November 22nd, 2010 by admin

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Much of the information in this article has been gleaned from publications from the Multiple Sclerosis International Federation as well as details from the relevant drug manufacturers..

Bladder problems associated with MS can be just as unpredictable as the course of the disease itself. while statistics can help in  better understanding things it remains true for any MS symptom that each person can have a different experience.

A table of common bladder problems in MS  has been published which shows:

Table 1: Common symptoms of bladder dysfunction and their prevalence in people with MS*

Urgency (80%)The feeling of having to empty the bladder immediatelyFrequency (80%)An increase in the number of times urination occursNocturia (80%)Frequent urination during the nightIncontinence (50%)Inability to hold urine in the bladderHesitancy (20%)Difficulty in beginning to urinate

• Multiple Sclerosis, DW Paty, GC Ebers eds. FA Davis Company, Philadelphia. 1998.

When MS damages the myelin, messages between the brain and the section of the spinal cord that controls the bladder can be interrupted, resulting in bladder problems.

There are three primary bladder control problems that occur as a result of MS: overactive bladder (OAB), sphincter dyssynergia (SD), and underactive bladder

Another way of looking at it is to say there are two major types of bladder malfunction that commonly occur in MS – failure of storage and failure of emptying. it is not known why some people experience one disorder and not the other, or why some individuals experience a combination of both.

Failure of storage occurs when an interruption of the spinal connecting pathway transmits messages that cause involuntary bladder contractions. the bladder begins to contract when only a small amount of urine has collected this is known as an ‘over-active’ bladder (OAB) and is the most common bladder problem

experienced by people with MS. Sometimes sudden, uncontrollable urgency

and the loss of urine, called urge incontinence may even occur.

Failure of Emptying can occur because of sphincter dyssynergia or underactive bladder.

Sphincter Dyssynergia

This  is usually due to nerve damage in the spine as opposed to the brain.

MS impacts how the bladder sphincter coordinates with the bladder. instead of a co-ordinated activity between the  muscles, the sphincter (bladder outlet) also contracts when the detrusor (bladder wall) contracts. the bladder is trying to contract and empty, but the sphincter is contracting instead of relaxing. this allows little or no urine to pass so that urine flow is poor and interrupted, making bladder emptying incomplete. it is important to treat this because high pressure in the bladder can cause bladder or kidney damage over time.

Underactive Bladder

Nerve damage found in MS can cause the bladder to weaken, so the bladder may not contract to release the urine.

Also if nerve signals cannot tell  the bladder to empty, the bladder continues to fill and expand. Eventually, it overflows, with leakage of urine (i.e., overflow incontinence). Even if urination occurs, the bladder usually does not

Infections

People with MS are more susceptible to urinary tract infections.

You may experience painful urination, frequency, and urgency and it may be accompanied by fever. However, because of nerve damage you may not sense the symptoms of burning and pain that normally accompany a urinary

tract infection (UTI). instead you may find that your MS suddenly gets worse and you seem to be experiencing a flare up. Thus when a flare up arrives one of the first things to do is have your urine tested as an immediate course of antibiotics can often resolve the situation.

Treatment

Treatment for over-active bladder usually starts with medication:

OxybutyninOxybutynin helps decrease bladder muscle spasms and the frequent urge to urinate. Oxybutynin is likely to cause a variable degree of dry mouth because the same chemical messengers control the bladder and the salivary glands. as this medication can worsen other MS symptoms while treating the bladder problem, some people may switch to another treatment.

Oxybutynin – extended releaseThis extended-release form of oxybutynin is relatively new and not available in all countries. it needs be taken only once a day, as the tablets are designed to release the drug at a controlled rate, maintaining a steady level of medication in the body. a skin patch with fewer side effects, is also available in some countries.

TolterodineTolterodine is used to treat bladder spasms causing urinary frequency, urgency, or urge incontinence. it works by reducing bladder muscle contractions. Tolterodine has fewer side effects, but is more expensive than oxybutynin. Patients should take the exact amount prescribed by their doctor as too much can cause adverse effects. An extended release form is also available.

Solafenacin

Solafenacin is in a class of medications called anticholinergics. it works by relaxing the bladder muscles to prevent urgent, frequent, or uncontrolled urination.Trospium chlorideTrospium chloride is an alternative for those who find the side effects of oxybutynin unacceptable.

PropiverinePropiverine is another alternative to oxybutynin.

ImipramineImipramine is usually used for the treatment of depression. However its main use in MS is to treat bladder symptoms, including frequency and urge incontinence, though it is used occasionally for MS-related neurologic pain. Sometimes this treatment is combined with oxybutynin. If taken at bedtime imipramine can also help to reduce insomnia.

DesmopressinDesmopressin is a hormone used as a nasal spray. the hormone works by reducing the amount of urine the kidneys produce thereby reducing frequent urination. this medication needs to be kept in the refrigerator and must not be allowed to freeze. Desmopressin can cause an increase in blood pressure and must not be taken by those with heart disease or high blood pressure.

Sativex is the first cannabis-based medicine to be licensed in the UK. In June 2010 the UK Medicines and Healthcare products Regulatory Agency (MHRA) licensed Sativex for use as an add-on treatment for MS-related spasticity when people have shown inadequate response to other symptomatic treatments or found their side effects intolerable. it is also licensed in Canada. However, further tests have found that it is effective in treating bladder dysfunction so it is likely to be licensed for that next.• Always ensure healthcare professionals are aware of any other medications being taken, as interactions may occur. since it may be difficult to distinguish between some side effects and certain common symptoms of MS, healthcare professionals should always be consulted if an abrupt change occurs after starting a course of any

More recently there has been the development of Sacral Neuromodulation (see the video above)

Not every patient will gain benefit from sacral neuromodulation and it is now accepted practice that every patient considered for this technique should undergo a

trial period of temporary stimulation known as percutaneous nerve evaluation (PNE). the test electrode is placed using local anaesthesia. Correct positioning of the electrode is determined by both motor and sensory responses. once well positioned, the temporary electrode is held in place with an adhesive dressing

and an external pulse generator provides stimulation for three to five days. the patient provides subjective information regarding their response to the PNE, while objective data comes from accurately completed frequency/volume

charts. Only those patients who gain significant benefit from the PNE proceed to neuromodulator implantation.

The PNE is generally considered successful when there is at

least 50% improvement in the main bladder symptoms

Around 50% of patients will respond well to the trial stimulation and go on to receive a definitive sacral neuromodulator implant.

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