Randall T. Schapiro, M.D.

Many people with MS experience difficulties with bladder control and urination at some point during the course of the disease. Bladder symptoms usually may be controlled with medication or other approaches that minimize any changes in daily activities and life-style.

The Urinary System and Its Control

Figure 10-1 shows the urinary system, whose main function is to collect and eliminate bodily wastes in the form of urine. The urinary system includes the kidneys, which filter the blood to remove waste products and produce urine at a rate of approximately one ounce (30 cc) per hour;
the bladder, a muscular sac that stretches to store the urine until it is emptied by urination, a process referred to as voiding;
the urethra, a hollow tube through which urine passes from the body when voiding occurs;
the urethral sphincter, a valve-like muscle that opens and closes to control whether urine remains in the bladder or is voided

When 6 to 8 ounces (180 to 240 cc) of urine is present in the bladder, it becomes sufficiently stretched to stimulate nerve endings located in its wall. These nerves send a signal of fullness to an area in the spinal cord that may be thought of as a "voiding reflex center" (Figure 1 0-2A). This center in turn sends the signal on to the brain, and you become aware of the need to urinate. The brain then signals the spinal center, which sends two signals, one to the bladder telling it to contract and a second to the urethral sphincter muscle telling it to relax. This combination of a contracted bladder and a relaxed sphincter permits urine to flow from the bladder.

Bladder Problems Associated with Multiple Sclerosis

The elimination of urine by conscious choice is dependent on the integrity of the spinal cord pathways that connect the brain and the voiding reflex center. The downward command by the brain to "empty" causes relaxation and opening of the sphincter, whereas the command to "wait" signals the sphincter to remain closed. The pathways between the reflex center and the brain may be damaged or interI1lpted in MS, producing a variety of problems and/or symptoms. The specific nature of the problem depends on the location of the damage. For example, if the connections between the reflex center and the brain are severely damaged, the reflex center may assume direct control of voiding and automatically stimulate the bladder to empty whenever it fills. The most common bladder problems associated with MS are increased frequency of urination, urgency, dribbling, hesitancy, and incontinence.

Frequency involves an increase in the number of times urination occurs within the day. In some people, voiding may occur as often as every 15 to 20 minutes, usually in small amounts each time. The frequency of urination depends on the rate at which urine is formed and the ability of the bladder to store it.

Urgency is the feeling of having to empty the bladder immediately, combined with an inability to "hold" urine once the urge to void is felt. People who experience this problem have little time to reach a bathroom.

Dribbling is the leakage of small amounts of urine from the bladder. This may occur as the result of urgency and the inability to retain urine. In some cases, a person may only be aware of this problem when damp undergarments are noted.

Hesitancy involves difficulty in beginning to urinate after the urge to void is felt. This symptom may be associated with urgency, so that one is unable to urinate while the urge to do so remains.

Incontinence is an inability to hold urine in the bladder. It may result either from not being able to reach the toilet in time or from being unaware of the need to empty the bladder because of blockage of the pathways between the voiding reflex center and the brain. Despite the ability of the bladder to stretch as it fills, it can hold only a certain amount of urine and empties spontaneously after this limit is reached.

Probably the most common type of bladder problem in MS results from a small spastic bladde1; sometimes referred to as a "failure to store" bladder, which results from demyelination of the spinal cord pathways between the voiding reflex center and the brain (Figure lO-2B).

TABLE 10-1. Types of Bladder Dysfunction
Problem Symptoms Treatment
Small, spastic bladder
("failure to store") Increased frequency,
urgency, dribbling,
and/or incontinence Oxybutynin (Ditropan)
Hyoscyamine (Levsinex, Levbid)
Tolterodine tartrate (Detrol)
Flavoxate HCI (Urispas)
Imipramine (Tofranil)
Antihistamines
Flaccid ("big") bladder
("failure to empty") Frequency, urgency,
dribbling, hesitancy,
incontinence Crede technique
Intermittent
self-catheterization
Dyssynergic bladder
("conflicting") (a) urgency followed
by hesitation in
beginning to void;
OR
(b) dribbling or incontinence Alpha blockers

Because the pathways to the brain are blocked, bladder emptying no longer is under voluntary control. Voiding then becomes a reflex activity, with messages to "empty" coming only from the spinal center. A small spastic bladder may produce symptoms of increased frequency, urgency, dribbling, and/or incontinence.
When demyelination occurs in the area of the spinal voiding reflex center, messages cannot be transmitted to or from either the brain or the bladder. A flaccid or "big" bladder results (Figure 1O-2C). The bladder fills with large amounts of urine, but because the spinal center cannot transmit messages on to the brain, the person is unaware of this fullness. Because the spinal center also cannot transmit messages to the bladder and sphincter, there is very little voluntary or reflex control over urination. The bladder fills and then overfills, producing symptoms of frequency, urgency, dribbling, hesitancy, and incontinence. This situation sometimes is refeued to as the "failure to empty" bladder.

The third type of bladder dysfunction is the dyssynergic or "conflicting" bladder, in which the problem is related to coordination between bladder wall contraction and sphincter relaxation (Figure 1 O-2D) rather than to the size of the bladder. In the dyssynergic bladder, either (1) the bladder wall contracts while the sphincter remains closed, resulting in a sense of urgency followed by hesitancy in beginning to void; or (2) the bladder wall relaxes while the sphincter remains open, resulting in dribbling of urine or incontinence. This lack of coordination between the bladder wall and the sphincter frequently is seen in combination with either the spastic or the flaccid bladder.

It is important to remember that the bladder does not make urine - urine is made by the kidneys. Disease of the kidneys is not a routine complication of MS and only occurs if infection of the bladder is uncontrolled. This is surprisingly uncommon in MS, which makes the routine kidney X-ray (intravenous pyelogram, or IVP) for the most part unnecessary. However, the risk of urine backing up from the bladder toward the kidney is increased in a man with a dyssynergic bladder (women usually do not experience this problem because the pressures within the female bladder aJe lower). This potential problem must be carefully managed by a physician.

Management of Bladder Problems

Bladder problems often may be managed with medications and/or other approaches. To determine the most appropriate mode of treatment, it first is necessary to distinguish between the spastic (failure to store), flaccid (failure to empty), and dyssynergic bladder. This is easily done by carefully recording the frequency of urination and the amounts of fluid urinated over a 48- hour period, followed by determining how much urine remains in the bladder after voiding. The amount of this "residual" urine is measured by inserting a catheter into the bladder or by ultra- sound technology after urination; a residual of less than 5 ounces (150 cc) indicates either a normal bladder or a small spastic bladder, whereas a larger amount indicates a flaccid bladder.

The small spastic bladder is best treated with medications that "slow" the bladder by decreasing transmission in the nerves to the bladder that cause it to empty. These include oxybutynin (Ditropan), tolterodine tartrate (Detrol), hyoscyamine (Levsinex, Levbid, Cystospaz), flavoxate hydrochloride (Urispas), imipramine (Tofranil), and several medications that are used for the "runny" nose of a cold. These medications lengthen the intervals between urination and decrease urgency, thus allowing for more time to reach the bathroom and avoiding dribbling and incontinence.
Treatment of the flaccid bladder is not as simple, and management frequently relies on alternative techniques for bladder emptying rather than on medication. One common method that facilitates more complete bladder emptying is the Crede technique of bladder massage. This technique involves applying downward pressure to the lower abdomen with both hands while bearing down after as much urine as possible has been voided naturally; it is necessary for men to sit while using the technique. This technique should not be used in the dyssynergic bladder because the urine may back up into the kidneys. This mainly is a problem in men because pressure is much lower in the female bladder.

If the bladder cannot be emptied sufficiently by the Crede technique, intermittent self-catheterization may be used for more complete bladder emptying. A small tube, or catheter, is inserted through the urethra into the bladder to allow the urine to drain out. This may seem rather complicated, but actually it is simple to learn and it poses no risk. It allows a person to empty the bladder at planned intervals, thus avoiding dribbling or incontinence. The frequency of self-catheterization varies from person to person but generally need not be done more frequently than every four to six hours. Medications such as oxybutynin frequently are used in conjunction with self-catheterization to allow the bladder to fill more completely and to decrease the need to urinate between catheterizations.

As mentioned previously, conflict or dyssynergia often is combined with either a spastic bladder or a flaccid bladder. Initial treatment based on the 48-hour diary is aimed at either spasticity or flaccidity; if the previously described techniques do not provide adequate control, it becomes apparent that the bladder wall and the sphincter are not functioning in a coordinated fashion. Occasionally, formal testing with a "bladder analysis machine" (cystometer) is needed to accurately pinpoint the source of the problem. The problem may be helped by the addition of an alpha blocker to the treatment regimen. Most alpha blockers were developed to aid in the treatment of high blood pressure, but they also help the bladder work in a more coordinated manner. Phenoxybenzamine (Dibenzyline), clonidine, and terazosin (Hytrin) are alpha blockers that improve coordination and increase bladder control.

Problems with incontinence may occur mainly at night during sleep. One approach to this problem involves the use of a medication called DDAVP (desmopressin), a hormone that slows the production of urine by the kidneys. DDAVP comes in many forms, but the most practical form is now a pill. One or two pills decrease urine formation during the night and decrease the chances of a wet bed. This helps one to get a good night's sleep, which may decrease morning fatigue. The body eliminates the stored fluid during the daytime, so the person has to be able to control his or her bladder during the day. DDAVP is very expensive.

If a bladder problem cannot be controlled with medication and/or intermittent self-catheterization, continuous (chronic) catheterization may become necessary. This is done with a permanent Foley catheter. This type of catheter is used only when absolutely necessary because it is associated with an increased incidence of urinary tract infection. A condom type catheter also may be used by men. The penis must be of sufficient size that the condom has enough area to adhere to the shaft. Because this area is damp and mechanical stress is involved, care must be taken not to ulcerate the penis. Unfortunately, female condom catheters are not sufficiently reliable to be used on a regular basis.

Urinary Tract (Bladder) Infection

Urinary tract infection (UTI) is an example of what is termed a secondary problem in MS. UTI is not a direct result of the demyelination process but occurs as the result of (secondary to) the retention of urine in the bladder. Mild infection may result only in increased frequency and urgency of urination, whereas severe infection produces fever and generalized illness.

The incidence of urinary tract infection is higher than normal in (I) those who have a flaccid bladder because bacteria may grow in the retained urine; (2) those who need to perform intermittent self-catheterization; and (3) those who have an indwelling Foley catheter, which may provide bacteria with a direct route into the bladder. Women generally are at higher risk for the development of bladder infection than men. The diagnosis of a urinary tract infection is made by a urine culture, in which urine is collected in a sterile fashion and tested for the presence of bacteria. The presence of bacteria in the urine does not necessarily mean that there is an infection that requires treatment. Many persons with MS have what is described as "asymptomatic bacteriuria," especially if they have an indwelling Foley catheter. If the person is asymptomatic, without pain, fever, or other signs of the spread of infection, it is appropriate simply to watch the process.

Other symptoms of a urinary tract infection may include frequent urination, urgency, burning or discomfort when urinating, fever, or foul-smelling urine accompanied by the presence of blood or mucus. Because some of these symptoms are similar to symptoms frequently experienced by an individual with MS, treatment should not be started until the presence of infection has been confirmed. Generally, infection is suspected when symptoms occur suddenly or if fever is present. A urine specimen is cultured in the laboratory to confirm that bacteria are present before treatment is initiated with an antibiotic specific for the organism causing the infection; the antibiotic generally is taken for seven to ten days. New antibiotics are being developed constantly, and they have been very helpful in managing severe bladder infection.

Bladder infection may largely be prevented by complete bladder emptying, using self-catheterization techniques if necessary. Bacterial growth is prevented or retarded when the urine is acidic, which is best achieved by taking high doses of vitamin C. A person who has a history of urinary tract infection may be helped by substances that suppress the growth of bacteria in the urine and low doses of antibiotics, usually sulfa or nitrofurantoin. Prevention is the key to avoiding bladder infections.

Urination should be frequent and complete, and holding urine in the bladder for long periods should be avoided.
Women should be careful to wipe from front to back, especially after a bowel movement, and should avoid undergarments that are made of synthetic materials, which tend to trap moisture. Women who have recurrent infection should empty the bladder both before and after intercourse.

Adequate amounts of fluid should be taken to keep the bladder "flushed." Generally six to eight glasses per day is sufficient.

Those who are prone to the development of bladder infection should take up to 1000 mg of vitamin C four times each day to make their urine more acidic because higher acidity inhibits bacterial growth.

People who have an indwelling Foley catheter should be especially careful to keep the catheter, tubing, and drainage bag as clean as possible. The catheter should be changed at least once a month, using proper sterile technique.

Urinary tract infection may pose a serious threat to health if it is not properly treated, so it is very important to seek medical attention if symptoms occur:
When a urinary tract infection does occur, the key to treatment is the use of an appropriate antibiotic, as indicated by the results of the urine culture and a related test for the antibiotic sensitivity of the infecting organism. It is important that this medication be taken as directed for the complete time period indicated to ensure that all the invading bacteria will be destroyed. It is a mistake to stop taking an antibiotic if you are feeling better because not all the bacteria will have been destroyed; the remaining bacteria will reinvade and cause further problems.

Bladder Spasms

The bladder sometimes contracts involuntarily. The result often is pain and a squirt of urine that may lead to total emptying of the bladder. If a catheter is in place, the urine will leak out around it. This is a bladder spasm. The medications used for leg spasms (see Chapter 5) often are helpful, as are the medications used for the small, spastic bladder.

Bladder Procedures

Occasionally, nothing works well to control the bladder and wet- ness is a constant and unacceptable companion. It may then be necessary for a urologist to place an opening to the bladder in the front of the body, a procedure called a continence viscostomy. In women this allows for much better visualization of an entrance to the bladder and with an appropriate valve implantation self-catheterization may be accomplished through the opening.

If the bladder is very small and shrunken, a bladder augmentation procedure sometimes may be performed by surgically taking a piece of colon and using it to enlarge the bladder. This allows for more storage room.
An indwelling Foley catheter may irritate the bladder wall, and bladder stones may form in response to this irritation. Bladder stones may increase the likelihood of infection and decrease urinary flow. The stones usually are removed by a fairly simple surgical procedure called a cystoscopy, which is performed through a "scope" that the urologist uses to look into the bladder.

With chronic, significant infections, the bladder wall may become so damaged that the infection cannot be cleared and the bladder must be bypassed or diverted. A piece of intestine is used to divert the urine to a bag on the body like a colostomy. This procedure is reserved for extreme situations, but it does permit infection to be controlled more easily.

Incontinence Pads

The number of incontinence devices and pads has multiplied in the 1990s. There are many kinds of adult incontinence devices and diapers. The key is to prevent skin irritation, to have no specific offensive odor, and to be comfortable. It is beyond the scope of this chapter to discuss this topic in detail, but improvements are occurring constantly and must be assessed accordingly.

Available from Demos Medical Publishing
386 Park Avenue South, Suite 201, New York, NY 10016,
USA. Tel +(212) 683 0072. Fax: +(212) 683 0118.
Web site:http://www.omm.btinternet.co.uk/demos.htm