Parkinson's disease is the second most common neurodegenerative disorder in the UK (Worth, 2013). It is an incurable and progressive disease, although the rate of progression can vary from patient to patient (Worth, 2013). People with Parkinson's disease also have increased muscle weakness and the typical symptoms of tremor, stiffness, slowness, balance problems and/or gait disorders (National Institute for Health and Care Excellence (NICE), 2017). Other symptoms may include an overactive bladder, urgency and nocturia in Parkinsonism, due to the role of dopaminergic mechanisms and its function in maintaining normal bladder control (Sakakibara et al, 2012). Certainly, autonomic dysfunction, including orthostatic hypotension, sialorrhea, altered sexual function, urinary dysfunction and constipation, are common features of Parkinson's disease (Perez-Lloret et al, 2013). Some 80% of patients with Parkinson's disease also develop psychiatric problems, such as hallucinations and dementia, with a reduction in life expectancy (Hobson et al, 2010).
Aetiology
Parkinson's disease is caused by a loss of the dopaminergic neurons in the pars compacta of the substantia nigra (SNpc), which is part of the basal ganglia. Dopamine plays a vital role in regulating the movement of the body (NHS, 2019). The reasons for this damage are unknown, but there are suggestions that oxidative stress, inflammatory assault and mitochondrial inhibition are causes (Breuer et al, 2013). Recent studies suggested a possible link between the human gastric pathogen Helicobacter pylori and Parkinson's disease (McGee et al, 2018). Some of the causes of the symptoms of Parkinson's disease are still unknown, such as lower urinary tract symptoms (LUTS) (Badri et al, 2014). Autonomic dysfunction certainly plays a role in the manifestation of LUTS in Parkinson's disease, and it has been suggested that the frontal cortex, basal ganglia, thalamus and anterior cingulate gyrus play a role in this (Fowler et al, 2010).
Urinary symptoms
Patients with Parkinson's disease experience both storage symptoms, specifically overactive bladder, and voiding difficulties. Urinary incontinence related to urinary urgency or frequency is a common non-motor disorder in Parkinson's disease (McDonald et al, 2017). Bladder dysfunction is not always responsive to treatment with levodopa, so it is suggested that the brain pathology causing bladder dysfunction is due to an altered dopamine basal ganglia-frontal circuit that suppresses the micturition reflex (Sakakibara et al, 2012; McDonald et al, 2017). Despite the high incidence of urinary problems among patients with Parkinson's disease, little is known about their pathogenesis in this condition and response to treatment (McDonald et al, 2017). It is suggested that some 24–96% of patients experience bladder dysfunction (Martinez-Martin et al, 2011; Uchiyama et al, 2011; Yeo et al, 2012), such as urinary incontinence, urge incontinence and faecal incontinence (Sakakibara et al, 2001). Incontinence is defined as the involuntary or inappropriate passing of urine and/or faeces (Abrams et al, 2010).
Management
The mainstay of treatment for Parkinson's disease is the pharmacological management of motor symptoms, which are dopamine agonists, specifically, levodopa and MAO-B inhibitors (NICE, 2017). Levodopa is a naturally occurring amino acid that is used to treat Parkinson's symptoms; it is metabolised to dopamine in the brain and is considered an effective drug for Parkinson's disease, but prolonged use may result in side effects, including changes in motor function and dyskinesias (Worth, 2013). However, levodopa does not always reduce urinary problems, and there is some dispute about the action of both levodopa and dopamine agonists for this condition (Sakakibara et al, 2010; Uchiyama et al, 2003). Initially, levodopa has a negative action, but long-term therapy has led to some positive effects (Brusa et al, 2007). It is also important to ensure that patients with Parkinson's disease have a thorough medication review, as some medication can affect bladder function and aggravate existing symptoms, such as beta-blockers and parasympathomimetics, as they can enhance detrusor activity (Jost, 2013). Tricyclic antidepressants can increase sphincter activity, leading to urinary retention (Chung et al, 2016; Faure Walker et al 2016; Annamalai, 2017).
The type, frequency and severity of symptoms relate to the age, duration and progression of the motor symptoms (Sakakibara et al, 2010). Treatment options vary depending on the cause of the incontinence, such as surgical management of prostatic obstruction in men (Badri et al, 2014). Treatment 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 (Badri et al, 2014). For patients with incomplete bladder emptying, intermittent catheterisation is helpful. Storage dysfunction is managed by antimuscarinic drugs, and intra-detrusor injections of onabotulinum toxin A (onabot A) are helpful for neurogenic detrusor overactivity (Panicker et al, 2015).
Anticholinergic drugs are used to treat bladder dysfunction in Parkinson's disease, although they should be used with caution, as they can cross the blood–brain barrier and have the potential to cause central nervous system-related side effects, such as confusion, or can exacerbate constipation (NICE, 2012; Sakakibara et al, 2012). Cystoscopy with low-dose onabot A injection is a long-term management strategy for patients who fail to respond to oral antimuscarinic agents. (Anderson et al, 2014). Certainly, studies suggest that a combination of bladder training, antimuscarinic drugs and intravesical botulinum toxin may improve lower urinary tract disorders in Parkinson's disease (Brucker and Kalra, 2017; Madan et al, 2017; McDonald et al, 2017).
The community nurse's role is to ensure that a comprehensive assessment of the patient occurs, as this is necessary before implementing an appropriate treatment plan (Yates, 2019). Continence assessment should be conducted by a professional with appropriate training (McClurg et al, 2013). A baseline continence assessment aims to determine the cause, impact on quality of life and any complications (Yates, 2019). NICE (2015) suggested that a comprehensive continence assessment should also include a full medical history, social history, medication, a 3-day bladder diary and a quality-of-life questionnaire. Additional tests should include fluid balance, urinalysis, urodynamic tests and general and specific system examination (Abrams et al, 2010). This is because there are many factors that can influence a particular individual's symptoms (Abrams et al, 2010). There appears to be a lack of specific assessment tools for Parkinson's disease, but tools like the EVIDEM-C dementia-focused continence assessment can be helpful for community nurses, as they facilitate local continence assessment for patients with Parkinson's disease (Iliffe et al, 2015).
Community nurses may also be involved in supporting families with tailor-made bladder training, such as establishing a regular toilet routine, education about pelvic floor exercises or supply of incontinence products. The training needs to consider a person's physical condition and cognitive function to promote their active participation in care (NICE, 2012). The assessment and supply of incontinence products are important, as it is not possible to promote continence. Patients need support for managing incontinence, enabling the person to maintain dignity and avoid the complications of incontinence (Nazarko, 2015). Community nurses can support the person with Parkinson's disease, enabling them to have access to the appropriate type of incontinence pads and minimising risks of complications, such as skin damage and leakage (Nazarko, 2015).
People with Parkinson's disease should also have regular clinical monitoring and medicines management; a point of contact for support, including home visits; and educational support from a Parkinson's disease nurse specialist (NICE, 2017). Undoubtedly, good communication with people with Parkinson's disease and their carers is required to help empower them to participate in judgements and choices about their own care (NICE, 2017).
Conclusion
Parkinson's disease is one of the most common progressive neurodegenerative disorder in the UK, with a range of symptoms. These vary from increased muscle weakness, tremor, stiffness, slowness, balance problems and/or gait disorders and lower urinary symptoms. Most of the causes of lower urinary symptoms in Parkinson's disease are unknown, so a thorough patient assessment is key to any treatment plan (NICE, 2017). Treatment aims are to help support quality of life using a multi-pronged diagnosis-specific approach to improve lower urinary tract disorders in Parkinson's disease. The community nurse has a key role to play in the assessment of these patients. They also have a role in supporting families with tailor-made bladder training, education about pelvic floor exercises or supply of incontinence products.
KEY POINTS
- Patients with Parkinson's disease experience both storage symptoms, specifically overactive bladder, and voiding difficulties
- Urinary incontinence related to urinary urgency/frequency is a common non-motor disorder in Parkinson's disease
- The causes of the symptoms of Parkinson's disease are still unknown, such as lower urinary tract symptoms (LUTS)
- The type, frequency and severity of lower urinary symptoms relates to the age, duration and progression of the motor symptoms
CPD REFLECTIVE QUESTIONS
- What are the main lower urinary symptoms patients with Parkinson's disease can develop?
- What are the main aims of management and treatment of lower urinary conditions?
- What are the main treatment options for incontinence in Parkinson's disease?