Understanding and Managing the Bladder Problems that Accompany MS
Denise I. Campagnolo, MD, MS-Director of Clinical Multiple Sclerosis Reserach, Barrow Neurological Institute, Phoenix, Arizona
Introduction
If you have been living with multiple sclerosis (MS) for ten years or more, there is a greater than 90% chance that you have trouble with urination (Crayton, Neyman, & Rossman, 2004). In fact, even if you were newly diagnosed, you may still have some degree of bladder symptoms. These symptoms are often some of the most distressing, and at times disabling, of MS symptoms. A working knowledge of how the urinary system works and how it is affected in MS is the first step in getting help for these issues. The good news is that more often than not, bladder symptoms can be controlled.
Urinary Symptoms and Their Causes
To persons with MS, the worst overall problem is probably incontinence—voiding a little or a lot in an inappropriate time and place. Several different voiding problems can result in “incontinence.”
Frequency: The symptom called “frequency” describes increased number of times the person needs to void in a given period of time. This could be as frequent as every 15 minutes to a half hour, which disrupts activities
of daily living and sleep. Frequency may be caused by “failure to empty” type of bladder dysfunction, but more typically it is caused by a small capacity spastic bladder, whose command and control messages are to expel urine even in situations where the volume is small.
Urgency: Frequency is also accompanied by a sense of urgency, or a feeling that one has to visit the urinal/commode, now not later, with no time to waste. The result may be dribbling or incontinence. Incontinence involves the leakage of urine from the bladder either because the bathroom wasn’t reached in time, or the person was unaware of the need to void until it was too late. Usually in these cases the bladder is small in capacity and spastic with an ongoing message to expel urine. The symptom of hesitancy involves the inability to start the urine stream, even when the urge to void is there.
Retention: Lastly, urinary retention is an inability to empty the bladder efficiently, which will result in a large post void residual urine determination. One of its presenting symptoms may be overflow incontinence. Although persons with MS may view incontinence as the biggest problem, retention can cause serious medical consequences (bladder and kidney infections and permanent kidney damage among others). So how is urination supposed to work and how does MS change this normal function? Let’s start with the anatomy and function of the urinary system.
The Anatomy and Function of the Urinary System
The urinary system consists of the kidneys, the ureters, the urinary bladder, urethra, and urethral sphincters. As you are probably aware, the kidneys are bean shaped organs that filter waste products from the blood, producing urine at a rate of about one ounce an hour. The urine is transported to the urinary bladder via tubes called ureters, one from each kidney. The ureters and kidneys are often referred to as the upper urinary tract, and these are less commonly affected by MS.
The lower urinary tract is comprised of the bladder, the urethra (which transports the urine out of the body), and the urethral sphincters or muscles that allow open passage or not, depending on the commands delivered to them through the spinal cord. The urinary bladder itself is a muscular bag that contracts when we want to expel urine (voiding) and relaxes when it is time to store urine (which is most of the time). Control of the urinary bladder is also dependent on messages or commands sent through the spinal cord. The bladder is not only responsible for storing or expelling urine, but it also allows us to sense how full it is (how much urine is in it). For example, when there is about 200 to 250 cc of urine in the bladder (about a cup), the wall of the bladder is stretched enough to send a signal from nerves in its walls to the spinal cord and ultimately to the brain, thus we have a sense of fullness in our bladder. As the bladder continues to fill, and if we are in an appropriate place, the brain then sends its own messages, one to the bladder and one to the sphincters. To the sphincters, the message is to relax, and simultaneously the bladder is told to contract, thus voiding occurs. This two-way highway of information from and to the bladder is conducted through the spinal cord and through nerves in the pelvis. Damage at any point along the pathway, brain, spinal cord or pelvic nerves, can influence bladder function. In the case of MS, damage to the spinal cord with subsequent interruption of the message from the brain, is the most common cause for urinary problems.
Command and Control Centers
Let’s take a closer look at the actual locations of the command and control centers both in the spinal cord and in the brain. This knowledge will provide the framework to better understand what can go wrong at these centers.
Within the spinal cord there are two key areas involved in the control of bladder function. The first is located in the lowest two thoracic segments of the cord and the upper two lumbar segments of the cord (T-11–L-2). This area is important because of the nerves that originate at these levels (called sympathetic nerves) that inhibit the bladder muscle from contracting and also tell the bladder outlet (urethral sphincter) to contract. This center sends a clear message to the bladder to store urine. In a normally functioning system, this message is continuously being sent to the bladder. To override it, other strong signals have to tell this center to quiet down (and allow voiding to occur).
Our second area of interest is located in the lowest aspect of spinal cord (sacral cord levels 2–4). Nerves originating from this level go to the bladder muscle and tell it to contract. The chemical messenger that these nerves respond to is acetylcholine. This is important to know because as we will see later, one way to treat urgency and incontinence due to over-activity in these “cholinergic” nerves is to give medications called anticholinergics that would block this “contract” message to the bladder.
It is important to understand that these two voiding control centers within the spinal cord can run all on their own––just by reflex––without input from the brain above. This reflexive voiding is abnormal and results in much of the urgency, frequency, incontinence, and sometimes hesitation we see in persons living with MS. Instead, these centers should be under the direct control of centers in the brain, such as the pontine micturition center. As the name implies, it is located in the part of the brain stem called the pons. Under its direction, at the appropriate time, a switch is flipped that tells the system as a whole to no longer store urine, but to expel urine via a coordinated interplay between the two spinal areas mentioned above as well as our conscious mind, which controls our ability to voluntarily relax and allow urine to pass freely.
Command and Control Problems
There are several common bladder patterns at the root of urinary dysfunction in persons with MS. In general, these patterns fall into two broad categories: a failure to store urine or failure to empty the bladder. The bladder is maintained usually in a state of storage (as we described above), with the brain telling the bladder muscle to relax and the sphincter muscles to contract. This state is maintained until the signal coming from the bladder is strong enough (bladder is full enough) to allow the brain (especially the pontine micturition center) to “flip the switch,” thus contract the bladder and relax the sphincters.
The most common point of MS involvement that interrupts this process is in the cervical (neck) segment of the spinal cord. Although MS plaques certainly can occur anywhere in the central nervous system, when there is damage in the cervical spinal cord, it commonly involves those fiber tracts of the cord responsible for brain’s communication with the bladder muscle and urethral sphincter. The outcome is commonly that the bladder reverts to an automatic (or reflex) cycle of filling and contracting when ever it has filled to a certain (usually small) volume. This typically results in symptoms of urgency and frequency of urination, as the bladder has contractions at small volumes, uninhibited by the brain because of the miscommunication due to MS involvement in the spinal cord.
Another pattern we see is when there is MS involvement in the lower aspect of the spinal cord itself. This is not the usual case, but when it occurs it results in damage to the centers at S-2–4. As a result the bladder is not able to contract, leaving it a big loose muscular bag. This in turn results in overflow incontinence, or an inability to void at all.
The third pattern that can be seen is one of a completely confused system in which the bladder is being told to contract, yet the sphincters have not been ordered to relax. Thus the bladder is trying to expel urine against a closed outlet. The name for this problem is detrusor sphincter dysenergia (DSD). This occurs typically when there is damage in the upper thoracic or cervical areas of the spinal cord. DSD can exist with bladder hyper-reflexia. Furthermore, DSD is particularly problematic because it results in intermittently high voiding pressures and potential for upper urinary tract problems.
All of this information is clearly only a portion of the total picture. Although oversimplified, the information above should provide a basis for understanding some of the techniques and medications clinicians use to improve bladder function and to try to restore some of the coordinated features of the system. Please note that this information is in no way meant to replace an expert urological evaluation and recommendations. Your MS professional may take initial steps with you to try to correct some of these problems, but ultimately a comprehensive evaluation by a urologist comfortable with the urologic manifestations of neurologic diseases will be needed. He/she may recommend some of the tests listed in Table 1. Your MS clinician will guide you as to when the time is right for a urological referral.
Supportive Measures
A team approach involving the patient’s MS clinician, a urologist, and physiatrist is essential to doing all that is possible to improve urologic function, especially when it is necessary to take into account physical disability, hand dexterity, social and supportive networks, and other issues.
Supportive measures can be used for patients with emptying problems, storage problems or both. For example, timed voiding is sometimes helpful in patients with mild incontinence, with predominantly normal bladder function, but an under-active urethral sphincter mechanism. Thus the idea is to have the patient void on a timed schedule before the bladder reaches full capacity, thus avoiding leakage between.
There are several products available for controlling incontinence. There are two general types of incontinence pads available, adult briefs and over the bed pads. Both types are made from a material that absorbs urine as it is released. These are easily available at the local drugstore and very simple to use. Generally, insurance does not cover the cost of incontinence pads. Although the price of incontinence pads doesn’t seem to cause much financial burden, multiple changes each day are often time consuming! Unfortunately, there is also a high risk of skin breakdown and pressure ulcers due to the constant moisture next to the skin, thus use of a barrier cream is recommended (Medline Plus, 2005, 2006). Particularly at risk for skin breakdown are those with decreased sensation, movement, or communication ability. There is also added risk of urinary tract infections. Preventative measures reducing the risk of urinary infections include urinary acidification and drinking plenty of fluids.
There are two types of indwelling catheters. Foley catheters are flexible tubes that are passed through the urinary opening into the bladder. The catheter is held in the bladder by means of a balloon at the catheter tip. After insertion, this balloon is inflated with sterile water and the catheter connected to a leg or bedside collection bag. Suprapubic catheters are short flexible tubes inserted into the bladder by a surgically created opening between the bladder and the skin of your lower abdomen. The catheter is then connected to a leg or bedside collection bag. Using an indwelling catheter allows the skin to stay dry. There is also a low initial cost associated with indwelling catheters because one catheter may be used for a period of weeks. Long-term use of indwelling catheters, however, can lead to an increased risk of urinary tract infections, kidney infections, and kidney/bladder stones.
There are three types of intermittent catheterizations involving insertion of a catheter through the urinary opening (meatus) into the urethra, which attaches to the bladder to drain the accumulated urine.
Clean Intermittent Catheterization (CIC) is the most common type done in a home environment. A catheter may be reused after being cleaned with antibacterial soap and rinsed well. Sterile Intermittent Catheterization requires cleaning the area around the urinary opening with antiseptic, a sterile drape, and sterile disposable gloves.
Closed Intermittent Catheterization, also known as “touchless,” is the third type. A sterile catheter is contained completely in a plastic bag, allowing insertion of the catheter into the body without physically touching the catheter. After use, the catheter and bag are thrown away. Intermittently catheterizing is a way for men and women with adequate hand function to empty their bladder with less chance of urinary tract infections and other health risks associated with indwelling catheters.
Men can use a Condom Catheter (also known as a Texas catheter) which is a thin flexible sheath with adhesive inside that is worn over the shaft of the penis with a tube at the end to attach to a leg or bedside urine collection bag.
Pharmacological treatments for bladder dysfunction are generally based on whether there is a failure to store, a failure to empty, or a confused combination such as in detrusor sphincter dyssynergia. Table 2 presents pharmacologic measures commonly used for these different types of bladder dysfunction. All should be used under the care of your MS doctor or urologist.
Other interventions to decrease DSD and allow for low pressure voiding are botulinum toxin injections to relax the urethral sphincter, usually for a period of 3 to 6 months (Karsenty, Baazeem, Elzayat, & Corcos, 2006). Also, endourethral stents have been used to circumvent urethral obstruction. If surgical intervention is needed to allow for reduced voiding pressures in DSD, it usually comes in the form of a transurethral external sphincterotomy. The urethral sphincter is surgically released to allow for reduced urinary outflow resistance, usually in men with spinal cord disease and known DSD. The goal is for them to be able to empty the bladder reflexively without the contracted urethral sphincter (Linsenmeyer, 2002).
Other surgical options for urinary management are bladder augmentation, also known as augmentation cystoplasty. This is a surgical procedure that increases bladder capacity by augmenting it with intestinal segment such as ileum, colon, or stomach, thus creating a low pressure intra-abdominal reservoir. Another surgical intervention is urinary diversion. In this procedure the ureters are transected just above the bladder and connected to a segment of intestine, which is brought out to the skin of the lower abdominal wall. This technique is used whenbladder complications prevent restoration of normal bladder function (Linsenmeyer, 2002).
Electrical stimulation of the sacral anterior nerve roots (S2-S4) has been used to produce a bladder contraction (Sheffler & Chae, 2007; McClurg, Ashe, Marshall, & Lowe-Strong, 2006). The Vocare® Bladder System is an implantable device that had been FDA approved for the treatment of neurogenic bladder secondary to spinal cord injury, although it has been used successfully in persons with damage to the spinal cord from MS. The device consists of a pacemaker type electrodes that are attached to the sacral anterior nerve roots with an under the skin receiver-stimulator. The person uses an external battery controlled controller and transmitter, about the size of a cassette player to stimulate the nerves and produce bladder contractions.
Conclusion
One of the well known characteristics of MS is that it is rather difficult to generalize about symptoms. MS effects on urologic function are no exception. There are several important points to remember from what you’ve just read. It is also very important to tell your MS clinician about your bladder problems early on. That’s the best way to get help and guidance in minimizing potential consequences, such as constant wetness, social isolation, infections, and kidney damage.
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