Episode 184: Finding Relief: Bladder Issues in Parkinson’s

Dan Keller 0:02

Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research, the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow.

Bladder issues are a common problem for people with Parkinson's disease. They may experience urinary frequency, urgency to void, leakage, or the very bothersome and sleep-disturbing condition of needing to get up at night to use the bathroom called nocturia. Our guest today, Dr. Ankita Gupta, a urogynecologist at University of Louisville Hospital, discusses these problems and some of the remedies for them. We also talked about how these medical problems and their symptoms can contribute to social isolation and even fall risks. A lot of people may not realize how Parkinson's can affect the bladder and how common the problem is. So, I asked Dr. Gupta to give an estimate of how likely it is to develop urinary problems.

Dr. Ankita Gupta 1:36

So, I think the numbers for the incidence of bladder dysfunction among Parkinson's patients vary a whole lot based on which study you look at, but we know that anywhere between 20% to 96% of patients with Parkinson's will report some level of lower urinary tract dysfunction. A lot of that is multifactorial, so there are more than one thing that affect your bladder. The two most common things that we see in our practice is age—so as patients get older, whether or not they have a history of Parkinson's, they kind of have more of that predisposition towards urinary symptoms—and then the second thing is Parkinson's itself causes some neurologic dysfunction. It affects the autonomic nervous system, and that can kind of exacerbate or worsen both urinary and bowel symptoms in patients who have Parkinson's.

Dan Keller 2:29

Right. And I guess there's possibilities of medications, and everybody's walking around with a water bottle, so you really have multifactorial stuff to sort out.

Dr. Ankita Gupta 2:39

Yeah, definitely. I mean, definitely kind of lifestyle and medications play a big role in that. There's also some differences in gender, so we find that people who have male anatomy, because they have a prostate and a longer urethra, they tend to have more difficulty with voiding, initiating stream, kind of hesitancy-type symptoms, whereas women, because they have a shorter urethra, tend to have more symptoms with leaking and urgency frequency. That's not to say that that doesn't overlap regardless of gender, but in general, men tend to have more retention symptoms, whereas women tend to have more incontinence symptoms, and the treatments for those can be a little bit different, just like the interventions and the management. All of that is a little bit different based on gender.

Dan Keller 3:30

But looking at bladder problems in general, whether it's retention or leakage, is there a sex preference for it, or do men and women suffer about equally in number?

Dr. Ankita Gupta 3:44

You know, it's interesting. There is some data about that. What we find, based on larger epidemiological studies, is that women tend to have more symptoms, but men tend to be more prone to seeking care. And so there is definitely a difference in the kind of care-seeking behaviors between the two genders. I think in women it may either be normalized more often, or—we did a study a few years ago that looked at why women don't seek care, and a lot of women talked about how it just didn't bother them enough to seek care. And so I think there's definitely some differences in care seeking for the same symptoms.

Dan Keller 4:24

Does previous pregnancy and delivery raise the risk of these bladder problems with Parkinson's, or not?

Dr. Ankita Gupta 4:31

Absolutely. I mean, those affect the pelvic floor in general, and so when we think about pelvic floor dysfunction and things that predispose us to pelvic floor issues, such as incontinence or bowel incontinence, fecal incontinence, prolapse, those are very much affected by previous obstetric history. Whether we had any injuries at the time of delivery, the route of delivery—so whether we delivered by C-section or vaginal routes—those things affect women's risks for pelvic floor dysfunction, and so that tends to get compounded or worsened when patients have Parkinson's.

Dan Keller 5:09

What are some of the common bladder challenges? You had mentioned retention, you had mentioned leakage. What else characterizes this condition?

Dr. Ankita Gupta 5:19

So, usually patients will complain of urinary urgency, frequency, and nocturia. Urgency would be that sudden desire to urinate that they're not able to defer, so they can't put it off, they have to go to the bathroom right away, or they're worried that they're going to leak, or they leak on the way to the bathroom. And then frequency would be where they feel like they have to go to the bathroom over and over again—so I'll have patients tell me that they go to the bathroom every 30 minutes, every 60 minutes, and when they go to the bathroom, they don't feel like a whole lot of urine comes out. And nocturia would be waking up in the middle of the night to go to the bathroom as well. And so that tends to be that syndrome that we call overactive bladder, which is very common among patients who have Parkinson's.

Dan Keller 6:01

I suppose it's not only annoying, it can be dangerous. Nocturia—someone gets up at night, it's dark, Parkinson's, people have balance issues—that sounds like a recipe for disaster.

Dr. Ankita Gupta 6:13

Absolutely, and it certainly is one of the things that we find leads to patients getting institutionalized more often. Patients who have incontinence issues are more likely to be in nursing homes than in their own houses. One of the things that we talk to patients about very often is how close is the bathroom, making sure that they have access to a bathroom, especially at night, making sure they don't have any obstacles, so making sure they don't have any rugs that could move, because one of the things we see is patients fall on their way to the bathroom because they're trying to make it over there so quickly.

Dan Keller 6:47

Can these problems lead to social and emotional challenges?

Dr. Ankita Gupta 6:53

Absolutely, and one of the biggest things that I talk to patients about is quality of life, because when we talk about incontinence, it's really the impact of incontinence on quality of life. We have patients who do things that we call "bathroom mapping," where anytime they go somewhere new, they look at where the closest bathrooms are, or they won't go somewhere where they know there is not access to a bathroom. They won't take long road trips, they won't just be somewhere that's outside their comfort zone, and for a lot of patients that's very socially isolating—just that inability to leave their house just because they're so constantly afraid they're going to leak, and it really restricts their ability to do things that they enjoy.

Dan Keller 7:36

Social isolation is a risk factor for dementia for anyone, and in Parkinson's, there's a higher risk of dementia.

Dr. Ankita Gupta 7:46

You know, dementia is so multifactorial, but yes, certainly, like improving patients' quality of life, giving them that ability to engage with other people outside of their house can improve so many different aspects of their life.

Dan Keller 8:04

When should someone bring this up with their doctor, and what kind of doctor is best suited to deal with it?

Dr. Ankita Gupta 8:12

Usually, I recommend that patients bring this up when it affects their quality of life, when it affects their ability to do things that they enjoy. That's the right time to seek care. A lot of my patients will bring it up with their primary care doctors or their neurologists, and we recommend getting referred to specialists, such as urologists or urogynecologists, who really are trained in pelvic floor dysfunction and managing incontinence. For patients who don't have access to those services, often a general gynecologist or primary care physician can start them on medications or first-line treatment options for their incontinence.

Dan Keller 8:51

Are urologists and urogynecologists familiar with Parkinson's disease for the most part? You seem to be up on that, but I would think they deal mostly with urinary problems and not things stemming from the brain.

Dr. Ankita Gupta 9:05

There are a lot of similarities in the treatment options for patients with and without Parkinson's. So, for most urologists and urogynecologists, they are familiar with neurogenic bladder, which is the subset that Parkinson's falls within, but even if Parkinson's patients don't make up the primary subset of their population, a lot of the treatments do overlap. So, most urologists or urogynecologists would feel very comfortable taking care of overactive bladder in patients with Parkinson's.

Dan Keller 9:37

Do bladder problems respond to dopaminergic drugs, L-DOPA, other ones, or do you have to treat it almost symptomatically?

Dr. Ankita Gupta 9:47

You know, that's a very interesting question. I think that there is a lot about that interplay that we don't fully understand. I do see some patients early on who might respond to dopaminergics, but I do find that when I see patients, it's usually because their Parkinson's is pretty well controlled, or they're under the care of a neurologist who's working with them for their Parkinson's, and they need some additional interventions to help with that bladder. And so usually I tell patients that it's a good idea to kind of control your Parkinson's with the medications that are appropriate for that, but also to add interventions for the bladder if they're having bothersome urinary symptoms.

Dan Keller 10:29

What are the main treatment options or modalities?

Dr. Ankita Gupta 10:33

So, usually we tailor our treatments individually to the patient, again, with the goal of making their quality of life better. Usually, we start with the least invasive option and kind of escalate that management until we get the patient's quality of life better. So, our first-line treatment options would be things like diet and lifestyle control—you know, making sure patients are drinking an adequate amount of fluids. We don't want them to get dehydrated, but we also don't want them drinking more than 60 to 80 ounces of fluids per day.

I usually would recommend that patients kind of structure that based on when they have access to a bathroom. So, I usually recommend that they consume that fluid mostly in the morning and cut their fluids out a few hours before bed to kind of prevent having to wake up at night to go to the bathroom. I'll also recommend that they adjust the timings for some of their medications, such as diuretics, if that's possible. So, again, recommending that they take those in the morning so that they can use the bathrooms throughout the day, rather than taking them before they go to bed to prevent them from waking up at night.

I usually will also recommend optimizing just some of their other comorbidities, so for patients who have sleep apnea, really making sure that they use their CPAP machines at night. There are other interventions that fall in that first-line treatment, so that would be something like pelvic floor physical therapy, bladder retraining, scheduled voiding. There are quite a few things that we can do that don't involve medications that can significantly improve the quality of life for patients.

Dan Keller 12:03

You had mentioned diuretics. There's certain things that are non-drug diuretics. What about coffee or tea consumption or colas containing caffeine and things like that? Do those affect bladder problems?

Dr. Ankita Gupta 12:18

They certainly do. There are a lot of bladder irritants or foods that make us urinate more often. I tell patients to cut down what they're drinking as far as non-water drinks, so definitely cutting down on that caffeine, tea, soda kind of beverages. Aerated and caffeinated beverages tend to be the worst, and I find things like diet products, diet sodas really tend to affect patients' urgency and frequency symptoms.

Dan Keller 12:48

What about things for women like Kegel exercises or other pelvic floor musculature?

Dr. Ankita Gupta 12:55

Yeah, definitely working with a pelvic floor physical therapist can be very beneficial. I like to kind of use the metaphor that, you know, if you were working out on your own versus working out with a physical trainer, that's kind of the difference between doing Kegel exercises at home versus doing pelvic floor physical therapy with an actual trained physical therapist. They can also work on things like bladder training—so where they're doing more of a scheduled or timed voiding, making sure that they're going to the bathroom every few hours to keep from going several hours without going to the bathroom and getting hit with that urge. There are techniques for urge suppression that they can learn and practice, but just like any other exercise, they have to keep up with those exercises to see the benefits of them.

Dan Keller 13:43

Right, this can be a sensitive topic for people. So, what advice would you give them who might feel hesitant to bring it up with their doctor?

Dr. Ankita Gupta 13:53

You know, that's one of the biggest reasons I went into urogynecology, because I find that in general people feel so ashamed or embarrassed to talk about this in front of their physicians, their family members. But usually I'll tell people it's so common—it really affects more than 50% of women. I always will joke with my patients that if you brought it up with your friends, I bet you most of your friends are leaking as well, or if someone tells a joke when you're at brunch, look around and see how many people cross their legs, and that's everyone who's leaking, you know. And so it's really just very, very common among women. And so one of the biggest things is there are treatment options. So we need to stop normalizing it. We need to kind of bring it up and say, "This is something that's happening to me. What are things I can do to make my quality of life better?" And there are people like us—there are urologists and urogynecologists who are deeply passionate about this, and we want to make people's lives better.

Dan Keller 14:52

Does surgery ever enter into it? I know they have all sorts of things to tighten up urethras and things.

Dr. Ankita Gupta 14:58

Yeah, there are definitely some procedure options that can help with incontinence. Usually, if we fail first-line treatment options, we typically would try medications. So, there are different classes of medications that we would use. And again, for Parkinson's patients, we try to stay away from anticholinergics because those can predispose patients to falls. So, we try to use beta agonists, and most of the time we want to try and fail at least one medication before we move on to any kind of procedures, but there are different procedures we can do. There are bladder pacemakers that we can use. There are injections we can do in the bladder of OnabotulinumtoxinA, which you know a lot of patients with neurological complaints might be familiar with. We have like slings and injections we can do for patients who leak when they cough, laugh, and sneeze, which is a slightly different type of leaking than the overactive bladder we were talking about before. There are active stimulators, implantable devices—really just a host of procedure options that we can offer patients when medications don't work.

Dan Keller 16:00

I was talking to a urologist some years ago who was talking about botulinum toxin injections, and I said, "Well, how frequently do you do them?" And he said, "When the patient comes back and tells me that they need it." So—

Dr. Ankita Gupta 16:14

Yeah, you know, they really do have a wide variety of how long they last. The recommendation is somewhere between six months and 18 months, so for most of my patients, I'll check in every six months and see kind of where they are with symptoms, but usually we see that the effect lasts about six months, so usually I'll tell patients twice a year is what they can expect to repeat their botulinum toxin injections.

Dan Keller 16:40

Is there anything important we've missed or interesting to add?

Dr. Ankita Gupta 16:44

There are some other risk factors that you want to bring up to your physician sooner rather than later. So, if you ever see blood in your urine, if you are having recurring UTIs or bladder infections, if you have burning when you urinate, those are definitely things that you want to bring up sooner rather than later. But I think for the most part just to remember that you're not alone, and it's very common for people to have bladder issues, and if you bring it up and get the help that you need, our goal is to make your life better.

Dan Keller 17:17

Well, I appreciate it. Thank you. I think it's good practical advice for people who may have the problem and were a little hesitant to address it, so thanks.

As Dr. Gupta mentioned, urinary issues are common in PD, and there are effective treatments, so don't hesitate to talk to your movement disorder neurologist, gynecologist, or urologist about any problems you're experiencing. There is lots of information on our website about bladder issues, including past podcasts, blog posts, and an expert briefing. A good starting point would be to search our website at parkinson.org for bladder, and then check the box that says resource library.

As always, our PD information specialists can answer questions and provide information in English or Spanish about this topic or anything else having to do with Parkinson's; you can reach them at 1-800-4PD-INFO. If you'd like to leave feedback on this episode, or to let us know what other topics you'd like us to cover, visit parkinson.org/feedback. Be sure to subscribe and rate us on Apple Podcasts, or wherever you get your podcasts. At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every month. Till then, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO. That's 1-800-473-4636. Thank you for listening.

Dr. Ankita Gupta 19:21

Thank you.

Ankita Gupta, MD, MPH, FACOG is a Urogynecologist and the associate fellowship director for the Urogynecology & Reconstructive Surgery fellowship at University of Louisville Hospital in Louisville, Kentucky. Dr. Gupta has served on the editorial board of AUGS e-learning, was a member of the social media and DEI committees and was a part of the pelvic floor consortium working group on urinary incontinence. She was also a member of the Fellows, Trainees and Early Career Professionals Committee as well as the IUGA Education Committee. She currently chairs the Systematic Review Group arm of the Society of Gynecologic Surgeons, which aims to evaluate existing data and propose new guidelines to improve evidence-based patient care.