About 75 percent of those with MS experience bladder difficulties at some time. The most common symptoms are frequency (the urge to urinate often) and urgency (the urge to urinate immediately and the inability to hold the urine once the urge is felt).
These symptoms, among others, are a result of demyelination either in an area on the spinal cord which controls bladder function or along nerves which carry messages to the brain concerning bladder function. The location of the demyelination will determine the type of bladder dysfunction along with the specific symptoms experienced.
Many may lose their ability to control the release of urine. Some find they cannot urinate (hesitancy, retention) despite the urge being felt. Others may experience dribbling (small amounts of leaking urine) or a full loss of control resulting in an unexpected emptying of the bladder (incontinence).
To manage such symptoms, patients may need to practice certain therapies, take medications, wear absorbent materials under clothing, or possibly use a catheter. While adjusting to these treatments may seem difficult, they are not nearly so bad as they may sound. In a great majority of instances, bladder problems are manageable and whatever is required by the patient soon becomes second nature.
Dealing with these problems psychologically often poses the biggest challenge. Even though these symptoms may only be temporary, feeling uncomfortable or self-conscious at social activities or the workplace is very natural. Knowing exactly how one's individual symptoms behave, along with the appropriate treatments, enables the development of a schedule and strategy which will help to avoid any situations which could affect one's dignity or self-esteem.
Skin problems and risk of infection are further complications of bladder dysfunction. Through proper management, these may be readily controlled.
As with all MS symptoms, the type, degree, and duration of bladder problems are impossible to predict. Understanding the process and knowing what is happening when difficulties do appear, however, may help to alleviate some of the anxiety someone with a bladder problem may be experiencing.
The urinary system consists of the four components listed below with their functions:
Related to the urinary system is the voiding reflex center (VRC). This is a group of nerves found along the lower section of the spinal cord whose purpose is to communicate bladder fullness to the brain and to release urine upon command. When the brain receives this message, it then instructs the VRC to open the sphincter and stimulate the bladder to empty.
When demyelination along the nerves to the brain closes off the lines of communication, the VRC works on its own, automatically allowing the bladder to empty. Dribbling, frequency, and/or incontinence results.
This dysfunction is called a spastic bladder, which is the less debilitating and more frequently experienced type of bladder problem found among people with MS. Also known as a "failure to store" or "small" bladder, this condition eventually causes the bladder muscles to become thick and spastic. The bladder then fills faster and urinating becomes an automatic reflex.
A second condition, known as a flaccid, "failure to empty," or "big" bladder, results when demyelination occurs in or near the VRC. Messages of bladder fullness are no longer perceived and the bladder overfills. The walls of the bladder become weak, stretched, and unable to empty upon command.
Causing the bladder to overfill and overflow, a flaccid bladder results in frequency, urgency, dribbling, hesitancy, or overflow incontinence. It also greatly increases the risk of infection as urine can overflow and encourage the growth of bacteria. Infection can easily spread up to the kidneys, causing pyelonephritis (kidney and kidney pelvis inflamation). Infection can even travel into the blood stream.
The third type of condition is called a dyssynergic or "conflicting" bladder. In this instance, the bladder and sphincter do not work in conjunction with one another; their movements and functions are no longer coordinated. The bladder may contract to empty while the sphincter contracts, causing urine to be retained. This situation can also reverse, with the bladder not releasing the urine and the sphincter relaxed, prepared to allow urine to flow.
The dyssynergic bladder may be seen with either the spastic bladder or the flaccid bladder. Symptoms include urgency followed by hesitancy, dribbling, or incontinence. Those with a dyssynergic bladder carry a higher risk of infection than those with the other types of bladder conditions.
Treatments for bladder difficulties range from simply changing one's daily routine and schedule, to medications, therapies, catheterization, and surgery (in severe cases). When a physician designs a program for someone with bladder problems, he or she has to first identify the type of dysfunction that the individual is experiencing.
Determining which kind of bladder condition is present from symptoms alone is impossible – a medical evaluation is mandatory. Urodynamic testing, which uses special instruments to measure pressure in the urinary system, is sometimes recommended.
Additionally, the social implications produced by bladder problems and the treatments must be considered. The goals of bladder treatment are to:
Many people experiencing minor bladder problems may simply leak urine during their sleep. Known as nocturnal incontinence, or enuresis, this condition can put stress on the relationship at home if this person sleeps with his or her spouse. It also puts stress on whoever cares for the bed.
Sometimes just eliminating late-night drinks (of any kind) will control nocturnal incontinence. Another treatment for nocturnal incontinence is the use of desmopressin (DDAVP), a hormone which slows the kidneys' production of urine. Available in different forms, the nasal spray is often the most convenient. One or two sprays in the evening will frequently prevent wetting the bed. Please note that this medication may only be taken once within a 24-hour period.
Desmopressin does have three disadvantages. First, it is very costly. Second, the production of urine is increased during the day to compensate for the reduction at night. The patient must have control over daytime urination in order for this medication to be practical. Third, although rare, desmopressin can cause the level of sodium in the blood to decline to dangerously low levels.
Medications for bladder dysfunction are usually the most effective for a spastic bladder. Baclofen (Lioresal®), a drug frequently given for spasticity, will occasionally relax the bladder, allowing it to function normally.
More often, however, anticholinergic drugs are prescribed. This is a class of drugs which interfere with bladder emptying by decreasing impulses from the VRC, thereby blocking reflexes in the spinal cord and the bladder wall. Generally, the time between needing to urinate is lengthened, and urgency is decreased.
While suppressing nervous system activity which would otherwise increase bladder emptying, anticholinergic drugs also affect the body's heat regulation and certain gastrointestinal functions. Hot flashes, constipation, retention, dry mouth, and possibly diarrhea can result for more sensitive individuals. The most frequently prescribed anticholinergic drugs for spastic bladder include oxybutynin (Ditropan®), oxybutynin chloride (Ditropan XL®), propantheline (Pro-Banthine®), and imipramine (Tofranil®).
Tolterodine tartrate (Detrol®) is an anticholinergic medication for bladder problems. This drug treats frequent urination, increased urgency, or urgent incontinence. While having similar effects on the bladder as oxybutynin, side effects such as dry mouth, dry eyes, blurred vision, and constipation are less severe with tolterodine tartrate. Initial dosage according to the FDA is 2 mg twice daily, although starting at 1 mg twice daily has been recommended by some doctors treating MS.
Oxybutynin controls leakage and frequency by regulating bladder contractions. It is usually taken one to four times daily (5 mg doses) and may be taken on an as-needed basis. This means that a person may take a dose before going out and discontinue the drug when at home. The dosage must be watched, however, as taking too much can cause toxicity. Side effects include confusion, rapid heartbeat, nausea, sinus dryness, and constipation.
Propantheline is an antispasmodic muscle relaxant, interfering with bladder contractions and spasms. Although less effective than oxybutynin, propantheline also has fewer side effects. Possible reactions to this drug include dry mouth,
drowsiness, rapid heartbeat, and constipation. Individuals taking this drug must limit their intake of antacids and vitamin C, as large doses of these reduce the effectiveness of propantheline.
Imipramine works by suppressing the mechanism that allows the bladder to open. This drug is commonly used for children who suffer from bedwetting. Also an antidepressant, imipramine helps improve the mood of someone experiencing depression. Typically one dose of 25 to 100 mg is given in the evening.
Other drugs prescribed for the spastic bladder include:
dicyclomine (Bentyl®), isopropamide (Darbid®, Ornade®), hyoscyamine (Cystospaz®) and flavoxate hydrochloride (Urispas®). While the spastic bladder tends to respond well to medications such as those mentioned, the flaccid bladder is more difficult to treat and usually requires methods other than medications.
No longer recommended with bladder dysfunction in MS, the Credé Maneuver is a technique that uses massage to assist the bladder with emptying. While sitting on the commode, the patient places his or her hands on the abdomen. With the stomach relaxed, he or she presses downward and inward on the lower abdomen while urinating. This technique encourages a maximum amount of urine to be expelled from the bladder.
The Credé Maneuver is no longer used to treat bladder problems in MS, as urine can be forced back toward the kidneys. Doing so can lead to a kidney infection, a condition which is treatable but can become serious if not attended to immediately. Using an intermittent catheter (discussed on p. 30) is a safer option for individuals experiencing difficulty with emptying the bladder.
A dyssynergic bladder can sometimes be successfully treated with an "alpha blocker." Phenoxybenzamine (Dibenzyline®), clonidine (Catapres®), and terazosin hydrochloride (Hytrin®) are alpha blockers which could help. Typically prescribed for high blood pressure, these offer an additional effect of enabling the bladder to become more coordinated.
When medication does not work adequately, some people wear absorbent padding throughout the day, especially if symptoms tend to be occasional. With mild cases of bladder dysfunction, leakproof pads are available. Others may need the added protection of adult diapers, although some find wearing "diapers" to be difficult psychologically, giving them a poor self-image.
As options such as therapy, medication, and diapers are eliminated, catheterization is the next step toward effectively treating bladder dysfunction. A catheter is a thin, hollow, plastic or rubber tube which is inserted through the urethra and up the urinary tract into the bladder. Along with a plastic bag on the one end, a catheter allows trapped urine to escape from the bladder in a controlled and safe manner. Once the catheter is positioned properly, gravity pulls the urine down the tube and into the bag.
Catheters are available in different styles and types. The most effective and safe method is the "intermittent" catheter which may be carried with the user in a purse or large pocket. When the time arrives to urinate, the individual self-administers the catheter in a normal restroom setting.
Catheters have actually been used for several thousand years and are presently used by several thousand people – many of whom continue to lead active and normal lifestyles. Inserting the tube is usually easier for women; men tend to need more time to become skilled at this procedure. Both men and women should sit or squat while inserting a catheter.
Most people are hesitant at first to use a catheter. This soon changes after being properly educated on its use and practicing the technique of inserting the tube. Before inserting the tube, the catheter must be washed and lubricated. After the bladder is empty, the catheter is removed, washed, and put away in a purse, backpack, or briefcase for later use.
The intermittent catheter allows a person to empty his or her bladder at planned times – usually every four to six hours. Incontinence, dribbling, and hesitancy are all avoided through its use. Medications may also be used in conjunction with an intermittent catheter to enable the bladder to become more full (helpful for a spastic bladder).
Reducing the risk of infection is another advantage to intermittent catheterization. For those unable to catheterize themselves, this is a procedure that care partners may easily follow, allowing those with poor upper-extremity function the advantages of intermittent catheterization.
For those who choose to use the intermittent catheter, following these easy guidelines will help to facilitate the process.
A second type of intermittent catheter is the "external catheter." This was originally designed for men, although a woman's version has since been developed. While the traditional intermittent catheter is inserted, the external catheter is placed over the excretory organ.
This type of catheter comes in many styles and shapes. It is typically used by people who have difficulty with the insertion of the tube and would otherwise need to wear absorbent pads or diapers. The men's most popular version is held in place with a condom-type design, while the woman's uses a silicone device that is held in place by a special bonding adhesive.
Once the external catheter is affixed to the urethra, the bag on the other end is strapped onto the leg. After urine has emptied into the bag, the bag is then either thrown away or washed and saved, depending on whether or not it is a disposable model. Most pharmacies and supply houses carry external catheters and a physician can help an individual decide which style is best.
For various reasons, some people are unable to use intermittent or external catheters. Such instances require the use of an indwelling catheter, also known as the Foley Catheter. This type of catheter remains inside the user around the clock and should only be selected if all other options, except surgery, have been exhausted. Infection, chronic inflammation, potential for stone formation, bladder tears, and lower urinary tract decompensation (inability to function adequately) are some of the dangers of using this type of catheter.
The indwelling catheter is similar to the intermittent catheter except for having a portion that inflates at the inserting end of the tube. The insertion of this is very difficult and should be fitted by a qualified medical professional. Once inserted, the inflating device expands within the bladder, rooting itself there until the time comes for the catheter to be removed.
The insertion point should be cleaned with soap and water at least once daily. The bag must be placed lower than the groin area to allow gravity to carry the urine. The bag is to be emptied prior to its reaching capacity and must then be rinsed with a water and alcohol solution.