Planning for the What-Ifs: Part Four

Bowel and Bladder Issues in Advanced Parkinson’s Disease

Today we continue Parkinson’s Disease: Planning for the What-Ifs, a special series of posts to address both motor and non-motor issues of people with advanced Parkinson’s disease (PD). We are defining advanced PD as those who are no longer independent in their activities of daily living and require help for their self-care such as eating, bathing, dressing and toileting. Remember, PD is a very variable condition and many never reach the advanced stages. Additional background and the full introduction to the series is still available if you missed it.

In previous blogs, we’ve addressed the mental health issues in relation to  advanced PD which include: cognitive decline/dementia, depression, anxiety, apathy, psychosis, mania and behavioral problems. We also addressed other topics of advanced PD here, including falls, extreme immobility, and drooling and swallowing difficulties.

Today we will focus on urinary and gastro-intestinal issues in advanced PD.

Non-motor symptoms affecting the bowel and bladder can be problematic throughout the disease course, but can also pose unique challenges in advanced PD.  These can be challenging issues for both the person with PD and the care partner. It can be helpful to better understand the potential issues, causes and treatments and discuss them with your doctor so you are prepared should they arise. While not the easiest of topics to discuss, it is important to address any issues and concerns with your medical team. We hope this information helps you do so.

Urinary issues in advanced Parkinson’s disease

Urinary dysfunction and symptoms in PD are most commonly caused by overactivity of the detrusor muscle, or the muscle of the bladder, which contracts excessively despite the fact that it is not filled with urine. This causes an increased urge to urinate and/or an increased frequency of urination, which can be especially prominent at night. In advanced PD, this could culminate in urinary incontinence, or involuntary release of urine. Mobility issues which make getting to the bathroom slower and more cumbersome, compound the problem.

Always remember that people with advanced PD may have other medical problems that affect their urination such as an enlarged prostate. Make sure to have a complete evaluation before assuming that the problem is only related to PD. It is also essential to keep in mind that if changes in urination occur suddenly, there could be a urinary tract infection present.

Once other medical issues and urinary tract infection are ruled out, there are a number of approaches to the issue of urinary incontinence in a person with advanced PD:

• Behavioral management – the person with PD is taken to the bathroom on a schedule to empty the bladder.
• Use of medical equipment such as a bedside commode to try to circumvent mobility issues that interfere with getting to the bathroom
• Pelvic floor exercises have been shown to help urinary incontinence in the general population and may be helpful in PD. This could be difficult to implement however, if the person with advanced PD has cognitive challenges which interfere with his/her ability to understand and perform the exercises.
• Medications for overactive bladder – although there have not been clinical trials specifically in people with PD for these medications, they are nevertheless used frequently in PD:
  1. Mirabegron –a beta3 adrenergic receptor agonist which causes the detrusor muscle to relax
  2. Antimuscarinic medications –a subset of a larger group of medications known as anticholinergics. Typically, anticholinergics are avoided in people with advanced PD because they can have many side effects including cognitive effects, constipation and urinary retention. However, there have been specific medications developed with particular affinity to the muscarinic receptors found in the bladder and which have a low tendency to cross the blood-brain barrier and affect brain function. These medications, which include trospium and darifenacin can more reasonably be tried in the advanced PD population.
• Botulinum toxin injections into the bladder. Open label studies (in which there is no control group of patients that did not receive the treatment) support its use in PD. Side effects of this treatment however, can include urinary retention, so it must be used with caution.
• Small, uncontrolled studies of other procedures such as implantable sacral nerve stimulation and tibial nerve stimulation may be effective. A new trial for tibial nerve stimulation for urinary difficulties in PD is underway.

Unfortunately, for some, the above available options may not be sufficient to effectively treat urinary incontinence in advanced PD. If this is the reality, it becomes extremely important to keep the skin dry with frequent changes of incontinence products to prevent skin breakdown and the potential development of skin infection.

In a small number of patients, detrusor overactivity is not the underlying issue, but rather, detrusor underactivity, with incomplete emptying of the bladder. This issue, if not treated, can predispose a person with PD to frequent urinary tract infections. In this situation, intermittent catheterization may be required, or for some, a permanent catheter may be advised. There is also an internal prosthesis for women that can help an underactive bladder. Your doctor will be able to discuss and determine the most suitable option for you, or your loved one.

Gastrointestinal issues in advanced Parkinson’s disease

Problems with motility of the gut can be a major source of difficulty throughout the disease course and can be particularly problematic in advanced PD as well. (You might find our blog post about the gut and PD to be helpful.). Constipation, which can be one of the earliest symptoms of PD is a very common problem throughout the disease course. Two gut issues that tend to be particularly problematic in people with advanced PD are abdominal pain and fecal incontinence.

Abdominal pain in advanced Parkinson’s disease

Always remember that abdominal pain can have many causes that are not related to PD and should be fully evaluated before PD is assumed to be the culprit.

If no other medical reason is identified, advanced PD can contribute to abdominal pain in the following ways:

• Gastroparesis or delayed gastric emptying – this is a condition in which the stomach’s normal movements are slow. Gastroparesis can cause nausea, a bothersome sense of fullness, and abdominal pain. Treatment of gastroparesis includes eating small frequent meals, drinking fluids during meals, avoiding fat, taking a walk after eating, and avoiding medications that can slow down the gut such as opioids. Unfortunately, the only medication approved for gastroparesis in the general population is metoclopramide, which blocks the dopamine receptor and is contra-indicated (cannot be used) in PD. Erythromycin is sometimes used, but its benefits are often short-lived because tolerance to its effects can develop. This condition is therefore very challenging to treat with medications in advanced PD patients and treatment focuses on the lifestyle changes mentioned above.
• A symptom of OFF time. It is possible that stomach pain is an OFF phenomenon (a symptom that returns when medication effects wane) and is related to medication ingestion. If this is the case, adjustments of timing and dosage of medication may help the abdominal pain. However, this phenomenon is complicated by the fact that gastroparesis can inhibit the transport of medication to the small intestine where it is absorbed. Therefore, gastroparesis itself can cause PD meds to remain in the stomach and not be absorbed, leading to OFF time.
• Constipation can be painful and should be aggressively treated to result in a daily bowel movement. It must be noted that very severe constipation can lead to bowel obstruction, a dangerous condition in which part of the gut is blocked. This is a medical emergency and could require surgery. Advanced PD patients who also have cognitive dysfunction and cannot effectively communicate the extent of their constipation or source of their discomfort, may be particularly susceptible to this problem. The care partner or aide should therefore be aware of the frequency of bowel movements and keep track of whether constipation is worsening.

Fecal incontinence in advanced Parkinson’s Disease

Fecal incontinence is a very debilitating symptom that can occur in advanced PD and refers to the involuntary release of fecal matter.

Once again, fecal incontinence, especially if it is a new symptom, should be fully evaluated to determine if there is a cause unrelated to PD. Diseases of the gut such as inflammatory bowel disease or compression of the lower spine cord can be the reason.

If related to PD, there are typically two situations to consider. One possibility is that severe constipation with impacted bowel movement allows loose stool from higher up in the gastrointestinal tract to escape around the edges of the obstruction. In this situation, fecal incontinence could be a harbinger of bowel obstruction. Aggressive and continuous treatment of constipation can help avoid this potential scenario.

Fecal incontinence can also be related to nerve dysfunction of the anal sphincter, or the ring of muscle that controls when feces is released. Cognitive dysfunction and mobility issues may further interfere with getting to the bathroom in time. Some treatment options are similar to urinary incontinence including the use of bedside equipment to minimize mobility issues and introduction of pelvic floor exercises to strengthen the musculature that keeps feces in place.

High-fat and low fiber diets should be avoided as they can contribute to loose stools which are more likely to escape the anal sphincter. Other foods that can contribute to loose stools may differ depending on the individual but may include sugar, caffeine, and dairy products. Keeping a food diary can help identify potential foods to avoid. A daily fiber supplement may be considered. Sacral nerve stimulation can be considered, but has not been tested specifically for fecal incontinence in PD.

As with urinary incontinence, frequent and rapid exchange of dirtied incontinence products can keep skin intact and prevent infection.

Tips and Takeaways

• Bowel and bladder symptoms can be problematic in PD throughout the disease course.
• These issues can be particularly challenging for both the care partner and the person with PD. It is important to talk to your medical team about these problems, even if they seem embarrassing, as it is very important to address and treat these issues right away.
• Particular challenges, such as urinary incontinence, fecal incontinence and abdominal pain can develop in advanced PD.
• Each of these symptoms must be evaluated for other causes, especially if the symptom is new.
• Abdominal pain from PD may be caused by gastroparesis, OFF time, or constipation.
• Urinary incontinence can be treated with lifestyle modifications, medication or botulinum toxin injections. Fecal incontinence is treated primarily with lifestyle and diet modifications.