Continence Assessment in Parkinson’s Disease

In Parkinson’s disease the non-motor symptoms which accompany and often precede motor features are increasingly recognised as a significant predictor of patients’ disease perception and quality of life (1,2). Urinary tract dysfunction is a very common non-motor symptom which has been highlighted as being under-diagnosed and undertreated in clinical practice(3,4). It encompasses a spectrum of urinary symptoms, from nocturia and frequency (relatively benign, although in clinical practice these commonly contribute to falls), to full incontinence. Such conditions can be highly functionally limiting, patients may feel embarrassed, be unable to travel far in case of accidents, and become socially isolated; quality of life is therefore substantially reduced (5). Urinary incontinence is also a common factor for admission to a care home. For all these reasons, effective and ongoing management of lower urinary tract dysfunction is highly desirable.

Current NICE guidance for Parkinson’s disease (GG35) (4) discusses urinary tract dysfunction but there is only limited focus on assessment of this aspect of care. However, NICE guidance (CG148) for management of neurological disease (including Parkinson’s disease) (6) recommends that urinary tract function should be assessed throughout the period of care: as a new patient, at routine assessment at least every three years, and in the case of any changing symptoms. A full history and physical examination should be taken and any particular Parkinson’s-related challenges noted: for instance, mobility and easy access to the toilet. In symptomatic patients, urinalysis should be performed, a post-void residual volume measured, and a three day frequency/volume chart completed.

Our concern was that continence issues may not be treated adequately in clinical practice. To investigate this, assessment of urinary symptoms at a multidisciplinary geriatrician-led movement disorders clinic was audited.

Aims

1. Investigate how closely clinicians are adhering to NICE CG148 in the assessment of urinary tract dysfunction.
2. Examine how clinicians can improve the standard of assessment.

Audit standards – to ascertain whether:

1. Patients are asked whether they suffer from lower urinary tract dysfunction.
2. In patients suffering with lower urinary tract dysfunction the type of dysfunction is further characterised
3. In patients suffering from lower urinary tract dysfunction symptoms are further investigated – as appropriate a dipstick test, a bladder scan, and/or the completion of a frequency/volume chart. If not, the reasons for this should be noted in the patient’s record.
4. Written or verbal information about their continence management plan is provided to patients suffering from lower urinary tract dysfunction.

Results

20 consecutive patients attending clinic were audited. All 20 (100%) patients were asked about the presence or absence of lower urinary tract symptoms including incontinence. 18 (90%) were found to have symptoms. Of these, 33% had a urine dipstick test, 11% underwent a bladder scan, and none had a frequency/volume chart completed. In 7 patients with urinary dysfunction, their symptoms were further categorised (stress, urge, functional, mixed etc) and in 5 of these (71%) some form of bladder management plan was commenced. The corresponding figure for treatment in the remaining patients whose dysfunction was not further characterised was only 18%.

Finally in only 22% of patients suffering from urinary tract dysfunction there was a record of the patient having received written or verbal bladder management information.

Discussion

It is clear that the majority of patients suffering symptoms of urinary incontinence are not being assessed according to NICE guidelines. Urinary tract dysfunction can be a difficult condition to assess, often reliant on patients’ self-reporting of subjective symptoms. However, these results also show that while continence problems are identified in patients, further investigation of symptoms is suboptimal and urinary tract dysfunction is being undertreated.

Future Plans

1. Education: Raising awareness amongst members of the Parkinson’s team (and beyond) of the need for more detailed assessment of urinary tract dysfunction through education sessions including presenting these results.
2. Proforma: Developing the standard patient assessment form so that consideration of further investigations (post-void residual volume ultrasound scan, urine dipstick test, and frequency/volume chart) are prompted in patients with urinary tract dysfunction.
3. Improved access to investigations: The presence of a new bladder scanner at the clinic will make the investigation of symptoms quicker and easier.

More detailed and accurate clinical assessment of patients’ urinary tract symptoms should lead to more focused management. The initial assessment and interventions recommended by NICE do not require highly specialised equipment and can be carried out as part of routine input in a multidisciplinary clinic. Ignoring treatable or potentially reversible urinary tract symptoms represents a wasted opportunity to greatly improve quality of life, without a large outlay of resources, for patients living with this chronic disease.

Bethan England, 4th year medical student, University of Manchester

Dr David Ahearn
Consultant Physician – Elderly Medicine
University Hospital of South Manchester NHS Foundation Trust Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester, M23 9LT

References

1. Martinez-Martin P. Non-motor symptoms and health-related quality of life in early Parkinson’s disease. Mov Disord 2013 Dec 27.
2. Duncan GW, Khoo TK, Yarnall AJ, O’Brien JT, Coleman SY, Brooks DJ, et al. Health-related quality of life in early Parkinson’s disease: The impact of non-motor symptoms. Mov Disord 2013 Oct 7.
3. Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor symptoms in Parkinson’s disease. Parkinsonism Relat Disord 2002 Jan;8(3):193-197.
4. National Institute for Health and Care Excellence. Parkinson’s Disease: Diagnosis and management in primary and secondary care. 2006;CG35.
5. Kobelt G, Kirchberger I, Malone-Lee J. Review. Quality-of-life aspects of the overactive bladder and the effect of treatment with tolterodine. BJU Int 1999 Apr;83(6):583-590.
6. National Institute for Health and Care Excellence. Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease. 2012;CG148.