Prevalence of bladder dysfunction in Parkinsons disease

Digital biomarkers for non-motor symptoms in Parkinson's disease: the state of the art

Digital biomarkers that remotely monitor symptoms have the potential to revolutionize outcome assessments in future disease-modifying trials in Parkinson's disease (PD), by allowing objective and recurrent measurement of symptoms and signs collected in the participant's own living environment. This biomarker field is developing rapidly for assessing the motor features of PD, but the non-motor domain lags behind. Here, we systematically review and assess digital biomarkers under development for measuring non-motor symptoms of PD. We also consider relevant developments outside the PD field. We focus on technological readiness level and evaluate whether the identified digital non-motor biomarkers have potential for measuring disease progression, covering the spectrum from prodromal to advanced disease stages. Furthermore, we provide perspectives for future deployment of these biomarkers in trials. We found that various wearables show high promise for measuring autonomic function, constipation and sleep characteristics, including REM sleep behavior disorder. Biomarkers for neuropsychiatric symptoms are less well-developed, but show increasing accuracy in non-PD populations. Most biomarkers have not been validated for specific use in PD, and their sensitivity to capture disease progression remains untested for prodromal PD where the need for digital progression biomarkers is greatest. External validation in real-world environments and large longitudinal cohorts remains necessary for integrating non-motor biomarkers into research, and ultimately also into daily clinical practice.

Expert consensus on endodontic therapy for patients with systemic conditions

The overall health condition of patients significantly affects the diagnosis, treatment, and prognosis of endodontic diseases. A systemic consideration of the patient's overall health along with oral conditions holds the utmost importance in determining the necessity and feasibility of endodontic therapy, as well as selecting appropriate therapeutic approaches. This expert consensus is a collaborative effort by specialists from endodontics and clinical physicians across the nation based on the current clinical evidence, aiming to provide general guidance on clinical procedures, improve patient safety and enhance clinical outcomes of endodontic therapy in patients with compromised overall health.

[Nocturia in Parkinson's disease]

OBJECTIVE

Evaluation of nocturia and its relationship with clinical characteristics of Parkinson's disease (PD) and dopaminergic therapy.

MATERIAL AND METHODS

One hundred and thirteen patients with PD of I-III Hoehn and Yahr stage (H&Y) were examined using the following scales: IPSS, including nocturia domain, UPDRS, Sch&En, PDQ-39, MMSE, FAB, BDI, STAI-S and STAI-T, PFS-16, NMSQuest, GDSS, GSRS, and orthotest.

RESULTS

Nocturia was detected in 93 patients. It depended on the age of the patients (rS=0.345; p<0.001) and was more spread among women (p=0.002). We obtained positive correlations of nocturia (p<0.05) with: PDQ-39 (rS=0.296), H&Y (rS=0.223), UPDRS (rS=0.265) and its items (speech, walking disorders, standing up from chair, posture and postural stability), NMSQ (rS=0.318), FAB (rS= -0.359), BDI, STAI-S and STAI-T, PFS-16, gastrointestinal parameters and blood pressure in the supine position. No significant effect of dopaminergic therapy on the severity of nocturia was found. According to regression analysis (stepwise method), predictors of nocturia are depression, higher lying blood pressure, constipation and postural instability (R2=0.474).

CONCLUSIONS

Nocturia is the most common urological symptom in patients with PD and it significantly reduces the quality of life starting from the early stages of the disease. Nocturia increases as PD progresses, it is independent of dopaminergic medications, and it is directly associated with a number of parkinsonian symptoms (postural, frontal cognitive, affective and autonomic), which are partly dopamine-resistant. This indicates the common pathogenesis of nocturia and other symptoms of PD and the significant influence of polytransmitter imbalance.

Nocturia and Sleep in Parkinson's Disease

BACKGROUND

Nocturia has a high prevalence in Parkinson's Disease (PD) and is known to be a bothersome symptom for people with Parkinson's disease (PwPD).

OBJECTIVE

to characterize nocturia in a sample of PwPD, in relation to sleep, fatigue and other non-motor symptoms (NMS).

METHODS

we assessed 130 PwPD using a comprehensive battery of scales, which includes the Non-Motor Symptoms Questionnaire (NMSQ), International Parkinson and Movement Disorder Society Non-Motor Rating Scale (MDS-NMS), Parkinson's Disease Sleep Scale version 2 (PDSS-2), Parkinson's Disease Questionnaire (PDQ-39), The Overactive Bladder Questionnaire-Short form (OABq-SF), and the Parkinson's Fatigue Scale (PFS-16).

RESULTS

according to the positive answers to the item of the NMSQ related to nocturia, patients were divided into PwPD + nocturia, and PwPD - nocturia. Nocturia was reported by 112 patients (86.15%). Quality of life in PwPD + nocturia was worse than in PwPD - nocturia, according to the PDQ-39 scores (13.32 ± 9.00 vs. 26.29 ± 14.55, p < 0.001). Sleep was significantly disturbed in PwPD + nocturia compared to PwPD - nocturia, according to the total scores of various scales, such as PDSS-2, PFS-16. PwPD who complained of nocturia presented higher scores of several NMS.

CONCLUSIONS

nocturia has a high prevalence in PwPD and it is associated with impaired sleep, fatigue, and reduced quality of life.

Prevalence of lower urinary tract symptoms, urinary incontinence and retention in Parkinson's disease: A systematic review and meta-analysis

Background

Lower urinary tract symptoms (LUTS) are common non-motor symptoms but are often overlooked in Parkinson's disease (PD). The prevalence of LUTS in PD is inconsistent among different studies.

Objective

To estimate the prevalence of LUTS, urinary incontinence, and urinary retention in PD patients, then, investigate potential sources of inconsistency in prevalence estimation.

Methods

We searched PubMed, EMBASE, and Web of Science databases from inception to May 2022. Studies reporting the prevalence of LUTS or LUTS subtypes in PD were included. Pooled prevalence of LUTS, LUTS subtypes, urinary incontinence, and urinary retention was calculated via random-effects models. Meta-regression and subgroup analyses were performed.

Results

Of 7,358 studies after duplicate removal, a total of 73 studies comprising 14,937 PD patients were included. The pooled prevalence of LUTS was 61% (95% CI 53–69; 27 studies; n = 5,179), while the pooled prevalence of storage symptoms and voiding symptoms was 59% (44–73; 9 studies; n = 798) and 24% (14–33; 11 studies; n = 886), respectively. The pooled prevalence of urinary incontinence, retention and post-void residual (PVR) volume ≥ 100 ml were 30% (95% CI 22–39; 21 studies; n = 6,054), 27% (17–37; 14 studies; n = 1,991), and 4% (1–7; 5 studies; n = 439), respectively. The prevalence of LUTS, urinary incontinence, or urinary retention was significantly associated with diagnostic methods.

Conclusion

LUTS and its subtypes present in a significant proportion of PD patients. It is necessary to use standardized and validated methods to detect and screen LUTS and its subtypes.

Systematic review registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022311233, Identifier: CRD42022311233.

Characteristics and risk factors of lower urinary tract dysfunction in patients with Parkinson's disease: A systematic evaluation and meta-analysis

To systematically evaluate the risk factors of lower urinary tract dysfunction in patients with Parkinson's disease(PD), and to provide theoretical basis for clinical medical staff to identify the risk factors of lower urinary tract dysfunction in patients with PD. From the establishment of the database to January 2021, PubMed, the Cochrane Library, EMBASE, Web of Science, other English database, were searched for literatures about the risk factors of lower urinary tract dysfunction in patients with Parkinson's disease. According to the inclusion and exclusion criteria, after browsing the title, abstract and full text, the high-quality literature in line with the inclusion criteria was selected, and the Newcastle-Ottawa Scale（NOS）document quality evaluation tool was used to evaluate the literature quality and extract the data. The included research results were analyzed by RevMan 5.3 software. A total of 8 studies were included for Meta analysis. The results showed that 7 of the 20 related risk factors were statistically significant, and the statistically significant risk factors were duration of disease [Mean Difference (MD)= 0.59, 95% Confidence Interval (CI) (0.04, 1.14), P < 0.005], age [MD = 2.01, 95%CI (-0.36, 3.34), P < 0.005], Hoehn-Yahr (H-Y) score >2 [Odds Ratio (OR) = 1.56, 95%CI (1.09, 2.23), P < 0.001], sleep disorder [OR = 1.79, 95%CI (1.36,2.35), P < 0.001], constipation [OR = 1.88, 95%CI (1.42,2.48), P < 0.001], unified Parkinson's disease rating scale (UPDRS III) [MD= 4.43, 95%CI (2.20, 6.66), P < 0.001], Mini-mental state examination (MMSE) [MD = -1.16, 95%CI (1.23, -1.09), P < 0.001]. Age, duration of disease, H-Y score >2, sleep disorder, constipation, higher UPDRS Ⅲ score and lower MMSE score were the risk factors of lower urinary tract dysfunction in patients with Parkinson's disease.

Sleep Disturbance, Sleep Disorders and Co-Morbidities in the Care of the Older Person

Sleep complaints can be both common and complex in the older patient. Their consideration is an important aspect of holistic care, and may have an impact on quality of life, mortality, falls and disease risk. Sleep assessment should form part of the comprehensive geriatric assessment. If sleep disturbance is brought to light, consideration of sleep disorders, co-morbidity and medication management should form part of a multifaceted approach. Appreciation of the bi-directional relationship and complex interplay between co-morbidity and sleep in older patients is an important element of patient care. This article provides a brief overview of sleep disturbance and sleep disorders in older patients, in addition to their association with specific co-morbidities including depression, heart failure, respiratory disorders, gastro-oesophageal reflux disease, nocturia, pain, Parkinson's disease, dementia, polypharmacy and falls. A potential systematic multidomain approach to assessment and management is outlined, with an emphasis on non-pharmacological treatment where possible.

Melatonin as a Chronobiotic and Cytoprotective Agent in Parkinson's Disease

This article discusses the role that melatonin may have in the prevention and treatment of Parkinson’s disease (PD). In parkinsonian patients circulating melatonin levels are consistently disrupted and the potential therapeutic value of melatonin on sleep disorders in PD was examined in a limited number of clinical studies using 2–5 mg/day melatonin at bedtime. The low levels of melatonin MT1 and MT2 receptor density in substantia nigra and amygdala found in PD patients supported the hypothesis that the altered sleep/wake cycle seen in PD could be due to a disrupted melatonergic system. Motor symptomatology is seen in PD patients when about 75% of the dopaminergic cells in the substantia nigra pars compacta region degenerate. Nevertheless, symptoms like rapid eye movement (REM) sleep behavior disorder (RBD), hyposmia or depression may precede the onset of motor symptoms in PD for years and are index of worse prognosis. Indeed, RBD patients may evolve to an α-synucleinopathy within 10 years of RBD onset. Daily bedtime administration of 3–12 mg of melatonin has been demonstrated effective in RDB treatment and may halt neurodegeneration to PD. In studies on animal models of PD melatonin was effective to curtail symptomatology in doses that allometrically projected to humans were in the 40–100 mg/day range, rarely employed clinically. Therefore, double-blind, placebo-controlled clinical studies are urgently needed in this respect.

Transcutaneous tibial nerve home stimulation for overactive bladder in women with Parkinson's disease: A randomized clinical trial

AIMS

This study aims to investigate the efficacy of transcutaneous tibial nerve home stimulation for overactive bladder (OAB) in women with Parkinson's disease (PD).

METHODS

The current study is a prospective, randomized, double-blind, sham-controlled trial. Home intervention was carried out and assessments were conducted at a tertiary hospital in South Brazil. Women with PD and OAB symptoms were included in the study. Patients were randomly divided into two groups: (1) stimulation and (2) sham. Both groups underwent intervention at home for 12 weeks. Patients were evaluated at baseline and at 12 weeks (end of intervention), 30- and 90-day follow-up. The primary outcome was the mean reduction in the number of urgency incontinence episodes, and secondary outcomes included daytime and nighttime urinary frequency, urinary urgency episodes, use of pad (reported in a 24-h bladder diary), OAB-V8 and King's Health Questionnaire scores, and maintenance of symptom relief after discontinuation of the intervention.

RESULTS

In total, 30 consecutive patients completed the study (15/group). The stimulation group showed a reduction in nighttime urinary frequency (0.9 ± 0.6), urinary urgency (1.0 ± 1.2), urgency incontinence episodes (0.5 ± 0.6), use of pads (1.3 ± 1.2), and OAB-V8 (1.3 ± 1.2) and King's Health Questionnaire scores. In a 30-day and 90-day follow-up, 8 (53.3%) and 5 (33.3%) stimulation patients, respectively, reported full maintenance of symptom relief after discontinuation of the intervention. Stimulation patients presented a statistically significant improvement of symptoms as compared with sham patients (p = .001).

CONCLUSIONS

Transcutaneous tibial nerve home stimulation can be used in clinical practice as an effective nonpharmacological resource for the reduction of OAB symptoms in women with PD, and the resulting relief seems to persist in the follow-up (30 and 90 days).

Executive Function Is Related to the Urinary Urgency in Non-demented Patients With Parkinson's Disease

Introduction: Evidence suggests urinary urgency is associated with cognitive impairment in a subtype of Parkinson’s disease (PD) patients. This study investigates if cognitive impairment independently predicts the presence of urinary dysfunction.

Methods: We report data of 189 idiopathic PD patients, excluding those with concomitant diseases or medication interacting with bladder function. A standardized questionnaire was used to define the presence of urinary urgency. All patients underwent a comprehensive motor, cognitive non-motor and health-related quality of life (HRQoL) assessment. Multivariable linear regression analysis was performed to identify independent variables characterizing urinary urgency in PD (PD-UU), which were assigned as discriminant features to estimate their individual contribution to the phenotype of the PD-UU group.

Results: Of 189 PD patients, 115 (60.8%) reported PD-UU. The linear regression analysis showed that among cognitive domains, executive function (EF; p = 0.04) had a significant negative association with PD-UU. In a second model, scores of the Montreal Cognitive Assessment (MoCA) significantly differentiated between study groups (p = 0.007) and also non-motor symptom (NMS) burden (p < 0.001). The third model consisted of reports of HRQoL, of which stigma was the only subscale of the Parkinson’s Disease Questionnaire (PDQ-39) differentiating between patients with and without PD-UU (p = 0.02). The linear discriminant analysis provided evidence that the combination of EF, NMS burden, nocturia, and stigma discriminated between groups with 72.4% accuracy.

Conclusion: In our large, non-demented PD cohort, urinary urgency was associated with executive dysfunction (EF), supporting a possible causative link between both symptoms. A combination of neuropsychological and non-motor aspects identified patients with PD-UU with high discriminative accuracy.

Nocturia and Nocturnal Polyuria in Neurological Patients: From Epidemiology to Treatment. A Systematic Review of the Literature

CONTEXT

Nocturia is among the most common and bothersome lower urinary tract symptoms (LUTS), but there is no clear consensus on how to identify and manage this symptom in the neurological population.

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

Studies were identified by electronic search of Cochrane and Medline databases. The studies were included if their participants had acquired neurological pathology among multiple sclerosis (MS), Parkinson's disease (PD), stroke, spinal cord injury (SCI), and reported data on the epidemiology, aetiology, diagnosis, or treatment of nocturia. An independent extraction of the articles was performed by two authors using predetermined datasets, including quality-of-study indicators.

EVIDENCE SYNTHESIS

A total of 132 studies were included; 46 evaluated the epidemiology of nocturia, 28 the possible aetiologies, 10 the diagnostic tools, and 60 the treatments. Nocturia prevalence ranged from 15% to 96% depending on the pathology and definition used. It was one of the most frequently reported LUTS in PD and stroke patients. Several validated questionnaires were found to screen for nocturia in this population. Causalities were numerous: LUT, renal, sleep, cardiovascular dysfunctions, etc. Treatments targeted these mechanisms, with an overall risk of bias assessed as high or serious. The highest level of evidence was seen in MS patients: pelvic floor muscle training, cannabinoids, and desmopressin were effective, but not melatonin. In stroke patients, transcutaneous sacral and transcutaneous tibial nerve stimulation (TTNS) improved nocturia; in PD patients, TTNS, solifenacin, and rotigotine did not.

CONCLUSIONS

Nocturia is highly prevalent in patients with neurological disorders. Causalities and treatments are not different from the general population, but are poorly studied in neurological patients.

PATIENT SUMMARY

In this report, we looked at the published studies about nocturia-the fact of waking to void during the hours of sleep-in patients with neurological diseases. We found that nocturia is very frequent in this population, that the causes are the same as in the general population but may be combined, and that treatments are also the same but have an overall weak level of evidence. We conclude that more research is needed on this topic.

Mastering nocturnal jigsaws in Parkinson's disease: a dusk-to-dawn review of night-time symptoms

Finding out about night-time symptoms from Parkinson's disease (PD) patients can be a challenge as many patients and their carers cannot recall many symptoms that occur during the night, resulting in an under-recognition or a large variability of responses from clinical interviews and scales. Moreover, technology-based assessments for most night-time symptoms are still not universally available for use in a patient's home environment. Therefore, most physicians rely on their clinical acumen to capture these night-time symptoms based on pieces of patients' history, bedpartner's reports, clinical features, associated symptoms or conditions. To capture more night-time symptoms, the authors identified common nocturnal symptoms based on how they manifest from dusk to dawn with selected features relevant to PD. While some symptoms occur in healthy individuals, in PD patients, they may impact differently. The authors intend this narrative review to provide a practical guide on how these common night-time symptoms manifest and highlight pertinent issues by focusing on prevalence, clinical symptomatology, and specific relationships to PD. It is also important to recognise that PD-specific sleep disturbances increase with advancing disease with additional contributions from ageing, comorbidities, and medication side effects. However, the relative contribution of each factor to individual symptom may be different in individual patient, necessitating clinical expertise for individual interpretation. While there are debatable issues in certain areas, they underlie the complexity of night-time symptoms. Understanding night-time symptoms in PD is like re-arranging jigsaw pieces of clinical information to create, but never complete, a picture for physicians to instigate appropriate management.

Randomized, controlled trial of fesoterodine fumarate for overactive bladder in Parkinson's disease

AIMS

To evaluate short-term efficacy and safety of fesoterodine fumarate in Parkinson's disease (PD) patients with overactive bladder (OAB) symptoms.

METHODS

This is a randomized, double-blind, placebo-controlled study. It also has an open-label extension phase. From May 2016 to May 2018, 63 patients were randomized to receive fesoterodine 4 mg or placebo for 4 weeks. At the end of 4 weeks of randomization phase, patients were received fesoterodine fumarate 4 mg daily for another 4 weeks at the open-label extension phase. The change in the mean number of micturition episodes per 24 h period was the primary outcome measure of the study.

RESULTS

The number of micturition episodes per 24 h period significantly improved with the use of fesoterodine fumarate in the double-blind phase (p < 0.001). Also the mean number of nocturia and urgency episodes decreased in the fesoterodine group. In the open-label phase, the mean number of micturition, urgency and urgency urinary incontinence episodes were improved significantly. The number of nocturia episodes did not change in the open-label phase. Cognitive functions were stable after 4 weeks of fesoterodine 4 mg treatment.

CONCLUSIONS

OAB symptoms were significantly improved in older adults with PD under fesoterodine fumarate treatment, and this advantage continued in the open-label portion in the short term. In this randomized controlled study, the cognitive functions of the participants were not affected by fesoterodine 4 mg treatment compared with placebo.

The Use of Neuromodulation for Symptom Management

Pain and other symptoms of autonomic dysregulation such as hypertension, dyspnoea and bladder instability can lead to intractable suffering. Incorporation of neuromodulation into symptom management, including palliative care treatment protocols, is becoming a viable option scientifically, ethically, and economically in order to relieve suffering. It provides further opportunity for symptom control that cannot otherwise be provided by pharmacology and other conventional methods.

Investigation of urinary storage symptoms in Parkinson's disease utilizing structural MRI techniques

BACKGROUND

Lower urinary tract symptoms occur in 27% to 86% of patients with Parkinson's disease (PD), however, the mechanisms responsible for bladder dysfunction are not fully understood. This study utilized magnetic resonance imaging (MRI) to test the hypothesis that key brainstem bladder control areas (including the pontine micturition center and the pontine continence center (PCC) and their links with the basal ganglia are important in the development of urinary storage symptoms in PD.

METHODS

Seventeen patients with PD completed a "bladder symptom questionnaire" and underwent diffusion-weighted MRI (1.5 T). Storage symptom severity and MRI measures of white matter microstructural integrity were correlated using tract-based spatial statistics.

RESULTS

Mean diffusivity in the ventral brainstem correlated significantly with the bladder symptom severity in areas close to the predicted anatomical co-ordinates of the PCC. Tracts seeded from these regions passed via areas involved in pelvic floor musculature control and urinary voiding including the cerebellum, pallidum, and precentral gyrus.

CONCLUSION

We used diffusion-weighted MRI to investigate the role of the brainstem and its structural connections in the development of urinary storage symptoms in PD. Our data suggest that the brainstem degenerative change in the vicinity of the PCC may be implicated in the pathogenesis of storage symptoms in these patients.

Reliability of supraspinal correlates to lower urinary tract stimulation in healthy participants - A fMRI study

Previous functional neuroimaging studies provided evidence for a specific supraspinal network involved in lower urinary tract (LUT) control. However, data on the reliability of blood oxygenation level-dependent (BOLD) signal changes during LUT task-related functional magnetic resonance imaging (fMRI) across separate measurements are lacking. Proof of the latter is crucial to evaluate whether fMRI can be used to assess supraspinal responses to LUT treatments. Therefore, we prospectively assessed task-specific supraspinal responses from 20 healthy participants undergoing two fMRI measurements (test-retest) within 5-8 weeks. The fMRI measurements, conducted in a 3T magnetic resonance (MR) scanner, comprised a block design of repetitive bladder filling and drainage using an automated MR-compatible and MR-synchronized infusion-drainage device. Following transurethral catheterization and bladder pre-filling with body warm saline until participants perceived a persistent desire to void (START condition), fMRI was recorded during repetitive blocks (each 15 s) of INFUSION and WITHDRAWAL of 100 mL body warm saline into respectively from the bladder. BOLD signal changes were calculated for INFUSION minus START. In addition to whole brain analysis, we assessed BOLD signal changes within multiple 'a priori' region of interest (ROI), i.e. brain areas known to be involved in the LUT control from previous literature. To evaluate reliability of the fMRI results between visits, we applied different types of analyses: coefficient of variation (CV), intraclass correlation coefficient (ICC), Sørensen-Dice index, Bland-Altman method, and block-wise BOLD signal comparison. All participants completed the study without adverse events. The desire to void was rated significantly higher for INFUSION compared to START or WITHDRAWAL at both measurements without any effect of visit. At whole brain level, significant (p < 0.05, cluster corrected, k ≥ 41 voxels) BOLD signal changes were found for the contrast INFUSION compared to START in several brain areas. Overlap of activation maps from both measurements were observed in the orbitofrontal cortex, insula, ventrolateral prefrontal cortex (VLPFC), and inferior parietal lobe. The two highest ICCs, based on a ROI's mean beta weight, were 0.55 (right insular cortex) and 0.47 (VLPFC). Spatial congruency (Sørensen-Dice index) of all voxels within each ROI between measurements was highest in the insular cortex (left 0.55, right 0.44). In addition, the mean beta weight of the right insula and right VLPFC demonstrated the lowest CV and narrowest Bland and Altman 95% limits of agreement. In conclusion, the right insula and right VLPFC were revealed as the two most reliable task-specific ROIs using our automated, MR-synchronized protocol. Achieving high reliability using a viscero-sensory/interoceptive task such as repetitive bladder filling remains challenging and further endeavour is highly warranted to better understand which factors influence fMRI outcomes and finally to assess LUT treatment effects on the supraspinal level.

Parkinsonian GM2 synthase knockout mice lacking mature gangliosides develop urinary dysfunction and neurogenic bladder

Parkinson's disease is a neurodegenerative disorder that reduces a patients' quality of life by the relentless progression of motor and non-motor symptoms. Among the non-motor symptoms is a condition called neurogenic bladder that is associated with detrusor muscle underactivity or overactivity occurring from neurologic damage. In Parkinson's disease, Lewy-body-like protein aggregation inside neurons typically contributes to pathology. This is associated with dopaminergic neuron loss in substantia nigra pars compacta (SNc) and in ventral tegmental area (VTA), both of which play a role in micturition. GM1 gangliosides are mature glycosphingolipids that enhance normal myelination and are reduced in Parkinson's brain. To explore the role of mature gangliosides in vivo, we obtained GM2 Synthase knockout (KO) mice, which develop parkinsonian pathology including a loss of SNc dopaminergic neurons, which we reconfirmed. However, bladder function and innervation have never been assessed in this model. We compared GM2 Synthase KO and wild type (WT) littermates' urination patterns from 9 to 19 months of age by counting small and large void spots produced during 1 h tests. Because male and female mice had different patterns, we evaluated data by sex and genotype. Small void spots were significantly increased in 12-16 month GM2 Synthase KO females, consistent with overactive bladder. Similarly, at 9-12 month GM2 KO males tended to have more small void spots than WT males. As GM2 Synthase KO mice aged, both females and males had fewer small and large void spots, consistent with detrusor muscle underactivity. Ultrasounds confirmed bladder enlargement in GM2 Synthase KO mice compared to WT mice. Tyrosine hydroxylase (TH) immunohistochemistry revealed significant dopaminergic loss in GM2 Synthase KO VTA and SNc, and a trend toward TH loss in the GM2 KO periaqueductal gray (PAG) micturition centers. Levels of the nerve growth factor precursor, proNGF, were significantly increased in GM2 Synthase KO bladders and transmission electron micrographs showed atypical myelination of pelvic ganglion innervation in GM2 Synthase KO bladders. Cumulatively, our findings provide the first evidence that mature ganglioside loss affects micturition center TH neurons as well as proNGF dysregulation and abnormal innervation of the bladder. Thus, identifying therapies that will counteract these effects should be beneficial for those suffering from Parkinson's disease and related disorders.

Clinical Rating Scales for Urinary Symptoms in Parkinson Disease: Critique and Recommendations

Background

The prevalence of lower urinary tract symptoms (LUTS) is high in Parkinson's disease (PD). These problems negatively affect quality of life and include both storage and voiding problems. The International Parkinson and Movement Disorder Society established a task force to review clinical rating scales/questionnaires for the assessment of urinary symptoms in PD.

Methods

According to prespecified criteria, these scales/questionnaires were classified as "Recommended" or "Recommended with caveats" when clinimetric properties were satisfactory for Recommended status but had not been assessed specifically in PD, "Suggested" or "Listed." These assessments were applied to rate scales as screening tools for the diagnosis of LUTS and for the rating of symptom severity.

Results

Among scales that included LUTS but focused on overall autonomic or non-motor symptoms in PD, no scale reached the clinimetric rigor to be designated as Recommended or Recommended with caveats, but some were Suggested for either diagnostic screening tools or severity measures. Among primary urological scales, most are well validated in urological setting, but none was validated specifically in PD. DAN-PSS (Danish PSS), ICIQ (International Consultation for Incontinence Questionnaire)-MLUTS (Male Lower Urinary Tract Symptoms), OABq, OABq-SF (ICIQ-OABqol), OAB-V8 (as screening tool), and OABSS (OAB Symptom Score) met criteria for Recommended with caveats.

Conclusion

The Task Force does not recommend the development of a new scale. However, all above-mentioned questionnaires need to be studied further and specifically validated in PD.

Long-term Outcome of Adenosine A2A Receptor Antagonist on Lower Urinary Tract Symptoms in Male Parkinson Disease Patients

Supplemental digital content is available in the text.

Objectives

In addition to motor symptoms, bladder dysfunction is a major clinical issue in patients with Parkinson disease (PD). Istradefylline is adenosine A2A receptor antagonist approved for PD patients with wearing-off symptoms. The aim of this study was to determine the long-term effects of istradefylline on lower urinary tract symptoms (LUTSs) in PD patients.

Methods

We enrolled 14 male PD patients. The mean age of patients was 73 years (61–77 years), the Hoehn-Yahr stage was 2 (2–3), and disease duration was 9 years (3–28 years). The effects of istradefylline (20 mg/d) on LUTSs in PD patients with motor complications after 3, 6, and 12 months of therapy were evaluated based on the International Prostate Symptom Score and Overactive Bladder Symptom Score before and after its administration.

Results

Motor symptoms significantly improved at 12 months' administration (Movement Disorder Society–sponsored revision of the Unified Parkinson's Disease Rating Scale part III: 30.0 ± 12.9 vs 13.8 ± 8.1; P < 0.01). Significant improvements were also observed in the answers provided on urinary questionnaires (International Prostate Symptom Score, 14.4 ± 7.6 vs 8.5 ± 6.8; Overactive Bladder Symptom Score, 6.9 ± 2.8 vs 5.5 ± 3.7; P < 0.05). Nighttime urinary frequency and the percentage of the nocturnal urine volume also improved significantly at 3 months' administration (P < 0.01).

Conclusions

Istradefylline effectively improved not only motor symptoms, but also LUTSs in patients with PD.

An overview of sleep and circadian dysfunction in Parkinson's disease

Sleep and circadian alterations are amongst the very first symptoms experienced in Parkinson's disease, and sleep alterations are present in the majority of patients with overt clinical manifestation of Parkinson's disease. However, the magnitude of sleep and circadian dysfunction in Parkinson's disease, and its influence on the pathophysiology of Parkinson's disease remains often unclear and a matter of debate. In particular, the confounding influences of dopaminergic therapy on sleep and circadian dysfunction are a major challenge, and need to be more carefully addressed in clinical studies. The scope of this narrative review is to summarise the current knowledge around both sleep and circadian alterations in Parkinson's disease. We provide an overview on the frequency of excessive daytime sleepiness, insomnia, restless legs, obstructive apnea and nocturia in Parkinson's disease, as well as addressing sleep structure, rapid eye movement sleep behaviour disorder and circadian features in Parkinson's disease. Sleep and circadian disorders have been linked to pathological conditions that are often co-morbid in Parkinson's disease, including cognitive decline, memory impairment and neurodegeneration. Therefore, targeting sleep and circadian alterations could be one of the earliest and most promising opportunities to slow disease progression. We hope that this review will contribute to advance the discussion and inform new research efforts to progress our knowledge in this field.

Increased odds of bladder and bowel symptoms in early Parkinson's disease

AIMS

To compare the prevalence of urinary and bowel symptoms in a sample of adults with early Parkinson's disease (PD) and healthy controls (HC).

METHODS

Data were obtained from the Michael J. Fox Parkinson's Progression Markers Initiative (PPMI). Prevalent bladder (urinary incontinence (UI) and nighttime voiding) and bowel (constipation and fecal incontinence (FI)) symptoms were defined as occurring at least sometimes when queried using the Scale for Outcomes in PD for Autonomic Symptoms.

RESULTS

The proportion of men (65% vs 64%) and the mean age (61.0 ± 9.7 vs 60.2 ± 11.2 years) was similar between early PD (n = 423) and HC (n = 195). UI and constipation were more prevalent among early PD versus HC (UI: 26.7% vs 8.2%, constipation: 32.4% vs 11.8%; P's < 0.0001). Prevalent nighttime voiding was high among both groups, but not significantly different (82.5% vs 84.1%, P = 0.62). FI was infrequent in both. The odds of UI and constipation were significantly higher in early PD even after adjustment for age, sex, cognition, and overactive bladder (UI model only), constipation (UI and constipation models only), depression, and anxiety medication usage (UI: OR: 4.39 [95% CI: 2.92, 5.87]; constipation: 3.34 [2.20, 4.42]; P's < 0.0001).

CONCLUSIONS

While constipation is known to precede PD diagnosis, these data suggest that the occurrence of UI is elevated in early PD compared to a well-matched HC population.

Sleep Dysfunction in Parkinson's Disease

The spectrum of sleep problems in Parkinson's disease (PD) is broad. These symptoms are recognized as being clinically relevant by the PD patients and may seriously affect their quality of life. Some studies reveal the occurrence of sleep disorders in more than half of the PD patients. The etiology is multifactorial and it mainly involves the degeneration of the sleep-regulating structures. Sleep disorders in PD can be classified into: disturbances of sleep and disturbances of wakefulness. Generic and specific scales were designed to help the screening and evaluation of sleep dysfunction. Further assessment can be done using sleep recording techniques, like actigraphy or polysomnography. All types of sleep disturbances may be encountered in PD: insomnia, excessive daytime sleepiness, rapid eye movement sleep behavior disorders, and restless legs syndrome. This chapter will focus on reviewing the main characteristics, pathophysiology, assessment, and management of the most frequent sleep disturbances encountered in PD.

Periodontal surgery in a stage II Parkinson’s disease patient: Report of a case with special considerations

Parkinson’s disease (PD) is an idiopathic progressive neurological disorder characterised by resting tremor, restrictions in mobility and muscular rigidity that can lead to problems in maintaining oral health. Here we report a case where crown lengthening surgeries were successfully performed in a PD patient for complete oral rehabilitation. Certain special considerations that are required before and during periodontal surgery in such patients are also elucidated. Often dentists and PD patients are reluctant to embark on complex dental procedures resulting in a compromised outcome. However, early intervention along with proper education and motivation of these patients can aid in achieving satisfactory results.

Imaging Parkinson's disease below the neck

Parkinson's disease is a systemic disorder with widespread and early α-synuclein pathology in the autonomic and enteric nervous systems, which is present throughout the gastrointestinal canal prior to diagnosis. Gastrointestinal and genitourinary autonomic symptoms often predate clinical diagnosis by several years. It has been hypothesized that progressive α-synuclein aggregation is initiated in hyperbranched, non-myelinated neuron terminals, and may subsequently spread via retrograde axonal transport. This would explain why autonomic nerves are so prone to formation of α-synuclein pathology. However, the hypothesis remains unproven and in vivo imaging methods of peripheral organs may be essential to study this important research field. The loss of sympathetic and parasympathetic nerve terminal function in Parkinson's disease has been demonstrated using radiotracers such as 123I-meta-iodobenzylguanidin, 18F-dopamine, and 11C-donepezil. Other radiotracer and radiological imaging methods have shown highly prevalent dysfunction of pharyngeal and esophageal motility, gastric emptying, colonic transit time, and anorectal function. Here, we summarize the methodology and main findings of radio-isotope and radiological modalities for imaging peripheral pathology in Parkinson's disease.

Association between cognitive impairment and urinary dysfunction in Parkinson's disease

Urinary dysfunction (UD) is a common non-motor feature of Parkinson's disease (PD), and might be secondary to neurodegeneration involving cortical and subcortical brain areas. The possible link between UD and cognitive deficits has never been examined in frontal cortex impairment, and is still not completely understood in PD. In the present study, 94 PD patients underwent a comprehensive motor, cognitive and non-motor assessment. It was shown that 55.3% of patients reported UD, of which 17% needed specific urological treatment. Patients who reported UD performed worse on global cognition (PANDA, p = .05), visuo-constructive functions (CERAD/praxis, p = .03; and Figure Test, p = .03), and instrumental activities of daily living functions (IADL, p = .03), than patients without UD. The group with UD medication performed worse on global cognition (PANDA, p = .02) and visuo-constructive functions (CERAD/praxis, p = .05; CERAD/praxis recall, p = .05) than the UD group without medication, independent of anticholinergic treatment effect. Our findings suggest an association between cognitive impairment and UD in PD independent from symptomatic treatment.

Assessment of voiding dysfunction in Parkinson's disease: Reliability and validity of the Turkish version of the Danish Prostate Symptom Score

AIMS

To investigate the reliability and validity of the Turkish version of the Danish Prostate Symptom Score (Dan-PSS) questionnaire in patients with Parkinson's disease (PD) and to compare the burden of LUTS (Lower urinary tract symptoms) in men and women.

METHODS

For analysis of test-retest reliability, the Turkish version of the Dan-PSS scale was developed using the back translation method, and it was administered on the day of admission and repeated 1 week after in 60 patients with PD. The OAB-q (Overactive Bladder Questionnaire) and PDQ-39 (Parkinson's Disease Questionnaire-39) were administered to 73 patients for validity analysis.

RESULTS

Both the internal consistency (Cronbach's alpha coefficient: 0.99-1.00) and the test-retest reliability (intraclass correlation coefficient: 0.99-1.00) of the Dan-PSS were found to be high in patients with PD. Although weak to moderate correlations were found between the subscales of the Dan-PSS and PDQ-39 (r: 0.20-0.42; P < 0.05), a strong correlation was found with the OAB-q (r: 0.60-0.79; P < 0.05). Nocturnal urination was the most frequent (93.2%), and bothersome (54.8%) symptom. The majority of the symptom and bother responses were similar in men and women.

CONCLUSIONS

Current study shows that the Turkish version of the Dan-PSS questionnaire is an internally consistent, reliable, and valid scale for patients with PD. Therefore, it can be used to evaluate frequency and severity of LUTS in PD. LUTS are commonly seen in patients with PD in both sexes. It is suggested that all patients with PD should be referred for urological assessment.

Prevalence and treatment of LUTS in patients with Parkinson disease or multiple system atrophy

The lower urinary tract is controlled by complex neural mechanisms not only in the periphery, but also in the central nervous systems (CNS). Thus, patients with a wide variety of neurological diseases often also have lower urinary tract symptoms (LUTS), including those with Parkinson disease (PD) or multiple system atrophy (MSA). LUTS are common comorbidities associated with both of these neurodegenerative diseases and are likely to impair patients' quality of life. The motor symptoms of PD and MSA often seem similar; however, the pathophysiology, and thus the treatment of LUTS differs considerably. Antimuscarinics are the first-line treatment of storage LUTS in patients with PD or MSA; however, care should be taken in the management of these patients, especially in those with MSA owing to the high risk of inefficient voiding, and thus an increased post-void residual volume. Other treatments of PD-related LUTS include α-adrenoceptor antagonists, which improve voiding dysfunction, transurethral resection of the prostate for bladder outlet obstruction owing to prostate enlargement, and neuromodulation and intradetrusor botulinum toxin injections for storage LUTS. However, more conservative treatments, including intermittent catheterization, are required for LUTS in patients with MSA, owing to the high incidence of impaired detrusor contractility and detrusor-sphincter dyssynergia.

Lower urinary tract symptoms in Parkinson's disease: Prevalence, aetiology and management

Lower urinary tract symptoms (LUTS) are common in Parkinson's disease (PD), effecting 27-85% of patients with PD. Irritative symptoms predominate and urodynamic studies confirm high prevalence of detrusor overactivity in PD. LUTS are present early in PD and are more common in PD than in age matched controls. The assessment of LUTS in PD is complicated by coexisting bradykinesia and cognitive impairment. Although LUTS become more troublesome as PD progresses it remains unclear if LUTS severity correlates with motor symptoms and/or duration of PD. The underlying cause of LUTS in PD remains to be fully elucidated. Animal and human studies suggest the net effect of the basal ganglia is to supress micturition. Although LUTS are a common in PD, few studies have examined the assessment and management of LUTS specifically in patients with PD. Pilot studies have suggested that bladder training, antimuscarinic drugs and intravesical botulinum toxin maybe helpful but these trials have been small and frequently lacked a suitable control group making them vulnerable to the placebo effect. Furthermore the adverse effects of antimuscarinic drugs on cognitive and gastrointestinal function may limit the use of these drugs in PD. In this review we summarise the literature describing the prevalence of LUTS in PD, discuss the emerging data delineating the underlying pathophysiology of LUTS and examine interventions helpful in the management of LUTS in people with PD.

Nocturia in Parkinson's Disease: Why Does It Occur and How to Manage?

BACKGROUND

Nocturia is one of the commonest nonmotor symptoms in Parkinson's disease (PD) and has a significant impact on quality of life both for patients and their carers. There exists a relation between nocturia and poor sleep quality, falls, and institutionalization. Nocturia may manifest as a result of reduced functional bladder capacity or nocturnal polyuria; however, most often the cause is multifactorial. Disorders of circadian rhythm regulation are known to occur with sleep disturbances in PD may also contribute to nocturia.

METHODS AND RESULTS

In this review, an overview of the assessment and management of nocturia in patients with PD is presented. History taking, medication review, and a bladder diary form the cornerstone of the evaluation. Urinalysis, ultrasonography, and urodynamic studies help to assess the cause for lower urinary tract symptoms and exclude concomitant pathologies, such as bladder outlet obstruction. Antimuscarinic medications are the first-line treatment for the overactive bladder; however, caution is needed when using these medications in individuals predisposed to cognitive impairment. Desmopressin is effective for managing nocturnal polyuria.

CONCLUSIONS

An individualized approach is recommended to optimize the management of nocturia in PD.

Effects of Deep Brain Stimulation on Autonomic Function

Over the course of the development of deep brain stimulation (DBS) into a well-established therapy for Parkinson's disease, essential tremor, and dystonia, its utility as a potential treatment for autonomic dysfunction has emerged. Dysfunction of autonomic processes is common in neurological diseases. Depending on the specific target in the brain, DBS has been shown to raise or lower blood pressure, normalize the baroreflex, to alter the caliber of bronchioles, and eliminate hyperhidrosis, all through modulation of the sympathetic nervous system. It has also been shown to improve cortical control of the bladder, directly induce or inhibit the micturition reflex, and to improve deglutition and gastric emptying. In this review, we will attempt to summarize the relevant available studies describing these effects of DBS on autonomic function, which vary greatly in character and magnitude with respect to stimulation target.

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.

Parkinson's disease: a review of non-motor symptoms

Parkinson's disease (PD) is a neurodegenerative disorder resulting from degeneration of the substantia nigra and the dopaminergic nigrostriatal pathway. Most treatments are geared toward the management and relief of motor symptoms in Parkinson's patients; however, as the disease progresses, various complications can be observed. Non-motor symptoms (NMS) may arise simply from the disease itself and are highly destructive to quality of life. These symptoms include mood disorders, cognitive dysfunction, pain, sensory dysfunction, and dysautonomia. Though it is undisputed that many NMS may appear years or even decades prior to the clinical diagnosis of PD, the focus of this review will be the overt motor phase of the condition. As such, the focus of this paper is to review the major NMS found in PD patients status post-diagnosis, their etiology, as well as treatment options available for the individual NMS.

Nonmotor Symptoms and Subthalamic Deep Brain Stimulation in Parkinson's Disease

Subthalamic deep brain stimulation (STN DBS) is an established treatment for the motor symptoms in patients with advanced Parkinson’s disease (PD). In addition to improvements in motor symptoms, many studies have reported changes in various nonmotor symptoms (NMSs) after STN DBS in patients with PD. Psychiatric symptoms, including depression, apathy, anxiety, and impulsivity, can worsen or improve depending on the electrical stimulation parameters, the locations of the stimulating contacts within the STN, and changes in medications after surgery. Global cognitive function is not affected by STN DBS, and there is no increase in the incidence of dementia after STN DBS compared to that after medical treatment, although clinically insignificant declines in verbal fluency have been consistently reported. Pain, especially PD-related pain, improves with STN DBS. Evidence regarding the effects of STN DBS on autonomic symptoms and sleep-related problems is limited and remains conflicting. Many symptoms of nonmotor fluctuations, which are occasionally more troublesome than motor fluctuations, improve with STN DBS. Although it is clear that NMSs are not target symptoms for STN DBS, NMSs have a strong influence on the quality of life of patients with PD, and clinicians should thus be aware of these NMSs when deciding whether to perform surgery and should pay attention to changes in these symptoms after STN DBS to ensure the optimal care for patients.

A guideline for the management of bladder dysfunction in Parkinson's disease and other gait disorders

Parkinson's disease (PD) is a common neurodegenerative disorder, and lower urinary tract (LUT) dysfunction is one of the most common autonomic disorders with an estimated incidence rate of 27-80%. Studies have shown that bladder dysfunction significantly influences quality-of-life (QOL) measures, early institutionalisation, and health economics. We review the pathophysiology of bladder dysfunction in PD, lower urinary tract symptoms (LUTS), objective assessment, and treatment options. In patients with PD, disruption of the dopamine D1-GABAergic direct pathway may lead to LUTS. Overactive bladder (OAB) is the most common LUT symptom in PD patients, and an objective assessment using urodynamics commonly shows detrusor overactivity (DO) in these patients. The post-void residual (PVR) volume is minimal in PD, which differs significantly from multiple system atrophy (MSA) patients who have a more progressive disease that leads to urinary retention. However, subclinical detrusor weakness during voiding may also occur in PD. Regarding bladder management, there are no large, double-blind, prospective studies in this area. It is well recognised that dopaminergic drugs can improve or worsen LUTS in PD patients. Therefore, an add-on therapy with anticholinergics is required. Beta-3 adrenergic agonists are a potential treatment option because there are little to no central cognitive events. Newer interventions, such as deep brain stimulation (DBS), are expected to improve bladder dysfunction in PD. Botulinum toxin injections can be used to treat intractable urinary incontinence in PD. Transurethral resection of the prostate gland (TURP) for comorbid BPH in PD is now recognised to be not contraindicated if MSA is excluded. Collaboration of urologists with neurologists is highly recommended to maximise a patients' bladder-associated QOL. Neurourol. Urodynam. 35:551-563, 2016. © 2015 Wiley Periodicals, Inc.

Underactive and overactive bladders are related to motor function and quality of life in Parkinson's disease

AIM OF THE STUDY

Overactive bladder occurs in up to 70% and underactive bladder in up to 50% of patients with Parkinson's disease (PD), which is thought to reflect an altered frontal-basal ganglia circuit. However, it is not clear how bladder disorder is related to motor function and to quality of life (QOL) in PD. We studied these relationships by conducting multiple regression (MR) and bivariate correlation (BV) statistical analyses.

METHODS

We recruited 58 PD patients, irrespective of the presence of bladder disorder: 35 men and 23 women of mean age 66.8 years, mean duration of the disease 5.4 years, and median score of Hoehn-Yahr stage 3. We administered a bladder questionnaire including two major types of lower urinary tract symptoms, 'overactive bladder (OAB)' and 'voiding difficulty,' in addition to a QOL index and a pressure-flow urodynamic study to detect detrusor overactivity (DO) during filling; and detrusor weakness, outlet obstruction, and post-void residuals (PVR) during voiding. We analyzed the results using the MR and BV methods.

RESULTS

(1) Motor impairment (by HY grades) was significantly related to detrusor weakness (P < 0.05 MR); voiding difficulty, OAB (P < 0.05 BV) (by de novo, levodopa honeymoon, and wearing-off); and voiding difficulty (P < 0.05 MR). (2) Bladder QOL was significantly related to OAB, increased bladder sensation (P < 0.05 MR) and voiding difficulty (P < 0.05 BV). (3) Male gender was significantly related to outlet obstruction, DO (P < 0.05 MR). (4) Age was significantly related to DO and PVR (P < 0.05 MR). Disease duration was significantly related to OAB (P < 0.05 MR).

CONCLUSION

From these results, detrusor weakness (relevant to motor impairment) and OAB (relevant to bladder QOL) are thought to be fundamental in PD. In contrast to the mechanism of OAB, the mechanism of detrusor weakness in PD remains unclear and warrants further exploration.

Randomized, controlled pilot trial of solifenacin succinate for overactive bladder in Parkinson's disease

OBJECTIVE

To evaluate the efficacy of solifenacin succinate in Parkinson's disease (PD) patients suffering from overactive bladder (OAB).

BACKGROUND

Urinary dysfunction is a commonly encountered non-motor feature in PD that significantly impacts patient quality of life.

DESIGN/METHODS

This was a double-blind, randomized, placebo-controlled, 3-site study with an open label extension phase to determine the efficacy of solifenacin succinate in idiopathic PD patients with OAB. Patients were randomized to receive solifenacin succinate 5-10 mg daily or placebo for 12 weeks followed by an 8-week open label extension. The primary outcome measure was the change in the mean number of micturitions per 24 h period. Secondary outcome measures included the change in the mean number of urinary incontinence episodes and the mean number of nocturia episodes.

RESULTS

Twenty-three patients were randomized in the study. There was no significant improvement in the primary outcome measure in the double-blind phase, but there was an improvement in the number of micturitions per 24 h period in the solifenacin succinate group compared to placebo at a mean dose of 6 mg/day (p = 0.01). In the open label phase, the mean number of urinary incontinence episodes per 24 h period decreased (p = 0.03), as did the number of nocturia episodes per 24 h period (p = 0.01). Adverse events included constipation and xerostomia, which resolved after treatment was discontinued.

CONCLUSIONS

In this pilot trial, solifenacin succinate treatment led to an improvement in urinary incontinence, despite persistence in other OAB symptoms.

Local Change in Urinary Bladder Contractility Following CNS Dopamine Denervation in the 6-OHDA Rat Model of Parkinson's Disease

BACKGROUND

Urinary problems, including urinary frequency, urgency, and nocturia are some of the non-motor symptoms that correlate most with poor quality of life in Parkinson's disease. However, the mechanism behind these symptoms is poorly understood, in particular regarding peripheral bladder pathophysiology following dopamine degeneration.

OBJECTIVE

In this study, we compared the contractile responsiveness of urinary bladder from the 6-OHDA unilateral rat model of Parkinson's disease with that of normal untreated animals.

METHODS

The contractility of the urinary detrusor muscle was evaluated in bladder strip preparations using electrical field stimulation, and muscarinic and purinoceptor stimulations in an vitro organ bath setup.

RESULTS

Our data show that the overall contractile response following electrical field stimulation was significantly higher (43% at maximum contraction by 20-40 Hz stimulation) in the 6-OHDA-lesioned rats as compared to control animals. This increase was associated with a significant increase in the cholinergic contractile response, where the muscarinic agonist methacholine produced a 44% (at 10 -4 M concentration) higher response in the 6-OHDA-treated rats as compared to controls with a significant left-shift of the dose response. This indicates an altered sensitivity of the muscarinic receptor system following the specific central 6-OHDA-induced dopamine depletion. In addition a 36% larger contraction of strips from the 6-OHDA animals was also observed with purinoceptor activation using the agonist ATP (5×10 -3 M) during atropine treatment.

CONCLUSIONS

Our data shows that it is not only the central dopamine control of the micturition reflex that is altered in Parkinson's disease, but also the local contractile function of the urinary bladder. The current study draws attention to a mechanism of urinary dysfunction in Parkinson's disease that has previously not been described.

Neurological status predicts response to alpha-blockers in men with voiding dysfunction and Parkinson's disease

OBJECTIVES

To evaluate predictors of the response to doxazosin, a selective alpha-adrenoceptor antagonist, when used for the treatment of lower urinary tract symptoms in men with Parkinson's disease.

METHODS

In a prospective study, 33 consecutive men (mean age 59.2 ± 7.0 years) with Parkinson's disease and lower urinary tract symptoms were evaluated. Neurological dysfunction was assessed with the Unified Parkinson's Disease Rating Scale. Urological assessment was performed at baseline and after 12 weeks of treatment with 4 mg/day of extended-release doxazosin, including symptom evaluation with the International Continence Society male short-form questionnaire, an assessment of the impact of lower urinary tract symptoms on quality of life and urodynamics. Clinical and urodynamic predictors of response were specifically evaluated.

RESULTS

Compared with the score at baseline, the total International Continence Society male short-form score was reduced after doxazosin administration, from 17.4 ± 7.5 to 11.1 ± 6.9 (p<0.001). The impact of lower urinary tract symptoms on quality of life was also significantly reduced, from 1.8 ± 1.1 to 1.0 ± 1.0 (p<0.001) and the maximum urinary flow varied from 9.3 ± 4.4 to 11.2 ± 4.6 ml/s (p=0.025). The severity of neurological impairment was the only predictor of the clinical response. Additionally, patients with a Unified Parkinson's Disease Rating Scale score lower than 70 had a significantly higher chance of clinical improvement with doxazosin treatment than those with higher Unified Parkinson's Disease Rating Scale scores did (RR=3.10, 95% CI=[1.15 to 5.37], p=0.011).

CONCLUSIONS

Doxazosin resulted in the improvement of lower urinary tract symptoms and the maximum flow rate and was well tolerated in men with Parkinson's disease. The response to treatment is dependent on the severity of neurological disability.

Effective management of lower urinary tract dysfunction in idiopathic Parkinson's disease

Parkinson's disease, also known as paralysis agitans, is a progressive degenerative disorder of the central nervous system, with onset usually between the ages of 50 and 65 years, and is associated with loss of dopaminergic neurons in the subsantia nigra and the presence of Lewy bodies. It is characterized by the triad of resting tremor, muscular rigidity and bradykinesia. Often-accompanying abnormalities include disorders of equilibrium, posture and autonomic function, including micturition. Symptoms from the lower urinary tract add a significant comorbidity factor in these patients. The incidence and prevalence of lower urinary tract dysfunction rise with increasing progression of the underlying neurological disease. They present a troublesome and difficult to treat health issue with a profound impact on the patient's quality of life. Storage symptoms seem to predominate. In the long term, renal function might be compromised, mainly as a result of elevated intravesical pressure. Various conservative, minimally-invasive and surgical treatment options are available to prevent harmful sequelae, and to improve the quality of life of these patients. We present an overview of current and prospective treatment strategies.

Autonomic symptoms and dopaminergic treatment in de novo Parkinson's disease

OBJECTIVES

Autonomic symptoms are present in early stages of Parkinson's disease (PD), but evidence on how they are influenced by dopaminergic treatment remains unclear. The aim of this study was to investigate the impact of dopaminergic treatment on autonomic symptoms in early PD in a population-based cohort.

METHODS

A total of 171 drug-naive patients with PD were investigated at diagnosis and 12 months later. Orthostatic blood pressure was measured, and autonomic symptoms were assessed by a preliminary version of the Movement Disorders Society-sponsored new version of the Unified Parkinson's Disease Rating Scale (range 0-4).

RESULTS

In the 82% using dopaminergic treatment after 1 year, constipation and orthostatic blood pressure drop increased. There was a tendency towards increased orthostatic dizziness and urinary dysfunction. Dysphagia scores were reduced, and this was associated with higher levodopa-equivalent daily dose.

CONCLUSIONS

Dopaminergic treatment during the first year after initiation seems to have only a minor impact on autonomic symptoms in early PD. It may increase constipation and orthostatic dizziness, while dysphagia can improve. Autonomic symptoms remained mild after 1 year of dopaminergic treatment.

Nocturia and overnight polysomnography in Parkinson disease

AIM

Characterize clinical factors related to nocturia and sleep disruption in Parkinson disease (PD) using polysomnography (PSG).

METHODS

Sixty-three PD patients were recruited regardless of sleep or voiding complaints from a university-based movement disorders clinic for a 48 hr inpatient PSG protocol. Nocturia frequency and bother related to urinary symptoms were assessed using the International Prostate Symptom Score (IPSS) and were corroborated by measurements of PSG-defined sleep made immediately preceding and subsequent to each in-lab voiding episode. PSG measures included whole-night total sleep time (TST), sleep efficiency (SE), apnea/hypopnea index (AHI), and time to PSG-defined sleep following nocturia episodes. Differences between groups were assessed using Mantel-Haenszel chi-square, t-tests, or Wilcoxon signed rank tests. Linear regression was used to assess factors associated with reported nocturia frequency.

RESULTS

Sixty patients completed the IPSS. Thirty-seven (61%) reported at least two nocturia episodes nightly; those individuals demonstrated lower PSG-defined SE (P = 0.01) and TST (P = 0.02) than patients with 0-1 episodes. Participants reporting 2-3 episodes of nocturia with high bother on the IPSS (n = 12) demonstrated lower whole-night TST (280.5 ± 116.1 min vs. 372.5 ± 58.7 min, P = 0.03) and worse SE (59.2 ± 22.7% vs. 75.9 ± 11.2%, P = 0.04) when compared to participants with 2-3 episodes of nocturia with low bother (n = 13).

CONCLUSIONS

These results verify objectively that PD patients with nocturia have poor sleep. Furthermore, among individuals with comparable levels of reported nocturia, higher bother is associated with poorer sleep as defined on PSG. Neurourol. Urodynam. Published 2013. This article is a U.S. Government work and is in the public domain in the USA.