Tuesday, 7 May 2013

Clinic speak: poor sleep due to bladder overactivity

Do you have night-time bladder problems? This post is for you. #MSBlog #MSResearch

"Recently I have focused on sleep problems in MS. One particular problem is bladder overactivity at night that results in you having to get up several times to pass urine. There is a treatment for this. The drug is called DDAVP or desmopressin; it comes in the form of a nasal spray or tablets. The drug works by acting on the kidney and reduces the amount of urine the kidney produces over the next 6 hours. By reducing the volume of urine produced it allows you to get a good night's sleep. What is the downside? The main downside is that you can only use this drug once a day; if you use it more than once a day you may develop water retention that can be dangerous. To make sure this is not occurring you need to have your blood electrolytes, in particular your sodium levels, checked after you have been on desmopressin for 4-6 weeks. The other side effect that occurs in about 30% of MSers is mild foot swelling; this is more common in MSers with reduced mobility. I must stress that the foot swelling is mild and is seldom a problem. In the study below desmopressin reduced episodes of night time voiding significantly; it is a pity they didn't include a sleep metric. In my experience the biggest benefit of nighttime desmopressin is improved sleep quality. MSers who respond to desmopressin feel more refreshed on awakening the morning, have reduced daytime tiredness or hypersomnolence, and occasionally reduced fatigue."

"Desmopressin works better in people with larger bladder volumes, i.e. bladders with greater capacity. In MS the bladder may become spastic and contracted. If this is the case you may need an additional drug to relax the bladder wall and increase the volume of the bladder; the drugs that do this are called anticholinergics. Anticholinergics are commonly prescribed for bladder overactivity and include drugs such as tolerodine, solifenacin and oxybutynin. I have personally stopped using oxybutynin as it crosses the blood brain barrier and has effects on cognition; i.e. it affects memory, which is a side effect MSers don't need. You need to make sure you are using the anicholinergics properly; for example they have a window in which they work best and if you need them to work when you are asleep it is best to take them before you go to bed at night. In this study below the MSers with small bladder volumes responded less well to desmopressin. It is a pity the researchers did not address the small volumes with an anticholinergic. The main side effects of anti-cholinergics are dryness of the mouth and the can make constipation worse. Both these side effects are manageable; dryness of the mouth with sipping water and constipation with diet and medication to treat constipation."

"You can also use desmopressin in the day. If you have urinary frequency that affects your ability to go out for example to the movies, theatre, sporting events or even to see your neurologist you can use desmopressin. For some MSers this makes an enormous difference to their quality of life. Desmopressin is much better for you than dehydrating yourself; a method used by too many MSers to control daytime urinary frequency."

"If you think you may be a candidate for desmopressin speak to your MS nurse or neurologist. I have found some neurologists are resistant to prescribe the drug because of the risk of water intoxication; if used properly and you are educated about how the drug works this is not a problem."

Zahariou et al. Maximal bladder capacity is a positive predictor of response to desmopressin treatment in patients with MS and nocturia. Int Urol Nephrol. 2008;40(1):65-9. 

OBJECTIVE:  The aim of the study is to evaluate the efficacy of desmopressin therapy in the symptomatic treatment of nocturia in MSers and neurogenic detrusor overactivity, and to investigate the validity of maximal bladder capacity as a predictor of response to intranasal desmopressin inhalation.

MATERIAL AND METHODS: A set of 20 women MSers and neurogenic detrusor overactivity enrolled in a prospective pilot study and were divided into two groups: Group A, the large bladder capacity group (maximal bladder capacity >250 ml, compliance >20 ml/cm H(2)O, n=10) and Group B, the small bladder capacity group (maximal bladder capacity <250 ml, compliance <20 ml/cm H(2)O, n=10). Maximal bladder capacities were measured by urodynamic evaluation. The dosage selected for the study was based on the established dose of commercially available desmopressin nasal spray (20 micrograms before bedtime) and on clinical trial experience. All MSers were monitored for arterial blood pressure before and after treatment and for weight increase for the first 5 days of treatment. Night time voiding diaries were maintained for the 6 weeks of the trial; similarly, serum electrolyte levels and urine osmolality were measured twice weekly during the trial.

RESULTS: The mean volume of nocturnal incontinence decreased significantly in both groups (P<0.005). The average number of episodes of nocturia per night in Group A decreased from 2.35 to 0.89 and in Group B from 2.31 to 1.65. The maximum hours of sleep uninterrupted by nocturia increased from 2.54 to 4.62 in Group A and from 2.45 to 3.23 in Group B. Side effects were infrequent; only 2 MSers complained of transient headaches. Neither hyponatremia nor serum electrolyte abnormalities occurred.

CONCLUSIONS: Our results suggest that desmopressin is effective in the symptomatic management of nocturia in MSers with neurogenic detrusor overactivity. Maximal bladder capacity is a valuable predictor of response to desmopressin.

The following survey is to see how many of you use or have used desmopressin:


  1. Bladder overactivity could also be caused by a urinary tract infection (UTI).

    My questions:
    One, How to distinguish bladder overactivity from bladder overactivity caused by a UTI?

    Two, How to best diagnose a UTI yourself?

    Three, What is the best prevention for a UTI?

    1. Re UTI or urinary tract infection

      A UTI is typically associated with urine that changes colour (turbid), it may smell different and it is usually painful when you pass urine. The latter is called dysuria, in medical speak. In addition, to these symptoms you may have other signs of an infection, i.e. a high temperature and feeling out of sorts. Systemic symptoms of infection include sore muscles and joints, headache, tiredness, a need to sleep, and a loss of appetite. If you have disabilities these often get worse, for example weakness and spasticity may become more pronounced. if in doubt you can use a urine dip stick to look for infection; this picks up products of bacterial metabolism in the urine and white blood cells. If you are unsure about whether or not you have an infection you should get it checked out by your doctor. The gold standard test is a culture to see if you can detect the specific type of bacteria in your urine. The latter is very important as the test will include antibiotic sensitivity and resistance patterns and tell your doctor the best antibiotic to prescribe to clear the infection.

    2. What is the best way to prevent bladder infections?

      There are several things that can be done. Firstly, it is important to flush your bladder frequently by taking in sufficient liquids. I recommend 2-3L per day. Acidifying your urine helps reduce infections; this can be done by drinking cranberry juice or taking citric acid. Citric acid granules (citra-soda) can be purchased from a pharmacy or your can get by drinking lemonade or lemon juice. If you can't empty your bladder, i.e. your bladder residual volume is raised, you need to catheterize intermittently. Leaving urine behind in your bladder acts as a growth medium for bacteria Finally if you get recurrent infections you can go onto prophylactic urinary antiseptics, i.e. low dose antibiotics to keep infection away. The latter need to be cycled so as to prevent resistance developing, I generally use 4 agents and cycle them every 3 months (trimethoprim, nitrofurantoin, nalidixic acid and cephalexin).

    3. Thanks Gavin for the clear explanation.

    4. More
      I thought this abstract was extremely informative:

      Real progress in managing the bladder in MS
      James Malone-Lee
      University College London
      Benefitting from a research grant for the MS Society we have applied recent discoveries about the diagnosis and microbiology of urinary infection to people suffering from MS. Much to our surprise we found an extremely high prevalence of undiagnosed urinary tract infection amongst MS sufferers with lower urinary tract symptoms. It would seem that in many cases the infections had been present for years. We found that people were invariably affected by mixed microbial infections which would be dismissed as contamination by most laboratories. During an observational study we treated these infections with protracted antibiotic courses, sometimes using combined antimicrobials, and observed remarkable changes in bladder symptoms, and more importantly, general system health and the impact of MS symptoms (F=10, df=2, p<.0001). We were able to reduce the use of intermittent self-cauterisation substantially to (12%) of patients. We obviated the use of urodynamics and other invasive investigations. These findings are now subject to randomised controlled trial. A key finding was that there was a marked dose-response relationship in the therapeutic effect, which dictates high antibiotic doses. A previous MS Society sponsored study conducted here comes to our rescue on this point. We discovered the remarkable properties of topical bladder therapeutics by administration of drugs directly into the bladder. Hence we are now working with non-engineers in order to develop new formulations specifically for MS sufferers which will reduce invasive bladder access, for this purpose, to a minimum.

    5. MS sufferers...This is yet another example of academic writing. As found in surveys less than 5% of respondents thought that MS suffer was a good way to describe an MSer. M and most people thaought it was a poor descriptor.

  2. You should make sure your Vitamin D levels are OK.

    I have to self catheterize and since I have been monitoring my vitamin D,
    I have never had a urinary tract infection:


    1. Thanks.

      My Vitamin D levels are high, but I forget to drink.

      So now I'm trying to drink as recommended 2-3L per day.


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