Clinical problem: I am 36 years of age and I have developed urinary frequency and urgency. Apart from this, I am well and active. I was incontinent last week on the train and was very embarrassed. It also happened several weeks ago on the way home from the pub. I had been out with friends and had 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 my MS clinic. More than half of MSers have bladder problems.
The following generic advice is what I would give MSers with different sorts of bladder symptoms:
I view bladder dysfunction in MSers as an integrator of damage and an early read-out of a poor prognosis. I would, therefore, take this symptom in any of patients very seriously. I would have a frank discussion with her about her prognosis and treatment and would assess her to see if she has possibly had a relapse and has other signs to localise the lesion causing her bladder problems. Most often it is due to spinal cord lesions and you may find other signs, for example, subtle weakness in the legs.
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 more sensitive to early 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 main 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 high up on my list of poor prognostic factors in MS.
The bladder has two muscles that need to be coordinated. The (1) detrusor muscle, or balloon, and the (2) sphincter, or valve, muscle. 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. Simple?
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 placed 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 the 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 to 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 this problem when starting anticholinergics; I have several MSers under my care go into retention on starting anticholinergics.
There is a new class of drug that works on the so-called β₃ adrenergic receptor in the detrusor muscle in the bladder, which leads to muscle relaxation and an increase in bladder capacity. Mirabegron (Betmiga) is the first drug in this class and has the advantage over the other bladder drugs in that it does not have anticholinergic side effects. I am increasingly using mirabegron to prevent the unwanted anticholinergic side effects.
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. When urinary frequency is your 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 very long. As MS may be a progressive disease the bladder pathways may be affected by new MS lesions and hence get worse with time.
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 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 will have to use ISC as well. 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 flushing your bladder with urine you can prevent bladder infections. However, the opposite can occur. If you are don’t get the ISC technique correct you can introduce bacteria into the bladder that can then cause recurrent infections.
There is a 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? By drinking lots of liquids; flushing the bladder reduces infection rates. Also alkalinising 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 which are meant to limit the 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. 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 blood 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 up feeling awful. You can also use DDAVP intermittently. If you use it the day, for example, when you need to go on a trip or to go out, you mustn’t use it again.
WARNING: You can only use DDAVP once a day. The most common side effect of DDAVP 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 you may want to consider stopping. 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 to make more urine. Medically this is referred to as diuresis and these agents are mild 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 2.0 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.
If you have bladder problems tell your nurse or neurologist; they will be able to help you. Don’t suffer in silence.