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April2011 Vol.48 Issue:      2 Table of Contents
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Voiding Dysfunction in Parkinson's Disease

Rasha H. Soliman1, Amr Masoud2

 

Departments of Neurology1, Urology2, Beni Suef University; Egypt

 



ABSTRACT

Background: Voiding dysfunction and bladder disturbance often occur in patients with Parkinson's disease (PD) and severely disturb the quality of the patients' life. Objective: To evaluate the lower urinary tract dysfunction in PD patients and to study its possible association with various indices of the disease. Methods: Twenty-five PD patients (14 males, 11 females) were included and subjected to thorough neurological examination, clinical evaluation by Hoehn and Yahr staging and Unified Parkinson Disease Rating Scale (UPDRS). Lower urinary tract symptoms were evaluated by the international prostate symptom score (IPSS). Urodynamic study was done to all patients. Results: Urinary manifestations included irritative symptoms in 13 patients (52%), obstructive symptoms in 4 patient (16%) and total symptoms in 4 patients (16%). Urodynamic study was abnormal in 18 patients (72%), it included: detrusor hyper-reflexia in 14 patients (56%), prolonged time of micturition in 11 patients (44%), decreased maximum bladder capacity in 6 patients (24%), decreased maximum flow rate in 10 patients (40%), and presence of residual urine in 5 patients (20%). Only severity of the disease and quality of life index of IPSS were significantly associated with the urinary dysfunction, with no significant association between age, sex, duration of the disease or UPDRS scores and urinary dysfunction. Conclusion: Voiding dysfunction in PD patients is frequent, and progressively develops in advanced stages, affecting their quality of life, which has to be investigated early for proper evaluation, diagnosis and management. [Egypt J Neurol Psychiat Neurosurg.  2011; 48(2): 117-122]

 

Key Words: Parkinson's disease, urinary manifestations, urodynamic study

 

 

 

Correspondence to Rasha Hassan Soliman, Department of Neurology, Beni-Sueif University, Egypt.

Tel.: +20123374563.   E-mail: dr.rashasoliman@windowslive.com.





INTRODUCTION

 

The presence of autonomic alterations in Parkinson's disease (PD) could influence the diagnosis and prognosis of the disease. Until recently clinicians have often neglected such autonomic symptoms or ascribed them to the levodopa or anticholinergic drugs which these patients receive1.

Abnormalities of bladder function are surprisingly common, the reported incidence of voiding dysfunction in PD patients ranges from 37% to 70%.2,3 The distortions in these studies include problems in selecting patients, inclusion of patients with other forms of Parkinsonism, the identification of urinary symptoms and the use of medications such as Levodopa4,5.

Urodynamic study identifies properly the abnormal urinary dysfunction which may help in their proper evaluation and diagnosis in different neurological diseases especially in PD1.

The aim of this study was to evaluate the lower urinary tract dysfunction in PD patients, and to study its possible association with various indices of the disease.

 

PATIENTS AND METHODS

 

The participants were recruited from neurology outpatient clinic of Beni Suef University Hospital from the period of February 2010 to December 2010. A total of twenty-five patients (14 males, 11 females) were included in the present study and were diagnosed as Parkinson's disease (PD) according to the United Kingdom Parkinson's Disease Brain Bank Criteria6,7 (20 probable and 5 possible). Patients' age ranged from 51 years to 75 years with a mean age of 60.8±8.3 years. Mean duration of illness was 4.5±2.7 years (range 1 to 11 years), mean duration of L-dopa intake was 4.2±2.3 years.

Excluded from the study, patients with secondary parkinsonism and other types of degenerative parkinsonism, patients with Mini-Mental State Examination (MMSE)(8) score less than 24. Patients with prostatic hypertrophy or previous prostatectomy or history of pelvic surgery, patients with urinary tract infection or receiving drugs related to urinary symptoms as diuretics.

 

Methods

               All patients in this work were subjected to thorough history taking with complete general, urological and neurological examination. Routine laboratory investigations including complete blood picture, blood sugar, liver and renal function tests and complete urine analysis. Abdominal and pelvic sonography. Computed tomography (CT) or magnetic resonant imaging (MRI) of the brain was done to ensure diagnosis of PD.

 

               Clinical evaluation of PD patients was done through:

§     The Hoehn and Yahr staging9.

§   Unified Parkinson Disease Rating Scale (UPDRS)10.

 

Urinary manifestations were evaluated by using the International Prostate Symptoms Score (IPSS)(5) and were divided into: Irritative symptoms including nocturia, frequency and urgency. Obstructive symptoms including incomplete emptying, intermittency, week stream and straining at beginning of micturition. Total symptoms including both irritative and obstructive symptoms.

According to the IPSS questionnaire, each symptom was scored on a frequency scale from 0 to 5: (0) not at all, (1) less than once every 5 times, (2) less than half the time, (3) about half the time, (4) more than half the time, and (5) almost always. The scores were aggregated to form a symptom index from 0 to 35. Overall subjective satisfaction on urinary conditions was scored from (0) delighted to (6) terrible, to use as quality of life index. When the score in irritative or obstructive or total symptoms was ≥7 or ≥9 or ≥12 respectively, the patients were considered to be symptomatic.

 

Urodynamic evaluation:

Cystometry, flowmetry and micturitional study were done by a urologist using the Wiest 6000 urodynamic device.

Anticholinergic drugs were excluded 1 week before the study to exclude possible drug induced vesical hypocontractility or incomplete relaxation of the pelvic floor. Other dopaminergic drugs were stopped the night before the study.

For cystometry, the bladder was filled at an average infusion rate of 40 ml/min and bladder pressure was measured with a two way nelaton catheter, along with either a rectal or vaginal catheter to assess extravesical pressure flactuations.

The normal bladder can fill to 400-500 ml with only a slight increase in pressure (less than 15 cm H2O), peak filling ultimately producing a moderately strong desire to void.

In a bladder with normal sensation, normal high compliance with no involuntary contractions during the filling phase. The bladder content increases in volume, provoking no sensation until about 150 ml has been infused. When bladder filling has been completed, the patient voids into the flowmeter with intravesical and rectal pressure lines still in place.

Urine flow rate depend on both detrusor pressure and outlet resistance. Normal pressure of men should be less than 50 cm water and for women less than 30 cm H2O, with flow rates of 15 ml/second for men and 20 ml/second for women.

 

Statistical Methods

The Statistical Package of Social Sciences (SPSS) was used for statistical analysis. Descriptive statistics (i.e. frequency, percentage, mean and standard deviation) were calculated. Testing significance between the two study groups was applied using the unpaired t-test.

 

RESULTS

 

Clinical evaluation of PD patients revealed:

               Duration of illness ranged from 1 year to 11 years, with a mean of 4.5±2.7 years. Severity ranged from 1 to 4 with a mean of 3.1±0.37 (Hoehn and Yahr). The UPDRS scores were: part I (mentation) score 3.7±1.2, part II (activity of daily living) score 18.7±8.2, part III (motor) score 27.6±13.3.

 

Urinary manifestations in PD patients revealed:

§   Irritative symptoms in 13 patients (52%), obstructive symptoms in 4 patients (16%), total symptoms in 4 patients (16%) and 4 patients (16%) had no urinary symptoms (Table 1). Quality of life index score ranged from 2 to 6 with a mean of 3.7±1.4.

§   Irritative symptoms included frequency of micturition in 15 patients (60%), urgency in 6 patients (24%) and nocturia in 10 patients (40%). Whereas obstructive symptoms included, incomplete emptying in 5 patients (20%), intermittency in 3 patients (12%), week urinary stream in 3 patients (12%) and straining at the beginning of micturition in 4 patients (16%).

§   According to the IPSS scoring(5), patients were divided into symptomatic group including 18 patients (72%) and asymptomatic group including 7 patients (28%).

 

Urodynamic study of PD patients showed that (Table 2):

§   18 patients (72%) had abnormal urodynamic study, whereas 7 patients (28%) had normal urodynamic findings as they had normal bladder sensitivity, they reported first desire to void when bladder filling reached 90 to 160 ml. Maximum bladder capacity was 410 to 530 ml. Non of these patients had involuntary contractions during the study. They all had normal detrusor contraction.

§   Patients with abnormal urodynamic study showed detrusor muscle hyperreflexia in 14 patients (56%), prolonged time of micturition in 11 patients (44%), decreased maximum bladder capacity in 6 patients (24%), presence of residual urine in 5 patients (20%), decreased maximum flow rate in 10 patients (40%), 7 patients (28%) had sudden involuntary detrusor contraction that occurred during bladder filling when filling volume reached 80 to 220 ml. The contraction was uncontrolled and was accompanied by various degrees of incontinence. This urodynamic pattern was defined as hyperreflexia with vesicosphincteric synergy.

 

On comparing symptomatic PD patients to the asymptomatic patients, there was significant difference regarding only severity of the disease (Hoehn and Yahr) and the QOL index of the IPSS scale (p<0.05) with no statistical significance regarding other patients and disease characteristics (age, sex, duration of illness, UPDRS) (Table 3).


 

 

Table 1. Urinary symptoms in PD patients

 

PD patients

Urinary symptoms

Irritative

Obstructive

Total

Free

Number

13

4

4

4

Percentage

52%

16%

16%

16%

 

Table 2. Urodynamic findings in PD patients

 

Urodynamic results

PD patients

Number

Percentage

§     Normal

§     Abnormal

§     Destrusor hyperreflexia

§     Prolonged time of micturition

§     Decreased maximum bladder capacity

§     Presence of residual urine

§     Decreased maximum flow rate

§     Hyperreflexia with vesico-sphincteric synergy

7

18

14

11

6

5

10

7

28%

72%

56%

44%

24%

20%

40%

28%

 

Table 3. Disease characteristics and QOL index in symptomatic and asymptomatic PD patients.

 

 

Symptomatic group

(18 patients)

Asymptomatic group

(7 patients)

p-value

Age (mean)

62.9±8.1

59.5±7.2

>0.05

Sex

Male (%)

55.6%

57.1%

>0.05

Female (%)

44.4%

42.9%

>0.05

Duration (mean) in years

4.7±2.8

3.9±2.3

>0.05

Severity (Hoehn & Yahr)

4.1±0.54

2.06±1.0

<0.05*

UPDRS (mean):

-                   Sector I

-                   Sector II

-                   Sector III

 

3.2±1.1

20.7±7.9

30.5±12.9

 

3.1±0.8

17.9±7.8

26.4±11.2

 

>0.05

>0.05

>0.05

QOL index (mean)

4.3±1.6

2.9±1.5

<0.05*

UPDRS Unified Parkinson Disease Rating Scale; QOL Quality of life

p<0.05* = Significant

 


DISCUSSION

 

The identification of autonomic symptoms such as urinary symptoms in the initial phase of Parkinsonism could influence the diagnosis, treatment efficacy and life quality11.

However, there have been few studies done on the prevalence and accurate measuring of the lower urinary tract symptoms in patients with established diagnosis of PD. The prevalence of symptomatic patients in past studies varied from 27% to 75%.3,12,13.

In this study the percentage of PD patients having symptomatic urinary manifestations was 72%, this figure was in accordance with others14,15. Soler and LePortz11 mentioned that bladder sphincter dysfunction varies from 30% to 90% depending on severity of disease in PD. On the other hand, Araki and Kuno5 reported only 27% of patients with voiding dysfunction.

These discrepant findings may be probably due to bias selection in urological clinics16,17,18, clinical differences in patients studied or inclusion of other kinds of Parkinsonism5.

Our study showed that most of patients had irritative symptoms where as few patients had obstructive symptoms. This was in accordance with Campos Sousa et al.18, who mentioned that all symptomatic patients had irritative symptoms and 25% of them had also obstructive symptoms. Many authors augment this finding11,19,20,21.

On the contrary De Marinis et al.22 previously reported irritative symptoms in only 8% where as obstructive symptoms in 58% of patients. This may be explained by the small number of patients in that study, which included only 12 patients with no exclusion of patients with organic obstructive lesions.

On performing the urodynamic study, 72% of our patients had abnormal findings. The most frequent and important finding was detrusor hyper-reflexia which was present in 56% of our patients, and 28% of patients had sudden involuntary detrusor contraction occurring at 80-220 ml. These findings were in accordance with previous studies3,20,23.

Soler and LePortz11 added that in most studies, micturition in PD is synergic and in few studies dyssynergia is present. Whereas Myers et al.19 previously reported detrusor hyper-reflexia in 92.8% and involuntary contractions at 150 ml.

Decreased maximum bladder capacity was present in 24% of our patients, a finding which goes hand in hand with other studies19,23,24. On the other side, DeMarinis et al.22 previously reported the same finding but in only 8% of their patients.

Finally, our urodynamic results showed prolonged time of micturition in 44%, decreased maximum flow rate in 40% and residual urine in 20% of our patients. These findings were in agreement with Stocchi et al.3, who reported close incidence of these abnormalities.

Urinary manifestations in PD patients may be explained as the coordinating center of micturition is thought to be in the dorsal tegmentum of pons with neural pathways from it reach the sacral spinal cord. Inhibitory control from medial frontal lobe, anterior cingulate gyrus and the nucleus tegmento-lateralis dorsalis is exerted on pontine micturition center3.

Among other brain structures that regulate micturition, the globus pallidus, subthalamus and substantia nigra have been reported to suppress spontaneous detrusor contractions and inhibit reflex bladder contractions, whereas the finding of hyper-reflexia with vesicosphincteric synergy suggests a suprapontine lesion25.

As a result, in PD patients urinary abnormalities may be due to lack of inhibitory effects exerted by dopamine neurons originated in the pars compacta of the substantia nigra and mediated by D1-receptors on urinary reflex4,26.

Voiding difficulties in parkinsonian patients may be due to bradykinesia of PD27. Campos-Sousa et al.18 mentioned that obstructive urinary symptoms could be explained by sphincter and/or somatic pelvic muscle dysfunction, whereas Galloway28 reported that bradykinetic external sphincter was responsible for obstructive symptoms.

They added that patients with prostate hypertrophy or previous prostatectomy were excluded in their study. Moreover, they compared the urinary manifestations of PD women with control group and revealed significant difference, which reinforces the evidence that urinary dysfunction either irritative or obstructive are related to the disease18.

What augments these explanations, that many authors reported improvement of urinary symptoms after intake of L-dopa, increasing its dose or SC injection of apomorphine3,14,20. Whereas others reported that L-dopa has no effect on bladder dysfunction11 or its influence is uncertain5.

Kirby25 previously mentioned that, there was no consistent trend towards more stable bladder response to bladder filling when patients' parkinsonian symptoms were controlled by medications. This suggests that although basal ganglia are involved in the control of bladder function, their influence is more complex than the simple inhibition of micturition reflex.

The influence of age, sex and duration of illness of PD patients on urinary symptoms were controversial, our results showed no significant relation of age, sex and duration of illness and different urinary manifestations and which was in agreement with others3,23.

Araki and Kuno5 mentioned significant increase in the mean value of total, irritative symptom indices and quality of life index scores with age, whereas obstructive index correlated significantly with duration of the disease not with age. Moreover, the mean score of obstructive symptoms in male patients was significantly higher than that in female patients. But the mean scores of total and irritative symptom index and quality of life index showed no sex difference.

Severity of the disease was significantly related to symptomatic urinary manifestations in our results. This was in accordance with other reports5,11,20 which mentioned that both irritative and obstructive symptom index scores significantly increased with advancing stage of the disease.

               Also, Stocchi et al.3 reported that patients who had hyper-reflexia with synergy had significantly more severe disease.

On the other hand, others reported no significant correlation between severity of PD and urodynamic parameters18,23.

Although symptomatic patients showed worse scoring in UPDRS than asymptomatic patients, it didn't reach a significant value. Whereas QOL index score reached a statistical significance.

These results goes with Campos-Sousa et al.18, who reported no significant difference between mean scores for the three-sectors of UPDRS with and without urinary symptoms. Moreover, no correlation between the total points of UPDRS and the total urinary scores was observed.

Also, Palleschi et al.21 mentioned that urinary symptoms of PD patients cause a severe lowering of quality of life determining social withdrawal. On the contrary, Krygowska-Wajs et al.20 found that detrusor hyperactivity was significantly more in patients with extended motor signs.

In conclusion, lower urinary dysfunction in PD patients is common occurring significantly in advanced stages of the disease and affects patients' quality of life. So, it has to be considered early to be properly evaluated and managed.

 

[Disclosure: Authors report no conflict of interest]

 

REFERENCES

 

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4.        Singer C, Weiner WJ. Autonomic dysfunction in men with Parkinson disease. Eur Neurol. 1992; 32: 134-40.

5.        Araki I, Kuno S. Assessment of voiding dysfunction in Parkinson's disease by the International Prostate Symptoms Score. J Neurol Neurosurg Psychiatry. 2000; 68: 429-33.

6.        Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson's disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry. 1992; 55: 181-91.

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8.        Folstein M, Folstein S, McHugh P. "Mini-Mental Scale": a practical method for grading the cognitive state of patients for the clinician. J Psychiatry Res. 1975; 12: 189-98.

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11.     Soler JM, LePortz B. Bladder sphincter disorders in Parkinson's disease. Ann Urol. 2004; 38: 57-61.

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17.     Sakakibara R, Shinotoh H, Uchiayama T. Questionnaire-based assessment of pelvic organ dysfunction in Parkinson's disease. Auton Neurosci. 2001; 92: 76-85.

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19.     Myers DL, Arya LA, Friedman JH. Is urinary incontinence different in women with Parkinson's disease? Int. Urogynecol. J. Pelvic Floor Dysfunct. 1999; 10(3): 88-191.

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21.     Palleschi G, Pastore AL, Stocchi F, Bova G, Sigala S, Carbone A. Correlation between the overactive bladder questionnaire and urodynamic data of Parkinson disease patients affected by neurogenic detrusor overactivity. Clin Neuropharmacol. 2006; 29(4): 220-9.

22.     De Marinis M, Argenta G, Mele D, Carbone A, Baffigo G, Agnoli A. Evaluation of vesico-urethral and sweating function in disorders presenting with Parkinsonism. Clin. Auton. Res. 1993; 3(2): 125-30.

23.     Defreitas GA, Lemack GE, Zimmern PE, Dewey RB, Roehrborn CG. 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; 62(4): 651-5.

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الملخص العربي

 

اضطرابات التبول في مرض الشلل الرعاش (باركنسون)

 

تهدف هذه الدراسة إلى تقييم اضطرابات التبول في مرضى باركنسون (الشلل الرعاش) وعلاقتها بالعوامل والمؤشرات المختلفة للمرض.

وقد أجريت هذه الدراسة على خمس وعشرين من مرضى الشلل الرعاش باركنسون الذين تم فحصهم إكلينيكياً وتقييم المرض باستخدام مقياس هون ويار والمقياس الموحد لمرض باركنسون. وقد تم تقييم اضطرابات التبول في المرضى باستخدام المقياس الدولي لأعراض البروستاتا ودراسة تفصيلية لديناميكية التبول. وقد أظهرت النتائج اضطرابات التبول في 18 مريض (72%) وأيضاً وجود اضطراب في ديناميكية التبول في 18 مريض (72%). كما أثبتت أن درجة المرض ترتبط ارتباطاً ذو دلالة إحصائية باضطرابات التبول في حين أن باقي العوامل مثل السن، الجنس، مدة المرض أو نتائج مقياس مرض باركنسون الموحد لم تصل إلى دلالة إحصائية.

ومن هنا يتضح أن اضطرابات التبول في مرضى باركنسون تظهر باضطراد في المراحل المتقدمة من المرض والتي يجب أن يتم بحثها وتقييمها مبكراً ليتم تشخيصها جيداً والتعامل معها.



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