The risk of bladder and autonomic dysfunction in a community cohort of Parkinson's disease patients and normal controls
Introduction
In older people bladder urgency, frequency of micturition and urinary incontinence are common and are associated with poorer quality of life, social isolation, depression and an increased risk of falls and fractures [1], [2], [3], [4]. The variations in the incidence of urinary incontinence of between 10 and 35% in individuals aged 65 years and over, are most likely due to the methodological inconsistencies in reported studies. Around 75–85% of women and 85–95% of men aged 75 presenting as urological referrals are found to have detrusor instability [5]. Prevalence rates of urinary incontinence are likely to be an underestimate due to the reluctance of individuals to report these embarrassing symptoms [5], [6], [7]. The autonomic nervous system plays an important role in the control of bladder function and micturition. Age related changes commonly occur and autonomic dysfunction is strongly associated with several neurological diseases such as dementia, stroke and Parkinson's disease (PD) [8], [9], [10].
In PD, urinary dysfunction symptoms, such as frequency, urgency and nocturia are frequently reported [11], [12], [13], [14], [15]. The major abnormality of bladder function in PD appears to be detrusor hyperreflexia, which results in bladder contractions at bladder volumes that under normal circumstances would not trigger detrusor activity. The loss of dopaminergic output from the substantia nigra in PD may directly be the cause of detrusor hyperreflexia [16], [17]. It is likely that the subthalamic nucleus hyperactivity underlies not only the motor, but also the urodynamic complications in PD [18]. Support for this view was reported recently by Finazzi-Agrò et al. (2003) who found significant improvements in detrusor hyperreflexia in an open trial of PD patients with urinary tract symptoms who underwent subthalamic deep brain stimulation [19]. Other factors such as prostrate problems in men, pelvic floor weakness in women and some prescribed medication may also contribute to bladder dysfunction in PD. Pharmaceutical preparations with anticholinergic properties used to treat PD and the symptoms of the overactive bladder can often cause sedation, confusion and constipation that can often worsen the symptoms of bladder dysfunction in PD. The wide reported estimates of the prevalence for bladder dysfunction in PD of between 36 and 90% reflect varying definitions, methodology and the likely inclusion of patients with atypical Parkinsonism. In addition, many studies have failed to recruit a control group for comparison making it impossible to calculate the risk estimates of bladder disturbance in PD. Similarly, the reported prevalence of autonomic dysfunction in PD also varies, reflecting erratic diagnostic criteria and patient selection bias [10], [20], [21], [22], [23], [24]. The interpretation of autonomic symptoms are also confounded by a number of other factors such as age, drug toxicity and psychopathology.
The purpose of this study is to estimate the prevalence of bladder and autonomic symptoms in a community-based sample of PD patients and a similarly aged healthy elderly control group, using a self-report questionnaire.
Section snippets
Methods
Patients who fulfilled diagnostic criteria for probable PD [25] were randomly drawn from a community-based PD register.1 The
Results
Out of a single mailing of 150 PD patients, 132 (88%) returned the questionnaire. Nine (6%) of these questionnaires had one or more omissions in their responses and were excluded from further analysis. The total number of controls who responded to the single mailing was 102/150 (68%) and as 10 (9.8%) of these questionnaires also had several omissions, they were excluded from the analysis. There were no reminders or further contact made with the patients or controls, who did not reply to the
Parkinson's disease patients
The disease specific variables of PD (age of onset, duration of symptoms, disease severity) were not found to be significantly associated with bladder symptoms, autonomic functioning or the age of patients. However, within group analysis revealed that male patients reported more autonomic function symptoms (r=0.22, p<0.01). Increased depressive symptoms in all the patients were moderately correlated with worsening bladder (r=0.51; p<0.0001), autonomic function (r=0.45; p<0.0001) and social/ADL
Discussion
This study shows that the RR of bladder symptoms in PD patients was two-fold and the risk of autonomic dysfunction was over four times that of control subjects. However, the severity and duration of PD symptoms in the present did not appear to be significantly associated with bladder or autonomic symptoms. A recent study has similarly reported a negative relationship between motor impairment and autonomic dysfunction in PD [28]. This may reflect the insensitivity of the scale used to determine
Acknowledgements
This study was funded by The Institute of Health Studies North Wales.
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