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Bladder Management in Multiple Sclerosis
Catherine W. Britell, M.D. (April, 1995)
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The demyelination caused by MS often affects the motor and sensory pathways
of the bladder. When a person is affected in this way, he/she is said to
have a "neurogenic bladder".
Bladder symptoms can vary in MS, depending which nerves are affected.
Also, they can change with time, just as other aspects of the disease change.
It has been estimated that 50-80% of people with MS experience some kind
of bladder difficulty.
What causes these problems?
There are three main types of neurogenic bladder symptoms seen in MS, related to the area of the lesion.
The urine seems to want to come out too frequently and too easily. When
a person first gets the urge, he/she doesn't have very long to get to the
bathroom, and has to go quite often-- more than 6-8 times per day and more
than once at night. And, sometimes if a person doesn't make it to the bathroom,
she does lose control.
The urine just doesn't seem to want to come out. The stream is weak
or intermittent, and it's difficult to get it started. And sometimes when
the bladder gets full, the urine overflows and starts dribbling out. The
person may have frequent infections.
A combination of the above.
These symptoms can be caused by a variety of functional bladder problems.
The bladder wall muscle (detrusor) might contract too hard...or it might
not contract hard enough. The sphincter may contract at the same time the
detrusor contracts, thus keeping the urine in and causing high pressure
in the system (That's called "detrusor-sphincter dyssynergy"). Or, the
sphincter may not contract when it needs to in order to hold the urine
in. Or, some of those can happen together. As you can well imagine, it's
sometimes pretty difficult for the doctor to tell exactly which of these
things is happening from the symptoms a person is having. Therefore, some
diagnostic tests are usually done, in order to determine the best way to
deal with this. A "cystometrogram" or "CMG-EMG" is often done in order
to tell what's happening to the detrusor and sphincter muscles as the bladder
fills and empties. Other tests that are sometimes performed to further
diagnose the problem may include Ultrasound of the abdomen, kidney X-rays
with dye injected into your vein or into the bladder via a catheter, measurement
of how much urine is left after you've finished voiding, or cystoscopy
(looking up through the urethra) if a prostate problem is also suspected
to be part of the problem.
How are they managed?
The goals of treatment include:
In general, the bladder should be emptied about every 4-6 hours, or every time it has 200-400 cc of urine in it, or more often if the bladder capacity is low. One will generally will make about 800-1,000 cc less urine than the fluid you drink (you lose the rest from sweating and respiration). So, if you drink about six glasses (1800 cc) of fluid per day, you'll make about 800-1000 cc of urine, and will have to void about 4 or 5 times per day if your bladder capacity is 200 cc. The reason for understanding and keeping track of bladder capacity and fluid intake is that if you empty your bladder on a timed basis, rather than waiting until you have to go, you'll often be able to avoid accidents very consistently. Where this gets difficult is when you collect fluid during the day in the form of edema or swelling of your legs and feet, and then put it out at night. That can make for a difficult problem of having to urinate a great deal at night. Some doctors prescribe a small dose of a diuretic (water pill) in the afternoon so that the fluid will not accumulate so significantly.
So, to recapitulate: When there are bladder problems, the first step is to see a doctor (neurologist, urologist, physiatrist) who specializes in MS treatment, and have this evaluated. Next, controlled fluid intake and timed voiding are the simplest and most effective first-line treatment. Often the doctor will prescribe medications to relax the bladder wall at this time. If this doesn't work, a regimen of regular clean intermittent self-catheterizations (with or without bladder relaxants) is most often prescribed. This is not as difficult as it might seem, and often works quite well on a long-term basis. But what if a person doesn't have good enough hand function to do this, or what if this is just not effective in keeping the person dry?
There are some effective ways of collecting urine externally. In men, an external collecting device (a condom with adhesive at the top and a tube at the bottom connected via a rubber tube to a leg bag) will often work very well. In women external collecting devices of various types have been tried, but none seem to work very well. The first option is "padding up" in this instance. There are a number of special panties on the market with waterproof pockets to hold very absorbent pads. This will often adequately contain the urine.
If the bladder doesn't drain adequately, however, external collection isn't enough to maintain a healthy bladder. In this case, some kind of mechanical emptying is needed. Sometimes, if a person does not have adequate hand function to perform self-catheterization an indwelling catheter (one that stays in the bladder) is often an effective way to manage bladder dysfunction, though most doctors generally prescribe this only after having tried other measures. It used to be that catheters were always pretty awful and led to a great many infections, but with modern materials and management, complications are not frequent, and things can be managed quite easily. Catheters can be inserted through the urethra (tube where the urine normally comes out of the body) or through an opening made below the belly button called a "suprapubic cystostomy". Often for women, the latter is recommended because of greater ease of management and not having to sit on a catheter or stretch out the urethra. It also has an advantage in men and women of interfering less with sexual practice. The catheter is a rubber tube with two passages in it...one going to the end to drain the urine and the other going to a balloon near the end that holds the catheter in place when filled with sterile water. The catheter is connected to a drainage tube which then goes under the clothing to a latex or polyethylene bag that is strapped to the lower leg under the pants and has a valve on the bottom to open and drain the bag as necessary under the pants cuff. When one has an indwelling catheter, the doctor usually encourages high fluid intake...3 to four liters of fluid per day...to keep bacteria and crystals washed out. Usually the catheter is changed about every two weeks, and the tubing and leg bag are washed out daily with diluted chlorine bleach and hung to dry.
How can one prevent infections?
There is much information around about how to prevent infections that occur in patients with MS, and there is still a fair amount of disagreement about the very best way to do this.
First, it's really important not to get dehydrated. When the urine becomes concentrated and flow slows down, the bacteria grow and infections often occur. Of course, that's difficult, particularly when traveling or attending a family reunion or other important social function. Who wants to drink fluids and risk an accident? The wisest thing is, if possible, to maintain a fluid intake of about 2000 cc per day (more if you have an indwelling catheter) and try to make provisions to empty your bladder frequently, no matter where you are or what you need to do. Sexual activity is another thing that sometimes predisposes to infections. In both women and men (more in women) coitus tends to introduce some normal skin bacteria into the urethra. Bathing with an antibacterial soap prior to making love ("Honey, please excuse me while I do a surgical prep") decreases the bacteria in this area, but may not be very feasible or romantic. One thing that does help, however, is making sure to urinate after sex, to wash out the urethra and empty the bladder.
Cranberry juice and/or Vitamin C...are they any good? Well, if you look at the scientific literature, there have been studies on this with spinal cord injury, and the conclusions are that it does nothing to prevent symptomatic infections. However, I have patients who swear by it, and indeed, since they've started using either cranberry juice in large amounts, or vitamin C tablets, they seem to have fewer or no infections. The only drawback to cranberry juice is the sugar (bad for diabetics or those with weight problems) and if aspartame (Nutra-sweet) is added instead, it seems to cause an inordinate amount of gas.
If you are having frequent infections, it's important to find out why this is occuring, and to treat the problem specifically and directly. As with most health issues, it's vital to have a physician who understands MS and can follow you carefully, performing urine cultures if you get symptoms and treating infections appropriately. Your doctor needs to be aware of this problem and how you are managing it so that he/she can help you be as healthy and infection-free as possible. Most rehabilitation centers that specialize in MS care have associated with them a rehabilition nurse specialist. This person can be very helpful in the practical everyday issues of bladder management.
In conclusion, then, bladder problems in people with MS are frequent,
occur for a number of reasons, and may differ among individuals. There
are a number of ways to approach bladder issues, and it's vitally important
to form an alliance with a health care professional who understands the
pathophysiology of these problems, knows how to treat them, and maintains
sensitivity to your emotional needs and lifestyle.
