Apr 14, 2018
In today’s episode I highlight Sir Roger Bannister, the first man to run a 4-min mile, who became a prominent neurologist, and suffered late in life with Parkinson’s disease.
Parkinson’s disease is a progressively degenerative neurologic disorder characterized by progressive loss of dopaminergic neurons specifically in one area of the brain and abnormal aggregates of protein called LEWY bodies that develop inside nerve cells.
Parkinson’s disease affects approximately seven million people globally and one million people in the United States. Parkinson's disease typically occurs in people over the age of 60 and about 1% of people over age 60 will be affected. Its cause is unknown.
We commonly think of Parkinson’s disease as motor dysfunction with a resting tremor, rigidity, bradykinesia and postural instability. The characteristic “pill-rolling” tremor in the hand is seen when the hand is at rest.
The reason we are discussing Parkinson’s disease in a urology podcast is that Parkinson’s disease has non-motor dysfunction as well: cognitive, psychiatric, sleep, and autonomic dysfunction characterized as bladder, gastrointestinal and erectile dysfunction.
Diagnosis of typical cases of Parkinson’s disease is mainly based on symptoms, with tests such as neuroimaging being used to rule out other diseases.
There is no cure for Parkinson's disease, with treatment directed at improving symptoms.
It is the bladder and erectile dysfunction that will bring patients to the urologist.
The primary complaints are urgency, frequency, and nocturia.
The urinary symptoms are quite common, occurring in up to 90% of patients. Urinary urgency is the greatest bother for patients. Up to 50% of patients have urgency with urge incontinence.
Further urinary symptoms result from external sphincter bradykinesia which is a delayed relaxation of the sphincter muscle during micturition. This delayed relaxation is different from other neurologic disorders where there is dyssynergia, an actual increase in activity of the muscle during micturition.
In the initial evaluation of patients use of a validated urinary symptom score such as the IPSS or UDI–6 are valuable tools for screening patients, quantifying the extent of symptom bother initially, and in assessing success of instituted treatments. A comprehensive clinical history and physical examination are standard along with the validated questionnaires and when appropriate, a self-reported voiding diary.
The most common finding on urodynamic testing in patients with Parkinson’s Disease is detrusor overactivity but urodynamics are usually reserved for complex cases.
Management is tailored to the individual depending on symptoms severity.
Anti-muscarinic medication should be considered first-line therapy for patients with overactive bladder symptoms and minimal post void residual after failure of behavioral therapy.
The concern with any anti-muscarinic agents is impaired bladder emptying therefore it is imperative to assess for adequacy of bladder emptying by post void residual before and after starting medication. Concerns regarding cognitive decline and postural instability with the use of non-selective agents should be addressed preferably with more selective medication.
Patient with refractory symptoms may be candidates for alternative secondary treatments: intradetrusor botox, posterior tibial nerve stimulation, intermittent self-catheterization in patients with large post void residuals and reasonable dexterity, or an indwelling catheter.
Alpha-blocker therapy can help in some patients with sphincter function due to bradykinesia although careful attention must be paid to postural hypotension.
Transurethral resection of the prostate has a high-risk of postoperative stress or urge urinary incontinence and can be considered only after careful evaluation.
The prevalence of stress urinary incontinence in women with Parkinson’s disease is unknown and can be difficult to manage. Urodynamic studies are critical prior to performing any surgery. Urethral bulking agents may be more appropriate because of a lower risk of postoperative voiding dysfunction.
Erectile dysfunction and sexual dysfunction contributes to worsened quality-of-life for patients and partners. The exact reason why Parkinson’s causes sexual dysfunction is not well understood but decreased libido and erectile and ejaculatory dysfunction in men and orgasmic dysfunction, coital incontinence and dyspareunia in women are all very common.
Parkinson’s disease is a debilitating disorder. Medicine has made progress in treating the symptoms of the disease, to be sure, but we have a long way to go to find a cure.
More Resources about Roger Bannister
https://itunes.apple.com/us/podcast/what-it-takes/id1025864075?mt=2(ep 45 Sir Roger Bannister)
“The Perfect Mile” by Neal Bascomb
“The First Four Minutes” by Roger Bannister