Bladder Problems

Many people including those with Multiple Sclerosis find that their bladder becomes troublesome at some point in their lives. With a little forward planning and use of expert medical and nursing advice, most problems can be brought under control.
 
Bladder problems are fairly common symptoms amongst people with MS. There has been a lot of research into this problem and what the best way to deal with it is. In fact 3 in 4 people with MS will experience continence problems at some point in their lives.

The bladder is a muscular organ that acts as a reservoir for storing urine and emptying it when appropriate.
 
It is made up of a ‘balloon’ type muscle called the detrusor, which expands on filling and contracts to empty. The bottom of the bladder    funnels into what is known as the bladder neck. A ‘sling’ of muscles called the pelvic floor muscles, which help with continence, support the bladder neck. There is also a sphincter muscle located at the neck of the bladder, which acts as an opening and closing mechanism. At rest, the sphincter remains closed, therefore maintaining continence. At the bottom of the sphincter is the urethra through which urine passes out.
 
Most adult bladders can hold up to 500mls of urine and normal voiding generally occurs every 3-4 hours in a day and once at night. However, this can range between different people and yet still be classified as ‘normal’.
 
In MS the nerve signals between the brain and the bladder can be impaired or damaged which changes how the bladder works. Sensations felt in the bladder can become altered so you don’t always feel the need to pass urine, or you may feel the need more frequently and/or urgently.
 
Bladder problems
The most common problems are urgency and frequency during both day and night, difficulty in emptying the bladder, feeling of incomplete bladder emptying or a combination of all.
 
The bladder has complex nerves which are easily disrupted. This can lead to an overactive or ‘unstable’ bladder which needs emptying very often (frequency) and in a hurry (urgency). If a toilet is not reached in time urge incontinence can result. Alternatively nerve damage can mean that the bladder does not empty properly leading to overflow incontinence and other possible bladder problems which fluctuate between the two patterns.
 
It is important to realise that bladder problems are extremely common in the general population, not just in those who have MS. It is thought that around 6 million people in Britain have bladder problems. There are many possible causes for this, MS being just one of them. Do not simply assume that MS is the cause – symptoms should always be properly investigated and an accurate diagnosis made. Despite being so common bladder difficulties are often hidden and people do not like to talk about it.
 
Helping yourself and preventing problems
Generally keeping as fit and active as possible will have a beneficial effect on your bladder. It is important to try to avoid constipation as this can also disrupt the bladder. Do not get into the bad habit of emptying the bladder more and more often ‘just in case’. You may find that the habit becomes very hard to break and you end up with a very sensitive capacity bladder.
 
Many people are sensitive to caffeine and if you pass urine too often it is worth trying decaffeinated drinks to see if this reduces the frequency.
 
Drug treatments
Urgency, frequency and urge incontinence may be controlled by drugs which dampen unstable bladder muscle contractions.
 
There are a number of drug treatments available to help with bladder issues, two of the main ones used are tolterodine (detrusitol) and oxybutinin (ditropan). These are known as anticholinergics which are used to calm the bladder. They do this by blocking the involuntary nerve messages that cause the bladder wall to contract, therefore reducing how often someone needs to empty their bladder. They relax the bladder’s squeezing muscle while tightening those of the sphincter. They are usually prescribed as oral tablets and sometimes as a skin patch. They can also be given via a catheter directly into the bladder.
 
Of course as with all drug treatments they come with side effects. The most common for anticholinergics is dry mouth; other side effects are disrupted vision and constipation. Preventative measures should be taken against constipation as this can make bladder problems worse - when the bowel does not empty it swells up and pushes on the bladder.
 
Sometimes a drug therapy will be used in combination with a bladder retraining programme - depending on the main cause this programme may be recommended. Bladder retraining slowly stretches the bladder muscle and as it gradually becomes used to holding more urine, the problems of overactive bladder and urgency are reduced. Pelvic floor exercises may also be suggested as they are aimed to increase the control of the bladder, therefore increasing the bladder capacity.
 
Urinary hesitancy is a term used when it is difficult to actually empty the bladder. This can include a reduced flow rate which can often be accompanied by the feeling of incomplete emptying (retention). Damage to the nerve supply to the bladder is the main cause of the problem. Hesitancy is managed in the same way as urinary retention.

Intermittent self-catheterisation
This will ensure the bladder is completely empty. This involves learning how to insert a thin tube (catheter) up the urethra into the bladder to drain the urine; an MS Nurse or Continence Nurse will teach you how to do this. The main aim of this is to drain away any urine that may be left in the bladder. This ‘left behind’ retained urine is what can irritate the bladder causing the urgency even though the bladder is not full. It can also cause Urinary Tract Infections (UTI’s).
 
Self-catheterisation is usually done twice or three times a day and maybe before bed too. Although this can seem quite alarming at first most people find learning to catheterise very easy. Many people with MS have said their lives have been transformed by self-catheterisation.
 
Incontinence
When despite every effort and the bladder control remains unreliable, finding a way to manage the problem will help to improve the person’s quality of life. Not being able to reach the toilet in time can result in the occasional incontinence.
 
There are great ranges of absorbent products available, both washable and disposable depending on the scale of the problem. You can get pads to wear and sheets for bed protection. Different sizes and designs can be tried to find the one that suits you best. It may be possible to get these for free from your local health authority; if not there are many varieties available for sale in shops and by mail order.
 
You can find out more about these products from the Bladder and Bowel Foundation (details at the end of this leaflet) or contact your local Continence Nurse.
 
Catheters
If intermittent self-catheterisation is difficult to manage or the person just does not get on well with doing it themselves there are other options available.
 
Indwelling catheters
Once other methods of bladder management have been exhausted an indwelling catheter may be recommended. This is a long term solution whereby the catheter is inserted into the urethra basically in the same way as an intermittent catheter only it is left in place.
 
Urine is drained from the bladder by either using a valve or by having it attached to a bag. If a valve is used then urine will be stored in the bladder and can then be released at regular intervals into a toilet, a bottle or a bag. It is important to not let the bladder become over full. Urine can free flow into a catheter bag or the valve can still be used to help prevent the bladder from shrinking as it gets used to not storing as much urine.
 
Bags can be very discreet and are available in different sizes. They can be strapped to the leg under clothing or held in specially designed underwear.
 
The catheter needs to be changed regularly, usually in 12 week intervals or less but this depends on the individual.
 
Supra Pubic catheters
The insertion of this type of catheter involves a minor operation whereby it is inserted through a small incision into the abdomen (a few inches below the tummy button) directly into the bladder. This is usually done by a Urologist under local or general anaesthetic.
 
As with the indwelling catheters either a valve or bag can be attached; whichever is more convenient for the individual. This type of catheter is a permanent solution to bladder problems. They are sometimes preferred as they are easier to change and it bypasses the genital area by going directly in the abdominal wall and can be much easier to manage.
 
Although people are often put off by surgery, those who have had the procedure often find that the improvement to quality of life is well worthwhile.
 
Other options…
 
Botulinum toxin (Botox)
Botulinum Toxin acts by binding to the muscles nerve endings, which blocks the release of the chemical that causes the muscle to contract. When injected into specific muscles, the muscle becomes paralysed or weakened, but leaves surrounding muscles unaffected, allowing for normal muscle function.
 
It is injected into the bladder wall and has been found to be extremely effective for people with MS who experience bladder problems. Therefore reducing incontinence and making a significant impact on their quality of life.
 
The procedure is carried out as an outpatient using local anaesthetic. Approximately 40 injections are given in one procedure and the benefits of this should last between 6 and 12 months.
 
It is important to note that Botox is generally only used when oral drug therapies have not been beneficial. Being prepared to learn how to self-catheterise is also important in case you develop problems emptying your bladder.
 
Complementary therapies
Some people have reported beneficial effects from complementary therapies. The main ones being High Dose Oxygen Therapy, Reflexology and Acupuncture (see our ‘Therapy Centre’ leaflet to find out where you can have these treatments and our ‘Complementary and Other Therapies’ leaflet to read more about them).
 
The relaxation that can be gained from these therapies can help calm the bladder. However, they are not a cure and should not be a replacement for any medical therapies that are offered.
 
Cranberry juice or cranberry tablets are also reported to be a helpful supplement for those with bladder problems. Many people find that this helps to prevent urinary tract infections. It has been stated by researchers that there is no ‘best’ amount of juice or tablets to take each day, or if one works more effectively than the other. It is personal preference.

Further Information

• What helped my incontinence
• Incontinence Aids that work for me
• Incontinence Products

The National Institute for Health and Clinical Excellence are currently developing clinical practice guidelines concerning neurological disease related incontinence.

The guidance, for NHS use in England, Wales and Northern Ireland, covers a number of areas, including treatment to improve bladder storage and emptying, prevention of urinary tract infections, information, support and access to services.

Amy Bowen, Director of Service Development, MS Trust said “Bladder problems are among the most common symptoms reported by people with MS. They can have a significant impact on everyday life and people’s emotional well-being.

“There are many positive options to manage bladder problems and it is vital that people with MS have access to appropriate continence information and treatments. The MS Trust welcomes the development of the clinical practice guideline and will be ensuring that the needs of people with MS are represented in the consultation process.”

Adult incontinence is a common problem amongst men and women of a certain age but a variety of incontinence products are currently available to help to manage the problem and improve hygiene including many varieties of Incontinence Pants and Incontinence Pads.

Incontinence UK are an online supplier of high quality incontinence aids for men and women of any age, and also provide professional, discreet and personal service from an experience team of incontinence professionals.

MS related incontinence issues can be dealt with by nurses or specialist incontinence advisors. Depending on the nature of the problem, treatment can involve medication, bladder retraining, catheterisation or finding ways to control the effect of the symptom.

Source: Webwire WebWire® 1995 - 2012 (27/03/12)

Bladder problems are a common and distressing aspect of multiple sclerosis. Their management is currently erratic in the UK, although the problems are highly amenable to treatment.

In order to provide guidance on the management of bladder problems a multi-disciplinary expert group has assessed all the current evidence and has published in the British Journal of Neurology, Neurosurgery and Psychiatry a consensus statement of best practice.

Prof Clare Fowler, from the Uro-Neurology Department at the National Hospital for Neurology and Neurosurgery, coordinated the work of the group. She said "Having worked with people with MS over many years I was concerned that simple, straightforward management options were not being made widely available because of a belief by healthcare professionals that complex invasive investigations were necessary before treatment could be started. With this consensus we have agreed in the UK who should see MS patients at different stages of their condition and what investigations and treatments should be made available. Many people with MS stand to benefit if these recommendations are widely adopted.

Urinary incontinence is one of the worst symptoms of MS often leading to people being forced to give up work, or feeling trapped in their homes. We have good management options which should be more freely available and the use of Botulinum toxin A bladder injections and intermittent self catheterization means that we now have a highly effective treatment if first line measures are not enough. Proper management of bladder symptoms at each stage of this variably progressive condition can dramatically improve peoples' quality of life."

Jill Lovell lives with MS and said "Exciting discoveries regarding possible cures for MS in the future, such as stem cell treatment are, of course very important, but the reality of living day to day with MS also needs to be addressed. That's why I'm pleased to support today's publication commending a consensus on bladder management. Of course it's embarrassing to have to admit to needing to use catheters and pads but that isn't as embarrassing as being caught short. Far worse, I think is when people stop going out at all. I lead as fulfilling a life as I can within the limits of my MS symptoms. Good bladder management and of course, the provision of accessible public toilets contribute to my ability to do this."

Nicola Russell, Director of Services MS Trust said "Data from the recent MS audit we did with the Royal College of Physicians shows categorically that continence management is very patchy across the UK. We are grateful to all the experts who gave their time so freely to make this consensus statement a reality and hope that the principles outlined in the paper will be adopted across the UK"

MS affects about 100,000 people in the UK and two thirds of these are women. MS is most often diagnosed when people are in their 20s and 30s and is the most common neurological condition affecting young people.

In MS, damage or scarring occurs to the myelin sheath - a layer of fatty protein that protects the nerves in the same way that insulating material protects an electric wire. This damage disrupts the way in which nerve impulses are carried to and from the brain and leads to a range of symptoms, including fatigue, bladder and bowel problems, difficulties with walking and pain or abnormal sensations.

MS is a complex and unpredictable condition, which varies from person to person and does not follow a set pattern. Symptoms can come and go from day to day but there can also be relapses followed by periods of complete or partial remission.

Source: Medical News Today © 2009 MediLexicon International Ltd (24/04/09)

If you are suffering from incontinence and would like some help, or someone to talk to, contact the UK organisation for people affected by bowel and bladder problems.

Tel 0845 345 0165

Email - info@bladderandbowelfoundation.org  

Alternatively talk to your G.P. and he will refer you to a Continence adviser

Your GP, nurse or continence adviser are first contacts for specialist advice and help.

You can contact the Continence Foundation, a charity providing information and education for professionals and the public which publishes a range of leaflets and has a mail order book service, and Incontact, a self-help organisation which also publishes a quarterly newsletter. Both can be contacted at 307 Hatton Square, 16 Baldwins Gardens, London EC1N 7RJ.

There is a confidential information helpline staffed by nurse continence advisers between 9.30am and 4.30pm Monday to Friday. Call 020 7831 9831.

Charter for Continence

The Charter for Continence presents the specific needs and rights of people with bladder or bowel problems. It outlines the resources available and the standards of care that can be expected

As a person with bladder or bowel problems you have the right to:

• Be treated with sensitivity and understanding.
• Become continent if achievable.
• Receive a thorough individual assessment of your condition by a doctor or nurse knowledgeable in this aspect of care.
• Request specialist advice about continence care.
• Be provided with a clear explanation of your diagnosis.
• Participate in a full discussion of treatment options, their advantages and disadvantages.
• Be provided with full, impartial information on the range of products which are available and how to obtain them.
• Expect products to have clear instructions for use.
• Receive regular reviews of treatment and be given the opportunity to change treatments if your condition has changed.
• Be made aware of any treatments or products as they become available.
• Be provided with a personal contact point to give you on-going advice and support.

Source: The Continence Foundation “Commissioning Comprehensive Continence Services - Guidance for Purchasers” (May 1995) 

© Multiple Sclerosis Resource Centre (MSRC)