Subject: Incontinence: What the Algorithm has to say, and More
         Selected Abstracts
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What is incontinence and its causes in the Parkinson's family?
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Authors
  Amarenco G.
Institution
  Laboratoire d'urodynamique et de neurophysiologie, Centre
hospitalier Robert-Ballanger, Aulnay-sous-Bois.
Title
  [Vesico-sphincter disorders of nervous origin]. [Review]
[French]
Original Title
  Troubles vesico-sphincteriens d'origine nerveuse.
Source
  Revue du Praticien.  45(3):331-5, 1995 Feb 1.
 
Abstract
 
  Neurogenic bladder is a common feature in many neurological
disorders such as stroke, multiple sclerosis, paraplegia,
Parkinson disease, peripheral neuropathy. Specific treatment is
always necessary to improve quality of life and decrease renal
potential risk. Urodynamic investigations (cystometry, pelvic
floor electromyography) are very useful to determine physiopathologic
mechanisms of bladder dysfunction. [References: 10]
 
Authors
  Sakakibara R.  Hattori T.  Tojo M.  Yamanishi T.  Yasuda K.
Hirayama K.
Institution
  Department of Neurology, Chiba University School of Medicine,
Japan.
Title
  Micturitional disturbance in progressive supranuclear palsy.
Source
  Journal of the Autonomic Nervous System.  45(2):101-6, 1993
Nov.
 
Abstract
 
  Detailed micturitional histories were taken from nine patients
with progressive supranuclear palsy (PSP), and eight of them
(89%) had micturitional symptoms including urinary incontinence
in seven. Urodynamic studies were performed in six patients and
the results were as follows.
 
Three had residual urine of 100 ml on average. Four had detrusor
hyperreflexia and one had a low compliance cystometrogram. One
had detrusor-sphincter dyssynergia. Motor unit analysis of
external sphincter was performed in four patients and two had
neurogenic changes. The results were compared with our previous
findings in Parkinson's disease and in striato-nigral degeneration
(SND), and we found that a severe degree of micturitional disturbance
in PSP seems to be as common as in SND, especially in the urinary
storage phase, and more frequent than in Parkinson's disease.
Supranuclear types of pelvic and pudendal nerve dysfunctions seemed
to be mainly responsible for micturitional disturbance in PSP.
 
Authors
  Aranda B.  Cramer P.
Institution
  Department of Rehabilitation, Centre Hospitalier, Gonesse,
France.
Title
  Effects of apomorphine and L-dopa on the parkinsonian bladder.
Source
  Neurourology & Urodynamics.  12(3):203-9, 1993.
 
Abstract
 
  Neurogenic bladder frequently occurs in Parkinson's disease.
Detrusor hyperreflexia is a consequence of nigrostriatal
dopamine depletion, whereas the cause of hyporeflexia remains
unclear. We compared the results of cystometry and urethral
profilometry with and without apomorphine (and L dopa) in 12
idiopathic parkinsonians with urinary disorders free of
dopaminergic treatment. Whereas hyperreflexic patients improved
with apomorphine, and to a lesser extent with L dopa, these
drugs had no effect on hyporeflexic patients. These results
confirm the role of dopaminergic lesions in the occurrence of
bladder hyperreflexia and the possible implication of
nondopaminergic lesions in the occurrence of hyporeflexia.
 
Authors
  Desi M.  Pelhuche A.  Benoit G.
Institution
  Service de Neurologie, Hopital de Bicetre.
Title
  [Vesico-sphincteric disorders in patients with Parkinson's
disease].
  [Review] [French]
Original Title
  Les troubles vesico-sphincteriens chez le parkinsonien.
Source
  Progres en Urologie.  2(5):925-32, 1992 Oct.
 
Abstract
 
  Vesicosphincteric disorders are frequent in patients with
Parkinson's disease, due to a lesion of the locus niger of the
extrapyramidal tract which no longer secretes sufficient
dopamine to activate the nigrostriatal tract. The commonest
symptoms are urgent micturition, dysuria or a combination of the
two. 50% of patients with Parkinson's disease present  with
disturbances of micturition and these symptoms may be presenting
complaint of the disease in 10% of cases. Cystomanometry reveals
detrusor hyperactivity in more than 60% of cases and
hypoactivity in less than 30% of case, while dyssynergia is less
common. Delayed relaxation of the striated sphincter may sometimes
be observed. Urological problems must therefore be distinguished
from urodynamic problems in these patients. A combined urological
and urodynamic assessment is essential as the risk of incontinence
following prostate surgery is 20%. Stress urinary incontinence in
women may mask or be associated with urgency. These vesicosphincteric
disorders must therefore be treated cautiously with a combination
of medical treatment (dopatherapy increases detrusor control),
retraining and occasionally surgery after a detailed urodynamic
assessment. [References: 22]
 
 
WHAT THE ALGORITHM HAS TO SAY ABOUT THE MEDICINAL TREATMENTS FOR
INCONTINENCE.
 
URINARY PROBLEMS. The neuro-anatomic substrate for normal
voiding is widespread. The detrusor motor area in the frontal
lobes connects with a similar functional region in the
pontomesencephalic reticular formation. Input from the basal
ganglia to this cortico-mesencephalic loop depresses detrusor
contraction; hypothalamic input increases detrusor contraction.
Peripherally the detrusor is innervated via sacral
parasympathetic neurons, a pathway that is facilitated by
noradrenergic neurons in the locus ceruleus. Seemingly more
important for patients with PD, however, is the loss of
dopaminergic output from the substantia nigra, which appears to
increase detrusor hyperreflexia. Most patients with PD suffer
from detrusor hyperactivity. Relatively few have detrusor
hypoactivity or urethral sphincter dysfunction.
 Common symptoms in PD patients that result from detrusor
hyperactivity include urgency, frequency, and nocturia. Nocturia
is the most common and usually the earliest complaint, only much
later followed by daytime symptoms. In fact, if daytime frequency
or urgency occurs as an initial complaint, causes from mechanical outlet
obstructions, such as prostatic hypertrophy, must be considered.
 Management (breakout 5) Many patients can reduce nighttime
frequency by the simple expedient of reducing liquid intake in
the evening (no liquids after supper). If this nonpharmacologic
intervention is ineffective, peripherally acting
anticholinergics, such as oxybutynin or propantheline, can be
tried. Oxybutynin, 5 to 10 mg, can be administered at bedtime
only or on a tid basis. Propantheline, 7.5 to 15 mg, may also
work well at bedtime or on a tid schedule. If anticholinergics
prove ineffective, hyoscyamine, a parasympatholytic agent, may
work on a qid regimen or at night only (0.15 to 0.30 mg). A
trial of desmopressin, administered at night in escalating doses
(usually 10 to 20 micro g) as an intranasal spray, may work for
otherwise refractory cases.
 Anticholinergic agents, used in the treatment of detrusor
hyperactivity, reduce detrusor contractions, an effect that
may worsen voiding problems in patients with detrusor hypoactivity
or outlet obstruction. Detrusor hyporeflexia, producing incomplete
bladder emptying and urinary frequency, may respond to a reduction
in the dosage of an anticholinergic antiparkinsonian medication
when that is the cause. It is therefore essential that PD patients
with urinary dysfunction have urologic evaluations that include
recording of bladder and sphincter pressure, sphincter
electromyography, and fluoroscopy and that these tests be performed
only by a urologist familiar with their interpretation.
 When cystometric studies reveal a hypoactive detrusor, benefit
may be obtained from alpha adrenergic-blocking agents such as
phenoxybenzamine or prazosin, which decrease tone in the bladder neck.
Unfortunately, these agents can exacerbate or cause orthostatic
hypotension and cardiac arrhythmias and should be used with
caution in patients with PD. Drugs that relax striated
muscle--such as diazepam, baclofen, or dantrolene--can
ocasionally be effective when the external sphincter is
hyperreflexic. Intermittent catheterization is necessary with
myogenic overdystension. Any deterioration in voiding pattern
(even in the absence of dysuria) should raise the concern of
infection, which should be treated promptly.[78]
 
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WHAT ABOUT MEN WHO HAVE URINARY TRACT OBSTRUCTION DUE TO AN ENLARGED
PROSTATE?
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 Although most men over 50 have some prostatic enlargement, in benign
prostatic hyperplasia or hypertrophy (BPH), the prostate gland enlarges
sufficiently to compress the uretha and cause some overt urinary
obstruction. Depending on the size of the enlarged prostate, the age
and health of the patient, and the extent of obstruction, BPH is
treated symptomatically or surgically.
 
 Whatever the cause, BPH begins with changes in periurethral glandular
tissue. As the prostate enlarges, it may extend into the bladder
and obstruct urinary outflow by compressing or distorting the
prostatic urethra. BPH may also cause a diverticulum that retains
urine when the rest of the bladder empties, possibly leading to
calculus formation or cystitis.
 
Signs and symptoms
 
Clinical features of BPH depend on the extent of prostatic enlargement
and the lobes affected. Typically, the condition starts with symptoms
known as "prostatism": reduced urine stream caliber and force;
urinary hesitancy; difficulty starting micturition, which results
in straining, feeling of incomplete voiding, and an interrupted stream.
As obstruction increases, it causes frequent urination with nocturia,
dribbling, urine retention, incontinence, and possibly hematuria.
Radiating pain from the rectal area following intercourse can also
be a symptom. Physical examination can indicate a visible midline mass
above the symphysis pubis that represents an incompletely emptied
bladder; rectal palpation discloses an enlarged prostate.
 
As BPH worsens, complete obstruction may follow bacterial infection
or use of decongestants, tranquilizers, alcohol, antidepressants, or
anticolinergics. Complications include infection, renal insufficiency,
hemorrage, ejaculation reflux, and shock.
 
When symptoms or severe or recurring, a cystourethroscopy (CYSTO) is
a definitive diagnostic measure. Urodynamic tests can be performed during
this procedure.
 
Medical Treatment
 
Conservative therapy includes prostatic massages, sitz baths, fluid
restriction for bladder distention, and antimicrobials for infection.
Regular intercourse may relieve congestion.
 
Early treatment with antimicrobials can start with Bactrim progressing
on to the Cipro family as the period between infections shorten.
 
Urinary flow-rates can be improved with alpha-1-andrenergic blocking
agents such as terazocin (HYTRIN) and prazosin. These drugs relieve
bladder outlet obstruction by preventing contractions of the prostatic
capsule and bladder neck. (detrusor hyperreflexia)
 
Surgical Treatment
 
In the United States, the most common surgical procedure for men
performed under Medicare is the TURP (TransUrethal Resection of the
Prostate). A new procedure that shows promise is VLAP (Visual Laser
Ablation of the Prostate).
 
Surgery is the only effective therapy for relief of acute urine
retention, hydronephrosis, severe hematuria, and recurrent infection
or for palliative relief of intolerable symptoms.
 
VLAP
 
The VLAP procedure is gathering popularity due to the outpatient basis
on which it is done, which reduces cost.
 
The patient enters the hospital or clinic on the same day as the
procedure. A general anesthetic or spinal block is used. ...... The
laser is used to heat the uretheral walls where the obstructions exist,
which does not remove all of ablated tissue but kills the cells which
will be sloughed off in the urine over the next 12 to 26 weeks.
 
A three-way foley is inserted through the penis, prostate and into the
bladder, in the surgical suite. The purpose of the foley is to allow
saline solution to be circulated into the bladder to monitor bleeding,
and flush out blood and any chunks of tissue not flushed during the
laser procedure. It also allows urine to bypass the prostate during
the swelling and healing process for the next three or four days.
Saline irrigation is generally discontinued when the urine color
returns.
 
Barring complications, the patient is sent home the same day, with
instructions on how to remove the foley in three or four days.
 
Recovery
 
Neurogenic bladder patients with detrusor hyperreflexia can have a
painful recovery if untreated due to the urologist not being forewarned
about your condition. Your urinary sphincter will continually fight
with the foley and even when it is removed, chunks will be as painful as
your care-giver's ovulation time. Sypmtoms can be presented as
involuntary straining to empty an already empty bladder. After a
sloughed off chunk has been passed, the symptoms subside. This condition
will present itself for up to and sometimes over 12 weeks.
 
In an uncomplicated recovery, return to light duty work can be done
in a matter of days.
 
The percentage of failure from this procedure is 2%, but some hyperflexic
patients are in this 2%.
 
Benefits at 6 months include improved stream, better control over when
urination starts and stops, and perhaps improved ejaculation.
 
 
TURP
 
Many urologists today combine the features of two procedures into one
when they perform a TURP. The TURP procedure removes the obstructions
in the uretheral canal and increases its area. The TUIP (TransUretheral
Incision of the Prostate) procedure allows the prostate to collapse,
reducing its size. The modern TURP procedure incorporates some of the
TUIP procedure.
 
The anesthetic and three-way foley insertion in the surgical suite are
similar to that done with the VLAP.
 
The surgical tool used for the TURP is the resectoscope, which removes
tissue with a wire loop and electric current. Most removed tissue is
flushed during the process, making any atypical tissue available for
laboratory testing.
 
Once tissue removal is complete, one or more incisions are made on the
prostate floor to allow the prostate to reduce in size.
 
Irrigation of the bladder with saline solution is important post-
operatively with the TURP due to the actual tissue removal and more
blood being present with this procedure.
 
Recovery
 
Neurogenic bladder patients with detrusor hyperreflexia can have a
painful recovery if untreated due to the urologist not being forewarned
about your condition. Your urinary sphincter will continually fight
with the foley.
 
Irrigation usually continues a day or two post-operatively. When it is
discontinued, urinary output and color are charted. Within three or four
days, the foley is removed and when it is verified that you can urinate
normally, you are sent home.
 
Recovery generally takes 12 to 26 weeks for the expected outcomes to
fully appear.
 
The percentage of failure from this procedure is 2%, but some hyperflexic
patients are in this 2%.
 
Benefits at 6 months include improved stream, better control over when
urination starts and stops, and perhaps improved ejaculation.
 
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OVERVIEW
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 I have had both of these procedures. I took prazosin for several years
before it lost its effectiveness. It was a wonder drug for me from the
first dose. Before the surgery, the urologist wanted me on HYTRIN so I
ramped up on it. It seemed to excasserbate my hyperflexia so after the
VLAP, the urologist took me off of it. While lying at rest on my back,
my prostate (in the rectal area) would quiver.
 
VLAP
 
The chunks caught in the urinary sphincter would shut me down until
sometimes several days later, it would pass. An adequate supply of
pain medication is a must. Twenty tablets of Oxycodone are only about
a 4 day supply and you are going to need them for at least two weeks.
If the urologist has reservations about pain medication, GET ANOTHER
UROLOGIST. If you have RLS, you will probably notice that you are
sleeping better. You will probably still have sloughing beyond 12 weeks.
 
TURP
 
This was a piece of cake!
 
OUTCOME
 
After 6 months, post-operatively, I am symptom free without any urological
medication. I have now have willful control and improved sexual plumbing
performance.
 
 
John Cottingham                     "KNOWLEDGE is of two kinds: we know
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