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

2. Face of Parkinson’s Disease
Michael j fox foundation website
Journal of the Neurological Sciences, , 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

3. Urologic Manifestations of Parkinson’s Disease
Overview of today’s webinar
How PD affects urination and sexual dysfunction
Followed by treatments
Urologic Manifestations of Parkinson’s Disease

4. 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
Urologic Manifestations of Parkinson’s Disease

5. 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

6. 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

7. 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

8. 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)  ; DOI:
Why?

9. 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?

10. 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?

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

12. 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

13. Voiding diary
UDI 6 questionnaire
Males- IPSS
Tools for evaluation

14. 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

15. 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

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

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

18. 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

19. 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

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

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

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

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

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

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

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

34. 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

35. 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

36. 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

37. 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 Nov; 4(6): 375–383.
doi:   /
Curr Treat Options Neurol. 2016; 18(10): 45.
Published online 2016 Sep 27. doi:   /s
Sexual Dysfunction in PD

38. 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 Nov; 4(6): 375–383.
doi:   /
Curr Treat Options Neurol. 2016; 18(10): 45.
Published online 2016 Sep 27. doi:   /s
Sexual Dysfunction in PD

39. 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