Bladder difficulties, especially incontinence and difficulty emptying the bladder, may be experienced in Parkinson's, particularly in the later stages of the condition.
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 and when it is about half-full of urine, sensors send a signal to the brain, warning that the bladder will need to be emptied. As it continues to fill, more urgent signals are sent announcing the need to urinate. The average bladder can hold about half a litre of urine and on average, a healthy person urinates four to six times a day.
The sphincter muscles around the urethra (bladder outlet) and the pelvic floor muscles maintain a watertight seal and most people are able to delay emptying and can choose when to go to the toilet. When you are ready to urinate, your brain sends a signal to the bladder, telling it to contract. At the same time, the sphincter muscles relax, allowing urine to pass from the body.
Bladder function is very complicated and sometimes, for a variety of reasons, bladder (urinary) problems occur. These are common in the general population at all ages and may include:
- Increased frequency of going to the toilet - this is generally associated with age-related reduced bladder capacity (as we get older, our bladder capacity decreases), but may also be due to other causes, for example urinary infections such as 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 getting to the toilet as the bladder involuntarily contracts and the sphincter muscles relax.
- Stress incontinence - laughing, coughing and other actions that cause pressure inside the abdominal cavity (where the bladder sits) to rise can result in urine leaking out. 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 may have weakened 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 which may be particularly distressing.
- 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 may significantly impact quality of life.
How might Parkinson's affect bladder problems?
Bladder difficulties can be common in Parkinson’s, particularly in the later stages of the condition. The loss of dopamine and the resulting interruption of signals from the brain, can mean that messages telling the bladder to retain or expel urine are disrupted.
However, it is important to stress that bladder problems are not inevitable in Parkinson’s. If difficulties do arise, especially in older people, they may be caused by factors totally unrelated to the condition, so a thorough medical evaluation should be carried out with any appropriate 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 with only small amounts of urine in the bladder. This instability is more common in the later stages of Parkinson’s, so extreme urgency in the early stages should be investigated as the cause may be unrelated to Parkinson's - for example, prostate problems in men - or another form of Parkinsonism, such as multiple system atrophy (MSA), may be the cause.
- Physical problems, such as reduced mobility, particularly as Parkinson’s progresses, can make it hard to get to the toilet in time, resulting in urge incontinence. Falls may also occur if rushing to the toilet, particularly if you 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), 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 if the bladder fails to contract when required, or because the sphincter does not 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 causing 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. Unfortunately, there is an increased risk of urinary infection if the bladder is not emptied completely.
- 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 out of the body from the bladder) 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.
Treating and managing bladder problems
It is important to discuss any bladder difficulties, including those listed below, with your doctor, even if this is embarrassing. Your doctor will then be able to properly assess and treat any problems, for example:
- inability or difficulty emptying the bladder even when it feels full.
- significant, uncontrolled leakage of urine at any time (incontinence).
- 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.
It may be helpful to write notes to discuss with your doctor, for example, the type of difficulties experienced, their frequency, when you first noticed a change, 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 and prostate problems in men. Treatment may then include:
General assessment and advice
Often a doctor will avoid bladder-specific medication initially while he or she investigates whether diet, drinks, bowels, mobility, toilet environment and optimising Parkinson's medication can affect, and improve, your bladder function.
Your doctor may adjust 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 urine leaking. 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 and your weight 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.
- Repeat this, finally taking the lift 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 will not be effective. Breathing correctly and releasing 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.
Surgery may sometimes be suggested to treat stress incontinence and prostate problems.
Intermittent catheterisation may be recommended if the problem is failure to empty the bladder and a significant amount of urine remains in the bladder. This involves inserting a hollow tube into the urethra to drain urine away from the bladder.
How can I help myself?
There are many things you can do to 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 problems and advise on ways to overcome these. They may suggest, for example:
- using a stool to lift your feet off the ground to 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 the toilet
- using incontinence aids and equipment, including:
- undergarments that are gently elasticated at the hip, making them easy to pull up and down
- underwear shields or pads to absorb any leakages. Various sizes of pads are available with different levels of absorbency to suit your needs during the day and night. Underwear needs to be a snug fit when using pads so that they are held firmly in place and to prevent circulation of air as this reduces the chance of sore skin, odours or leakage.
- briefs with sticky tabs on the sides and elasticated legs to make them easier to get into, or your carer can simply slip between the legs and then fasten.
- a commode or portable urinal at night so you do not 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 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 evening, especially an hour or so before bed-time, can help.
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, particularly 'long' drinks such as beers and lagers, can make incontinence problems worse so try not to consume too much, especially if you are not in a position to access a toilet easily and quickly.
If bed-wetting 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 wake-up call time and it is wise to vary the alarm time 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 go to the toilet.
Our thanks to Parkinson's UK for permission to use the following source(s) in compiling this information:
- Bladder and bowel problems in Parkinson's.