Hypothesis / aims of study
The aim of the study was to evaluate urodynamic and demographic findings in women referred to the neurourology clinic with movement disorders (multiple system atrophy [MSA] and Parkinson’s disease [PD]). We sought to explore if any of these factors were clearly associated with a specific neurological diagnosis, since distinguishing these disorders is often quite difficult based on clinical exam alone.
Study design, materials and methods
We performed an IRB-approved retrospective review of all female patients with PD or MSA who were evaluated for lower urinary tract symptoms with a urodynamic study between March 2007 and February 2020. We excluded any patient without a definitive diagnosis of either PD or MSA or any confounding neurologic diagnoses (multiple sclerosis, prior cerebral vascular accident, spina bifida, etc.). We also excluded patients with a history of GU malformation/fistula, or malignancy, and any patients who had previously undergone any anti-incontinence operations. We examined presenting demographics, co-morbidities, medications, ambulatory status, bladder management and urodynamic parameters. Statistics were completed using student t-test, Fisher’s exact test or Pearson’s chi-squared test, when applicable.
Results
A total of 38 women, 26 with PD and 12 with MSA, were included in the study. The average age at neurologic diagnosis of our PD and MSA cohorts was 60.9±10.2 and 65.2±8.8, respectively. The average time from neurologic diagnosis until urologic referral was 5.2±4.9 years for PD patients and 2.7±2.9 years for MSA patients (p=0.186). More patients with PD had diabetes mellitus (26.9% vs 0.0%, p=0.047). MSA patients were more likely to be wheelchair bound (41.7% vs 7.7%, p=0.022). Patients in both cohorts were referred with similar chief complaints, with the most common being urinary incontinence in both cohorts (57.7% of the PD versus 41.7% of the MSA patients), followed by lower urinary tract symptoms (LUTS) in the PD group, and urinary retention/incomplete emptying and recurrent urinary tract infections (rUTIs) in the MSA group. Regarding bladder management, the majority of patients were able to void at presentation (89% vs 92% for PD and MSA respectively, p=0.765). Among the patient’s with PD, only 5 (18.2%) were on either an anticholinergic or beta-3 agonist at time of referral versus 6 (50%) of the MSA patients (p=0.147). Average urinary distress inventory- 6 (UDI-6) scores were 48.6±22.5 for patients with PD and 41.7±5.9 for patients with MSA (p=0.646). Of those who had fluoroscopy during urodynamics (13 with PD and 4 with MSA), none had evidence of vesico-ureteral reflux. Women with MSA had a higher incidence of open bladder neck (75.0% vs 15.4%, p=0.026; Power= 0.64) and were more likely to have detrusor-external sphincter dyssynergia (DESD) (33.3% vs 3.8%, p=0.027; Power= 0.657). There was no statistically significant difference noted in bladder compliance, maximal flow (Qmax), post void residual, volume at first urge or incidence of detrusor overactivity.
Interpretation of results
Our population consisted only of females with PD or MSA. Contrary to previous studies, we were not able to see any difference in the flow rate, post void residual, volumes at first urge or maximal cystometric capacity, likely due to the mixed (gender) nature of prior studies[1]. We did demonstrate a sizable disparity in rates of DESD and a higher prevalence of an open bladder neck in women with MSA compared to their PD counterparts.