Behavioral Intervention Reduces Urinary Incontinence in Parkinson's Disease Patients

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NATIONAL HARBOR, Md.—Preliminary results suggest a role for exercise-based, biofeedback-assisted behavioral therapy for preventing urgency urinary incontinence (UUI) in older patients with Parkinson's disease (PD).

The findings, released at the 2011 Annual Scientific Meeting of the American Geriatrics Society and also published in the May 10, 2011 issue of Neurology, are from the ongoing Behavioral Therapy to Treat Urinary Incontinence in Parkinson's Disease (BETTUR PD) study.

The behavioral intervention was administered to 20 patients every two weeks for a total of five visits over eight weeks.

“Patients with Parkinson's disease are typically prescribed anticholinergic  agents for their urinary incontinence even though there have been no randomized, controlled trials to support such a practice,” said Camille Vaughan, MD, Assistant Professor of Geriatric Medicine and Gerontology at Emory University School of Medicine in Atlanta. “Unfortunately, anticholinergic medications can worsen the mild cognitive impairment or dementia along with the constipation and orthostasis that commonly occur in Parkinson's patients.”

Up to 3% of individuals over 65 years of age develop PD, Dr. Vaughan pointed out.  Of these patients, nearly a third report UUI which is probably due to detrusor hyperactivity.

Earlier research had shown that behavioral and exercise-based interventions can effectively treat urge symptoms of overactive bladder in elderly populations, she said.

The present analysis included PD patients who were 50 years of age or older  and had noted that they had  urgency and at least four weekly urinary incontinence episodes on a seven-day bladder diary.

At the first clinic visit, computer-assisted anorectal or vaginal computer-assisted biofeedback was used to help patients identify their pelvic floor muscles and to teach them how to relax and contract these muscles while maintaining their rectus abdominalis muscles intact. They were also given guidance regarding fluid management (decrease caffeine intake and drink six to eight eight-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 two weeks later, patients were taught to use pelvic floor muscle exercises as part of a “Freeze and Squeeze” urge suppression strategy to prevent UUI.  Individuals who had stress-related urine loss were instructed to squeeze pelvic floor muscles immediately before triggers of stress leakage including such as sneezing, coughing, or laughing.

The final three clinic visits were used to reinforce bladder control strategies.

Three of the initial 20 patients withdrew from the study for reasons unrelated to treatment.

Results in the remaining 17 patients who completed the study had a  decrease in mean weekly UUI episodes from 11.9 at baseline to 1.3 at the end of the study.

A review of weekly bladder diaries showed a significant reduction in UUI episodes compared with the prior week after lifestyle and PFME training (mean weekly UUI was 4.2  at the second clinic visit) and four weeks after urge suppression training (mean weekly UUI was 0.7 at the fourth visit).

The magnitude of reduction in UUI at the fourth visit was similar to the reduction at the fifth and final visit. There were no treatment-related side effects.

Dr. Vaughan cautioned that the sample size was small and most participants were men. She emphasized, however, that earlier studies of behavioral therapy in women without PD have shown similar efficacy. 

She also pointed out that computer-assisted feedback needs special equipment and it remains to be determined whether it is possible to achieve the same results without a trained operator. 

Finally, she noted that the results are preliminary and added that larger, randomized studies are needed to determine how the behavioral intervention compares with standard treatment in terms of efficacy.

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