Bowels and Bladders — Meeting Notes Update

Speaker notes have been posted quite a bit after the meeting, but the information is so excellent as to be worthy of a late post. Notes follow the original meeting announcement. 

LADIES, while we were all putting our umbrellas up and down and being honored and feted on Mother’s Day, the month of May slipped by unnoticed. June is about to start so that means it’s time for a meeting.

And what a meeting we have lined up. It’s the topic no one wants to talk about and everyone needs to talk about. Mary called it “Bowels and Bladders”.  As we know, Parkinson’s disease affects the autonomic nervous system.  We have a wonderful guest speaker, Carrie Pagliano

And thanks again to Mary for finding us such a quality speaker. I encourage you to click on the above link and see all she covers in her practice before the meeting.. We hope to take 30 minutes before or after the speaker to get an idea of topics you would like to see for next year.  I’ve  been approached by another DBS Rep  who would like to introduce us to  information about his product.  An occupational therapist has offered to speak to us. But I want speakers to be worth the lost support time.
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Don’t forget your bags if you intend to go the farmers market, located in the parking lot of our meeting space.

To remind you, there’ll be a summer break with no meetings in July or August, so don’t miss this last group until fall.

MEETING NOTES: 
At our June 2018 meeting, Carrie Pagliano spoke about Bowel and Bladder Control with Parkinson’s Disease, aka Everything You Ever Wanted to Ask About Peeing and Pooping But Had No One to Ask. In addition to her extensive experience and credentials, Carrie is intimately familiar with Parkinson’s. Her father has been living with the disease for 17 years and has Parkinson’s-related constipation and nighttime frequency issues.

As far as we women go, “Once postpartum, always postpartum,” according to Carrie. Pregnancy affects the pelvic floor. The question then becomes what issues are due to babies, what issues are due to meds, and what issues are due to Parkinson’s. No one can answer that question. So she has to look at symptoms to try and figure out their source.

One of the biggest issues with Parkinson’s is falling. If she determines falls are related to continence issues because someone is rushing, worried they won’t make it to the bathroom on time, she addresses the reasons for urgency and frequency. Why is stress there? Why are fears there? When stress increases, all Parkinson’s symptoms increase, including urgency.

BOWEL MOVEMENTS
More fiber is not the answer when it comes to Parkinson’s!

“Constipation is part of the disease process,” Carrie says. So much so that chronic constipation is being looked at as a potential screening for Parkinson’s. Transit in general is an issue, beginning with swallowing. With constipation, you have to look at intake, transit and output.

Intake: If you increase fiber, you have to increase fluid. Too much fiber alone can cause constipation. Miralax can help if constipation is making you uncomfortable. Stool consistency should be as close to a loose snake as possible.

Transit: Bowel movements are stimulated by saliva production. Meds can cause dry mouth, interfering with this stimulation. Belly massage can help gut mobility and alleviate stress. It can be done while eating or after eating. Start at the bottom right by your pelvis and rub lightly in a clockwise circle over your stomach. Then sit on the toilet.

Output: Focus is on evacuation positioning and relaxation.

1. Squatting relaxes the pelvic floor, so stool can go straight through. Put your feet on a stepstool while sitting to get your feet above the level of the pelvis.
2. Relax by placing your elbows on your knees and give a low hum or blow as if through a straw. Pressure from above causes relaxation below.
3. If you are sitting for more than five minutes and nothing happens, come back later. Straining is not good.

Pelvic Organ Prolapse
In addition to occurring postpartum, pelvic organ prolapse can be related to chronic straining.

In women, the bladder is located behind the pelvic floor muscles, the uterus behind the bladder, and the rectum behind the uterus. Any of those organs can prolapse, or drop down. If the rectum prolapses, stool can get stuck in pockets formed by the prolapse. You can use a finger or a tampon to manually push a prolapsed organ up, or a pessary (a device inserted in the vagina to support the pelvic organs).

“Don’t bear down when having a bowel movement or hold your breath when lifting something,” Carrie cautions. “If you are using your diaphragm for stability, you are not breathing.” She recommends pelvic floor contraction and relaxation exercises (Kegels) to manage pelvic floor problems. However, if ligaments are loose (usually in people who are naturally super flexible), collagen may not have the elasticity to spring back, Kegels may not be enough to help, and surgery may be needed to correct the problem.

Carrie’s Words of Wisdom on Bowel Movements:
Only hold your breath underwater.
Blow before you go.
Feet up on a stool.

LEAKAGE
There are two types issues when it comes to leakage, Stress Urgency Incontinence and Urgency, both more prevalent with Parkinson’s.

Stress Urinary Incontinence from coughing, sneezing, bending, and lifting. It can also occur when getting up from a chair or out of a car. When we inhale, the diaphragm drops and the pelvic floor drops. When we exhale, everything rises. If you are holding your breath, you are holding that inhale. Increasing pressure above, releases things below.

Carrie looks in various body directions to identify causes of stress incontinence: front (belly), behind (back), above (diaphragm), and below (pelvic floor).

1. Back pain is highly corollary to incontinence.
2. Women with back or urinary issues pre-pregnancy can have issues later.
3. Episiotomies and forceps deliveries increase risk to pelvic floor.
4. Abdominal separation, or abdominal weakness, is a new ‘buzz diagnosis.’

What can we do to prevent leakage? “Don’t hold your breath,” Carrie advises. “Pressure takes the path of least resistance—from the top down. Only hold your breath underwater.”

Blow Before We Go when bending, lifting, rolling over, getting out of a chair or car.

• Exhale on exertion. Practice with sit-to-stand exercise.
• Start to exhale before or during anything that’s hard for you to do.
• When sitting down, start exhalation before starting to sit.
• To activate deep abdominals muscles and control pressure, exhale like you’re blowing through a straw.
• Watch how you lift things—determine your pattern of breathing and adjust it.

Pelvic Floor Contractions (Kegels)can be done in conjunction with controlling the breath, which is good for coughing and sneezing leakage (but only for about one or two of each). Kegels are also helpful for weak stream or incomplete emptying issues.

• Close around the opening of your vagina.
• Draw up and inside your body.
• Try not to hold your breath.
• Make sure you let it go (relax).

Comfort height and ADA toilets actually work against you for continence issues. Carrie’s recommends the same positioning as for bowel movements: feet up on a stool (“squatty potty’). Be creative. In hotels, she rolls the bathroom trashcan onto its side and puts her feet on it.

Sometimes none of these conservative measures help, prescribed medication or Botox injections don’t work, and no reason for leakage can be found (termed ‘neurogenic bladder’). Surgical intervention may be needed. Carrie advises that surgery is no small thing and any surgery has no guarantee, but it offers life changing potential. Incontinence is a high predictor of depression and there can also be depression with Parkinson’s. If you feel comfortable you’ve gotten a good diagnosis and that your medical practitioners have done all they can, surgical options are appropriate considerations.

Urgency: feeling the urge to go and can’t control it.
There are numerous causes of urgent incontinence. Parkinson’s makes it difficult to get to the bathroom quickly enough. Nighttime frequency compounds the issue. Sometimes it’s the caused by an overactive bladder. Not knowing where the bathroom is causes stress and stress makes urgent incontinence worse.

A normally functioning bladder can hold up to two cups of urine. When full, the stretch reflex sends a message to the brain that you have to go. Going more frequently (‘just in case’ voiding) works against you on the capacity side as the bladder starts to send messages to brain that you have to go at smaller amounts (one cup).

Two to three hours is a normal void frequency. Control is 50% mental, 50% physical.

When You Feel The Urge To Go.

• Stave off with a quick contract and relax function. This stops the message to the brain.
• Do a couple quick squeezes and relaxes.
• Walk calmly and relaxed to the bathroom.
• Keep up the squeezes and relaxed while undoing your clothes.
• Keep your head in the game until you sit down.
• Running water does trigger us to have to go. Think about your other triggers and practice to control urgent incontinence.

For Nighttime Frequency. Eliminating even one nighttime wakening is huge!

• Don’t drink two hours to limit fluids before bedtime.
• Look at when you take your meds, especially ones taken at night with a full glass of water. Can you take these two hours earlier?
• Veins don’t do as good a job pumping fluid up from the legs when we get older, so as soon as we lie down in bed, all the accumulated daytime fluid is released and we have to go. Recline for two hours before bedtime with your feet above the level of the heart.

For Weak Stream/Incomplete Emptying. Pelvic muscles must relax for complete voiding.

• Put feet on a stool so they are above the level of the pelvis.
• Do pelvic tilts.
• If due to pelvic organ prolapse, urine might be stuck. Stand up and walk around to get things moving in there.

Carrie’s Words of Wisdom on Leakage:
Figure out where you can make small changes to get something bigger.
Keep a 3-day bladder diary, noting food intake and activity.
Practice urge control techniques in situations you can control.
Retrain your bladder so that you go less often.

* * * * *

Dr. Carrie Pagliano has her own practice at 2160 N Glebe Road in Arlington. She does in-person visits at her office as well telephone visits. She has generously offered if anyone has any questions or needs a referral for a pelvic doctor or surgeon, to feel free to email her at carrie@carriepagliano.com. Another excellent resource to locate pelvic health physical therapists nationwide is http://www.womenshealthapta.org (Section on Women’s Health of the American Physical Therapy Association, of which Carrie is President)