Parkinson’s Disease and YOU-rination Urologic Manifestations of PD Christopher Tenggardjaja, MD KP LAMC Urology December 20, 2017

Face of Parkinson’s Disease Michael j fox foundation website Journal of the Neurological Sciences, 2017-10-15, Volume 381, Pages 35-35, Copyright © 2017 Described in essay form in 1817 Illustrated 6 cases Physician more populary known as geologist though Termed Parkinson’s disease by charcot Still causing suffering 250 years later No known picture of james parkinson Face of Parkinson’s Disease

Urologic Manifestations of Parkinson’s Disease Overview of today’s webinar How PD affects urination and sexual dysfunction Followed by treatments https://www.pinterest.com/pin/385409680589771319/ Urologic Manifestations of Parkinson’s Disease

Urologic Manifestations of Parkinson’s Disease Urinary symptoms Sexual dysfunction Overview of today’s webinar How PD affects urination and sexual dysfunction Followed by treatments https://www.pinterest.com/pin/385409680589771319/ Urologic Manifestations of Parkinson’s Disease

Urologic Manifestations of Parkinson’s Disease 70 year old man Diagnosed with Parkinson’s disease Going to restroom to often Urologic Manifestations of Parkinson’s Disease

Urologic Manifestations of Parkinson’s Disease Up to 70% affected by lower urinary tract dysfunction Nocturia – getting up at night to urinate Frequency – bothersome Urgency – difficulty in postponing Urologic Manifestations of Parkinson’s Disease

Urologic Manifestations of Parkinson’s Disease “I leak before I get to the restroom” “I know where every urinal is in the mall” “I just look at the clock when I try to sleep” Urologic Manifestations of Parkinson’s Disease

Neurologic disease affecting loss of dopamine neurons in the substantia nigra in the brain Beautiful scanning electromicrographs Affects nerves in the body Specifically resting tremor, bradykinesia, rigidity Journal of Neuroscience 29 June 2005, 25 (26) 6251-6259; DOI: https://doi.org/10.1523/JNEUROSCI.4601-04.2005 Why?

This then affects the bladder and you get issues of DO and urinary urgency All of this without even throwing in the dysfunction you get with age due to the prostate! Why?

Bladder? Outlet? This then affects the bladder and you get issues of DO and urinary urgency All of this without even throwing in the dysfunction you get with age due to the prostate! Why?

What a Urologist can offer Further evaluation Advanced testing Treatment options What a Urologist can offer

What a Urologist can offer Further evaluation History and Physical How often Association Disability (bother) How often is this occurring When does it happen Association with behaviors – ie caffeine Difficulty with getting to restroom 2/2 movement Dementia play a role Bother? What a Urologist can offer

Voiding diary UDI 6 questionnaire Males- IPSS Tools for evaluation

Irritative vs Obstructive Irritative Symptoms Frequency Urgency Nocturia Sensation of incomplete emptying If they have a lot of irritative symptoms then the treatment options are decidedly different than obstructive Often times it starts with something for the outlet; if we’re talking about women, then we’re not talking about a prostate and usually not something causing outlet obstruction in Parkinson’s patients Irritative vs Obstructive

Irritative vs Obstructive Irritative Symptoms Frequency Urgency Nocturia Sensation of incomplete emptying – Sensation vs actually not emptying! If they have a lot of irritative symptoms then the treatment options are decidedly different than obstructive Often times it starts with something for the outlet; if we’re talking about women, then we’re not talking about a prostate and usually not something causing outlet obstruction in Parkinson’s patients Irritative vs Obstructive

Irritative vs Obstructive Obstructive Symptoms Hesitancy Weak/slow stream Straining Voiding diary UDI 6 questionnaire Irritative vs Obstructive

What a Urologist can offer Advanced testing Uroflow and post void residual Urodynamics Cystoscopy What a Urologist can offer

What a Urologist can offer Advanced testing Uroflow and post void residual Non-invasive Performed in office can provide information on flow and emptying but not etiology What a Urologist can offer

What a Urologist can offer Advanced testing Uroflow and post void residual Urodynamics Invasive with catheters Performed in office More detailed information What a Urologist can offer

What a Urologist can offer Advanced testing Uroflow and post void residual Urodynamics What a Urologist can offer

What a Urologist can offer Advanced testing Uroflow and post void residual Urodynamics What a Urologist can offer

What a Urologist can offer Advanced testing Uroflow and post void residual Urodynamics Cystoscopy What a Urologist can offer

What a Urologist can offer Advanced testing Uroflow and post void residual Urodynamics Cystoscopy Invasive Performed in office What a Urologist can offer

What a Urologist can offer Advanced testing Uroflow and post void residual Urodynamics Cystoscopy What a Urologist can offer

Treatment options Treatment options depend on what urinary symptoms we are dealing with

Bladder? Outlet? Treatment options Comes down to is it the bladder or is it the outlet or a little bit of both Urge/frequency may be as easy as reducing fluid intake to 2L per day, modifying behavioral habits such as no fluids 2 hours prior to bed, or not drinking that pot of coffee before bed When that fails we start to go down the pathway of medications and surgeries Briefly: mainstay medication for urge/frequency - anticholinergics

Treatments Behavioral therapy Timed voiding Decrease caffeine Limit fluids before bedtime Avoid constipation!!! Behavioral therapy Treatment options depend on what urinary symptoms we are dealing with Urge/frequency may be as easy as reducing fluid intake to 2L per day, modifying behavioral habits such as no fluids 2 hours prior to bed, or not drinking that pot of coffee before bed When that fails we start to go down the pathway of medications and surgeries Briefly: mainstay medication for urge/frequency - anticholinergics Treatments

Treatments Constipation Not just drinking 8 glasses 35-40 grams of fiber Ambulation Medications can contribute Treatment options depend on what urinary symptoms we are dealing with Urge/frequency may be as easy as reducing fluid intake to 2L per day, modifying behavioral habits such as no fluids 2 hours prior to bed, or not drinking that pot of coffee before bed When that fails we start to go down the pathway of medications and surgeries Briefly: mainstay medication for urge/frequency - anticholinergics Treatments

Treatments Behavioral therapy Bedside commode Bedside urinal PT for movement Behavioral therapy Treatment options depend on what urinary symptoms we are dealing with Urge/frequency may be as easy as reducing fluid intake to 2L per day, modifying behavioral habits such as no fluids 2 hours prior to bed, or not drinking that pot of coffee before bed When that fails we start to go down the pathway of medications and surgeries Briefly: mainstay medication for urge/frequency - anticholinergics Treatments

Treatments Anticholinergic/antimuscarinics Oxybutynin Trospium Benefits: reduction in urge/frequency and leak episodes Risks: constipation/dry mouth most common risks Treatment options depend on what urinary symptoms we are dealing with Urge/frequency may be as easy as reducing fluid intake to 2L per day, modifying behavioral habits such as no fluids 2 hours prior to bed, or not drinking that pot of coffee before bed When that fails we start to go down the pathway of medications and surgeries Briefly: mainstay medication for urge/frequency - anticholinergics Treatments

Treatments Third line treatments: PTNS Onaboutlinumtoxin A Sacral neuromodulation Treatment options depend on what urinary symptoms we are dealing with Urge/frequency may be as easy as reducing fluid intake to 2L per day, modifying behavioral habits such as no fluids 2 hours prior to bed, or not drinking that pot of coffee before bed When that fails we start to go down the pathway of medications and surgeries Briefly: mainstay medication for urge/frequency - anticholinergics Treatments

Treatments Treatment options – obstructive symptoms Rarely do patients with PD develop true dyssnergia of their sphincter and bladder leading to obstructive symptoms Uds can help determine this but in a male most likely prostate issues Medications can help: alpha blockers (terazosin and Tamsulosin) first line Followed by 5 ARI and then consideration for outlet surgery – most common being a TURP Treatments

Urologic Manifestations of Parkinson’s Disease Quickly discuss sexual dysfunction in regards to PD Urologic Manifestations of Parkinson’s Disease

Sexual dysfunction depending on the sex can be like a black box Without even throwing PD into the mix sexual dysfunction itself can be hard to treat due to the complicated nature of sexual desire and physiology Sexual Dysfunction

Sexual dysfunction depending on the sex can be like a black box Without even throwing PD into the mix sexual dysfunction itself can be hard to treat due to the complicated nature of sexual desire and physiology Sexual Dysfunction

Sexual Dysfunction Parkinson’s factors: Bradykinesia Rigidity Tremors Self- consciousness Sexual dysfunction depending on the sex can be like a black box Without even throwing PD into the mix sexual dysfunction itself can be hard to treat due to the complicated nature of sexual desire and physiology Sexual Dysfunction

Sexual Dysfunction in PD Male: Erectile dysfunction Premature ejaculation Hypersexuality Lack of desire Female: Vaginal dryness Hypersexuality Lack of desire Sexual dysfunction depending on the sex can be like a black box Without even throwing PD into the mix sexual dysfunction itself can be hard to treat due to the complicated nature of sexual desire and physiology Also commonness between two sexes and baseline symptoms of PD can contribute to awkwardness in intimacy ie rigidity/tremor/incontinence etc Ther Adv Neurol Disord. 2011 Nov; 4(6): 375–383. doi:  10.1177/1756285611411504 Curr Treat Options Neurol. 2016; 18(10): 45. Published online 2016 Sep 27. doi:  10.1007/s11940-016-0427-0 Sexual Dysfunction in PD

Sexual Dysfunction in PD Male: Sildenafil/revatio Selective serotonin reuptake inhibitors Female: Topical vaginal estrogen Sexual dysfunction depending on the sex can be like a black box Without even throwing PD into the mix sexual dysfunction itself can be hard to treat due to the complicated nature of sexual desire and physiology Also commonness between two sexes and baseline symptoms of PD can contribute to awkwardness in intimacy ie rigidity/tremor/incontinence etc Ther Adv Neurol Disord. 2011 Nov; 4(6): 375–383. doi:  10.1177/1756285611411504 Curr Treat Options Neurol. 2016; 18(10): 45. Published online 2016 Sep 27. doi:  10.1007/s11940-016-0427-0 Sexual Dysfunction in PD

Urologic Manifestations of PD Summary: Common urologic manifestations Lifestyle changes may make a difference If meds aren’t helping time to refer to Urology for further evaluation Sexual dysfunction depending on the sex can be like a black box Without even throwing PD into the mix sexual dysfunction itself can be hard to treat due to the complicated nature of sexual desire and physiology Also commonness between two sexes and baseline symptoms of PD can contribute to awkwardness in intimacy ie rigidity/tremor/incontinence etc Urologic Manifestations of PD