Urinary tract dysfunction in Parkinson’s disease: a review

Treatment of Older Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease. The prevalence of PD increases with age. The spectrum of clinical features, the rate of progression of the disease, the burden of nonmotor symptoms, and the response to medications are different in older patients with PD from the relatively younger patients. Management of symptoms of PD in older patients is challenging because of possible existence of several age-related systemic illness. While dealing with older patients, it is crucial not to attribute all the physical symptoms to PD. Thorough evaluation for existence of diseases such as normal pressure hydrocephalus and vascular parkinsonism which partially mimic the symptoms of PD carries immense importance. Medical management of parkinsonian symptoms should be preferred with levodopa monotherapy. However, in patients with significant motor fluctuations, dopaminergic agents may be added with caution, as they are notorious for several adverse reactions. Nonmotor symptoms must be provided high importance as they substantially worsen the quality of life. In addition to parkinsonian symptoms, older patients with PD may need to undergo surgery for several conditions. Meticulous perioperative management is crucial as older patients with PD may face several surgery-related complications compared to the younger patients. Compliance to treatment is an important issue in old age. Hence multidisciplinary approach to management of PD in older patients should be emphasized.

The course of insomnia in Parkinson's disease

INTRODUCTION

Insomnia is a debilitating symptom in Parkinson's disease (PD) that has been scarcely investigated in a longitudinal design. Knowledge of factors associated with occurrence of insomnia may provide clues for an increased understanding of underlying pathophysiology and facilitate early detection. The objective of this study is to examine the course and factors associated with longitudinal changes in insomnia severity in patients with PD.

METHODS

Analyses were performed in data of the SCOPA-PROPARK cohort, a 5-year longitudinal cohort study (2003-2011) of 421 PD patients who have been examined annually. Linear mixed models were used to identify factors associated with longitudinal changes in scores of the SCOPA-SLEEP-Nighttime sleep (NS) problems section. A generalized estimating equations (GEE) analysis was performed to determine which baseline variables were associated with the different aspects of insomnia (sleep initiation or maintenance difficulty).

RESULTS

Baseline SCOPA-SLEEP-NS scores were available for 412 patients, of whom 110 (27%) had insomnia (i.e. score ≥ 7). Of the remaining 302 patients, 99 (33%) developed insomnia at some point during follow-up. More severe depressive symptoms, motor fluctuations, higher dopamine agonist doses and sleep medication use were independently associated with higher SCOPA-SLEEP-NS scores over time. GEE analysis did not identify an unique set of determinants that affected specific aspects of insomnia.

CONCLUSION

The presence of depressive symptoms, motor fluctuations and the use of higher doses of dopamine agonists are associated with more severe insomnia. Attention to these aspects could potentially contribute to a better management of insomnia symptoms in PD.

Transcutaneous tibial nerve stimulation in the treatment of lower urinary tract symptoms and its impact on health-related quality of life in patients with Parkinson disease: a randomized controlled trial

PURPOSE

A randomized controlled trial study was performed to evaluate the efficacy of transcutaneous tibial nerve stimulation (TTNS) and sham TTNS, in patients with Parkinson disease (PD) with lower urinary tract symptoms (LUTS).

DESIGN

Randomized controlled trial.

SUBJECTS AND SETTINGS

Thirteen patients with a diagnosis of PD and bothersome LUTS were randomly allocated to one of the following groups: Group I: TTNS group (n = 8) and group II: Sham group (n = 5). Both groups attended twice a week during 5 weeks; each session lasted 30 minutes.

METHODS

Eight patients received TTNS treatment and 5 subjects allocated to group II were managed with sham surface electrodes that delivered no electrical stimulation. Assessments were performed before and after the treatment; they included a 3-day bladder diary, Overactive Bladder Questionnaire (OAB-V8), and the International Consultation on Incontinence Quality of Life Questionnaire Short Form (ICIQ-SF), and urodynamic evaluation.

RESULTS

Following 5 weeks of treatment, patients allocated to TTNS demonstrated statistically significant reductions in the number of urgency episodes (P = .004) and reductions in nocturia episodes (P < .01). Participants allocated to active treatment also showed better results after treatment in the OAB-V8 and ICIQ-SF scores (P < .01, respectively). Urodynamic testing revealed that patients in the active treatment group showed improvements in intravesical volume at strong desire to void (P < .05) and volume at urgency (P < .01) when compared to subjects in the sham treatment group.

CONCLUSION

These findings suggest that TTNS is effective in the treatment of LUTS in patients with PD, reducing urgency and nocturia episodes and improving urodynamic parameters as well as symptom scores measured by the OAB-V8 and health-related quality-of-life scores measured by the ICIQ-SF.

The clinical symptoms of Parkinson's disease

In this review, the clinical features of Parkinson's disease, both motor and non-motor, are described in the context of the progression of the disease. Also briefly discussed are the major treatment strategies and their complications. Parkinson's disease is a slowly progressing neurodegenerative disorder, causing impaired motor function with slow movements, tremor and gait and balance disturbances. A variety of non-motor symptoms are common in Parkinson's disease. They include disturbed autonomic function with orthostatic hypotension, constipation and urinary disturbances, a variety of sleep disorders and a spectrum of neuropsychiatric symptoms. This article describes the different clinical symptoms that may occur and the clinical course of the disease. This article is part of a special issue on Parkinson disease.

Investigation of Urination Disorder in Parkinson's disease

BACKGROUND

Urination disorders are common in Parkinson's disease (PD) and respond poorly to medication. This study aimed to analyze the risk factors for urination disorders in PD.

METHODS

Ninety-one patients with PD (aged 34-83 years old) were recruited. Patients were assessed with the Unified PD Rating Scale (UPDRS), Hoehn and Yahr stage, Pittsburgh Sleep Quality Index (PSQI), Hamilton Depression Rating Scale (HAMD), and Hamilton Anxiety Scale (HAMA). Micturition number was recorded, and Type B ultrasound was used to evaluate residual urine. Statistics was performed using binary logistic regression, bivariate correlations, and Chi-square and t-tests.

RESULTS

Of 91 patients, urinary dysfunction occurred in 55.0%. Among these, 49.5% suffered with nocturia, 47.3% with pollakiuria. Nocturia number had a positive linear relationship with HAMA score (odds ratio [OR] = 0.340, P = 0.001), HAMD score (OR = 0.323, P = 0.002), duration of L-dopa medication (OR = 0.328, P = 0.001), dose of L-dopa (OR = 0.273, P = 0.009), UPDRS-II (OR = 0.402, P = 0.000), UPDRS-III score (OR = 0.291, P = 0.005), and PSQI score (OR = 0.249, P = 0.017). Micturition number over 24 h was positively associated with HAMA (OR = 0.303, P = 0.004) and UPDRS-II scores (OR = 0.306, P = 0.003). Of patients with residual urine, 79.3% had a volume of residual urine <50 ml. Residual urine was present in 44.4% of the patients with nocturia, 46.5% of the patients with pollakiuria, and 80.0% of the patients with dysuria. More men than women had residual urine (35.2% male vs. 13.3% female; P = 0.002).

CONCLUSIONS

Nocturia and pollakiuria were common micturition symptoms in our participants with PD. Nocturia was associated with depression, anxiety, sleep problems, and severity of PD. Pollakiuria was associated with anxiety and severity of PD. Male patients were more prone to residual urine and pollakiuria.

Outcomes After Non-neurological Surgery in Patients With Parkinson's Disease: A Nationwide Matched Cohort Study

Patients with Parkinson disease (PD) were known to have increased risk of complications during hospitalization. The purpose of this study is to validate the global features of postoperative adverse outcomes for patients with PD.Using reimbursement claims from Taiwan's National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of 6455 patients with preoperative PD receiving major surgery during 2008 to 2012. With a propensity score matching procedure, 12,910 surgical patients without PD were selected for comparison. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for 9 major postoperative complications and 30-day postoperative mortality associated with preoperative PD were calculated in the multivariate logistic regressions.Patients with PD had increased risk of postoperative pulmonary embolism (OR 2.72, 95% CI 1.45-5.10), stroke (OR 1.77, 95% CI 1.53-2.05), pneumonia (OR 1.98, 95% CI 1.70-2.31), urinary tract infection (OR 1.52, 95% CI 1.35-1.70), septicemia (OR 1.54, 95% CI 1.37-1.73), acute renal failure (OR 1.36, 95% CI 1.07-1.73), and mortality (OR 1.45, 95% CI 1.06-1.98). The association between preoperative PD and postoperative adverse events was significant in both sexes and every age group. Low income, ≥65 years of age, surgery not in medical center, highest quartile of PD medication users, and more medical conditions worsen the risk of postoperative adverse events in patients with PD.This study showed increased postoperative complications and mortality in patients with PD. Our findings suggest that revision of postoperative care protocols for this population is urgently needed.

Autonomic consequences of spinal cord injury

Spinal cord injury (SCI) results not only in motor and sensory deficits but also in autonomic dysfunctions. The disruption of connections between higher brain centers and the spinal cord, or the impaired autonomic nervous system itself, manifests a broad range of autonomic abnormalities. This includes compromised cardiovascular, respiratory, urinary, gastrointestinal, thermoregulatory, and sexual activities. These disabilities evoke potentially life-threatening symptoms that severely interfere with the daily living of those with SCI. In particular, high thoracic or cervical SCI often causes disordered hemodynamics due to deregulated sympathetic outflow. Episodic hypertension associated with autonomic dysreflexia develops as a result of massive sympathetic discharge often triggered by unpleasant visceral or sensory stimuli below the injury level. In the pelvic floor, bladder and urethral dysfunctions are classified according to upper motor neuron versus lower motor neuron injuries; this is dependent on the level of lesion. Most impairments of the lower urinary tract manifest in two interrelated complications: bladder storage and emptying. Inadequate or excessive detrusor and sphincter functions as well as detrusor-sphincter dyssynergia are examples of micturition abnormalities stemming from SCI. Gastrointestinal motility disorders in spinal cord injured-individuals are comprised of gastric dilation, delayed gastric emptying, and diminished propulsive transit along the entire gastrointestinal tract. As a critical consequence of SCI, neurogenic bowel dysfunction exhibits constipation and/or incontinence. Thus, it is essential to recognize neural mechanisms and pathophysiology underlying various complications of autonomic dysfunctions after SCI. This overview provides both vital information for better understanding these disorders and guides to pursue novel therapeutic approaches to alleviate secondary complications.

Research Findings on Overactive Bladder

Several physiopathologic conditions lead to the manifestation of overactive bladder (OAB). These conditions include ageing, diabetes mellitus, bladder outlet obstruction, spinal cord injury, stroke and brain injury, Parkinson's disease, multiple sclerosis, interstitial cystitis, stress and depression. This review has discussed research findings in human and animal studies conducted on the above conditions. Several structural and functional changes under these conditions have not only been observed in the lower urinary tract, but also in the brain and spinal cord. Significant changes were observed in the following areas: neurotransmitters, prostaglandins, nerve growth factor, Rho-kinase, interstitial cells of Cajal, and ion and transient receptor potential channels. Interestingly, alterations in these areas showed great variation in each of the conditions of the OAB, suggesting that the pathophysiology of the OAB might be different in each condition of the disease. It is anticipated that this review will be helpful for further research on new and specific drug development against OAB.

Prescription rate of medications potentially contributing to lower urinary tract symptoms and detection of adverse reactions by prescription sequence symmetry analysis

Background

The lower urinary tract symptoms (LUTS) increases with age and can have a significant effect on the quality of life of the patients. Elderly patients, who are often characterized by a decline in physiological functional and polypharmacy, are susceptible to adverse drug reactions to pharmacotherapy. LUTS can also be a side effect of medication. The purpose of this study was to investigate the possible association between the initiation of LUTS-causing drug therapy and the onset of LUTS.

Methods

Drug dispensing data at the individual level were retrieved from the CISA (Platform for Clinical Information Statistical Analysis: http://www.cisa.jp) database. A retrospective study was conducted by reviewing patients with LUTS who were dispensed drugs that increased the risk of LUTS between April 2011 and March 2012. Prescription sequence symmetry analysis (PSSA) was employed to investigate the associations between the dispensing of medicines of LUTS and that of LUTS-causing drugs.

Results

LUTS-causing drugs were frequently dispensed to patients with LUTS. The use of medications potentially contributing to LUTS was associated with polypharmacy [number of prescription drugs:12.13 ± 6.78 (user) vs. 5.67 ± 5.24 (nonuser)] but not patient age [ age: (71.38 ± 13.28 (user) vs. 70.45 ± 14.80 (nonuser)]. Significant adverse drug events were observed the use of donepezil, cyclophosphamide, antiparkinson drugs, antidepressant, diazepam, antipsychotic drugs for peptic ulcer, tiotropium bromide, and opioids.

Conclusions

The use of prescription LUTS-causing drugs was correlated with polypharmacy. The adverse drug events associated with LUTS-causing drugs were highly prevalent in elderly patients. To prevent of adverse drug events in patients with LUTS, pharmacists and physicians should regularly review medication lists and reduce the prescribed medicines.

Electronic supplementary material

The online version of this article (doi:10.1186/s40780-014-0004-1) contains supplementary material, which is available to authorized users.

New horizons: urinary incontinence in older people

Urinary incontinence is a common complaint in older people, and is associated with significant impact on the individual, their carers and the wider healthcare system. As the numbers of frail elderly people increase, so will the burden of incontinence. This review examines recent developments in research into the aetiology, physiology, pathology and treatment of urinary incontinence and lower urinary tract symptoms in older people, and explores potential future developments which might reduce or ameliorate both urinary incontinence and its effects on frail older people. These include increasing understanding of the importance of central control of continence, the role of the urothelium as a sensory organ, novel targets for pharmacological treatments and surgical and invasive interventions.

Clinical and pathological features of Parkinson's disease

Parkinson's disease (PD) is, after Alzheimer's disease, the second most common neurodegenerative disorder with an approximate prevalence of 0.5-1% among persons 65-69 years of age, rising to 1-3% among persons 80 years of age and older. Pathologically, PD is characterized by the loss of neurons in the substantia nigra pars compacta (SNpc), and by the presence of eosinophilic protein deposits (Lewy bodies) in this region, in other aminergic nuclei and in cortical and limbic structures. Moreover, it has now been shown that pathology also involves the peripheral nervous system. Braak and colleagues suggested a thread of pathology starting from the vagal nerve to progress to the brainstem, and eventually to limbic and neocortical brain regions. This progression of pathology may account for the clinical evolution of PD toward a composite symptomatology. However, this hypothesis has been criticized by others. In this chapter, we review the clinical features of PD (motor and nonmotor) and their pathological correlates.

Antimicrobial susceptibility pattern and epidemiology of female urinary tract infections in South Korea, 2010-2011

This study aimed to (i) investigate the antimicrobial susceptibilities of bacteria that cause urinary tract infections (UTIs) in outpatient and inpatient settings and (ii) evaluate the risk factors for emerging antimicrobial drug resistance in UTIs in South Korea. In total, 3,023 samples without duplication were collected from females between 25 and 65 years of age who had been diagnosed with a urinary tract infection. Multicenter patient data were collected using a Web-based electronic system and then evaluated. The isolation rates of Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecium in the outpatient setting were 78.1, 4.7, and 1.3%, respectively; in the inpatient setting, the isolation rates of these microorganisms were 37.8, 9.9, and 14.8%, respectively. The susceptibilities of E. coli to amikacin, amoxicillin-clavulanic acid, cefotaxime, cefoxitin, ciprofloxacin, piperacillin-tazobactam, and imipenem in the outpatient setting were 99.4, 79.8, 89.4, 92.8, 69.8, 96.9, and 100.0%, respectively; in the inpatient setting, the susceptibilities to these antibiotics were 97.8, 73.9, 73.7, 82.1, 53.6, 93.2, and 100.0%, respectively. The most unique and common risk factor for emerging antimicrobial-resistant E. coli, K. pneumoniae, and E. faecium was previous exposure to antimicrobials. On the basis of these data, the use of fluoroquinolones should be reserved until culture data are available for the treatment of UTIs in South Korea. The present study will serve as a useful reference for Far Eastern Asia.

Circadian dysfunction may be a key component of the non-motor symptoms of Parkinson's disease: insights from a transgenic mouse model

Sleep disorders are nearly ubiquitous among patients with Parkinson's disease (PD), and they manifest early in the disease process. While there are a number of possible mechanisms underlying these sleep disturbances, a primary dysfunction of the circadian system should be considered as a contributing factor. Our laboratory's behavioral phenotyping of a well-validated transgenic mouse model of PD reveals that the electrical activity of neurons within the master pacemaker of the circadian system, the suprachiasmatic nuclei (SCN), is already disrupted at the onset of motor symptoms, although the core features of the intrinsic molecular oscillations in the SCN remain functional. Our observations suggest that the fundamental circadian deficit in these mice lies in the signaling output from the SCN, which may be caused by known mechanisms in PD etiology: oxidative stress and mitochondrial disruption. Disruption of the circadian system is expected to have pervasive effects throughout the body and may itself lead to neurological and cardiovascular disorders. In fact, there is much overlap in the non-motor symptoms experienced by PD patients and in the consequences of circadian disruption. This raises the possibility that the sleep and circadian dysfunction experienced by PD patients may not merely be a subsidiary of the motor symptoms, but an integral part of the disease. Furthermore, we speculate that circadian dysfunction can even accelerate the pathology underlying PD. If these hypotheses are correct, more aggressive treatment of the circadian misalignment and sleep disruptions in PD patients early in the pathogenesis of the disease may be powerful positive modulators of disease progression and patient quality of life.

Spinal cord lesions in sporadic Parkinson's disease

In this autopsy-based study, α-synuclein immunohistochemistry and lipofuscin pigment-Nissl architectonics in serial sections of 100 μm thickness were used to investigate the spinal cords and brains of 46 individuals: 28 patients with clinically and neuropathologically confirmed Parkinson's disease, 6 cases with incidental Lewy body disease, and 12 age-matched controls. α-Synuclein inclusions (particulate aggregations, Lewy neurites/bodies) in the spinal cord were present between neuropathological stages 2-6 in all cases whose brains were staged for Parkinson's disease-related synucleinopathy. The only individuals who did not have Lewy pathology in the spinal cord were a single stage 1 case (incidental Lewy body disease) and all controls. Because the Parkinson's disease-related lesions were observable in the spinal cord only after Lewy pathology was seen in the brain, it could be concluded that, within the central nervous system, sporadic Parkinson's disease does not begin in the spinal cord. In addition: (1) α-Synuclein-immunoreactive axons clearly predominated over Lewy bodies throughout the spinal cord and were visible in medial and anterior portions of the anterolateral funiculus. Their terminal axons formed dense α-synuclein-immunoreactive networks in the gray matter and were most conspicuous in the lateral portions of layers 1, 7, and in the cellular islands of layer 9. (2) Notably, this axonopathy increased remarkably in density from cervicothoracic segments to lumbosacral segments of the cord. (3) Topographically, it is likely that the spinal cord α-synuclein immunoreactive axonal networks represent descending projections from the supraspinal level setting nuclei (locus coeruleus, lower raphe nuclei, magnocellular portions of the reticular formation). (4) Following the appearance of the spinal cord axonal networks, select types of projection neurons in the spinal cord gray matter displayed α-synuclein-immunoreactive inclusions: chiefly, nociceptive neurons of the dorsal horn in layer 1, sympathetic and parasympathetic preganglionic neurons in layer 7, the cellular pools of α-motoneurons in layer 9, and the smaller motoneurons in Onuf's nucleus in layer 9 (ventral horn). The spinal cord lesions may contribute to clinical symptoms (e.g., pain, constipation, poor balance, lower urinary tract complaints, and sexual dysfunction) that occur during the premotor and motor phases of sporadic Parkinson's disease.