Bladder problems are one of the most common symptoms reported by people with multiple sclerosis and they can have a big impact on many aspects of life. However, successful treatment is available and straightforward lifestyle changes can also make a real difference.
You may have bladder problems related to MS if you:
- sometimes have a desperate need to go to the toilet with little or no warning
- need the toilet more than eight times a day
- have difficulty emptying your bladder
- have a feeling that your bladder isn’t completely empty
- experience bladder accidents (incontinence)
- have a urinary tract infection (UTI, water infection).
You might have one or more of these symptoms. Bladder problems can make other MS symptoms worse for example spasticity, thinking problems or they may cause a relapse.
There are a wide range of approaches to managing bladder symptoms in MS. These can include, making simple changes to what you eat and drink, medication or using a catheter. Working together with your MS health professionals you can find the best way of managing your bladder problems.
What are bladder problems?
The bladder stores urine and empties it at an appropriate time when you reach the toilet. MS can cause nerve damage in areas of the brain and spinal cord that play a part in controlling these functions and this is why problems are experienced.
It could be time to see your health professional if:
- you experience urine leakage, and avoid important activities because of it
- you often feel urgency to urinate and rush to a bathroom, but sometimes don't make it in time
- you go to the toilet much more often than you used to, during the day and at night
- going to the toilet is painful or your urine has an unusual smell
- you feel the need to urinate, but you're unable to
- you notice that your urine stream is getting weaker, or you feel as if you haven't fully emptied your bladder.
Not all bladder issues are caused by MS nerve damage and here are some of the other common causes:
- enlarged prostate in men
- pregnancy and childbirth which can weaken the pelvic floor muscles in women
- infection in the urinary tract (water infection)
- abdominal surgery
- caffeine and alcohol consumption.
What causes bladder problems?
The symptoms you experience will depend on where the MS nerve damage has occurred. Usually when urine reaches a certain level in the bladder, nerve endings in the wall send signals to the part of the spinal cord that controls bladder emptying. This is known as the reflex centre in the spinal cord and it also sends messages to the brain, making you aware of the need to empty your bladder. These messages can usually be controlled by the brain until there is an opportunity to get to a toilet.
You may experience a sudden urge to go to the toilet or be unable to hold on and reach the toilet in time. You may need to use the toilet more than eight times a day and at night, sometimes as soon as half-an-hour after already going. The problem then is most likely to be with your bladder storing urine.
If damage has occurred between the spinal cord reflex and the brain. the bladder starts emptying as soon as it starts filling. The bladder becomes overactive (overactive bladder, AOB) and you may experience a bladder spasm, your bladder may contract unpredictably and sometimes uncontrollably.
I feel as though my bladder has a life of its own
Typical experiences include a reduced flow or an interrupted stream of urine (hesitancy), often accompanied by a feeling of not emptying the bladder completely. The problem is then most likely to be emptying urine from your bladder.
The area of the spinal cord that controls the bladder emptying reflex becomes damaged by MS. As there is no signal to urinate, your bladder becomes very full but you are not aware of how full it is, so leakage of urine may occur. Sometimes messages from the brain become confused, so that when the bladder muscle contracts to start emptying, the valve which allows urine out of the bladder closes at the same time, blocking or interrupting the bladder's attempts to empty.
I can be absolutely desperate to go to the loo and once I get there - I can't go!
For some people, these symptoms may also be combined with feelings of needing to find a toilet quickly and often. This can lead to urine leakage in spite of earlier efforts to empty the bladder.
Bacterial infections in the urinary tract are common in MS particularly if you have problems emptying your bladder. It is important that these infections are detected early and treated as they can make other MS symptoms such as spasm or stiffness, or thinking difficulties worse and they can cause a relapse.
How many people have bladder problems?
More than 75 in every 100 people with MS experience bladder problems at some time. Some people feel a sense of shame and embarrassment and feel awkward raising them with health professionals.
All health professionals should understand that MS has an impact on how the bladder works so don't be shy in raising this. Your MS specialist nurse, GP or continence advisor are all experienced in dealing with bladder problems and should be able to put you at your ease.
What can I do if I have bladder problems?
Get in touch with a health professional if you are worried about how your bladder problems are affecting your life. If things have changed or you have any questions about any medication you are taking do not hesitate to contact your MS specialist nurse, GP or continence advisor.
Get to know your bladder, keeping a diary can be a good start as it gives you an overview of how your bladder problems affect you over time. It can be simple paper or one of the available apps. You can note when and what you drink or eat – how many times you use the toilet – if you don’t make it in time, if you have difficulty starting to urinate. You can share this with your health professionals. It can also help you to see what difference changing something in your diet might make – for example drinking less caffeinated drinks.
Make some changes to your lifestyle as these can make a real difference:
- Look at what you eat and drink as drinking too much can make bladder symptoms worse - increasing your visits to the toilet and the need to get there quickly. On the other hand drinking too little can lead to concentrated urine that irritates the bladder and creates a good environment for infection. Healthy urine is clear and straw coloured. General advice is to drink around six to eight glasses, of liquid a day (more if the weather is hot or if exercising). Some food and drink can irritate the bladder and are best avoided such as drinks containing caffeine, alcohol, fizzy drinks, acidic fruit and juices (including citrus and tomatoes) and spicy food.
Maintain a healthy weight as being overweight can increase pressure on the pelvic floor muscles and result in stress incontinence.
Stop smoking as nicotine can irritate the bladder.
- Try pelvic floor exercises, where bladder symptoms are mild, these exercises can be helpful . The pelvic floor is a sheet of muscles that form the 'floor' to the pelvis and support the bladder and bowel. These muscles give you control when you urinate as they relax at the same time as the bladder contracts to let urine out. In MS nerve damage can result in weakness to the pelvic floor as messages to the muscles are impaired. Where bladder symptoms are mild, pelvic floor exercises can be helpful. Both men and women can do pelvic floor exercises. You can find out more about pelvic floor exercises from NHS Choices.
Avoid constipation as a full bowel can obstruct the flow of urine or affect the capacity of your bladder, increasing the number of times you need to empty.
How are bladder problems treated?
Different types of bladder problems are treated differently. This means you need a thorough assessment to find out the cause of the problem. Your health professional will take a full history of your symptoms and might ask you to keep a detailed bladder diary for a short period of time. They will usually carry out simple ivestigations:
- Test for infection using a dipstick test. Your health professional will ask you to bring a sample of your urine.
- Check bladder emptying (urodynamic investigation) to find out the amount of urine left in your bladder after urinating. This is a bladder scan carried out with a simple ultrasound scanner. If there is less than 100ml left after your bladder has been emptied, then symptoms are more likely to be due to problems storing urine. If more than 100ml remains after emptying, then the symptoms are likely to be due to problems with emptying the bladder.
The results will enable your health professional to understand the cause of the problem and to work with you to find the most appropriate approach to treatment.
Treatment approaches when you need the toilet urgently or frequently
The aim of bladder training is to increase the length of time between using the toilet. You gradually increase the time between urinating (this can be just by five minutes). It may take weeks or months to be effective but your continence advisor or MS specialist nurse can put together a timetable to support you to achieve this.
You may be offered drugs that block the messages that start bladder contractions and so reduce how often you need to empty your bladder. They are also thought to reduce sensations of urgently needing to reach the toilet. These drugs are called antimuscarinic (anticholinergic) drugs and may be taken as tablets or, in some instances, through skin patches. Drugs include oxybutynin (Ditropan, Lyrinel XL), tolterodine (Detrusitol, Detrusitol XL), solifenacin (Vesicare), fesoterodine (Toviaz), trospium (Regurgin, Flotros). If antimuscarinics haven't been effective or if the side effects are difficult to tolerate a medication with a different mode of action may be suggested such as mirabegron (Betmiga).
Where medication hasn’t been effective an injection of botulinum toxin (botox) into the bladder wall is an option. This acts by stopping nerve messages to the bladder muscles and can freeze their contraction. Following this treatment the bladder can’t empty itself and you will then need to use a catheter to empty your bladder.
If medications have not been effective and someone doesn't want to try botulinum toxin, nerve stimulation may be offered. An electric current is passed through a small needle inserted into the posterior tibial nerve (PTNS) in the ankle, which stimulates the nerves around the bladder and pelvic floor. It requires at least 12 weekly sessions lasting 30 minutes each and has been shown to reduce symptoms of overactive bladder. Effects do not always last long after the sessions have stopped and more sessions may be needed.
Treatment approaches when you have problems emptying the bladder or staring to urinate
Trying to relax when passing urine can help to improve hesitancy. For some people the sound of running water, for example from a tap, can relax the bladder valve to start the urine flow.
Supra pubic vibration
There is some evidence to suggest that a vibration device or buzzer, such as the Queen Square bladder stimulator, placed over the pubic area can help the bladder valve to relax and improve emptying if hesitancy is a problem.
A urinary catheter is a tube used to drain urine from the bladder. Catheters may be used when needed (intermittently), usually several times a day and this is a procedure that you carry out yourself. For some people more permanent catheters are the best option. Using a catheter can sound daunting but for many people it is life changing, allowing freedom from fear on outings.
Using catheters means my bladder empties properly, and I get less of those awful water infections
Last updated: 06 July 2017
Last reviewed: 26 September 2015
This page will be reviewed within three years