Urodynamic and neurophysiological evaluation in Parkinson's disease and multiple system atrophy

Anal sphincter EMG in the diagnosis of parkinsonian syndromes

BACKGROUND

The role of electromyography (EMG) recorded from the external anal sphincter (EAS) in the diagnosis of atypical parkinsonian syndromes is a matter for continuous debate. Most studies addressing this issue are retrospective.

METHODS

In this study, we prospectively investigated six patients with Parkinson's Disease (IPD), 14 patients with multiple system atrophy (MSA) and eight with progressive supranuclear palsy (PSP) using EMG of the EAS, motor-evoked potential (MEP) to the EAS and EMG of m. gastrocnemius and nerve conduction velocity measured at the sural nerve. Patients were followed up for 2 years to secure correct diagnosis.

RESULTS

The mean duration of motor unit potentials (MUPs) recorded from the EAS was significantly longer in patients with MSA and PSP compared with MUPs recorded from patients with PD (P < 0.005 for both). There were no signs of diffuse loss of motor neurons or peripheral neuropathy. MEP revealed signs of supranuclear affection in patients with MSA, whereas in patients with PSP the mechanism is a focal loss of motor neurons in Onuf's nucleus.

CONCLUSION

Abnormal EMG of the EAS is strongly suggestive of atypical parkinsonism and the pathophysiology may be different in patients with MSA and PSP.

Multiple system atrophy

BACKGROUND

It has been almost 4 decades since the descriptions of the 3 parts of multiple system atrophy (MSA) have taken place, characterized clinically by dysautonomia, parkinsonism, and cerebellar dysfunction. The discovery of a distinctive pathologic maker has finally provided the conceptual synthesis of these 3 entities into the universal designation of MSA as a distinct disease process with a complex combination of clinical presentations. Although advances have been made in terms of awareness and knowledge concerning the clinical features and pathophysiology of MSA, it remains challenging for neurologists who treat these patients to differentiate MSA from its mimics as well as providing them with effective treatment.

REVIEW SUMMARY

The aim of this review is to provide an overview of the advances in the knowledge of the disease, to highlight typical features useful for the recognition of its entity, and to enlist different treatment options.

CONCLUSION

Despite the fact that there is still no treatment modality that can alter the disease progression, a number of useful symptomatic treatment measures are available and should be offered to patients to ameliorate the nonmotor features of MSA and even the motor features that may at least transiently respond to treatment.

Bladder and bowel dysfunction in Parkinson's disease

Bladder dysfunction (urinary urgency/frequency) and bowel dysfunction (constipation) are common non-motor disorders in Parkinson's disease (PD). In contrast to motor disorder, the pelvic autonomic dysfunction is often non-responsive to levodopa treatment. Brain pathology mostly accounts for the bladder dysfunction (appearance of overactivity) via altered dopamine-basal ganglia circuit, which normally suppresses the micturition reflex. In contrast, peripheral enteric pathology mostly accounts for the bowel dysfunction (slow transit and decreased phasic contraction) via altered dopamine-enteric nervous system circuit, which normally promotes the peristaltic reflex. In addition, weak strain and paradoxical anal contraction might be the results of brain pathology. Pathophysiology of the pelvic organ dysfunction in PD differs from that in multiple system atrophy; therefore it might aid the differential diagnosis. Drugs to treat bladder dysfunction in PD include anticholinergic agents. Drugs to treat bowel dysfunction in PD include dietary fibers, peripheral dopaminergic antagonists, and selective serotonergic agonists. These treatments might be beneficial not only in maximizing patients' quality of life, but also in promoting intestinal absorption of levodopa and avoiding gastrointestinal emergency.

Neurophysiology of the neurogenic lower urinary tract disorders

The nervous system structures involved in the control of the lower urinary tract (LUT) are usually divided using a neuroanatomical classification system into suprapontine, pontine, spinal and sacral. In all patients with LUT symptoms, after exclusion of local causes, a nervous system disorder needs to be considered. For the diagnosis of neurogenic LUT disorders, in addition to clinical assessment, neurophysiologic testing might be useful. Imaging and other laboratory studies (e.g., cystometry) often provide relevant additional information. Neurophysiologic tests are more useful in patients with sacral compared with suprasacral disorders. Although in patients with LUT disorders external urethral sphincter (EUS) electromyography (EMG) would seem the most appropriate, anal sphincter EMG is the single most useful diagnostic test, particularly for focal sacral lesions, and atypical parkinsonism. Another clinically useful method that tests the sacral segments, and complements EMG, is the sacral (penilo/clitoro-cavernosus) reflex. Kinesiologic EMG is useful to demonstrate detrusor sphincter dyssynergia (i.e., increased EUS activity during bladder contraction), which is particularly common in spinal cord disease. Somatosensory evoked potential (SEP) and motor evoked potential (MEP) studies (cortical and lumbar) may be useful to diagnose clinically silent central lesions. MEP, in addition, seems to be very promising in research into cortical excitability. Theoretically, cortical SEP on bladder/urethra stimulation would be much more useful than pudendal SEP because it tests thin nerve afferents from the pelvic viscera. However, the utility of this technique is limited by technical difficulties, which can be partially overcome by the concomitant recording of a palmar sympathetic skin response (SSR). SSR recorded from the saddle region is also useful for testing the lumbosacral sympathetic system. Although the technique of detrusor EMG has been recently described in humans, a clinically useful test for evaluating the sacral parasympathetic system, which is crucial for LUT functioning, is still lacking.

Chapitre I - Troubles vésico-sphintériens des syndromes parkinsoniens

Lower urinary tract dysfunction is frequent in Parkinson's disease and other Parkinsonian syndromes and can cause urinary incontinence complicating a urgency-frequency syndrome or on the contrary, dysuria. These disorders are a frequent urological presenting complaint due to their impact on the patient's quality of life. Urologists must be aware of the different natural histories of diseases such as Parkinson's disease and Parkinsonian syndromes such as multisystem atrophy, which often have a severe course and are marked by resistance to neuropharmacological treatments. These various diseases can also directly induce urinary symptoms, independently of urological complications. Inversely, the development of urinary disorders, especially obstructive symptoms, in a patient with Parkinsonian syndrome may require review of the neurological diagnosis. Finally, therapeutic management is complex due to the difficulty of using pharmacological treatments, and the risk of deterioration after surgical treatment of obstructive uropathy.

Overactive bladder in Parkinson's disease: alteration of brainstem raphe detected by transcranial sonography

Urinary dysfunction is very common in idiopathic Parkinson's disease (PD) and manifests primarily with symptoms of overactive bladder (OAB). Affection of central serotonergic systems has been suggested to play a role in OAB. The objective of this study was to evaluate whether in PD patients with OAB symptoms a specific alteration of the brainstem raphe (BR), which contains serotonergic neurons, can be detected with transcranial sonography (TCS). Of 116 PD patients enrolled, 19 had PD-related OAB symptoms (OAB+) unlike remaining 97 patients (OAB-). Patients were examined by a sonographer blinded to the clinical data. Reduced echogenicity of BR was found in 12 (63%) OAB+ patients but only in 18 (19%) of 93 assessable OAB- patients (Mann-Whitney U-test, P < 0.001). In OAB+ patients, lower raphe echogenicity score was associated with longer duration of OAB symptoms (anova, P = 0.033). Other TCS findings such as echogenicity of substantia nigra, thalami, lenticular and caudate nuclei, and widths of third and lateral ventricles did not differ between OAB+ and OAB- patients. TCS findings suggest a pathogenetic role of BR in OAB related to PD. Alterations may reflect disturbance of its central serotonergic system.

Brain SPECT imaging in multiple system atrophy

Clinical diagnosis of multiple system atrophy (MSA) relays on signs and symptoms that are often difficult to identify particularly at early stage. Indeed neuropathological studies have demonstrated that MSA is the first cause of misdiagnosis in a cohort of patients presenting with parkinsonian features. Dopamine transporter imaging (DAT) shows striatal decrements in both MSA and Parkinson's disease (PD) making it not sensitive for differential diagnosis. Studies of dopamine D2 receptors with IBZM may help revealing striatal degeneration but a large overlap exist particularly if PD patients with advanced disease are included. We have measured brain flow with technetium-99m ethyl cysteinate dimer (ECD-SPECT) in 36 MSA patients and compared it with 43 PD and 39 age-matched controls. Using Statistical Parametric Mapping (SPM99) we found areas of significant reduced perfusion in the striatum, brain stem and cerebellum in MSA compared to the other groups. We believe that ECD-SPECT imaging may offer significant advantages compared to other imaging techniques in the assessment of neuronal degeneration in MSA and may help the clinician in the diagnostic characterization of patients presenting with atypical parkinsonism.

Gabapentin treatment of neurogenic overactive bladder

OBJECTIVE

Detrusor overactivity is a well-recognized and distressing medical condition affecting both men and women, with a significant prevalence in the population and with a higher incidence rate in people older than 70 years. This pathological condition is characterized by irritative symptoms: urinary urgency, with or without incontinence, and urinary frequency, often seriously compromising the quality of life of the people who have it. The complaint of these symptoms is defined by the International Continence Society (www.continet.org) as "overactive bladder." Many neurological patients experience irritative symptoms of the lower urinary tract related to their disease, and this condition drastically limits their social life. Various drugs have been introduced in therapy protocols to treat neurogenic detrusor overactivity; however, in many cases, the outcomes of these treatments have proven to be unsatisfactory. This fact is probably related to the incomplete understanding of the pathophysiological aspects of detrusor overactivity. Recent studies suggest the possible role in the detrusor overactivity pathogenesis of bladder receptors, afferent pathways, and spinal cord interneurons; consequently, the modulation of bladder receptor and/or spinal cord centers activity has been proposed as a possible approach to control involuntary detrusor contractions, using drugs capable of acting on bladder afferent pathways. The aim of this study was to evaluate the efficacy of gabapentin, an anticonvulsive agent used by neurologists in the treatment of epilepsy and neurogenic pain, in the treatment of detrusor overactivity of neurogenic origin.

METHODS

Sixteen patients affected by neurogenic overactive bladder were enrolled in the study. The clinical outcomes were assessed by symptomatic score evaluations, voiding diary, and urodynamic test before and after 31 days of gabapentin treatment.

RESULTS

The preliminary results showed significant modifications of urodynamic indexes, particularly of the detrusor overactivity, whereas the symptomatic score evaluation and the voiding diary data demonstrated a significant lowering of the irritative symptoms. Furthermore, we did not record significant adverse effects and no patient interrupted the drug treatment.

CONCLUSIONS

These data support the rationale that detrusor overactivity may be controlled by modulating the afferent input from the bladder and the excitability of the sacral reflex center and suggest a novel method to treat overactive bladder patients.

Correlation Between the Overactive Bladder Questionnaire (OAB-q) and Urodynamic Data of Parkinson Disease Patients Affected by Neurogenic Detrusor Overactivity During Antimuscarinic Treatment

INTRODUCTION

Parkinson disease (PD) patients present urinary symptoms during the course of the disease, very often suggestive of overactive bladder and sustained by neurogenic detrusor overactivity. These symptoms cause a severe lowering of quality of life determining social withdrawal and they need to be early diagnosed to restore social interaction and prevent urinary tract complications. Today overactive bladder diagnosis is easier, thanks to the availability of new investigative tools, particularly voiding questionnaires. The aim of the present study was to evaluate the reliability of the Overactive Bladder screener (OAB screener/OAB-questionnaire), a new voiding questionnaire specifically developed for the overactive bladder diagnosis in PD subjects suffering from overactive bladder symptoms. Clinical data obtained by the questionnaire were compared with urodynamic outcomes, at basal conditions and after antimuscarinic treatment, to better explorate the questionnaire reliability.

MATERIALS AND METHODS

Forty PD patients have been enrolled in the protocol, and submitted to the OAB screener, voiding diary and urodynamic investigation before and after antimuscarinic treatment. OAB-score and urodynamic parameters were statistically analyzed and compared.

RESULTS

The OAB-q well correlated with voiding diary and urodynamic data of Parkinson subjects either at baseline or after the antimuscarinic treatment. The study suggests that this clinical tool might be used for neurogenic overactive bladder diagnosis and that it seems to be a useful outcome measure for treatments of neurogenic OAB.

Bladder dysfunction in Parkinsonism: Mechanisms, prevalence, symptoms, and management

The advent of functional imaging methods has increased our understanding of the neural control of the bladder. This review examines current concepts of the role of brain function in urinary control with particular emphasis on the putative role of dopamine receptors. Dopaminergic mechanisms play a profound role in normal bladder control and the dysfunction of these may result in symptoms of overactive bladder in Parkinsonism. The importance of this nonmotor disorder has been overlooked. We address the problem of bladder dysfunction as it presents to patients and their neurologist. The prevalence of bladder symptoms in Parkinson's disease is high; the most common complaint is nocturia followed by frequency and urgency. In multiple-system atrophy, the combination of urge and urge incontinence and poor emptying may result in a complex combination of complaints. The management of bladder dysfunction in Parkinsonism addresses treatment of overactive detrusor as well as incontinence.

Incomplete emptying and urinary retention in multiple-system atrophy: When does it occur and how do we manage it?

Neurogenic urinary retention can be a major cause of morbidity in multiple-system atrophy (MSA). However, the timing of its appearance has not been entirely clear, and neither have the medical and surgical modalities for managing patients. We present the data obtained from our uroneurological assessment and therapeutic interventions at various stages of MSA. We recruited 245 patients with probable MSA. We measured postvoid residuals (PVR) and performed EMG cystometry in all patients. The grand average volume of PVR was 140 mL (range, 0-760) in our patients. The average PVR volume was 71 mL in the first year, increasing to 129 mL in the second year and 170 mL by the fifth year. The percentages of patients with complete urinary retention, acontractile detrusor, and detrusor-sphincter dyssynergia (DSD) also increased. The increase in PVR resulted in a decrease in functional bladder capacity, together with an increase in detrusor overactivity and neurogenic sphincter EMG. Clean intermittent self-catheterization (CISC) was introduced in most patients. Bladder-oriented therapy (cholinergic agents) had a limited value, whereas urethra-oriented therapy benefited patients with DSD (surgery) for up to 2 years, but syncope occurred in a subset of patients (alpha-blockers). MSA patients present with large PVR by the second year of illness, and that large PVR secondarily causes urinary frequency. CISC is the recommended treatment for most patients. Urethra-oriented medication and surgery benefit patients who would have difficulty performing CISC, although careful consideration of the short-term efficacy and potential adverse effects of these alternatives is mandatory.

Central acute D2 stimulation worsens bladder function in patients with mild Parkinson's disease

PURPOSE

The different roles of D1 and D2 dopamine receptors in LUT behavior have been demonstrated in animal studies. In particular D2 selective agonists and D1 selective antagonists seem to produce a reduction of the bladder capacity in conscious rats. This finding has never been confirmed in human studies. Thus, in this study we investigated the role of D1 and D2 agonists/antagonists on LUT behavior in patients with PD.

MATERIALS AND METHODS

A total of 87 patients with mild PD were evaluated. Patients were evaluated with urodynamic studies (cystometry followed by a pressure flow study with perineal floor electromyography) performed in off status and after oral administration of 250 mg of LD. In 70 patients a third urodynamic evaluation was conducted in one of the following conditions: after simultaneous administration of 250 mg oral LD and 60 or 120 mg oral domperidone (D2 peripheral antagonist); after simultaneous administration of 250 mg oral LD and 25, 50 or 150 mg intramuscular L-sulpiride (D2 central and peripheral antagonist). Several urodynamic parameters were evaluated and results obtained in different conditions compared.

RESULTS

LD alone worsened detrusor overactivity: in particular, a reduction of first urinary sensation, involuntary detrusor contraction threshold (reflex volume) and bladder capacity was observed. L-sulpiride (central and peripheral D2 antagonist) coadministration counteracted the worsening in a dose dependent manner. Domperidone (peripheral D2 antagonist) coadministration failed to determine the same counteraction.

CONCLUSIONS

According to our results, a central acute D2 stimulation seems to be responsible of a reduction of bladder capacity with worsening of detrusor overactivity in patients with mild PD.

Prevalence of bladder dysfunction in Parkinsons disease

BACKGROUND AND AIMS

Prevalence of lower urinary tract symptoms (LUTS) in Parkinsons disease (PD) is reported as 27%-39% based on validated questionnaires which do not consider the degree of bother. To estimate the prevalence of LUTS in patients with PD, the severity of symptoms, the volume of postmicturitional urine, and to estimate differences compared to non-PD patients referred for urological evaluation.

METHODS

One hundred seven patients with PD were evaluated using two sets of validated questionnaires (Dan-PSS and IPSS) about LUTS; postmicturitional residual urine was recorded, and compared to 61 patients without PD presenting at an urological clinic for examination.

RESULTS

Bothersome LUTS measured using Dan-PSS scores correlated significantly with Hoehn and Yahr stage of disease (P = 0.02), but not with duration of disease or age. IPSS scores did not correlate to stage of disease, duration of disease or age. Two arbitrary cut-offs were applied, identifying patients with significant LUTS, Dan-PSS > 10 and IPSS > 10. There were no significant differences between the age or duration of disease of patients with and without significant LUTS. The most frequent symptom was nocturia (IPSS: 86%) followed by frequency (IPSS: 71%) and urgency (IPSS: 68%). The most frequently reported bothersome bladder symptom was urgency (Dan-PSS: 61%), followed by nocturia (Dan-PSS: 50%) and urge incontinence (Dan-PSS: 44%). The prevalence of bothersome frequency is low (Dan-PSS: 37%). The postmicturitional volumes (PMV) did not correlate to stage of disease, duration of disease or age, or to scores on questionnaires. Mean PMV was 34 ml. Seven patients (6%) with PD had a PMV larger then 100 ml.

DISCUSSION

The prevalence of severe LUTS was similar with other studies, but the correlation between Dan-PSS and stage of disease, and not IPSS indicates that despite seeing no increase in frequency and severity of LUTS as PD progresses, patients find symptoms more bothersome. This may be due to progression in gait difficulties or a decreasing ability to separate and integrate sensory input, or both.

How to diagnose MSA early: the role of sphincter EMG

Multiple system atrophy (MSA) is a degenerative disease manifesting a combination of parkinsonism, cerebellar, pyramidal, and autonomic (including urinary, sexual and anorectal) dysfunction. It is pathomorphologically defined, but lacks a definitive clinical diagnostic test. In patients with probable MSA, abnormal sphincter EMG, as compared to control subjects, has been found in the majority of patients in all the different forms of the disease in most studies, including patients who, as yet, have no urological or anorectal problems. Patients with Parkinson's disease (PD) as a rule do not show marked sphincter EMG abnormalities in the first five years of the disease. Thus, abnormal spontaneous activity or marked motor unit potential changes in sphincter muscles are helpful in distinguishing MSA from PD in the first five years after the onset of symptoms and signs, and from pure autonomic failure, as well as from cerebellar ataxias, if other causes for sphincter denervation have been ruled out. EMG does not distinguish MSA from progressive supranuclear palsy. How early in the course of MSA these abnormalities become significant enough to support diagnosis remains to be established by prospective studies.

Present and future drug treatment for Parkinson's disease

Considerable advances made in defining the aetiology, pathogenesis, and pathology of Parkinson's disease (PD) have resulted in the development and rapid expansion of the pharmacopoeia available for treatment. Anticholinergics were used before the introduction of levodopa which is now the drug most commonly used. Dopamine agonists are effective when used alone or as an adjunct to levodopa, while monoamine oxidase B inhibitors improve motor function in early and advanced PD. However, treatment mainly addresses the dopaminergic features of the disease and leaves its progressive course unaffected; the drug treatment available for the management of non-motor symptoms is limited. This article seeks to set current treatment options in context, review emerging and novel drug treatments for PD, and assess the prospects for disease modification. Surgical therapies are not considered.

Sonographic assessment of urinary retention in multiple system atrophy and idiopathic Parkinson's disease

Sonography of the bladder was performed before and after voluntary voiding in 20 subjects with possible/probable multiple system atrophy (MSA), 20 patients with idiopathic Parkinson's disease (PD), and 20 healthy controls. Mean residual volume was 173 ml (SD, 194) in MSA and significantly increased compared to both PD (21 ml; SD, 49) and controls (13 ml; SD, 12). Incomplete voiding (>100 ml of residual volume) was found in 11 subjects with MSA but only in 1 patient with PD. Positive predictive value of increased residual volume for MSA was 91.6% in this study, whereas negative predictive value was only 67.8. Bladder sonography is an objective, simple, and safe tool that allows one to screen for urinary retention, which is highly suggestive but incompletely sensitive for MSA. Because sonography is easily accessible and rapidly performed, it is feasible for routine assessment of atypical Parkinsonism.

Reduced cerebellar vermis activation during urinary storage and micturition in multiple system atrophy: 99mTc-labelled ECD SPECT study

Single-photon emission computed tomography brain imaging with special reference of bladder function was performed in eight multiple system atrophy (MSA) patients (two men, six women; mean age, 61 years) and age-matched five normal control subjects (three men, two women; 62 years). In both groups imagings were obtained in three conditions; empty bladder, storage, and micturition. [99mTc]-labelled ECD (555 MBq) was intravenously injected, which was immediately trapped and stabilized within the brain. Using NEUROSTAT software, which could also cancel morphologic differences between MSA and canonical brain, statistical difference between normalized mean tracer counts of both groups in each phase was calculated and visualized. In the storage phase, there was a significant decrease in tracer activity in bilateral cerebellar vermis, particularly of the right side in the MSA group (P < 0.05), which is also known to be involved in the neural control of micturition. In the micturition phase, the area of decrease in tracer activity in the cerebellar vermis became wider in the MSA group. In the resting state, no statistically significance was seen between both groups. In conclusion, it is suggested that the decrease in tracer activity in the cerebellar vermis during urinary storage and micturition is contributing to the micturitional disturbance in this disorder.

Urodynamic evaluation of the older adult: bench to bedside

Urinary symptoms are prevalent in the geriatric population.Symptoms, however, often are misleading. Urodynamic evaluation can help target specific treatments of specific disorders. In this article, the fundamentals of urodynamics are described. In addition,urodynamic findings in common geriatric conditions, such as Parkinson's disease, cerebral vascular accidents, benign prostatic hypertrophy, and incontinence, are discussed.

Effects of pergolide on nocturia in Parkinson's disease: three female cases selected from over 400 patients

We started the subject screening from over 400 patients with Parkinson's disease using strict selection criteria to identify the patients with nocturia who would allow accurate and efficient evaluation of the pergolide effects. The subjects were confined to female patients to exclude patients with potential prostate hypertrophy. The patients treated with bromocriptine at 7.5-15 mg/day adjunctive to l-dopa were selected to replace bromocriptine with pergolide of the equivalent dosage approved in Japan. The nocturia was defined as having more than two episodes of urination during sleep per night on average. The subjects received the urinary sediment test before and during the study for screening urinary tract infection and the study was discontinued when urinary tract infection was found. As a result, we identified total 11 patients with nocturia and three of those completed the 12-week study of switching dopamine agonist from bromocriptine to pergolide. We observed a decrease in nocturia frequency in all three patients, a decrease in irritative urinary symptoms in two and an improvement of sleep QOL in two. The effect of pergolide on nocturia was independent of improvement of parkinsonian symptoms, suggesting a distinct mechanism from that of anti-parkinsonian effects. Our study also suggests that switching from bromocriptine to pergolide improves nocturia, thereby improving sleep status of patients with Parkinson's disease.

Erectile and urinary dysfunction may be the presenting features in patients with multiple system atrophy: a retrospective study

Multiple system atrophy (MSA) is a progressive neurodegenerative disease characterized by parkinsonism and cerebellar, autonomic, urinary, and/or pyramidal dysfunction. Urinary and erectile dysfunction (ED) symptoms are prominent early features in men with MSA. Autonomic failure, considered until recently to be the cause of ED in these men, is commonly expressed through symptoms of orthostatic hypotension (OH). The aim of this retrospective study is to examine the chronological relationship between the development of urogenital symptoms and those of OH in patients diagnosed with MSA and discuss its significance in the aetiology of ED in these patients. A total of 71 male patients, referred to a Uro-Neurology department with a diagnosis of 'probable MSA', were reviewed in terms of 'autonomic' symptoms only--OH and lower urinary tract symptoms, accompanied by ED--present at the time of their referral. Laboratory investigations including anal sphincter EMG and/or autonomic function tests (AFTs) were performed in 75 and 90% of the patients, respectively. At presentation, urinary complaints were recorded in 96% of patients and ED in all patients that this was inquired about. The onset of ED had preceded the onset of bladder symptoms in 58% and the onset of OH symptoms in 91% of these men. Bladder symptoms also preceded symptoms of OH in 76% of patients. Sphincter EMG was abnormal in 91% and AFTs in 77% of the patients tested. Almost all patients with abnormal EMG had troublesome urinary symptoms. AFTs showed similar sensitivity relating to symptoms. At presentation, urogenital symptoms are common in patients with probable MSA and are often not accompanied by symptoms of OH. The earlier occurrence of ED in men with MSA suggests a lack of a causal relationship to hypotension. The notion that MSA possibly affects the dopaminergic mechanism of erectile function is discussed.

Sphincter electromyography and multiple system atrophy

Electromyographic studies of the sphincter in patients with multiple system atrophy have shown increased duration and polyphasia of motor unit potentials. These electrophysiological markers have been used to argue for the selective degeneration of sacral motor neurons in Onuf's nucleus in patients with multiple system atrophy. Studies comparing sphincter electromyographic changes in patients with multiple system atrophy and Parkinson's disease have shown significant differences between these two patient populations. Despite the controversy surrounding this claim, recent studies using quantitative electromyographic techniques support the view that reinnervation of the anal sphincter muscles may be a useful diagnostic marker for distinguishing multiple system atrophy from Parkinson's disease. A critical review of these data is needed to assess the validity and reliability of electromyographic changes in multiple system atrophy.

Short-term effect of a single levodopa dose on micturition disturbance in Parkinson's disease patients with the wearing-off phenomenon

We investigated the short-term effects of a single dose of levodopa (L-dopa) on micturition function in PD patients with wearing-off phenomenon. Eighteen PD patients who had median Hoehn and Yahr scores of 5 during the off phase and 3 during the on phase were recruited. We carried out urodynamic studies before and about 1 hour after the patients had taken 100 mg of L-dopa with dopa-decarboxylase inhibitor (DCI). After taking the L-dopa/DCI, urinary urgency and urge incontinence aggravated, whereas voiding difficulty was alleviated in all 12 patients. When compared to the baseline assessment, urodynamic study results after taking 100 mg of L-dopa/DCI showed aggravated detrusor hyperreflexia; decreased maximum bladder capacity (P = 0.006); an increased maximum Watts Factor value (P = 0.001), reflecting the detrusor power on voiding; an increased Abrams-Griffiths number (P = 0.042), reflecting urethral obstruction on voiding; decreased residual urine volume (P = 0.025); and increased static urethral closure pressure (P = 0.012). One hundred milligrams of L-dopa/DCI worsened detrusor hyperreflexia, producing worsened urinary urgency and urge incontinence during the storage (bladder-filling) phase. It also increased detrusor contractility much more than it did urethral obstruction in the voiding phase, producing overall lessening of voiding difficulty and improving voiding efficiency in our PD patients with the wearing-off phenomenon.

Neurological disorders cerebrovascular disease and parkinsonism

To store and expel urine at appropriate intervals, the lower urinary tract requires extensive input and control from the peripheral autonomic, somatic, and central nervous systems. Neurological disorders, such as cerebrovascular disease and Parkinson's disease, often cause functional disturbances of the lower urinary tract.

Autonomic nervous system testing may not distinguish multiple system atrophy from Parkinson's disease

BACKGROUND

Formal laboratory testing of autonomic function is reported to distinguish between patients with Parkinson's disease and those with multiple system atrophy (MSA), but such studies segregate patients according to clinical criteria that select those with autonomic dysfunction for the MSA category.

OBJECTIVE

To characterise the profiles of autonomic disturbances in patients in whom the diagnosis of Parkinson's disease or MSA used criteria other than autonomic dysfunction.

METHODS

47 patients with parkinsonism and autonomic symptoms who had undergone autonomic laboratory testing were identified and their case records reviewed for non-autonomic features. They were classified clinically into three diagnostic groups: Parkinson's disease (19), MSA (14), and uncertain (14). The performance of the patients with Parkinson's disease was compared with that of the MSA patients on five autonomic tests: RR variation on deep breathing, heart rate changes with the Valsalva manoeuvre, tilt table testing, the sudomotor axon reflex test, and thermoregulatory sweat testing.

RESULTS

None of the tests distinguished one group from the other with any statistical significance, alone or in combination. Parkinson's disease and MSA patients showed similar patterns of autonomic dysfunction on formal testing of cardiac sympathetic and parasympathetic, vasomotor, and central and peripheral sudomotor functions.

CONCLUSIONS

This study supports the clinical observation that Parkinson's disease is often indistinguishable from MSA when it involves the autonomic nervous system. The clinical combination of parkinsonism and dysautonomia is as likely to be caused by Parkinson's disease as by MSA. Current clinical criteria for Parkinson's disease and MSA that direct patients with dysautonomia into the MSA group may be inappropriate.

Sphincter electromyography in diagnosis of multiple system atrophy: technical issues

Possible technical reasons for the controversy over the role of sphincter electromyography (EMG) in the diagnosis of multiple system atrophy (MSA) were analyzed. In a review of the literature, a high sensitivity (>60%) was found reported in 11 studies that included late components, and no value of the test was found in 4 studies that excluded them. This was also corroborated in a pilot study of 5 patients with probable MSA. With late components included, the mean motor unit potential (MUP) duration was prolonged in all 4 patients with an adequate single-MUP analysis sample and, with late components excluded, in 2 of 5 patients on multi-MUP analysis. At least in diagnostic EMG of MSA patients, late components should be included in the measurement of MUP duration.

Micturition-related electrophysiological properties in the substantia nigra pars compacta and the ventral tegmental area in cats

Parkinson's disease patients are known to have not only motor but also urinary autonomic disorders, suggesting central dopaminergic pathways being involved in the micturition function. However, there is little evidence that the substantia nigra pars compacta (SNC) and the ventral tegmental area (VTA), the major dopamine-containing nuclei in the midbrain, should participate in regulating micturition. We investigated micturition-related electrophysiological properties in the SNC and VTA. In 20 male cats under ketamine anaesthesia, in which spontaneous isovolumetric micturition reflex was generated, we performed electrical stimulation and extracellular single-unit recording in the SNC and the VTA, and correlation analysis of the neuronal firings and antidromic stimulation between the SNC/VTA and the pontine storage centre (PSC). Electrical stimulations in the SNC elicited termination of the micturition reflex, whereas those in the VTA elicited both termination and facilitation of the reflex. Forty-nine neurons in the SNC/VTA showed firing in response to the bladder storage/micturition cycles. The major neurons were tonic storage (55%) and phasic storage neurons (22%), which were found diffusely in th e SNC/VTA. The rest were tonic micturition (16%) and phasic micturition neurons (6%), which were concentrated in the caudal part (A2-4 in the Horsley-Clarke coordinates). These neuronal types were further subclassified into augmenting, constant, binary and decrementing neurons according to their temporal discharge rate change. The decrementing neurons were concentrated in the caudal part (A2-4), whereas the augmenting neurons in the rostral part (A4-6). Some of the recorded neurons had preceding firing pattern, which was more frequently found in the tonic type than in the phasic-type neurons. Twenty-four of the neuronal firings in the SNC/VTA were recorded simultaneously with those in the PSC. However, there was no apparent time-correlation between both sets of neuronal firings. In 15 of the simultaneous recording sites, electrical stimulation was applied to one site to see if antidromic response might be evoked in another site. However, there was no orthodromic or antidromic response in either SNC/VTA or PSC. In conclusion, the present study indicates that neurons in the SNC and the VTA are involved in supra-pontine control of micturition, particularly of urinary storage phase. It is also likely that the major role of the SNC is inhibition of the micturiton reflex, whereas that of the VTA is both facilitation and inhibition of the micturition reflex.

Reference values of motor unit potentials (MUPs) of the external anal sphincter muscle

OBJECTIVE

To provide reference values for the isolated motor unit potentials (MUPs) in the external anal sphincter (EAS) muscle, as mean duration, mean amplitude, mean area, number of turns and number of phases, related to the age of the patient. These data are not available in worldwide literature in spite of the fact that the EAS muscle is being increasingly mentioned in relation to differential diagnosis.

METHODS

Study of 235 subjects aged 0-80 years using an automated analysis program.

RESULTS

The study performed shows a clear gradual progression of the mean duration with patient age. The variability of all other parameters tested is also analyzed.

CONCLUSIONS

Our study shows that the classical values of MUPs isolated in the EAS muscle are directly related to age, and that this method is fully reliable to study its pathological conditions.

Effects of a startle on heart rate in patients with multiple system atrophy

The patient cooperation usually required for neurophysiological assessment of autonomic cardioregulatory function is difficult to obtain from patients with bradykinesia. A particularly interesting condition occurs in multiple system atrophy (MSA), which features both bradykinesia and autonomic dysfunction. Another characteristic of patients with MSA is their normal motor reaction to a startling stimulus. We used startle as a stimulus for testing autonomic cardioregulatory function in patients with MSA, thus avoiding the need for patient cooperation. In 10 healthy volunteers and 8 MSA patients, we recorded the electrocardiographic QRS complex with surface electrodes attached over the chest and delivered an acoustic startle stimulus after 8 seconds of baseline recording. We calculated the ratio between the pre-stimulus and the post-stimulus heart beat intervals (R-R ratio) by dividing the mean prestimulus R-R interval by the shortest R-R interval obtained within 10 seconds poststimulus. Healthy volunteers had a significant shortening of the R-R interval. The peak of the effect occurred after 2 to 5 seconds, with a mean R-R ratio of 1.14 (S.D. = 0.09). In contrast, R-R shortening was markedly reduced in patients, even though they had a normal motor response. The mean R-R ratio in patients was 1.03 (S.D. = 0.03), significantly lower than in healthy volunteers (P < 0.01). Our results demonstrate an abnormally reduced modulation of the heart beat frequency in patients with MSA, compatible with a dysfunction on pathways responsible for autonomic regulation. The method described here may be useful in the assessment of cardioregulatory function in poorly cooperative patients with normal startle responses.

Videourodynamic and sphincter motor unit potential analyses in Parkinson's disease and multiple system atrophy

OBJECTIVES

Urinary dysfunction is a prominent autonomic feature in Parkinson's disease (PD) and multiple system atrophy (MSA), which is not only troublesome but also a cause of morbidity in these disorders. Recent advances in investigative uroneurology offer a better insight into the underlying pathophysiology and appropriate management for urinary dysfunction.

METHODS

twenty one patients with PD (15 men, six women, mean age 64 (49-76), mean disease duration 4 years (1-8 years), median Hoehn and Yahr grade 3 (1-4), all taking 300 mg/day of levodopa (100-500 mg)) and 15 with MSA (eight men, seven women, mean age 59 (48-72), mean disease duration 3 years (0.5-6 years)) were recruited. Videourodynamic and sphincter motor unit potential analyses in the patients with PD and MSA were carried out, looking for distinguishing hallmarks that might be useful in the differential diagnosis of these two diseases.

RESULTS

Urinary symptoms were found in 72% of patients with PD and in 100% with MSA. Filling phase abnormalities in the videourodynamic study included detrusor hyperreflexia in 81% of patients with PD and 56% with MSA, and uninhibited external sphincter relaxation in 33% of patients with PD and 33% of those with MSA. However, open bladder neck at the start of filling was not seen in patients with PD but was present in 53% of those with MSA, suggestive of internal sphincter denervation. Sphincter motor unit potential analysis showed neurogenic motor unit potentials in 5% of patients with PD and in 93% of those with MSA, suggestive of external sphincter denervation. On voiding, detrusor-external sphincter dyssynergia was not seen in patients with PD but was present in 47% of those with MSA. Pressure-flow analysis showed that the Abrams-Griffiths number, a grading of urethral obstruction (outflow obstruction >40), in PD (40 in women and 43 in men) was larger than that in MSA (12 in women and 28 in men). Weak detrusor in PD (66% of women and 40% of men) was less common than that in MSA (71% of women and 63% of men). Postmicturition residuals >100 ml were absent in patients with PD but were present in 47% of patients with MSA.

CONCLUSION

Patients with PD had less severe urinary dysfunction with little evidence of internal or external sphincter denervation, by contrast with the common findings in MSA. The findings of postmicturition residuals >100 ml, detrusor-external sphincter dyssynergia, open bladder neck at the start of bladder filling, and neurogenic sphincter motor unit potentials are highly suggestive of MSA.

Quantitative anal sphincter EMG in multisystem atrophy and 100 controls

OBJECTIVE

To evaluate data of quantitative anal sphincter EMG in normal controls and to compare them with patients with multiple system atrophy (MSA).

METHODS

Quantitative anal sphincter EMG were performed on 100 normal controls and 11 patients with MSA to characterise EMG data in these two groups.

RESULTS

In the normal controls, there was a trend for increased motor unit potential (MUP) amplitude, duration, area, and polyphasicity with advancing age. Patients with MSA exhibited similar MUP size and fibre density. Significant differences were found only in parameters of the recruitment pattern, which were reduced in MSA, with a diminution in the number of active MUPs during rest.

CONCLUSIONS

These results may reflect either decreased number of motor cells in Onuf's nucleus without significant consequential reinnervation, or upper motor neuron involvement affecting the anal sphincter in MSA. They further underline the importance of comparative data for age matched controls.

Questionnaire-based assessment of pelvic organ dysfunction in Parkinson's disease

Although patients with Parkinson's disease (PD) experience pelvic organ dysfunction of the urinary bladder, bowel and genital organs, an accurate incidence of the dysfunction and its characteristics have yet to be ascertained. We devised a detailed questionnaire on these three pelvic organ functions in PD patients and control subjects, in our search for a hallmark that would distinguish between the two groups. The PD group comprised 115 patients; 52 men and 63 women, age range 35-69 (average 59) years old, average duration of illness 6 years, median Hoehn and Yahr stage 3. All were taking levodopa with/without dopamine agonists. The control group comprised 391 local individuals who were undergoing an annual health survey; 271 men and 120 women, age range 30-69 (average 48) years old. The questionnaire had three parts: bladder (nine questions), bowel (four questions), and sexual (three questions for women, five for men) function. Each question was scored from 0 (none) to 3 (severe) with an additional quality of life (QOL) index scored from 0 (satisfied) to 3 (extremely dissatisfied). The completion rate was 100% for bladder and bowel functions, whereas for sexual function, it was 95% (control) and 88% (PD) for men and 82% (control) and 60% (PD) for women. As compared with the control group, the frequency of dysfunction in the PD group was significantly higher for urinary urgency (women 42%, men 54%), daytime frequency (28%, 16%), nighttime frequency (53%, 63%), urgency incontinence (25%, 28%), retardation (44% of men), prolongation/poor stream (men 70%), straining (women 28%); constipation (63%, 69%), difficulty in expulsion (men 57%), diarrhea (men 21%); decrease in libido (84%, 83%), decrease in sexual intercourse (55%, 88%), decrease in orgasm (men 87%), and in men, decreases in erection (79%) and ejaculation (79%). The QOL index for the PD patients was significantly higher for bladder (27%, 28%) and bowel (46%, 59%) but not for sexual dysfunction, despite the group's high prevalence of sexual dysfunction. In the PD patients, fecal incontinence was associated with urinary incontinence. Stress urinary incontinence and a decrease in libido were more common in women than in men. Bladder and bowel dysfunction, but not sexual dysfunction increased with the Hoehn and Yahr stage. Sexual dysfunction, but neither bladder nor bowel dysfunction, increased with age. Patients taking levodopa and bromocriptine more frequently had bladder (voiding phase) dysfunction than those taking levodopa only. The findings show that bladder, bowel and sexual dysfunction are all prominent in patients with PD. Amelioration of pelvic organ dysfunction, particularly bowel dysfunction which most affects the quality of life, therefore should be a primary target in the treatment of patients with PD.

Sphincter EMG and differential diagnosis of multiple system atrophy

Multiple system atrophy (MSA) is a degenerative disease manifesting a combination of parkinsonism, cerebellar, pyramidal, and autonomic (including urinary, sexual, and anorectal) dysfunction. It is pathomorphologically defined, but lacks a definitive clinical diagnostic test. Sphincter electromyography (EMG), reflecting Onuf's nucleus degeneration, has been proposed as a helpful test; its value has been reevaluated by a critical review of the literature. In patients with probable MSA, abnormal sphincter EMG, as compared to control subjects, has been found in the majority of patients in all the different forms of the disease in most studies, including patients who, as yet, have no urological or anorectal problems. The prevalence of abnormalities in the early stages of MSA is as yet unclear. Patients with Parkinson's disease (PD) as a rule do not show severe sphincter EMG abnormalities in the early stage of the disease. Anal sphincter EMG abnormalities (abnormal spontaneous activity or motor unit potential changes three standard deviations above valid control data) distinguish MSA from PD in the first 5 years after the onset of symptoms and signs, and from pure autonomic failure, as well as from cerebellar ataxias, if other causes for sphincter denervation have been ruled out. With such criteria, the sensitivity of the method is, however, low. EMG does not distinguish MSA from progressive supranuclear palsy. Future studies should use standardized anal sphincter EMG to better compare results from different centers and precisely define the sensitivity and specificity of the method.

SPECT imaging of the dopamine transporter with [(123)I]-beta-CIT reveals marked decline of nigrostriatal dopaminergic function in Parkinson's disease with urinary dysfunction

We studied a correlation of urinary dysfunction with nigrostriatal dopaminergic deficit in Parkinson's disease (PD) by single-photon emission computed tomography (SPECT) imaging of dopamine transporter with [123I]-2beta-carbomethoxy-3beta-(4-iodophenyl)tropane (beta-CIT). Eleven patients were enrolled in the study, including four men and seven women, with a mean age of 64 years. Seven patients had urinary symptoms 1-5 years after the onset of motor disorder, which included nighttime frequency in six, urinary retardation in four, daytime frequency in one and urge urinary incontinence in one. Using a SPECT camera, the ratio specific to nondisplaceable [123I]-beta-CIT uptake, designated as "striatal V3" was obtained in the caudate, anterior and posterior putamen 24 h after the tracer injection. The striatal V3 was compared in patients with and without urinary dysfunction, and between men and women, using unpaired Student's t-test. Correlation of motor dysfunction and duration of illness with urinary dysfunction, was also analyzed. In the patients, there was a reduction of [123I]-beta-CIT binding in the striatum on both sides, particularly in the putamen contralateral to the affected body side. The striatal V3 of the caudate (p<0.01, Rt; p<0.05, Lt), anterior putamen (p<0.05, Rt) and posterior putamen (p<0.05, Rt) in patients with urinary dysfunction was significantly reduced than those without urinary dysfunction. No sex difference was seen in reduction of [123I]-beta-CIT binding. Urinary dysfunction in PD was more common in patients with higher Unified Parkinson's Disease Rating Scale (UPDRS) score, higher Hoehn-Yahr grade, but not in those with longer duration of disease, although there was no statistical significance. It is likely that our results reflect the association of urinary dysfunction and degeneration of the nigrostriatal dopaminergic cells in PD.

Standardization of anal sphincter electromyography: normative data

OBJECTIVES

Electromyography (EMG) of the external anal sphincter (EAS) is important in the evaluation of conus/cauda lesions, the differential diagnosis of parkinsonism and anal incontinence. The aim of our study was to establish normative data in a sufficiently large group of healthy subjects, using a rigorously standardized examination technique.

METHODS

Sixty-four subjects (aged 19-83 years) without pelvic or neurological disorders were included. Motor unit potentials (MUPs)/interference pattern (IP) samples were obtained from the EAS using multi-MUP and turn/amplitude analyses, respectively. The effect of age, gender, parity, and constipation on MUP/IP parameters was studied. For MUP parameters the lower/upper limits for mean values, and 'outlier' limits, and for IP parameters normal 'clouds' were calculated.

RESULTS

From 112 muscles 15-30 MUPs were sampled. As no effect of evaluated factors on mean values could be demonstrated, common reference values were calculated. Lower/higher limits for mean values were: amplitude 148/661 microV, duration 3.2/7.8 ms, area 87/625 microVms, and number of phases 2. 3/3.7. 'Outlier' limits for individual MUPs were: amplitude 84/1315 microV, duration 1.6/13.8 ms, area 46/1222 microVms, number of phases 2/6. From 95 muscles 2706 IP samples were obtained.

CONCLUSIONS

The presented normative data should allow valid quantitative EMG of the EAS muscle in patients.

The spinocerebellar ataxias

The spinocerebellar ataxias (SCAs) are diseases characterized by the progressive degeneration and subsequent loss of neurons accompanied by reactive gliosis, degeneration of fibers from the deteriorating neurons, and clinical symptoms reflecting the locations of the lost neurons. The degenerative changes affect specific neuronal groups while others remain preserved, and these diseases can therefore be viewed as system degenerations. The SCAs result from either genetically transmitted diseases with dominant inheritance or unknown causes with sporadic occurrence. Most of these disorders affect the cerebellum and its pathways, resulting in progressive deterioration of cerebellar function manifested by increasing unsteadiness of gait, incoordination of limb movements with impairment of skilled movements such as handwriting, and a distinctive dysarthria. Other neuronal systems are affected in some of these disorders, notably the corticospinal pathway, basal ganglia, and autonomic nuclei of the brain stem and spinal cord.

The value of external anal sphincter electromyography for the diagnosis of multiple system atrophy

OBJECTIVE

To assess the value of external anal sphincter electromyography (ASEMG) for the diagnosis of multiple system atrophy (MSA) among various causes of parkinsonism. ASEMG denervation profiles have previously been proposed as a diagnosis test for MSA, but their specificity is disputed.

METHODS

ASEMG variables of 52 parkinsonian patients were analyzed according to the clinical diagnosis: MSA (n = 31) or no MSA (n = 21). Mean motor unit potential duration, percentage of polyphasicity, and the electromyographer's interpretation were analyzed according to clinical diagnosis, disease duration, genitourinary symptoms, gender, parity, and history of pelvic surgery.

RESULTS

All patients with MSA showed ASEMG denervation. Mean motor unit potential duration was the most discriminant variable. No patient with MSA had a mean duration less than 12 ms and no patient without MSA had one greater than 16 ms. ASEMG discriminates between patients with MSA and Parkinson's disease. Using a threshold of 13 ms, the sensitivity was 80% and specificity was almost 70% (positive predictive value, 80%) for the diagnosis of MSA. Age, history of pelvic surgery, and to a lesser extent, female gender, parity, disease duration, and presence of urinary symptoms increased the likelihood of abnormal ASEMG.

CONCLUSION

ASEMG was highly sensitive and rather specific for the diagnosis of MSA.

Questionnaire-based assessment of bladder dysfunction in patients with mild to moderate Parkinson's disease

OBJECTIVES

To assess the lower urinary tract symptoms (LUTS) in men and women with mild to moderate Parkinson's disease (PD) using validated symptom questionnaires.

METHODS

Eighty men and 39 women with mild to moderate PD (Hoehn and Yahr score less than 3) were mailed LUTS questionnaires to complete and return. Men received the American Urological Association Symptom Index and women received the Urogenital Distress Inventory-6. Patients not responding by mail were called and asked to complete the survey over the telephone. Control populations of both symptomatic and asymptomatic men and women (without PD) were identified for comparison.

RESULTS

The overall response rate was 78%. Men with early-stage PD had higher American Urological Association Symptom Index scores than age-matched controls (total score of 12.0 versus 7.7, P <0.05) and scores similar to those reported for men with symptomatic benign prostatic hyperplasia (12.5). Specific items noted to be higher among the men with PD included questions regarding frequency and urgency. Women with PD had higher scores on the Urogenital Distress Inventory-6 than non-age-matched controls (total score of 4.8 versus 2.1, P <0.05), but lower scores than an age-matched group of neurologically intact women presenting for urologic evaluation of LUTS (6.9, P <0.05).

CONCLUSIONS

On the basis of the responses to the validated symptom indexes, the development of LUTS appears to occur at an earlier stage of PD than was once appreciated. Prompt evaluation and treatment of patients with lower urinary tract complaints in the setting of PD may identify bladder dysfunction at an earlier, more treatable stage.

Quantitative electromyography of the external anal sphincter in Parkinson's disease and multiple system atrophy

The distinction of multiple system atrophy (MSA) from Parkinson's disease (PD) can be difficult, especially early in the disease. In MSA degeneration of sacral anterior horn cells (Onuf's nucleus) results in denervation-reinnervation of anal and urethral sphincter muscles, which can be recognized as neurogenic electromyographic (EMG) changes of motor unit potentials. Sphincter EMG has therefore been recommended as a test for distinguishing MSA from PD. Our results confirm the presence of marked neurogenic EMG changes of the external anal sphincter muscle in patients with probable MSA compared to healthy controls. However, in patients with probable PD, our quantitative EMG data show a scatter from normal to marked neurogenic changes and the degree of EMG abnormality is correlated to the duration of the disease. Thus an abnormal sphincter EMG cannot be taken as a strong indicator of MSA rather than PD in the individual patient, especially in long-standing cases.

Anal sphincter EMG does not distinguish between multiple system atrophy and Parkinson's disease

Clinical distinction of multiple system atrophy (MSA) from Parkinson's disease (PD) is often difficult. Several recent reports indicate that objective classification may be accomplished using electromyographic (EMG) testing of the anal or urethral sphincters, but some authors have found that these tests are not reliable for this purpose. We studied 13 patients with PD and 10 with probable MSA, as diagnosed by consensus of four movement disorders specialists, according to accepted clinical criteria. Anal sphincter EMG was performed blind to the clinical diagnosis. We found no significant differences in the mean duration of motor unit potentials (MUPs), mean MUP amplitude, or prevalence of polyphasic potentials, satellite potentials, very long duration MUPs, or spontaneous activity between the two groups. Thus, anal sphincter EMG does not differentiate between PD and MSA.

Assessment of voiding dysfunction in Parkinson's disease by the international prostate symptom score

OBJECTIVES

To find the incidence of voiding dysfunction in Parkinson's disease and to examine the relation between the voiding dysfunction and various indices of the disease (disease severity, disease duration, age, sex, and treatment with antiparkisonian drugs), the presence of voiding dysfunction was quantitatively estimated in patients sampled on the unselected (consecutive) basis.

METHODS

Using the international prostate symptom score, lower urinary tract symptoms were quantitatively evaluated in all patients with Parkinson's disease visiting this neurological clinic during 1 month.

RESULTS

Of the 203 patients who had completed the questionnaire, 55 (27%) were considered to have symptomatic voiding dysfunction. The degree of lower urinary tract symptoms in these patients was well correlated with the severity of the disease rather than with the disease duration or the age. Thirty three (16%) patients had irritative symptoms alone, whereas three (1.5%) patients had obstructive symptoms alone. The irritative and obstructive symptoms were concomitant in 13 (6%) patients. Quality of life was disturbed by lower urinary tract symptoms, and this disturbance paralleled the severity of the disease. The influence of antiparkisonian drugs on the lower urinary tract symptoms was uncertain. The incidence of lower urinary tract symptoms seemed to be independent of sex, but obstructive symptoms were prevalent in male patients.

CONCLUSIONS

This study suggests that voiding dysfunction in patients with Parkinson's disease progressively develops at advanced stages (> or =Hoehn and Yahr stage 3 of the disability). The International prostate symptom score is useful in evaluating the voiding dysfunction of neurodegenerative disease in both men and women, not only reflecting prostatic symptoms.

Are alpha-blockers involved in lower urinary tract dysfunction in multiple system atrophy? A comparison of prazosin and moxisylyte

Lower urinary tract dysfunction is a major cause of morbidity in patients with multiple system atrophy (MSA). alpha1-Adrenergic receptors are present in the proximal urethra where impaired relaxation may be responsible for voiding difficulty and a large amount of residual urine. An open study was designed to evaluate whether the blockade of these receptors by prazosin (a nonselective alpha1 blocker) and moxisylyte (an alpha1A-selective blocker) would improve bladder emptying in patients with MSA. Post-micturition residual volumes and clinical symptoms of 49 patients with MSA were evaluated at trial entry and after 4 weeks (prazosin; n=21 and moxisylyte; n=28). The respective means for the prazosin and moxisylyte groups were 38.1% and 35.2% reductions in residual urine volume (P<0.05), and there was lessening of urinary symptoms. Side effects due to orthostatic hypotension were seen in 23.8% of the prazosin group but in only 10.7% of the moxisylyte group. These effects were common in patients with postural hypotension of more than -30 mmHg at trial entry (P<0.05). Modulation of alpha1-receptors may function in the management of lower urinary tract dysfunction in MSA.

Anorectal function in multiple system atrophy and Parkinson's disease

This study was designed to investigate anorectal function in Parkinson's disease and multiple system atrophy (MSA). After a standardized interview, 17 patients with Parkinson's disease (PD) and 16 patients with multiple system atrophy (MSA) underwent anorectal manometry with a continuously perfused multi-lumen catheter, located to record pressures from the anal canal, and a balloon for rectal distension. Data were analyzed by observers blind to the neurologic diagnosis. Disease duration was shorter in the MSA than in the PD group (6+/-4 versus 10+/-5 yrs, p<0.05). Most patients reported a bowel frequency of less than three evacuations per week and some patients had fecal incontinence. Most manometric recordings disclosed an abnormal pattern during straining (a paradoxic contraction or lack of inhibition) in 13 patients with MSA and 11 patients with PD. Mean anal pressures and rectal sensitivity threshold were not significantly higher in the MSA group, whereas the inhibitory anal reflex and rectal compliance thresholds were within the normal range in both groups. Manometric patterns did not differentiate patients with MSA from patients with PD. Most patients in both groups showed an abnormal straining pattern, decreased anal tone, or both dysfunctions. In conclusion, our findings suggest that although bowel and anorectal dysfunctions do not differentiate MSA from PD, both abnormalities occur earlier and develop faster in MSA than in PD.