Urinary Tract Infections in People with Parkinson Disease

People with idiopathic Parkinson disease (PD) commonly experience lower urinary tract symptoms (LUTS), referred to as neurogenic bladder, with a prevalence reported between 27-80% (Cheng, B., et al., 2023). The neuroanatomical degeneration in the dopaminergic system is one of the main precipitating factors for LUTS and other autonomic dysfunction. The most common LUTS reported are urgency/frequency (detrusor hyperreflexia) and nocturia. As the disease progresses or in cases when the individual has atypical Parkinsonism, urinary incontinence and urinary retention (detrusor hyporeflexia, detrusor sphincter dyssynergia, bladder outlet obstruction/benign prostatic hypertrophy) become more prevalent. Taken together, these storage and voiding symptoms increase the risk of developing a urinary tract infection (UTI). Additionally, PD is considered an age-related disease, occurring most often in people over 60. Generally, the risks for UTIs increase with age, in particular, affecting aging women more due to age-related changes in the lower urinary tract after menopause.

UTIs are a leading cause of hospitalization, morbidity, and mortality in people with PD. These individuals happen to be twice as likely to be admitted to the hospital for a UTI in comparison to age-matched controls, 48% to 23% respectively (Su, C., M., et al., 2018). Additionally, UTIs seem to occur in equal proportions between older men and women with PD. This gives implication to the theory that there may be something about PD itself that overrides the typical age-related female UTI risk. Additionally, the literature reports a dramatic elevated risk in UTIs for people with PD undergoing orthopedic surgeries, with 1/3 developing a UTI after knee arthroplasty. We can also examine the inverse relationship of the person with PD experiencing UTI, inducing motor and cognitive dysfunction, especially with systemic infection causing a “UTI-induced neurotoxicity,” leading to falls and orthopedic injury with surgical repair (Hogg, E., et al., 2022). UTIs happen to be the single most frequent underlying cause for PD motor symptoms exacerbation, accounting for 25% of exacerbations (Zheng, K.S., et al., 2012). UTI-related sepsis is of very large concern as people with PD are twice as likely to experience a hospital stay longer than 3 months, and it is a leading cause of morbidity in PD.

Several other compounding factors can also increase the risk of UTI in people with PD. First, it is reported that greater than 80% of people with PD experience gastrointestinal symptoms, referred to as neurogenic bowel, with the most common being constipation. Constipation in PD is complex and is often due to both slow motility and dyssynergic defecation, leading to the risk of microorganisms entering the urinary tract. Second, is the use of anticholinergic bladder medication, especially since PD motor symptoms medications cause anticholinergic side effects, which will then be compounded and potentially increase constipation and potential urinary retention. Third, immobility and frailty affect getting to the bathroom regularly and safely, increasing the risk of urinary incontinence and pad use. There may be challenges with self-hygiene and an increased chance of long-term care facility admission, where there is an increased risk of being exposed to antibiotic-resistant bacteria. Fourth, is cognitive impairment, which ranges from mild cognitive impairment (MCI) to dementia and is 2.5-6 times more likely to develop in the person with Parkinson disease (Aarsland, D., et al., 2021). This may lead to difficulty expressing toileting needs, difficulty expressing symptoms of UTI, leading to over or under treatment, and potentially catheterization, further increasing the risk. Fifth, it may be related to the urinary tract microbiome in individuals with neurogenic bladder. A shift from a healthy microbiome to overgrowth of pathogenic species is theorized to worsen with antibiotic overuse and catheterization. There is, however, a research gap in this area, especially with PD subjects.

Multiple modifiable and non-modifiable risk factors have been identified, resulting in the person with PD being more susceptible to UTI. As pelvic health therapists, we have the opportunity for prevention education and recommendations, from lifestyle modifications to formal holistic assessment, treatment, and specialist referral. Join me for my course, Parkinson disease and Pelvic Rehabilitation, as we explore how to optimize your treatment plan for modifiable risk factors of UTI.

Resources:

1. Aarsland, D., Batzu, L., Halliday, G. M., Geurtsen, G. J., Ballard, C., Ray Chaudhuri, K., & Weintraub, D. (2021). Parkinson disease-associated cognitive impairment. Nature reviews Disease primers, 7(1), 47.
2. Cheng, B., Huang, S., Huang, Q., Zhou, Z., & Bao, Y. (2023). The efficacy and safety of medication for treating overactive bladder in patients with Parkinson's disease: a meta-analysis and systematic review of randomized double-blind placebo-controlled trials. International Urogynecology Journal, 34(9), 2207-2216.
3. Gerlach, O. H., Winogrodzka, A., & Weber, W. E. (2011). Clinical problems in the hospitalized Parkinson's disease patient: systematic review. Movement Disorders, 26(2), 197-208.
4. Hogg, E., Frank, S., Oft, J., Benway, B., Rashid, M. H., & Lahiri, S. (2022). Urinary tract infection in Parkinson’s disease. Journal of Parkinson’s Disease, 12(3), 743-757.
5. Su, C. M., Kung, C. T., Chen, F. C., Cheng, H. H., Hsiao, S. Y., Lai, Y. R., ... & Lu, C. H. (2018). Manifestations and Outcomes of Patients with Parkinson’s Disease and Serious Infection in the Emergency Department. BioMed Research International. 2018; 2018: 6014896.
6. Zheng, K. S., Dorfman, B. J., Christos, P. J., Khadem, N. R., Henchcliffe, C., Piboolnurak, P., & Nirenberg, M. J. (2012). Clinical characteristics of exacerbations in Parkinson disease. The neurologist, 18(3), 120-124.

AUTHOR BIO:
Erica Vitek, MOT, OTR, BCB-PMD, PRPC

Erica Vitek, MOT, OTR, BCB-PMD, PRPC (she/her) graduated with her master’s degree in Occupational Therapy from Concordia University Wisconsin in 2002 and works for Aurora Health Care at Aurora Sinai Medical Center in downtown Milwaukee, Wisconsin. Erica specializes in female, male, and pediatric evaluation and treatment of the pelvic floor and related bladder, bowel, and sexual health issues. She is board-certified in Biofeedback for Pelvic Muscle Dysfunction (BCB-PMD) and is a Certified Pelvic Rehabilitation Practitioner (PRPC) through Herman and Wallace Pelvic Rehabilitation Institute.

Erica has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman) BIG and is a trained PWR! (Parkinson’s Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. Erica is an LSVT Global faculty member. She instructs both the LSVT BIG training and certification course throughout the nation and online webinars. Erica partners with the Wisconsin Parkinson Association (WPA) as a support group, event presenter, and author in their publication, The Network. Erica has taken a special interest in the unique pelvic floor, bladder, bowel, and sexual health issues experienced by individuals diagnosed with Parkinson disease.