Controlling Bladder Problems in Multiple Sclerosis · in Multiple Sclerosis For Information: 1-800-FIGHT-MS znationalmssociety.org ES 0039 3/05 $1.50 For Information: 1-800-FIGHT-MS

Managing Specific Issues

Controlling Bladder Problemsin Multiple Sclerosis

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The National Multiple Sclerosis Societyis dedicated to ending the devastating

effects of multiple sclerosis.

National Multiple Sclerosis Society733 Third Avenue

New York, NY 10017-3288Tel: (212) 986-3240Fax: (212) 986-7981

National Web site: nationalmssociety.orgE-mail: [email protected]

The National Multiple Sclerosis Society isproud to be a source of information aboutmultiple sclerosis. Our comments arebased on professional advice, publishedexperience, and expert opinion, but do notrepresent individual therapeutic recom-mendations or prescription. For specificinformation and advice, consult your per-sonal physician.

The Society publishes many other pamphletsand articles about various aspects of MS. Toask for these, or for other information, call theNational MS Society at 1-800-FIGHT-MS(1-800-344-4867).

All our publications are on our Web site, alongwith handouts called "Basic Facts" on varioustopics. For a list, click the bar on our homepage called “Library”. If you have no access tothe Internet, just call your chapter and ask fora copy of the latest Publications List.

Some of our popular pamphlets include:

Living With MSWhen a Parent has MS: A Teenager’sGuideManaging MS Through RehabilitationFood for Thought: MS and NutritionUrinary Dysfunction and MS

We welcome your comments by mail or [email protected].

Nancy J. Holland, RN, EdD, MSCN, is vicepresident of Clinical Programs for theNational Multiple Sclerosis Society.

Grateful acknowledgment to Michele G.Madonna, RN, MA, who co-authored theoriginal edition.

Note to health-care providers: ClinicalPractice Guidelines—Urinary Dysfunctionand Multiple Sclerosis can be found atwww.pva.org, click on “PVA Store”.

Illustrations by Richard Keith Lopez andJordi Perez.

This publication is supported by contribu-tions to the National Multiple SclerosisSociety from its members and friends.

Reviewed by members of the ClientEducation Committee of the NationalMultiple Sclerosis Society’s Medical AdvisoryBoard.

© 2005 National Multiple Sclerosis Society

Controlling BladderProblems inMultiple Sclerosis

by Nancy J. Holland, RN, EdD, MSCN

Introduction

This booklet explains how multiple sclerosismay affect the urinary system and what canbe done to keep problems under control.Urinary dysfunction, or bladder problems, arecommon in MS, though not everyone with MSwill have them. For those who do, symptomsvary from person to person. They must alwaysbe handled on an individual basis—but theycan be handled, and they should be, for bothhealth and quality of life.

When problems with urination first occur,they often feel overwhelming, especially ifa person loses bladder control. It’s common forpeople to resort to self-help first—restrictingfluids and using absorbent pads—in order todeal privately with an embarrassing or fright-ening situation.

Self-help does play an important part ineffective management, but it cannot substitutefor medical help. Some self-help techniqueswill actually make matters worse. Restrictingfluids, for example, increases the risk of infec-tion and irritates the bladder.

Getting a proper diagnosis is an essential firststep. It is important to inform your physician

2 Controlling Bladder Problems in Multiple Sclerosis 3

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needed to identify the medical measures thatare most effective. In short, it may take timeto achieve successful management.

A self-help partnership

The best self-help also involves a partnershipbetween the person and the health-care pro-fessionals, and again, a trial-and-error periodmay ensue before the most helpful techniquesare identified.

Drinking at least 6 to 8 glasses of fluid everyday is recommended for general health andthe health of the urinary system. This oftenrequires learning how to spread fluid intakeover the course of the day, and perhaps drink-ing less at night if awakening to urinate is aproblem. Restricting fluids is not recommend-ed for managing bladder problems!

Avoiding beverages containing caffeine isa positive step. Caffeine can be a bladder irri-tant, which worsens some symptoms. Taking acranberry tablet or drinking cranberry juicedaily is a positive step. Cranberry contains achemical that reduces the risk of infection bypreventing bacteria from sticking to the blad-der wall. Talk with a nurse, physician, or reg-

or other health-care provider as soon as anyproblems occur.

Understanding how the bladder works nor-mally, what causes symptoms, the tests andprocedures used to make a diagnosis, and themeasures used to relieve symptoms and pre-serve urinary tract function are all part of theprocess of managing bladder problems.

Goals

The goals of bladder management are:

To preserve normal urinary tract functionand prevent potentially dangerous compli-cations.

To relieve symptoms.

The focus of the health-care professional is onpreserving function, especially kidney func-tion, as this is critical to life itself. The focusof people living with MS is usually to relievethe distressing symptoms. Both goals can beattained through an active partnershipbetween the professional and the person withMS. Since individuals respond differently tointerventions, a trial-and-error period may be


Anatomy: a portrait of the system

The urinary system, illustrated in Figure 1,removes waste products from the blood andeliminates them, together with the body’sexcess fluid, as urine. Urine is continuouslyformed in the kidneys, which lie on either sideof the spinal column. Urine flows from the kid-neys to the bladder through two connectingtubes called ureters. Finally the bladderexpels urine from the body through a tubecalled the urethra.

The bladder,illustrated inFigure 2, is amuscularbag whichslowlyexpands asurine col-lects, just asa balloongraduallyenlarges asair enters it. The muscle part of the bladder iscalled the detrusor muscle.

Where the bladder meets the urethra there isa muscle called the external sphincter which

istered dietitian about other possible dietchanges and adaptations.

Avoiding exercise and social life because ofbladder problems is a negative step. Planningcan help. Learn where the bathrooms are atyour gym, house of worship, movie theater,bowling alley, shopping mall.

For some, absorbent pads provide security,which isessential forliving a fulllife. Whilepads shouldnot be usedas the solesolution tobladder prob-lems, theycan make apositive con-tribution todaily living.The idealoutcome is toeliminateleaking orloss of controlso pads are not needed.


place simultane-ously: the bladderdetrusor musclemust contract toexpel urine at thesame time that thesphincter musclerelaxes and opens,permitting a freeflow of urine out ofthe body. Thisprocess is illustrat-ed in Figure 4.

In summary, nor-mal urination isunder voluntarycontrol. When thebladder has collect-

ed 1 to 2 cups of urine, the person will experi-ence the urge. When the person decides thetime and place are right, the bladder contractsto push out the urine, while the sphincteropens to allow urine to exit.

MS can disrupt the system

MS plaques in the brain and spinal cord mayinterrupt the transmission of signals to and

remains contracted andclosed between times ofurination. The bladder andsphincter are normallyunder voluntary control,which means that a personhas conscious control overwhen and where to urinate(or void).

Voluntary control of urina-tion is managed by thebrain. When the bladder isfull, it signals this to thebrain via impulses up thespinal cord. Impulsesneeded for normal urina-tion are transmitted from the brain back tothe bladder (see Figure 3).

Normal voiding

Urine collects in the bladder until 1 or 2 cup-fuls (250 to 500 milliliters) have accumulated.The bladder gradually stretches as this takesplace. When the bladder nears capacity, theperson will experience an urge to urinate.

For urination to occur, two events must take


Consultation

Consultation with a physician (Figure 5) isessential to establishing an accurate bladderdiagnosis. The symptoms alone cannot deter-mine whether the basic problem involves stor-age or emptying—or something else! Virtuallyall these symptoms could signal a urinarytract infection, or UTI. A UTI may not berelated tothe MS atall. How-ever UTIsshould bepromptlytreatedwith anappropriateantibiotic,which isdeterminedby urineculture (See below). UTIs are often associatedwith an increase in other MS symptoms, suchas spasticity and fatigue.

If a urine culture rules out a UTI, one or moreother bladder function tests will be needed tohelp identify the problem and determine thebest medical management.

from the brain. This in turn can result inproblems storing urine to normal capacity orproblems emptying the bladder completely.

Any of these symptoms may occur, regardlessof the underlying problem:

Urinary urgency: A very strong sensationthat urination is imminent and cannot bepostponed.

Incontinence: Loss of urinary control.

Nocturia: Urinating several times during thenight.

Urinary hesitancy: Difficulty initiating theflow of urine.

Overflow incontinence: Loss of urinary con-trol due to a very full bladder, usuallydescribed as “dribbling” or “leaking”.

Sensation of incomplete emptying: A feel-ing that some urine remains in the bladderafter voiding. (Sometimes bladder sensation isdecreased in MS, and a person may haveincomplete emptying with no awareness thaturine is being retained.)

Weak urinary stream: The flow is noticeablythin and slow.


obtained by IVP, but a radioisotope, an ele-ment that emits radiation, is injected andtraced on its path through the body.

Urodynamics: Performed by a urologist,physiatrist, or nurse, the test employs a uri-nary catheter and rectal probe to determinethe storage capacity of the bladder and func-tioning of the urinary tract.

Storagedysfunction

A storage problemoccurs when thebladder is unableto retain urine as itaccumulates. Themost common formof storage dysfunc-tion is illustratedin Figure 6. In thiscase, the detrusormuscle of the blad-der is overly active.Contractions ofthe bladder occurwhen only a small

Tests of bladder function

Urinalysis and urine culture: These are labtests done with a fresh sample of urine todetermine if infection is present, and whichantibiotic is appropriate if infection is detected.

Post-void residual urine: A person urinatesnormally, followed by catheterization to deter-mine how much urine has remained in thebladder. While this is the simplest test to deter-mine bladder function, a noninvasive alterna-tive, the bladder sonogram, may be an option.

Bladder sonogram: An ultrasonic scan toevaluate the urinary system. Conductive jellyis applied to the abdomen, and a microphone-like instrument is moved slowly over the areato obtain an image of the bladder and anyresidual urine.

Intravenous Urogram (IVU or IVP): AnX ray of the entire urinary system that pro-vides information about the kidneys as well asthe bladder. This hour-long test involves aninjection of a contrast material, followedby X rays.

Radioisotope renal/residual urine scan:The information obtained is similar to that


A different kind of medication works by reduc-ing the amount of urine the kidneys produce.This is DDAVP (desmopressin acetate) and isadministered as a nasal spray, or a pill.

Emptying dysfunction

Emptying dysfunction is the inability of thebladder to completely eliminate stored urine.The most common form is illustrated in Figure7. In this case, the urethra is blocked by aspastic or tight sphincter, which prevents thebladder from emptying completely. Morespecifically, the urinary sphincter tightensinstead of relaxing when the bladder’s detru-sor muscle contracts to push the urine out.Usually some urine is eliminated, but a signif-icant amount remains in the bladder.

amount of urine has collected. The sphincteropens in a normal way, resulting in frequentand urgent urination.

Management of storagedysfunction

Management of the most common type ofstorage dysfunction is aimed at relaxing thebladder detrusor muscle so that a normalamount of urine may accumulate before theurge to urinate is experienced. This may beachieved by using medications such as Pro-banthine (propantheline bromide), Tofranil(imipramine), Ditropan (oxybutynin), or Detrol(tolterodine), all of which relieve spasms of thebladder.

Ditropan XL delivers oxybutynin, the mostcommon drug for calming the bladder, pack-aged as a controlled release, one-a-day tabletthat maintains a steady level of medication inthe body. Detrol (tolterodine), works by reduc-ing bladder muscle contractions.

All of these medications also reduce the fre-quency of bathroom trips by increasing thevolume of urine passed each time.


dure is most conveniently performed at thetoilet.

If symptoms are not controlled by IC alone,a medication such as Ditropan XL, Detrol, orone of the others mentioned above, may beadded to the routine in order to relax thebladder.

The sometimes dramatic relief of symptomsand the prospect of avoiding serious compli-cations in the long term usually encouragepeople to continue IC. Some people need todo IC for only a few weeks or months, as thebladder often returns to normal or near-normal function in time. For others, IC simplybecomes a part of life.

Complications

Emptying dysfunction causes urine to beretained, and bacteria multiply freely in stag-nant urine. Thus urine left in the bladder,which is known as “post-void residual urine”,may predispose a person to frequent UTIs, orurinary tract infections.

Kidney damage can occur from frequent upperurinary tract infections. Infected urine can

17

There is another form of emptying dysfunctionin which the detrusor is too weak to expel allthe urine, but this occurs infrequently in MS.

Management of emptyingdysfunction

Some people with a mild emptying problemin which a small amount of urine is retainedmay respond well to the drug Lioresal(baclofen). Most people with emptying prob-lems will need to use intermittent catheteriza-tion (IC). IC is the most successful manage-ment tool for emptying dysfunction. Urine isperiodically drained by inserting a thin tubeinto the bladder through the urinary opening.It is a painless procedure, which is generallymuch easier to do than it sounds, even if MShas caused numb, uncooperative fingers.Minimal instruction and a few practice ses-sions with a nurse are required.

Women are initially more receptive than mento IC, perhaps because they are familiar withthe process of tampon insertion. Men tend tobe more psychologically resistant, but oncethey overcome this and realize the benefits,they have an easier time since the male uri-nary opening is more accessible. The proce-

16 Controlling Bladder Problems in Multiple Sclerosis

Points to remember

Bladder disturbance is common in peoplewith MS. A good understanding of thepotential solutions helps people come toterms with this upsetting problem.

Control of symptoms is more easily accom-plished with early treatment. Consultationwith a knowledgeable health-care providershould take place at the first sign of a uri-nary problem.

In most instances, bladder symptoms canbe controlled successfully using strategies

that include appro-priate medication,management tech-niques, and self-help.

Serious complica-tions usually can beprevented with good

care and follow up.

Since bladder and sphincterfunction may vary over time, itmay be necessary to repeatdiagnostic tests and vary thestrategies.

19

actually back up through the ureters into thekidneys if the exit is blocked by a contractedor tight sphincter. Bladder or kidney stone for-mation is another potential complication ofincomplete emptying. Minute mineral parti-cles normally expelled in urine may clumptogether to form stones which cannot bepassed through urination. Stones can furthercomplicate normal voiding. Frequent UTIs,kidney or bladder stone formation, and kidneydamage all suggest a problem with chronicurinary retention.

In the past, a technique called “credé” wassometimes taught to people with retentionproblems. It involved pushing down on thelower abdomen while voiding. It is nowconsidered harmful. The pressure of credéoften moves the urine up, not down. It is notrecommended.

Some people experience more complex bladderproblems which resist other strategies. Thereare options available. Some individuals mayultimately need a catheter (or drainage tube)inserted into the bladder on a more or lesspermanent basis. In other rare situations, sur-gery is required for an improved quality of lifeand better health.


Sources of additional informationand other services

1-800-FIGHT-MS (1-800-344-4867) can beused to reach the National MS Society chapternearest you. Your chapter offers local refer-rals, education programs, counseling, self-helpgroups, and booklets and brochures on manyaspects of living with MS.

If you join the Society, you will receive ournational magazine, InsideMS, a bi-monthlypacked with news and features of interest toanyone affected by MS, and MS Connection,a newsletter from the Society office closest toyou, which covers nearby events andresources.

For the best MS information online, consultthe National MS Society Web site. You canfind information on diagnosis, treatments,medications, clinical trials, research news,issues in coping and management, MS publi-cations, news on advocacy, events and servicesoffered by your chapter, MS clinics, and howyou can join the Society. Log on to:nationalmssociety.org.


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