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THE JOURNAL OF UROLOGY Vol. 140,
Copyright© 1988 by The Williams & Wilkins Co. Printed in

POST-PROSTATECTOMY CONTINENCE IN THE PARKINSONIAN

PATIENT: THE SIGNIFICANCE OF POOR VOLUNTARY SPHINCTER
CONTROL
DAVID S. STASKIN, YORAM VARDI AND MIKE B. SIROKY
From the Department of Urology, Boston University Medical Center, Boston, Massachusetts

ABSTRACT
A retrospective urodynamic study of 50 parkinsonian patients was done to determine the incidence
and causes of post-prostatectorny incontinence. At presentation 22 per cent of the patients were
incontinent. In 36 patients who underwent transurethral prostatectomy the incontinence rate was
17 per cent preoperatively and 28 per cent postoperatively. There was a clear association between
normal voluntary sphincter control and urinary continence. After transurethral prostatectomy 5 of
6 patients continent preoperatively (83 per cent) who had abnormal sphincter control became
incontinent compared to 1 of 24 (4.2 per cent) who had normal sphincter control. We conclude that
the major risk of incontinence following prostatectomy in the parkinsonian patient is associated
with lack of voluntary sphincter control. (J. Ural., 140: 117-118, 1988)

Permanent incontinence following transurethral prostatec- RESULTS

tomy, generally estimated to have an incidence of less than 1
per cent, may result from detrusor instability, sphincter weak-
ness or a combination of these factors. 1 • 2 Patients with
Parkinson's disease have a high incidence of detrusor hyper-
reflexia as well as abnormalities of external sphincter control. 3
However, little information is available regarding the incidence
or the etiology of post-transurethral prostatectomy inconti-
nence in patients with Parkinson's disease. To investigate these
questions we performed a retrospective urodynamic study of
parkinsonian patients undergoing transurethral prostatectomy
for benign prostatic hypertrophy and analyzed the results with
special reference to the development of postoperative inconti-
nence.
CLINICAL MATERIAL AND METHODS
Patients. We evaluated retrospectively in our urodynamics
laboratory 50 consecutive patients with Parkinson's disease
between 1977 and 1984. Patient age ranged from 50 to 82 years
(mean age 67 years). The diagnosis of Parkinson's disease was
established by a neurological consultant from 2 to 25 years
before referral for urodynamic study (mean 9.7 years). Post-
operatively, the patients were followed for 1 to 28 months
(mean 9.2 months).
Urodynamic evaluationo Gas cystometry with carbon dioxide
(filling :rate 120 cc per minute) was performed with the patient
in the supine position with provocative maneuvers as indicated
to elicit a detrusor contraction. Electromyography of the peri-
neal striated musculature was performed with a concentric
needle electrode placed percutaneously into the bulbocaverno-
sus muscle.
Voluntary sphincter control. The presence of voluntary
sphincter control was determined by the ability of the patient
to produce upon request an increase in perinea! muscle activity
as monitored by electromyography. The patient was instructed
to tighten the perineum or hold urine with the bladder empty
as well as during bladder filling. Patients who were unable to
contract voluntarily the perinea! musculature were judged to
have absence of voluntary sphincter control.
Detrusor hyperreflexia. Detrusor hyperreflexia was defined
as the inability to suppress detrusor contraction at any bladder
volume.
Accepted for publication November 9, 1987.
117
Of the patients 36 required transurethral prostatectomy,
while 14 were unobstructed and did not undergo an operation.
Continence status. Of 50 patients 39 (78 per cent) were
continent, while 11 (22 per cent) were not (9 had urge and 2
overflow incontinence) (see figure). The continence rate in the
operative group (36 patients) was 83 per cent and it was not
statistically different from that in the nonoperative group,
which was 64 per cent (p >0.10 by Fisher's exact test).
Changes in continence status. Postoperatively, 26 of the 36
patients (72 per cent) were continent and 10 had urge inconti-
nence. Of 30 patients continent before transurethral prostatec-
tomy 24 remained continent postoperatively, while 6 had urge
incontinence. Thus, the incidence of de novo incontinence was
6 of 30 patients (20 per cent). Of 6 patients incontinent before
transurethral prostatectomy (4 urge and 2 overflow inconti-
nence) 4 continued to have urge incontinence and 2 patients
became continenL Thus, 28 of 36 patients (78 per cent) had no
change in the continence status postoperatively, while 8 (12
per cent) experienced a change. In this latter group 2 patients
with overflow incontinence became continent, while 6 became
newly incontinent.
Of 50 patients 46 (92 per cent) had detrusor hyperreflexia,
while 4 had a noncontractile bladder. In the operative group 2
patients with a noncontractile bladder regained detrusor con-
tractility postoperatively" Since hypeneflexia was extremely
common preoperatively and postoperatively, no relationship to
the development of incontinence could be discerned.
Voluntary sphincter control. Of the 50 patients 33 (66 per
cent) demonstrated normal voluntary sphincter control and 17
did not. In the operative group normal voluntary sphincter
control was found in 26 patients (72 per cent), while in the
nonoperative group it was present in only 50 per cent but this
difference was not statistically significant (p >0.05 by Fisher's
exact test).
In the entire group of 50 patients continence was highly
associated with the presence of normal voluntary sphincter
control. Of 33 patients with normal voluntary sphincter control
31 were continent compared to only 8 of 17 with poor voluntary
sphincter control (p <0.01, chi-square). The association be-
tween continence and normal voluntary sphincter control was
present within the operative and nonoperative subgroups as
well. Interestingly, patients with poor voluntary sphincter con-
trol who did not undergo prostatectomy were more likely to be
118 STASKIN, VARDI AND SIROKY
Diagrammatic representation of continence status of 36 parkinson-
ian patients before and after transurethral prostatectomy with refer-
ence to voluntary sphincter control ( VSC).
incontinent (71 per cent) than those who required an operation
(40 per cent). It is possible that this difference is owing to the
fact that the operative group presumably was more obstructed
than the nonoperative group, which tended to mask any incon-
tinence before prostatectomy. However, the difference was not
statistically significant (p = 0.22 by Fisher's exact test).
The presence or absence of voluntary sphincter control did
not change postoperatively. Postoperatively, 25 of 26 patients
with normal voluntary sphincter control were continent, com-
pared to only 1 of 10 with abnormal voluntary sphincter control
(p <0.001 by Fisher's exact test). Of the patients who were
continent preoperatively 5 of 6 (83 per cent) with abnormal
voluntary sphincter control became incontinent postopera-
tively compared to only 1 of 24 (4.2 per cent) with normal
voluntary sphincter control. Surprisingly, both patients who
were incontinent preoperatively but who had normal voluntary
sphincter control became continent postoperatively and none
of the 4 with abnormal voluntary sphincter control became
continent.
DISCUSSION
Parkinson's disease has an estimated prevalence in the
United States of 100 to 150 per 100,000 population.4 Classically,
the clinical presentation consists of tremor, rigidity and bra-
dykinesia. We reported previously sphincter bradykinesia and
neuropathy in 17 per cent of the parkinsonian patients studied
urodynamically and found detrusor hyperreflexia in 75 per
cent. 3 However, the effect of sphincter abnormalities, such as
loss of voluntary sphincter control, on preoperative and post-
operative incontinence has not been studied previously.
Urologists historically have approached prostatic surgery in
parkinsonian patients with caution but there is no documen-
tation in the literature of the incontinence risk in these pa-
tients. Attention has been focused on distinguishing detrusor
hyperreflexia secondary to parkinsonism from detrusor insta-
bility owing to outflow obstruction. 5 Urodynamic investiga-
tions, such as pressure flow studies, have improved the ability
to select patients with true outflow obstruction but such inves-
tigation does not permit prediction of continence status after
transurethral prostatectomy.
In our study the presence of detrusor hyperreflexia did not
correlate with the development of postoperative incontinence.
Detrusor hyperreflexia was common in the incontinent as well
as the continent patients and, thus, it could not be used as an
indicator of continence risk. In contrast, the relationship be-
tween poor or absent voluntary sphincter control and inconti-
Voluntary Sphincter
Control
No.
Group Normal Abnormal
Pts.
Continent Continent
(%) (%)
Before transurethral prostatectomy 36 24 (92) 6 (60)
After transurethral prostatectomy 36 25 (96) 1 (10)
No transurethral prostatectomy 14 7 (100) 2 (29)
nence was demonstrated clearly in patients who required pros-
tatectomy as well as in those who did not (see table). The risk
of de novo incontinence arising after transurethral prostatec-
tomy in a parkinsonian patient is approximately 20 per cent.
This risk is, of course, much higher than the risk of approxi-
mately 1 per cent for the general population. However, the
incontinence risk in a continent parkinsonian patient with
normal voluntary sphincter control is approximately 4 per cent,
while the comparable risk in a parkinsonian patient with ab-
normal voluntary sphincter control is approximately 83 per
cent. Thus, the majority of the excess risk ofpost-transurethral
prostatectomy incontinence suffered by parkinsonian patients
is associated with the loss of normal voluntary sphincter con-
trol.
The reasons for the association between loss of voluntary
sphincter control and incontinence are not completely clear. It
has been shown that complete paralysis of the external sphinc-
ter does not produce incontinence in the otherwise normal
patient following transurethral prostatectomy. 6 Thus, other
factors must be implicated, such as the concomitant presence
of detrusor hyperreflexia owing to parkinsonism that does not
abate after prostatectomy. This would be consistent with the
fact that all of our newly incontinent patients had urge incon-
tinence.
The clinical implications of our findings are clear for parkin-
sonian patients who are continent before prostatic surgery.
Urinary incontinence is likely and it should be expected in
patients with absent or poor voluntary sphincter control pre-
operatively. In this group nonoperative means of management
(for example intermittent catheterization) might be recom-
mended whenever feasible. If an operation is required the high
risk of incontinence should be communicated to the patient. In
contrast, parkinsonian patients with normal voluntary sphinc-
ter control suffer a risk of incontinence that approximates that
in the nonparkinsonian population. Indeed, patients who are
incontinent preoperatively may become continent after trans-
urethral prostatectomy if they demonstrate normal voluntary
sphincter control. However, no incontinent patient with abnor-
mal voluntary sphincter control became continent postopera-
tively. Nevertheless, an operation may be indicated in this
group to relieve outflow obstruction even though the continence
status probably will remain the same.
REFERENCES
1. Fitzpatrick, J. M., Gardiner, R. A. and Worth, P. H. L.: The
evaluation of 68 patients with post-prostatectomy incontinence.
Brit. J. Urol., 51: 552, 1979.
2. Mayo, M. E. and Ansell, J. S.: Urodynamic assessment of inconti-
nence after prostatectomy. J. Urol., 122: 60, 1979.
3. Pavlakis, A. J., Siroky, M. B., Goldstein, I. and Krane, R. J.:
Neurourologic findings in Parkinson's disease. J. Urol., 129: 80,
1983.
4. Yahr, M. D.: Parkinson's disease-overview of its current status.
Mt. Sinai J. Med., 44: 183, 1977.
5. Andersen, J. T. and Bradley, W. E.: Cystometric, sphincter and
electromyelographic abnormalities in Parkinson's disease. J.
Urol., 116: 75, 1976.
6. Krahn, H. P. and Morales, P. A.: The effect of pudenda! nerve
anesthesia on urinary continence after prostatectomy. J. Urol.,
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