Exercise, Behavioral Therapy Ease Incontinence in PD

May 18, 2011 (National Harbor, Maryland) — Behavioral therapy using
pelvic floor muscle exercises may help prevent urgency urinary
incontinence (UUI) episodes in older patients with Parkinson's disease
(PD), according to preliminary data released here at the American
Geriatrics Society (AGS) 2011 Annual Scientific Meeting.
Results showed that patients who combined pelvic floor muscle therapy
with lifestyle recommendations decreased their weekly UUI episodes by
more than 50% at 2 weeks. In addition, continued and sustained
reductions in UUI episodes were reported after additional instruction in
a pelvic floor muscle exercise-based urge suppression strategy.
"We are strongly encouraged by our findings, given that UUI, as well
as other forms of urinary incontinence, can be extremely bothersome in
older PD patients who already have a host of debilitating motor
symptoms," Camille Vaughan, MD, assistant professor of geriatric
medicine and gerontology at Emory University School of Medicine in
Atlanta, Georgia, and investigator with the Birmingham (Alabama)/Atlanta
Veterans Affairs (VA) Geriatric Research, Education, and Clinical
Center, told Medscape Medical News.
"The possibility of a nonpharmacologic therapy for urinary
incontinence in PD is particularly attractive because anticholinergic
medications typically used to treat urinary symptoms can worsen the
cognitive decline, constipation, and orthostasis that are frequently
seen in PD patients."
The investigators reported findings in a group of patients enrolled
in the ongoing Behavioral Therapy to Treat Urinary Incontinence in
Parkinson's Disease study.
Urinary Incontinence Problematic in Patients With PD

Dr. Camille Vaughan

Up to 3% of individuals older than 65 years develop PD, Dr. Vaughan
pointed out. Of these patients, about 30% complain of UUI. Although the
exact mechanisms for lower urinary tract symptoms such as UUI in PD have
not been determined, detrusor hyperactivity, leading to symptoms of
overactive bladder and UUI, is common. UUI has been widely shown to
worsen quality of life.
Clinical guidelines for the treatment of nonmotor symptoms in PD
recommend empiric therapy with anticholinergic agents for the treatment
of urinary incontinence in PD, despite the lack of randomized controlled
trials supporting such a recommendation, Dr. Vaughn said. However,
general treatment guidelines for urinary incontinence in older patients
recommend behavioral and exercise-based interventions as first-line
therapy over drug treatment in older adults because of an absence of
adverse effects with these therapies, and because of their proven
efficacy for urge symptoms of overactive bladder in elderly populations.
Pilot Study

Study participants were patients 50 years of age or older who had
been diagnosed with PD by a movement disorders specialist and who
reported urgency and at least 4 weekly urinary incontinence episodes on a
7-day bladder diary.
Study participants visited the study clinic 5 times during the 8-week
study period. At their initial visit, they underwent pelvic floor
muscle training using dual-channel computer-assisted biofeedback. They
were also given guidance regarding fluid management (decrease caffeine
and drink six to eight 8-ounce glasses of fluid daily) and education
about constipation management when indicated (increase physical
activity, fiber, and fluids, and use over-the-counter medications if
needed).
At their second visit 2 weeks later, patients were taught to use
pelvic floor muscle exercises as part of a "Freeze and Squeeze" urge
suppression strategy to prevent UUI.
Subsequent visits were used to reinforce bladder control strategies.
Significant Reduction in UUI Episodes

Three of the initial 20 patients dropped out of the study, although
not because of treatment-related issues. Results in the remaining 17
patients who completed the study showed a decrease in mean weekly UUI
episodes from 11.9 ± 16.0 episodes at baseline to 1.3 ± 1.8 episodes at
the end of the study (P = .02).
Analysis of weekly bladder diaries showed a significant reduction in
UUI episodes compared with the previous week after lifestyle and pelvic
floor muscle exercise training (mean weekly UUI, 4.2 ± 5.0 at the second
clinic visit; P = .05) and 4 weeks after urge suppression training (mean weekly UUI, 0.7 ± 1.3 at the fourth visit; P = .006).
The reduction in UUI at the fourth visit was statistically similar to the reduction at the fifth and final visit.
Dr. Vaughan noted that although most of the study participants were
men, prior studies of behavioral therapy in women without PD have
demonstrated similar efficacy.
She added that although these results are promising, randomized controlled trials are needed.

Louise Walter, MD

"Urinary incontinence is a major problem in PD patients, but patients
are often too embarrassed to mention it to their physician," Louise C.
Walter, MD, professor of medicine in the Geriatrics Division at the
University of California–San Francisco School of Medicine, said in an
interview with Medscape Medical News. "Instead, at the end of
their office visit, they may say 'oh, by the way, can you order me some
pads,' and that's the first the doctor will hear of it."
The findings of the present study are encouraging, given that they
show that a nonpharmacologic strategy may be effective and completely
free of adverse effects, she added. "This is important because it makes
no sense to prescribe additional medications to PD patients who are
already on multiple medications if a drug treatment can be avoided. And,
it would be good to avoid anticholinergics, in particular, given that
anticholinergics used to manage urinary symptoms may cause delirium and
have been associated with falls.
"Also, constipation is commonly a side effect of anticholinergics,
and constipation is already problematic in PD patients," Dr. Walter
noted.
The John A. Hartford Southeast Center of
Excellence in Geriatric Medicine at Emory University and the US
Department of Veterans Affairs supported the study. Dr. Vaughan has
reported receiving research grant support from Astellas Pharma, Inc. Dr.
Walter has disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2011 Annual Scientific Meeting: Abstract C87. Presented May 13, 2011.