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A UK consensus on the management of the bladder in MS

Professor Clare Fowler
Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, London

Way Ahead 2009;13(1):6-7

In February 2008, a group of interested parties met in London to discuss bladder management of patients with multiple sclerosis. The aim was to publish a consensus paper setting out what we thought were reasonable UK guidelines for this condition. Participants in the consensus meeting included representatives from the following:

Association of British Neurologists
Association for Continence Advice
British Association of Urological Surgeons
British Association of Urological Nurses
Centre for Research in Primary Care
Royal College of Nursing
UK MS Specialist Nurse Association
MS Trust

Bladder symptoms are very common in patients with multiple sclerosis; usually affecting around three quarters of people with MS. The severity of bladder problems is related to the degree of spinal cord malfunction. In other words, the more restricted an individual is in terms of their walking, the more complex their bladder problems, both in terms of symptoms and management. It therefore made sense to consider what treatments should be recommended at different stages of the illness.

Early stages

In patients who are walking around well, or perhaps need one stick, poor bladder emptying is less likely to be a problem. The main symptoms at this stage will most likely be urgency and frequency due to an over active bladder. Effective treatments are oral medications called anti-cholinergics, including oxybutinin, tolterodine, solifenacin and trospium chloride. These all work by blocking the effect of acetylcholine, the chemical which connects the nerves to the bladder, thus making the bladder less over active. The problem with these drugs is that they may prevent the bladder emptying effectively or if the efficiency of bladder emptying has already been affected they may actually make things worse. The consensus was that investigations and treatment should follow the scheme shown in Figure 1.

diagram showing consensus for treatment. For patients with urgency and frequency, test for UTIs and measure post void residual volume (PVR). If less than 100ml, treat with anticholinergics, otherwise teach clean intermittent self catheterisation and then treat with anticholinergics. If these approaches don't work, measure PVR again and repeat.

There is evidence that desmopressin (Desmospray) can help manage frequency but this treatment should be used with caution. Pelvic floor exercises may also help at this stage if patients are able to get good pelvic floor voluntary control.

When an individual presents with new urinary symptoms, a dipstick test should be performed to check for infection. The amount of urine left behind after voiding should also be measured (post void residual volume), ideally before starting treatment with anti-cholinergics.

Post void residual volume testing works well for all stages of the condition as it can be used to detect incomplete bladder emptying, which may be a factor contributing to bladder over activity. There was some discussion about the performance of this procedure which is a very simple test that can be carried out in the patient's home by a continence advisor using a small portable ultrasound machine. Some countries recommend much more elaborate investigations but the UK consensus group agreed that this simple, relatively non-invasive test, gives important information that would not otherwise be available. This is an important recommendation because it enables safe and effective management of problems using only simple, non-invasive testing.

Intermediate stage

If the patient becomes more disabled and has more difficulty walking, it is likely that their ability to empty their bladder will also be affected. Where this is the case, the individual needs to be taught to perform clean intermittent self catheterisation. This technique should be taught by the urology specialist nurse or continence advisor and should be offered to anyone who is found to have a residual volume of more than 100ml in their bladder. With sufficient training most people with MS can manage clean intermittent self catheterisation.

There is also a vibration device that can be applied over the bladder which helps some patients with incomplete bladder emptying. Pressure on the lower abdomen to empty the bladder (the Crede manoeuvre) is not recommended.

A treatment that has become available in the last five or six years is the injection of the bladder wall with botulinum toxin A (Botox). This is a highly effective treatment with very few adverse effects but almost all patients with MS who have had it, need to perform intermittent self catheterisation afterwards. It is not, therefore, a treatment for somebody who is unwilling to consider doing that. It must be noted, however, that this treatment is not yet licensed either in the UK or elsewhere in Europe and is not available in all parts of the UK. Each hospital will have had to give special permission for this to be given as a treatment by their urologists. In many centres it can be done as an outpatient procedure using a flexible cystoscope and usually takes less than fifteen minutes to inject at about 30 different sites in the bladder wall. It has a surprisingly rapid effect on reducing urinary urgency and this benefit seems to last for about ten months, at which time it is repeated. Encouragingly, the procedure appears to be as effective at the second, third and fourth time as it was at the first.

Advanced stages

If disability worsens and intermittent self catheterisation is no longer possible, but poor bladder emptying remains a problem as well as bladder over-activity, an indwelling catheter is the best option. The urologists in the group strongly recommended a supra pubic rather than an indwelling urethral catheter.

Possible urological surgery

Occasionally, urological surgery may be indicated. Stress incontinence in women who have had babies and who leak when they cough or sneeze should be considered. In such patients further investigations would be appropriate rather than just measurement of the residual volume. Very rarely urologists consider a procedure such as an ileal conduit if incontinence remains a major problem and catheters do not work.

Referral to urology services

The consensus group agreed that the following indications warrant urological referral:

Haematuria - blood in the urine
Frequent urinary tract infections
Symptoms unresponsive to treatment
Consideration for botulinum toxin A injections
Long term suprapubic catheter required
Rarely, consideration of urological surgery

Urinary tract infections

Urinary tract infections are a real problem for people with MS. Many patients report deterioration of their neurological condition following an infection of any sort, including a bladder infection. There is some evidence that cranberry juice may reduce the likelihood of an infection. If genuine infections do occur it is sensible for the patient to see a urologist to check that they have not developed some trouble in their bladder such as a bladder stone. In patients doing intermittent self catheterisation it is thought inadvisable to send regular urine specimens to the laboratory since these will always report some sort of bacterial contamination, which is different from a genuine urinary tract infection. It was agreed that where no cause can be found, but urinary tract infections remain a recurrent problem, the patient should start on a low dose antibiotic.

Conclusion

There was complete agreement amongst the group that all patients with MS complaining of bladder symptoms should be able to be assessed by an expert. There is no stage of the illness when bladder symptoms should not be attended to and individuals or their carers, should ask their GP to refer them appropriately.

Individuals should be encouraged to understand why they have developed poor bladder control and what management options are available to them. Both the MS Trust and MS Society have produced information that serves this purpose.

These guidelines have been accepted for publication by the Journal of Neurology Neurosurgery and Psychiatry and it is hoped that commissioners will give credence to these guidelines when developing their services.