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
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
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
Dr Forsyth: Constipation in Parkinson's often has several
- poor fluid intake
- reduced activity levels
- reduced food intake (what comes out is a product of what goes
- 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
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
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
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
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
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
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
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
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
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
Helen: Does Sinemet give you urine
infections sometimes or repeatedly? I've had two recently weeks
Dr Forsyth: No. Sinemet is not known to cause urine
Anonymous: I have heard that levodopa is
a diuretic. Is this true? If so, how can I counteract this
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
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
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
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
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
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
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
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
- If they are soft you need extra fibre and maybe a stimulant
- If they are hard and large then fibre, senna and a softener
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
Dr Forsyth: I will assume that your Parkinson's is well
controlled from a motor point of view and that you are not
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,
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
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
I should add that my frequency of urination is largely
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,
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
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
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
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
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
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
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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