MS Bladder Issues: Manage Multiple Sclerosis Bladder Problems

It seems like a good idea to start off with a little review. Similarly to the way high school teachers always start off the year. Multiple Sclerosis (MS) is a chronic inflammatory disease of the Central Nervous System (CNS). It causes “relapsing-remitting attacks of inflammation, demyelination and axonal damage, leading to various degrees and spectra of neurological symptoms and disability” ⁽³⁾.  Wow, that was a mouthful. For those who are new to MS, that probably sounds like a bunch of gibberish. Even veterans to MS: it’s definitely not a hot conversation starter at dinner.

MS Bladder Issues

How Does Multiple Sclerosis Affect the Bladder?

That is just fancy talk. Let’s break it down to understand the nerves and how they work. The nerves are messengers of the brain and spinal cord (the 2 components of the CNS). The brain will send a message down the nerve to its target organ and will communicate both ways via an “axon”. For example, take the bicep muscle in your arm. When you want to curl that super-duper heavyweight at the gym, the arm at the elbow joint needs to move or contract. In order for this to occur, the nerves will then signal the muscle. And BOOM- you have your muscle contraction (gains!).

The axon is designed with an outer “coat”. It is intended to help them from being exposed. Therefore, the coat behaves as protection as well as aiding the super-fast movement of the electric signals! This is known as the myelin sheath. Unfortunately, people with MS have attacks on their myelin sheath causing Demyelination and therefore, nerve damage.

The bladder is also a muscle- and it is no surprise that people with MS have bladder dysfunction or MS bladder issues ⁽⁵⁾. Nerves supplying muscles are the same all-around! The bladder is no exception.

Types of MS Bladder Dysfunctions

Can MS Cause Neurogenic Bladder?

The MS lesions that cause axonal damage cannot send signals to the urinary system. Consequently, this disturbs the way the bladder should originally work. When it’s full, the muscles in the bladder stretch to send a signal to your brain and tell you to go pee! When the nervous system is not functioning properly, this can cause MS-related bladder issues called “neurogenic bladder”. Most commonly, the lower urinary tract is affected in MS⁽⁴⁾.

The CareClinic platform can help you track your multiple sclerosis bladder symptoms by using the “Symptom Tracker” ability directly on the app. That way, you are in full control. Or should you say “bladder control”? Sorry, no more corny dad jokes. Being able to report your symptoms and notifying your physician of any urinary changes are critical to the treatment of multiple sclerosis neurogenic bladders. That being the case, the CareClinic platform allows keeping track of and being more transparent with your symptoms* in a simple fashion. A prompt, open discussion with your doctor is the fastest, safest, and most effective way to manage urinary dysfunction ⁽²⁾. Instead of trying to remember everything on the top of your head or scribbling something down on your lunch napkin- let’s strive to be more 21st century.

*These different types of multiple sclerosis neurogenic bladder issues are separated into different types of dysfunctions which are explained below:

Bladder Storage Dysfunction

Okay, major apologies but another fancy medical word coming up. The Detrusor Muscle. This is the muscular portion of the bladder that contracts to release the urine from the bladder. Suffering from storage dysfunction, people with MS bladder issues will have a hard time holding their urine, inevitably. Every time a small amount of urine enters the bladder, that muscle starts contracting right away! These constant signals lead to constant feelings of needing to void the urine. Due to the demyelination from MS, the overactive muscle contraction fails to notify the brain that the bladder is not full and does not need to expel its content ⁽²⁾. Because of this, people with this MS bladder dysfunction will have the following signs and symptoms:

1. Urgency: inability to delay urination once the urge to void has been felt ^(2,5)
2. Frequency: the need to urinate in spite of having voided very recently ^(2,5)
3. Nocturia: the need to urinate during the night ^(2,5)
4. Incontinence: the inability to control the time and place of urination ^(2.5)

Storage dysfunction is the most commonly reported MS bladder dysfunction ⁽⁴⁾.

Voiding Dysfunction

As you probably noticed already, the nervous system is the communication center. The demyelination of the nerves can be detrimental to this bi-directional conversation. This MS bladder dysfunction is still caused by the same anatomical destruction of the myelin sheath but this time, the signal does not tell the brain the bladder is full! When the bladder stretches, it causes a “voiding reflex” that the spinal cord needs to send to the brain to contract the detrusor muscle to release the urine. Because of this, people with this MS bladder dysfunction will have the following signs and symptoms:

1. Urgency (same as above)
2. Incontinence (same as above)
3. Dribbling: uncontrolled leakage of urine ⁽²⁾
4. Hesitancy: delay inability to initiate urination even though the need to void is felt ⁽²⁾

Combined Bladder Dysfunction

Combined Dysfunction is a combination of both storage and emptying dysfunction. Huh, go figure! This is from the lack of coordination of the nerve signals to and from the brain. Instead of working together, the muscles contract simultaneously, trapping the urine in the bladder and can cause the following signs and symptoms:

1. Urgency
2. Hesitancy
3. Dribbling
4. Incontinence
5. Urinary tract infections* (UTI) ⁽²⁾

*Please read the sub-note below

MS and Bladder Infections

When the urine is stored in the bladder for long periods of time, evident in MS bladder dysfunction, it allows time to breed bad bacteria eventually leading to infections. It can also allow mineral deposits to settle and form stones that promote infection and irritate bladder tissues ⁽²⁾. In consequence, signs and symptoms for MS and bladder infections are the following:

1. Urgency
2. Frequency
3. Burning sensation ⁽²⁾
4. Abdominal and/or lower back pain ⁽²⁾
5. Fever ⁽²⁾
6. Increased spasticity ⁽²⁾
7. Dark-colored, foul-smelling urine ⁽²⁾

What are the Complications of a Neurogenic Bladder?

Living with MS bladder problems or MS neurogenic bladder can have a huge negative influence on one’s quality of life (QoL) ^(2,4,5). Imagine being at the social party of the year and your underwear is soaked with urine. Or you are at your child’s birthday party and cannot be a part of making new memories because you are constantly going back and forth to the bathroom to urinate. Undeniably, this can take a toll on your mental health. Surely, MS bladder issues are greater than just a simple inconvenience.

Therefore, having a bladder diary will also be crucial ⁽⁴⁾ for you to be able to log these symptoms and check in with yourself as well in dealing with your MS bladder problems. Using the CareClinic platform, you can use the “Diary Entry” button to input, in your own words, how you are feeling that day and how you are tolerating those symptoms. You can also write about how your treatments are going and how much your QoL is improving or declining. It can also be a resource for your professional healthcare team as treatments given for MS bladder issues are often multidisciplinary. Not only will your family physician do the necessary tests needed to confirm neurogenic bladder, but a urologist (specialist physician) and other disciplines will also most likely be involved in the care of your MS bladder problems.

How Often do Bladder Issues Occur with MS?

The exact number is still unclear because, in order for scientists to come up with this number, they would need to ask every single person living with MS. But they can still make estimations from sampling a large group. Neurogenic bladder symptoms are roughly experienced by at least 80% of MS patients. Some studies are more specific such as De Seze and colleagues reported a prevalence of 37–99% for overactive bladder syndromes, characterized by irritative bladder symptoms, a prevalence of 34–79% for obstructive symptoms and 25% for chronic urinary retention ⁽¹⁾.

The Women VS. Men Debate

Is there a difference between women and men for MS bladder issues? Simple answer: not really. But the MS prevalence ratio of women to men has increased markedly during the last decades which indicates a true increase in MS in women but not in men ⁽³⁾. Because more women are being diagnosed with MS, not surprisingly, a higher number of women report bladder dysfunction. Women, generally speaking, are also more likely to get UTIs due to female anatomical reasons.

Treatment for MS Bladder Issues

How do MS Patients Stop Bladder Issues?

This is the million-dollar question. A treatment regimen that is tailored to your symptoms can be designed to relieve the symptoms, prevent unnecessary complications, and allow you to be more comfortable and confident in your daily life ⁽²⁾. Treatment options will differ depending on the type of dysfunction discussed above.

MS Bladder Control Management for Storage Dysfunction

MS Bladder Issues and Fluid Intake

Fluid Intake is going to be significant here. It is recommended to drink at least 8 cups of fluids each day (especially water and not to exceed 8 cups). This will ensure flushing of waste and decrease chances of bacterial & mineral build-up in the bladder. Drinking a small glass of water (about 6 to 8 ounces) all at once every few hours is also recommended. It is superior to sipping drinks constantly, which might make you want to pee more often. It is also great bladder training to stop all fluid intake 2 hours prior to bedtime or before starting an activity where bathroom breaks are not readily available^(2,5).

The CareClinic platform allows you to input all fluids including juices, caffeine, alcohol, etc. These are important to record as they are not recommended in the care plan of managing bladder issues. These substances act as bladder irritants and contribute to storage dysfunction. Caffeine behaves as a “diuretic” which means it blocks the kidneys from retaining water. Alcohol behaves the same way but also has other organ dysfunction properties. Citrus juices should also be limited as it makes the urine more alkaline than acidic, which favors the growth of bacteria and increases the risk for UTI and bladder infections ⁽²⁾.

Bladder Training

It is useful and highly advocated to implement bladder training into your routine to combat multiple sclerosis bladder symptoms. Such recommendations are as follows (but should be discussed with your doctor first):

1. 1. Timed voiding: follows a schedule with set times to visit the restroom. This method does not try to teach the person to resist the urge to go. This can help train the bladder and reduce over-filling ^(2,5).
   2. Prompted voiding: trains a caregiver to remind someone to go to the bathroom. The goal is to have fewer accidents by making the person aware that they need to pee every so often. People often use timed voiding at the same time ⁽⁵⁾.
   3. Kegel exercises: strengthen the pelvic floor muscles, which help with bladder control (can be adapted for men) ^(2,5).
   4. Absorbent products: for extra protection in women and men ^(2,5).

Nicotine Cessation

Tobacco/Nicotine can irritate your bladder and increase bladder symptoms. Speaking to your physician about exploring different options on helping you quit can provide better results long-term ⁽⁵⁾.

MS Bladder Medications

In conjugation, medications can be prescribed to provide better bladder control. Antimuscarinics are usually the first-line treatment such as Darifenacin (Enablex) ⁽⁴⁾ as seen in the picture on the right. Other drugs examples are Fesoterodine (Toviaz), Imipramine (Tofranil), Solifenacin (Visicare), Tolerodine (Detrol), etc. These medications work by relaxing the detrusor muscle⁽⁵⁾.

Using the CareClinic platform, you can record the medications prescribed by your physician to keep you on track with daily intake and refill reminders. There is a section where you can write down some notes about side effect symptoms as the side effect profile can be high in some of these drugs. It is important to let your physician know; therefore, they may need to switch if medication is not tolerated⁽⁴⁾.

There are a copious number of MS symptoms; it is not just a neurogenic bladder. With that in mind, other medications that may have been prescribed to combat MS (overall) can be also listed via the CareClinic platform to help you oversee your medication plan.

If medications and bladder training are either not tolerated or provide an inadequate response, some other options can be available if decided by the healthcare professional team. Ensure speaking to your physician before exploring these options:

• Intradetrusor botulinum toxin A injections ⁽⁴⁾
• Tibial nerve stimulation and sacral neuromodulation⁽⁴⁾
• Surgery (usually the last resort when all else fails) ⁽⁵⁾

MS Bladder Control Management for Emptying Dysfunction

Intermittent self-catheterization is often the preferred option for emptying dysfunction. Due to the urine being retained in the bladder, a flexibly thin tube (called a catheter) will be placed inside the urethra to drain the urine. The urethra is the tube where urine will travel through to exit the bladder and out of our bodies^{(2, 3, 4)}.

MS Bladder Control Management for Combined Dysfunction

For MS patients struggling with combined dysfunction, all the mentioned above are used to help with the management ^{(2, 3, 4)}.

MS Medical Considerations

Urology

Despite using medications and self-care techniques (i.e. bladder training for better bladder control), if the patient is still struggling, it might be best to be referred to a specialist for more specific testing(s). That way, the specialist might be able to exactly pinpoint where the abnormality lies and may have a tailored solution best suited for the patient ⁽²⁾.

MS Symptoms

On occasion, bladder issues can be related to other MS symptoms, other medication interactions, or other MS conditions. Do not assume! As if dealing with bladder issues was not difficult enough…People may have difficulty with bladder management due to fatigue, constipation, cognitive problems, or other MS-related changes ⁽²⁾.

Non-MS Related Symptoms

Perhaps the bladder issue does not stem from MS itself. That is a consideration that needs to be addressed as this is not super unlikely. Other medical conditions unrelated to MS, such as pregnancy, diabetes, prolapsed bladder or uterus, enlarged prostate, arthritis, or the post-menopause period can lead to bladder issues. These need to be recognized, assessed and properly treated if overall bladder control is the ultimate goal ⁽²⁾.

Moving Forward from MS Bladder Issues

Dealing with bladder dysfunction is no simple task. As mentioned before, it can be debilitating to one’s mental health and quality of living. Fortunately, such medical advancements in bladder management strategies have made it a lot easier for people to enjoy their day-to-day activities with confidence. But there can still be difficulties in external factors such as sleeping patterns and energy levels that can dictate how one will conquer new goals. The CareClinic platform has a multi-faceted approach to make sure those external factors are aiding your recovery; not hindering them instead.

By using the CareClinic platform’s Check-In page, you are able to record factors such as your mood/mood changes (reasons why it might be changing such as the weather, menstruation, etc), sleeping patterns (and how you felt when you woke up that particular day), and any other factors that are recommended in your care plan. If you have a therapist, a personal trainer, or a previous doctor visit where you wish to record a blood pressure measurement…that is up to you! This will help you secure the knowledge and give your bladder (and other health needs) the upper hand. Knowledge is indeed power!

A lot of information to take in. Multiple sclerosis bladder issues should not be ignored. Understanding the signs and symptoms, different causes of dysfunctions, and treatment options are integral to implementing real change into your life. Begin your bladder-controlled life today using either your iOS or Android devices to download the CareClinic platform by clicking the banner below or buttons on top.

References

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Irene Choi

Irene Choi is a recent IMG (International Medical School Graduate) and has also attained a degree in Kinesiology at the University of Toronto. Her interests and experience include mental health advocacy, family and sports medicine as well as giving a helping hand to underserved communities.

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