ClinicSpeak: why the bladder is so important to MSers

Bladder dysfunction; is it a problem for you? #MSBlog #MSResearch #ClinicSpeak

Clinical problem: I am 36 years of age and I have developed urinary frequency and urgency. Apart from this I am well and very active. I was incontinent last week on the tube and was very embarrassed. It happened on the way home from the pub; I had been out with friends and had several glasses of wine. I had emptied my bladder before leaving the pub, but clearly this was not enough to prevent wetting myself. What can I do?

"Bladder dysfunction is the most common symptomatic problem I have to deal with in clinic. The meta-analysis below shows that more than 50% of MSers have bladder problems."

"The following post covers generic advice I would give MSers with different sorts of bladder symptoms."

"I view bladder dysfunction in MSers as integrator of damage and an early read-out of a poor prognosis. I would therefore take this symptom in this MSer very seriously and would have a frank discussion with her about her 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 muscles. 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 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 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 at night to pass urine. 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 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 are don't get the ISC technique correct  you can introduce bacteria into the bladder that then 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 slay 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. You can only use DDAVP once a day. 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 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: Ruffion et al. Systematic Review of the Epidemiology of Urinary Incontinence and Detrusor Overactivity among Patients with Neurogenic Overactive Bladder. Neuroepidemiology. 2013 Aug 8;41(3-4):146-155.

Background: The prevalence and incidence of neurogenic overactive bladder (nOAB) are poorly defined. This systematic literature review identified nOAB epidemiological data and estimated the incidence and prevalence of urinary incontinence (UI) and detrusor overactivity (DO) in MSers, spinal cord injury (SCI), Parkinson's disease (PD), stroke and spina bifida. 

Methods: An initial search of MEDLINE, Embase, PubMed, and the Cochrane library was supplemented by an internet search for grey literature and manual searching of the bibliographies of retrieved articles. Additional study selection identified comparable studies for statistical analysis. A descriptive statistical analysis, single-arm meta-analysis and stratified analysis were conducted using predefined criteria. 

Summary: Initial selection identified 189 articles containing prevalence data. Secondary selection for statistical analysis identified 39 and 52 articles with prevalence of UI and DO, respectively. Random-effect meta-analysis found the prevalence of UI was 50.9% in MSers, 52.3% with SCI, 33.1% with PD and 23.6% with stroke. Spina bifida was excluded due to insufficient data. The prevalence of DO may be biased and artificially elevated because it can only be measured with urodynamic investigations. 

Key Messages: A substantial proportion of patients with neurological conditions develop UI that may be attributable to nOAB. 

"I would appreciate it if you could complete the following survey to see how common bladder problems are in MSers who read this blog. Thanks."

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