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Bladder Dysfunction

Bladder dysfunction, which occurs in at least 80% of people with MS, can usually be treated quite successfully. Treatment strategies include dietary and fluid management, medications and intermittent or continual catheterisation (inserting a thin tube into the bladder to remove urine).

Bladder dysfunction develops because MS blocks or delays transmission of nerve signals in areas of the central nervous system that controls the bladder and urinary sphincter. The sphincter is the muscle surrounding the opening of the bladder that either keeps urine in or allows it to flow out.

Symptoms and Complications

Symptoms of bladder dysfunction may include:

These symptoms may be caused by a "spastic" bladder that is unable to hold the normal amount of urine, or by a bladder that does not empty properly and thus always retains some urine in it. Retaining urine may lead to complications such as repeated infections or kidney damage.

Left untreated, bladder dysfunction may also cause emotional and personal hygiene problems that can interfere with normal activities of living and socialisation. It is therefore important to seek appropriate medical evaluation and treatment early, so that the cause of the bladder symptoms can be determined and treated and complications avoided.

Antidepressants

Antidepressants are widely used in treating psychiatric and neuralgic disorders. In addition to their role in fighting depression, they are also effective against several physical symptoms. In people with MS, tricyclic antidepressants, are often prescribed to treat different types of pain.

Some of the commonly used tricyclic antidepressants are:

Some of the commonly used selective serotonin reuptake inhibitors (SSRIs) are:

Other commonly used antidepressants include:

May Also Help to Control Other MS-Related Symptoms

There is some evidence that these agents may help alleviate the uncontrollable laughing or crying (known as pathological laughing or crying) that is occasionally seen in people with MS. Because some of these agents can cause people to retain urine, they are also used in low doses to help control bladder incontinence. Common side effects include dry mouth, blurry vision, constipation, sexual dysfunction and a sedated or calmed feeling.

Understanding the effects of MS on the bladder

The information in this section is from the booklet Understanding the effects of MS on the bladder.

This document is available in Adobe Acrobat's Portable Document Format (PDF). If you do not already have the Acrobat Reader you can download it for free from Adobe.External Link

Download a copy of the booklet in pdf form (1.4 mb)

The purpose of this information is to help people with MS and others to understand the common problems in bladder function.

Multiple sclerosis is a disease of the central nervous system (CNS) affecting parts of the brain and spinal cord. It is the most common neurological condition of young Australian adults. Scars, known as plaques, develop in areas where the covering of the nerves, called the myelin sheath, is destroyed. This interferes with the conduction of impulses from the brain to various parts of the body. The physical effects depend on the position of the plaques and the severity of interruption of the nerve function.

Bladder problems

Bladder problems are commonly encountered in those who have multiple sclerosis. Surveys have indicated that between 60-90 percent of people can be affected at least at some stage, with some symptoms.

The urinary system excretes the body's impurities and excess fluid. The two kidneys filter the impurities from the blood and the urine formed is passed, via the ureters into the bladder. The bladder is basically a storage organ of the body where urine is held, at low pressure, until a certain volume is reached. As we mature past early childhood years we learn to contain the urine and empty at convenient times. The muscle of the bladder, the detrusor muscle, relaxes whilst the bladder fills and the bladder opening muscle, the sphincter, remains shut. Where there is about 400-500ml of urine in the bladder. the urge to empty or urinate is felt.

The detrusor muscle then contracts with si-multaneous opening of the sphincter allowing the bladder to empty via the urethra, to the exterior. This is a coordinated process and is normally under voluntary control, that is, we can control when urination will occur. Control of the bladder is by way of nerves from the spinal cord which connect to centres in the brain. It is the interruption of these nerve pathways and interference with the impulses conducted along them, which result in the bladder problems seen in multiple sclerosis. This is not a static process, but fluctuates in severity over time.

Symptoms described vary widely from the need to pass urine frequently or urgently, to problems of difficulty starting or continuing to empty the bladder. In more severe cases there can be problems of incontinence with the bladder failing to contain the urine or acute retention when emptying is not possible.

Such loss of control is not only embarrassing and socially unacceptable in society, it may also unwittingly lead the person to increase their problem by restricting fluids or becoming socially isolated rather than acknowledging the problem and seeking appropriate help.

With appropriate assessment and management, much can be done to improve bladder function, resulting in increased self-esteem and quality of life in a person with multiple sclerosis.

Broadly, there are three types of bladder disturbances seen in MS:

  1. Failure to store urine.
  2. Failure to empty urine.
  3. A combination of these.

Failure to store

The "failure to store" type of bladder means that the bladder is unable to contain urine as it normally would. This is the pattern seen most frequently in MS and is the result of an overactive detrusor muscle. The symptoms associated with this condition are urgency, (the bladder must empty immediately), nocturia, (the need to empty the bladder during the night) and incontinence.

Failure to empty

The "failure to empty" type is one where the bladder is unable to empty completely and is usually the result of the sphincter failing to remain open whilst the detrusor muscle contracts. The urine left in the bladder may provide a breeding ground for bacteria much the same as a stagnant pond and predisposes to urinary infections and the formation of bladder stones. The symptoms associated with this type of bladder are hesitancy, (difficulty commencing the flow of urine), incontinence due to overflow of the full bladder and the feeling of incomplete emptying which can lead to frequency, urgency and sometimes nocturia. Thus it may mimic the "failure to store" bladder.

Combination

The third type of bladder problem seen is a combination of difficulty both storing and emptying effectively and due to lack of coordination between the detrusor muscle and the sphincter.

Assessment

With similar symptoms occurring with the different types of bladder dysfunction, it is difficult to diagnose the actual problem on history alone. It is important that the situation be fully assessed by your doctor to allow appropriate management to be undertaken. This may include identification of the past and present medical problems and a physical examination. A trial of a particular medication may be part of that assessment.

Access to the toilet, mobility, ability to get there in time, spasticity and transfer skills, need to be looked at as well as the presence of infection, enlarged prostate glands in males causing obstruction to the flow of urine and stress incontinence in women resulting from weakness of the muscles of the pelvic floor.

A bladder diary, recording for a period of days or weeks the times and amounts of urine passed, provides a more accurate picture of the problem and may Isolate the difficulty to certain periods of the day or night. Following assessment by your doctor, certain investigations may need to be performed. Most commonly these will include:

Management

The problem identified, what remains is the finding of the right solution for the individual. This may include general measures such as improving access and mobility, establishing a bladder retraining program with pelvic floor exercises and rigid toileting times.

Treatment includes:

Other aids for incontinence:

Indwelling catheters

Indwelling catheters are hollow silicone tubes inserted into the urinary bladder via the urethra and left in situ for 4 weeks for drainage of urine. The use of indwelling catheters, whilst avoided if possible, may be the only way to cope with the problem of incontinence and may be necessary for medical reasons including the prevention of renal complications.

It must not be viewed as a failure of treatment, but rather an appropriate means of providing continence to certain individuals who otherwise would be wet and suffering not only from discomfort and embarrassment, but also from the risk of developing skin breakdown and infections.

Proper diet

Constipation, a common feature of MS, can cause disturbance of the bladder. Establishing a regular bowel pattern can normalize the bladder function. This may only require supple measures such as en-suring a healthy, high fibre diet and adequate fluid intake of at least two litres a day. This will include soups, jellies and yoghurt. Whilst this volume of fluid seems a lot to someone who in the past has restricted fluid intake because of incontinence, it is an important measure to prevent infections, stone formation and constipation. Establishing a regular bowel pattern takes time and patience.

The result of any dietary changes may take days or weeks to be seen. Thus, one must proceed slowly and monitor the effects of various methods or diets which are applied. Advantage can be made of the gastrocolic reflex - a reflex where the bowel is more easily evacuated after a meal, after breakfast is a convenient time for many. It must be remembered that frequency of bowel actions varies with individuals and daily evacuation may be unnecessary or even undesirable. Your doctor or nurse can advise on what is most appropriate for YOU.

Fluid intake

By gradually increasing the fluid intake and charting the effect, it can be determined when the bladder is most active and when it is best to drink more. Certainly large amounts prior to social outings and retiring to bed are inadvisable, but it is to be remembered that restricting the daily intake of fluid excessively, will result in concentrated urine and this has an irritant effect on the bladder, compounding the problems of frequency and urgency and predisposes to infection.

Exercise

An active lifestyle, with adequate rest, is encouraged as an essential means of normalizing bladder and bowel function.

Alcohol and caffeine

Alcohol has the effect of increasing the amount of urine formed and so moderation of alcohol intake is advised. Similarly, too much caffeine, such as in tea or coffee, may have an adverse stimulating effect.

Medication

Medications can be most effective in dealing with both an overactive detrusor muscle and also a sphincter which fails to open or close appropriately. Propantheline bromide, Donnatabs, Oxybutynin and Imipramine are most commonly prescribed to prevent frequent detrusor contractions and to help keep the sphincter closed. All have the side effect of dryness of the mouth and can cause some blurriness of vision and gastrointestinal upset.

On the whole though, they are widely prescribed, well tolerated and effective.

Usual dosage:

Prazosin and Phenoxy-benzamine act on the sphincter, allowing it to relax and facilitate emptying for those who have a problem with retention. Both these agents can be used to lower blood pressure and that pressure must therefore be checked as the dosage is adjusted to avoid fainting or dizziness due to too low a blood pressure.

Phenoxybenzamine is a long acting drug that is effective over many hours and is normally taken at night. Its other side effects include nasal congestion and visual changes, but it is usually well tolerated and effective.

Usual dosage: Prazosin 1 mg three times a day, Phenoxybenzam-ine 10mg at night.

Sometimes one medication is more effective than another in different individuals and it may be a matter of trial and error to find the medication and the close most suitable.

Use of incontinence products

Intermittent self catheterisation

Bladder emptying can also be facilitated by a procedure known as intermittent self catheterisation (ISC). The individual is taught to insert a thin tube into the bladder at regular intervals, usually 3-4 hourly to prevent overdistension of the bladder and simulate a normal voiding pattern. Apart from the catheter, no other special equipment is needed and the person can empty the bladder at home or any other convenient place.

Difficulties with hand function such as weakness or tremor, or transfer skills limiting transfer on or off the toilet, may make the use of intermittent self catheterisation inappropriate in some cases. Visual impairment may also be a limiting factor. The technique is simple and can be taught easily by nurses experienced in the area of incontinence. There is no increase in the risk of infection compared with permanent indwelling catheters and with reduction of high residual urine volumes, infection may actually be eradicated.

Indwelling catheters

Catheters may facilitate persons remaining at home alone or on their own who would otherwise be dependent on assistance with toileting.

Indwelling catheters require careful ongoing management to avoid complications such as infections, stones and bypassing (voiding around the catheter.) Silicone catheters are commonly changed every 4 weeks. They drain freely into a collecting bag which can be neatly strapped to the leg and worn discretely under clothing. At night a larger collecting bag can be hung at the side of the bed.

Gravity drainage is maintained to prevent bypassing. Much can be done to improve problems of incontinence and discussing these difficulties with your doctor or the MS Society, can improve the situation. For patients requiring longterm catheterisation. a suprapubic bladder catheter inserted through the abdominal wall just above the pubic bone may be more appropriate as it is associated with fewer complications. Other urological techniques may also be available depending on the problem.

Fluid intake must be at least two litres a day to irrigate the bladder and reduce the risk of infection and stone formation. Catheters are always associated with low grade infections and if these become symptomatic they may require long term antiseptic treatment or a short course of antibiotics.

Uninhibited bladder spasm may cause bypassing as can the presence of infection and stones. Spasm can be treated successfully with Propantheline bromide to dampen the activity of the detrusor muscle.

Condom drainage

Condom drainage may be an alternative to indwelling catheterisation in males. An external collecting system, it requires careful fitting for appropriate penile size and care must be taken to ensure that twisting does not occur and obstruct the flow of urine. Penile hygiene is important to prevent infection and skin breakdown. Condom drainage may also be used as an adjunct to continence on an occasional basis, such as for social outings.

Continence products

Other aids to continence include such protective devices as absorbent pads, pants and sheets. For mild incontinence the normal feminine hygiene pads or panty liners may suffice. More severe cases may benefit from larger pads which can hold up to 500ml of fluid depending on the size and type. There is also a large variety of pants providing similar protection. For travellers, devices are also available to assist voiding, when access to toilets may be limited. Nurses working with the MS Society can give assistance in determining appropriateness and availability of such devices.

Thus it can be seen that the bladder can be affected in different ways in multiple sclerosis and only by assessment can the appropriate treatment be prescribed. Much can be done to improve problems of incontinence and discussing these difficulties with your doctor or the MS Society can improve the situation. Do not be embarrassed.

Trained staff are only too aware of problems of incontinence and are happy to assist in finding not only the right solution for you, but also providing, the necessary ongoing monitoring.

Source - Understanding the effects of MS on the bladder. © The National Multiple Sclerosis Society of Australia. All rights reserved. ISBN 0-9586902 2 7. Revised June 1995. Reprinted August 1997.

Source - NMSS Information Resource Center and Library. Compendium of Multiple Sclerosis Information (CMSI). © 2003, National Multiple Sclerosis Society. Reproduced with permission.

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