Managing bowel and bladder problems in Parkinson's

What does the data tell us about the need for early intervention in bladder and bowel complication’s in Parkinson’s and what is your role both in primary and secondary care to ensure best outcomes for your patients. Join the panel to learn about this important aspect of Parkinson’s management.

Summary

The win/win of managing bladder and bowel problems in Parkinson’s

Managing bladder and bowel dysfunction is a win/win in terms of improving quality of life and driving down healthcare costs.

But people with Parkinson’s disease (PD) are often reluctant to talk about these issues with their care team, said Sue Thomas.

Stigma, embarrassment, and, for women, the misconception that incontinence is an inevitable part of getting older are all barriers to the conversation.

“Bladder and bowel issues are much more common that you might think in PD,” said Sue, adding that constipation often occurred during the prodromal stage of the disease.

“It should be something that we're thinking about straight away, from diagnosis, and trying to advise patients about.”

The data story

In 2018/9, NHS England spent £168m – the equivalent of funding 7,304 newly-qualified nurses for a year – on treating constipation. Of that, £81m was on emergency admissions.

Hospital Episodes Statistics (HES) data from 2019/20 show more than 77,000 of England’s 121,000 PD patients, or two in five, were admitted to hospital as an emergency costing a total of £301m. The average cost of an emergency admission was £3,889, and a total of £26m was spent treating urinary tract infections.

“The costs are huge in comparison to managing people at home and looking after them properly. If we could alleviate problems with constipation and bladder and bowel issues, we would make tremendous savings,” said Sue. “I think this is something we really ought to focus on if at all possible.”

Stimulating conversation

Getting people to talk about the problem is the first step to effective management, said Sue, suggesting the non-motor systems questionnaire (NMS quest) was a useful tool.

It lists a wide range of symptoms that can be related to PD, including bladder and bowel problems. Patients simply tick the boxes that apply to them before they arrive at clinic.

Not only does this give the healthcare professional (HCP) an opportunity to raise the subject, it also removes the stigma from the patient’s point of view.

“There are ways and means of helping people,” said Sue, recommending the “helpful literature” published by Parkinson’s UK.

“We need to recognise that bladder and bowel problems are very distressing. They're costly and have a real impact on quality of life.

“With appropriate assessment and intervention, we can usually find a solution for management,” she concluded.

Bladder and bowel “just as important” as motor symptoms

There is a high prevalence of bladder and bowel problems among people with PD, and the problem tends to get worse as the disease progresses.

Jane Young described constipation as per the Rome criteria of fewer than three bowel movements a week, adding that it was associated with straining, bloating, and abdominal discomfort.

“In Parkinson’s, this is largely due to the deregulation of the brain/gut microbiota axis which affects interactions between the enteric and central nervous systems… that then leads to a reduction of the GI transit,” she said.

“It is under reported, as with most bladder and bowel dysfunction, because of the embarrassment factor but it has a massive impact on quality of life… these patients need regular support.”

Constipation: Treatment

Treatment options for constipation include recommending a high fibre diet, increased water intake, and more exercise. Synthetic fibre products may also be useful. Jane’s team also recommends multi-strain probiotics to most patients with constipation.

Other options include drugs such as Lubiprostone / Bisacodyl / Prucalopride, suppositories, and anal irrigation. However, Jane also offered a warning about using antimuscarinic drugs in elderly PD patients, due to the anticholinergic burden. “I certainly would never advocate putting any Parkinson's patient on an antimuscarinic without a bladder scan before and afterwards,” she said.

Bladder issues

Bladder issues are also common, including chronic or acute retention secondary to constipation, nocturia, UTIs, and overactive bladder.

Many of these are compounded by other PD symptoms and can contribute to problems such as falls risk and fatigue.

“I think it's really important that these PD patients have access to a specialist adult bladder and bowel clinic,” said Jane, adding that self-referral increased access by removing the embarrassment of discussing the problem with a GP first.

“It is really important that local bladder and bowel services link up with their local neuro rehab teams and their Parkinson's nurse specialists in the acute sector and in the community, so that we can all work together.

“I'm sure you'll agree that managing bladder and bowel dysfunction is just as important as managing motor symptoms,” said Jane, adding that regular follow up was key.

Ask the question: It is the first step to treating bladder dysfunction

HCPs should ask about bladder and bowel symptoms at every consultation, said Dr Robin Fackrell.

“If you don't ask, you're not necessarily going to be told about these symptoms, as people find that they're quite embarrassing to talk about,” he said.

“But if you normalise it early on in your relationship with the patient, then it will just be part of your consultation. They will be expecting it and only too happy to share the details of their bowel and urinary dysfunction, or hopefully function.”

He explained that bladder control was extremely complex and involved the basal ganglia, the part of the brain affected by PD.

Common bladder problems

People with PD often describe symptoms associated with overactivity, such as urgency and frequency. Nocturnal frequency is also common, having a huge impact on sleep quality, affecting cognition and increasing the risk of falls.

Incontinence, Robin went on, can be a major reason for people entering residential care and losing their independence.

Another common issue is voiding problems, such as poor urine stream, straining, and slow initiation of urine. Performing a bladder scan and looking at post-void residual volumes is important here. “If you notice high post-void residual volumes, then you need to think about other diagnoses being present,” he said, highlighting multiple system atrophy (MSA).

Bladder issues: Treatment

The treatment of bladder dysfunction starts with asking the question, then taking a detailed history and investigating appropriately. Again, Robin recommended a bladder scan and correlating the results to the patient’s symptoms.

When dealing with storage issues, HCPs should always optimise dopaminergic treatment. It can have an inhibitory effect leading to urgency and frequency when the patient is in the “off” stage.

Robin reiterated Jane’s point about the anticholinergic burden.

“I cannot stress enough that anticholinergic drugs are dangerous and toxic for patients. We really need to be careful when we're giving them, particularly to our cognitively, and more physically frail patients,” he said, recommending acbcalc.com for trustworthy anticholinergic scores.

Mirabegron, Robin said, was much more effective and well tolerated for bladder storage issues, adding that urinary Botox was sometimes useful.

“But let’s also think about using our underuse urology colleagues for the management of bladder dysfunction in PD,” he added.

Nocturnal polyuria

Nocturnal polyuria, or passing more than 50% of your 24-hour urine volume overnight, is also common in PD. If in doubt, the HCP should ask the patient to collect and measure their urine, said Robin.

The problem, he said, usually responds well to desmopressin. “People can actually get a much better quality of sleep and then have much better motor and cognitive function the next day as a result.”

Robin also touched on the importance of managing constipation, agreeing with Sue and Jane on the huge quality of life burden.

Podcast

Our Parkinson's webinars are available on SoundCloud:
soundcloud.com/neurologyacademy