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

Burden of non-motor symptoms of Parkinson's disease: cost-of-illness and quality-of-life estimates through a scoping review

INTRODUCTION

Parkinson's Disease (PD) is a progressive, chronic neurodegenerative disease, representing significant economic and social burdens. It is typically defined by motor symptoms (MSs), however, this does not reflect the full patient burden. Non-motor symptoms (NMSs) are increasingly recognized as central characteristics of PD. However, they still lack recognition in research. Therefore, this study aims to identify relevant NMSs, their prevalence, and the effect they have on Quality-of-Life (QoL) and Cost-of-Illness (COI). Secondly, it aims to identify gaps in the current body of knowledge and propose possible ways future research could bridge those gaps.

METHODS

The study employed a scoping review, identifying 60 records for inclusion, using PubMed and Web of Science. It included studies from Spain or Italy, including data on People with Parkinson's Disease. A comparative analysis was performed using Microsoft Excel.

RESULTS

It showed that the body of evidence relevant to NMSs, their prevalence, QoL, and COI is limited, or that estimates vary to an extent where interpretation is difficult.

CONCLUSION

Most studies suffer from generalization, representation, and standardization issues, stemming from their designs and methodological decisions. Although the findings of this study should be interpreted with caution, several recommendations are made for future research.

Insomnia in Parkinson's Disease: Causes, Consequences, and Therapeutic Approaches

Sleep disorders represent prevalent non-motor symptoms in Parkinson's disease (PD), affecting over 90% of the PD population. Insomnia, characterized by difficulties in initiating and maintaining sleep, emerges as the most frequently reported sleep disorder in PD, with prevalence rates reported from 27 to 80% across studies. Insomnia not only significantly impacts the quality of life of PD patients but is also associated with cognitive impairment, motor disabilities, and emotional deterioration. This comprehensive review aims to delve into the mechanisms underlying insomnia in PD, including neurodegenerative changes, basal ganglia beta oscillations, and circadian rhythms, to gain insights into the neural pathways involved. Additionally, the review explores the risk factors and comorbidities associated with insomnia in PD, providing valuable insights into its management. Special attention is given to the challenges faced by healthcare providers in delivering care to PD patients and the impact of caregiving roles on patients' quality of life. Overall, this review provides a comprehensive understanding of insomnia in PD and highlights the importance of addressing this common sleep disorder in PD patients.

Insular and limbic abnormal functional connectivity in early-stage Parkinson's disease patients with autonomic dysfunction

Autonomic symptoms in Parkinson's disease result from variable involvement of the central and peripheral systems, but many aspects remain unclear. The analysis of functional connectivity has shown promising results in assessing the pathophysiology of Parkinson's disease. This study aims to investigate the association between autonomic symptoms and cortical functional connectivity in early Parkinson's disease patients using high-density EEG. 53 early Parkinson's disease patients (F/M 18/35) and 49 controls (F/M 20/29) were included. Autonomic symptoms were evaluated using the Scales for Outcomes in Parkinson's disease-Autonomic Dysfunction score. Data were recorded with a 64-channel EEG system. We analyzed cortical functional connectivity, based on weighted phase-lag index, in θ-α-β-low-γ bands. A network-based statistic was used to perform linear regression between Scales for Outcomes in Parkinson's disease-Autonomic Dysfunction score and functional connectivity in Parkinson's disease patients. We observed a positive relation between the Scales for Outcomes in Parkinson's disease-Autonomic Dysfunction score and α-functional connectivity (network τ = 2.8, P = 0.038). Regions with higher degrees were insula and limbic lobe. Moreover, we found positive correlations between the mean connectivity of this network and the gastrointestinal, cardiovascular, and thermoregulatory domains of Scales for Outcomes in Parkinson's disease-Autonomic Dysfunction. Our results revealed abnormal functional connectivity in specific areas in Parkinson's disease patients with greater autonomic symptoms. Insula and limbic areas play a significant role in the regulation of the autonomic system. Increased functional connectivity in these regions might represent the central compensatory mechanism of peripheral autonomic dysfunction in Parkinson's disease.

Recognizing Debilitating and Fatal Dysautonomia in Patients With Parkinson's Disease in the Emergency Room: A Case Report and Narrative Review

Dysautonomia impacts multiple systems leading to a spectrum of severe disorders independent of the motor symptoms in Parkinson's disease (PD). Although the motor symptoms of dyskinesia and immobility in patients with PD were traditionally considered the major reasons leading to emergency visits, the significance of non-motor symptoms, particularly dysautonomia-related disorders, have been increasingly appreciated during their emergent encounters. We present the case of an elderly patient with advanced PD who was hit by a full spectrum of dysautonomia-related disorders, had frequent emergency visits and hospital admissions over one year, and eventually died on his fifth emergency visit. His dysautonomia-related disorders included dysphagia, gastroesophageal reflux disease, neurogenic bladder, chronic constipation, and cardiac dysautonomia with orthostatic intolerance. We further review emergent presentations, assessments, and immediate management of these dysautonomia-associated disorders in patients with PD. In summary, these dysautonomia-linked comorbidities can be debilitating and sometimes fatal. As for our case, the patient was on a clinical decline majorly due to dysautonomia and nearing the end of life over the past year. A holistic approach of possible de-escalating care and palliative care might lead to a better quality of life for the patients and their families. Nevertheless, generally speaking, emergent presentations of dysautonomia symptoms in patients with PD should be recognized and treated timely and appropriately in the emergency room. Emergency clinicians need to increase awareness and make efforts to manage these acute worsening episodes of dysautonomia disorders in patients with PD to prevent debilitating and fatal complications.

Brain carbon monoxide can suppress the rat micturition reflex through brain γ-aminobutyric acid receptors

OBJECTIVES

To investigate roles of brain carbon monoxide (CO), an endogenous gasotransmitter, in regulation of the rat micturition reflex.

METHODS

In urethane-anesthetized (0.8 g/kg, ip) male rats, evaluation of urodynamic parameters was started 1 h before intracerebroventricular administration of CORM-3 (CO donor) or ZnPP (non-selective inhibitor of heme oxygenase, a CO producing enzyme) and continued for 2 h after the administration. We also investigated effects of centrally pretreated SR95531 (GABAA receptor antagonist) or SCH50911 (GABAB receptor antagonist) on the CORM-3-induced response.

RESULTS

CORM-3 significantly prolonged intercontraction intervals (ICIs) without changing maximal voiding pressure (MVP), while ZnPP significantly shortened ICI and reduced single-voided volume and bladder capacity without affecting MVP, post-voided residual volume, or voiding efficiency. The ZnPP-induced ICI shortening was reversed by CORM-3. The CORM-3-induced ICI prolongation was significantly attenuated by centrally pretreated SR95531 or SCH50911, respectively.

CONCLUSIONS

Brain CO can suppress the rat micturition reflex through brain γ-aminobutyric acid (GABA) receptors.

Prevalence of overactive bladder among overweight and obese women: A prospective cross-sectional cohort study

OBJECTIVE

To evaluate the effect of body mass index (BMI) on the prevalence of overactive bladder syndrome (OAB), severity of symptoms, and quality of life in affected patients.

METHODS

We conducted a prospective cross-sectional study of 1351 consecutive patients who were recruited between June 2021 and May 2022. Patients were divided according to BMI (normal: <25.0, overweight: 25-29.9, obese: ≥30) and menopausal status. The latter were divided according to the presence or absence of urinary incontinence in the normal, wet-OAB and dry-OAB groups. A validated questionnaire, the International Consultation on Incontinence Questionnaire in Overactive Bladder (ICIQ-OAB), in the English and Arabic languages was used.

RESULTS

A total of 1351 patients were included. For women who were overweight, there was a greater prevalence of dry-OAB (p = 0.02), However, the prevalence of both dry and wet-OAB were higher in obese women (p < 0.00001). Compared to women with a normal BMI, women who were overweight or obese had a greater likelihood of developing abnormal daytime urine frequency and nocturia, with p values ≤ 0.01. The ORs of overweight and obese women were 3.1 and 5.3, respectively, for experiencing wet OAB in comparison to women with a normal BMI. Additionally, the odds of developing severe OAB in overweight and obese women were 5.8 and 18.6, respectively, which negatively affects their quality of life (QoL).

CONCLUSION

The risk of developing OAB symptomatology is significantly greater in overweight and obese patients. As BMI increases, the symptomatology, perceived discomfort and QoL of patients with OAB worsen.

Management of lower urinary tract symptoms in Parkinsonian disorders

INTRODUCTION

The aim of the study was to present a narrative review of the literature on the management of lower urinary tract symptoms (LUTS) in patients presenting Parkinsonian disorders (PD).

MATERIAL AND METHODS

We carried out a literature search in PubMed and Embase database, without time restriction. We used keywords and free-text words around "Parkinsonian disorders" AND "lower urinary tracts symptoms" without language restriction. We focused mainly on papers less than 10 years old. We included all studies evaluating LUTS in patients with PD.

RESULTS

For the diagnostic management, authors emphasized the importance of differentiating Parkinson's disease with symptoms of bladder overactivity from multiple system atrophy with symptoms of bladder hypoactivity. Urodynamic evaluation was noted as the key element of diagnostic management. The therapeutic management proposed was symptomatic, based on functional urology techniques for the treatment of LUTS, both with drugs (especially anticholinergics) or surgery (intradetrusor injections of botulinum toxin, neuromodulation). Moreover, it was pointed out that it is always necessary to take into account the existence of a possible associated uropathy (prostate adenoma or pelvic prolapse).

CONCLUSION

Urodynamic evaluation is the cornerstone of diagnostic management of LUTS in patients with PD. Therapeutic management is above all symptomatic and must be done in a collegial way involving the urologist, neurologist, gynecologist, and physical medicine and rehabilitation physician.

[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.

Effects of a new selective β3 -adrenoceptor agonist, vibegron, on bladder and urethral function in a rat model of Parkinson's disease

OBJECTIVES

Parkinson's disease caused by the loss of dopaminergic neurons induces not only motor dysfunction but also lower urinary tract dysfunction. Patients with Parkinson's disease have recently been reported to experience both urge urinary incontinence (overactive bladder) and stress urinary incontinence, the latter of which occurs when the pressure of the bladder exceeds that of the urethra. Vibegron is a highly selective novel β3 -adrenoceptor agonist approved for the treatment of overactive bladder. However, how β3 -adrenoceptor agonists affect urethral function remains unclear. In a clinical report, the urethral function of patients with Parkinson's disease was shown to be degraded. The present study aimed to investigate the effects of vibegron on lower urinary tract activity in a rat model of Parkinson's disease.

METHODS

In a rat model of Parkinson's disease induced by unilateral 6-hydroxydopamine injection into the substantia nigra pars compacta, we examined the effects of vibegron on bladder and urethral activity.

RESULTS

Cystometric analysis revealed that, compared with vehicle injection, intravenous injection of 3 mg/kg vibegron significantly increased the inter-contraction interval (p < .05) and reduced voiding pressure (p < .01). However, no significant effects on urethral function were observed.

CONCLUSIONS

The results of the present study provide corroborating evidence that bladder dysfunction is suppressed by the administration of vibegron in Parkinson's disease model rats, confirming that vibegron is effective for treating overactive bladder without further worsening urethral function. These findings may contribute to a better understanding of the mechanisms of β3 -adrenoceptor agonists.

The Impact of Polypharmacy on Management of Lower Urinary Tract Symptoms in Parkinson's Disease

Lower urinary tract (LUT) symptoms are a common presentation of autonomic dysfunction in Parkinson's disease (PD). Symptoms significantly impact quality of life and are associated with worsening of motor symptoms and increased risk for falls. Different medical co-morbidities can often contribute to LUT symptoms, and a thorough evaluation therefore becomes essential. The effects of medications used for Parkinson's disease and other co-existing medical co-morbidities on LUT symptoms is often underestimated. Treatment options include behavioural therapy, oral agents such as antimuscarinic and beta-3 receptor agonist agents, botulinum toxin and neuromodulation. The first-line oral agents cause adverse effects that may exacerbate pre-existing Parkinson's disease-related symptoms. Furthermore, these oral agents can interact with other medications used in Parkinson's disease, and the challenges posed by interactions on pharmacological effects and metabolism are discussed. Knowledge about drug interactions can help in effective management of such patients and mitigate the risks for developing adverse effects.

Voiding Dysfunction Due to Urethral Sphincter Dysfunction Might Be an Early Neurological Presentation of Central Nervous System Disorders in Aged Patients

PURPOSE

To investigate the incidence of central nervous system (CNS) diseases in adult patients with voiding dysfunction and videourodynamics (VUDS) proven urethral sphincter dysfunction.

METHODS

This retrospective analysis reviewed the medical charts of patients aged > 60 years who underwent VUDS for non-prostatic voiding dysfunction from 2006 to 2021. A chart review was performed to search for the occurrence and treatment of CNS diseases after the VUDS examination up to 2022. The diagnosis of CNS disease, such as cerebrovascular accidents (CVA), Parkinson's disease (PD), and dementia, by neurologists was also retrieved from the charts. Based on the VUDS findings, patients were divided into the following subgroups: dysfunctional voiding (DV), poor relaxation of the external sphincter (PRES), and hypersensitive bladder (HSB) and coordinated sphincter subgroups. The incidence of CVA, PD, and dementia in each subgroup was recorded and compared among them using one-way analysis of variance (ANOVA).

RESULTS

A total of 306 patients were included. VUDS examinations revealed DV in 87 patients, PRES in 108, and HSB in 111. Among them, 36 (11.8%) patients had CNS disease, including CVA in 23 (7.5%), PD in 4 (1.3%), and dementia in 9 (2.9%). Among the three subgroups, the DV group had the highest incidence rate of CNS disease (n = 16, 18.4%), followed by PRES (n = 12, 11.1%) and HSB (n = 8, 7.2%). However, no significant difference was noted in the incidence of CNS disease across the three subgroups. Nevertheless, the incidence of CNS disease was higher in patients with DV and PRES than that in the general population.

CONCLUSIONS

The incidence of CNS diseases was high in patients aged > 60 years with voiding dysfunction due to urethral sphincter dysfunction. Patients with VUDS-confirmed DV had the highest incidence of CNS disease among the three subgroups.

Role of Urological Botulinum Toxin-A Injection for Overactive Bladder and Voiding Dysfunction in Patients with Parkinson's Disease or Post-Stroke

Botulinum toxin A (BoNT-A) paralyzes muscle by blocking acetylcholine release at the synaptic junction. BoNT-A has shown its therapeutic effects in neurological disorders such as Parkinson's disease (PD) and post-stroke spasticity. A high proportion of patients with PD and post-stroke develop neurogenic detrusor overactivity (nDO) and then develop urinary incontinence and overactive bladder (OAB) symptoms. This study aimed to disclose the safety and efficacy of BoNT-A injection in treating bladder and voiding dysfunction in PD and post-stroke patients by reviewing the current evidence. At present, intradetrusor injection of BoNT-A is a Food and Drug Administration (FDA)-approved third-line therapy for nDO and idiopathic OAB. Although intradetrusor injection of onaBoNT-A 200 U is already approved for nDO treatment, most researchers would like to manage PD and post-stroke patients by using onaBoNT-A 100 U intradetrusor injection to achieve long-term efficacy and reduce adverse effects. However, in contrast to its inclusion in the International Continence Society guidelines for PD treatment, the clinical use of BoNT-A for post-stroke patients is limited to experimental use due to the development of urinary retention in about one-fifth of patients. For treating urethral pseudodyssynergia, half of patients may respond to onaBoNT-A 100 U urethral injection. However, refinement is needed to reduce unwanted urinary incontinence.

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.

Surgical outcome of male patients with chronic central nervous system disorders and voiding dysfunction due to bladder outlet obstruction

PURPOSE

Voiding dysfunction is common in patients with chronic central nervous system (CNS) diseases and has great impact on quality of life. Patients with chronic CNS disorders might have concomitant detrusor overactivity, detrusor underactivity, and voiding dysfunction. Although bladder outlet surgeries could relieve bladder outlet obstruction (BOO), patients might have persistent or exacerbated storage symptoms. This study investigated surgical outcome of patients with chronic CNS disorders after bladder outlet surgery.

METHODS

A total of 63 male patients with cerebrovascular accident (CVA, n = 44), Parkinson's disease (PD, n = 11), and early-stage dementia (n = 8), had received bladder outlet surgery after videourodynamic proven BOO refractory to medical treatment. The preoperative and postoperative lower urinary tract symptoms (LUTS) and uroflowmetry parameters were assessed. If the storage symptom subscore decreased or increased by 1, the outcome was considered improved or exacerbated after treatment. When patients had improvement in maximum flow rate (Qmax) and voiding efficiency (VE) and decreased voiding symptom subscore, they were considered having improvement of voiding dysfunction.

RESULTS

The mean age was 71.1 ± 9.8 years and mean duration from diagnosis of BOO to surgical intervention was 15.1 ± 25.0 months. Overall, there was significant improvement in voiding LUTS and urinary retention after surgery. The post-void residual volume (PVR), corrected Qmax (cQmax), and VE significantly improved after surgery. In subgroup analysis, although voiding symptoms improved in CVA patients, urgency and exacerbated urgency incontinence persisted after surgery. In PD patients, there was improvement in voiding condition such as PVR, cQmax and VE, but the storage symptoms did not change after surgery. Patients with dementia had no improvement both in storage and voiding symptoms.

CONCLUSIONS

Bladder outlet surgeries are effective to relieve voiding dysfunction in patients with CVA and PD, but have little effect on storage LUTS in patients with chronic brain lesions.

Stimulation of the tibial nerve-a randomised trial for urinary problems associated with Parkinson's-the STARTUP trial

BACKGROUND

non-motor symptoms such as bladder dysfunction are common (80%) in people with Parkinson's increasing the risk for falls with a negative impact on health-related costs and quality of life.We undertook STARTUP to evaluate the clinical and cost-effectiveness of using an adhesive electrode to stimulate the transcutaneous tibial nerve stimulation (TTNS) to treat bladder dysfunction in people with Parkinson's disease (PD).Study design, materials and methods: STARTUP was a parallel two-arm, multi-centre, pragmatic, double-blind, randomised controlled trial. Each participant attended one clinic visit to complete consent, be randomised using a computer-generated system and to be shown how to use the device.The trial had two co-primary outcome measures: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the International Prostate Symptom Score (IPSS). These were completed at baseline, 6 and 12 weeks. A bladder frequency chart and resource questionnaire were also completed.

RESULTS

two hundred forty two participants were randomised. About 59% of participants were male, the mean age was 69 years and mean time since diagnosis was 6 years. Questionnaire return rate was between 79 and 90%.There was a statistically significantly lower score in the active group at 6 weeks in the IPSS questionnaire (mean difference (Standard deviation, SD) 12.5 (6.5) vs 10.9 (5.5), effect size -1.49, 95% CI -2.72, -0.25). There was no statistically significant change in any other outcome.

CONCLUSION

TTNS was demonstrated to be safe with a high level of compliance. There was a significant change in one of the co-primary outcome measures at the end of the treatment period (i.e. 6 weeks), which could indicate a benefit. Further fully powered RCTs are required to determine effective treatments.

Constipation Symptoms in Multiple System Atrophy Using Rome Criteria and Their Impact on Personalized Medicine

Constipation is one of the most common non-motor symptoms in multiple system atrophy (MSA); however, it has not been evaluated according to the standard diagnostic criteria for constipation in patients with MSA. We evaluated the characteristics of constipation in patients with MSA by using Rome criteria (Rome III), which has been validated and the widely used for gastrointestinal disorders. Fifty-one patients with MSA (29 female) were enrolled in the study. Based on the Rome III criteria, constipation was diagnosed in 29 patients (56.9%); irritable bowel syndrome was not detected. Thirty-seven patients (72.5%) were aware of their constipation. The most common constipation symptom was the sensation of anorectal obstruction (68.6%). Patients’ self-awareness of constipation was most strongly correlated to the sensation of incomplete evacuation (odds ratio: 7.377, 95% confidence interval: 1.402−38.817). The number of constipation-related symptoms was correlated with the total levodopa equivalent dose (p < 0.05). Rome criteria, which can detect various constipation symptoms, are useful for evaluating constipation in MSA, and these findings may greatly impact personalized medicine.

Perspectives on the urological care in Parkinson's disease patients

Parkinson's disease (PD) is recognized as the most common neurodegenerative disorder after Alzheimer's disease. Lower urinary tract symptoms are common in patients with PD, either storage symptoms (overactive bladder symptoms or OAB) or voiding symptoms. The most important diagnostic clues for urinary disturbances are provided by the patient's medical history. Urodynamic evaluation allows the determination of the underlying bladder disorder and may help in the treatment selection. Pharmacologic interventions especially anticholinergic medications are the first-line option for treating OAB in patients with PD. However, it is important to balance the therapeutic benefits of these drugs with their potential adverse effects. Intra-detrusor Botulinum toxin injections, electrical stimulation were also used to treat OAB in those patients with variable efficacy. Mirabegron is a β3-agonist that can also be used for OAB with superior tolerability to anticholinergics. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Deep brain stimulation (DBS) surgery is effective in improving urinary functions in PD patients. Sexual dysfunction is also common in PD. Phosphodiesterase type 5 inhibitors are first-line therapies for PD-associated erectile dysfunction (ED). Treatment with apomorphine sublingually is another therapeutic option for PD patients with ED. Pathologic hypersexuality has occasionally been reported in patients with PD, linked to dopaminergic agonists. The first step of treatment of hypersexuality consists of reducing the dose of dopaminergic medication. This review summarizes the epidemiology, pathogenesis, risk factors, genetic, clinical manifestations, diagnostic test, and management of PD. Lastly, the urologic outcomes and therapies are reviewed.

Is sacral neuromodulation effective in patients with Parkinson's disease? A retrospective review

INTRODUCTION AND OBJECTIVE

Parkinson's disease (PD) is the second-most common degenerative neurologic disease worldwide. Overactive bladder (OAB) is prevalent in this population but can be challenging to treat. Sacral neuromodulation (SNM) is an attractive option but remains understudied. We have utilized SNM in PD patients and herein describe our outcomes.

METHODS

We performed a retrospective chart review of PD patients who underwent peripheral nerve evaluation (PNE) or Stage 1 SNM from 2000 to 2020. The primary outcome was progression to a permanent implant. The impact of PD stage and preprocedural urodynamic (UDS) parameters on test-phase outcome were investigated. Long-term efficacy was assessed using Wilcoxon matched-pairs test looking at a change in urinary symptoms (frequency, nocturia, incontinence episodes, and pad use) documented at follow-up visits and further need for treatment.

RESULTS

Thirty-four patients underwent test phase SNM (7 PNE and 27 Stage 1). Median follow-up was 11 (interquartile range 5.8-29.8) months. Indications included refractory OAB (30/34) and nonobstructive urinary retention (4/34). Overall, 82% (28/34) of patients proceeded to a permanent implant. 71% (5/7) of PNEs were successful. Test-phase success did not differ based on PD disease severity or UDS parameters. In patients with OAB/urgency incontinence who progressed to the permanent implant, there was a statistically significant improvement in their urinary symptoms from baseline. Most (68%) patients were able to discontinue OAB medications post-implant. The overall lead revision rate was 14% (4/28) and 3 devices required removal.

CONCLUSIONS

SNM is an efficacious treatment option for PD patients with a high percentage of patients having improvement in their urinary symptoms.

New approaches to treatments for sleep, pain and autonomic failure in Parkinson's disease - Pharmacological therapies

Non-motor symptoms (NMSs) are highly prevalent throughout the course of Parkinson's disease (PD). Pain, autonomic dysfunction and sleep disturbances remain at the forefront of the most common NMSs; their treatment is challenging and their effect on the quality of life of both patients and caregivers detrimental. Yet, the landscape of clinical trials in PD is still dominated by therapeutic strategies seeking to ameliorate motor symptoms; subsequently, effective strategies to successfully treat NMSs remain a huge unmet need. Wider awareness among industry and researchers is thus essential to give rise to development and delivery of high-quality, large-scale clinical trials in enriched populations of patients with PD-related pain, autonomic dysfunction and sleep. In this review, we discuss recent developments in the field of pharmacological treatment strategies designed or re-purposed to target three key NMSs: pain, autonomic dysfunction and sleep disturbances. We focus on emerging evidence from recent clinical trials and outline some exciting and intriguing findings that call for further investigations.

Treatment of Advanced Parkinson's Disease

Advanced Parkinson's disease (PD) often brings a set of motor and non-motor features that are particularly challenging to manage. Medication options can be limited by side-effects and quality of life can be severely affected by an accumulating burden of nonmotor symptoms. Here, we reviewed the literature and our clinical experience with the aim of providing a practical approach to the management of advanced PD. We provide guidelines for treatment of physical and neurobehavioral concerns, that occur in advanced PD.

The safety and effectiveness of mirabegron in Parkinson's disease patients with overactive bladder: a randomized controlled trial

PURPOSE

To assess the safety and effectiveness of mirabegron in patients with PD complaining of overactive bladder (OAB).

PATIENTS AND METHODS

From January 2017 to November 2020, we performed a prospective randomized, double-blind, placebo-controlled trial that enrolled PD patients with symptoms of OAB. The total duration of the study was 13 weeks, comprising a 1-week screening period and a 12-week treatment period. A total of 110 patients were randomized in one of two groups: treatment group (mirabegron 50 mg) or placebo group. The primary outcomes of our study were the change from baseline in OAB symptom score (OABSS) and the overactive bladder questionnaire short form (OAB-q SF) score. The secondary outcomes were the change from baseline in the mean number of micturitions/24 hours, the mean number of urgency episodes/24 hours, the mean number of urgency incontinence episodes/24 hours and the mean number of nocturia episodes/night, volume voided/micturition (ml) as recorded on a 3-day bladder diary. Safety assessments included adverse events, electrocardiogram, QT corrected for heart rate using Fridericia's correction (QTcF) interval and blood pressure and pulse rate measurements.

RESULTS

There was a significant improvement in the primary outcome and secondary outcome measures in the treatment group compared to the placebo group. Adverse events were mild and the same in the two groups. The cardiovascular safety profile was high. This study is limited by its sample size and its short follow-up period.

CONCLUSIONS

Mirabegron is a promising drug to control OAB symptoms in patients with PD with an excellent safety profile.

Urodynamic Evaluation in Multiple System Atrophy: A Retrospective Cohort Study

Background

Urological dysfunction in patients with multiple system atrophy (MSA) is one of the main manifestations of autonomic failure. Urodynamic examination is clinically relevant since underlying pathophysiology of lower urinary tract (LUT) dysfunction can be variable.

Objective

Evaluation of the pathophysiology of urological symptoms and exploration of differences in urodynamic patterns of LUT dysfunction between MSA-P and MSA-C.

Methods

Retrospective study of patients with possible and probable MSA who were referred for urodynamic studies between 2004 and 2019. Demographic data, medical history, physical examination and urodynamic studies assessing storage and voiding dysfunction were obtained.

Results

Seventy-four patients were included in this study (MSA-P 64.9% n = 48; median age 62.5 (IQR 56.8-70) years). Detrusor overactivity during filling phase was noted in 58.1% (n = 43) of the patients. In the voiding phase, detrusor sphincter dyssynergia and detrusor underactivity were observed in 24.6% (n = 17) and in 62.1% (n = 41) of the patients, respectively. A postmicturition residual volume of over 100 ml was present in 71.4% (n = 50) of the patients. Comparison of MSA subtypes showed weaker detrusor contractility in MSA-P compared to MSA-C [pdetQmax 26.2 vs. 34.4 cmH20, P = 0.04]. In 56.2% (n = 41) of patients pathophysiology of LUT dysfunction was deemed to be neurogenic and consistent with the diagnosis of MSA. In 35.6% (n = 26) urodynamic pattern suggested other urological co-morbidities.

Conclusion

Urodynamic evaluation is an important tool to analyze the pattern of LUT dysfunction in MSA. Impaired detrusor contractility was seen more in MSA-P which needs to be investigated in further studies.

Early recognition and diagnosis of multiple system atrophy: best practice and emerging concepts

Introduction: Multiple system atrophy (MSA) is a progressive degenerative disorder of the central and autonomic nervous systems characterized by parkinsonism, cerebellar ataxia, dysautonomia, and pyramidal signs. The confirmatory diagnosis is pathological, but clinical-diagnostic criteria have been developed to help clinicians. To date, the early diagnosis of MSA is challenging due to the lack of reliable diagnostic biomarkers.Areas covered: The authors reappraised the main clinical, neurophysiological, imaging, genetic, and laboratory evidence to help in the early diagnosis of MSA in the clinical and in the research settings. They also addressed the practical clinical issues in the differential diagnosis between MSA and other parkinsonian and cerebellar syndromes. Finally, the authors summarized the unmet needs in the early diagnosis of MSA and proposed the next steps for future research efforts in this field.Expert opinion: In the last decade, many advances have been achieved to help the correct MSA diagnosis since early stages. In the next future, the early diagnosis and correct classification of MSA, together with a better knowledge of the causative mechanisms of the disease, will hopefully allow the identification of suitable candidates to enroll in clinical trials and select the most appropriate disease-modifying strategies to slow down disease progression.

Lower urinary tract dysfunction in Parkinsonian syndromes

PURPOSE OF REVIEW

The aim of this review is to outline the clinical presentation, pathophysiology and evaluation of lower urinary tract (LUT) dysfunction in Parkinson's disease and other parkinsonian syndromes including multiple system atrophy, dementia with Lewy bodies, progressive supranuclear palsy and corticobasal degeneration.

RECENT FINDINGS

LUT dysfunction commonly occurs in neurological disorders, including patients with parkinsonian syndromes. The pattern of LUT dysfunction and its severity are variable, depending upon the site of lesion within the neural pathways. Parkinsonian syndromes are broadly divided into Parkinson's disease (PD) and a typical parkinsonian syndromes such as multiple system atrophy (MSA), dementia with Lewy bodies (DLB), progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD). Different parkinsonian syndromes have distinct clinical features (e.g. dysautonomia, early dementia, supranuclear gaze palsy, higher cortical signs), and the pattern of LUT dysfunction and its severity can differ.

CONCLUSIONS

LUT dysfunction is a common feature in patients with parkinsonian syndromes. Recognising the pattern of LUT dysfunction during the assessment of these patients can help management and possibly facilitate an earlier diagnosis.

Recent advances in understanding hereditary spastic paraplegias and emerging therapies

Hereditary spastic paraplegias (HSPs) are a group of rare, inherited, neurological diseases characterized by broad clinical and genetic heterogeneity. Lower-limb spasticity with first motoneuron involvement is the core symptom of all HSPs. As spasticity is a syndrome and not a disease, it develops on top of other neurological signs (ataxia, dystonia, and parkinsonism). Indeed, the definition of genes responsible for HSPs goes beyond the 79 identified SPG genes. In order to avoid making a catalog of the different genes involved in HSP in any way, we have chosen to focus on the HSP with cerebellar ataxias since this is a frequent association described for several genes. This overlap leads to an intermediary group of spastic ataxias which is actively genetically and clinically studied. The most striking example is SPG7, which is responsible for HSP or cerebellar ataxia or both. There are no specific therapies against HSPs, and there is a dearth of randomized trials in patients with HSP, especially on spasticity when it likely results from other mechanisms. Thus far, no gene-specific therapy has been developed for HSP, but emerging therapies in animal models and neurons derived from induced pluripotent stem cells are potential treatments for patients.

Does Depression Contribute to the Bladder and Bowel Complaint in Parkinson's Disease Patients?

Background

The question of whether depression contributes to the bladder and bowel complaint in Parkinson's disease (PD) has not been addressed.

Objectives

We studied bladder, bowel and sexual symptoms in PD patients with/without depression.

Methods

We had 267 referred PD patients: age 68.3 ± 7.7 years, 150 men, 117 women. We divided them into those with/without depression and performed the pelvic function questionnaires including bladder, bowel and sexual items; for example, OABSS, IPSS, and a pelvic organ questionnaire).

Results

The patient age, sex ratio, disease duration, Hoehn-Yahr motor grade, and cognitive score were not significantly different between the PD with depression (n = 35, 13.1%) and PD without depression (n = 232, 86.9%) groups. Regarding bladder, bowel and sexual complaints, significant difference was noted in constipation (P = 0.000854) and sensation of residual urine (P = 0.04820) items.

Conclusions

Our PD patients with depression showed significantly more common constipation and sensation of residual urine compared to the patients with PD alone, suggesting that depression contributes to the bladder and bowel complaint in PD patients.

Mirabegron for treatment of overactive bladder symptoms in patients with Parkinson's disease: A double-blind, randomized placebo-controlled trial (Parkinson's Disease Overactive bladder Mirabegron, PaDoMi Study)

AIMS

This study aimed to investigate the efficacy and safety of mirabegron for Parkinsonism patients with overactive bladder (OAB) symptoms in a randomized, placebo-controlled, multicenter study.

MATERIALS AND METHODS

Inclusion criteria are Parkinsonism with OAB symptoms for 4 weeks or more, OAB symptom score (OABSS) questionnaire scores greater than 2, and OABSS urgency question scores greater than 1. After a 2-week wash-out period, the patients were randomized into placebo and mirabegron groups at visit 2. Visit 3 was performed after 4 weeks of medication. Mirabegron was prescribed to the two groups for the rest of the study period at visit 4.

RESULT

The mean age was 68.1 ± 8.1 years and 72 males and 64 females were included. A total of 136 patients were screened, 117 patients were randomized, and 25 patients dropped out. The OABSS scores were significantly different between the two groups at Weeks 4 and 8. The OABSS scores became the same in the two groups at Week 12 (visit 5). The postvoid residual urine volume showed a mild increase to 64 ml in the mirabegron group compared to the placebo group at visit 4. Adverse events occurred in 27 patients (23.1%). The degree was mild in 26 cases (78.8%), moderate in five (15.2%), and severe in two (6.1%). Only 13 cases (39.4%) showed medication-related adverse events. Acute urinary retention occurred in a single case. The treatment satisfaction questionnaires showed no significant differences between the two groups.

CONCLUSION

Mirabegron was effective in treating OAB symptoms in patients with Parkinsonism with acceptable adverse events.

Effect of Deep Brain Stimulation on Female Parkinsonian Patients with Lower Urinary Tract Symptoms

PURPOSE

This study aimed to investigate the characteristics of urodynamics in female parkinsonian patients with lower urinary tract symptoms (LUTS) and evaluate the outcomes of deep brain stimulation (DBS) based on overactive bladder (OAB) scores and quality of life (QOL) scores.

PATIENTS AND METHODS

Urodynamic assessment was performed in 20 female parkinsonian patients with LUTS. OAB scores and QOL scores were collected before and 6 months after DBS treatment (The target of DBS is STN). We evaluated the related factors affecting QOL score and also the changes in QOL score after DBS treatment.

RESULTS

The mean age of 20 patients was 60.6±6.3 years, with 65% of patients identified with OAB in urodynamic studies. The mean OAB total score and QOL score at baseline were 7.3±3.7 and 5.0±1.1, respectively. Four items in the OAB score were found to be independent factors and they influenced the baseline QOL scores. Six months after DBS treatment, the OAB total score and the QOL score were significantly decreased (3.7±3.2 (p = 0.002) and 3.4±1.4 (p < 0.001), respectively). Improvements in OAB item 2 (nocturia) and item 3 (urgency) scores were found to be independent factors, which had an influence on the improvement in QOL scores from multivariate analysis. Improvement of OAB item 2 (nocturia) exhibited the greatest influence on improvement in the QOL score. After DBS treatment, 40% of the patients showed significant improvement in urination symptoms (≥2 points reduction in QOL score), 30% of the patients showed mild improvement (1 point reduction in QOL score), and 30% patients showed no improvement (no change in QOL score). No patients exhibited worsening urination symptoms.

CONCLUSION

Most parkinsonian female patients with lower urinary tract symptoms were diagnosed with OAB. DBS treatment improved OAB symptoms. Improvement of nocturia and urgency positively impacts the QOL of female parkinsonian patients.

The Role of Pelvic Neurophysiology Testing in the Assessment of Patients with Voiding Dysfunction

Purpose of Review

The role of pelvic neurophysiology testing in the evaluation of patients with lower urinary tract (LUT) symptoms is explored in this review.

Recent Findings

Different neurophysiology tests such as sphincter EMG and pudendal somatosensory evoked potentials are useful in evaluating the sacral somatic afferent and efferent innervation. S2 and S3 dermatomal evoked potentials assess individual sacral roots and are feasible to perform using standard neurophysiology machines.

Summary

The innervation of the LUT has a substantial contribution from splanchnic and somatic nerves arising from the sacral segments. Pelvic neurophysiology tests, which assess somatic nerve functions, are therefore a useful tool in assessing sacral nerve functions in patients presenting with unexplained voiding dysfunction. In this review, the commonly performed neurophysiology studies that assess the S2, S3 and S4 sacral afferent and efferent pathways are outlined, and their clinical applications reviewed.

Urinary incontinence associated with anxiety and depression: the impact of psychotropic drugs in a cross-sectional study from the Norwegian HUNT study

BACKGROUND

Anxiety and depression are in both cross-sectional and longitudinal studies associated with urinary incontinence (UI) in women, strongest for the urgency component of UI. The role of psychotropic drugs in this association, especially antidepressants, has been questioned, but not clarified. The present study aimed to explore the associations between UI and anxiety/depression and the possible impact of psychotropic drugs on these associations.

METHODS

We conducted a cross-sectional, population-based study with questionnaire data from 21,803 women ≥20 years in the Norwegian Nord-Trøndelag Health Study merged with the Norwegian Prescription Database, which contains information on all dispensed prescriptions. We used multivariate logistic regression to investigate the association between UI (any UI, and by type and severity) and anxiety/depression (by different score on Hospital anxiety and depression scale), and the influence of psychotropic drugs on this association (by different volume of drug use).

RESULTS

Compared with normal anxiety- and depression score, having moderate/severe anxiety or depression (HADS≥11) increased the prevalence of UI from 27.6 to 37.8% (OR 1.59 (1.40-1.81), p < 0.001) for anxiety and from 28.0 to 43.7% (OR 1.79 (1.46-2.21), p < 0.001) for depression. According to type of UI, mixed UI was most strongly associated with a high HADS-score with an odds ratio 1.84 (1.65-2.05) for anxiety and 1.85 (1.61-2.13) for depression. Compared to no UI, severe UI was associated with depression with odds ratios of 2.04 (1.74-2.40), compared with no UI. Psychotropic drug use did not influence the associations between UI and anxiety/depression. We found high prevalence of UI among users of various psychotropic drugs. After adjustments, only antidepressants were associated with UI, with OR 1.36 (1.08-1.71) for high defined daily dose of the drug. Anxiolytics were associated with less UI with OR 0.64 (0.45-0.91) after adjustments for anxiety.

CONCLUSION

This study showed that anxiety, depression and use of antidepressants are associated factors with UI, strongest for urgency and mixed type of UI, with increasing ORs by increasing severity of the conditions and increased daily dose of the medication. Use of antidepressants did not influence the associations between UI and anxiety/depression.

Neurogenic Bladder: Epidemiology, Diagnosis, and Management

Lower urinary tract dysfunction is a common sequel of neurological disease resulting in symptoms that significantly impacts quality of life. The site of the neurological lesion and its nature influence the pattern of dysfunction. The risk for developing upper urinary tract damage and renal failure is considerably lower in patients with slowly progressive nontraumatic neurological disorders, compared with those with spinal cord injury or spina bifida. This acknowledged difference in morbidity is considered when developing appropriate management algorithms. The preliminary evaluation consists of history taking, and a bladder diary and may be supplemented by tests such as uroflowmetry, post-void residual measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the clinical indications. Incomplete bladder emptying is most often managed by intermittent catheterization, and storage dysfunction is managed by antimuscarinic medications. Intra-detrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. In select patients, reconstructive urological surgery may become necessary. An individualized, patient-tailored approach is required for the management of lower urinary tract dysfunction in this special population.

Autonomic Dysfunction in Parkinson's Disease

Recognition of the importance of nonmotor dysfunction as a component of Parkinson's disease has exploded over the past three decades. Autonomic dysfunction is a frequent and particularly important nonmotor feature because of the broad clinical spectrum it covers. Cardiovascular, gastrointestinal, urinary, sexual, and thermoregulatory abnormalities all can appear in the setting of Parkinson's disease. Cardiovascular dysfunction is characterized most prominently by orthostatic hypotension. Gastrointestinal dysfunction can involve virtually all levels of the gastrointestinal tract. Urinary dysfunction can entail either too frequent voiding or difficulty voiding. Sexual dysfunction is frequent and frustrating for both patient and partner. Alterations in sweating and body temperature are not widely recognized but often are present. Autonomic dysfunction can significantly and deleteriously impact quality of life for individuals with Parkinson's disease. Because effective treatment for many aspects of autonomic dysfunction is available, it is vitally important that assessment of autonomic dysfunction be a regular component of the neurologic history and exam and that appropriate treatment be initiated and maintained.

Sleep Issues in Parkinson's Disease and Their Management

Parkinson's disease (PD) is an alpha-synucleinopathy that leads to prominent motor symptoms including tremor, bradykinesia, and postural instability. Nonmotor symptoms including autonomic, neurocognitive, psychiatric symptoms, and sleep disturbances are also seen frequently in PD. The impact of PD on sleep is related to motor and nonmotor symptoms, in addition to the disruption of the pathways regulating sleep by central nervous system pathology. Rapid eye movement sleep behavior disorder is a parasomnia that can lead to self-injury and/or injury to partners at night. Restless legs syndrome is a subjective sensation of discomfort and urge to move the legs prior to falling asleep and can lead to insomnia and reduced sleep quality. Excessive daytime sleepiness is common in PD and exerts a negative impact on quality of life in addition to increasing the risk of falls. Obstructive sleep apnea is a breathing disorder during sleep that can cause frequent awakenings and excessive daytime sleepiness. Circadian rhythm dysfunction can lead to an advanced or delayed onset of sleep in patients and create disruption of normal sleep and wake times. All of these disorders are common in PD and can significantly reduce sleep quantity, sleep quality, or quality of life for patients and caretakers. Treatment approaches for each of these disorders are distinct and should be individualized to the patient. We review the literature regarding these common sleep issues encountered in PD and their treatment options.

A Pragmatic Approach to the Perioperative Management of Parkinson's Disease

Patients with Parkinson's disease (PD) may undergo several elective and emergency surgeries. Motor fluctuations, the presence of a wide range of non-motor symptoms (NMS), and the use of several medications, often not limited to dopaminergic agents, make the perioperative management of PD challenging. However, the literature on perioperative management of PD is sparse. In this descriptive review article, we comprehensively discuss the issues in the pre-, intra-, and postoperative phases which may negatively affect the PD patients and discuss the approach to their prevention and management. The major preoperative challenges include accurate medication reconciliation and administration of the dopaminergic medications during the nil per os (NPO) state. While the former can be addressed with staff education and PD-specific admission protocols, knowledge of non-oral formulations of dopaminergic agents (apomorphine, inhalational levodopa, and rotigotine transdermal patch) is the key to the management of the Parkinsonian symptoms in NPO state. Deep brain stimulation (DBS) devices should be turned off to avert potential electromagnetic interference with surgical appliances. Choosing the appropriate anesthesia and avoiding and managing respiratory issues and dysautonomia are the major intraoperative challenges. Timely reinitiation of dopaminergic medications, adequate management of pain, nausea, and vomiting, and prevention of postoperative infections and delirium are the postoperative challenges. Overall, a multidisciplinary approach is pivotal to prevent and manage the perioperative complications in PD. Administration of anti-Parkinson medications during NPO state, prevention of anesthesia-related complications, and timely rehabilitation remain the key to healthy surgical outcomes.

Subthalamic Stimulation Inhibits Bladder Contraction by Modulating the Local Field Potential and Catecholamine Level of the Medial Prefrontal Cortex

Aims

The patients with Parkinson’s disease (PD) present with lower urinary tract symptoms (LUTS), but the efficacy of subthalamic nucleus deep brain stimulation (STN-DBS) on LUTS is unknown. The medial prefrontal cortex (mPFC) is a known higher micturition center which are modulated by STN-DBS. We aim to clarify STN-DBS-related changes in the neuronal activity of the mPFC in terms of bladder contraction, using normal and PD rats.

Methods

Experiments in normal and 6-hydroxydopamine hemi-lesioned PD rats were conducted under urethane anesthesia. STN-DBS was applied to the left STN, with simultaneous monitoring of bladder contractions. The mPFC’s local field potential (LFP) was recorded before, during, and after STN-DBS (n = 6: normal rats, n = 6: PD rats). Before, during and after STN-DBS (n = 5: normal rats, n = 6: PD rats), extracellular fluid was collected from mPFC.

Results

STN-DBS significantly increased bladder inter-contraction interval. STN-DBS significantly decreased mPFC alpha power in normal rat and increased alpha power in PD rat. The mPFC levels of levodopa, dopamine, serotonin and their metabolites in PD rats decreased significantly during and after STN-DBS, whereas the serotonin and its metabolites and homovanillic acid (HVA) levels decreased significantly in normal rats following STN-DBS.

Conclusion

STN-DBS increased intercontraction intervals for the bladder in both normal and PD rats, as assessed by alpha power and catecholamine levels in mPFC, probably due to changes in neural activity. The effect of STN-DBS on mPFC levels of catecholamine differentiated between the normal and PD rats.

Urodynamic Assessment of Neuronal Intranuclear Inclusion Disease

Neuronal intranuclear inclusion disease (NIID) is a disease that causes leukoencephalopathy (dementia) and peripheral neuropathy (variable manifestation including bladder dysfunction). This is the first urodynamic report to show that bladder dysfunction in NIID is a combination of detrusor overactivity, decreased bladder sensation, large post-void residual, and neurogenic changes in the sphincter electromyogram. This report will help managing bladder dysfunction in NIID.

Relations of clinical symptoms with dopamine transporter imaging in drug-naïve Parkinson's disease

OBJECTIVES

The aim of the present study was to determine the relations of clinical symptoms with nigrostriatal neuron loss in drug-naïve patients with Parkinson's disease (PD). We examined the severity of motor symptoms and freezing of gait (FOG), falls and overactive bladder (OAB) in PD patients and their relations with striatal dopamine transporter (DAT) binding.

PATIENTS AND METHODS

Thirty-two untreated PD patients (14 men and 18 women with a mean age of 71.4 ± 7.2 years) were included in this study. Clinical assessments were performed by using Unified Parkinson's Disease Rating Scale (UPDRS) and overactive bladder symptom score (OABSS), and striatal dopamine transporter (DAT) binding was measured by¹²³I-FP-CIT SPECT.

RESULTS

The results showed that striatal DAT availability was significantly lower in the high UPDRS motor score group, high akinetic-rigid score group, FOG group, and OAB group than in the low UPDRS motor score group, low akinetic-rigid score group, non-FOG group, and non-OAB group. However, the results also showed that there was no significant difference in striatal DAT availability between the high tremor score group and low tremor score group or between the faller group and non-faller group.

CONCLUSIONS

The severity of bradykinesia and axial symptoms and the existence of FOG and OAB in untreated PD patients are related to a decrease in striatal DAT availability. Severity of tremors and occurrence of falls are not related to a decrease in striatal DAT availability. The mechanisms underlying the clinical symptoms of PD involve not only dopaminergic pathways but also non-dopaminergic pathways.

Lower urinary tract dysfunction in common neurological diseases

The lower urinary tract has the main function of urine storage and voiding. The integrity of the lower urinary tract nerve supply is necessary for its proper function. Neurological disorders can lead to lower urinary tract dysfunction (LUTD) and cause lower urinary tract symptoms (LUTS). Common causes of neurogenic LUTS or LUTD include spinal cord injury, multiple sclerosis, Parkinson's disease, cerebrovascular accidents, cauda equina syndrome, diabetes mellitus, and multiple system atrophy. The pathophysiology is categorized according to the nature of the onset of neurological disease. Assessment requires clinical evaluation, laboratory tests, imaging, and urodynamic studies. Impaired voiding is most often managed by clean intermittent self-catheterization if the postvoid residual urine exceeds 100 ml, whereas storage symptoms are most often managed by antimuscarinic medications. Intradetrusor injection of botulinum toxin type A is emerging as an effective treatment for managing refractory neurogenic detrusor overactivity. This review provides an overview of the clinical characteristics, diagnosis, and management of LUTD in patients with central and peripheral common neurological diseases.

Assessment and Management of Urinary Dysfunction in 187 Patients with Parkinson's Disease

BACKGROUND

Urinary dysfunction is common in Parkinson's disease (PD) patients and management options are limited.

OBJECTIVE

This study aimed to explore the management of urinary dysfunction by researching the special needs of PD patients.

METHODS

PD patients with urinary dysfunction who underwent urodynamic testing were recruited from a single center from October 2013 to February 2019. The urinary symptoms, International Prostate Symptom Score and Hoehn-Yahr scale were evaluated. Management was made at the urologists' discretion with follow-up after three weeks. Urinary symptoms, urodynamics and the management of urinary dysfunction were analyzed.

RESULTS

A total of 187 patients with a median age of 66.2 and Hoehn-Yahr scale soccer of 2 were enrolled. Irritative symptoms were more common than obstructive symptoms, while obstructive symptoms were more common in male than female patients, except for incomplete voiding. There were 51% cases of detrusor overactivity, followed by 33% with bladder outlet obstruction, 13% had normal function, 12% had detrusor underactivity, 9% had stress incontinence, 7% had increased bladder sensation and 4% had an acontractile bladder. Tolterodine and tamsulosin were the most common therapeutic agents, respectively prescribed to 38.5% and 27.3% of the patients. Other treatments included catheterization, botulinum toxin A bladder wall injection, transurethral resection of the prostate and urethral dilatation. Urinary symptoms were improved significantly in 74.5% of the patients (p < 0.001), including 27 patients treated with tamsulosin only and 54 patients with tolterodine only.

CONCLUSIONS

Urinary symptoms and urodynamics were highly variable in PD patients, indicating that most patients may benefit from personalized management.

Urodynamic and gait analyses in multiple system atrophy

BACKGROUND

Limited attention has been paid to the relationship between bladder dysfunction and motor disorder in multiple system atrophy (MSA).

OBJECTIVE

We aimed to correlate pressure-flow urodynamic parameters with video-gait analysis parameters in MSA.

METHODS

We recruited 34 patients with MSA: 20 men, 14 women; age 64.0 + - 7.9 years; disease duration 2 years (1-4 years). Nineteen cases had the cerebellar form, and 15 had the parkinsonian form; the patients were taking levodopa 300 mg/day (100-400 mg). All patients underwent pressure-flow urodynamics (parameters: detrusor overactivity [noted in 72%] and Watts factor) and video-gait analysis (parameters: time and the number of strides taken to walk 5 m (simple task) and time for timed up and go (complex task). Statistical analysis was done using Student's t-test to analyze the relation between detrusor overactivity and gait, and Spearman's rank correlation coefficient test to analyze the relation between the remaining parameters and gait.

RESULTS

We found no relation between filling-phase urodynamics (detrusor overactivity) and video-gait analysis parameters. Also, we found no relation between voiding-phase urodynamics (Watts factor, reflecting detrusor power) and all three video-gait analysis parameters in our MSA patients.

CONCLUSION

The fact that neither detrusor overactivity nor the Watts factor was related with motor disorders in the present study suggests that bladder dysfunction occurs independently from motor disorder in MSA.

Effect of need to void on Parkinsonian gait

AIMS

Beside motor control alteration and tremor, the main symptoms in Parkinsonian disorders, lower urinary tract dysfunction is very common and thus often associated with gait disorder. No studies have assessed their association yet. The aim of this study was to assess the effect of the need to void on walking speed in this particular population. The secondary aim was to assess the effect of desire to void in a double task condition on the walking speed, and on the time to raise up from the floor.

METHODS

This prospective study included all Parkinsonian disorders who had a follow-up for overactive bladder (OAB). We invited them to drink until a desire to void or equivalent (DV), then they performed three ten-meters walk tests, one double-task ten-meters walk test, one timed-up-and-go test (TUG), one timed raise of the floor (GMT). We repeated the same tests just after bladder emptying.

RESULTS

Nine men and two women (age 69±6) were included in the study (seven Parkinson's Diseases, two multisystem atrophies, two not yet characterized). Mean scores of UPDRS-III were 17±6.5, Hoehn & Yahr scale were 1.9±0.7, time since onset 7±4.4 years, levodopa daily equivalent 691±478mg. Patients performed the walking tests at DV with a mean bladder volume from 220±189mL. The mean speed was 1m/s at DV and 1.1m/s at PV (P<0.001). TUG was also increased for patients at DV: mean 9.8 s at DV versus 8.8sec at PV (P<0.003).

CONCLUSION

In Parkinsonian disorders, need to void may impact the walking speed, a strong desire to void worsening gait velocity.

LEVEL OF EVIDENCE

4.

Urinary incontinence following deep brain stimulation of the globus pallidus internus: case report

Deep brain stimulation (DBS) is a well-established therapy for patients with advanced Parkinson's disease (PD), dystonia, and other movement disorders. In contrast to the strong positive effects that have been documented for motor symptoms, the effects of DBS on nonmotor symptoms have not been fully elucidated. Some reports suggest that stimulation of the subthalamic nucleus may improve lower urinary tract symptoms in patients with PD; however, reports of the effects of globus pallidus internus (GPi) DBS on urinary symptoms are limited. The authors present the case of a 49-year-old woman with PD who developed severe urinary incontinence after 27 months of GPi DBS. The urinary incontinence disappeared when stimulation was turned off, and reemerged after it was turned on again. After activation of a more dorsal contact in the left electrode, the patient's urinary dynamics returned to normal.

Autonomic dysfunction in Parkinson's disease: Implications for pathophysiology, diagnosis, and treatment

Parkinson's disease (PD) is a neurodegenerative disease with a 200 year-long research history. Our understanding about its clinical phenotype and pathogenesis remains limited, although dopaminergic replacement therapy has significantly improved patient outcomes. Autonomic dysfunction is an essential category of non-motor phenotypes that has recently become a cutting edge field that directs frontier research in PD. In this review, we initially describe the epidemiology of dysautonomic symptoms in PD. Then, we perform a meticulous analysis of the pathophysiology of autonomic dysfunction in PD and propose that the peripheral autonomic nervous system may be a key route for α-synuclein pathology propagation from the periphery to the central nervous system. In addition, we recommend that constipation, orthostatic hypotension, urinary dysfunction, erectile dysfunction, and pure autonomic failure should be viewed as prodromal dysautonomic markers in PD prediction and diagnosis. Finally, we summarize the strategies currently available for the treatment of autonomic dysfunction in PD and suggest that high-quality, better-designed, randomized clinical trials should be conducted in the future.

Deep brain stimulation in Parkinson's disease: A multicentric, long-term, observational pilot study

BACKGROUND

The impact of deep brain stimulation (DBS) on cognitive and urinary disorders, falls, and eventually hospitalizations and mortality in Parkinson's disease (PD) is still debated.

OBJECTIVE

We compared the rates of dementia, mild cognitive impairment (MCI), urinary incontinence, nocturia, falls, hospitalizations, and mortality in a cohort of PD patients undergoing DBS with a cohort of medically-treated patients chosen as controls.

METHODS

We conducted a retrospective pilot study in six Italian DBS centers. 91 PD patients receiving DBS and 91 age- and gender-matched controls receiving the best medical treatment alone with a minimum follow-up of one year were enrolled. Clinical data were collected from baseline to the last follow-up visit using an ad-hoc developed web-based system.

RESULTS

The risk of dementia was similar in the two groups while patients in the surgical cohort had lower rates of MCI, urinary incontinence, nocturia, and falls. In contrast, the risk of hospital admissions related to PD was higher in the surgical cohort. However, when excluding hospitalizations related to DBS surgery, the difference between the two cohorts was not significant. The surgical cohort had a lower number of hospitalizations not related to PD. The risk of death was similar in the two groups.

CONCLUSION

Despite a higher risk of hospitalization, patients receiving DBS had a lower rate of MCI, urinary incontinence, nocturia and falls, without evidence of an increased risk of dementia and mortality. Although these findings need to be confirmed in prospective studies, they seem to suggest that DBS may play a significant role in the management of non-motor symptoms and common complications of advanced PD.

From Pathogenesis to Novel Therapeutics for Spinocerebellar Ataxia Type 3: Evading Potholes on the Way to Translation

Spinocerebellar ataxia type 3 (SCA3), also known as Machado-Joseph disease (MJD), is a neurodegenerative disorder caused by a polyglutamine expansion in the ATXN3 gene. In spite of the identification of a clear monogenic cause 25 years ago, the pathological process still puzzles researchers, impairing prospects for an effective therapy. Here, we propose the disruption of protein homeostasis as the hub of SCA3 pathogenesis, being the molecular mechanisms and cellular pathways that are deregulated in SCA3 downstream consequences of the misfolding and aggregation of ATXN3. Moreover, we attempt to provide a realistic perspective on how the translational/clinical research in SCA3 should evolve. This was based on molecular findings, clinical and epidemiological characteristics, studies of proposed treatments in other conditions, and how that information is essential for their (re-)application in SCA3. This review thus aims i) to critically evaluate the current state of research on SCA3, from fundamental to translational and clinical perspectives; ii) to bring up the current key questions that remain unanswered in this disorder; and iii) to provide a frame on how those answers should be pursued.

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.

Feasibility of mirabegron in the treatment of overactive bladder in patients affected by Parkinson's disease: A pilot study

Background:

We investigated the effectiveness and safety of mirabegron oral treatment in a group of patients with Parkinson’s disease (PD) and overactive bladder (OAB), refractory to antimuscarinics.

Materials and methods:

Thirty patients with PD and refractory OAB were prospectively included in the study. At baseline, motor symptoms, severity of disease and cognitive status were assessed with the Hoehn–Yahr Scale, the Unified Parkinson’s disease Rating Scale, the Mini Mental State examination and the Montreal Cognitive Assessment. At baseline, urinary symptoms, satisfaction with treatment and the impact of urinary incontinence on quality of life (QoL) were assessed with the 3-day voiding diary, the Visual Analogue Scale (VAS), the Incontinence–QoL questionnaire and urodynamics. Patients started assuming mirabegron 50 mg tablets once daily. Evaluation of urinary symptoms and related questionnaires, motor symptoms, severity of PD and uroflowmetry with postvoid residual volume measurement were then repeated at the 3- and 6-month follow up. Side effects were also noted.

Results:

At baseline, the most frequently reported urinary symptoms were: urinary urgency (present in all the patients), urge urinary incontinence in 28/30 (93.3%) and increased daytime urinary frequency in 25 (83.3%) patients. At the 3-month follow up, 7 out of the 30 patients achieved a complete urinary continence. Significant improvements in VAS and Incontinence–QoL scores were observed in 24 patients. These benefits were maintained for the whole observation period. Four patients discontinued treatment due to poor efficacy, and two due to the cost of the drug.

Conclusions:

Mirabegron is a safe and effective treatment in patients with PD and OAB refractory to anticholinergics in the short-term follow up.

[Results and compliance of transcutaneous tibial nerve stimulation on overactive bladder syndrome in patients with Parkinson's disease. Retrospective Study.]

PURPOSE

To investigate efficiency and tolerance of transcutaneous tibial nerve stimulation (TNS) in the overactive bladder syndrome in patients with Parkinson's disease (PD), and to identify predictive factors for compliance.

METHODS

We conducted a retrospective monocentric study with a cohort of 17 patients with PD who have used TNS for an overactive bladder syndrome. The efficiency of the treatment was evaluated on the clinical improvement felt (rated out of ten). Patients were classified as « adopters » if they continued using TNS for at least one year after beginning the treatment or as « non adopters » if they stopped. Patients characteristics were evaluated for their predictive value for compliance with TNS.

RESULTS

Out of 17 patients, there were 9 women and 8 men, median age 66 years (55-77), median history for Parkinson's disease 8 years (1-22) and for urinary symptoms 3 years (1-10). Subjective efficiency was seen in 10 patients (59%), on nocturia and/or urinary incontinence for 9 patients (mean efficiency 5.75/10 and median efficiency 6.5/10). Three patients found TNS not effective, and four patients didn't use it long enough to evaluate. Two patients had side effects and stopped the TNS (feeling of electricity and restless leg syndrome). 7 patients were classified as « adopters » and 10 patients as « non adopters » after one year. Most evaluated characteristics proved not to be of predictive value for compliance with TNS except nocturia and pollakiuria (P=0.03 and P=0.05).

CONCLUSION

Our study seems to reveal TNS is particularly effective on nocturia and urge. Moreover, nocturia and pollakiuria appear to be predictive factors for SNT compliance. Nocturia could be a prominent symptom in SNT's prescription. But studies with more patients should be conducted for obtain better patient selection in TNS.

LEVEL OF EVIDENCE

IV.