The chronic neurodegenerative disorder of the central nervous system, Parkinson’s disease, manifests as the motor impairment due to the loss of specific group of neurons situated in the nigrostriatal region of the brain which are particularly associated with the production of chemical neurotransmitter dopamine.
The clinical features of Parkinson’s disease present as a constellation of various symptoms including tremors, rigidity, stiffness of muscles, muscular dyskinesia or loss of control over body movements, freezing of gait, and frequent falls in the later stages. Urinary incontinence constitute one such symptom of this disease. The inability to control the release of urine from the bladder and involuntary leakage of urine is known as urinary incontinence. It is condition that affects millions of people throughout the world and is not unique to Parkinson’s patients. It can be both embarrassing and distressing to a person and for Parkinson’s patients who are bedridden or unable to attend to themselves, it can prove even more frustrating.
Types of Urinary Incontinence
- Stress incontinence. Any sort of stress such as coughing, sneezing, laughing or lifting heavy weights can cause leakage of small or large amounts of urine. Weakening of the sphincter muscle of the bladder brings on this type of incontinence which is usually seen in women after menopause. Prostate gland removal may cause stress incontinence in males.
- Urge incontinence. There is an intense desire to pass urine, with involuntary passage of urine if the person cannot reach the toilet in time. The frequency of urination is also increased and is particularly distressing because the patient has to get up often at night. Parkinson’s patients most commonly suffer from this type of incontinence.
- Mixed incontinence. Some patients may suffer from two or more types of urinary incontinence at the same time, such as stress and urge incontinence. This is known as mixed incontinence.
- Functional incontinence. This is a type of incontinence where a person with Parkinson’s diseases is unable to reach the toilet in time or unfasten or unbutton his/her garments either due to his/her physical or mental disability.
- Overflow incontinence. This can follow urinary retention. Urine may leak without the person feeling any urge to urinate.
Causes of Urinary Incontinence in Parkinson’s Disease
Although not everyone with Parkinson’s will develop urinary incontinence issues, but in those who develop the condition, the cause is rooted in the disruption of the messages from brain to the bladder. Bladder expands as urine gets collected and is guarded by a sphincter. Overactivity of the detrusor muscle of the bladder is the main cause of urinary incontinence in elderly people. In Parkinson’s disease, there is interference with the nerve signals responsible for bladder control which results in an overactive bladder, leading to incontinence.
The bladder becomes overactive to develop unwanted contractions which are usually difficult or impossible to stop. The contractions happen at a low volume of filling, creating a higher frequency of micturition associated with urgency, ultimately leading to a “I can’t hold it” moment during which, the leakage may occur. Getting up often at night, due to bed wetting, has been shown to be the most common non-motor symptom associated with the patients of Parkinson’s disease. So also, the unwanted and frequent trips to the washroom during the night, might increase the risk of falls and injuries to the elderly PD patients.
Detrusor underactivity, with urinary retention and overflow incontinence may occur in Parkinson’s disease patients too. In addition, since Parkinson’s disease is more often a disease of old age, other associated factors causing incontinence may be present, such as stress incontinence in menopausal women or prostate problems in men.
Impacted stool may be another cause of urinary incontinence, especially in the elderly. Certain drugs may also contribute to incontinence.
Treatment of Urinary Incontinence
The methods of managing urinary incontinence caused due to the Parkinson’s disease is done by using conservative methods and could be easily incorporated into the daily routine. Behavioral and exercise-based therapies are often quite effective in treatment of incontinence.
- Behavioral therapies include :
- Bladder training to control incontinence.
- Establish routines to avoid accidents. Limit drinks two hours before going to bed to avoid bedwetting overnight. Eat and drink at regular times.
- Biofeedback to become more aware of signals from the body.
- Scheduled visits to the toilet at set intervals.
- Avoiding excessive alcohol and caffeine intake as these can irritate the bladder.
- Reducing intake of liquids, especially in the evenings and before bed time.
- Exercise-based therapies include:
- Taking adequate exercise.
- Pelvic floor muscle exercises (Kegels).
- If these methods are not effective enough, medication may be used :
- Anticholinergics such as oxybutynin, tolterodine, darifenacin, solifenacin and trospium are especially helpful in urge incontinence.
- Topical estrogen creams.
- Imipramine may be effective in mixed incontinence.
- Urethral implants or vaginal pessaries may be tried.
- Indwelling Catheterisation: Done in the cases of severe urinary incontinence, the long term catheterization is a better way to manage the bladder. A fine tube is inserted through the urethra up to the bladder, which can be attached to either a valve or a drainage bag. The catheter is usually replaced after every few weeks.
- Suprapubic Catheterisation: This provides an alternate form to the long term indwelling catheterization and is done by a small surgical procedure in which a tube is placed directly into the bladder through the abdominal approach. Again the tube is attached to a valve or a drainage bag, which is emptied regularly at fixed intervals.
- Surgery may become necessary in certain cases, such as in stress incontinence.
- Other measures :
- Wearing high absorbency pads and pants. These are available in a variety of sizes and absorbance which helps to draw the fluid away from the skin, so as to keep the skin dry and protect it from maceration due to continuous wetness of leaked urine.
- Male continence sheath: Worn over the penis and attached to a leg bag, these sheets are particularly useful during the night and in the long distance travel.
- Wearing clothes that can be easily removed. The use of elasticated waist without zips and buttons can help the elderly people who struggle with the fine movements of their hands or have slowness of movements. This might prove useful for those patients who have urge incontinence.
- Keeping a bedside commode.
- Make necessary bathroom adaptations to help the people with mobility and balance issues. The installation of handrails, adjusting the height on the toilet seat, and the use of footstools can not only be easily added into the home but also makes the toilet more easily accessible.