Q&A: Bladder and bowel problems in Parkinson's

Geriatrician Dr Duncan Forsyth joined our discussion forum in September 2011 for a question and answer (Q&A) session on all aspects of bladder and bowel issues in Parkinson's.

Transcript of the session

Hello and welcome to the Q&A session. My name is Dr Duncan Forsyth and I look forward to answering your questions on bladder and bowel problems in Parkinson's.

I have over 20 years' experience as a consultant geriatrician with a specialist interest in Parkinson's. With my multidisciplinary team, I have made every effort to ensure that people with Parkinson's have the best possible care.

I have been instrumental in developing the Cambridge Parkinson's clinic which, in turn, provides a teaching forum for clinicians and other healthcare professionals as well as the pharmaceutical industry.

I have also advised several hospitals on setting up a Parkinson's service and am a national mentor for consultants wishing to establish a Parkinson's service and Parkinson's disease nurse specialists.

I hope that I can use my knowledge to answer your questions or point you in the direction of an answer.

Questions and answers

LP: Why are people with Parkinson's so often affected by these issues? What's the reason behind it or relationship to Parkinson's?

Dr Forsyth: Constipation in Parkinson's often has several causes:

• poor fluid intake
• reduced activity levels
• reduced food intake (what comes out is a product of what goes in)
• effects of drugs (eg painkillers such as codeine, anticholinergics prescribed for tremor)
• direct effects of Parkinson's on the nerves that control bowel function, which leads to a slowing of bowel transit time (in other words all movements are slow in Parkinson's) 

Bladder problems also occur due to Parkinson's affecting the nerves that control bladder emptying, leading to an overactive bladder. Constipation can also result in pressure on the bladder reducing bladder capacity and leading to need to pass urine more frequently.

A full bowel can lead to difficulties emptying the bladder, especially in older men with larger prostates, and result in an increased risk of urine infection.

Finally, the need to get to the toilet quickly does not always sit well with the slowness of Parkinson's and so incontinence may occur.

Oscar: In Parkinson's are urge to urinate/incontinence and premature ejaculation linked?

Dr Forsyth: The nerve control of the bladder is different to that of erection and ejaculation. For fairly obvious reasons we are designed not to urinate during intercourse!

The link between incontinence, premature ejaculation and Parkinson's would be anxiety. Sexual problems in Parkinson's are common and often relate to anxiety over ability to 'perform' or concern regarding tremor and dyskinesia, pain, and/or stiffness interfering with performance or our sexual appeal. Being ashamed about incontinence or fear of being incontinent may also affect sexual performance.

In many cases premature ejaculation resolves on its own over time without the need for medical treatment. Practising relaxation techniques or using distraction methods may help you delay ejaculation. For some men, stopping or cutting down on the use of alcohol, tobacco or illegal drugs may improve their ability to control ejaculation.

Joint relaxation techniques with your partner can also help. Specific techniques to help delay ejaculation may involve identifying and controlling the sensations that lead up to ejaculation and communicating to slow or stop stimulation.

Other options include using a condom to reduce sensation to the penis, anaesthetic gel applied to the penis or trying a different position (such as lying on your back) during intercourse. Counselling or behavioural therapy may help reduce anxiety related to premature ejaculation. Occasionally drug treatment may be recommended.

Anonymous: I take one sachet of macrogol every night which has completely cleared up my problems with constipation. I have been using it for 2 years. Are there any problems concerning long-term use of this medication?

Dr Forsyth: If constipation is a feature of Parkinson's then neither go away and all Parkinson's symptoms need addressing one way or another. If attention to fluid intake, diet and exercise don't do the trick then you need a regular laxative.

It is true that after long-term laxative use the bowel becomes less efficient and the need for laxative becomes a permanent issue.

But then as I said earlier the Parkinson's is not going to go away so neither will the tendency to constipation so you need to attend/prevent the constipation. If this means a laxative that is the right solution and don't let anyone say otherwise.

JPOD: Can you update us on where we stand with pre-symptomatic(motor) diagnosis of Parkinson's by methods investigating adult-onset apparently idiopathic constipation?

Parkinson's UK research team: Research is continuing to find ways to identify people at risk of developing Parkinson's early on before the motor problems (problems with movement) start.

It is known that constipation and other problems can occur years before diagnosis. It is hoped that finding which specific set of these problems occurring together indicate Parkinson's will develop along with other early markers will allow doctors to diagnose Parkinson's at its very earliest stages.

One example of such a research project is our funded Predict PD study.

Beth: Lately I've been having constipation and sciatica problems that are extremely painful. Could they be linked?

Dr Forsyth: If you take anything other than paracetamol for pain, virtually every painkiller causes constipation and so you may need a regular laxative if you need to take regular painkillers.

Sciatica often restricts mobility and this will exacerbate any tendency to constipation. Finally, if the sciatica is new, you should make sure the diagnosis is correct. In most cases it will be and due to disk problems but rarely there might be other things wrong with the spinal cord that can mimic sciatica and cause new alteration in bowel habit.

So, if these symptoms have come on together recently you need to see your doctor and especially so if there are bladder problems or altered sensation below the waist as well.

nerak1963: Can you please advise whether Parkinson's would have any effect on someone with diverticular disease. My mum can suffer very badly with this and more so if she is anxious. Is there anything she can do?

Dr Forsyth: Diverticular disease is more common in the Western hemisphere due to the low fibre content of our diet.

It is more common in those who are chronically constipated. By and large though, as Parkinson's is predominantly a later life condition and the seeds for diverticular disease are sewn throughout our life, I do not think there is a link between the two, other than for constipation in Parkinson's to potentially aggravate diverticular disease.

So, the answer is make sure she does everything to try and prevent constipation.

Helen: Does Sinemet give you urine infections sometimes or repeatedly? I've had two recently weeks apart.

Dr Forsyth: No. Sinemet is not known to cause urine infections.

Anonymous: I have heard that levodopa is a diuretic. Is this true? If so, how can I counteract this effect?

Dr Forsyth: Levodopa is not a diuretic.

Levodopa can sometimes cause fluid retention due to its side effect of dilating blood vessels. This can result in swollen feet and, when we are in bed or put our feet up for any length of time, this fluid is redistributed (the ankle swelling goes down) and the excess fluid is passed as urine.

There is some limited research of the use of levodopa in heart failure suggesting it might be beneficial but this appears to be due to possible actions in improving heart muscle efficiency not as a diuretic.

ali j: I have got irritable bowel syndrome (IBS). I seem more constipated though than the others. I'm on 100mg a day of morphine along with a lot of other meds for different problems, so I'm sure meds don't help me at all.

I have laxative liquid 20ml two times a day and Senekot at night, but I still struggle. Sometimes my belly can look like I'm expecting a baby I'm so constipated.

Can you think of anything that might help me?

Dr Forsyth: The morphine will be a major cause of your constipation and whilst on this you definitely need regular laxatives, usually a stimulant like senna and a softener (that's probably what the liquid one is).

Also, look carefully at how much you drink - do not get dehydrated. Ensure you take plenty of fibre in your diet (fruit and vegetables).

There is no perfect laxative and you must work out what works for you (which laxatives and how often). Finally, keep as active as you can and remember if you do not eat much then not much will come out!

Anonymous: I have heard it said that men are more likely to get bladder problems (such as incontinence) if they have sexual intercourse much less frequently or not at all. Is there any truth in that?

Dr Forsyth: Nope! But it does sound like a good myth and an excuse to have more sex!!

Frock: I was OK until I started taking medication a month ago - Symmetrel 100mg daily and Eldepryl 5mg daily. I manage okay with Metamucil (natural psyllium fibre), eating a serve of baked beans and also vegetables each day, but it's not great. Is there a better way?

Dr Forsyth: Whilst constipation is potentially a side effect of all medication (Parkinson's and non-Parkinson's) it is more likely that the constipation in your case is related to the need for medication, ie the Parkinson's rather than the drugs.

There is no single best laxative or combination - it is a matter of finding the best for you:

• If the motions are hard pellets then you need to drink more.
• If they are soft you need extra fibre and maybe a stimulant like senna.
• If they are hard and large then fibre, senna and a softener like docusate.

If the natural remedies you mention work for you then carry on with them - the only downside of beans can be the wind!

Silver Tabby: I've had Parkinson's for about 14 years, since my early 40s. Over the last year or so I've been experiencing sudden need to go to the toilet with hardly any warning and so a great sense of urgency. I've stopped drinking coffee and limit my fluid intake when I'm out. Is there anything else I can do about this? I don't want to have to limit my life in response to it.

Dr Forsyth: I will assume that your Parkinson's is well controlled from a motor point of view and that you are not constipated.

In which case, it sounds as though you may be developing overactive bladder syndrome. Frequent toileting and pelvic floor exercises can help. It will be important to exclude any urine infection and for completeness sake to test the urine for excess sugar, although the likelihood of diabetes, from your description, is low.

If the problem continues then you may need medication - tolterodine, oxybutynin or solifenacin. If you are a female, then it is also important to check that there are no problems such as prolapse or cystocele (your GP may need to do an external vaginal examination). If you are a man, then your GP should check that your prostate is not enlarged.

Anonymous: I am in the early stages of young onset Parkinson's (I'm 40 and was diagnosed 2 years ago). Since diagnosis, I have had some problems with sudden urges to urinate. What often happens is that I get to the bathroom and then everything goes pear shaped before I can deal with my clothing and sit down on the toilet. It's as if there's a psychological switch inside my head that says: "OK, folks, we're here! Off you go!" And they do...

This only seems to happen at home. This is partly due to my being a stay-at-home mum (ie I do spend a lot of time at home), but it seems as if there is a familiarity factor involved.

Obviously, having a clumsy left hand doesn't exactly help, but I don't think that it has very much to do with the speed that I am able to get undressed. Is this "normal" in Parkinson's, and is there anything that I can do to try and control the "switch"?

I should add that my frequency of urination is largely unaffected.

Dr Forsyth: The fact that this does not happen when you are away from home suggests that you have control or are restricting your fluids so that you are less likely to need to go to the toilet whilst out, so it's strange that this happens at home, unless you wear more cumbersome clothing at home. Or maybe it is that you hang on too long at home due to distractors (children, housework, etc).

This does not sound like overactive bladder syndrome (that should affect you wherever you are). I would look at your routine at home, how much tea/coffee you drink, and consider going to the toilet as soon as you feel a need.

Pelvic floor exercises might also be useful to further increase your ability to 'hold-on'. I hope this helps.

Anonymous: I was diagnosed with Parkinson's 6 months ago. I have noticed over the last year that I have to get up to urinate in the night. I know this is typical, but I would like to know the reasons for this happening. I have not changed the amount of liquid I consume.

Dr Forsyth: This could be due to prostate problems (unless you are a woman!).

Make sure you are not drinking a lot last thing at night. If you have swollen feet by day and they are less swollen in the morning on wakening then this is the fluid you are passing out.

Equally, when we awaken in the night (for whatever reason) most of us will go to the toilet - just in case! So, you need to consider why you awaken. It is unusual to have bladder problems just at night due to Parkinson's. Normally there will be day and night symptoms as Mr P does not know the 24hr clock!

ali j: I have had bladder and bowel problems now for 6 years. I had problems holding myself and needed to be by a loo, work out my routes of the day, and where the loos were.

As time went on things got worse. I had been given medication to help but nothing was helping me, I was getting worse, I ended up with big pads from the district nurses and got worse again as time increased.

I eventually lost all my control and had to have a catheter fitted. The doctors decided on the suprapubic catheter because a normal one was difficult for me to manage with my tremor. I had a bag on me leg for 4 years and now I've got a flip-flow action which is better for me.

I seem to get a lot of infections though and the team at the Princess Royal don't seem to know why it keeps happening to me. I am a very clean person. My catheter now gets changed every 2 months now. It used to be 3. But this still does not help.

I go in and out of hospital with severe infections and end up on drips and a high temperature. It seems like I’m always on antibiotics. Do you have any idea why I keep getting infections?

Dr Forsyth: Poor manual dexterity due to Parkinson's or arthritis can lead to difficulties wiping - especially in women - and increase the risk of urine infection. However, none of this is relevant to you by the sound of it.

The problem is that you have a foreign object (the catheter) in your bladder and this increases the risk of infections no matter how clean you are or how careful everyone is when the catheter is changed.

Sometimes changing the type of catheter to a silver-coated one can reduce the number of catheter-associated infections. In general, we would not recommend long-term antibiotics as a preventative measure in someone who has a catheter in place although this can be a solution in those prone to recurrent infections who do not have a catheter.

Mike: Why do I suffer such pain when I need to go to the toilet to urinate? I have urge incontinence, am wheelchair bound, and in the time I have to reach the toilet I have such pain in retaining control. My urologist does not know why I should feel such pain. It's excruciating!

Dr Forsyth: One possibility is that this is due to spasm of the bladder muscles. The combination of this pain and urge incontinence, assuming that there is no evidence of urine infection, would lead me to suggest trying a drug such as tolterodine or solifenacin (commonly prescribed drugs for overactive bladder syndrome) to see if these helped.

It is possible that pelvic floor exercises might also help but sometimes these can precipitate the pain and so people give up on them. If there is pain at other times or you suffer from frequent urine infections then I would suggest an ultrasound scan of the urinary tract to make sure you do not have problems with stones in the bladder.

Further discussion with your GP would identify if you need any other tests to look at the lining of the bladder (a cystoscopy) for an explanation of this pain.

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