In rare instances, severe bladder dysfunction may require surgery for proper management. A "cystostomy" makes a hole in the bladder where a drainage tube is then inserted. A "sphincterotomy" enlarges the sphincter muscle. These types of surgical procedures are not typically performed as initial treatment for bladder problems caused by MS.
Infection is a constant concern for those with bladder difficulties. A bladder infection can cause urinary incontinence in anyone, not just those with MS. An infection left undetected or untreated can quickly lead to serious conditions. For anyone with bladder problems, a great deal of attention must be given to the prevention, detection, and treatment of infection.
Infections can only be confirmed through lab tests, specifically urinalysis. This procedure checks the urine for inflammation (by the presence of white and red blood cells) and bacteria, which will need to be cultured and identified for the appropriate antibiotic to be prescribed. Bacteria can exist in the bladder without active infection, but such an instance would need to be determined by a doctor.
Frequently used antibiotics for treating bladder and other urinary tract infections include ampicillin and trimethoprim (Bactrim®, Septra®). Cephalexin (Keflex®) may be prescribed if the individual is allergic to the previously mentioned drugs. These are often given over a seven to 10-day course. Occasionally antibiotics will be given over a long period of time if infection is chronic or severe. Methenamine mandelate (Mandelamine®) may be given on a regular basis to prevent recurrent urinary tract infections.
Infection typically occurs when urine is retained in the bladder or anywhere along the urinary tract, allowing bacteria to grow. An infection only reaches the kidneys when a bladder infection is not controlled.
The shorter length of the urethra is one reason why women are more susceptible to bladder infection than men. Those with a flaccid bladder or who use a catheter, especially the indwelling type, are also more prone to infection.
Anyone at risk of an infection needs to watch for any of the following symptoms:
If any of these symptoms are present, a physician should be contacted immediately for prompt evaluation and treatment.
The ideal treatment for urinary tract infections is to prevent them. Proper cleaning is essential, especially after sexual intercourse. Women should wipe from front to back and use mild soap and water (never harsh detergents) to clean the groin area. Intermittent catheters must always be washed and stored; those with indwelling catheters need to be especially careful to keep the insertion area and bag clean.
Urinating often and completely is important to avoiding bacteria growth. Holding urine for a prolonged period can encourage infection. Women should not wear undergarments made of synthetic materials and should always urinate before and after sexual activity.
Drinking six to eight glasses of fluid daily flushes the system and is recommended along with taking vitamin C. Vitamin C inhibits the growth of bacteria. Although 4000 mg daily in divided doses is typically prescribed, the exact dose should be determined by a doctor.
Prune or cranberry juices help to make the urine very acidic, a condition which suppresses bladder infections. Foods high in protein, such as meats and poultry, may also be helpful. Tomato, orange, grapefruit, and other citrus juices are to be avoided. These actually reduce acidity in the urine and can encourage the growth of bacteria.
Some easy, common-sense tips can assist with the management of bladder difficulties. Plan ahead before going out, noting when a restroom will be needed and where the nearest one is located. Always empty the bladder before going out and also when arriving home.
Restricting the intake of fluids prior to sports or other activities may be helpful, along with avoiding diuretics (agents which increase the elimination of the body's water). Diuretics include alcohol and caffeinated drinks such as coffee, tea, and certain sodas. Restricting fluids, however, may cause constipation as more water is absorbed from the bowels when not available elsewhere.
Safety measures should be used around the home for frequent use of the bathroom. A bedside commode may be the simplest and safest way to solve this problem. If this is not an option, be sure to have a clear route to the bathroom to help prevent falls. A night-light, handles or grab bars, and rugs with non-slip surfaces also increase safety. Avoid wearing baggy clothes that are easy to trip over, especially at night.
Other techniques include using a special battery-operated vibrator to assist with emptying. This is held on the lower abdomen and has been shown to be effective for 80 percent of patients who are ambulant. Additionally, biofeedback has been shown to significantly reduce urgency, frequency, and incontinence, according to the results of a small study.
Bladder problems may require some extra effort and changes in routine, but they are manageable. By working along with a physician, preventing infections, and designing an individualized schedule, a successful treatment plan may be developed.
Many people with MS experience a bowel difficulty at one time or another. The most frequent symptoms are constipation, diarrhea, or incontinence. Depending upon the cause of the problems and the individual's type of MS, a symptom could be temporary or may continue indefinitely. In either case, controlling symptoms may require changes in diet and routine, the addition of bulk supplements, or possibly medications. Only in very rare instances, after years of experiencing a severe difficulty, is surgery considered an option.
Constipation is the difficult or infrequent elimination of solid waste from the body. This is the most common bowel symptom found with MS and may be caused by a variety of reasons. Sometimes demyelination is the cause of constipation, but other factors may just as easily be at fault.
Constipation commonly occurs when not enough fluid is present in the stool. Some people decrease their fluid intake to help with bladder problems. Reduced physical activity or certain medications, such as tricyclic antidepressants and anticholinergic drugs, slow bowel activity, allowing for less fluid to be retained in the stool. Weakness or pain, depression, stress, or poor diet can also affect the ability to have regular bowel movements.
Laxatives are not the first choice for treating constipation. Making appropriate changes to the diet and increasing physical activity is the best plan for initial treatment and long-term management. Some may find massaging the abdomen in a clockwise direction for several minutes twice a day will help to alleviate constipation.
Drinking eight to 12 cups of fluid daily (preferably water) is important to good bowel health. Exercise needs to be a part of the daily routine and is vital to regularity. Balanced meals should be eaten at similar times each day and in a comfortable atmosphere. Sweets, fried foods, meats high in fat, and sometimes even spicy foods will need to be eliminated from the diet.
Adding dietary fiber (bulk) to the diet will help stools to be softer and move more quickly through the intestines. Care must be taken not to add too much fiber too quickly to the diet. Doing so may result in excess gas and possibly diarrhea. Fiber needs to be introduced in small amounts and gradually increased, allowing time for the body to adjust to the change.
Fiber may be added to the diet by eating fresh fruits (with the skin on, if applicable), vegetables, fruit juices, whole-grain breads, and bran cereals. Some foods and drinks, such as sauerkraut, cabbage juice, pickles, yogurt, garlic, prunes, and prune juice, may act as natural laxatives. One or two tablespoons of powdered or granular 100% bran may be added to cereal each morning. Too much bran, however, can cause constipation by clogging the intestines.
Bulk laxatives, which may be taken at night, are not habit-forming and may be used on a regular basis. These are available in powder, wafer, and chewable tablets, depending on the brand. Popular bulk formers include psyllium (Metamucil®, Perdiem Plain®, Fiberall®) FiberCon®, and methylcellulose (Citrucel®). Bulk laxatives need to be taken according to instructions and include following the dose with liquid.
With MS, constipation is sometimes caused or compounded by decreased sensation in the rectal area. When this occurs, patients don't feel the urge to have a bowel movement, causing the stool to backup and become hard. Establishing a regular time to have a bowel movement may be helpful.
Anyone experiencing this type of constipation should allow 15 to 30 minutes to use the bathroom after a particular meal at the same time daily, regardless of whether or not the urge is felt. Having a warm drink, such as coffee or tea, may assist the process. Some sources suggest scratching the skin above the anus to stimulate nerve endings and possibly encourage a bowel movement.
Stool softeners pull water from the body's tissues and may be used to help alleviate constipation. These are non-habit forming but must be used regularly to be effective. Stool softeners include docusate sodium (Colace, D-S-S®), docusate potassium (Surfac®), and lactulose syrup (Chronulac®).
As the person with MS and physician work together to solve a constipation problem, identifying the cause will help to determine the best treatment. If lack of fluid or hard stool are not at fault, difficulty in expelling the stool could be a problem, in which case a laxative (oral stimulant) may be recommended.
Laxatives have chemicals that irritate the bowel, thereby increasing intestinal activity and allowing the stool to be moved along more quickly. Certain over-the-counter laxatives should be avoided as they can be potent and habit-forming. Such laxatives include: phenolphthalein (Correctol®, Ex-Lax®, Feen-A-Mint®), danthron (Doxidan®), bisacodyl (Dulcolax®) and castor oil.
Milder laxatives with less-harsh chemicals gently promote a bowel movement, often overnight or within the day. Cascara (Peri-Colace®), Perdiem® (not Perdiem Plain®, which is the bulk former) and magnesium hydroxide (Milk of Magnesia®) are examples of milder laxatives.
Another option for treating constipation is the use of suppositories. Often these may be used along with the laxatives just mentioned, but always check with a medical professional before combining any medical treatments.
Suppositories typically work in less than an hour. Glycerin suppositories provide lubrication for smoother elimination, while others, such as bisacodyl (Dulcolax® Suppositories), contain a medication to encourage movement of the rectal muscles. Naturally, suppositories which contain medication are not as mild as those offering only lubrication.
Enemas may be used when a number of days have passed without a bowel movement. (A physician should be consulted if the number of days since a prior bowel movement has been excessive.) Different types, such as bisacodyl (Fleet's®), Therevac® mini-enemas, and soapsuds enemas may be recommended. These usually relieve constipation but should not be used on a regular basis as the bowel could become dependent upon them.
Diarrhea and fecal incontinence are not common MS symptoms, although occasionally these conditions are seen as a result of the disorder. For instance, people who have lost muscle control and feeling in their legs and lower part of their bodies may lose the ability to control bowel movements. Others may experience this condition from inappropriate nerve signals to the intestines.
Fecal incontinence is often temporary. Finding the exact cause is important and MS should not automatically be blamed. Medications such as antibiotics or even those to relieve constipation may promote fecal incontinence.
Once the cause of the problem has been identified by the physician, changes in routine or medications may be recommended. Altering the diet according to the doctor may also help.
Bowel movements often occur soon after a meal, when activity in the intestines is taking place. People with diarrhea or incontinence may find sitting on the toilet or bedpan immediately following a meal to be well timed.
Interestingly, bulk formers – which are used to treat constipation – may also be used in the treatment of diarrhea and incontinence. While absorbing water, they help to make the stool firmer. Metamucil® and Perdiem Plain® are two brands that may prove useful. When used for this condition, no more than one dose a day should be taken and no extra liquid should follow this dose.
With persistent diarrhea, a doctor may recommend a diarrhea medication such as kaolin and pectin (Kaopectate®), Imodium®, and Lomotil®. This works to slow intestinal activity. Occasionally, medication which blocks bladder spasms may have an effect on slowing down bowel muscles also. Other therapies include bowel retraining and biofeedback.
Chronic diarrhea and incontinence, rarely found with MS, may require someone to wear diapers. A very few individuals who have experienced these problems for years and who have no other means of changing their condition, may opt for surgery. A "colostomy" is the usual procedure, which allows for the intestines to empty into a bag in front of the patient's abdomen.
Again, surgery is extremely rare for people with MS for the treatment of bowel symptoms. In most cases, constipation is the most common problem, usually a result of reduced activity and fluid intake. Changes in diet, routine, and occasionally medication will allow most people to manage their bowel problems easily.
With normal muscle function, opposite muscles work in opposite directions. This means that when one muscle pulls or contracts, the other relaxes. Spasticity is a condition which occurs when muscles opposite each other both contract or relax at the same time. This syndrome causes an increase in muscle tone. Typical symptoms include muscle stiffness, lack of coordination, clumsiness, muscle spasms, and related discomfort or pain.
As with the majority of MS symptoms, spasticity appears to result from changes in the flow of nerve impulses, in this case along the spinal cord. Spasticity can be transient or may last indefinitely. Discomfort with spasticity ranges from an occasional tightness, achiness, pulling, or restless sensation to strong pain resulting from severe spasms. Spasticity is one of the most common symptoms of MS.
Typical treatments for spasticity include exercise, physical therapy, mechanical devices (such as an ankle brace or "spreaders" for the fingers), medication, baclofen pump implant, and nerve-blocking procedures (in severe instances). In addition to any pain relief, treatments offer the potential for increased coordination, easier movement, and less fatigue as a result of less effort involved in movement.
A successful exercise program, emphasizing stretching and range of motion, in conjunction with proper medication (if necessary), will normally decrease the symptoms of spasticity and potentially prevent the development of more severe conditions. Spasticity frequently leads to contractures (joint immobility), which can cause an increased risk of infection as well as pressure sores as a result of limited movement. Severe muscle spasms are also possible.
Much of the difficulties involved with spasticity results from spastic muscles pulling across joints. Weak or unused muscles can shorten and joints may become injured or even deformed while range of motion is greatly reduced.
As the joints worsen and muscles function improperly, the mobility of the joints may be lost and contractures result. This "freezing" of joints often occurs in a contracted (bent) position, but sometimes a joint may become immobile with an arm or leg in an extended (straight) position. Should limb strength return, movement of the limb will be inhibited from the contracture.
Treatment for contractures includes physical therapy which may slowly mobilize the joint, often using heat or ice followed by stretching to ease pain and increase mobility. A "tiltboard" may be used. This is a small wooden plank which may be adjusted to different angles to the floor to stretch ankle and lower-leg muscles. An ankle brace may also be used, gradually adjusting the angle to further stretch and improve the muscle. Antispasticity medications may be prescribed, although some doctors may recommend an injection of cortisone directly into the joint to decrease inflammation and increase mobility.
When contractures are severe and movement becomes difficult, pressure sores (also known as decubiti or bedsores) result from lack of movement. This occurs as blood flow stops or slows at an area of skin which has remained against pressure (often that of a chair or bed) for too long. The lack of circulation causes a blister, which can eventually develop into an infection. Left untreated, this sore can expand deep into the tissues and reach the bone. Such infections have the potential of becoming abscesses or chronic bone infections.
In addition to pressure sores, being less mobile increases the risk of other infections as well. Pneumonia is always a risk when someone has been in bed for a long period of time. Urinary tract infections are also common and can lead to kidney infections and possible kidney failure if not managed properly.
Any of these infections – pressure sores, pneumonia, and kidney problems, may progress to serious and even life-threatening conditions if not aggressively monitored and treated. Physical therapy, proper diet, and medical treatments all play a role with avoiding these complications of contractures and spasticity.
Episodic spasms are involuntary contractions or extensions of spastic muscles. These occur most frequently in the legs, often at night. These are usually painful and can greatly impact a person's balance while walking.
Tonic spasms, also known as paroxysmal spasms, occur when an entire arm or leg abruptly pulls up into a rigid clenched position or pushes out into an extended stiff position. When both legs are affected this way, the condition is called an extensor or flexor spasm. These spasms can be so severe, that one may be thrust from his or her chair. Treatment, involving physical therapy, medication, or even surgery, is mandatory for this obviously dangerous condition.
An experienced physical therapist should be consulted for any type of therapeutic physical therapy. Such treatment seeks to return joints to their proper alignment, reduce the stress or trauma to the joints, create muscle elasticity while lessening stiffness, and ultimately gain maximum range of movement. Such stretching and straightening exercises can help return a degree of usefulness to a limb which has lost its ability to perform.
The easiest and frequently the most successful type of physical therapy for spasticity is passive stretching. This method slowly positions spastic muscles and affected joints to where they are stretched for approximately one minute. The therapist will usually begin at the ankle and work upward to the groin area. Interestingly, by first stretching the calf muscles, tension in all of the spastic muscles may be reduced. Standing on a tiltboard (mentioned earlier) for two or three minutes can also promote muscle relaxation by stretching calf muscles.
A complete program of stretching exercises is often prescribed if you suffer from spasticity. Many exercises can be done from a lying or sitting position and some incorporate the use of a belt or towel to pull against the muscles you are stretching. Lying on your stomach across a beach ball and rocking back and forth can also be beneficial.
Using a swimming pool for therapy can be both fun and productive. Exercising in water tends to stretch your muscles while encouraging a larger range of movement. Slow and rhythmic calisthenics are ideal for this type of workout. The pool temperature should be kept at approximately 85 degrees or below to avoid fatigue from warmer water.
Tai chi and Aikido are oriental martial arts practices that use slow, languid exercises. These can help to stretch muscles. A physician should always be consulted before beginning any new physical activity. The instructor should also be informed of any conditions that may limit a participant's involvement in the exercises.
Sometimes retraining is necessary for those whose spasticity creates difficulties in a person's daily activities. Something as basic as getting in and out of a chair can pose challenges to individuals without full range of motion. Through retraining, people may learn new techniques for performing normal activities within their own limitations.
Relaxation training, often a combination of tensing and relaxing different muscle groups while using special breathing and visualization techniques, can prove to be useful in the treatment of spasticity. Regardless of which treatments a person finds to be the most advantageous, the common goal with physical therapy is to increase the amount and types of movements, while expending the least effort.
Customized devices or orthoses are braces that are designed to aid an individual experiencing limited or spastic movement. These aids, which may be made to fit toes, fingers, feet, ankles, or wrists, serve to reduce tightness while increasing mobility.
A frequently used device is the ankle-foot orthosis (AFO). It is a treatment for those who drag a foot when walking (due to a weakness in the dorsiflexors of the foot – commonly called "foot drop"). This slim brace cups the heel and positions the foot at an angle to the ground conducive to walking. This device enables the wearer to walk comfortably and easily slips into the shoe and under the pant leg.
Canes, crutches, and walkers can provide additional safety and support. Corsets and braces are also available for those with back problems or pain. These should not be overused, as muscles required for normal posture may weaken as they become dependent upon such devices for strength.
Patients and their doctors may need to try a few different types of medications and various dosages before finding what works the best for them. Some medications affect the CNS directly, while others may affect the muscle, work elsewhere, or simply reduce inflammation.
Baclofen (Lioresal®) is the most commonly prescribed drug for spasticity. It is an antispasticity agent that works within the spinal cord to stop spasticity in the arms and legs. Taken orally, dosages of baclofen vary from 5 mg daily to 40 mg four times a day. Taking too little of this drug can prove to be ineffective, while too much can cause muscle weakness and overall fatigue.
Doctors prescribing this drug carefully monitor its dosage and effects to ensure optimum benefit for the patient. Baclofen is usually started at a small dose and increased gradually until a point is reached where symptoms are relieved but side effects are not experienced. Starting at a full dose can cause weakness, drowsiness, and nausea. High doses of baclofen should not be discontinued abruptly as this may cause seizures.
Blood tests are conducted on a regular basis for individuals taking baclofen. This drug may promote changes in liver function, and physicians need to be aware of potential drug interactions.
Tizanidine (Zanaflex®) is a newer drug that is also effective in treating spasticity. This medication is less likely to cause weakness, and seizures have not been reported. Hypotension, liver function abnormalities, and hallucinations have occurred with this drug, so individuals taking tizanidine need to be regularly monitored.
The most challenging side effect may be sedation, so beginning with a small dose (2 to 4 mg per day) and slowly increasing the amount by 2 mg daily is recommended until an optimal response has been reached. Doses are usually divided into three equal portions to be taken three times daily. Many people may find their optimal dose to be less than 24 mg daily, and 36 mg is considered the maximum daily limit. Some physicians may give tizanidine along with baclofen when one medication alone is not effective.
For cases of severe spasticity that do not respond to traditional treatment, an intrathecal baclofen pump implant may be used. This pump is implanted under the skin and delivers computer-controlled dosages of baclofen directly into the spinal fluid through a small catheter placed in the spinal canal.
This method of administering baclofen uses much lower doses and results in far fewer side effects, while offering greater effectiveness. This procedure is very expensive and does carry risks, including bleeding and infection. For these reasons, the baclofen pump is only considered for severe spasticity that is not responding to other types of treatments.
Dantrolene (Dantrium®) is an alternative to baclofen and tizanidine if both drugs are ineffective or not tolerable. Sedation, changes in the blood, allergic reactions, eventual liver damage, and fluid in the chest are possible side effects of dantrolene. This is a strong medication which acts directly upon muscles. Weakness may occur as it interferes with the contraction of muscle fibers. Doctors normally prescribe this drug on a trial basis to determine if the patient is deriving any benefit.
Botulinum toxin A (Botox®) is a strong nerve toxin that is produced by bacterium. When given by injection, a very small dose of this agent can be effective in treating conditions that cause muscle spasms. While Botox® injections may temporarily relieve MS spasticity, each injection is expensive and must be given in each affected muscle separately. Additionally, the effects only last for a matter of months, and then the entire procedure needs to be repeated.
Clonazepam (Klonopin®) is very similar to diazepam and is commonly prescribed for epilepsy. Also useful in treating tremors of the arms or head, clonazepam significantly relaxes muscles. This drug is best given at night and can cause tolerance or dependency.
Diazepam (Valium®) is especially useful for those who experience spasticity at night. It not only reduces stiffness but also has a calming effect that promotes sleep. Its sedative properties make this drug helpful for those who are depressed or anxious, but because of this sedation, it is best taken at bedtime. Side effects include sleepiness or dizziness. Continued use of diazepam can cause drug dependency.
Chlordiazepoxide (Librium®), as does diazepam, improves mobility by reducing stiffness. Sensitivity, lethargy, and sleepiness are common side effects. Cyclobenzaprine (Flexeril®) is another drug which may help limb spasms, but more often acts upon back spasms. Under a doctor's guidance, both of these drugs may be given in conjunction with other antispasticity medications.
Carbamazepine (Tegretol®) is an anticonvulsant drug that can help control tonic or paroxysmal spasms. Cortisone is also effective but can only be used on a short-term basis.
Many of the drugs used to relieve spasticity can become less effective over time as people become "more tolerant" to them. When this occurs, the drug can either be increased, or discontinued and then restarted at a later date when the treatment may be effective again.
When pain from spasticity and spasms is caused by tendon strains, joint injuries, or pulled muscles, anti-inflammatory drugs are sometimes prescribed. These may include ibuprofen (Motrin®, Advil®, Nuprin®), naproxen (Naprosyn®, Anaprox®), piroxicam (Feldene®), and diflunisal (Dolobid®).
Illegal drugs such as marijuana, cocaine, and "crack," are often contaminated with other drugs, herbicides, or pesticides. Even without these potentially toxic ingredients, the effects of such drugs on MS are not known and are generally not recommended to be used by people with MS. Since they do affect the CNS, they may also have the potential to seriously worsen the disease.
Recent studies with cannabis (marijuana) have been cautiously optimistic about its effects on spasticity and resultant pain. But again, this could potentially increase MS symptoms, particularly problems with balance and cognition. Until more study results are available to support its use, cannabis is not recommended for the treatment of MS.
When all else fails in the treatment of severe spasticity, irreversible medical procedures may be necessary to permanently eliminate spasticity and its associated pain and complications. Nerves relating to affected muscles may be destroyed either by injecting a chemical (phenol) into the muscle (known as a "motor point block") or by surgically cutting the nerve.
Both methods produce "flaccidity" – which is a significantly loose muscle (opposite of spasticity). Although these procedures reduce or eliminate spasticity, spasms, and pain, they do not increase mobility and also carry risks. Nerve destruction or blocks should only be performed in severe situations where years of limb uselessness and related complications dictate no other option. Neurolytic blocks may also facilitate perineal and genital hygiene, making catheter care as well as wheelchair and bed transfers easier.