Opinion statement
Autonomic nervous system (ANS) dysfunction is common in Parkinson’s disease (PD), affects 70% to 80% of patients, and causes significant morbidity and discomfort. Autonomic nervous system dysfunction symptoms in PD include sexual dysfunction, swallowing and gastrointestinal disorders, bowel and bladder abnormalities, sleep disturbances, and derangements of cardiovascular regulation, particularly, orthostatic hypotension. Autonomic nervous system dysfunction in PD may be caused by an underlying degenerative process that affects the autonomic ganglia, brainstem nuclei, and hypothalamic nuclei. Anti-parkinsonian medications can cause or worsen symptoms of ANS dysfunction. The care of a PD patient with ANS dysfunction relies on its recognition and directed treatment, including coordinated care between the neurologist and appropriate subspecialist. Pharmacotherapy may be useful to treat orthostasis, gastrointestinal, urinary, and sexual dysfunction.
Similar content being viewed by others
References and Recommended Reading
Spiegel EA, Wycis HT, Schor S, et al.: The incidence of vegetative symptoms in Parkinson patients with and without bradykinesia. In In Third Symposium on Parkinson Disease Royal College of Surgeons in Edinburgh. Edinburgh: E & S Livingston, Ltd; 1969:200.
Turkka J, Suominen K, Tolonen U, et al.: Selegiline diminishes cardiovascular autonomic responses in Parkinson’s disease. Neurology 1997, 48:662–667.
Martignoni E, Micieli G, Cavallini A, et al.: Autonomic disorders in idiopathic Parkinsonism. J Neural Transm 1986, 22:149–161.
Parkinson J: An essay on shaking palsy. London: Sherwood, Neely and Jones; 1817.
Gowers WR: A Manual of Diseases of the Nervous System, edn 2. London: Churchill; 1893:648.
Porter RW, Bors E: Neurogenic bladder in Parkinson’s disease: effect of thalamotomy. J Neurosurg 1971, 34:27.
Singer C, Weiner WJ, Sanchez-Ramos JL: Autonomic dysfunction in men with Parkinson’s disease. Eur Neurol 1992, 32:134–140.
Lemack GE, Dewey RB Jr, Roehrborn CG, et al.: Questionnaire-based assessment of bladder dysfunction in patients with mild to moderate Parkinson’s disease. Urology 2000, 56:250–254.
Lisenmeyer TA, Stone JM: Neurogenic Bladder and Bowel Dysfunction. Rehabilitation Medicine: Principles and Practice, edn 3. Edited by Delisa JA, Gans BM. Philadelphia: Lippincott-Raven Publishers; 1998:1073–1106.
Principles of Neuroscience. Edited by Kandel ER, Schwartz JH, Jessel TH. New York: McGraw-Hill; 2000:968.
Pavlakis AJ, Siroky MB, Goldstein I, Krane RJ: Neurourologic findings in Parkinson’s disease. J Urol 1983, 129:80–83.
Lewin RV, Dilland GV, Porter RW: Extrapyramidal inhibition of the urinary bladder. Brain Res 1967, 4:301.
Andersen JT, Bradley WE: Cystometric, sphincter and electromyelographic abnormalities in Parkinson’s disease. J Urol 1976, 116:75–78.
Resnick NM, Yalla SV: Management of urinary incontinence in the elderly. N Engl J Med 1985, 313:800–805.
Yarker YE, Goa KL, Fitton A: Oxybutynin: a review of its pharmacodynamic and pharmacokinetic properties, and its therapeutic use in detrusor instability. Drugs Aging 1995, 6:243–262. This paper reviews the pharmacodynamic and pharmacokinetic properties of oxybutynin.
Andersson KE: Drug therapy for urinary incontinence. Bailliere’s Clin Obstet Gynaecol 2000, 14:291–313.
Hills CH, Winter SA, Balfour JA: Tolterodine. Drugs 1998, 55:813–820.
van Kererebroeck PE, Amarence G, Thuroff JW, et al.: Dose-ranging study of tolterodine in patients with detrusor hyperreflexia. Neurourol Urodyn 1998, 17:499–512.
Larsson G, Hallen B, Nilvebrant L: Tolterodine in the treatment of overactive bladder: analysis of the pooled phase II efficacy and safety data. Urology 1999, 53:990–998.
Abrams P, Freeman R, Anderstrom C, Mattiasson A: Tolterodine, a new antimuscarinic agent: as effect but better tolerated than oxybutynin in patients with an overactive bladder. Br J Urol 1998, 81:801–810. In this randomized, double blind trial, tolterodine at 2mg twice daily was effective in treating bladder overactivity and was better tolerated than oxybutynin.
Hilton P, Hertogs K, Stanton SL: The use of desmopression (DDAVP) for nocturia in women with multiple sclerosis. J Neurol Neurosurg Psych 1983, 46:854–855.
Kinn AC, Larsson PO: Desmopressin: a new principle for symptomatic treatmetn of urgency and incontinence in patients with multiple sclerosis. Scand J Urol Nephrol 1990, 24:1109–1121.
Eckford SD, Swami KS, Jackson SR, Abrams PH: Desmopressin in the treatment of nocturia and enuresis in patients with multiple sclerosis. Br J Urol 1994, 74:733–735.
Fredrikson S: Nasal spray desmopressin treatment of bladder dysfunction in patients with multiple sclerosis. Acta Neurol Scand 1996, 94:31–34.
Horowitz M, Combs AJ, Gerdes D: Desmopressin for nocturnal incontinence in the spina bifida population. J Urol 1997, 158:2267–2268.
Robson WL, Norgaard JP, Leung AK: Hyponatremia in patients with nocturnal enuresis treated with DDAVP. Eur J Pediatr 1996, 155:959–962.
Schwab M, Ruder H: Hyponatremia and cerebral convulsion due to DDAVP administration in patients with enuresis nocturia or urine concentration testing. Eur J Pediatr 1997, 156:668.
Raybould HE, Pandol SJ: The integrated response of the gastrointestinal tract to a meal. In In Textbook of Gastroenterology, edn 3. Edited by Yamada T, Alpers DH, Laine L, et al. Philadelphia: Lippincott Williams & Wilkins; 1999:2–10.
Furness JB, Costa M: The Enteric Nervous System. Edinburg: Churchill Livingston; 1997.
Furness JB, Bornstein JC, Kunze WAA, Clerc N: The enteric nervous system and its extrinsic connections. In In Textbook of Gastroenterology, edn 3. Edited by Yamada T, Alpers DH, Laine L, et al. Philadlephia: Lippincott Williams & Wilkins; 1999:11–30.
Hasler WL: Motility of the small intestine and colon. In In Textbook of Gastroenterology, edn 3. Edited by Yamada T, Alpers DH, Laine L, et al. Philadlephia: Lippincott Williams & Wilkins; 1999:236.
Byrne KG, Pfeiffer R, Quigley EM: Gastrointestinal dysfunction in Parkinson’s disease: a report of clinical experience at a single center. J Clin Gastroenterol 1994, 19:11–16.
Eadie MJ, Tyrer JH: Alimentary disorders in Parkinsonism. Aust Ann Med 1965, 14:13–22.
Edwards LL, Quigley EM, Pfeiffer RF: Gastrointestinal dysfunction in Parkinson’s disease: frequency and pathophysiology. Neurology 1992, 42:726–732.
Stroudley J, Walsh M: Radiological assessment of dysphagia in Parkinson’s disease. Br J Radiol 1991, 64:890–893.
Johnston BT, Li Q, Castell JA, Castell DO: Swallowing and esophageal function in Parkinson’s disease. Am J Gastroenterol 1995, 90:1741–1746. This paper reviews swallowing abnormalities in Parkinson’s disease.
Ali GN, Wallace KL, Laundl TM, et al.: Oropharnyngeal dysfunction in patients with Parkinson’s disease and dysphagia [abstract]. Gastroenterology 1994, 106:459.
Weber J, Roman C, Hannequin D, et al.: Esophageal manometry in patients with unilateral hemispheric cerebrovascular accidents or idiopathic Parkinsonism. J Gastrointest Motility 1991, 3:98–106.
Den Hartog Jager WA, Bethlem J: The distribution of Lewy bodies in the central and autonomic nervous system in idiopathic paralysis agitans. J Neurol Neurosurg Psychiatry 1960, 23:283–290.
Qualman SJ, Haupt HM, Yang P, et al.: Esophageal Lewy bodies associated with ganglion cell loss in achalasia: similarity to Parkinson’s disease. Gastroenterology 1984, 87:848–856.
Wakabayashi K, Takahahi H, Takeda S, et al.: Parkinson’s disease: the presence of Lewy bodies in Auerbach’s and Meissner’s plexuses. Acta Neuropathol 1988, 76:217–221.
Bramble MG, Cunliffe J, Dellipiani AW: Evidence for a change in neurotransmitter affecting esophageal motility in Parkinson’s disease. J Neurol Neurosurg Psychiatry 1978, 41:709–712.
Soykan I, Sarosiek I, Shifflett J, et al.: Effect of chronic oral domperidone therapy on gastrointestinal symptoms and gastric emptying in patients with Parkinson’s disease. Mov Disord 1997, 12:952–957.
Edwards LL, Pfeiffer RF, Quigley EM, et al.: Gastrointestinal symptoms in Parkinson’s disease. Mov Disord 1991, 6:151–156.
Mathers SE, Kemptster PA, Swash M, Lees AJ: Constipation and paradoxical puborectalis contraction in animus and Parkinson’s disease: a dystonic phenomenon? J Neurol Neurosurg Psychiatry 1988, 51:1503.
Byrne KG, Pfeiffer R, Quigley EM: Gastrointestinal dysfunction in Parkinson’s disease: a report of clinical experience at a single center. J Clin Gastroenterol 1994, 19:11–16.
Bedford TA, Rowbotham DJ: Cisapride: drug interactions of clinical significance. Drug Saf 1996, 15:167–175.
DiPalma JA, DeRidder PH, Orlando RC, et al.: A randomized, placebo-controlled, multicenter study of the safety and efficacy of a new polyethylene glycol laxative. Am J Gastroenterol 2000, 95:446–450. In this trial, Braintree polyethylene glycol laxative was safe and effective in the short-term treatment of constipation.
Welsh M, Hung L, Waters CH: Sexuality in women with Parkinson’s disease. Mov Disord 1997, 12:923–927.
Singer C, Weiner WJ, Sanchez-Ramos J, Ackerman M: Sexual function in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry 1991, 54:94–237.
Brown EB, Brown GM, Kofman O, Quarrington B: Sexual function and affect in Parkinsonian men treated with L-dopa. Am J Psychiatry 1978, 135:1552–1555.
Zesiewicz TA, Helal M, Hauser RA: Sildenafil citrate (Viagra) for the treatment of erectile dysfunction in men with Parkinson’s disease. Mov Disord 2000, 15:305–308.
Goetz CG, Lutge W, Tanner CM: Autonomic dysfunction in Parkinson’s disease. Neurology 1986, 36:73–75.
Hirashima F, Yokota T, Miyatake T, et al.: Sudomotor dysfunction in Parkinson’s disease. Rinsho Shinkeigaku 1993, 33:709–714.
Mano Y, Nakamuro T, Takayanagi T, Mayer RF: Sweat function in Parkinson’s disease. J Neurol 1994, 241:573–576.
Sage JI, Mark MH: Drenching sweats as an off phenomenon in Parkinson’s disease: treatment and relation to plasma levodopa profile. Ann Neurol 1995, 37:120–122.
Saito H, Kogure K: Thermal sudomotor deficits in Parkinson’s disease. Rinsho Shinkeigaku 1989, 29:734–740.
McLeod JG, Tuck RR: Disorders of the autonomic nervous system: II. Investigation and treatment. Ann Neurol 1987, 21:519–529.
Adams RD, Victor M, Ropper AH: Principles of Neurology, edn 6. New York: McGraw-Hill; 1997.
Mathias CJ: Disorders affecting autonomic function in Parkinsonian patients. Adv Neurol 1996, 69:383–391.
Gross M, Bannister R, Godwin-Austen R: Orthostatic hypotension in Parkinson’s disease. Lancet 1972, 1:174–176.
Mathias CJ: Orthostatic hypotension: causes, mechanisms, and influencing factors. Neurology 1995, 45(suppl):S6-S11.
Shy G, Drager GA: A neurological syndrome associated with orthostatic hypotension. Arch Neurol 1960, 2:511.
Barbeau A, Gillo-Joffroy L, Boucher R, et al.: Renin-aldosterone system in Parkinson’s disease. Science 1969, 165:291–292.
McDowell FH, Lee JE: Levodopa, Parkinson’s disease, and hypotension. Ann Intern Med 1970, 72:751.
Gross M, Bannister R, Godwin-Austen R: Orthostatic hypotension in Parkinson’s disease. Lancet 1972, 1:174–176.
Orskov L, Jakobsen J, Dupont E, et al.: Autonomic function in Parkinsonian patients relates to duration of disease. Neurology 1987, 37:1173–1178.
Meco G, Pratesi L, Bonifati V: Cardiovascular reflexes and autonomic dysfunction in Parkinson’s disease. J Neurol 1991, 238:195–199.
Piha SJ, Rinne JO, Rinne UK, Seppanen A: Autonomic dysfunction in recent onset and advanced Parkinson’s disease. Clin Neurol Neurosurg 1988, 90:221–226.
Kuroiwa Y, Shimada Y, Toyokura Y: Postural hypotension and low R-R interval variability in Parkinsonism, spinocerebellar degeneration, and Shy-Drager syndrome. Neurology 1983, 33:463–467.
Aminoff MJ, Wilcox CS: Assessment of autonomic function in patients with a Parkinsonian syndrome. BMJ 1971, 4:80–84.
Ludin SM, Steiger UG, Ludin HP: Autonomic disturbances and cardiovascular reflexes in idiopathic Parkinson’s disease. J Neurol 1987, 235:10–15.
Turkka J, Tolonen U, Myllyla V: Cardiovascular reflexes in Parkinson’s disease. Eur Neurol 1987, 26:104–112.
Senard JM, Rai S, Lapeyre-Mestre M, et al.: Prevalence of orthostatic hypotension in Parkinson’s disease. J Neurol Neurosurg Psych 1997, 63:584–589.
Uono Y: Parkinsonism and autonomic dysfunction. Auton Nerv Syst 1993, 10:163–170.
Netten PM, De Vos K, Horstink MWIM, et al.: Autonomic dysfunction in Parkinson’s disease, tested with a computerized method using Finapres device. Clin Auton Res 1995, 5:85–89.
Barbeau A, Gillo-Joffroy L, Brossard Y: L-Dopa and Parkinsonism. Edited by Barbeau A, McDowell FH. Philadelphia: FA Davis; 1970:286.
Gross M, Bannister R, Godwin-Austen R: Orthostatic hypotension in Parkinson’s disease. Lancet 1972, 1:174–176.
Micieli G, Martignoni E, Cavallini A, et al.: Postprandial and orthostatic hypotension in Parkinson’s disease. Neurology 1987, 37:386–393.
Michelakis AM, Robertson D: Plasma renin activity and levodopa in Parkinson’s disease. JAMA 1970, 213:83–85.
Rappelli A, Glorioso N, Tedde R, et al.: Effects of levodopa alone and in combination with dopadecarboxylase inhibitors on plasma renin activity in patients with Parkinson’s disease. J Neurol Neurosurg Psych 1978, 41:915–918.
Turkka JT, Juujarvi KK, Lapinlampi TO, Myllyla VV: Autonomic dysfunction in Parkinson’s disease: serum noradrenaline response to standing up. J Neurol 1985, 232:66.
Camerlingo M, Ferraro B, Gazzaniga GC, et al.: Cardiovascular reflexes in Parkinson’s disease: long-term effects of levodopa treatment on de novo patients. Acta Neurol Scand 1990, 81:346–348.
Hilsted J: Autonomic neuropathy: the diagnosis. Acta Neurol Scand 1983, 67:193–201.
Persson A, Solders G: R-R variations in Guillain-Barré syndrome: a test of autonomic dysfunction. Acta Neur Scand 1983, 67:294–300.
Wheeler T, Watkins P: Cardiac denervation in diabetes. BMJ 1973, 4:584–586.
Meco G, Pratesi L, Bonifati V: Cardiovascular reflexes and autonomic dysfunction in Parkinson’s disease. J Neurol 1991, 238:195–199.
Appenzeller O, Goss JE: Autonomic deficits in Parkinson’s syndrome. Arch Neurol 1971, 24:50–57.
Reid JL, Calne DB, Pallis GC, Vakil SD: Cardiovascular reflexes in Parkinsonism. Clin Sci 1971, 41:63–67.
Goldstein DS, Holmes C, Li ST, et al.: Cardiac sympathetic denervation in Parkinson’s disease. Ann Intern Med 2000, 133:338–347.
Sachs C, Berglund B, Kaijser L: Autonomic cardiovascular responses in Parkinsonism: effect of levodopa with dopa-decarboxylase inhibition. Acta Neurol Scand 1985, 71:37–42.
Dooley M, Markham A: Pramipexole: a review of its use in the management of early and advanced Parkinson’s disease. Drugs Aging 1998, 12:495–514.
Abs R, Verhelst J, Maiter D, et al.: Cabergoline in the treatment of acromegaly: a study in 64 patients. J Clin Endocrin Met 1998, 83:374–378.
Micieli G, Martignoni E, Cavallini A, et al.: Lisuride and bromocryptine in levodopa stable-responder Parkinsonian patients: a comparative, double-blind evaluation of cardiopressor and neurochemical effects. Func Neurol 1996, 11:317–325.
Kujawa K, Leurgans S, Raman R, et al.: Acute orthostatic hypotension when starting dopamine agonists in Parkinson’s disease. Arch Neurol 2000, 57:1461–1463.
Schoenberger JA: Drug-induced orthostatic hypotension. Drug Saf 1991, 6:402–407.
Micek ST, Ernst ME: Tolcapone: a novel approach to Parkinson’s disease. Am J Health Syst Pharm 1999, 56:2195–2205.
Heinonen EH, Myllyla V: Safety of selegiline (deprenyl) in the treatment of Parkinson’s disease. Drug Saf 1998, 19:11–22.
Turkka J, Suominen K, Tolonen U, et al.: Selegiline diminishes cardiovascular autonomic responses in Parkinson’s disease. Neurology 1997, 48:662–667.
Bannister R: Testing autonomic reflexes. In Autonomic Failure: A Textbook of Clinical Disorders of the Autonomic Nervous System. Edited by Bannister R. London: Oxford University Press; 1983.
Goldberg LI, Whishett TL: Cardiovascular effects of levodopa. Clin Pharmacol Ther 1971, 12:376–382.
Wright RA, Kaufmann HC, Perera R, et al.: A double-blind, dose-response study of midodrine in neurogenic orthostatic hypotension. Neurology 1998, 51:120–124.
Low PA, Gilden JL, Freeman R, et al.: Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension: a randomized, double-blind multicenter study. Midodrine Study Group. JAMA 1997, 277:1046–1051.
Polinsky FJ, Martin JB: Disorders of the autonomic nervous system. In In Harrison’s Principles of Internal Medicine, edn 13. Edited by Isselbacher KJ. New York: McGraw-Hill; 1994:2344–2246.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Zesiewicz, T.A., Baker, M.J., Wahba, M. et al. Autonomic nervous system dysfunction in Parkinson’s disease. Curr Treat Options Neurol 5, 149–160 (2003). https://doi.org/10.1007/s11940-003-0005-0
Issue Date:
DOI: https://doi.org/10.1007/s11940-003-0005-0