Perspectives On The Urological Care in Parkinson’s Disease Patients Part 1

Summary

Parkinson's disease (PD) is recognized as the most common neurodegenerative disorder after Alzheimer's disease. Lower urinary tract symptoms are common in patients with PD, either storage symptoms (overactive bladder symptoms or OAB) or voiding symptoms. 

Parkinson's disease is a common neurological disease whose main symptoms include stiffness, tremors, and uncoordinated movements. In addition to these movement disorder manifestations, Parkinson's disease is often associated with symptoms such as memory impairment. But people shouldn't be too concerned about the connection between memory impairment and Parkinson's disease. Many studies have shown that the incidence of memory loss in patients with Parkinson's disease is not high, and related problems usually occur only when the disease develops to a more severe stage.

While memory impairment may be linked to Parkinson's disease, there are many steps you can take to combat these problems. For example, by maintaining a healthy lifestyle and being active in daily activities, people can maintain good memory even with Parkinson's disease. More importantly, setting a feasible schedule, allocating time reasonably, focusing on energy, and establishing good sleep habits can all help people improve their memory and maintain good health.

To enhance memory, patients with Parkinson's disease can also participate in some professional training and activities, such as participating in cognitive behavioral therapy, reading, learning new skills, and performing simple intellectual challenges. These activities help stimulate people's brains, and improve attention and concentration, while enhancing memory and thinking skills, helping people better cope with diseases and enjoy a better life.

In summary, although Parkinson's disease may be associated with memory problems, it is not a very common problem. By adopting a healthy lifestyle, actively participating in daily activities, and participating in some beneficial training and activities, people can better combat these problems, enhance their memory and thinking skills, and enjoy a good life. It can be seen that we need to improve memory, and Cistanche deserticola can significantly improve memory because Cistanche deserticola is a traditional Chinese medicinal material that has many unique effects, one of which is to improve memory. The efficacy of Cistanche deserticola comes from the multiple active ingredients it contains, including tannic acid, polysaccharides, flavonoid glycosides, etc. These ingredients can promote brain health through a variety of pathways.

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The most important diagnostic clues for urinary disturbances are provided by in the patient's medical history. Urodynamic evaluation allows the determination of the underlying bladder disorder and may help in the treatment selection. 

Pharmacologic interventions especially anticholinergic medications are the first-line options for treating OAB in patients with PD. However, it is important to balance the therapeutic benefits of these drugs with their potential adverse effects. Intra-detrusor Botulinum toxin injections and electrical stimulation were also used to treat OAB in those patients with variable efficacy. 

Mirabegron is a B3-agonist that can also be used for OAB with superior tolerability to anticholinergics. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. 

Deep brain stimulation (DBS) surgery is effective in improv. ing urinary functions in PD patients. Sexual dysfunction is also common in PD, Phosphodiesterase type 5 inhibitors are first-line therapies for PD-associated erectile dysfunction (ED). Treatment with apomorphine sublingually is another therapeutic option for PD patients with ED. Pathologic hypersexuality has occasionally been reported in patients with PD, linked to dopaminergic agonists. 

The first step of treatment of hypersexuality consists of reducing the dose of dopaminergic medication. This review summarizes the epidemiology, pathogenesis, risk factors, genetic, clinical manifestations, diagnostic test, and management of Lastly, the urologic outcomes and therapies are reviewed.

KEYWORDS: Parkinson's disease; Lower urinary tract dysfunction; Neurogenic bladder, Urology.

INTRODUCTION

Parkinson's disease (PD) is the most common neurodegenerative movement disorder. In Europe, the prevalence and incidence rates for PD are estimated at approximately 108- 257/100 000 and 11-19/100 000 per year, respectively (1). 

Although the cause of PD is unknown, the pathologic manifestation involves the loss or dysfunction of dopaminergic neurons in the substantia nigra pars compacta (2). The neuropathologic hallmark of PD is the presence of Lewy bodies composed mostly of alpha-synuclein and ubiquitin. 

It is believed that the occurrence of PD is due to a combination of genetic and environmental factors (3). The cardinal motor symptoms of PD are tremor, rigidity, bradykinesia/akinesia, and postural instability, but the clinical picture includes other motor and non-motor symptoms (4). 

A variety of non-motor symptoms are common in PD. They include disturbed autonomic function with orthostatic hypotension, constipation, urinary disturbances, a variety of sleep disorders, and a spectrum of neuropsychiatric symptoms (5). 

Diagnosis of PD is based on history and examination. History can include prodromal features (rapid eye movement, sleep behavior disorder, hyposmia, constipation), characteristic movement difficulty (tremor, stiffness, slowness), and psychological or cognitive problems (cognitive decline, depression, anxiety). Examination typically demonstrates bradykinesia with tremor, rigidity, or both. 

Dopamine transporter single-photon emission computed tomography can improve the accuracy of diagnosis when the presence of parkinsonism is uncertain (6). Misdiagnoses between Parkinson's tremor and essential tremor are relatively common. Electrophysiological and functional imaging examinations can be useful in the distinction of the two, but both approaches suffer from some limitations (7). 

PD interferes with various aspects of quality of life, particularly those related to physical and social functioning (8). The primary goal in the management of PD is to treat the symptomatic motor and nonmotor features of the disorder. 

Effective management should include a combination of nonpharmacological and pharmacological strategies to maximize clinical outcomes (9). Oral levodopa, the initial gold-standard therapy for PD, is still the most effective and widely used therapeutic option (10). 

In advanced PD, therapeutic interventions include device-aided therapies such as continuous subcutaneous apomorphine infusion, levodopa-carbidopa intestinal gel infusion, and deep brain stimulation (11). Supportive non-pharmaco logical therapies are used in early and advanced PD patients. 

It should include physical rehabilitation, psychological support, occupational therapy, speech, language, and swallowing therapy, and nutrition (12). Bladder dysfunctions are quite common in PD. They may occur at any stage of the illness and get worse with advancing and aggravating disease. The most prominent dysfunction is the so-called overactive bladder (OAB). 

The main clinical problem of PD patients consists of reduced inhibition with consequentially resulting overactivity of the detrusor muscle, meaning the urge to urinate in the absence of adequate bladder filling (13). The most common storage symptoms of patients with PD are nocturia, followed by frequency and urinary incontinence. Some patients presented with functional obstructive symptoms. 

The most frequent obstructive symptom was incomplete emptying of the bladder (14). Obstructive symptoms may be secondary to anticholinergics, obstructive uropathy, or point to the presence of multiple system atrophy (MSA). 

Dysfunction of the striated urethral sphincter and pelvic musculature can be seen in variable numbers in PD (15). Antimuscarinic medications are the first-line treatment for OAB symptoms. Antimuscarinic drugs may exacerbate PD-related constipation and xerostomia, and caution is advised when using these medications in individuals where cognitive impairment is suspected. 

Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Intra-detrusor injections of botulinum toxin are effective therapy for detrusor overactivity, however, are associated with the risk of urinary retention (16). 

Subthalamic deep brain stimulation (DBS) has a significant and urodynamically recordable effect leading to a normalization of pathologically increased bladder sensibility (17). Percutaneous tibial nerve stimulation (PTNS) improves the urinary symptoms and urodynamic parameters in patients with PD (18). 

Sexual dysfunction (SD) in PD, has been suggested as a result of central and autonomic dysfunction compounded by defective motor skills, reduced self-esteem, and comorbid psychiatric states like anxiety and depression (19). 

The prevalence of SD is reported high in male patients (65%), but much lower in female patients (36%). There are different types of SD: erectile dysfunction (ED) and loss of ejaculation control in male patients, and much lower self-esteem in female patients (20). 

Optimal dopaminergic treatment should facilitate sexual encounters of the couple. Appropriate counseling diminishes some of the problems (reluctance to engage in sex, problems with ejaculation, lubrication, and urinary incontinence). 

Treatment of ED with sildenafil and apomorphine is evidence-based (21). We performed a narrative review to briefly discuss the epidemiology, pathogenesis, risk factors, genetic contribution, clinical course, diagnosis, and treatment of PD. 

The urologist had an important role in the management of urologic manifestations of patients with PD. We reviewed the current literature regarding the urological outcomes and management of patients with PD.

MATERIALS AND METHODS

We searched electronic databases including PubMed, the Scopus database for published studies that analyzed the role of the following Medical Subject Headings terms: 'Parkinson's disease' (AND) 'Management' (AND) 'Diagnosis' (AND) 'epidemiology' (AND) 'genetic contribution' (AND) 'risk factor' (OR) 'Parkinson's disease' (AND) 'urologic dysfunction' (AND) 'Management' (OR) 'Parkinson's disease' (AND) 'Erectile dysfunction' (AND) 'Management'. 

This was done to ensure the comprehensive inclusion of articles related to neurogenic bladder in PD patients. The initial search resulted in 350 articles. After review, we initially excluded papers that were not relevant (72). 

After the review, articles were selected based on their clinical relevance related to the aim. When all duplicates were thrown out, a total of 90 papers were used to extract necessary information.

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