Urinary Dysfunction

Key Facts

  • Infections should be evaluated in PD patients with urinary symptoms.
  • Peripheral anticholinergics to relax the bladder are not recommended in patients with cognitive impairment, dementia, or constipation.
  • Treatment options include alpha-blockers.

Clinical Best Practices

  • Carefully assess current medication intake before prescribing new medication for treatment of urinary dysfunction, as secondary effects may worsen other PD related symptoms.

Voiding (urinary) complaints in PD are very common, and may be present from early on in the disease. Symptoms are caused by PD and not linked to antiparkinsonian medications.

Presentations

The most common urinary problems are:

  • Urinary urgency and frequency-especially nocturnal
  • Incontinence

Causes

  • Dysautonomia due to PD

Diagnosis

  • Comprehensive medical history
  • Gram stain and culture and sensitivity are important to evaluating infections
  • Urodynamic study may be helpful
  • Differential diagnose include prostate hypertrophy, prostatitis, bladder infections, or inflammations

Barriers to Diagnosis

  • Urinary symptoms are common in older patients and may have other origins.
  • Patients often do not consider important to disclose.

Treatment Options

  • Treat urinary infections if they are present.
  • Peripheral anticholinergics to relax the bladder can be used (but are not recommended in those patients with cognitive impairment or dementia due to anticholinergics' effects):
    • Oxybutynin (Ditropan)
    • Tolterodine (Detrol)
    • Solifenacin (VESIcare)
  • Additional options include alpha-blockers such as terazosin (Hytrin) and doxazosin (Cardura)-these may exacerbate orthostatic hypotension.
  • If these medications fail, some cases may benefit from injections of botulinum toxin into the bladder.
  • Evaluation by an urologist may be necessary.

Important Caveats to Therapy

  • Trihexyphenidyl should not be used with peripheral anticholinergics.
  • Anticholinergic side effects include symptoms that may already be problematic for PD, including cognitive impairment and constipation.
  • Some patients may already be taking an anticholinergic drug (eg, tricyclics for sleep, depression or headache; medications for irritable bowel); inadvertent doubling of anticholinergic drugs is a common oversight.
  • Some patients with preexisting cognitive impairment may be taking a procholinergic medication, which can be offset by anticholinergic drugs.
References: 

Ahlskog, JE. Urinary symptoms. In: Ahlskog, JE. Parkinson’s Disease Treatment Guide for Physicians. New York, NY: Oxford University Press; 2009:279-285.

 

Blackett H, Walker R, Wood B. Urinary dysfunction in Parkinson’s disease: a review. Parkinsonism Relat Disord. 2009;15(2):81-87.