Tremors, rigidity, shuffling steps: they are just a few of the slings and arrows suffered by people with Parkinson’s disease. Then there are the less talked-about secondary symptoms – including urinary problems – that can profoundly influence quality of life. This year, for the first time, the Sunflower Revolution Symposium & Expo will include a segment that focuses on bladder problems, diagnostics and the treatments available to patients with Parkinson’s disease at UC Health.

Speaking about the topic at the free Sept. 12 event will be Ayman Mahdy, MD, PhD, Associate Professor of Urology at the University of Cincinnati College of Medicine and Director of Voiding Dysfunction and Female Urology at UC Health. Dr. Mahdy also will give a brief overview of sexual dysfunction, another secondary symptom of Parkinson’s disease.

The 11^th annual Sunflower Revolution Symposium, to be held Saturday, Sept. 12, at the Oasis Conference Center in Loveland, Ohio, is organized by the James J. and Joan A. Gardner Family Center for Parkinson’s Disease and Movement Disorders at the University of Cincinnati Neuroscience Institute.

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Dr. Mahdy, who trained in Egypt, performed fellowships at the University of South Carolina and Cleveland Clinic Florida. He joined UC Health in 2011. He treats patients with a variety of different neurologic conditions, including Parkinson’s, multiple sclerosis and neurotrauma.

“Families come to me who are concerned with their loved one’s mental status,” Dr. Mahdy says. “Their loved one is soaking wet, wetting the bed. The family is coming with frustration, depression.”

The situation is hard on families and caregivers, he says.

Bladder problems affect many

Bladder problems are common in people with Parkinson’s disease, a chronic, degenerative neurological disorder that affects one in 100 people over the age of 60. Of the 1 million people with Parkinson’s in the United States, 38 percent to 71 percent will suffer bladder problems, according to Dr. Mahdy. Sometimes urinary problems are caused by Parkinson’s, and sometimes they arise independently of the disease as a result of aging.

“Some patients have dementia or other disorders that may impact their ability to control and/or empty their bladders,” Dr. Mahdy says. “Some may have prostate issues or prolapse issues, which can add to the problem. But in general, when we have a patient with Parkinson’s, we presume that bladder symptoms are primarily related to Parkinson’s. Incontinence, urgency, frequency or night frequency are more likely to be related to Parkinson’s.”

Optimal care for patients with bladder problems begins with diagnostics. The core evaluation involves a video-urodynamics exam, a minimally invasive exam that enables the physician to use fluoroscopy and a contrast medium to visualize the bladder under x-ray. “We evaluate pressures and volumes, and the imaging shows us how the bladder looks,” Dr. Mahdy says.

A urinalysis is performed to check for infection, and an ultrasound and blood test may be ordered to assess kidney health.

A wide range of treatments

Several treatments, ranging from conservative to invasive, are available to improve bladder symptoms in patients with Parkinson’s disease. In some cases, levodopa, the primary Parkinson’s medication, will succeed in improving bladder symptoms. But unfortunately, that is not always the case.

“We always start conservatively,” Dr. Mahdy says. “We stay away from surgery if at all possible. And if surgery is required, we explore minimally invasive options first.” Conservative treatment options include:

• Avoidance of “bladder triggers,” including caffeinated drinks, alcohol, acidic juices and spicy foods;
• Avoidance of fluid intake within 4 hours of bedtime if bladder symptoms include night frequency, which robs patients (and caregivers) of sleep;
• Medications that focus on relaxing the bladder. Because older adults usually take a long list of prescriptions, the bladder medication must not cause drug-to-drug interactions or affect cognitive function;
• Absorbents (diapers, pads) to protect clothing and bedding;
• As a last resort, catheters, whose unwelcomed risks include infection, irritation and pain.

Minimally invasive treatments

When patients fail to benefit from conservative treatments, Dr. Mahdy may recommend a minimally invasive treatment that is appropriate to the patient’s diagnosis. Minimally invasive treatments include:

• Cystoscopy with an injection of botulinum toxin (marketed as Botox, Dysport, Xeomin and Myobloc); during this test, the doctor looks inside the bladder and urethra with a thin, lighted tube called a cystoscope. The doctor then injects the drug into the bladder wall, with the goal relaxing the bladder and treating symptoms of urgency, frequency and urge incontinence.
• InterStim bladder control therapy, an FDA-approved treatment developed by Medtronic, Inc., to help a select group of patients who suffer from urge incontinence or urinary retention. InterStim also is used off label for select patients with neurogenic bladder conditions, including patients with Parkinson’s disease.
• Urgent PC, an outpatient stimulation procedure used to help a select group of patients who suffer from urinary urgency, urinary frequency or urge incontinence.
• Minimally invasive prostate surgery, a procedure in which an enlarged prostate is treated so that flow is improved and bladder overactivity subsides.

A small minority of patients may need more invasive surgery, including urinary diversion, Dr. Mahdy says. But for most people who struggle with bladder problems, a wide variety of helpful options are available.

“The bladder is a huge topic,” Dr. Mahdy says. “It is in the caregiver’s best interest to learn about the disease of their loved one and to know what treatments are out there. People who come to see me often don’t know what to expect. Our presentation at the Sunflower Revolution will help them take the best care of their loved ones. It will help them understand the underlying cause, or causes, of patients’ bladder symptoms and what to expect down the road.”

— Cindy Starr