Subject: Incontinence: What the Algorithm has to say, and More Selected Abstracts ---------------------------------------------------------------------- What is incontinence and its causes in the Parkinson's family? ---------------------------------------------------------------------- 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] ---------------------------------------------------------------------- WHAT ABOUT MEN WHO HAVE URINARY TRACT OBSTRUCTION DUE TO AN ENLARGED PROSTATE? ----------------------------------------------------------------------- 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. ------------------------------------------------------------------------- OVERVIEW ------------------------------------------------------------------------- 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 [log in to unmask] a subject, or we know where we can OR find information upon it." [log in to unmask] Dr. Samuel Johnson