Treating Lower Urinary Tract Symptoms in the Neuro-Urologic Patient, Focus on Parkinson’s- Lysanne Campeau

(Length of Discussion: 12 min)

Ben Brucker and Lysanne Campeau discuss her research and clinical practice in treating lower urinary tract symptoms specifically in the Parkinson's population. Careful assessment of these patients prior to diagnosis coupled with effective physician/patient dialogue may lead to the most effective treatment selection.

Biographies:

Lysanne Campeau, MDCM, Ph.D, FRCSC, Assistant Professor, Urology, McGill University, Montreal, Quebec, Urologist, Jewish General Hospital, Clinical Researcher, Lady Davis Institute

Benjamin M. Brucker, MD
Read the Full Video Transcript:
Dr. Ben Brucker: Hi, I'm Ben Brucker. This is UroToday. I'm joined today with a close friend, colleague, and really, I think one of the, if not the rising star in functional urology, Lysanne Compo. Thank you for joining me today. Lysanne, why don't you take a couple of moments to just introduce to our audience a little bit about who you are and what your practice is like. 

Dr. Lysanne Campeau: Sure, sure. Sounds good. My name is Lysanne Compo. I'm an assistant professor at McGill University. I'm a urologist at the Jewish General Hospital, and I'm a clinician and researcher at the Lady Davis Institute for Medical Research. I completed, after my residency, a PhD in physiology and pharmacology in order to pursue my interest in basic science research, and then I did my female pelvic medicine and reconstructive surgery at NYU along with Dr. Brucker. 

Dr. Ben Brucker: Great. Thank you. It's great to get to talk with you a little bit. I always have lots of good scientific questions for you. Today, I wanted to actually tap into the 50 percent of your time that you spend treating patients and talk to you a little bit about some conditions that we see as functional urologists and I think as a researcher, you probably have some interest in as well.

But I wanted to talk about neuro-urologic patients, and specifically, I know that you've done and are continuing to do work with the Parkinson's population and I know you have an MS practice as well. So I wanted to dive into some of the things that are specific maybe to your treatment or how you think about patients with neurologic diseases that can affect the lower urinary tract. So, tell me a little bit about, I guess, Parkinson's to start. How commonly are you seeing those patients? And tell me a little bit about, I guess, some of the conditions that you're treating them for. 

Dr. Lysanne Campeau: Yeah. Well, I have a particular interest for neurogenic lower tract dysfunction. I find that there are a vulnerable population to begin with, but then they can be mismanaged and it just, they're often not a priority for many clinicians. So, I focus a lot of energy and interest in basic science research, actually, in Parkinson's disease. During my PhD, we actually looked at an animal model of Parkinson's disease.

So that brought me, when I started my practice, to really try to bring that to the bedside. And so, I have a dedicated clinic several times per month for Parkinson's disease patients who were often left to the neurologist to try to manage their lower urinary tract symptoms, and they can be a very challenging population to treat because there's a lot of comorbidities. 

They also have a lot of medications that are affecting their conditions. There's also the condition aspect which can make things challenging. So trying to find the best way to manage it can be challenging but also very interesting. We have a few clinical trials that we're looking at it in this population. 

Dr. Ben Brucker: So, in terms of some of the Parkinson's specific things, I know as a urologist, when I watched the speed with which the patient walks to the bathroom to give the urine sample, I'm sort of in my mind calculating a little bit how much of this is functional, how much of this is actually driven by the biochemistry or the dysfunction and dopamine related sort of issues. How big of a deal or how do we sort of deal with, or how do we put into our algorithm the mobility issue with Parkinson's? 

Dr. Lysanne Campeau: Yeah. That's a good question. I think you can definitely assess their level of the stability, as you mentioned, based on how quickly they're walking, and the communication, and also by asking their caregivers how affected they are cognitively. They form a very heterogeneous population, right? It ranges quite widely in terms of how affected they are by their condition. Based on that, and also with MS population, as you know, you really have to individualize your approach based on the picture and the overall presentation of the patient.

Dr. Ben Brucker: Yeah. So we know that there are, in fact, a lot of urinary conditions that affect patients with Parkinson's or MS. If we take Parkinson's, for example, and we think about therapies that we use, let's say for overactive bladder, how much data do we have on how well these therapies work? Are they going to work? What are some of the other considerations you have when you're seeing a patient in your Parkinson's clinic versus your outpatient, just well 50-year-old patient who has OAB symptoms?

Dr. Lysanne Campeau:Well, the vast majority of them are actually male. You have to consider the overactive bladder component along with the outlet. Is there any underlying bladder outlet obstruction? Which with age, there's a component of benign prostatic hyperplasia, which can contribute to their symptoms. There is actually not a whole lot of data out there in terms of using different drugs for these patients.

There's several small studies that have been done looking at either solifenacin or other anticholinergics, but very few large studies have been done on this patient population. You have to refer back to using drugs that have the least potential effect on their cognition and interaction with their other medications. So that's definitely challenging. 

The bladder outlet obstruction also has to be considered. In my assessment, depending on their presentation, and their symptoms, and doing an initial evaluation, uroflowmetry or residual, I may take it a little further with more invasive testing depending on their presentation. 

Dr. Ben Brucker: Yeah, I mean, it's one of the populations that I feel very strongly about urodynamics because there can be different phenotypes within the patient with LUTS. Even sort of the diagnosis of Parkinson's versus MSA and some of the sort of more urodynamic features can sort of direct us one way or the other. Maybe jumping away from medication, and I know you do have an ongoing trial of anti-cholinergic versus placebo in Parkinson's patients. 

Once we have that data, we'll have you back on UroToday to present it. But what about outlet reduction? How confident or uncomfortable are you TURPing or choose whatever outlet procedure you like for that Parkinson's patient that may have a component of bladder outlet obstruction? 

Dr. Lysanne Campeau:Yeah, it's often very tricky. Actually, if we maybe consider other men that have not had the diagnosis of Parkinson's disease, it's occurred a few times where these men had very little neurological symptoms and they underwent a resection. Later on, after their resection, they develop neurological conditions that tend to have more of a Parkinsonian syndrome, and they don't do very well. At least anecdotally, I haven't had that experience. 

Now, patients who have a diagnosis of Parkinson's disease who have clearly demonstrated bladder outlet obstruction, I think these patients, you definitely can consider a bladder outlet reducing procedure, but again, with a lot of caution, with a lot of counseling for the patient and their caregivers about what are the possible risks? And I think they are at an increased risk of your complications or just inefficiency or poor outcomes. 

Dr. Ben Brucker: Yeah. I would agree a thousand percent. I think you nailed it. The counseling is hugely important, and when you're talking about a Parkinson's patient and the quality of life and some of the potential issues, yes, confirm that they have obstruction. We treat the obstruction, and I think we found in our smaller series, really, there can be good outcomes. 

So it is patient selection and I guess I'm even a little bit more confident now that we have other therapeutics, onabotulinimumtoxin for example, in the lower urinary tract that if we were afraid that urgency incontinence was going to be an issue after an outlet reduction, now we have therapies that are effective and hopefully more and more data from your trial to sort of say, "Hey look, these medications are okay to use in Parkinson's patients."

Cognitive issues, any particular concerns or outcomes you're going to look at in your study for cognition.

Dr. Lysanne Campeau: Yes, cognitively, I think we have to be very careful about the molecules that we use. As we're all aware, the beta three agonist has been considered somewhat safe as there is no beta three receptor in the central nervous system. However, we don't have actual data demonstrating that. 

So, a large proportion, actually, of these patients are being referred to me already on meribegrum from their neurologist, which is interesting. And some of them do very well. Some of them is sometimes not as efficient as they wish it would be. So, I think you have to be very careful about which molecule, and hopefully we're going to get more data about what is safe to be used in this more vulnerable patient population. 

Dr. Ben Brucker: Yeah. And unfortunately, I think we don't always get the data because they're smaller or sort of more difficult patients to recruit and sort of study. In terms of we talked a little bit about outlet obstruction, a little bit about overactive bladder. One of the other conditions that we, I think, see and want to get your feedback on is nocturia and sort of whether this is a piece of an overactive bladder and obstructive picture in the Parkinson's patient or whether it's really a standalone condition. Is nocturia something that you've been seeing or have considered or will consider treating in your Parkinson's patients?

Dr. Lysanne Campeau: I think nocturia is a symptom and not necessarily just a condition. And I think there's just such a varied presentation of different conditions that present with nocturia, just like fever would present from other ideologies. And I think the evaluation of the patient, considering many other factors, will allow us to pinpoint a little bit more, what is the actual problem and to treat the problem. And so, it's not just treating the symptoms. 

So obviously as any urologist, this is a recurrent problem that many patients present with, and it could be in a context of overactive bladder syndrome, it could be in the context of BPH LUTS. I think trying to identify other factors to treat or to address in addition to treating nocturnal polyuria is very important. 

Dr. Ben Brucker: Yeah, and certainly the Parkinson's patients, most of the ones that I see, are that older patient population. People age the same and just because you have a neurologic condition doesn't mean you can't have these other conditions, overactive bladder, BPH, or nocturia, whether it's a symptom or a condition from nocturnal polyuria.  I want to thank you for taking a couple of minutes to talk to me about the Parkinson's patients today. And again, we look forward to getting some more data and collaborating so that we can try to give our patients that have a condition that can affect lots of different aspects of their urologic care the therapies that they need. Thanks again for taking some time to talk with me.

Dr. Lysanne Campeau: Thank you for letting me.
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