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INTERNAL REGULATION PROBLEMS 11 CONSTIPATION: Seldom discussed but often experienced in PD, constipation can be very troublesome. Doctors may blandly dismiss the complaint with advice to eat more bulk and fibrous foods, drink more water, exercise more, and so forth. But the problem arises from weakening or paralysis in PD of the colon (lower or large intestine). Dopamine figures in neural control elsewhere than in the brain, and the autonomous control of muscles in the intestines seems to be impaired by PD. Neglected constipation may result in a hard impacted mass called megacolon, that becomes a surgical emergency. Even when controlled, the transit time of food waste through the colon may be increased in PD from a few hours to a day or more. I think for most PWP the alternative is a chemical laxative every few days, plus a precautionary stool softener. My doctor advises that the least harmful chemical is bisacodyl (Dulcolax or other tradenames) which stimulates nerve action in the colon. A suitable stool softener is docusate (various tradenames), which inhibits the colon's normal function of water extraction. SEXUAL DYSFUNCTION: PWP have various kinds of sexual dysfunction, but it is difficult to separate the effects of the disease from those of drug medication, indirect reflection of mental state, and normal aging. Men can experience painful dystonia in muscle surrounding the prostate gland, which may or may not be related to PD. Abnormal Libido: Sexual desire, pleasure, or energy may be either weakened by PD or enhanced by drugs taken for PD. A small controlled study showed that women with PD experienced and enjoyed sex less than the normal controls. In anecdotal reports, a few men getting apomorphine for PD had psychotic increase of libido, leading to psychological dependence and need for restraint. Impotence: I have heard remarks about this effect, but have no specific data. MENSTRUAL EFFECTS: Motor symptoms and fluctuations are much worsened during the peak of the ovulation cycle. In one report, acetazolamide (Diamox) dramatically relieved the effect. INTERNAL REGULATION PROBLEMS (cont.) 12 URINARY DYSFUNCTION: Normal discharge of urine requires coordination of muscles at several points along the urinary tract. Both incontinence and retention (at different times) may occur, I believe more often in men. An urologist unaware of a male patient's PD may diagnose a common obstruction due to precancerous growth in the prostate gland, and strongly urge a popular surgery called Trans-Urethral Resection of Prostate (TURP), which not only fails to remedy the problem if due to PD, but needlessly destroys the sexual function of the prostate. Incontinence: As the effect of PD medication declines after each dose, the PWP may have an uncontrollable urge to urinate. Urination therefore tends to synchronize with the medication schedule. Retention: Due to lost coordination of various muscles under autonomous control, intentional voiding just prior to the scheduled dose of PD medication may be incomplete. Levodopa in particular seems to have some effect within a minute or less, and immediately after a dose the need to urinate returns. Color In Urine: Some PD drugs, including Sinemet, may as a harmless side effect cause deeper color in urine. INTERNAL REGULATION PROBLEMS (cont.) 13 EXUDATIONS: Among the more annoying symptoms of autonomous system failure in PD are changes in the body's normal secretions of the skin and elsewhere. Drooling, runny nose, excessive or abnormally dark perspiration, oily skin, sebaceous cysts, and eyelid irritation are all well known in PD. Drooling: This is simply excess salivation, which may occur either when awake or asleep. It is more noticable when the patient with reduced autonomous function forgets to swallow. Runny Nose: At times the subject's nose may suddenly "drip like a faucet" a clear watery discharge, with no sign of a cold or allergic insult, and just as suddenly stop. I think it might be a peak-dose effect of levodopa. Sweating: This sometimes frightening effect has been noted in scientific literature as due specifically to levodopa therapy which has reached the fluctuation stage. It occurs within a narrow range of plasma dopamine level, and is said to be abolished by addition of a dopamine agonist to therapy. Unusual dark-colored perspiration has also been blamed on levodopa. A possibly interesting sidelight is that the Sinemet formulation of levodopa in tap water, which usually contains chlorine as a disinfectant, will leave a black evaporation residue, but not in distilled water. Seborrhea: Excessive oiliness of the scalp, face, and neck is common enough to be mentioned in patient handbooks, although the recommended remedy of an astringent shampoo offers only short-lived relief. Dandruff: Usually a harmless byproduct of oily scalp, in people with or without PD. You probably can forget the usual anti-dandruff preparations, and concentrate on the oiliness. I use Boraxo, a powdered hand soap, instead of shampoo. Skin Cysts: The sebaceous glands become clogged by overactivity, and develop pores containing waxy matter that may be gently squeezed out. When the outlet is clogged, a solid benign cyst may form, that may require surgical removal to avoid possible infection or further growth. More often such cysts on the hairless part of the scalp are tiny and can be removed by liquid nitrogen. Blepharitis: When related to seborrhea, called "seborrheic blepharitis" (irritation of eyelids). With no pain or sign of infection, eyelids are continually red and swollen, often accompanied by copious tears and/or solid deposit that interferes with vision unless frequently removed. Books (and doctors who read them) advise "no tears" baby shampoo, but plsin water will do just as well. Note, this condition is just the opposite of the "dry eye" complaint that results from inadequate blinking by PD patients. INTERNAL REGULATION PROBLEMS (cont.) 14 LOW BLOOD PRESSURE: Low blood pressure has been cited in scientific literature as a symptom of PD, and I have heard it mentioned often by other PWP. In related diseases such as multiple system atrophy (MSA), orthostatic hypotension (failure to compensate upon arising from seated or supine position) is an important diagnostic sign. PROLACTINEMIA: The bean-size pituitary gland, situated at the base of the brain and connected by a stalk of neurons to the hypothalamus, secretes several important hormones including prolactin, which stimulates lactation in nursing mothers but also is present to a degree in men. Prolactin is inhibited in a feedback loop by dopamine, so one might expect an elevated prolactin level to accompany the dopamine shortage of PD. The accepted treatment for prolactinemia is a dopamine agonist such as bromocriptine (Parlodel). An increased level may also be due to a pituitary tumor, therefore an MRI scan to rule out that possibility may be a good idea. THERMAL CONTROL: PD affects the perception of ambient temperature, causing the subject to feel colder or warmer than warranted by actual conditions, but not the internal body temperature. However at times one hand or foot may be colder or warmer than the other. NAUSEA: I don't know of nausea caused directly by PD, but it is a common side effect of numerous PD medications. Levodopa in particular causes nausea, that may be avoided by addition of carbidopa. The combination is named Sinemet, after the Latin "sine emesis", for "no vomiting". SENSORY DYSFUNCTION 15 SENSORY DYSFUNCTION: Although the effects may be overshadowed by the more urgent motor symptoms of PD, Virtually all the senses are impaired. Sensory impairment is very common, if not universal, among PWP but tends to be ignored, not only by attending neurologists but also in research projects. Its importance lies in the evidence that PD definitely affects parts of the brain other than the basal ganglia. VISUAL EFFECTS: Aside from the motor effects already discussed above, PD affects the optical function of the eyes, sometimes long before appearance of the skeletal movement symptoms. Color Perception: There are several known kinds of colorblindness, distinguishable by ingenious neuropsychological tests. In PD the sensitivity to color is only partly lost, but it appears early enough for use as a preclinical indicator. Contrast Perception: In tests involving a grid with two different shades of alternating gray bars, PWP definitely are less sensitive to contrast. This loss may affect driving ability, where poorly maintained lane-marking stripes or other visual aids may require a bigger share of the driver's attention. TEMPERATURE SENSATION: PWP may feel colder or warmer than called for by actual temperature of surroundings. The effect seems to be more pronounced as the levodopa dosage interval draws to an end. MECHANICAL SENSATION: Numerous common manual tasks that may need a fine sense of touch in the fingertips, reliable control of applied force, or kinesthetic sense of position (as in sewing on a button) are harder for PWP. SMELL AND TASTE: These closely related senses are very commonly impaired in PD. Insensitivity to smell (anosmia) may be nearly complete, so that even strong odors, such as that of gasoline, are barely noticed. The PWP may also develop a preference for strong flavors in food. TINNITUS: Neurologists claim there is no connection with PD, but I'm not sure. In my own case, tinnitus in the form of a loud, very high-pitched whistle has persisted 24 hours a day since about the time I was diagnosed with PD. Hearing sensitivity is about normal for my age, 76: high-frequency (in the range of the tinnitus) loss is pronounced. Cheers, Joe -- J. R. Bruman (818) 789-3694 3527 Cody Road Sherman Oaks, CA 91403-5013