Urinary dysfunction in early and untreated Parkinson's disease

Can We Differentiate Between Organic and Functional Bladder Outlet Obstruction in Males With Parkinson's Disease?

OBJECTIVES

To determine the type of bladder outlet obstruction (BOO) in patients with Parkinson's disease (PD).

MATERIAL AND METHOD

A case-control study was carried out in 46 patients divided into two groups. Group 1 formed by 23 PD patients with BOO (a URA parameter ≥ 29 cm H2O). Group 2 formed by 23 patients with benign prostatic hyperplasia (BPH) and compressive obstruction (an opening pressure > 35 cm H2O) and URA parameter ≥ 29 cm H2O). Both groups underwent a pressure-flow study to calculate Dynamic Urethral Resistance Relationship (DURR) patterns. Based on previous research, we describe two types of DURR pattern. Pattern A typical of dynamic or functional obstruction and pattern B typical of static or organic obstruction.

RESULTS

We found that PD patients had a significantly higher frequency of pattern A (70%) than BPH patients (4%). Other significant differences between groups were age (greater in PD group), bladder compliance (greater in PD group), maximum flow rate [Qmax (greater in BPH group)], maximum detrusor pressure [Pmax (greater in BPH group)], detrusor pressure at maximum flow rate [PQmax (greater in BPH group)], opening detrusor pressure (greater in BPH group), and the bladder contractility parameters BCI and Wmax (greater in BPH group). There were no significant differences in perineal voiding electromyography (EMG) activity between groups nor relationship between voiding EMG activity and the type of DURR pattern.

CONCLUSIONS

Our results are consistent with the usefulness of the DURR pattern to differentiate between functional and organic BOO in PD patients. Most PD patients have functional obstruction although a minority has organic obstruction consistent with BPH.

Real-World Use of Intradetrusor Botulinum Toxin Injections: A Population-Based Study from France

In recent decades, intradetrusor injections of botulinum toxin A (BoNT-A) have been widely applied to treat incontinence in both idiopathic overactive bladder (iOAB) and neurogenic detrusor overactivity incontinence (NDOI). This analysis, based on the French National Hospital Discharge Database (PMSI), aims to describe real-world trends in intradetrusor BoNT-A use between 2014 and 2022. Among 32,864 patients who received at least one intradetrusor BoNT-A injection, 18,320 (55.7%) had conditions coded under iOAB, 13,376 (40.7%) under NDOI, and 1168 (3.6%) under other indications. The overall mean interval between two intradetrusor BoNT-A injections was 9.7 months, ranging from 8.7 months in patients with multiple sclerosis (MS) to 11.5 months in patients with cerebral pathologies. The median number of injections was two (quartile 1-quartile 3, 1-4) in patients with spina bifida, whereas it was five (2-10) in those with MS. Only 31% of patients with iOAB received more than two intradetrusor BoNT-A injections. Regardless of its indication, BoNT-A was well tolerated. Adverse events occurring during or requiring hospitalization included infections (3.8%), hematuria (0.53%), and bleeding episodes necessitating transfusions (0.11%), all recorded within the initial month following BoNT-A injection. Our analysis of the PMSI database highlights a broad spectrum of intradetrusor BoNT-A injection practices.

Urodynamic study and its correlation with cardiac meta-iodobenzylguanidine (MIBG) in body-first and brain-first subtypes of Parkinson's disease

BACKGROUND AND PURPOSE

Lower urinary tract symptoms (LUTS) are frequently observed in patients with Parkinson's disease (PD), but the underlying mechanism remains elusive. The concept of "body-first" and "brain-first" subtypes in PD has been proposed, but the correlation of PD subtype with LUTS remains unclear. We aimed to investigate the disparities in urological dysfunctions between body-first and brain-first subtypes of PD using urodynamic studies (UDS).

METHODS

We reviewed patients with PD (disease duration <3 years) who had undergone UDS and completed urological questionnaires (Overactive Bladder Symptom Score [OABSS] and International Prostate Symptom Score [IPSS]) and a voiding diary. Patients were categorized as having body-first or brain-first PD based on cardiac sympathetic denervation (CSD) using cardiac meta-iodobenzylguanidine (MIBG) uptake and the presence of rapid eye movement sleep behavior disorder (RBD), assessed using a questionnaire (PD with CSD and RBD indicating the body-first subtype).

RESULTS

A total of 55 patients with PD were categorized into body-first PD (n = 37) and brain-first PD (n = 18) groups. The body-first PD group exhibited smaller voiding volume and first desire volume (FDV) than the brain-first PD group (p < 0.05 in both). Also, the body-first PD group had higher OABSS and IPSS scores, and higher prevalence of overactive bladder diagnosed by OABSS, compared to the brain-first PD group. In multiple linear regression, cardiac MIBG uptake was positively correlated with FDV and voiding volume and negatively correlated with OABSS and IPSS (p < 0.05 in all).

CONCLUSIONS

Patients with the body-first PD subtype exhibited more pronounced overactive bladder symptoms and impaired storage function in the early stage of disease. Additionally, cardiac MIBG was significantly associated with urological dysfunction.

Sleep and Overactive Bladder in Parkinson's Disease

Patients with Parkinson's disease (PD) have disturbances in their bladder and sleep physiology that lead to nocturia and overactive bladder (OAB). These symptoms can be extremely bothersome and impact not only their quality of life (QoL) but also the QoL of their caretakers. We aim to highlight the changes in bladder and sleep physiology in PD and explore OAB/nocturia treatment strategies in this population.

Quantitative anatomical analysis of lumbar interspaces based on 3D CT imaging: optimized segment selection for lumbar puncture in different age groups

BACKGROUND

Optimal lumbar puncture segment selection remains controversial. This study aims to analyze anatomical differences among L3-4, L4-5, and L5-S1 segments across age groups and provide quantitative evidence for optimized selection.

METHODS

80 cases of CT images were collected with patients aged 10-80 years old. Threedimensional models containing L3-S1 vertebrae, dural sac, and nerve roots were reconstructed. Computer simulation determined the optimal puncture angles for the L3-4, L4-5, and L5-S1 segments. The effective dural sac area (ALDS), traversing nerve root area (ATNR), and area of the lumbar inter-laminar space (ALILS) were measured. Puncture efficacy ratio (ALDS/ALILS) and nerve injury risk ratio (ATNR/ALILS) were calculated. Cases were divided into four groups: A (10-20 years), B (21-40 years), C (41-60 years), and D (61-80 years). Statistical analysis was performed using SPSS.

RESULTS

1) ALDS was similar among segments; 2) ATNR was greatest at L5-S1; 3) ALILS was greatest at L5-S1; 4) Puncture efficacy ratio was highest at L3-4 and lowest at L5-S1; 5) Nerve injury risk was highest at L5-S1. In group D, L5-S1 ALDS was larger than L3-4 and L4-5. ALDS decreased after age 40. Age variations were minimal across parameters.

CONCLUSION

The comprehensive analysis demonstrated L3-4 as the optimal first-choice segment for ages 10-60 years, conferring maximal efficacy and safety. L5-S1 can serve as an alternative option for ages 61-80 years when upper interspaces narrow. This study provides quantitative imaging evidence supporting age-specific, optimized lumbar puncture segment selection.

The low dopamine hypothesis: A plausible mechanism underpinning residual urine, overactive bladder and nocturia (RON) syndrome in older patients

INTRODUCTION

Aging is associated with a combination of several lower urinary tract (LUT) signs and symptoms, including residual urine, overactive bladder and nocturia. One of the mechanisms of this LUT dysfunction that has not been discussed in dept so far is the role of dopamine (DA).

METHODS

In this narrative review, we explore the dopaminergic hypothesis in the development of this combination of LUT signs and symptoms in older adults.

RESULTS

DA is one of the neurotransmitters whose regulation and production is disrupted in aging. In synucleinopathies, altered DAergic activity is associated with the occurrence of LUTS and sleep disorders. Projections of DAergic neurons are involved in the regulation of sleep, diuresis, and bladder activity. The low dopamine hypothesis could explain the genesis of a set of LUT signs and symptoms commonly seen in this population, including elevated residual urine, Overactive bladder syndrome and Nocturia (discussed as the RON syndrome). This presentation is however also common in older patients without synucleinopathies or neurological disorders and therefore we hypothesise that altered DAergic activity because of pathological aging, and selective destruction of DAergic neurons, could underpin the presentation of this triad of LUT dysfunction in the older population.

CONCLUSION

The concept of RON syndrome helps to better understand this common phenotypic presentation in clinical practice, and therefore serves as a useful platform to diagnose and treat LUTS in older adults. Besides recognizing the synucleinopathy "red flag" symptoms, this set of multi-causal LUT signs and symptoms highlights the inevitable need for combination therapy, a challenge in older people with their comorbidities and concomitant medications.

Association Between Gait and Dysautonomia in Patients With De Novo Parkinson's Disease: Forward Gait Versus Backward Gait

OBJECTIVE

Studies on gait and autonomic dysfunction have been insufficient so far, particularly de novo Parkinson's disease (PD). The aim of this study was to identify the association between gait dynamics and autonomic dysfunction in patients with de novo PD.

METHODS

A total 38 patients with de novo PD were retrospectively included in this study. Details of patients' dysautonomia were assessed using the Scales for Outcomes in Parkinson's Disease-Autonomic Dysfunction (SCOPA-AUT). For assessment of gait, a computerized gait analysis was performed using the GAITRite system for forward gait and backward gait. High SCOPA-AUT score (PD-HSAS) group and low SCOPA-AUT score (PD-LSAS) group were identified according to their SCOPA-AUT scores.

RESULTS

Nineteen (50%) patients with high SCOPA-AUT scores above median value (12.5) were assigned into the PD-HSAS group and others were assigned to the PD-LSAS group. Compared with the PD-LSAS group, the PD-HSAS group exhibited slower gait, shorter stride, decreased cadence, increased double support phase, decreased swing phase, and increased variability in swing time. Total SCOPA-AUT score showed significantly positive correlations with gait variability and instability but a negative correlation with gait hypokinesia. In subdomain analysis, urinary dysautonomia was highly associated with impairment of gait dynamics. All significant results were found to be more remarkable in backward gait than in forward gait.

CONCLUSION

Our findings suggest that alteration in gait dynamics, especially backward gait, is highly associated with autonomic dysfunction in patients with de novo PD.

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.

Sleep and Autonomic Manifestations in Parkinson’s Disease Complicated With Probable Rapid Eye Movement Sleep Behavior Disorder

Patients with Parkinson’s disease (PD) complicated with rapid eye movement sleep behavior disorder (RBD) present with distinct clinical features. The purpose of this study was to determine the clinical features of sleep and autonomic symptoms in PD patients with probable RBD (pRBD). The study included 126 patients with PD. pRBD was defined as having a history of dream-enacting behavior with a total score of 5 or greater on the Japanese version of the RBD Screening Questionnaire (RBDSQ-J). The Parkinson’s Disease Sleep Scale-2 (PDSS-2) was used to evaluate sleep disturbances. Scales for Outcomes in Parkinson’s Disease-Autonomic dysfunction (SCOPA-AUT) were used to evaluate autonomic symptoms. Clinical assessments included disease severity, motor symptoms, olfaction, depression, cognitive function, levodopa equivalent dose (LED), and cardiac metaiodobenzylguanidine (MIBG) scintigraphy. Correlations between RBDSQ-J total scores and clinical variables were analyzed. Compared to PD patients without pRBD, PD patients with pRBD showed severe hyposmia, severe sleep-related symptoms, severe dysautonomia, and more reduced cardiac MIBG scintigraphy. Within the PDSS-2, the “PD symptoms at night” domain was significantly more severe in PD patients with pRBD. Within the SCOPA-AUT, the “urinary” and “cardiovascular” domains were significantly higher in PD patients with pRBD. In correlation analyses, RBDSQ-J total scores were positively correlated with PDSS-2 total scores, “PD symptoms at night” and “disturbed sleep” domains, Epworth Sleepiness Scale scores, SCOPA-AUT total scores, “urinary,” “cardiovascular,” and “thermo” domain scores, and LED. RBDSQ-J total scores were negatively correlated with cardiac MIBG scintigraphy uptake. Binary logistic regression analysis showed that PDSS-2 subitem 7 (distressing hallucinations) and SCOPA-AUT subitem 11 (weak stream of urine) were significant determinants for pRBD. Our study showed that PD patients with pRBD had characteristic sleep and autonomic symptoms.

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.

Effect of bladder dysfunction on development of depression and anxiety in Parkinson's disease

OBJECTIVES

Parkinson's disease (PD) often presents with movement disorder. However, besides motor complaints, there are many complaints such as anxiety, depression, urinary complaints and constipation. The aim of this study was to investigate whether neurogenic lower urinary dysfunction (NLUD), which is frequently seen in PD, has an effect on the development of anxiety and depression in these patients.

MATERIALS AND METHODS

The study included 32 males (66.6%) and 16 females (33.3%); in total 48 subjects were registered. For the diagnosis and severity of PD, the UK Parkinson's Disease Society Brain Bank Criteria, Unified Parkinson's Disease Rating Scale (UPDRS) and the Hoehn-Yahr scale were used. Urological evaluation was performed using history, physical examination, laboratory tests and standard forms such as IPSS and OAB-V8.

RESULTS

There was no difference between the genders in terms of duration, severity and NLUD (p > 0.05). The incidence of anxiety and depression in PD patients was 62.8% and 72.1%, respectively. The prevalence of NLUD was 67.4% and depression and anxiety was found to increase (1.06 and 1.28 times, respectively) in relation to NLUD. In particular, there was a relationship between storage lower urinary tract symptoms and anxiety and depression development (p < 0.05).

CONCLUSIONS

As expected, it was found that the incidence of NLUD, anxiety and depression was increased in PD. In addition, NLUD was found to be a risk factor for the development of anxiety and depression. Therefore, it is concluded that NLUD, which can potentially cause important complications, as well as motor complaints, should be closely monitored and treated in PD patients.

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

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

Role of the community nurse in Parkinson's disease and lower urinary disorders

Parkinson's disease (PD) is an incurable and progressive neurodegenerative disorder. People with PD also have increased muscle weakness and the typical symptoms of tremor, stiffness, slowness, balance problems and/or gait disorders. Other symptoms may include an overactive bladder, urgency and nocturia which can often lead to incontinence. Treatment options vary are dependent on the cause of the incontinence and should focus on improving Quality of life with a multi-pronged diagnosis-specific approach that takes into consideration a patient's ability to comply with treatment. The article looks at the role of the community nurse in caring for patients with PD and lower urinary disorders. They have a key role in assessment of patients and supporting families with tailor made bladder training such as establish a regular toilet routine, education about pelvic floor exercises or supply of incontinence products.

Progression of Nonmotor Symptoms in Parkinson's Disease by Sex and Motor Laterality

Nonmotor symptoms (NMS) in Parkinson's disease (PD) can start up to a decade before motor manifestations and strongly correlate with the quality of life. Understanding patterns of NMS can provide clues to the incipient site of PD pathology. Our goal was to systematically characterize the progression of NMS in PD (n = 489), compared to healthy controls, HC (n = 241), based on the sex of the subjects and laterality of motor symptom onset. Additionally, NMS experienced at the onset of PD were also compared to subjects with scans without dopaminergic deficit, SWEDD (n = 81). The Parkinson's Progression Markers Initiative (PPMI) database was utilized to analyze several NMS scales. NMS experienced by PD and SWEDD cohorts were significantly higher than HC and both sex and laterality influenced several NMS scales at the onset of motor symptoms. Sex Differences. PD males experienced significant worsening of sexual, urinary, sleep, and cognitive functions compared to PD females. PD females reported significantly increased thermoregulatory dysfunction and anxious mood over 7 years and significantly more constipation during the first 4 years after PD onset. Laterality Differences. At onset, PD subjects with right-sided motor predominance reported significantly higher autonomic dysfunction. Subjects with left-sided motor predominance experienced significantly more anxious mood at onset which continued as Parkinson's progressed. In conclusion, males experienced increased NMS burden in Parkinson's disease. Laterality of motor symptoms did not significantly influence NMS progression, except anxious mood. We analyzed NMS in a large cohort of PD patients, and these data are valuable to improve PD patients' quality of life by therapeutically alleviating nonmotor symptoms.

Premotor Parkinson's disease: Overview of clinical symptoms and current diagnostic methods

Parkinson's disease (PD) is characterized by typical motor symptoms. However, recent studies show several non-motor features that may precede the development of the motor symptoms of PD. The best known premotor symptoms include hyposmia, REM sleep behavior disorder (RBD), constipation, and depression; other symptoms are excessive daytime somnolence, orthostatic hypotension and symptomatic hypotension, erectile or urinary dysfunction, musculoskeletal symptoms, pain, and global cognitive deficit. In this review, we summarize currently available diagnostic methods for these symptoms. We also briefly summarize neuroimaging, polyneuropathy, peripheral markers, and cerebrospinal fluid biomarkers that may be used in the early diagnosis of PD.

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.

Urinary Dysfunction Is Associated with Nigrostriatal Dopaminergic Degeneration in Early and Untreated Patients with Parkinson's Disease

The aim of the present study was to determine the relation between urinary dysfunction and nigrostriatal dopaminergic degeneration in early and untreated Parkinson's disease (PD). The data were obtained from Parkinson's Progression Markers Initiative database. Two hundred and seventy-five patients and 149 healthy controls were included in our analysis. Urinary symptoms were evaluated with the Scale for Outcomes in Parkinson's Disease for Autonomic Symptoms (SCOPA-AUT). We performed correlation analyses between ¹²³I-FP-CIT SPECT imaging data and severity of urinary symptoms in patients with PD and healthy controls. Early and untreated patients with PD exhibited worse urinary symptoms when compared with healthy controls. The severity of urinary symptoms significantly correlated with dopamine transporter binding levels in the caudate and the putamen. After controlling for age and sex, the severity of storage symptoms significantly correlated with dopamine transporter binding levels in the less affected side of the putamen (r = −0.172, p=0.004). The correlation was observed in both male (r = −0.152, p=0.043) and female patients (r = −0.217, p=0.034). No correlations were found between dopamine transporter binding levels and voiding symptoms in male or female patients, or any urinary symptoms in healthy controls. Worse storage symptoms reflect greater nigrostriatal dopaminergic loss in early and untreated PD.

Neuroprotective Effects of Coffee Bioactive Compounds: A Review

Coffee is one of the most widely consumed beverages worldwide. It is usually identified as a stimulant because of a high content of caffeine. However, caffeine is not the only coffee bioactive component. The coffee beverage is in fact a mixture of a number of bioactive compounds such as polyphenols, especially chlorogenic acids (in green beans) and caffeic acid (in roasted coffee beans), alkaloids (caffeine and trigonelline), and the diterpenes (cafestol and kahweol). Extensive research shows that coffee consumption appears to have beneficial effects on human health. Regular coffee intake may protect from many chronic disorders, including cardiovascular disease, type 2 diabetes, obesity, and some types of cancer. Importantly, coffee consumption seems to be also correlated with a decreased risk of developing some neurodegenerative conditions such as Alzheimer's disease, Parkinson's disease, and dementia. Regular coffee intake may also reduce the risk of stroke. The mechanism underlying these effects is, however, still poorly understood. This review summarizes the current knowledge on the neuroprotective potential of the main bioactive coffee components, i.e., caffeine, chlorogenic acid, caffeic acid, trigonelline, kahweol, and cafestol. Data from both in vitro and in vivo preclinical experiments, including their potential therapeutic applications, are reviewed and discussed. Epidemiological studies and clinical reports on this matter are also described. Moreover, potential molecular mechanism(s) by which coffee bioactive components may provide neuroprotection are reviewed.

The voiding efficiency in rat models with dopaminergic brain lesions induced through unilateral and bilateral intrastriatal injections

Bladder dysfunction is a common phenomenon in Parkinson’s disease (PD) patients. A research attempt was made to analyze the voiding efficiency (VE) and bladder functions in rats with PD induced by unilateral or bilateral injections of 6-hydroxydopamine (6-OHDA) into the medial forebrain bundle. PD rats were divided into unilateral- and bilateral-injected groups and subjected to rotation and beam walking tests. Further, the experimental rats underwent cystometric measurements for analyses of bladder dysfunction and VE. Immunohistochemical analysis was performed to analyze the dopaminergic neuron depletion on the target area. Outcomes of the rotation and beam walking tests revealed the extent of parkinsonism in the experimental rats. Urodynamic observations denoted that rats with unilateral PD exhibited a significantly decreased VE (from 68.3±3.5% to 32.7±5.8%), while rats with bilateral PD displayed a much-reduced and substantially lower level of VE of 18.3±5.1% compared to the control value and to that of rats with unilateral PD. Rats with bilateral PD showed more-extensive behavioral deficits and urodynamic changes than did rats with unilateral PD. These significant changes in motor, behavioral, bladder function and VE were due to an extensive degeneration of dopaminergic neurons in the substantia nigra region on both sides of the brain. The obtained results were substantiated with appropriate immunohistochemical results.

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

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

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

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

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

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

CONTEXT

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

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

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.

'Atypical' Parkinson's disease - sporadic

Parkinson's disease still is a clinical diagnosis. Also, the MDS Clinical Diagnostic Criteria for Parkinson's disease published in 2015 are based on clinical characteristics and were designed codifying the diagnostic process of an expert. The purpose was to support less experienced neurologists to achieve the diagnostic procedure up to the level of an expert. The criteria include both negative and positive properties. However, some features exclude patients with typical Parkinson's disease mainly during their early or late stages. These includes symptoms such as the absence of the combination of typical motor symptoms, the insufficient response to dopaminergic treatment, autonomic dysfunction, dystonia, postural instability or cognitive impairment. This chapter discusses those "atypical" symptom constellations that complicate the differential diagnosis of PD versus atypical parkinsonism and illustrates additional considerations that might be helpful to achieve a correct diagnosis.

Urinary Symptoms in Patients with Parkinson's Disease and Progressive Supranuclear Palsy: Urodynamic Findings and Management of Bladder Dysfunction

OBJECTIVE

The objective of this study is to observe urinary symptoms in patients with Parkinson's disease (PD) and progressive supranuclear palsy (PSP) and advice bladder dysfunction management based on urodynamic study (UDS) findings.

PATIENTS AND METHODS

Twenty-two patients (12 males) with PD and PSP (15 and 7, respectively) with urinary symptoms were included in this study. All patients except one were on levodopa and carbidopa medication. UDS was performed, and bladder management determined.

RESULTS

Mean age was 60.4 years (range 41-73 years, standard deviation [SD] 8.4). Mean illness duration was 31.9 months (range 9-146 months, SD 31.0) and mean duration of urinary symptoms was 14.8 months (range 1-61 months, SD 15.8). Eighteen patients reported nocturia and 16 patients had urgency with or without urge incontinence. Three patients had retention and straining to void and 3 had mixed urinary complaints. Twelve out of 22 patients had absence of voluntary anal contraction on per-rectal examination. UDS was suggestive of 12 patients with neurogenic detrusor overactivity with or without sphincter dyssynergy. Six patients had normal detrusor pressure, and four patients were found to have contractile detrusor. Ten patients had significant postvoid residual. Bladder management included pharmacotherapy, supportive, and behavioral management as appropriate.

CONCLUSIONS

Patients with PD/PSP are known to develop urinary symptoms during illness. Clinical complaints and UDS findings do not necessarily match. UDS is required to manage urinary symptoms. Most of the patients respond to oral antimuscarinic medications along with behavioral and supportive therapy.

[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.

Parkinson's Disease and Parkinsonism

Parkinson's disease is a progressive neurodegenerative disease characterized by tremor and bradykinesia and is a common neurologic ailment. Male sex and advancing age are independent risk factors and, as the population ages, is taking an increasing toll on productivity and medical resources. There are a number of other extrapyramidal conditions that can make the diagnosis challenging. Unlike other neurodegenerative diseases, idiopathic Parkinson's disease has effective treatments that mitigate symptoms. Medications can improve day-to-day function and, in cases where medication does not give a sustained benefit or has significant side effects, treatments like deep brain stimulation result in improved quality of life.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 2 - Male and neurogical population

Recent studies in literature, have raised some doubts on the routine use of urodynamic testing. Many physicians and articles recommend a selective use of this tool, considering carefully risks and benefits. These recommendations are intended to guide clinicians in the right selection of the male and neurological patients to submit to a urodynamic evaluation. This is the second part of a previous article regarding the urodynamic recommendations in the female population. We reviewed the literature, regarding the use of UDS in male and neurological population with lower urinary tract symptoms (LUTS). Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and urogynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in male and neurological population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with LUTS, and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

Autonomic dysfunction in Parkinson disease and animal models

Parkinson disease has traditionally been classified as a movement disorder, despite patients' accounts of diverse symptoms stemming from impairments in numerous body systems. Today, Parkinson disease is increasingly recognized by clinicians and scientists as a complex neurodegenerative disorder featuring both motor and nonmotor manifestations concomitant with pathology throughout all major branches of the nervous system. Dysfunction of the autonomic nervous system, or dysautonomia, is a common feature of Parkinson disease. It produces signs and symptoms that severely affect patients' quality of life, such as blood pressure dysregulation, hyperhidrosis, and constipation. Treatment options for dysautonomia are limited to symptom alleviation because the cause of these symptoms and Parkinson disease overall are still unknown. Animal models provide a platform to interrogate mechanisms of Parkinson disease-related autonomic nervous system dysfunction and test novel treatment strategies. Several animal models of Parkinson disease are available, each with different effects on the autonomic nervous system. This review critically analyses key dysautonomia signs and symptoms and associated pathology in Parkinson disease patients and relevant findings in animal models. We focus on the cardiovascular system, adrenal medulla, skin/thermoregulation, bladder, pupils, and gastrointestinal tract, to assess the contribution of animal models to the understanding of Parkinson disease autonomic dysfunction.

Urinary symptoms are correlated with quality of life after deep brain stimulation in Parkinson's disease

AIMS

Deep brain stimulation (DBS) is known to dramatically improve motor complications in patients with Parkinson's disease (PD), but its effect on urinary symptoms and health-related quality of life (HRQOL) remains unknown. We aimed to examine the relationship between urinary symptoms and HRQOL in patients with PD who underwent DBS.

METHODS

The International Prostate Symptom Score (IPSS) and overactive bladder symptom score (OABSS) were determined to evaluate urinary symptoms in patients with PD who underwent DBS. Postoperative evaluations were performed at 3 months, 1 year, and 3 years postoperatively. We also performed a urodynamic study (UDS) in 13 patients with PD preoperatively and postoperatively. A follow-up UDS was performed 2.0 ± 0.5 years postoperatively.

RESULTS

The preoperative urinary symptoms questionnaire was completed by 28 patients, of whom 14 completed the postoperative urinary symptoms questionnaire after 3 months, 18 after 1 year, and 10 after 3 years. The mean OABSS and IPSS did not change significantly at any follow-up periods postoperatively. When assessing the relationship between urinary symptoms and HRQOL and motor functions, the OABSS and IPSS showed significant positive correlations with HRQOL at 3 months postoperatively. The OABSS and IPSS showed significant positive correlations with activities of daily living (ADL) during the off-phase at 3 years postoperatively. All urodynamic parameters remained unchanged postoperatively.

CONCLUSIONS

Deep brain stimulation did not significantly affect urinary dysfunctions in patients with PD. Urinary symptoms might partially contribute to HRQOL at 3 months postoperatively and ADL during the off-phase at 3 years postoperatively.

Urological dysfunctions in patients with Parkinson's disease: clues from clinical and non-invasive urological assessment

Background

Autonomic nervous system dysfunction, common in patients with Parkinson’s disease (PD), causes significant morbidity and it is correlated with poor quality of life. To assess frequency of urinary symptoms in patients with PD, without conditions known to interfere with urinary function.

Methods

Non-demented PD patients were consecutively enrolled from the outpatients clinic of our department. Scales investigating motor and non-motor symptoms were carried out. Evaluation of urinary dysfunctions was carried out using the AUTonomic Scale for Outcomes in Parkinson’s disease (SCOPA-AUT) questionnaire. Patients underwent noninvasive urological studies (nUS), including uroflowmetry and ultrasound of the urinary tract.

Results

Forty-eight (20 women, 42%) out of 187 PD patients met the inclusion criteria and were enrolled in the study. Mean SCOPA-AUT score was 14.1 ± 6.9 (urinary symptoms subscore 5.2 ± 3.8). Among those evaluated by the SCOPA-AUT scale, the urinary symptoms were among the most common complaints (93.8%). At nUS mean maximum flow rate (Qmax) was 17.9 ± 9.1 ml/s, and mean postvoid residual (PVR) urine volume was 24.4 ± 44.1 ml. Ultrasound investigation documented prostate hypertrophy in 12 male patients (42.8%). Urinary items of the SCOPA-AUT (SCOPA-U subscore) correlated with measures of disease severity only in female patients.

Conclusion

Urinary symptoms and abnormal findings in nUS are common in PD. Though nigrostriatal degeneration might be responsible for urinary symptoms also in the early-intermediate stage of the disease, when urinary dysfunction occurs other medical conditions need to be excluded.

Objective Measurement and Monitoring of Nonmotor Symptoms in Parkinson's Disease

The comprehensive evaluation of nonmotor symptoms (NMS) in Parkinson's disease (PD) starts with the awareness of physicians, patients, and caregivers on their nature, clinical presentation, and effect on patient's daily activities and quality of life. This awareness can be better achieved if the symptoms can be visualized, measured, and monitored. As NMS are largely subjective in nature, a majority of them cannot be visualized (unlike tremor, which is easily seen), making their identification and quantification difficult. While symptoms are nonmotor, it does not mean that they are not measurable, as many NMS are integral to motor symptoms of Parkinson's, yet often neglected. In this review, we attempt to provide the most up-to-date and comprehensive literature review on the objective measurement and monitoring of NMS in PD. The aim is to make it clinically relevant by approaching NMS by domains as identified in the NMS Questionnaire. A section on the assessment of nonmotor fluctuations is also included, providing prospects for future objective monitoring. With the advances of technology, it is likely that many NMS will have objective outcomes, thus making these symptoms easily measurable and hopefully lead to future clinical trials that incorporate nonmotor outcomes. Nevertheless, it still requires a physician's judgment to determine which method, scales, objective measures, or monitoring devices or a combination of these is most appropriate to the individual patient in order to answer a particular clinical question.

Long-Term Complications of the Neurogenic Bladder

It is widely accepted that neurogenic lower urinary tract dysfunction, when left untreated, has a natural history that has a potential for causing deterioration of renal function over time. However, certain patient profiles are at risk for this and other complications. This can be linked to their underlying neurologic disease process. Identifying risk profiles allows the provider to determine what surveillance strategies might be adopted. Risk factors for upper urinary tract deterioration include loss of bladder compliance, repeated bouts of pyelonephritis, and chronic indwelling catheterization. Other long-term complications include nephrolithiasis, refractory urinary incontinence, and malignancy.

Imaging Parkinson's disease below the neck

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

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

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

The Utility of Post-Void Residual Volume versus Sphincter Electromyography to Distinguish between Multiple System Atrophy and Parkinson's Disease

OBJECTIVE

To determine the ability of sphincter electromyography (EMG) and post-void residual urine volume (PVR) during a free-flow study and a pressure-flow study (PFS) for distinguishing multiple system atrophy (MSA) from Parkinson's disease (PD).

METHODS

We retrospectively reviewed 241 case records; both urodynamic study and sphincter EMG were performed in patients with MSA (n = 147) and PD (n = 94).

RESULTS

There was a statistically significant difference (p < 0.01) in the mean PVR during the free-flow study (113.1 ± 7.5 mL in MSA and 40.4 ± 3.8 mL in PD), mean PVR during PFS (230.1 ± 12.6 mL in MSA and 71.7 ± 6.6 mL in PD), and mean duration of MUP for sphincter EMG (9.3 ± 0.1 ms in MSA and 7.7 ± 0.1 ms in PD). The area under the curve used for differentiating MSA from PD was 0.79 and 0.73 for PVR during PFS and the free-flow study, respectively. There was a mean duration of 0.69 ms for the sphincter EMG.

CONCLUSIONS

The present results suggested that PVR was more appropriate than sphincter EMG for differentiating MSA from PD.

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

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

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Underactive Bladder

Underactive bladder (UAB) is a very common condition leading to disabling lower urinary tract symptoms. There has been an increasing interest in this condition as there is no effective treatment currently available. UAB has been described in many ways, but there is no agreed upon consensus on its terminology. The prevalence of UAB may be underestimated. This review focuses on the terminology, pathophysiology, common causes, its treatment, and future areas of research.

Investigation of Urination Disorder in Parkinson's disease

BACKGROUND

Urination disorders are common in Parkinson's disease (PD) and respond poorly to medication. This study aimed to analyze the risk factors for urination disorders in PD.

METHODS

Ninety-one patients with PD (aged 34-83 years old) were recruited. Patients were assessed with the Unified PD Rating Scale (UPDRS), Hoehn and Yahr stage, Pittsburgh Sleep Quality Index (PSQI), Hamilton Depression Rating Scale (HAMD), and Hamilton Anxiety Scale (HAMA). Micturition number was recorded, and Type B ultrasound was used to evaluate residual urine. Statistics was performed using binary logistic regression, bivariate correlations, and Chi-square and t-tests.

RESULTS

Of 91 patients, urinary dysfunction occurred in 55.0%. Among these, 49.5% suffered with nocturia, 47.3% with pollakiuria. Nocturia number had a positive linear relationship with HAMA score (odds ratio [OR] = 0.340, P = 0.001), HAMD score (OR = 0.323, P = 0.002), duration of L-dopa medication (OR = 0.328, P = 0.001), dose of L-dopa (OR = 0.273, P = 0.009), UPDRS-II (OR = 0.402, P = 0.000), UPDRS-III score (OR = 0.291, P = 0.005), and PSQI score (OR = 0.249, P = 0.017). Micturition number over 24 h was positively associated with HAMA (OR = 0.303, P = 0.004) and UPDRS-II scores (OR = 0.306, P = 0.003). Of patients with residual urine, 79.3% had a volume of residual urine <50 ml. Residual urine was present in 44.4% of the patients with nocturia, 46.5% of the patients with pollakiuria, and 80.0% of the patients with dysuria. More men than women had residual urine (35.2% male vs. 13.3% female; P = 0.002).

CONCLUSIONS

Nocturia and pollakiuria were common micturition symptoms in our participants with PD. Nocturia was associated with depression, anxiety, sleep problems, and severity of PD. Pollakiuria was associated with anxiety and severity of PD. Male patients were more prone to residual urine and pollakiuria.

Urinary Dysfunction in Progressive Supranuclear Palsy Compared with Other Parkinsonian Disorders

BACKGROUND

Autonomic urinary dysfunction affects patients with progressive supranuclear palsy (PSP); however, the severity and prevalence of urinary dysfunctions in these patients compared with those observed in patients with Parkinson's disease (PD) and multiple system atrophy (MSA) are unknown.

OBJECTIVE

We compared urinary dysfunction characteristics in patients with PSP, PD, and MSA.

PATIENTS AND METHODS

Forty-seven patients who satisfied the probable or possible criteria of the National Institute for Neurological Diseases and Stroke and Society for PSP were assessed using the urinary symptoms questionnaire and the urodynamic study at Chiba and Toho Universities (n = 26 and 21, respectively). The results were compared with those of patients with PD and MSA (n = 218 and 193, respectively).

RESULTS

The mean disease duration of PSP and the mean age were 2.97 ± 0.26 and 71.4 ± 0.88 years, respectively. The mini-mental state examination and frontal assessment battery scores were 22.6 ± 0.70 and 10.7 ± 0.49, respectively. Urinary storage and voiding symptoms were observed in 57% and 56% of patients with PSP, respectively. Detrusor overactivity in the urodynamic study was detected in 81% of patients with PSP, which was slightly more than that found in patients with PD (69%) and MSA (67%); however, this was not statistically significant. Postvoid residual volume in patients with PSP was significantly more than that in patients with PD (P < 0.01), but was equivalent to that in patients with MSA.

CONCLUSIONS

The present study demonstrated that patients with PSP experienced various urinary dysfunctions. Urinary storage dysfunction in patients with PSP was not different from that in patients with PD or MSA, whereas urinary voiding dysfunction in patients with PSP was milder than that in patients with MSA and more severe than that in patients with PD. These features should be taken into account for the differentiation of PSP from PD and MSA.

Autonomic dysfunction in subjects at high risk for Parkinson's disease

Aim of this project was to evaluate autonomic dysfunction in subjects proposed to be at high risk to develop Parkinson's disease (PD) compared to control subjects and PD patients at different disease stages. Combinations of substantia nigra hyperechogenicity (SN+) assessed by transcranial ultrasound (TCS), hyposmia, lifetime prevalence of depression and mild PD-specific motor signs were used to identify subjects at high risk for motor Parkinson's disease (HR-PD). Supine and standing blood pressure (BP), hearth rate (HR), orthostatic, urinary, sexual and bowel symptoms were evaluated in HR-PD, healthy control subjects and PD patients, divided into mild and advanced stages. The study group consisted of 113 PD patients (mild PD n = 71, advanced PD, n = 42), 40 HR-PD individuals and 50 controls. Compared to controls, HR-PD subjects complained more often about urinary (p = 0.002) and bowel dysfunction (p = 0.001) and had a higher diastolic BP drop after standing (p = 0.01). The cumulative number of autonomic symptoms differentiated PD as well as HR-PD significantly from controls (p < 0.001). Advanced PD patients presented often and severe orthostatic symptoms, not significantly different from mild PD after concomitant medication correction. Our results support the presence of urinary and bowel dysfunction in subjects at high risk for motor PD. Presence and severity of orthostatic symptoms was higher during stages and increase in advanced stages, at least partly due to increase in dopaminergic and conflicting medication. Understanding the progression of non-motor aspects in PD might offer the possibility to use them as targets for disease-modifying therapies.

Lower urinary tract dysfunction in the neurological patient: clinical assessment and management

Lower urinary tract (LUT) dysfunction is a common sequela of neurological disease, resulting in symptoms that have a pronounced effect on quality of life. The site and nature of the neurological lesion affect the pattern of dysfunction. The risk of developing upper urinary tract damage and renal failure is much lower in patients with slowly progressive non-traumatic neurological disorders than in those with spinal cord injury or spina bifida; this difference in morbidity is taken into account in the development of appropriate management algorithms. Clinical assessment might include tests such as uroflowmetry, post-void residual volume measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the indication. Incomplete bladder emptying is most often managed by intermittent catheterisation, and storage dysfunction by antimuscarinic drugs. Intradetrusor injections of onabotulinumtoxinA have transformed the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. An individualised, patient-tailored approach is required for the management of LUT dysfunction associated with neurological disorders.