Life with MS

Multiple sclerosis is a leading cause of urinary problems (lower urinary tract dysfunction) in patients with neurological disorders. It contributes to both difficulty holding and emptying the bladder. Urinary dysfunction is considered one of the most bothersome symptoms with MS and can greatly affect quality of life.

Bladder Stats
• Typically, patients report symptoms approximately six to eight years after initial MS diagnosis.
• However, one in 10 individuals will present with urinary symptoms at initial MS diagnosis.
• Approximately 80-100 percent of patients will have some type of urinary dysfunction by 10 years after initial diagnosis.

The symptoms may vary in severity and type, and may deteriorate as the disease progresses. Patients with MS most frequently report difficulty holding or storing urine, a.k.a. overactive bladder. These patients can experience a strong urge to urinate (urinary urgency), frequent urination (urinary frequency), and urinary leakage with the urge to void (urge urinary incontinence). Some patients will also experience weak or interrupted stream, straining to urinate, or feelings of incomplete bladder emptying.

MS can also cause inability to empty the bladder (urinary retention) that can occur in six to 49 percent of patients. About 56 percent of patients with MS may experience leaking of urine with coughing, sneezing, and changing positions (stress urinary incontinence). Approximately 50 percent of patients with MS can experience both difficulties storing urine and emptying the bladder retention simultaneously.

Urinary problem management
Management of urinary problems in patients with MS often requires a consensual approach, and cooperation between different medical professionals. The first step is to see a urogynecologist or other specialist who is trained in the management of urinary dysfunction. Initial assessment includes a detailed history and a thorough physical exam. Your medical provider may test your urine for infection and assess how much urine is left in your bladder after urinating. Additional testing may be needed to gain a better understanding of this complex issue. These may include blood-testing, ultrasound of your kidneys or a complex procedure to check how your bladder functions.

There are many options when it comes to managing these symptoms. Treatment options will range from conservative management to surgery depending on the nature and severity of the symptoms.

Physical therapy
Conservative management (pelvic floor physical therapy) is the first-line treatment in regaining control of overactive bladder symptoms. A specially trained physical therapist will assess the muscles of the pelvic floor, which are responsible for supporting the bladder and promoting continence. By increasing strength and control of these muscles, patients with MS can learn how to hold their urine for longer periods as well as being able to make it to the bathroom without leaking. Pelvic floor physical therapy has been shown to help improve frequent urination and urine leakage with urgency. The physical therapist may use different techniques such as biofeedback and/or electrical stimulation to help patients gain awareness and control of their pelvic floor muscles by identifying the correct muscles to either contract or relax.

In PFPT, patients are educated on reducing dietary bladder irritants, limiting environmental chemical exposure and proper fluid manage-ment in order to improve urinary symptoms. Many foods and drinks we consume – including: coffee, tea, citrus fruits or juices, spicy foods, tomato-based foods, alcohol and chocolate – can irritate the bladder and contribute to frequent urination and urinary leakage.

Often, a multimodal approach is used when managing bladder symptoms for patients with MS. If the initial treatment options are ineffective, second-line treatment options for overactive bladder, such as medications, can be utilized. There are two types of medications that are available (anticholinergics and beta 3 agonists), and have shown to improve overall quality of life in patients with MS. These act on two different receptors in the bladder (detrusor) muscle, and relax the bladder. This allows the bladder to hold more urine and hence, improve frequent urination and urinary leakage.

These medications can have side effects – including dry mouth, dry eyes, constipation, and headaches. Some of these medications may be a better choice than others for patients with memory loss, especially in advanced stages of the disease. It is important that patients with MS discuss their medical problems – such as memory loss, glaucoma, high blood pressure, and heart disease – with their medical provider in order to choose an appropriate medication. Let your medical provider know how the medications are working for you as you may have to try different medications before finding one that works for you.

Other treatment options
Other effective treatment options that are available for bladder control (overactive bladder) are bladder Botox injections, and nerve stimulation. Bladder Botox injections help relax the bladder muscle and allows the bladder to store more urine. A medical provider will perform a procedure called cystoscopy (placing a special camera in the bladder) and inject Botox on multiple areas inside the bladder. Most patients need the injection to be repeated once or twice a year. A small number of patients may experience urinary tract infection or difficulty emptying their bladder. Patients should discuss the procedure in detail with their medical provider to see if Botox is a treatment option for them.

Nerve stimulation can be done in two ways: posterior tibial nerve stimulation or sacral nerve stimulation. PTNS is an effective treatment option for overactive bladder. A small needle, similar to an acupuncture needle, is inserted in the lower leg near the ankle and connected to an electrode. The electrical impulses stimulate the nerves that relax the bladder muscle. The patient comes to the office for a series of office visits. Sacral Nerve Stimulation involves placing a battery device under the skin in the upper buttock, near the spine. This device stimulates the bladder nerve and hence improves bladder control. This battery device can be programmed using a small, hand-held remote. With recent innovation, patients have no restriction to undergo MRI with the implanted device in place.

Retention and leakage
Patients with MS may also experience an inability to empty their bladder during urination (urinary retention). Urinary retention affects up to 70 percent of patients with MS. These patients may have to manually drain urine from the bladder, by performing intermittent self-catheterization. ISC involves placing a small tube (catheter) in the bladder to empty the urine. Patients with urinary retention are taught by a medical provider on how to perform the procedure. Performing ISC on a regular basis has shown to improve quality of life in such patients.

Patients with MS may also experience urine leakage with physical exertion (stress urinary incontinence, SUI). These symptoms can be improved with physical therapy, placement of a vaginal pessary, or with surgery. Physical therapy can strengthen and improve pelvic floor muscle control. A pessary, a medical-grade silicone device, can be placed in the vagina by a medical provider and reduce the urinary leakage with stress. Surgery for SUI addresses the weakened support around the urethra. One of the common and effective surgeries for SUI is a mid-urethral sling. This is a surgical procedure in which a piece of polypropylene mesh is placed to support the urethra, thus improving SUI. You need to discuss the different surgical options with your medical provider to help choose the
best option for you.

In summary, urinary problems are common in patients with MS and can negatively affect their quality of life. It may be embarrassing but it is very important for patients to discuss these problems with an experienced healthcare provider. The treatment options can be tailored to individual patients based on their problems, which can improve overall health and quality of life.