Bladder problems - factsheet
Date of issue: September 2008
Contents
- Introduction
- How the healthy bladder works
- Bladder problems in MS and their treatment
- Bladder urgency and frequency
- Night-time bladder problems (nocturia)
- Difficulty emptying the bladder (urinary hesitancy)
- Feeling of incomplete bladder emptying (urinary retention)
- Complicated bladder problems – combination of symptoms
- Severe bladder problems
- Current research and experimental treatments
- Urinary tract infections
- Complementary and alternative treatments
- Useful organisations
- Further reading and references
1. Introduction
Bladder problems are among the most common symptoms reported by people with MS. In one study, 87% of people with MS reported bladder problems, with 70% reporting that this symptom had a moderate to high adverse effect on their day-to-day quality of life.[1] Over the years, there has been considerable research into bladder symptoms and there is a range of treatments and strategies that enable many of the bladder problems experienced people with MS to be effectively managed. Do not suffer in silence!
People with MS should be aware that an MS Nurse, where available, will play a pivotal role in the assessment, diagnosis and treatment of bladder problems.
This MS factsheet is designed to give an overview of the main symptoms and their treatments. More detailed information is available from the MS Trust on request.
2. How the healthy bladder works
This diagram gives an outline of the relationship between the brain and bladder. The kidneys create urine as a means of excreting waste products; urine is sent to the bladder which acts as a storage vessel. The bladder is a muscle that can expand and contract. When it contracts urine is pushed out through the outlet (the urethral sphincter), which works like a valve and is controlled by the urethral sphincter muscle.
When the bladder fills to a certain level, nerve endings in the bladder wall are stimulated to send a signal to the part of the spinal cord that controls the bladder emptying reflex. This area of the spinal cord then sends messages to the brain. Until there is an opportunity to empty the bladder, the signals are recognised by the brain but may be ignored for around one to two hours. When a suitable occasion arises, the brain sends messages back to the spinal cord reflex centre and onto the bladder, telling the bladder to contract and the urethral sphincter muscle to relax, thereby allowing urine to flow out through the urethra.
How often is normal? This varies but is thought to be when the bladder is emptied anywhere between six to eight times a day - commonly at intervals of about three to five hours - depending on the level of fluid intake. A healthy bladder has a capacity of between 300-500ml of fluid. It is rarely completely empty, with a residual volume left of around 10% of capacity after voiding has taken place.[2]
Fluid intake is vital to ensure the kidneys and bladder work as well as possible. People with bladder problems often drink less in the hope that reducing fluid intake will minimise bladder symptoms. However, reducing fluid levels causes a number of problems, including production of concentrated urine that creates a good environment for infection in the bladder. General advice is to drink around two litres, or 6-8 glasses, of liquid per day.[3]
3. Bladder problems in MS
The most common bladder problems in MS are: urgency and frequency during the day and night; difficulty in emptying the bladder; feeling of incomplete bladder emptying; or a combination of symptoms. These are considered consecutively below.
- Bladder urgency and frequency
- Night-time bladder problems (nocturia)
- Difficulty in emptying the bladder (urinary hesitancy)
- Feeling of incomplete bladder emptying (urinary retention)
- Complicated bladder problems – combination of symptoms
a. Bladder urgency and frequency
Bladder urgency can be defined as a desperate urge to go to the toilet with little or no warning. Frequency is defined as needing the toilet more than eight times a day. Urgency and frequency may be experienced separately or in combination. Either of these symptoms can be very disabling, as people may become unwilling to venture out of the house or to try new activities if they are unaware of the location of toilets. Frequency or urgency can also cause a need to urinate several times during the night, disturbing sleep, and impacting on other symptoms. Sometimes frequency and urgency can cause someone to lose control over their bladder completely - known as incontinence.
Urgency and frequency happens because when the bladder is partly full, messages are interrupted between the bladder emptying reflex signals in the spinal cord and the brain. This means that reflexes controlled by the spinal cord govern the bladder muscle and tell it to empty as soon as it starts filling.
Alternatively, over-frequent emptying of the bladder can be due to infection or anxiety. Emptying the bladder too often will reduce its ability to store urine. Over time frequency of urination can mean that bladder capacity falls to around 100ml or less. It will then need emptying more frequently.
For some people with MS, the area of the spinal cord that controls the emptying reflex may become damaged. As there is no reflex to urinate, the bladder becomes very full. The person is unaware of this so the bladder overfills and the wall stretches becoming thinner and less controllable. People with this problem may experience urgency and frequency, or dribble urine occasionally, or may experience urinary hesitancy (see Difficulty in emptying the bladder (urinary hesitancy)).
Investigations and treatments for urgency and frequency problems
There are a number of steps for investigating and treating a bladder problem. [4]
- Check for urinary tract infection
The tubes that drain urine out of the kidneys into the bladder are referred to as the urinary tract. Various factors can contribute towards infection within these tubes. An MS nurse can check for urinary tract infection using a dipstick test in a urine sample. (see Urinary tract infections). - Bladder diary
If a urinary tract infection is not present, the first step is for the person with MS to complete a bladder diary over a week or so, to record the amount drunk and how often the bladder is emptied. This gives a health professional such as an MS nurse, GP, or continence advisor, an idea of the nature and scale of the problem. - Check for efficient bladder emptying
If there is no sign of a urinary tract infection, the health professional may check the amount of urine left after someone has urinated. This is known as the post-void residual volume. An ultrasound bladder scan is normally used for this check, which is available through an MS Nurse, continence services, and possibly in GP surgeries. Research has shown that around half of all people with MS who thought they were emptying their bladder completely when going to the toilet in fact had not done so.[5] Finding more than 100ml of urine left after voiding shows that the bladder is not emptying properly. This symptom is known as 'urinary retention' (see section on urinary retention).
If bladder emptying is complete and there is no infection but urgency and frequency remain, the following steps are worth considering:
Options for managing urgency and frequency
- Review fluid intake
Reviewing the amount of liquid drunk in an 'average' day can be done independently or with a health professional. Some fluids, such as coffee, tea, cola and other caffeinated drinks, along with alcohol, irritate the bladder and can make symptoms worse. Replacing some or all of these with other liquids can help. It is important to ensure that enough liquid is being consumed, normally around six to eight glasses per day. Liquid foods such as soup, custard, and jelly can be included in this calculation. - Bladder retraining
Depending on the likely cause of symptoms, an MS nurse may recommend bladder retraining. Bladder retraining is a series of pelvic floor exercises aimed at increasing someone's control of their bladder, and increasing bladder capacity. This should help with frequency of urination. - Simplify the process
One straightforward step is for the person with MS to consider whether clothing and/or toileting arrangements are causing unnecessary delays. If so, changes such as wearing practical clothing or having access to a downstairs toilet or commode, might be considered. - Consider a RADAR key
RADAR, the campaigning group for disabled people's rights, operates the National Key Scheme. This scheme offers independent access to disabled people to around 6,500 locked public toilets around the country. Keys are available for a small charge directly from RADAR – details in section 8 – or, in some cases, from local authorities. Owning a RADAR key increases the number of accessible toilets someone can use. There is also a register of RADAR key toilets available to purchase or on their website, so that someone can identify how useful this might be. - Consider carrying a 'Just can't wait card'
The Bladder and Bowel Foundation, a national charity for people affected by bladder and bowel problems, produce 'Just can't wait' cards for people who experience urgency and frequency. You can show your card to shop owners and businesses or when there are long queues for the toilet. The cards won't guarantee you access to toilets, but help to explain that you have a medical condition which dictates urgent use of the toilet in such situations.
Drug treatment options for urgency and frequency
- Drugs to calm the bladder
An MS nurse, GP, or continence advisor may prescribe drugs known as anticholinergics to calm the bladder. Anticholinergic drugs block the messages that start bladder contractions, and so reduce how frequently someone needs to empty their bladder. Most anticholinergic drugs are oral tablets, and commonly prescribed ones include oxybutynin (brand name: Ditropan, Lyrinel XL) and tolterodine (brand name Detrusitol, Detrusitol XL). Some of the anticholinergic drugs may be given either as a skin patch or via a catheter directly into the bladder. The way the drugs are given will depend on medical advice.A common side effect of anticholinergics is a dry mouth. Sucking mints or frozen pineapple may help counter this problem. The drugs can also worsen retention of urine in the bladder and cause constipation. Where skin patches are used, skin reactions are one of the potential side effects.
Other options
If, despite these measures, symptoms do not improve, a referral to a specialist continence service for further assessment and advice should be made. A MS nurse, neurologist, or GP can refer.
b. Night-time bladder problems (nocturia)
For some people, urgency and frequency are a particular problem at night, leading to disturbed sleep. This is known as nocturia. There are a number of possible causes of nocturia, so it is important that any instances are properly investigated before treatment starts.
However, if MS is found to be the cause, desmopressin may be prescribed. Desmopressin is a synthetic form of the hormone vasopressin, which regulates the way that the kidneys handle water in the body. For nocturia it may be prescribed to reduce the amount of urine made by the kidneys. This reduces the amount being stored in the bladder, and therefore the number of night-time trips to the toilet. Desmopressin must be used with caution as reducing the amount of urine made by the kidneys over the long-term may eventually lead to kidney failure. Desmopressin is not licensed for anyone aged over 65.
c. Difficulty in emptying the bladder (urinary hesitancy)
Another common MS symptom can be difficulty in emptying the bladder. Typical experiences include a reduced flow rate or an interrupted stream of urine, often accompanied by a feeling of incomplete emptying. In some people these symptoms may be combined with feelings of urgency and frequency. Problems with bladder emptying may cause urine leaks in spite of earlier efforts to empty the bladder.
Urinary hesitancy can be the result of one of three processes. In all cases, damage to the nerve supply to the bladder is the cause of problems.
- The area of the spinal cord that controls the bladder emptying reflex becomes damaged. As there is no reflex to urinate, the bladder becomes very full but the person is unaware of how full it is and is not able to empty successfully. Urine leakage may occur.
- Messages from brain to bladder are confused, so that when the bladder muscle contracts to start emptying, the urethral sphincter muscle surrounding the bladder outlet does not relax but goes into spasm, causing an interrupted flow.
- When the bladder muscle contracts to start emptying, the urethral sphincter muscle contracts and closes the outlet at the same time, effectively blocking the bladder's attempts to empty.
Urinary hesitancy is managed in the same way as urinary retention – see below.
d. Feeling of incomplete bladder emptying (urinary retention)
People who experience this may be able to empty their bladders regularly and also may experience urgency and frequency, that is, a sudden need to empty their bladder without warning. However, while urine may be easy to pass and may flow normally, the bladder may feel as though it is never properly empty.
Urinary retention shares the same cause as some types of urinary hesitancy. The area of the spinal cord which controls the bladder emptying reflex becomes damaged. Messages from the bladder emptying reflex that keep the bladder muscle contracting until the bladder is empty get interrupted. When the bladder does contract, the contractions, although frequent, are poorly sustained. This means that the bladder never empties properly, leaving someone with a higher 'post-void residual volume' (see checking for efficient bladder emptying in the urgency section above) than normal.
Investigation and treatment of urinary hesitancy and urinary retention
Urinary hesitancy and urinary retention are treated in similar ways, and both are classed as incomplete bladder emptying.
There are currently no effective drug treatments for this symptom.
However, there are several management options available:
- Double voiding
Before other management options are explored, double voiding may be recommended as a means of relieving the bladder of any residual urine. Double voiding simply involves waiting a few minutes after urinating and trying to urinate again to empty the bladder some more. - Intermittent self-catheterisation
This ensures that the bladder is completely empty. Intermittent self-catheterisation involves passing a tube (catheter) up the urethra into the bladder, to drain off any liquid. An MS nurse can teach the person with MS how this should be used. It is used two or three times a day and perhaps before going to bed. As long as basic hygiene procedures are followed, infections should not be a problem. Intermittent self-catheterisation can reduce the incidence of urinary tract infections as it ensures that stagnant urine does not remain in the bladder.[6] - External bladder stimulation
One study has found that around 80% of people with urinary retention may find an external bladder stimulator - a vibrating device - helpful to ensure their bladder empties fully. This works by encouraging the bladder to continue to contract and so empty more efficiently. Specialist bladder vibrators are available but some anecdotal evidence suggests that a range of over the counter vibrators work equally effectively. It is important to seek professional advice on equipment and how to use it before embarking on this method of treatment.[7] - Catheterisation
Indwelling catheters, as described in section 4 below. These may be fitted for a period of time and need not be permanent.
e. Complicated bladder problems – combination of symptoms
Some people with MS experience feelings of incomplete emptying combined with urinary urgency and frequency. When this happens, treatment is normally a combination of anticholinergic drugs and intermittent self-catheterisation. However, referral to a continence service may be necessary to ensure full assessment is obtained before treatment starts. An MS nurse or GP can make the referral.
4. Severe bladder problems
Some people experience problems that do not respond to the treatments outlined above.
Incontinence
Many people with MS experience continence difficulties as already described, some of which can cause occasional incontinence, e.g. by not being able to reach a toilet in time.
However, a few may experience what is known as 'reflex incontinence' a sudden complete emptying of the bladder without warning - at any time or place.
Why reflex incontinence happens
Messages from the bladder to brain and vice versa are interrupted so that the bladder muscle that holds urine and the sphincter muscle that controls its outlet, completely relax at the same time without warning.
Treating and managing incontinence
If reflex incontinence is a problem, you may be referred to a specialist continence service for proper assessment and advice.
There are some management options:
- Containment products
There are a number of products available that can help contain incontinence. These include continence pants and pads, which come in a variety of sizes and shapes, including washable and disposable pads, depending on the scale of the problem. There are also a number of appliances such as penile sheaths for men (also known as external catheters) that can help contain urinary leakage. More information about all of these products is available from local continence services, or from The Bladder and Bowel Foundation. - Indwelling catheters
For a variety of reasons, some people find intermittent self-catheterisation difficult to manage safely. In these cases, an indwelling catheter may be recommended. Long-term indwelling catheters are only used after less invasive methods have been exhausted. Indwelling catheters are inserted via the urethra, in the same way as an intermittent catheter, with either a permanent bag attached or a valve to which a bag may be connected. An indwelling catheter may be recommended if it is suspected that a permanent solution is not required, eg if symptoms have worsened significantly in a relapse but are expected to improve. - Supra-pubic catheter
Inserting a supra-pubic catheter involves a minor operation that passes the catheter through the abdominal wall directly into the bladder. A bag or valve for use with a bag can then be attached. As a permanent solution, supra-pubic catheters are preferred as they bypass the genital area and may be easier to manage. They are particularly suitable for people who want to participate in sexual activity. Supra-pubic catheters do carry some risks, particularly with wound healing and infection at the insertion site, so it is important to discuss all the implications in advance with the relevant health professionals.[8]
5. Current research and experimental treatments
Botulinum toxin
Botulinum toxin stops nerve conduction to muscles. In large quantities it is poisonous, but in minute doses it can freeze muscles. Recent studies have indicated that injecting botulinum toxin into the bladder wall is exceptionally effective in improving urinary continence in people with MS[9]. One study also indicated that botulinum toxin injections significantly reduced the incidence of urinary tract infections encountered by people experiencing bladder dysfunction symptomatic of MS[10]. The procedure usually involves around 40 injections into the bladder wall but can be carried out under local anaesthetic as an outpatient. The benefits appear to last between 6 and 12 months. The treatment affects normal bladder emptying so people need to be prepared to carry out intermittent self-catheterisation. In the UK, botulinum toxin is not yet licensed for bladder problems and is only available at specialist centres.[4,11] In view of the promising results produced by small-scale trials so far, it is hoped that safety and efficacy will be proven in larger scale trials and that it will subsequently become widely available as a treatment.
Resiniferatoxin
This is a chemical that, like botulinum toxin, halts nerve conduction to muscles. Resiniferatoxin is a similar agent that was trialled in a mixed group of 36 people with neurological conditions, including nine with MS. Incontinence episodes decreased by around 50% in most people, and bladder capacity improved by around 50% in most people. Resiniferatoxin is administered in a similar way to botulinum toxin, and again, is only available in specialist centres.[12]
Cannabis-based medicine
Two small trials of cannabis-based medicine have shown some benefit for people with bladder problems. The first, a small trial of cannabis-based medicine in people with complicated bladder problems and advanced MS showed that urinary urgency, the number of incontinence episodes and volume of urine lost, frequency of urination and nocturia (night-time urination) all improved significantly following treatment. There were few side-effects, and the investigators suggested that these treatments are safe and effective for urinary difficulties in people with advanced MS.[13] Another trial in 42 people that looked at whether cannabis-based medicine had any effect on urge incontinence also found a significant reduction in the number of urge incontinence episodes and effectiveness of voiding. Although it seems likely that cannabis-based medicine can be an effective treatment for bladder problems in some people, the drug remains unlicensed for medicinal use in the UK.[14]
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS is an external electrical stimulation device that is placed on a person's back. A trial of TENS in 44 people with a number of bladder disorders caused by neurological problems - the majority had MS - showed that it significantly reduced the frequency with which people needed to urinate and the number of incontinence episodes experienced. Some people on the trial found it took 3-4 weeks for TENS to have any effect.[15] TENS is more commonly used un the treatment of pain in multiple sclerosis and is most likely to be found in pain clinics, physiotherapy departments and some GP surgeries. There are TENS machines that can be bought from high street chemists, ideally the machine should be demonstrated by a trained healthcare professional to determine its suitability, as well as to get the most benefit for the user.
6. Urinary tract infections
MS is not always the cause of the bladder problems that people experience. There are a variety of possible causes, but one common culprit is a urinary tract infection (UTI) or cystitis. Such infections are very common in the general population.
People affected may experience some or all of the following symptoms, although it is possible to experience no symptoms at all:
- frequent urge to urinate
- painful or burning sensation when urinating
- generally tired or washed out most of the time
- painful bladder or abdomen even when not urinating
- passing a small amount of urine when urinating, even though there is an urge to pass more
- milky or cloudy urine that smells unusual
- high temperature
Urinary tract infections normally respond well to antibiotics and clear up in a few days. A common cause of UTI for people with MS is stagnant urine due to urinary retention.
Anyone experiencing more than three such infections a year should be assessed by a continence specialist for risk factors, and offered appropriate treatment and guidance. An MS nurse or GP can make a referral.
7. Complementary and alternative treatments
Several complementary approaches to bladder problems in MS receive widespread anecdotal support. Two of the most common are:
Hyperbaric oxygen therapy
This involves breathing oxygen through a mask in a pressurised chamber, similar to a diving bell. Treatment usually consists of an initial course of around 20 sessions, each lasting an hour, spread over one month. Follow-up treatment is then needed at less frequent intervals. Research has failed to find scientific evidence that it is effective for MS,[16] although anecdotal evidence suggests that some people find it helpful, particularly for fatigue and bladder symptoms. In the UK, hyperbaric oxygen therapy is available through most MS Therapy Centres
Cranberry juice
Anecdotal evidence supports the use of cranberry juice as a means of guarding against urinary tract infections, and this is a popular choice among many people with MS. However, there is no consensus on the amount of cranberry juice it is best to consume and excessive, long term use could result in intolerance.
8. Other useful organisations
Bladder and Bowel Foundation
The Bladder and Bowel Foundation is an advocacy charity providing information and support for all types of bladder and bowel related problems, for patients, their families, carers and healthcare professionals.
Website: www.continence-foundation.org.uk
Telephone: 01536 533255
email: info@bladderandbowelfoundation.org
Multiple Sclerosis Therapy Centres
A group of self-help Therapy Centres offering assistance to thousands of people with Multiple Sclerosis throughout England, Wales, Scotland and Northern Ireland. These Centres provide a wide range of drug-free symptom management therapies as well as advice and support for all those with the illness and their families. Find your nearest centre, or telephone the MS Trust information team on 01462 476703
RADAR
RADAR is a national network of disabled people and disability organisations. Their main role is to lobby for a bigger voice for disabled people's rights. They also run the National Key Scheme for access to disabled toilets.
Website: www.radar.org.uk
Telephone: 020 7250 3222
email: radar@radar.org.uk
9. Further Reading and references
Further reading
- Dasgupta R, Fowler CJ.
Bladder, bowel and sexual dysfunction in multiple sclerosis: management strategies.
Drugs 2003;63(2):153-166. - NICE.
Management of multiple sclerosis in primary and secondary care. Clinical Guideline 8.
London: National Institute for Clinical Excellence; 2003.
References
- Hemmett L, Holmes J, et al.
What drives quality of life in multiple sclerosis?
Quarterly Journal of Medicine 2004; 97: 671-676. - Wells M.
The development of urinary continence, and causes of incontinence. 2nd edition.
Beaconsfield, Bucks: Beaconsfield Publishers. 1996. - Burgess M.
Multiple sclerosis: theory and practice for nurses.
London: Whurr publishers; 2002. - NICE.
Management of multiple sclerosis in primary and secondary care. Clinical Guideline 8.
London: National Institute for Clinical Excellence; 2003. - Betts CD, D'Mellow MT, et al.
Urinary symptoms and the neurological features of bladder dysfunction in multiple sclerosis.
Journal of Neurology, Neurosurgery and Psychiatry 1993;56(3):245-250. - Barton R.
Intermittent self-catheterisation.
Nursing Standard 2000;15(9):47-52 - Prasad RS, Smith SJ, et al.
Lower abdominal pressure versus external bladder stimulation to aid bladder emptying in multiple sclerosis: a randomized controlled study.
Clinical Rehabilitation 2003;17: 42-47. - Addison R, Mould C.
Risk assessment in suprapubic catheterization.
Nursing Standard 2000;14(36):43-46. - Kalsi V, Gonzales G, et al.
Botulinum injections for the treatment of bladder symptoms of multiple sclerosis.
Ann Neurol 2007: 62(5):452-457 - Gamé X, Castel-Lacanal E, et al.
Botulinum toxin A detrusor injections in patients with neurogenic overactivity significantly decrease the incidence of symptomatic urinary tract infections.
European Urology 2007: 5(2)299 - Reitz A, et al.
European experience of 200 cases treated with botulinum-A toxin injections into the detrusor muscle for urinary incontinence due to neurogenic detrusor overactivity.
European Urology 2004;45(4):510-515. - Kim JH, Rivas DA, et al.
Intravesical resiniferatoxin for refractory detrusor hyperreflexia: a multicenter, blinded, randomized placebo-controlled trial.
Journal of Spinal Cord Medicine 2003;26(4):358-363. - Brady CM, Das Gupta R, et al.
An open-label pilot study of cannabis-based extracts for bladder dysfunction in advanced multiple sclerosis.
Multiple Sclerosis 2004;10(4):425-433 - Freeman R, Adekanmi O, et al.
The effect of cannabinoids on lower urinary tract symptoms in multiple sclerosis: a randomised placebo controlled trial (CAMS-LUTS study) .
Poster. International Continence Society Congress, 25-26 August 2004, Paris. - Amarenco G, Ismael SS, et al.
Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder.
Journal of Urology 2003;169 (6):2210-2215. - Bennett M, Heard R.
Hyperbaric oxygen therapy for multiple sclerosis.
Cochrane Database Systematic Review 2004;(1):CD003057
Acknowledgements
This publication has been written by the MS Trust with the help of experts - those who live with MS and those who work professionally with people with MS. We would like to thank our Readers' Panel of people with MS, together with Deborah Rigby, Continence Services Manager, Bristol South and West PCT, Knowle Clinic, Bristol; Moya Low, Continence Advisor, Norfolk PCT Continence Advisory Service, Norwich Community Hospital, Norwich, and Nicola Mcleod, MS Specialist Nurse, Western Gerneral Hospital, Edinburgh.
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If you have specific questions about any aspect of MS, email the MS Trust Information Service or ring us on 01462 476700.
