URINARY INCONTINENCE IN FEMALE

PARKINSON DISEASE PATIENTS

Pitfalls of Diagnosis

Z. KHAN, M.D.

P STARER, M.D.

A. BHOLA, M.D.

From the Department of Urology, Beth Israel Medical Center, New York. New York

ABSTRACT-There are many causes of urinary incontinence in the female, with stress incon- tinence reported as the most common, However, a high incidence of detrusor instability has been described in incontinent patients with Parkinson disease. To assess this further, urodynamic studies were performed on 17female patients with Parkinson disease and complaints of urinary dysfunc- tion. Detrusor instability was demonstrated in the majority of the patients (70.6 %). Of the 8 pa- tients with specific symptoms of stress incontinence, 2 werefound to have a stable bladder, 3 had a hyporeflexic bladder, and 3 had detrusor instability. Surgical therapy may not be appropriate for all patients in this group. Since it is difficult to determine the causation of urinary incontinence on the basis of symptoms alone, urodynamic studies can be helpful in the evaluation of incontinent pa- tients. This is especially important in female patients with Parkinson disease who may have detru- SOT instability alone OT in addition to anatomic stress incontinence.

Stress urinary incontinence has been defined as the involuntary loss of urine caused by an in- crease in intra-abdominal pressure, but not caused by contraction of the detrusor muscle.’ Although it has been described as the most com- mon cause of urinary incontinence in women, other conditions may lead to the involuntary loss of urine.2 In Parkinson disease, a leading cause of neurologic disability in the elderly,3 there is a high incidence of bladder dysfunc- tion.4

In Parkinson disease there is a degenerative loss of pigmented nerve cells in the substantia nigra of the basal ganglia.3 Incontinent female patients with Parkinson disease may have urinary dysfunction which is different from that found in incontinent female patients without neurologic disease. Their symptomato- logy may simulate that seen with anatomic stress incontinence. To avoid surgical proce-

dures which are unlikely to relieve the symp- toms, the cause of incontinence in patients with Parkinson disease should be evaluated thor- oughly. We report on our urodynamic investiga- tion of 17 females with Parkinson disease and urinary complaints.

Material and Methods

Seventeen female patients with an es- tablished diagnosis of Parkinson disease were referred to our urodynamic laboratory for eval- uation of urinary symptoms during the period 1980 to 1986. Their ages ranged from fifty-one to ninety-three years (mean age 71 years). The duration of Parkinson disease ranged from one to fifteen years. Eight of these patients had pre- viously undergone a hysterectomy.

A detailed history for primary urinary symp- toms of frequency, urgency, urge incontinence, and stress incontinence was taken.

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TABLE I. Urinary symptoms in parkinsonian females referred for urodynamic investigation

No. of Patients Urinary Symptoms (N = 17) Frequency 13 Urgency 4 Urge incontinence 16 Stress incontinence* 8 Hesitancy 1

*All patients also reported urge incontinence in addition to stress incontinence.

Urodynamic studies included uroflowmetry, cystometry, and electromyographic (EMG) studies. Uroflowmetry was done using a DISA rotary disk uroflowmeter. Following measure- ment of the peak urinary flow rate and the voided volume, the patient was catheterized with a 14-F catheter and the residual urine was measured. Cystometry was performed with a DISA gas cystometer in both the supine and standing positions (filling rate = 100 mL/min).

Bladder function was classified as follows: 1.

2.

3.

4.

Normal (stable-cystometrogram showed a capacity of 300-500 cc. In addition, a detrusor contraction could be initiated and suppressed on command. Unstable bladder-involuntary bladder contractions occurred with a pressure rise of 15 cm water or more. Hypoflexic bladder-poor bladder con- traction was demonstrated when the pa- tient was asked to void. Stress incontinence-involuntary loss of urine associated with an increase in intra- abdominal pressure in the absence of de- trusor instability, was noted.

EMG studies were done by means of a bipo- lar coaxial needle electrode placed in the ex- ternal anal sphincter. Electrode placement was confirmed by audiomonitoring and oscilloscope display, Results were displayed on a heat writ- ing physiologic recorder for permanent refer- ence. Activity of the external sphincter was described as follows: (1) Normal coordinated external sphincter was defined as one having complete relaxation of the external sphincter during bladder contraction. (2) Sphincter dys- synergia was found to be present when the ex- ternal sphincter was nonrelaxing or intermit- tently relaxing during detrusor contraction.

Results

Urge incontinence was the most common complaint, found in 16 of the 17 patients stud-

TABLE II. Results of cystometric studies in parkinsonian females referred for investigation

Cystometrogram No. of Patients Pattern (N = 17)

Stable bladder 2 (11.8%) Unstable bladder 12 (70.6%) Hyporeflexic bladder 3 (17.6%)

TABLE III. Correlation of urinary symptoms with cystometric studies

--Patient’s Urinary Complaints- Urge Stress

CMG Freq. Urg. Incont. Incont. Hesit.

Stable 2 1 2 2’ 0 Unstable 9 3 11 3 1 Hyporeflexic 2 0 3 3’ 0

*Two patients with stable bladders and 2 patients with hy- poreflexic bladder had clinical evidence of urine loss associated with increase in intra-abdominal pressure. (Freq. = frequency: urg. = urgency; incont. = incontinence; hesit. = hesitancy.)

ied (Table I). Less than half (8 of 17 patients) reported stress incontinence. All of the patients complaining of stress incontinence also reported urge incontinence.

Peak urinary flow rates ranged from 5.0 to 2.2 mL/min. Cystometric studies demonstrated detrusor instability in the majority (70.6%) of the subjects (Table II). When the patients’ pre- senting symptoms were correlated with cysto- metric studies (Table III), it was found that only 2 of the 8 patients who complained of stress incontinence had a stable bladder (Fig. 1). Of the remaining 6 patients, 3 had detrusor instability (Fig. 2) and 3 had hyporeflexic blad- ders. Both of the patients with stable bladders and 2 of the 3 patients with hyporeflexic blad- ders were found to have an involuntary loss of urine with increase in intra-abdominal pres- sure. This loss of urine was not demonstrated in the third patient with hyporeflexia.

Of the 17 patients studied, 8 had previously undergone a hysterectomy. Six were found to have detrusor instability, 1 had stress incon- tinence demonstrated in the setting of a stable bladder, and 1 had stress incontinence demon- strated in the setting of a hyporeflexic bladder.

None of the 3 patients with hyporeflexic bladders had urodynamic evidence of bladder outlet obstruction. None were known to be tak- ing anticholinergic medications.

EMG of the external sphincter showed nor- mal coordinated sphincter activity in 9 of the 14

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stop

I i ii h_i_ +-+w---a *~._~~~;a

FIGURE 1. Cystometrogram study. Voluntary contraction produced, and patient asked to stop voiding. In this normal stable bladder, bladder pressure has gradually come back to baseline, indicating patient’s ability to voluntarily inhibit bladder contraction.

cm Hz0

“0 100 200 300 mil

FIGURE 2. Cystometrogram study. Involuntary bladder contraction was produced. When patient was asked to stop voiding, bladder pressure still remained high, indicating patient’s inability to voluntarily inhibit bladder contraction.

patients who underwent this study (64 %); 3 pa- tients did not tolerate EMG studies. Sphincter dyssynergia was seen in 5 of the 14 patients (36%).

Comment Stress urinary incontinence has been

described as the most common cause of urinary incontinence in women.’ A surgical procedure is often recommended as treatment. However, anatomic stress incontinence is not present in all incontinent women who, in turn, may not benefit from a surgical procedure.2 Prior to rec- ommending surgical therapy for incontinent fe- males, it is important to determine the causa- tion of their urinary dysfunction. This can be complicated if an underlying neurologic disease is present, such as parkinsonism.

Although the evaluation of the patient begins with a history of urinary complaints, the pa- tient’s description of symptoms may be mislead- ing. In a study by Glezerman et aL5 stress in- continence was diagnosed in 81.6 percent of 130 women complaining of urinary stress in- continence. It was concluded that history alone would not have been an appropriate indication

for surgery. Patients may describe several urinary symptoms which may complicate the assessment. In our study of 17 women with Parkinson disease referred for evaluation of urinary complaints, 16 reported a history of in- continence. All of the 8 patients who described stress incontinence also reported urge incon- tinence. The history should not be relied on solely in determining therapy for incontinence.

Urodynamic evaluation may reveal unsus- pected bladder dysfunction. An assumption cannot be made that all females suffer from stress incontinence, especially those patients with neurologic disease. Of the 8 patients in our study who reported stress incontinence, only 2 (25%) were found to have true anatomic stress incontinence with a stable bladder. Another 2 (25 % ) had stress incontinence with a hy- poreflexic bladder. The remaining 4 patients (50 % ) were found to have either detrusor insta- bility or a hyporeflexic bladder. The majority of the patients who complained of urge incon- tinence were found to have detrusor instability.

Detrusor instability was the most frequent finding (70.6%) in all our female parkinsonian patients. This has been described previously.6m11

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Voluntary control of voiding occurs via the influence of the cortical micturition center on the pontine-mesencephalic reticular formation. There is also input into this system from the thalamic nuclei, the basal ganglia, and the an- terior vermis of the cerebellum.8 There is a loss of dopamine in the caudate nucleus, putamen, and globus pallidus in patients with Parkinson disease. l2 Electrical stimulation of the globus pallidus in the cat was found to induce inhibi- tion of spontaneous urinary bladder contrac- tions.13 In Parkinson disease the neurologic le- sion in the basal ganglia interferes with the voluntary control of the micturition reflex.6

The significance of the presence of detrusor instability in the setting of stress incontinence needs to be understood when considering surgi- cal therapy. Stress incontinence and detrusor in- stability should be differentiated in the evalua- tion of urinary incontinence. In a study of 309 elderly incontinent patients, pure stress incon- tinence was rarely found. l4 In this study, detru- sor instability was often the cause of leakage of urine associated with coughing or laughing. In some incontinent women stress incontinence and detrusor instability both may be present.’ Drutz and Mandell reported that of women with a history suggestive of pure sphincter weakness incontinence, more than 20 percent had unstable bladders. Both stress incontinence and urgency incontinence may be cured by sur- gical elevation of the vesical neck.’ Although there are reports of postoperative failures in women with detrusor instability,16 detrusor in- stability in a patient with stress incontinence is not predictive of a poor operative result. l.17 On the other hand, patients with detrusor instabil- ity who do not have anatomic stress incon- tinence may not benefit from surgery. A small number of patients without stress incontinence may be detected by urodynamic and radio- graphic studies. l7 This number may increase when these studies are performed on women with neurologic disorders, such as parkin- sonism.

The presenting symptom of detrusor instabil- ity may be confused with anatomic stress incon- tinence, since an increase in intra-abdominal pressure may precipitate an unihibited detrusor contraction. The treatment plans may be dif- ferent, so it is important to differentiate be- tween them. A visual demonstration of urine loss associated with coughing is an important part of the evaluation, however a spontaneous

detrusor contraction may occur five to fifteen seconds after a cough.’ Since detrusor instabil- ity may not be detected in the supine position, it is necessary to perform cystometry with pos- tural change and with coughing. l6 It is difficult to classify the etiology of urinary incontinence based on symptoms alone. Urodynamic studies are useful in evaluating patients with symptoms of stress incontinence.ls This is especially im- portant in the evaluation of incontinent women with Parkinson disease who may have detrusor instability alone or in addition to anatomic stress incontinence.

New York, New York 10003 (DR. KHAN)

References

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12. Bradley WE: Neurologic disorders affecting the urinary bladder, in Krane RJ, and Siroky MD (Eds): Clinical Neuro-Urol- ogy, Boston, Little, Brown and Co, 1979, p 245.

13. Lewin RJ, and Porter RW: Inhibition of spontaneous blad- der activity by stimulation of the globus pallidus, Neurology 15: 1049 (1965).

14. Overstall PW, Rounce K, and Palmer JH: Experience with an incontinence clinic, J Am Geriatr Sot 28: 535 (1980).

15. Drutz HP and Mandel F: Urodynamic analysis of urinary incontinence symptoms in women, Am J Obstet Gynecol 134: 789 (1979).

16. Arnold EP et al: Urodynamics of female incontinence: fac- tors influencing the results of surgery, Am J Obstet Gynecol 117: 805 (1973).

17. McGuire EJ, Lytton B, Kohorn EI, and Pepe V: The value of urodynamic testing in stress urinary incontinence. J Urol 124: 256 (1980).

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