Bladder Problems

Urine is made in the kidneys, and travels down two tubes called ureters to the bladder, an elastic sac that stores urine. When things are working properly, urine collects slowly in the bladder, causing it to expand. When 4 to 8 ounces of fluid have accumulated, nerves in the bladder send signals to the spinal cord which signals the brain that the bladder needs to be emptied. As the person prepares to urinate, the brain/spinal cord signal triggers the voiding reflex, which causes two things to happen at the same time:

• The bladder muscle (detrusor) contracts to push urine out of the bladder
• The external sphincter — which normally remains closed — opens to allow urine to leave the body

Bladder dysfunction, which occurs in at least 80 percent of people with MS, happens when MS lesions block or delay transmission of nerve signals in areas of the central nervous system (CNS) that control the bladder and urinary sphincters. A spastic (overactive) bladder that is unable to hold the normal amount of urine, or a bladder that does not empty properly (retains some urine in it) can cause symptoms including:

• Frequency and/or urgency of urination
• Hesitancy in starting urination
• Frequent nighttime urination (nocturia)
• Incontinence (the inability to hold in urine)
• Inability to empty the bladder completely

Healthy bladder function is essential for long-term kidney health, prevention of infection, personal independence, self-confidence and overall quality of life. Untreated bladder issues can cause:

• Worsening of other MS symptoms, such as weakness and spasticity
• Repeated bladder or urinary tract infections (UTI), or kidney stones that can cause serious pain and compromise overall health
• Challenges with work, home and social activities
• Loss of independence, self-esteem and self-confidence

Early medical evaluation is important to determine the cause of the bladder symptoms and choose the appropriate management and treatment strategies. At their most serious, untreated urinary problems can lead to infections in the blood (urosepsis) and skin breakdown — two factors that can shorten life in someone with MS.

"Since first being diagnosed with MS or having neurologic symptoms:

• Am I finding it more difficult to start urinating when I get to the toilet?
• Do I feel as though my bladder isn’t completely empty when I’ve finished urinating?
• Do I experience frequent or recurrent urinary tract infections?
• Am I using pads or any other strategies to protect my clothing from urinary leakage?
• Am I limiting the amount of fluids I drink because I worry about having to urinate frequently?
• Am I planning my daily activities around my bladder symptoms?
• Do my bladder symptoms keep me from doing what I enjoy?
• If I had to spend the rest of my life with my bladder behaving the way it does now, would I be unhappy?"

If you answered ‘yes’ to any of these questions, contact your neurologist, nurse or primary care provider about an evaluation of your bladder function. Print these questions (.pdf) to bring with you for reference. Either your healthcare provider or the National MS Society (1-800-344-4867) can refer you to an urologist with expertise in MS bladder management.

Bladder symptoms can usually be managed successfully with lifestyle modifications, medications, physical therapy and/or nerve stimulation procedures.

Lifestyle changes may include

• diet modifications,
• adequate fluid intake up to a few hours before bedtime,
• bladder training or planned voiding, among others.

Learn more (.pdf) and ask your doctor for advice, as some changes — such as limiting fluid intake — can lead to dehydration and other potentially dangerous complications.

• More than a dozen medications in a variety of forms are available to address specific bladder symptoms in MS. You and your healthcare provider to select the optimal treatment approach for you after a careful assessment of your bladder symptoms.
• Pelvic floor physical therapy (often prescribed for spastic or overactive bladder symptoms) targets the group of muscles attached to the pelvic bone and sacrum that rule bladder and bowel function. The therapy uses biofeedback, neuromuscular stimulation and daily home exercises, and works by strengthening the pelvic floor muscles, improving muscle control, and promoting muscle relaxation as needed for urination.
• During percutaneous tibial nerve stimulation (PTNS) (for symptoms of spastic or overactive bladder), a very small needle electrode is inserted in the ankle. The electrode transmits a signal to the sacral plexus (a network of nerves that controls the bladder and pelvic floor muscles). Treatment for 30 minutes per week for 12 weeks has been shown to reduce urinary frequency, urgency, nighttime urination and incontinence.
• Intermittent self-catheterization (ISC) may be recommended for difficulty emptying the bladder. In ISC, a small tube (catheter) is inserted into the urethra to empty the bladder, and then removed. ISC one or more times per day can help control bladder leakage, urgency and frequency, and nighttime urination in people who cannot completely empty their bladder on their own.
• InterStim® is a small device surgically implanted under the skin that stimulates the sacral nerves and is used to treat overactive bladder, urinary retention and some types of bowel dysfunction.
• Other surgical interventions are available to address urinary problems that do not respond adequately to any of these interventions.

• Plan frequent stops.
• Use and carry discreet protection — such as pads. They afford you confidence, especially in situations where getting to the restroom could be difficult, like on an airplane.
• Wear easily removable clothes — such as trousers with elastic waistbands or Velcro closures.
• Stash a change of clothes, underwear, pads, wipes, catheters, paper towels — whatever you need — in a tote bag or backpack that you bring with you.

The health of your bladder is crucial to your overall health and quality of life. Any symptoms you experience are important to address with a healthcare professional. Available treatment options are effective for managing most symptoms, allowing you to live your life fully without bladder issues getting in your way.

• National Association for Continence - world’s largest consumer advocacy group and distributor of educational information about bladder/bowel control problems. Provides referrals to health care professionals specializing in the diagnosis & treatment of incontinence.
• Urology Care Foundation - supports urologic research and strives to provide, comprehensive and reliable urologic health information to the public. Provides an online search tool to locate urologists (more than 19,000 listings) who are members of the American Urological Association, as well as board-certified by the American Board of Urology. 
• Home Delivery Incontinence Supplies, Inc.
  Carries a variety of adult incontinence products including popular and specialty brands.
• Ask an MS Expert: Managing MS Bowel and Bladder Symptoms
• CanDo MS - Managing Bowel & Bladder Symptoms