• MOVEMENT DISORDERS
• PARKINSON-S DISEASE

A man in his sixties with idiopathic Parkinson's disease was referred after inserting a length of metallic flex attached to a metal curtain hook into his urethra (figure 1). His medications included 700 mg levodopa and 16 mg ropinirole as the extended release preparation. The foreign body was removed under general anaesthetic and lacerations to the urethra and glans penis repaired. Further enquiry identified that he had recently required two separate cystoscopies to remove cotton buds from his bladder. On one occasion, a CT abdomen and pelvis performed for an unrelated symptom had identified the foreign bodies. Despite previously denying gambling, compulsive behaviour or hypersexuality, he admitted to recurrent intrusive erotic thoughts that had resulted in him repeatedly inserting foreign bodies into his urethra. On most occasions he had been able to remove the objects himself. These thoughts and actions had been a source of significant distress for him. We made a diagnosis of impulse-control disorder relating to treatment with the dopamine agonist ropinirole. We reduced the dose of ropinirole to 12 mg daily, after which his symptoms completely resolved.

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Figure 1

Pelvic X-rays. Anteroposterior (A) and lateral (B) pelvic X-rays showing a length of flex and attached metal curtain hook lodged within the urethra.

Impulse control disorders reported in Parkinson's disease include pathological gambling, hypersexuality, compulsive shopping, eating and punding—a compulsion to perform repetitive ritualistic tasks. These occur mainly in people taking oral dopamine agonists, but can occur with any dopaminergic therapy, including transdermal rotigotine and levodopa. A recent study showed that up to 42% of patients taking oral dopamine agonists develop impulse control disorders.1 These disorders can have a devastating effect on patients and their families; sometimes bringing them into conflict with the judiciary. The diagnosis can be difficult as patients often hide their symptoms from family members and healthcare professionals due to embarrassment. It is important that patients receive careful counselling about the various types of impulse control disorders before starting treatment. Providing them with additional written information on the possible symptoms is sensible. After starting treatment, patients need regular monitoring and targeted considerate questioning to prevent the significant morbidity associated with impulse control disorders.