parameters (Table 6).

 

Antiparkinsonian drugs:

The patients were divided into 2 groups, one group was taking  anticholinergic drugs (24 patients) plus levodopa or dopamine agonists, the second group was  taking levodopa and dopamine agonists (25 patients). There was no significant difference between 2 groups as regards the mean of urodynamic parameters (Table 7).


 

 

Table 1. Frequency of the of lower urinary tract symptoms of idiopathic Parkinson’s disease patients.

 

Symptoms

Patients

Number

Percentage (%)

Nocturia

38

77.5

Urgency

18

36.7

Frequency

16

32.6

Incomplete emptying

4

8.1

Intermittency

3

6.1

Weak stream

1

2

 

Table 2. Total, irritative, and obstructive symptom indexes of IPSS at each stage of disease severity in idiopathic Parkinson’s disease patients.

Stages of disease severity

Number

Mean IPSS±SD

Irritative

Obstructive

Total

Mild(stages 1,2)

14

6.3±2.1

1.4±1.2

7.6±2.4

Moderate(stage 3)

29

7.9±3.2

3.3±2.6

11.2±4.5

Severe(stages 4,5)

6

10.4±2.7

6.2±3.5

16.6±5.1

SD standard deviation

One-way ANOVA P =0.001

 

Table 3. Correlation between IPSS and Quality of life scores at different stages of disease severity in patients with idiopathic Parkinson’s disease.

Stages of disease severity

Total I-PSS

mean±SD

Quality of life score

mean±SD

Mild (stages 1,2)

7.6±2.4

2.8±1.9

Moderate (stage 3)

11.2±4.5

3.7±1.4

Severe (stages 4,5)

16.6±5.1

5.2±1.1

IPSS International Prostate Symptom Score, SD standard deviation

One-way ANOVA P=0.003

 

 

  Table 4. The frequency of urodynamic findings in idiopathic Parkinson’s disease patients.

Stages of H &Y

Number

Normal

Hyperreflexia

Hyporeflexia

1

4

3

1

0

2

10

3

7

0

3

29

4

20

5

4

5

0

4

1

5

1

0

1

0

Total No. (%)

49

10(20.4)

33(67.3)

6(12.2)

 

 

Table 5. Urodynamic parameters at different stages of severity of idiopathic Parkinson’s disease.

Stages of disease severity

Initial void desire volume

(mean±SD)(ml.)

Maximum

bladder

capacity

(mean±SD)(ml.)

Maximum void phase.

detrusor pressure

(mean±SD)(cm.water)

Post-void residual urine volume.

(mean±SD)(ml.)

Mild

(14Pts)

115± 28

195± 60

55± 15

13± 12

Moderate

(29Pts)

95± 25

191± 59

57± 20

20± 18

Severe

(6Pts)

89± 20

184± 56

59± 25

22±20

ml. milliliter, SD standard deviation

One-way ANOVA P=0.006

 

 

Table 6. Correlation between urodynamic parameters and IPSS scores of idiopathic Parkinson’s disease patients.

Urodynamic parameters

Irritative score

Obstructive  score

r

p

r

p

Initial void desire vol.

0.95

0.001*

0.92

0.35

Max Bladder capacity

0.76

0.04*

0.68

0.27

Detruser pressure

0.96

0.24

0.89

0.17

Post residual Urine Vol.

0.89

0.43

0.94

0.06

IPSS International Prostate Symptom Score, r Pearson’s correlation

*Significant at p<0.05

 

 

 

Table 7. Correlation between urodynamic parameters (storage phase parameters) and antiparkinsonian drugs in idiopathic Parkinson’s disease patients.

 

Urodynamic parameters

Anticholinergic drug group

n=24

Non anticholinergic drug group

n=25

p

Initial void desire vol.

102±27

97±25

≥0.05

Max Bladder capacity

192±58

188±56

≥0.05

 

 

 


DISCUSSION

 

Urinary dysfunction in IPD is most frequently caused by urinary storage problems, rather than voiding dysfunction, and is manifest as an overactive bladder10. In current study, the most prevailing urinary symptom in IPD, was nocturia (up to 77.5%), followed by urgency (36.7%) and frequency (32.6%) and these results are going with previous studies11. These may lead to urinary incontinence, which may be in part functional if immobility or poor manual dexterity complicates the situation. Since many patients with IPD have a disturbed sleep pattern and nocturnal polyuria, the actual prevalence of definite nocturia may be overestimated12.

In this study, the most striking finding of bladder dysfunction in IPD patients is detrusor hyperreflexia, which is reported in 67.3% of symptomatic patients whereas detrusor hyporeflexia is reported in 12.2% of IPD patients and normal bladder function in 20.4%. Another study which evaluated voiding function in IPD found that 67% had detrusor hyperreflexia, 16% had hyporeflexia, 9% had detrusor hypereflexia with impaired contractile function, 3% had hyperreflexia with detrusor-sphincter dyssynergia and only 6% had normal detrusor functions13. Dopaminergic mechanisms are thought to play a central role in normal micturition control and dysfunction of these may lead to detrusor overactivity. Dopaminergic neurons have both inhibitory and stimulatory effects on micturition acting via D1 and D2 receptors respectively. Such neurons are of particular abundance in the substantia nigra pars compacta (SNC) and the ventral tegmental area (VTA) of the midbrain. The most widely accepted theory is that the basal ganglia inhibits the micturition reflex in the ‘normal’ situation via D1 receptors, and that cell depletion in the SNC in IPD, results in loss of this D1-mediated inhibition and consequently detrusor overactivity14. However, 12.2% of our patients had hyporeflexia which may be explained possibly by drugs especially anticholinergic and dopammiergic drugs which can inhibit bladder function and impairment of autonomic nervous system in advanced IPD15.

In this study both pathological urodynamic parameters, initial void desire volume and maximum bladder capacity decreased with disease severity. These findings can be explained by detrusor hyperactivity. In contrast, other studies showed that post-void residual urine volume increased with disease severity16. This finding was not fully understood, but it may be due to, with advanced disease process, long standing hyperreflexia may eventually lead to impairment of bladder contractility together with the hypokinesia of pelvic floor muscles resulting in bladder outlet obstruction with consequent increase in post-void residual urine volume17.

Because many IPD patients are on multiple drug therapy, which can inhibit bladder function, the current study, demonstrated that the mean of urodynamic parameters did not differ in patients who did and did not receive anticholinergics or dopaminergic drugs, which suggests it is part of the IPD itself. These results are going with that of Araki et al.13, who found no such difference in the mean of urodynamic parameters among patients who did or did not receive antiparkinsonian drugs. On the other hand many studies showed conflicting results, some reports showed that dopaminergic drugs produced a lessening of detrusor hyperreflexia18,19 whereas in others it provided amelioration of voiding difficulty20.

Lower urinary tract symptoms quantified by IPSS showed that irritative symptoms index score correlated with disease severity and with detrusor overactivity that was manifested urodynamically by decrease in initial void desire volume and maximum bladder capacity(storage phase) whereas the obstructive symptoms index score did not correlate with disease severity nor urodynamic parameters. In contrast,  some other studies show that, irritative symptoms index score correlated with detrusor overactivity and obstructive symptoms index score correlated with voiding underactivity. Additionally, both irritative and obstructive symptom index scores increased with disease severity13,21. This discrepancy between the present study and other studies may be explained by fewer numbers of patients in advanced disease stage and the patients evaluated under multiple drugs therapy in advanced disease.  

In conclusion, most of the patients with IPD suffer from urological disorder; most commonly is detrusor hyperactivity which results in irritative urinary symptoms that correlate well with disease severity. These disabling symptoms significantly affect quality of life of IPD patients. In IPD attention should be directed towards non motor symptoms as well as motor symptoms.

 

[Disclosure: Authors report no conflict of interest]

 

REFERENCES

 

1.      Clarke C. Parkinson’s disease in practice. 2nd ed. London: Royal Society of Medicine Press Ltd; 2006.

2.      Chaudhuri KR, Healy D, Schapira AH. The non motor symptoms of Parkinson’s disease. Diagnosis and management. Lancet Neurol 2006; 5: 235–45.

3.      Mitra T, Naidu Y, Martinez-Martin P. The non declaration of non motor symptoms of Parkinson’s disease to healthcare professionals. An international survey using the NMSQuest. 6th International Congress on Mental Dysfunctions and other Non-motor Features in Parkinson’s disease and Related Disorders. Dresden October, 2008. Park Related Disorders P0II: 161.

4.      Andersen J. Disturbances of bladder and urethral function in Parkinson’s disease. Int Urol Nephrol 1985; 17: 35-41.

5.      Blackett H, Walker R, Wood B. Urinary dysfunction in Parkinson's disease: a review. Parkinsonism Relat Disord 2009 Feb; 15 (2): 81-7.

6.      Hobson P, Islam W, Roberts S, Adhiyman V, Meara J. The risk of bladder and autonomic dysfunction in a community cohort of Parkinson’s disease patients and normal controls. Parkinsonism  Related Disorders 2003; 10:67-71.

7.      Gelb DJ, Oliver E, Gilman S. Diagnostic criteria for Parkinson disease. Arch Neurol 1999; 56:33-39.

8.      Eckhardt MD, van Venrooij GE, Boon TA. Symptoms and quality of life versus age, prostate volume, and urodynamic parameters in 565 strictly selected men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology 2001 Apr; 57(4):695-700.

9.      Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology 1967; 17: 427.

10.    Defreitas GA, Lemack GE, Zimmern PE, Dewey RB, Roehrborn CG, et al. Distinguishing neurogenic from non-neurogenic detrusor overactivity: A urodynamic assessment of lower urinary tract symptoms in patients with and without Parkinson's disease. Urology. 2003 Oct; 62(4): 651-5.

11.    Araki I, Kuno S. Assessment of voiding dysfunction in Parkinson’s disease by the international prostate symptom score. J Neurol Neurosurg and Psych 2000; 68: 429-33.

12.    Porter B, Walker R. The night time problems facing Parkinson’s patients. CME J Geriat  Med 2007;8: 99-103.

13.    Araki I, Kitahara M, Oida T, Kuno S. Voiding dysfunction and Parkinson's disease: urodynamic abnormalities and urinary symptoms. J Urol. 2000 Nov; 164 (5): 1640-3.

14.    Seki S, Igawa Y, Kaidoh K, Ishizuka O, Nishizawa O, Andersson KE. Role of dopamine D1 and D1 receptors in the micturition reflex in conscious rats. Neurourol Urodyn 2001; 20: 105–13.

15.    Yoshimura N, Mizuta E, Yoshida O, Kuno S. Therapeutic effects of dopamine D1/D2 receptor agonists on detrusor hyperreflexia in MPTP lesioned parkinsonian cynomoglogous monkeys. J Pharmacol Exper Therap 1998;286(1):228-33.

16.    Pavlakis AJ, Siroky MB, Goldstein I,  Krane RJ.  Neurourologic findings in Parkinson’s disease. J  Urol 1983; 129: 80-3.

17.    Siddiqui MF, Rast S, Lynn MJ, Auchus AP, Pfeiffer RF. Autonomic dysfunction in Parkinson’s disease: a comprehensive symptom survey. Parkinsonism relat disord. 2002; 8: 277-84.

18.    Wing K, Werdelin L, Nielson K, Stimpel H. Effects of dopaminergic treatment on bladder function in Parkinson's disease. Neurourol Urodyn. 2004; 23: 689-96.

19.    Aranda B, Cramer P. Effects of apomorphine and L-dopa on the Parkinsonian bladder. Neurourol Urodyn. 1993; 12: 203-9.

20.    Christmas TJ, Chapple CR, Lees AJ, Kempster PA, Frankel JP, Stern GM. Role of subcutaneous apomorphine in parkinsonian voiding dysfunction. Lancet. 1988; 2 (8626-8627):1451-3.

21.    Dubow JS. Autonomic dysfunction in Parkinson's disease. Dis Mon 2007; 53: 265-74.


 

 

 

الملخص العربى

 

مرض باركنسون ( الشلل الرعاش): الخلل الوظيفى للتبول واختبارات ديناميكية التبول

 

مقدمة :

مع أن مرض باركنسون (الشلل الرعاش) من أهم الأمراض التى تؤدى إلى اضطراب الحركة فى الإنسان فان له مجموعة من الأعراض الغير مرتبطة باضطرابات الحركة ومنها أعراض الخلل الوظيفى للتبول.

 

الهدف من البحث :

تقيم الأعراض الناتجة عن الخلل الوظيفى للتبول لمرضى باركنسون فى مراحله المختلفة وعلاقتها باختبارات ديناميكية التبول.

 

المرضى وطرق البحث :

تم إجراء هذه الدراسة على 49 مريضا بمرض باركنسون فى مراحله المختلفة حسب مراحل هوهن وياهر لقياس شدة المرض وكذلك تقيم أعراض الخلل الوظيفى للتبول عن طريق استخدام المقياس الدولى لأعراض البروستاتا (IPSS ) ورسم ديناميكية التبول.

 

نتائج البحث :

كان أكثر أعراض الخلل الوظيفى للتبول شيوعا بين مرضى باركنسون, كثرة إدرار البول أثناء الليل (77.5%),الرغبة الملحة للتبول (36.7%) وزيادة عدد مرات التبول (32.6%). أما التغيرات التى حدثت أثناء رسم دينامكية التبول فكانت كالأتي: زيادة النشاط العصبى للعضلة الكابسة للمثانة (67.3%), قلة النشاط العصبى لعضلة المثانة (12.2%) ونشاط طبيعى للعضلة  (20.2%).كان هناك علاقة ذو دلالة إحصائية بين كمية البول عند الإحساس بالرغبة الأولى للتبول و كمية البول العظمى التى تستطيع المثانة حبسها(مرحلة التخزين) مع شدة المرض وأعراض زيادة النشاط العصبى للمثانة حسب المقياس الدولى لأعراض البروستاتا(IPSS). من جهة أخرى لم يحدث اى ارتباط ذو دلالة إحصائية بين دينامكية التبول أثناء مرحلة الإفراغ وشدة مرض باركنسون وأعراض قلة النشاط  العصبى للمثانة. لم يوجد اختلاف احصائى فى رسم ديناميكية التبول مع اختلاف العلاج الدوائى لمرضى باركنسون.

 

الخلاصة :

قد تبين أثناء إجراء البحث أن الأعراض الناتجة عن الخلل الوظيفى للتبول منتشرة بين مرضى باركنسون وتزداد حدتها بصورة واضحة مع زيادة شدة المرض. زيادة النشاط العصبى للعضلة الكابسة للمثانة كان أكثر التغيرات حدوثا أثناء رسم ديناميكية التبول التى ينتج عنها مجموعة من الأعراض التى تؤثر تأثيرا مباشرا على كيفية استمتاع هؤلاء المرضى بحياتهم اليومية.

 



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