Urinary Tract Infection in Parkinson’s Disease

Urinary tract infection (UTI) is a common precipitant of acute neurological deterioration in patients with Parkinson’s disease (PD) and a leading cause of delirium, functional decline, falls, and hospitalization. Various clinical features of PD including autonomic dysfunction and altered urodynamics, frailty and cognitive impairment, and the need for bladder catheterization contribute to an increased risk of UTI. Sepsis due to UTI is a feared consequence of untreated or undertreated UTI and a leading cause of morbidity in PD. Emerging research suggests that immune-mediated brain injury may underlie the pathogenesis of UTI-induced deterioration of PD symptoms. Existing strategies to prevent UTI in patients with PD include use of topical estrogen, prophylactic supplements, antibiotic bladder irrigation, clean catheterization techniques, and prophylactic oral antibiotics, while bacterial interference and vaccines/immunostimulants directed against common UTI pathogens are potentially emerging strategies that are currently under investigation. Future research is needed to mitigate the deleterious effects of UTI in PD.

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.

The association between lower urinary tract symptoms and falls: Forming a theoretical model for a research agenda

BACKGROUND

There is a well-recognised association between falls and lower urinary tract symptoms (LUTS) in older adults, with estimates of odd ratios for falls in the presence of LUTS ranging between 1.5 and 2.3. Falls and LUTS are both highly prevalent among older people and both are markers of frailty, with significant associated morbidity, mortality, and healthcare resource cost. This association is not well examined or explained in the literature.

AIMS

We aimed to outline current knowledge of the association between falls and lower urinary tract symptoms and suggest a research program to further investigate this.

MATERIALS AND METHODS

A consensus conference of experts in the field was convened to review the current literature and brainstorm potential future investigative avenues.

RESULTS AND DISCUSSION

Despite the recognition of this association, there has been little research to examine its potential causes, and no intervention trial has established if reducing LUTS or urinary incontinence can reduce the risk of falls. The commonly held assumption that urgency causes falls through rushing to the toilet is likely incorrect. Falls and LUTS are both symptoms of frailty and have many common causes. Gait, balance, and continence are all processes requiring cognitive input, and the concept of dual tasking may be a further link.

CONCLUSION

The significant association between lower urinary tract symptoms and falls is currently unexplained, and further research into the potential causes of this association is needed.

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.

Constipation is reduced by beta-blockers and increased by dopaminergic medications in Parkinson's disease

BACKGROUND

Constipation is one of most frequent non-motor symptoms of Parkinson's disease (PD) and it may precede the clinical diagnosis of PD by years, with negative effects on quality of life. In contrast to motor features, levodopa is ineffective and possibly detrimental on constipation. Treatment of constipation in PD is non-specific and frequently unsuccessful. Stemming from a clinical observation of unexpected relief of bothersome constipation, abdominal bloating and pain after treatment with the beta-blocker carvedilol in one patient, we have evaluated the association between the use of beta-blockers and the presence of constipation in a large, unselected PD cohort.

METHODS

Retrospective review of the medical records of every patient with a diagnosis of PD seen in the Movement Disorders clinic at Cedars-Sinai Medical Center from October 2010 to April 2014.

RESULTS

341 medical records with a primary diagnosis of PD were reviewed, 336 of which contained information about constipation. Overall, 205/336 patients (61%) reported constipation. Among the 66 subjects treated with beta-blockers at the time of the encounter of record, only 28 (42.4%) reported constipation. By comparison, among the 270 subjects not treated with beta-blockers, 177 (65.5%) had constipation (χ(2) test p value = 0.001). Multivariate logistic analysis showed an odds ratio (OR) of 0.293 for beta-blockers (95% C.I. 0.161-0.535, p = 0.0001), 2.287 for levodopa (95% C.I. 1.271-4.117, p = 0.006) and 1.805 for dopamine agonists (95% C.I. 1.039-3.136, p = 0.036).

CONCLUSIONS

Beta-blockers are associated with a lower risk of constipation, while dopaminergic treatments appear to increase risk of constipation.