Effects of levodopa on the bladder outlet

[Is there any obstruction other than prostatic obstruction in Idiopathic Parkinson's Disease?]

OBJECTIVE

To highlight the existence of pseudo-dyssynergia in Idiopathic Parkinson's Disease (IPD) constituting a functional bladder outlet obstruction.

MATERIALS AND METHODS

A retrospective study was conducted by including men with a confirmed diagnose of IPD who participated in the SIROCCO rehabilitation program. Patients included clinically exhibited overactive bladder and voiding dysfunction without prostatic hypertrophy ultrasounded. They have been clinically assessed by the Urinary Symptoms Profile (USP) urinary symptom score. Bladder outlet obstruction was assessed by the pressure-flow study. Urodynamic obstruction has been quantified by the bladder obstruction index which depends on detrusor pressure at maximum flow rate and maximum flow rate. It has been defined by a BOOI>40.

RESULTS

The pressure-flow profile was analyzed in 5 patients who met the inclusion criteria. In this group of 5 patients with IPD, the diagnosis was made on average 10.6 years (7-14) before the pressure-flow studies were performed. Our results objectified 4 patients obstructive among 5 and one equivocal patient. A striated pseudo-dyssynergia was found in the 3 obstructive patients and associated with a smooth pseudodyssynergia in one patient.

CONCLUSION

We have observed, in this short series, a pseudo-dyssynergia by subjects suffering from IPD.

LEVEL OF EVIDENCE

3.

[Lower urinary tract dysfunctions in parkinsonian syndromes: a review by the Neuro-Urology Comittee of the French Association of Urology]

INTRODUCTION

Lower urinary tract disorders (LUTD) are common in Parkinson's disease (PD) and other parkinsonian syndromes (PS). They are responsible for a significant morbidity and mortality and impair patients' quality of life. The therapeutic management of these LUTD requires to know how to distinguish the PD from other PS and their epidemiology and pathophysiology.

OBJECTIVE

To provide a diagnostic and therapeutic management of LUTD in patients with PS.

METHOD

A review of litterature using PubMed library was performed using the following keywords: Parkinson's disease, multiple system atrophy, lower urinary tract disorders, neurogenic bladder, overactive bladder, obstruction, anticholinergics, dopamine, prostate surgery.

RESULTS

Sometimes revealing the neurological disease, LUTD in PS raise a diagnostic problem because they occur at an age when various urogynecological disorders can be intricated with neurogenic bladder dysfunction. The differential diagnosis between PD and multiple system atrophy is important to know by the urologist. The distinction is based on the semiological analysis, the clinical response to dopaminergic therapy and the clinical outcome but also on data from urodynamic explorations. The therapeutic management of these LUTD cannot be easy due to the difficulty of use of some pharmacological treatments and the risk of deterioration after inappropriate surgery. The different treatments include the careful use of anticholinergics, posterior tibial nerve stimulation, deep thalamic stimulation and low-dose intradetrusor injections of botulinum toxin without approval. The decision to perform prostate surgery will be taken with caution after proving the bladder obstruction.

CONCLUSION

When analysing LUTD in PS, the urologist must know to question the initial diagnosis of PD. Treatments in order to reduce morbidity and mortality of these LUTD and to improve the quality of life of patients suffering from these degenerative diseases, will be proposed after multidisciplinary neuro-urologic concertation. The decision to perform prostate surgery must be taken with caution after proving sub-vesical obstruction.

Les troubles vésicosphinctériens de la maladie de Parkinson

Parkinson's disease related to degeneration of the extrapyramidal structures is characterized in its typical form by the classic triad of tremors, rigidity and akinesia, constituting Parkinson's syndrome. These are combined with neurovegetative disorders, responsible for sexual and bladder sphincter dysfunction. The Latter occurs in from 30% to 90% of cases, depending on the stage of progression of the disease. The dopamine deficiency in the nigrostriataL tract leads to a lifting of the inhibition which is probably the cause of the bladder hyperreflexia. Irritative signs are most frequently observed. The flowmetry data are contradictory, depending on the publication whereas the bladder overactivity, objectified by cystomanometry, is described in most of the studies although certain authors report, on the contrary, bladder hypoactivity. Conflicting data have also been published on bladder sphincter dyssynergia although in most studies, micturition was described as synergic in Parkinson's disease patients. L-dopa, the main drug for Parkinson's disease, has, according to the publication, either no action, or contradictory effects with bladder hypoactivity or hyperactivity. Anticholinergics are effective on overactive bladder, the alphablockers on the urethral hypertonia at the price of a higher risk of arterial hypotension in this diathesis. The indication for prostatic surgery must be carefully considered and preceded by precise clinical, urodynamic and sometimes electromyography evaluation. There is a high risk of post surgical incontinence. Endourethral prostheses provide an attractive alternative in the case of prostatic obstruction.

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

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

Autologous adrenal medullary transplant in Parkinson's disease: critical review of our results in 13 patients

Autotransplantation of the adrenal medullary to the caudate nucleus has been proposed for severe Parkinson's disease (PD). We describe our experience in 13 patients using a transperitoneal approach to the medullary and craniotomy for the implant: the neurosurgical equipe's decision to opt for craniotomy made quick removal of the medullary with minimal morbidity more difficult. The surgical technique are discussed. We evaluated also the impact of the procedure on urinary symptoms and sexual disturbances associated with PD. Results were disappointing. Four patients died post-operatively. The neurological pattern improved in three men and one woman. No significant improvement was observed in the urological and sexual dysfunctions.

Effects of apomorphine and L-dopa on the parkinsonian bladder

Neurogenic bladder frequently occurs in Parkinson's disease. Detrusor hyperreflexia is a consequence of nigrostriatal dopamine depletion, whereas the cause of hyporeflexia remains unclear. We compared the results of cystometry and urethral profilometry with and without apomorphine (and L dopa) in 12 idiopathic parkinsonians with urinary disorders free of dopaminergic treatment. Whereas hyperreflexic patients improved with apomorphine, and to a lesser extent with L dopa, these drugs had no effect on hyporeflexic patients. These results confirm the role of dopaminergic lesions in the occurrence of bladder hyperreflexia and the possible implication of nondopaminergic lesions in the occurrence of hyporeflexia.

Side effects of selegiline (Eldepryl)

Selegiline (Eldepryl), recently approved as an adjunct to levodopa-carbidopa (Sinemet), was administered to eight patients with Parkinson's disease in an open-label study. Many side effects were seen pertinent in particular to the elderly patient. Urinary retention was precipitated in two gentlemen. We advise that this medication be used with caution in the parkinsonian patient.

Neurourologic findings in Parkinson's disease

A total of 30 patients with an established diagnosis of Parkinson's disease and symptomatic voiding dysfunction underwent neurourologic evaluation. Detrusor hyperreflexia associated with appropriate sphincter relaxation was found to be the most common urodynamic pattern, occurring in 75 per cent of the cases. Two types of increased electromyogram activity at the time of detrusor contraction were identified: 1) pseudo-dyssynergia (7 per cent)--a voluntary contraction of the perineal floor in an attempt to prevent leakage and 2) sphincter bradykinesia (11 per cent)--a manifestation of skeletal muscle hypertonicity characteristic of parkinsonism. On the basis of these observations it is assumed that the effect of the basal ganglia on micturition is inhibitory in nature. The diagnostic and therapeutic approach to the parkinsonian patient with voiding dysfunction is discussed.

Uropharmacology: X. Central nervous system stimulants and depressants

Several drugs that are utilized primarily for their effects on the central nervous system also affect lower urinary tract function. Most of these effects are produced by the action of these drugs on adrenergic and cholinergic receptors or by direct action of lower urinary tract musculature. Central nervous system stimulants and depressants which are known to affect the storage or evacuation role of the lower urinary tract are discussed.