Parkinson’s And Urinary Tract Infections

Urinary Tract Infections Which Are Very Frequent

Are other people out there being plagued by frequent infections? I am very fortunate that my Parkinsons is not severe but I am getting repeat infections which pull me down. I have been referred to a urologist.

I seem to have constant urinary infections and I am almost constantly on antibiotics. I’m seeing a urologist tomorrow.

I hope the appointment goes well.

Frances

My wife who has PD has suffered with these infections for 5 years and only been dx for 3 years. For a long time we didn’t know weather it was the infections or the PD that was making her bad. She saw a Urologist for the first time 2 years ago who came to the conclusion that my wife had nothing sinister and referred her back to her GP. The tablets she was on for bladder control that worked to a degree but these tablets mate her retain water in her bladder that was probably the cause of the infections. On Wednesday we are going to the clinic, after months of more investigations to discuss a catheter or botox. This is on top of trying to sort out her Parkinson meds because they are not working very well at all seeing PD nurse tomorrow.

I hope you get things sorted Frances…Billy

Update, My wife has had a catheter fitted which she is trying to get use to, it has a fip flow valve that opens and closes. Its so you don’t need to wear a bag all the time, of a night you fit a bag so you don’t have the problem of getting out of bed all the time During the day you open it every 2 hours to empty you bladder.

Billy

How Might Parkinson’s Affect Bladder Problems

Bladder difficulties can be common in Parkinsons, particularly in the later stages of the condition. The loss of dopamine and the resulting interruption of signals from the brain can mean that messages telling the bladder to retain or expel urine are disrupted.

However, it is important to stress that bladder problems are not inevitable in Parkinsons. If difficulties do arise, especially in older people, they may be caused by factors totally unrelated to the condition, so a thorough medical evaluation should be carried out with any appropriate tests.

Bladder problems associated with Parkinsons include:

Treating And Managing Bladder Problems

It is important to discuss any bladder difficulties, including those listed below, with your doctor, even if this may appear embarrassing. Your doctor will then be able to properly assess and treat any problems, for example:

• inability or difficulty emptying the bladder even when it feels full
• significant, uncontrolled leakage of urine at any time
• unusually frequent urination
• an urgent, immediate need to urinate, or urine leaking if you do not immediately do so
• pain when urinating.

It may be helpful to write notes to discuss with your doctor, for example, the type of difficulties experienced, their frequency, when you first noticed a change, and your normal eating and drinking habits.

Bladder problems can occur for a number of reasons, so the first approach will be to eliminate causes other than Parkinsons, such as urinary infections and prostate problems in men.

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Bladder Problems In Parkinsons

The primary function of the bladder is twofold to store urine as it is made and then to empty the urine. With Parkinsons, problems can emerge in both areas.

Recent studies suggest that 30-40% of people with Parkinsons have urinary difficulties. Despite the frequency of urinary dysfunction, actual urinary incontinence is relatively uncommon. Troublesome incontinence develops in only about 15% of people with Parkinsons.

The most common urinary symptoms experienced by people with Parkinsons are:

• The need to urinate frequently
• Trouble delaying urination once the need is perceived, creating a sense of urinary urgency

These symptoms usually mean you have an irritable or overactive bladder. Your bladder is signaling the brain that it is full and needs to empty when, in fact, it is not. This can happen at any time, so you might have to get up multiple times during the night to go to the bathroom.

Impairment of bladder emptying is a less frequent but still troublesome feature of urinary dysfunction in Parkinsons. This may be caused by delay or difficulty in relaxation of the urethral sphincter muscles. These muscles must relax for the bladder to empty. This can result in hesitancy in initiating urination, difficulty in generating a stream and incomplete emptying of the bladder. Dystonia involuntary muscle contractions of the urethral sphincter has also been described.

Why Do Urgency And Frequency Occur

Bladder difficulties in Parkinsons are related to changes in the level of dopamine affecting the function of the bladder muscle. Parkinsons is also thought to affect the nerve pathway between the bladder and the part of the brain controlling bladder function. Some of the symptoms that affect bladder control are related to the level of dopamine in your body which will rise and fall depending on your medication level.

Other conditions such as weak pelvic floor muscles or an enlarged prostate will contribute to bladder symptoms. Constipation can also worsen bladder symptoms by putting pressure on the bladder.

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Bladder Irrigation And Clean Catheterization

Bladder irrigation with various solutions such as aminoglycoside, glycosaminoglycans , povidone-iodine , chlorhexidine solution , and saline with acetylcysteine have been advocated as a management strategy for patients with indwelling catheters or those who require intermittent catheterizations . Although several studies have demonstrated the efficacy of bladder irrigation with various agents , gentamicin remains the best intravesical treatment that has shown efficacy in both the prevention and treatment of recurrent UTIs . Furthermore, the risk of developing antibiotic resistance and systemic adverse effects is low in patients treated with bladder irrigation with gentamicin .

What Is Parkinsons Disease

Parkinsons disease is a progressive neurological disorder that affects how your muscles move. In the beginning stages, it can be easy to miss the early signs and symptoms of Parkinsons disease. The most common ones include:

• Tremors, usually starting with the fingers or hand
• A noticeable change in handwriting
• Walking is slower, movement is stiffer
• Stiff, rigid muscles
• Memory loss

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Parkinsons Disease And Your Bladder

Many diagnosed with Parkinsons disease experience urinary tract issues. A Michigan Medicine urologist discusses treatment options for patients to consider.

Anne Pelletier-Cameron, M.D., often jokes to her patients that shes a female plumber of the lower urinary tract. On a more professional note, however, shes a urologist in the Michigan Medicine Department of Urology.

In this role, Pelletier-Cameron treats patients with a variety of lower urinary tract symptoms. Some of her patients have been diagnosed with Parkinsons disease, a progressive nervous system disorder that impacts movement. But the breakdown of nerve cells that characterize Parkinsons disease can also cause non-movement symptoms, including bladder issues.

Half of all women and 17% of men will experience urinary incontinence, or the inability to hold urine, she says, noting that for Parkinsons disease patients, those numbers escalate.

Many of my PD patients end up having other bladder problems, including issues with urgency and frequency, says Pelletier-Cameron. Nocturia, or the need to urinate many times during the night, is also common, along with difficulty in emptying the bladder.

Pelletier-Cameron says the impact of bladder symptoms cant be ignored.

Pathogenesis Of Urinary Tract Infection In Pd

The pathogenesis of UTI is complex and depends on multiple factors involving both the host and pathogen. Even a healthy persons urine is not completely sterile, so various host factors likely contribute towards the pathogenesis of UTI. Age, sex, host immune function, e.g., immune senescence in elderly patients with PD, and general illness can all predispose to the development of UTI. Additionally, structural abnormalities of the lower urinary tract including calculi, benign prostatic hyperplasia, and pregnancy are associated with increased risk of UTI .

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Risk Factors For Urinary Tract Infection In Older Adults

Certain factors may increase the risk of UTIs in older people.

Conditions common in older adults may lead to urinary retention or neurogenic bladder. This increases the risk of UTIs. These conditions include Alzheimers disease, Parkinsons disease, and diabetes.

They often require people to wear incontinence briefs. If the briefs arent changed regularly, an infection may occur.

Several other things put older adults at risk for developing a UTI:

• a history of UTIs

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Difficulty Emptying The Bladder

• Some people with Parkinsons find it difficult to pass urine if the bladder fails to contract when required, or because the sphincter does not let urine out or a combination of the two. This is a result of reduced dopamine levels interfering with the efficiency of the bladder muscles and causing a residual amount of urine to be left in the bladder. This reduces the total amount the bladder can hold and creates a feeling of wanting to empty the bladder very often. Unfortunately, there is an increased risk of urinary infection if the bladder is not emptied completely.
• In some older people, constipation which is often associated with Parkinsons can result in faeces collecting in the rectum. This can result in difficulties in bladder emptying, which may be because of pressure on the urethra, or mediated by the nerves in the region. The bladder is then unable to empty and may continue distending, causing dribbling incontinence.
• Anticholinergic medications can also make emptying problems worse.

Urinary Retention And Stasis

As previously mentioned, advanced PD may predispose to urinary retention through a variety of mechanisms. One Korean study of 197 PD patients found that 8.9% had increased post-void residual volumes over 100cc, a well-established risk factor for UTI . Another potential mechanism involves motor dysfunction itself, as patients with advanced PD may have severe rigidity/akinesia preventing access to toileting. Additionally, as PD patients may be at higher risk for urinary incontinence, they may be prescribed anticholinergics, which may independently contribute to an increased risk of UTI . Caution should be taken when titrating antimuscarinic agents on patients with advanced PD and PD dementia to avoid the risk of drug-induced urinary retention. PD patients with cognitive impairment and spastic bladder may benefit from timed or prompted voiding to prevent episodes of urinary incontinence and avoid the need for antimuscarinic therapy, as discussed in further detail below under Management strategies to prevent UTI in PD.

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What Causes A Urinary Tract Infection

The main cause of UTIs, at any age, is usually bacteria. Escherichia coli is the primary cause, but other organisms can also cause a UTI.

In older adults who use catheters or live in a nursing home or other full-time care facility, bacteria such as Enterococci and Staphylococci are more common causes.

Gastrointestinal Issues In Advanced Parkinsons Disease

Problems with motility of the gut can be a major source of difficulty throughout the disease course and can be particularly problematic in advanced PD as well. . Constipation, which can be one of the earliest symptoms of PD is a very common problem throughout the disease course. Two gut issues that tend to be particularly problematic in people with advanced PD are abdominal pain and fecal incontinence.

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What You Can Do To Help

• Discuss bladder problems with your family doctor or neurologist, who may perform some tests to rule out urinary tract infection or other problems.
• Speak with your family doctor or neurologist about a referral to a urologist . The urologist will be able to look into any bladder symptoms and provide treatment plans.
• Be aware that bladder difficulties can be a sign of wearing off. Wearing off is where some of the symptoms of Parkinsons occur or worsen between doses of medication and are related to the level of medication becoming too low. Taking your medication on time every time helps reduce fluctuations and that will help reduce bladder difficulties.
• Managing constipation and making sure that you have regular bowel movements will also assist in minimising bladder problems.

Diagnosing A Urinary Tract Infection In Older Adults

Vague, uncommon symptoms such as confusion make UTIs challenging to diagnose in many older adults. Once your doctor suspects a UTI, its easily confirmed with a simple urinalysis.

Your doctor may perform a urine culture to determine the type of bacteria causing the infection and the best antibiotic to treat it.

There are home UTI tests that check urine for nitrates and leukocytes. Both are often present in UTIs. Because bacteria are often in the urine of older adults to some degree, these tests arent always accurate. Call your doctor if you take a home test and get a positive result.

Antibiotics are the treatment of choice for UTIs in older adults and younger people. Your doctor may prescribe amoxicillin and nitrofurantoin .

More severe infections may require a broad-spectrum antibiotic such as ciprofloxacin and levofloxacin .

You should start antibiotics as soon as possible and take them for the entire duration of treatment as prescribed by your doctor. Stopping treatment early, even if symptoms resolve, increases the risks of recurrence and antibiotic resistance.

Antibiotic overuse also increases your risk for antibiotic resistance. For this reason, your doctor will likely prescribe the shortest treatment course possible. Treatment typically lasts no more than 7 days, and your infection should clear up in a few days.

Its important to drink plenty of water during treatment to help flush out the remaining bacteria.

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Urinary Issues In Advanced Parkinsons Disease

Urinary dysfunction and symptoms in PD are most commonly caused by overactivity of the detrusor muscle, or the muscle of the bladder, which contracts excessively despite the fact that it is not filled with urine. This causes an increased urge to urinate and/or an increased frequency of urination, which can be especially prominent at night. In advanced PD, this could culminate in urinary incontinence, or involuntary release of urine. Mobility issues which make getting to the bathroom slower and more cumbersome, compound the problem.

Always remember that people with advanced PD may have other medical problems that affect their urination such as an enlarged prostate. Make sure to have a complete evaluation before assuming that the problem is only related to PD. It is also essential to keep in mind that if changes in urination occur suddenly, there could be a urinary tract infection present.

Once other medical issues and urinary tract infection are ruled out, there are a number of approaches to the issue of urinary incontinence in a person with advanced PD:

Unfortunately, for some, the above available options may not be sufficient to effectively treat urinary incontinence in advanced PD. If this is the reality, it becomes extremely important to keep the skin dry with frequent changes of incontinence products to prevent skin breakdown and the potential development of skin infection.

Urinary Tract Infection In Parkinsons Disease

Article type: Review Article

Authors: Hogg, Elliota | Frank, Samuela | Oft, Jillianb | Benway, Brianc | Rashid, Mohammad Haruna | Lahiri, Shourid *

Affiliations: Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA | Department of Infectious Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA | Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA | Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA

Correspondence: Correspondence to: Shouri Lahiri, MD, Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, USA. E-mail: .

Keywords: Parkinsons disease, urinary tract infection, delirium, falls, exacerbation

DOI: 10.3233/JPD-213103

Journal: Journal of Parkinson’s Disease, vol. Pre-press, no. Pre-press, pp. 1-15, 2022

Abstract

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Institutional Characteristics And Patient Selection

This study was approved by the institutional review board at Yale University School of Medicine. Subjects were selected from patients followed by 1 physician at the Yale Urology Medical Group Clinic. All patient visits at the clinic are logged by the Patient Financial Services Department under corresponding diagnosis codes. Follow-up notes from clinic visits or phone calls are recorded in patient charts by the same physician after each encounter.

Inclusion criteria for the study were as follows: neurogenic bladder dysfunction stable traumatic SCI at least 1 year after injury bladder management with CIC minimum of 1 year follow-up by the same physician at the Yale Urology Clinic seen between the 2000 and 2010. Exclusion criteria were other etiology for neurogenic bladder such as multiple sclerosis, Parkinson disease, spina bifida, or diabetes other methods of bladder management, including other catheterization methods or Crede maneuver or had undergone urinary diversion.

Note: Data presented as mean ±SD, unless noted otherwise data in parentheses are percentages. PRx = prophylaxis UTI = urinary tract infection.

Urinary Problems In Parkinson’s Disease

Parkinsons disease has many features that have little or nothing to do with movement. Among these non-motor symptoms are problems with the autonomic nervous system the part of the nervous system that controls automatic bodily functions, such as heart rate, blood pressure, sweating, sexual function and both gastrointestinal and urinary function. These symptoms are often among the most serious and complex issues faced by people with PD.

Unlike bowel dysfunction , which often occurs before Parkinsons movement symptoms, urinary dysfunction is not typically a problem until the later stages of the disease.

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