The bladder has two main roles: to store urine as the kidneys produce it, and to expel urine from the body. The bladder expands like a balloon as urine fills it. The average bladder can hold about half a litre of urine at a time. On average, a healthy person urinates four to six times a day.
When the bladder is about half-full of urine, sensors send a signal to the brain, warning that the bladder will need to be emptied. Most people are able to delay emptying and can choose when to go to the toilet.
As the bladder continues to fill, more urgent signals are sent to the brain announcing the need to urinate. The sphincter muscles around the urethra (bladder outlet) and the pelvic floor muscles maintain a watertight seal.
When you are ready to urinate, your brain sends a signal to the bladder, telling it to contract. At the same time, you relax the sphincter muscles, allowing urine to pass from the body.
Bladder function is very complicated and sometimes, for a variety of reasons, bladder (or urinary) problems occur. These are common in the general population at all ages and may include:
- increased frequency of going to the toilet. Generally associated with age-related reduced bladder capacity (as we get older, our bladder capacity decreases), but may also be due to other causes, such as urinary infections including cystitis. Increased urination frequency during the night is known as nocturia
- difficulty in passing urine. The stream becomes poor and it takes longer to empty the bladder. This tends to happen in men with large prostates or in women who had gynaecological surgery resulting in a tight sphincter
- urinary incontinence. An unintentional passing of urine.
Urinary incontinence can be further classified as:
- urge incontinence. Urine leaks out before the person gets to the toilet when they have an urgent need to go. They simply cannot voluntarily stop the detrusor muscle in the bladder from starting to contract, or prevent the sphincter muscles from relaxing when the bladder pressure rises
- stress incontinence. Laughing, coughing and other actions that cause the pressure inside the abdominal cavity to rise can result in a leakage of urine. As the bladder is inside the abdominal cavity, any rise in pressure means bladder pressure also increases. The sphincter should contract and prevent any leaks, but if it is weak some urine may escape. Women who have had a number of babies could have weakened their sphincter and pelvic floor muscles and are therefore particularly susceptible to stress incontinence. Female hormone levels also affect the health of the sphincter, and older women may suffer with stress incontinence after the menopause. Men who have undergone prostate surgery could have some damage to their sphincter resulting in stress incontinence
- mixed incontinence. Urge and stress incontinence can occur together and is particularly distressing. A person with urge problems can cough and cause bladder pressure to rise. But as they have difficulty suppressing bladder contractions and as their sphincter is weak, the urine will start to flow without control
- dribbling or overflow incontinence. If the bladder is unable to empty properly, the residual urine can build up and eventually overflow, continuously and uncontrollably, in small amounts.
These difficulties can be very embarrassing and have an enormous impact on a person’s quality of life.
How might Parkinson's affect bladder problems?
Bladder difficulties can be common amongst people with Parkinson’s, particularly in the later stages of the disease. The loss of dopamine and the resultant interruption of signals from the brain, can mean that the messages telling the bladder to retain or expel urine are disrupted.
However, it is important to stress that bladder problems are not inevitable with Parkinson’s. If difficulties do arise, especially in older people, they may be caused by factors totally unrelated to the disease and, as such, a thorough medical evaluation would be recommended, including a medical history, clinical examination and, if appropriate, further tests.
Bladder problems associated with Parkinson’s include:
- The detrusor muscle, which relaxes to allow the bladder to fill and contracts to expel urine, can become unstable resulting in urge incontinence. Often the muscle will contract erratically and just with small volumes of urine in the bladder. This instability becomes more common in the later stages of Parkinson’s and major urgency in early stages should prompt one to investigate diagnoses unrelated to the disease, such as prostate problems in men, or consider the possibility that the person may have another form of Parkinsonism, such as multiple system atrophy (MSA).
- Physical problems, such as reduced mobility, particularly in the later stages of Parkinson’s, can prevent the person from getting to the toilet in time when they have an urgent need to go, resulting in urge incontinence. Falls may also result when trying to reach the toilet urgently, particularly in people who experience freezing or bradykinesia.
- Difficulties with the practicalities of using the toilet, such as undoing clothing and the process of sitting on the toilet, can also lead to urge incontinence if the bladder begins to contract involuntarily.
- A frequent need to go to the toilet during the night (nocturia), or night-time incontinence (nocturnal enuresis), when the person is unable to reach the toilet in time, can lead to sleep disruption. It is worth noting that urine production at night increases as we age.
Difficulty emptying the bladder
- Some people with Parkinson’s find it difficult to pass urine when the bladder fails to contract when required, or because the sphincter doesn’t let urine out - or a combination of the two. This is a result of reduced dopamine levels interfering with the efficiency of the bladder muscles and causes a residual amount of urine to be left in the bladder. This reduces the total amount the bladder can hold and creates a feeling of wanting to empty the bladder very often. Moreover, those people who cannot fully empty their bladder have an increased risk of urinary infection.
- In some older people, constipation - which is often associated with Parkinson’s - can result in faeces collecting in the rectum. This puts pressure on the urethra (the tube leading from the bladder to the outside) and may even obstruct it. The bladder is then unable to empty and may continue distending, causing dribbling incontinence.
- Anticholinergic medications can also make emptying problems worse.
Treatment and management of bladder problems
It is important to discuss any bladder difficulties, included those listed below, with your doctor, even if this is embarrassing. Your doctor will make a proper assessment of any bladder problems.
- Inability or difficulty in emptying the bladder even when it feels full.
- Significant uncontrolled leakage of urine at any time.
- Unusually frequent urination (unless you already know you have a urinary infection).
- An urgent, immediate need to urinate, or urine leaking if you do not immediately do so.
- Pain when urinating.
Writing notes to discuss with your doctor can help. These should include the nature of the difficulties experienced, their frequency, when the changes were first noticed and your normal eating and drinking habits.
Bladder problems can occur for a number of reasons, so the first approach will be to eliminate causes other than Parkinson’s, such as urinary infections (which can be common in older people) and Prostate problems in men.
Treatment approaches for bladder problems may include:
General assessment and advice
Often a doctor will avoid medication initially, preferring to investigate whether diet, drinks, bowels, mobility, toilet environment and optimum control of Parkinson’s can affect – and improve - your bladder function.
The doctor may adjust your Parkinson’s medication as sometimes this can help. Medications may also be prescribed to:
- improve urgency and frequency problems by relaxing the bladder while it is filling and reducing unwanted bladder contractions
- overcome night-time problems by reducing urine production for approximately eight to ten hours after the medication is taken.
Pelvic floor exercises are useful in preventing stress incontinence caused by weak pelvic floor muscles. These muscles, which stretch from the pubic bone at the front to the tail bone (coccyx) at the back of the body, are like a trampoline and work to support the bladder and bowel, as well as the uterus in women. They can become weak for many reasons, including childbirth, lack of exercise, hormonal changes and ageing, and this can cause urine to leak, particularly when coughing, sneezing, laughing or exercising.
Pelvic floor exercises can strengthen the muscles and so help control the bladder and prevent any leakage of urine. The following suggestions may help you to effectively do pelvic floor exercises on a daily basis, although it must be stressed that everyone is different and so each individual must find an exercise pattern to suit their own needs. A physiotherapist will be able to advise further.
Pelvic floor exercises:
- Sit comfortably in an upright chair with knees apart, making sure your weight is spread evenly on both buttocks.
- Imagine your pelvic floor is like a lift. Try to take the lift up and down to different floors, making sure you continue to breathe deeply down to the bottom of your rib cage throughout the exercise.
- Breathe in deeply, then all the way out, and take the lift to the first floor by tightening the lower abdominal muscles and back passage. As soon as you have tightened, resume normal breathing while you hold the muscles for a count of five.
- Slowly release the muscles completely.
- Next time, contract the muscles and take the lift to the second floor. Exhale as you contract, and resume breathing as you hold for a count of five, and then slowly release.
- Continue this again taking the lift finally to the third floor.
When performing the exercise, make sure you don’t tense your buttocks, bring your knees together, hold your breath, or lift your shoulders, eyebrows or toes upwards as you do them. If you do, your muscles will not be contracting correctly and the exercise won’t work.
Note: correct breathing and the ability to release the muscle to the basement floor after each hold is very important.
As you practice this each day, aim to squeeze harder to take the lift higher, and to hold the lift for longer at each floor. Increase the number of ‘lifts’ you do each time, but remember to rest between sets of squeezes. You may find it helpful to count and record how long you can hold for and how many squeezes you can do so that you can see your progress.
Try to build these exercises into your daily routine – ideally five times a day - and also use them whenever you think you may be about to leak urine, particularly if you are about to sneeze or cough.
Surgical techniques may sometimes be used to treat stress incontinence and prostate problems.
Intermittent catheterisation may be recommended if the problem is failure to empty the bladder resulting in much residual urine. It involves the insertion of hollow tubes into the urethra to drain urine away from the bladder and can be administered by the individual concerned, a carer or nurse.
How can I help myself?
There are many ways in which you can help overcome bladder problems. Many are very simple, such as changes in the set-up of your bathroom, the use of practical aids and changes in your daily routine.
In Parkinson’s, many incontinence problems are caused by difficulties with the practicalities of going to the toilet. An incontinence advisor or an occupational therapist can assess any difficulties you have and advise on ways of overcoming these. Some of the suggestions they may make include:
- using a stool to lift your feet off the ground can make you more comfortable if the toilet is too high
- a raised toilet seat if the toilet is too low
- grab rails fixed to the walls or floor to make getting to the bathroom easier
- clothing that is easy to undo. For example, Velcro fastenings are much easier than buttons or zips and elasticated waists are even simpler
- exercises and techniques to overcome the problems, for example training your bladder to hold on for longer when you need to urinate
- using incontinence aids and equipment, including:
- undergarments that are elasticated at the hip - but not too tightly - so are easy to pull up and down
- underwear shields or pads to absorb any leakages. There are various sizes of pads available with different levels of absorbency to suit your needs. High absorbency pads are available for use during the night. Remember when using pads they need to be worn close to the skin and held firmly in place to prevent circulation of air, so reducing the chance of sore skin, odours or leakage. So make sure your underwear is a snug fit
- briefs with sticky tabs on the sides and elasticated legs to make them easier to get into, or for carers to fit, as they can be slipped between the legs and then fastened, so do not need to be pulled up over the hips
- a commode or portable urinal at night so you don’t have to worry about getting to the toilet in time.
People with bladder problems often try to restrict the amount they drink because they worry about needing to go to the toilet. This is understandable but not recommended. It is important to drink approximately eight to ten cups of fluids each day in order to expel waste products efficiently. Taking plenty of fluids during the day whilst restricting fluid intake during the late evening, especially an hour or so before bed-time, is recommended.
Caffeine, which is found in tea, coffee, cola and some other fizzy drinks, can irritate the bladder so is best consumed only in small quantities.
Alcohol can exacerbate incontinence problems so try not to consume too much, especially if you are not in a position to access a toilet easily and quickly. ‘Long’ drinks, such as beers and lagers, tend to have a worse effect than ‘short’ drinks, such as spirits.
If bedwetting is a problem, it may be helpful to set an alarm clock for a couple of hours after you go to sleep so that you are woken up to go to the toilet. You may need to experiment to find the best wakeup call time for you. It is wise to vary the time you set the alarm as this will stop your bladder from becoming accustomed to emptying regardless of the time you go to bed.
Special alarms, known as enuresis alarms, are also available. These are designed to wake you either with a sound or by vibrating when urine starts to leak. Gradually your body may become accustomed to holding urine or waking you automatically so that you can urinate.
Our thanks to Parkinson's UK for permission to use the following source(s) in compiling this information: