Exploring Parkinson’s Disease’s Impact on Urinary Dysfunction

On a recent episode of APDA’s Dr. Gilbert Hosts, I spoke with Dr. Victor Nitti, a urologist with expertise in Parkinson’s disease (PD). We covered a lot of ground during the broadcast and answered questions from the audience. It was a very informative conversation, and we encourage you to watch the full episode, but for your convenience we’ve listed the topics and questions from the episode below with timestamps, so you can skip to what interests you most. Additionally, today we are answering some of the important questions that we didn’t have time to get to during the program.

Questions Addressed During the Episode:

19:20 My husband has to use the bathroom multiple times at night which disrupts both of our sleep. How can we address this?
23:20 What are Kegel exercises? Would you suggest that people do them?
26:06 Why do I have a lot of incontinence on certain days of the week, and on other days I have no problems?
28:45 Are bowel and bladder function related?
30:32 Can you discuss minimally invasive procedures for urologic dysfunction?
35:49 My wife is not on meds for PD but does have urinary frequency. Would PD medications help this symptom?
37:25 What medications do you use for people with PD who have urinary dysfunction?
41:13 Is intravaginal radio frequency treatment useful for urge incontinence?
43:09 What is the potential success of using an external catheter? Internal catheter?
45:52 I’m a water drinker. What is the best approach to getting hydrated if I also have urinary frequency and nighttime incontinence?
48:21 Do people with Parkinson’s tend to get frequent urinary tract infections, and if so, why?
52:13 I don’t have any urge to go to the bathroom anymore. What can help me?

Additional Questions About Urinary Dysfunction:

Our live audience was full of questions, and today we’d like to answer some of them that we didn’t have time to answer during the broadcast.

Q: Does PD cause urinary dribbling with laughter or sneezing?

A: Leakage of urine with laughter or sneezing is referred to as stress incontinence. These activities, as well as lifting a heavy object or coughing, put extra pressure on the bladder and can cause urine to trickle out. (Stress incontinence is not related to life stresses – which are not typically a cause of urinary leakage.) PD can be associated with an increased rate of stress incontinence, but there are other types of incontinence that are more commonly associated with PD, including urge incontinence and functional incontinence. Urge incontinence occurs when there is leakage of urine associated with frequent and sudden urges to urinate, even if the bladder is not full. Urge incontinence can be a part of a syndrome known as overactive bladder and is associated with the neurologic dysfunction of PD. Functional incontinence occurs when there is leakage of urine because a person is not able to get to the bathroom in time. The mobility difficulties of PD can predispose a person to functional incontinence.

Q: What is the safest medicine to control overactive bladder in PD to avoid cognitive side effects?

A: In the general population, anti-cholinergic medications, which block cholinergic receptors, are often used to calm an overactive bladder. However, because these medications block cholinergic receptors throughout the body, they can have undesirable side effects. They can cause constipation, dry eyes, and dry mouth. Even more problematic is that they can block cholinergic receptors in the brain and cause cognitive side effects as well as hallucinations in people with PD, who may already have cognitive issues.

Certain anti-cholinergic medications are less problematic than others. Solifenacin (Vesicare) preferentially blocks a specific cholinergic receptor that is found in the bladder and does not bind as well to other receptors in other parts of the body. This feature decreases the side effect burden of the medication. Trospium (Sanctura) does not cross the blood-brain barrier, so its side effects are also more limited and do not involve cognitive issues or hallucinations.

Mirabegron (Myrbetriq) calms an overactive bladder by a different mechanism of action entirely, the enhancement of beta3-adrenergic activity. This medication does not have cognitive side effects and is used frequently in people with PD. It can also raise blood pressure, which can be beneficial for those who have low blood pressure as a non-motor symptom of PD but can be problematic for those with high blood pressure.

Q: Is urinary retention a symptom of Parkinson’s? How do you treat urinary retention?

A: Urinary retention refers to the inability to completely empty the bladder. This can be due to an obstruction to the normal urinary stream, which in men is often due to an enlarged prostate. Urinary retention, however, can also be due to neurologic impairment, and non-obstructive urinary retention can be a symptom of Parkinson’s disease.

Treatment of urinary retention from PD may involve lifestyle modifications, including:

• Timed voiding or urinating at set times to prevent the bladder from overfilling.
• Double voiding, in which a person urinates and then waits a short time and tries to urinate again, can help get out as much urine as possible.
• Taking time while urinating and trying to relax as much as possible during urination.
• Physical therapy can be helpful in teaching relaxation techniques to maximize the chance that the bladder is emptied completely.

If these practices are not sufficient, intermittent catheterization, in which a tube is inserted into the bladder periodically during the day to get the urine out completely, may be necessary.

Q: Are there procedures that can help with symptoms of an overactive bladder? What about transcutaneous electrical nerve stimulation (TENS)?

A: TENS is a technique that uses mild electrical currents applied to the skin to stimulate nerves. It has been studied for bladder dysfunction in the general elderly population as well as in various neurologic conditions such as multiple sclerosis, and has been found to be effective. Its effectiveness specifically in Parkinson’s disease-related overactive bladder is not as well established, but research in this area is ongoing. Stimulation is applied to the lower back or to the tibial nerve in the ankle. TENS that is applied to the tibial nerve is referred to as transcutaneous tibial nerve stimulation, or TTNS.

More invasive stimulation of the tibial nerve can be applied with percutaneous tibial nerve stimulation, or PTNS. In this procedure, a needle is inserted in the ankle to stimulate the tibial nerve more directly.
Finally, implantable devices can deliver electrical stimulation more consistently. Sacral nerve stimulation (SNS) for example, also known as sacral neuromodulation, involves the implantation of a device under the skin in the upper buttock or lower abdomen. Thin wires deliver electrical stimulation to the sacral nerves which are located near the base of the spine and play a role in controlling bladder function. Posterior tibial nerve implants in the ankle are more recently available as well.

Q: Do people with PD get UTIs more often than people without PD? Does cranberry help prevent urinary tract infections?

A: Urinary retention allows urine to sit for too long in the bladder which can predispose a person to urinary tract infections (UTIs). People who experience urinary retention from PD, can therefore have an increased risk of UTIs compared to the general population. In addition, because of mobility challenges, individuals with PD may find it more difficult to access the bathroom promptly, potentially leading to urinary stasis and an increased risk of UTIs.

There is some evidence to suggest that certain compounds found in cranberries could help prevent bacterial adhesion to the bladder wall, potentially reducing the risk of UTIs. However, the evidence is not conclusive, and research results have been mixed. While some studies have suggested a modest benefit in reducing the risk of recurrent UTIs, others have not shown consistent results. Additionally, the optimal dose and form of cranberry (juice, capsules, etc.) are still subjects of research. There is also no specific evidence to suggest that cranberry products have a different impact on UTI prevention in individuals with PD compared to those without the condition. Talk with your healthcare provider about using cranberry products to prevent recurrent UTIs. Since they have little medical risk, there is no harm in giving them a try. However, your health care provider may feel that you need a stronger preventative strategy, such as Nitrofurantoin, an antibiotic that is sometimes given to those predisposed to UTIs..

Tips and Takeaways

• Urinary dysfunction is a common non-motor symptom in PD and can have a major impact on quality of life. Both overactive bladder and urinary retention can occur as well.
• Thankfully there are some potential treatments that may help these symptoms including lifestyle modifications, medications, and medical procedures.
• If urinary dysfunction is an issue for you, be sure to bring this to your doctor’s attention as you may be able to minimize your symptoms.
• Listen to a very interesting broadcast dedicated to answering questions about urinary dysfunction and PD.
• If you have a PD-related question, you can submit it to our Ask A Doctor portal.