One of the most common physical dysfunctions in multiple sclerosis is urinary incontinence (UI) - the leakage of urine at inappropriate times. It is also common in the general population with an estimated 115 million people worldwide reporting UI in 2013, and more than 12.6 percent of the general population in the United States being diagnosed with UI.
An estimated 50-100 percent of people with MS will experience UI. Both men and women can experience UI, but it is more common in women. UI frequently involves pelvic floor muscles that attach to the bottom of the pelvic bones to form a bowl-like structure that lifts to support internal organs and control sphincter muscles.
Lower urinary tract symptoms (LUTS) include frequency, urgency, stress and urge incontinence as well as voiding or obstructive complications. Stress incontinence occurs when the pelvic floor muscles are too weak to stop urine from leaking when you cough, laugh, or sneeze. Urge incontinence, or overactive bladder (OAB), occurs when urine leakage is closely preceded by a powerful urge to pass urine. It’s often a “I gotta go, gotta go, gotta go NOW," type of situation. Functional incontinence involves leakage when you struggle to get to the bathroom in time.
The most prevalent types of incontinence in MS are LUTS and OAB, affecting approximately 32-96 percent and 60-80 percent of people with MS, respectively. However, UI may be underreported in this population as it has been suggested that people with MS wait an average of 6.5 years after the onset of symptoms before seeking treatment.
Treatment options for UI
Conservative approaches to UI include catheterization, medication (anticholinergic agents, desmopressin, and cannabinoids), nerve stimulation, and physical therapy. Minimally invasive surgical treatments involve sacral neuromodulation, botulinum toxin injections, and augmentation cystoplasty.
A primary conservative strategy to help with urinary incontinence is training of the pelvic floor muscles with a technique developed by Dr. Arnold Kegel in 1948. The idea is that an increase in voluntary contraction of these muscles before things like coughing helps to reduce urinary leakage. However, a disadvantage of doing too many “Kegels” is an increase in bladder dysfunction if a person is unable to voluntarily relax the pelvic floor muscles.
Neuromuscular electrical stimulation (NMES) and electromyography (EMG) biofeedback are physical therapy interventions that teach the patient to control voluntary muscle relaxation and contraction through visual and auditory feedback. In a study of 197 women with UI (but not MS) showed that biofeedback-assisted behavioral treatment was significantly more effective in reducing incontinence symptoms than drug treatment, with 80.7 vs 68.5 percent reductions, respectively.
Can physical therapy (PT) treat UI symptoms in MS?
A physical therapist can help you find and strengthen your pelvic floor muscles and learn how to use them correctly to better control your bladder. This may be done through biofeedback techniques involving electrodes attached vaginally or rectally or electrical stimulation to build awareness. A physical therapist can also instruct you in how to stretch and strengthen other important muscles to support proper bladder function.
As there lacks a consensus regarding PT management of UI in people with MS, researchers recently conducted a meta-analysis of long-term nonsurgical and nonpharmaceutical treatment options, with a focus on current evidence for effectiveness of PT to decrease UI and improve quality of life (QOL) in people with MS.
What did the meta-analysis reveal?
• According to six studies meeting specified criteria, physical therapy protocols that included pelvic floor muscle training, electrical stimulation, or biofeedback were effective in reducing the frequency of urinary incontinence and in increasing QOL for people with MS compared with pretreatment and control groups not receiving the intervention.
• Electromyography biofeedback did not show a significant difference in ability to relax pelvic musculature after intervention, likely because the intensity or frequency of treatment was not adequate. Longer-duration treatments (eg, five weeks vs three weeks) were associated with greater effect sizes.
• Future studies may determine whether physical therapy improves QOL because of the direct effect on incontinence leakage episodes or because change in urinary incontinence affects other factors, such as fatigue, time required for activities of daily living, and depression, that contribute to poorer QOL.
More Helpful Information:
Block V, Rivera M, Melnick M, Allen DD. Do Physical Therapy Interventions Affect Urinary Incontinence and Quality of Life in People with Multiple Sclerosis?: An Evidence-Based Review. International Journal of MS Care. 2015;17(4):172-180. doi:10.7224/1537-2073.2014-031.
Lisa Emrich is a patient advocate, accomplished speaker, author of the award-winning blog Brass and Ivory: Life with MS and RA, and founder of the Carnival of MS Bloggers. Lisa uses her experience to educate patients, raise disease awareness, encourage self-advocacy, and support patient-centered research. Lisa frequently works with non-profit organizations and has brought the patient voice to health care conferences and meetings worldwide. Follow Lisa on Facebook, Twitter, and Pinterest.