Sunday, 2 February 2014

Clinic Speak: urinary symptoms in CISers

Urinary symptoms an early marker of damage in CISers. #ClinicSpeak #MSBlog #MSResearch

"You may get tired of me banging on about the early impact of damage in MS and how the damage begins early and in some cases before the first attack. Well I need to bang on a bit more about this isssue. The study below looks at urinary symptoms in CISers; i.e. people with only one clinical attack suggestive of MS. From a practical perspective this is the earliest we as neurologists and researchers can study this disease clinically. This study, albeit small, scarily shows that over half of CISers studied had urinary symptoms and this was backed up by hard or objective findings on testing. The latter is called urodymanic studies; these studies test the bladders function. For example how it deals with increasing pressure and does it empty properly at the correct flow rates."

"Urinary symptoms in the majority of CISers is giving you the same message as cognitive dysfunction in CISers. Damage occurs early therefore if you are eligible for DMTs you should take up the option. A lot of my colleagues tell me that if you treat all CISers you will be treating a lot of people who will end up with benign disease. Isn't that the point. Aren't we trying to convert all MSers disease course into a benign course? The truth is in natural history studies the proportion of MSers who have benign MS drops off with time and the vast majority of MSers become disabled with time. Having urinary symptoms early in the course of the disease is simply another indicator that you don't have benign MS."

"Do you have urinary symptoms? I view bladder dysfunction in MSers as integrator of damage and potentially an early read-out of a poor prognosis. I therefore take this symptom in MSers seriously as it has implications for prognosis and treatment. Over the years I have observed that MSers who develop bladder dysfunction tend to do worse than MSers who don't have bladder symptoms. Why? The bladder is a complicated organ with several neurological components that can be affected by MS and hence is sensitive to damage."

"Why is the bladder an integrator of MS damage? The descending nerve fibres that travel from the brain to the lower spinal segments are very long and hence have a greater chance of being affected by MS lesions in their path to the bladder centre in the lower spinal cord. The same is true for motor fibres that control movement in the lower legs. The bladder, unlike the motor fibres to the leg, is more complicated because of the need to coordinate the different muscular functions in the bladder. Therefore any progressive MS damage is more likely to manifest with bladder dysfunction early on. This is why I now include bladder problems in my list of poor prognostic factors in MS."

"The bladder has two muscles that need to coordinated; the detrusor or balloon and the sphincter or valve muscles. When the bladder is filling up the detrusor muscle has to relax to allow the bladder to expand with urine and the sphincter has to contract to keep the urine in the bladder. The opposite occurs when you pass urine; the sphincter or valve opens and the detrusor contracts to empty the bladder."

"What happens if the two muscles are not coordinated? This causes the symptom of hesitancy, i.e. when you try and pass urine the sphincter won't open and you have to wait for the bladder to open; MSers find this very frustrating. The sphincter can also close as you are passing urine, which breaks up the urine stream or prevents you from emptying your bladder completely. The latter also causes dribbling. The medical term for incoordination of the bladder muscles is dyssynergia or more correctly detrusor-sphincter-dyssynergia (DSD). The drug treatment for DSD includes the so called alpha-blockers ( prazosin, indoramin, tamsulosin, alfuzosin, doxazosin and terazosin). Other strategies include small bladder stimulators or vibrators; these are place over the pubic area and work by blocking signals that inhibit the sphincters. The vibrators work in some MSers and may help relax the sphincter. It is also important to try and relax when passing urine; this often helps improve hesitancy. The sound of running water, for example from a tap, may trigger relaxation of the sphincter. This can be a problem in public toilets when opening a nearby tap may not be possible or inappropriate. Some MSers find pressing on the lower abdomen helps. If all else fails regarding hesitancy intermittent self-catheterisation (ISC) may be the only option."


"In MS the commonest bladder problem is spasticity, or irritability, of the detrusor muscle. The detrusor can't relax and this prevents the bladder filling to its maximum capacity. Frequent spasms of the detrusor muscle tell the brain that it is full and you need to go to the toilet. This causes frequency; i.e. the need to go the toilet many times during the day and night. Frequency often goes with the symptom of urgency, the need to get to the toilet as quickly as possible to prevent yourself from being incontinent. Incontinence occurs as you often lose the ability to suppress or ignore the signals from the detrusor muscle and the sphincter relaxes or opens as part of spinal cord reflex. We treat this problem with the so called anti-cholinergic drugs, for example oxybutynin, solifenacin or tolterodine. The older generation anticholinergics such as oxybutynin cross the blood-brain-barrier and enter the brain where they can exacerbate cognitive problems in MSers. This is why I avoid using them. The commonest side-effect of anticholinergics is dryness of the mouth and they can make constipation worse. There is also a risk that they will relax the bladder too much and precipitate urinary retention. All MSers must be warned about the this problem when starting anticholinergics; I have had several MSers under my care go into retention on starting anticholinergics."

"When urgency is a problem try some distraction techniques such as breathing exercises and mental tricks (for example, counting) to take your mind off the bladder; some MSers find this helpful. If frequency is the main problem you may want to try and retrain your bladder by holding on for as long as you can each time before passing urine. The aim is to train the detrusor muscle to expand more so that it can hold on for longer when you need to go to the toilet. In my experience these behavioural techniques rarely work for long; MS is a relapsing and/or progressive disease and in all likelihood the bladder pathways will simply be affected by new MS lesions."

"If you fail to respond to anticholinergics and behavioural techniques you need to have your bladder scanned to see if you have a raised residual volume. The residual volume is the amount of urine left behind after you have emptied your bladder. If the residual volume is greater than 80-100mL you may need to consider intermittent self-catheterisation or ISC. ISC serves two purposes; it increases your so called functional residual bladder volume allowing more storage space for urine in the bladder; this reduces frequency and urgency. This is can help you if you have to take a long trip or or to get through a social activity without having to pass urine. It also helps reduce nocturia, or having to get up frequently to pass urine at night. You will be surprised how much better you feel if you get a good nights sleep. Reducing nocturia and improving sleep reduces daytime fatigue."

"Another treatment that is becoming more common is botox of the detrusor muscle. This paralyses the muscle turning it into a flaccid bag for urine storage. Almost all MSers who have detrusor botox are using ISC. In the past, before botox was available, there were surgical techniques that could be used to denervate or remove the nerve supply to the bladder that had the same effect; these surgical techniques are rarely used nowadays."

"ISC also removes urine from the bladder. This is important if you are having recurrent bladder infections. The residual urine acts as a culture medium for bacteria and by clearing your bladder you can prevent bladder infections. The opposite can occur. If you don't do ISC technique correctly  you can introduce bacteria into the bladder, which can cause infections."

"I have already posted on the potential link between bladder infections and disease progression. The more infections you have, in particular severe infections, the more likely it is your MS will progress. Therefore if you have recurrent bladder infections you should try and prevent them occurring. How do you do this? Drink lots of liquids; flushing the bladder reduces infection rates. Also acidifying your urine by drinking cranberry juice or citric acid (citrasoda or lemonade) also helps. Increasing the frequency of ISC may also help. Finally using urinary antiseptics may help reduce infection rates. Urinary antiseptics are antibiotics that are concentrated in the urine; they are given in low concentrations so they have little impact on the rest of the body. I tend to cycle their use, every 3-4 months, to prevent the bacteria in the bladder becoming resistant to them. The agents I use currently are trimethoprim, cephalexin, nalidixic acid and nitrofurantoin."

"If nocturia is your main problem using agents to concentrate the urine at night might help. There is a hormone called DDAVP that works on the kidney to reduce it making urine. You can take DDAVP as a nasal spray or tablets. DDAVP can only be taken once a day; if you use it continuously your kidneys will retain water and that can be very dangerous. The latter is called water intoxication; it presents as swelling of the feet and reduces the salt or sodium levels in your blood. If blood sodium level become too low it can cause problems. This is why when you start using DDAVP you need to have your sodium levels checked about 4-6 weeks after starting therapy. I am not sure why, but some neurologists are reluctant to prescribe DDAVP. This is a shame as it is a very good drug and can make the difference between getting a good nights sleep or waking feeling awful. You can use DDAVP intermittently and you can use it the day, for example when you need to go on a trip or when you need to go out. Please remember you can only use DDAVP once a day; so if you use in the day you can't use that day at night. The most common side effect is swelling of the feet; it happens in approximately a third of MSers and is more common in MSers who are less mobile."

"Other advice I give to MSers is that if you are a smoker then stopping smoking may significantly improve your bladder symptoms, as nicotine irritates the bladder. Similarly, reducing alcohol and caffeine consumption may also help; both these agents affect the kidney and cause it make more urine. Medically this is referred to as a diuresis and these agents act as diuretics. Try to anticipate times when urinary frequency and urgency are likely to be most inconvenient; reducing the amount that you drink beforehand may help. For example, when you go out, don't drink much for 2-3 hours before you go out. However, do not reduce your total fluid intake to less than 1.5 litres each day. After you have finished passing urine, go back to the toilet again after a few minutes to try to pass some more urine. This is called the double micturition technique, which aims to make sure the bladder is emptied completely."

"Finally, if all else fails some MSers may need to be catheterised. This can be done via the urethra or the lower abdominal wall. The latter is called a suprapubic catheter. Being permanently catheterised sounds awful, but in some MSers this drastically improves their quality of life. I have several MSers who have let bladder dysfunction control their lives as a result they have become socially isolated. They are typically anxious about being incontinent in public. To avoid this possibility they choose to stay at home. This is clearly unnecessary and with the strategies highlighted above adequate bladder control should be the norm in MS. In my experience the biggest hurdle to achieving adequate bladder control is MSers accepting their bladder symptoms as being part of the disease and living with them. Why? If you have problems tell your nurse or neurologist; they will be able to help you."


Epub: Di Filippo et al. Lower urinary tract symptoms and urodynamic dysfunction in clinically isolated syndromes suggestive of multiple sclerosis. Eur J Neurol. 2014 Jan.

BACKGROUND AND PURPOSE: Urinary symptoms associated with MS are common and negatively impact on quality of life, representing a considerable psychosocial and economic burden, often requiring care and hospitalization. Although the importance of identifying and adequately treating urinary symptoms in MS is now well recognized, there is no information, to date, about the real prevalence and impact of bladder symptoms in patients with clinically isolated syndromes (CISs) suggestive of MS.

METHODS: The aim of the present study was to investigate, in a cohort of patients with a diagnosis of CIS suggestive of MS, the prevalence of urinary tract symptoms, their impact on quality of life measures and their association with functional urodynamic dysfunctions. CISers underwent a complete neurological and urological visit, urodynamic investigation and the MSQoL-54 questionnaire.

RESULTS: Twenty-eight consecutive CISers were enrolled in the study; 53.6% of CISers reported urinary symptoms, 46.7% reporting irritative symptoms, 33.3% both irritative and obstructive symptoms and 20% obstructive symptoms alone. Urodynamic abnormalities were observed in 57.1% of the CISers. In 17.9% of the CISers urodynamic dysfunctions were asymptomatic. The presence of urinary symptoms was associated with lower scores on specific quality of life domains, particularly in women with obstructive symptoms.

CONCLUSIONS: A high prevalence of urinary symptoms and urodynamic dysfunctions in CISers and an association of urinary symptoms with quality of life measures were found. These results highlight the importance of identifying and optimally treating urinary symptoms also at the very early stages of MS.

4 comments:

  1. Thanks Prof G. Another depressing symptom of a entirely disease. I'm a big fan of the highly effective early treatment approach. This is fine for those diagnosed early on and have access to highly effective treatments. In reality most who visit this site will have had the disease for some time. I've had a highly effective treatment which has shut down the disease for the last 5 years. However, urgency is a deficit i carry from earlier relapses - not bad enough for drugs but annoying. Is there anything on the horizon which might repair damage e.g the damage to my spinal chord which has left with some annoying deficts? There appear to be trials for remylination and stem cell trials, but i will they help with some repair? What about ampyra? Or is that drug only for walking speed?

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    1. Repair from outside the brain and spinal cord is a long way off. The best chance of repair is switching off ongoing inflammation and allowing your own body to repair itself and/or compensate for itself. Fampridine (aka Ampyra) improves existing function. It only works in a minority of MSers with residual deficits.

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  2. Is it inevitable that progression will progress faster if bladder problems manifest themselves early on? This is very depressing.

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  3. I was ignored by GPs for years, now I have to ISC and I get UTIs regularly. I had to use a catheter practically from the day of my diagnosis. More and more I am hearing about GPs dismissing people until it is too late. I know two people now who ended up with advanced cancer and no hope because of GPs. Something needs sorting to stop this sort of thing happening.

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