Bladder dysfunction is common in MS, both in people with minimal symptoms and those with major impairments. Effective bladder management strategies help people with MS to stay active and pursue daily activities. It is important to remember that:
- Bladder symptoms might be responsible for withdrawal from social and vocational activities as frequency, urgency, and incontinence may negatively affect person to person interactions.
- Bladder problems can threaten an individual’s health with serious complications leading to morbidity.
- Bladder symptoms that are mismanaged may precipitate such problems as acute urinary retention, damage to the detrusor (primary bladder muscle), and urinary tract infections (UTIs).
Problems with the bladder can have different causes, but result in many of the same symptoms. Recurrent or persistent urinary symptoms require consultation and assessment by a urologist, preferably one who is experienced with MS.
Neurogenic bladder dysfunction is the result of demyelination of the nerves transmitting signals between the bladder, brain, and spinal cord, which interferes with the muscles that control urination. Dysfunction may occur in the detrusor muscle (which expands to store urine and contracts to expel urine), external urethral sphincters, or in the coordination of their functions. The detrusor muscle can be hyperactive, signaling the urge to void at very low urinary volume, or hypoactive, allowing a dangerously large amount of urine to accumulate before the brain gets the message to go to the bathroom.
Storage dysfunction may be caused by an over-active detrusor muscle that contracts as soon as a small amount of urine enters the bladder. The bladder does not fill to normal capacity which results in the following symptoms: urgency (inability to delay urination), frequency (need to urinate repeatedly), nocturia (need to urinate during the night), incontinence (inability to control the time and place of urination).
Therapies for storage dysfunction include anticholinergic medications (such as Ditropan XL, Detrol, Oxytrol, Vesicare, Sanctura, Enablex), desmopressin acetate (a hormone nasal spray that temporarily reduces the amount of urine produced in the bladder allowing for more restful sleep), pelvic floor exercises, absorbent pads, and behavioral modifications (such as limit caffeine, drink plenty of water during the day, maintain easy access to the restroom).
Emptying dysfunction happens when the bladder fills normally, but the spinal cord is unable to send the message to the brain to relax the urethral sphincter muscle, causing the bladder to retain urine and sometimes fill beyond normal capacity. Emptying dysfunction can lead to: urgency (inability to delay urination), dribbling (uncontrolled leaking of urine), hesitancy (delay in ability to urinate, though need to void is experienced), incontinence (inability to control time and place of urination), and infection.
Therapies for emptying dysfunction include intermittent self catheterization (ISC),
dietary changes to increase acidifying urine (ie. cranberry juice), assessment of mobility issues (proximity to toilet), antispasmodic medications (such as baclofen or tizanidine), or sympatholytic medications that increase urine flow (Flomax, Hytrin, Minipress).
Detrusor-external sphincter dyssynergia (DESD) (a combination of storage and emptying problems) is caused by a lack of coordination between different muscle groups. As a result urine becomes trapped in the bladder leading to: urgency (inability to delay urination), hesitancy (delay in ability to urinate, though need to void is experienced), dribbling (uncontrolled leaking of urine), incontinence (detrusor hyperreflexia, inability to control time and place of urination), and infection. Symptoms may persist despite intermittent catheterization.
Therapies for combined dysfunction include intermittent catheterization, anticholinergic (such as Detrol), antispasmodic medications (such as baclofen), sympatholytic medications (Minipress, Flomax,or Hytrin) to promote urine flow, or botulinum toxin (Botox) injected into the sphincter or bladder wall.
The inability to empty the bladder can lead to frequent urinary tract infections (UTI) in people with MS. Retained urine encourages the growth of bacteria and allows mineral deposits to settle and form stones that irritate bladder tissues. Symptoms of a UTI include: urgency, frequency, dysuria (burning sensation during urination), abdominal or lower back pain, fever, increased spasticity, and dark or foul-smelling urine. Urinary tract infections can also be the cause of pseudoexacerbations.
For more information regarding bladder dysfunction, read the “Bladder and Bowel” special issue of MS in Focus published by the Multiple Sclerosis International Federation (July 2014).