Bladder symptoms occur due to interrupted transmission of messages between the brain, spinal cord and urinary system.
Bladder problems associated with MS can be just as unpredictable as the course of the disease itself. Studies show that bladder symptoms may be related to the duration of MS, may be more prevalent amongst those whose MS began at a younger age and may correlate with a person’s level of disability. Statistics can help in a better understanding of a trend or tendency, however as is true for any MS symptom, each person lives his or her own individual experience of bladder problems.
Bladder symptoms occur due to interrupted transmission of messages between the brain, spinal cord and urinary system (see page 7). However, bladder problems can also be related to, or worsened by, difficulty in mobility, architectural barriers, complicated clothing, fluid intake, medications etc.
In turn, bladder problems themselves can make other aspects of life worse. Incontinence can cause embarrassment and anxiety, which may lead to social isolation and early retirement from employment. This can lead to unwanted changes in family dynamics and decreased self-esteem for the individual. This example underlines the complexity of bladder problems and their overall impact on a person’s life; it shows how important it is to make a comprehensive assessment of the individual and the approach to caring for and managing their MS, rather than addressing one symptom at a time.
Timely evaluation and management are important, not only because bladder problems negatively impact on a person’s daily activities, but because they can also have long-term consequences on one’s life-style, self-image and well-being and can even result in serious health consequences including kidney failure, dialysis and permanent damage.
Diagnosing bladder problems
The key to correct diagnosis of bladder problems is a thorough history of bladder habits and symptoms together with appropriate investigations. The MS nurse (or other healthcare professional, depending on the country and healthcare provision available) plays an important role in the diagnosis phase, as well as in management.
Initially the MS nurse will talk to the person with MS and gather relevant information on:
• the person’s concerns regarding bladder function
• what type of problems exist
• whether the person uses any self-management strategies and whether these strategies are effective
In addition to a thorough discussion, the MS nurse can ask the person to complete a urinary diary (Figure 1, see page 12). This is used to record the number, quantity and circumstances of urination (for example, if incontinence, urgency, hesitancy were experienced and the type and quantity of liquid consumed) over a period of 24 to 48 hours.
This information will help the MS nurse to have a better idea of the nature of the person’s bladder problems. It is also important to determine whether the individual has urine remaining in the bladder following urination (this is called ‘post-void residual’). This is generally done by a procedure, called catheterisation, and it is usually performed by the nurse, who catheterises the person after he or she has voluntarily urinated, in order to measure the amount of urine that is still in the bladder. However, other testing methods including ultrasound may also be used (see page 16).
Based on information from the clinical history, urinary diary and post-void residual, the nurse can determine whether there is a failure to store urine or a failure to sufficiently empty urine from the bladder, and in turn which course of action to follow.
As a standard rule, when bladder problems are present, it is important to perform a urinalysis and urine culture. This helps determine if the symptoms are caused by a urinary tract infection or are directly related to MS. The treatment for each type of symptom is different. When bladder problems cannot be attributed to MS or to a urinary tract infection, the individual is referred for further evaluation.
Managing bladder problems
Together with the nurse, the person with MS can explore various self-management strategies that can be useful in maintaining quality of life. The most commonly utilised strategies include bladder training, also called timed voiding, intermittent catheterisation and regulating fluid intake. These strategies, depending on the specific problem (failure to store urine or failure to empty the bladder completely), can be utilised in combination with medications that have been found to be effective for the treatment of bladder symptoms in MS (see page 9).
Bladder training is a behavioural technique that can be useful in improving bladder functioning. The individual has to follow a daytime schedule for urinating, for example, every two hours. Between the scheduled times the person must resist the urge to urinate. The MS nurse can determine whether this technique is appropriate for the individual, give instructions on the requirements for successful bladder training, and follow-up regularly to monitor progress.
‘When the neurologist told me I would have to start self-catheterisation,
I was really opposed to it. I now know that all you have to do is accept it and get on with it. I am doing just fine, it’s easy.’
Mark
Intermittent catheterisation is a technique for managing bladder problems related to insufficient emptying of the bladder.
| 
It is used as a rehabilitation technique for retraining the bladder and may even be discontinued if there is sufficient improvement in bladder emptying. Otherwise, intermittent catheterisation is an ongoing strategy for bladder management.
The aims of intermittent catheterisation are to prevent infections by reducing residual urine in the bladder and promote continence. Intermittent self catheterisation encourages autonomy and helps maintain self-esteem. Once the individual masters the technique, he or she is able to feel more in control of bladder problems, more confident and less anxious.
Since catheterisation allows for complete emptying of the bladder at scheduled intervals, the fear of embarrassment caused by accidental leaking of urine or frequent visits to the bathroom can be significantly reduced. In addition, intermittent catheterisation can be a successful strategy for people who experience the common MS symptom of nocturia (the need to urinate frequently during the night) because the bladder does not completely empty with voluntary urination. Nocturia can be a disturbing symptom as it affects the ability of the person to sleep through the night, and in some cases is also distressing for the carer if the person is not able to reach the bathroom independently. It can result in significantly decreased energy the following day and can have a negative impact on the person’s ability to perform daily activities. However, intermittent catheterisation permits the bladder to be emptied completely before going to bed, allowing the person to sleep uninterrupted for up to four to six hours.
Intermittent catheterisation consists of inserting a small tube, called a catheter, into the bladder, by way of the urethra, allowing urine to drain out through the tube (see figure 2, page 13). The technique is referred to as ‘clean’ catheterisation, meaning that it is not necessary to use sterile products or to perform the technique using gloves, but is done using basic rules of hygiene. Modern types of catheters are quite small and are pre-lubricated so that they do not require water or lubricating gel.
Self-intermittent catheterisation is not appropriate for everyone. It does require a sufficient level of manual dexterity. It may be difficult or impossible for people with tremor, upper limb weakness or poor co-ordination. In these cases the MS nurse can teach the technique to a personal assistant or carer. For carers already responsible for many other personal assistance duties, intermittent catheterisation can add to the burden of care and alternative management techniques may be considered.
The idea of performing intermittent catheterisation can be daunting for many people. However, it is easy to learn and does not create a risk of infection when performed correctly. It is necessary to learn the technique from the MS or continence nurse and is usually mastered in a short time. It is helpful to think of intermittent catheterisation as a way of gaining control of bladder problems, of being autonomous in managing a difficult MS symptom. Figure 2 lists the steps to follow for performing intermittent catheterisation. For information on other types of catheters see pages 16 and 20.
Other strategies
Regulating fluid intake by decreasing the amount consumed is often the first self-management technique used by many people with MS, in the hope that it will decrease urinary frequency and prevent incontinence. However it can be unhealthy and can create other problems, such as constipation.
It is important to drink one and a half to two litres of fluids every day, preferably water, even for people with bladder problems. A strategy for maintaining this level of fluid intake without worsening urinary frequency is to divide up the required amount of water and drink it at three or four times in the day, rather than sipping small amounts throughout the day which can result in frequent trips to the bathroom.
Some fluids, such as alcohol and drinks containing caffeine, are bladder irritants and can make bladder problems worse by increasing symptoms of urgency and frequency. It is better to avoid these types of drinks.
Cranberry supplements (tablets) are often used by people with MS as a self-help strategy for the prevention of urinary tract infections since cranberry makes urine more acidic, helping to inhibit bacterial growth. On the other hand, it is best to limit intake of citrus juices since they make urine more alkaline than acidic, which favours the growth of bacteria.
Importance of communication
The MS nurse or similar healthcare professional plays an important role in assessing and managing bladder problems. Optimal management requires that the person with MS feels comfortable talking about bladder problems with his or her nurse, and requires that the nurse has an understanding of his or her patient’s clinical history, concerns, goals and lifestyle. Working together, through open communication, the person with MS and the nurse can identify problems and decide the strategies for best managing bladder symptoms.
|
