ARTICLE #6: Bladder Management in Multiple Sclerosis Author(s): Claire D. Yang, MD VA Puget Sound Health Care System Urinary control is a very common concern among persons with multiple sclerosis, and the prevalence of bladder dysfunction is high in MS. The innervation to the bladder and urinary sphincters emanates primarily from the sacral spinal cord (with some contributions from the lumbar cord), and thus the long CNS pathways that regulate the micturition reflex are more “exposed” to the demyelinating process. The exact prevalence of urinary problems is not known because the onset is insidious, and if the symptoms are mild, they are often disregarded. The physiological effects on demyelination on bladder control are usually one or more of the following: 1) loss of sensation of bladder fullness, 2) loss of cortical inhibition of the micturition reflex, resulting in frequency, urgency and urge incontinence, 3) loss of bladder contractility, and 4) loss of coordination between the urinary sphincters and bladder contraction. Functionally, patients experience problems containing urine, problems empyting urine, or a combination of both. The objectives of bladder management are the same in multiple sclerosis as they are for any person with bladder dysfunction. The primary objective is to do what is necessary to preserve renal function, since problems of the bladder can result in renal deterioration. This can be achieved by emptying the bladder efficiently (completely) and regularly, whether by spontaneous voiding, clean intermittent catheterization or chronic catheterization. Fortunately, renal failure due to bladder dysfunction is not common in MS, in part because most of the patients are women, and the short (and generally, non-obstructive) female urethra allows for a “pop-off” valve in bladders with poor compliance. The secondary objectives for bladder management are the maintenance of social continence and the avoidance of complications such as cystitis and stone formation. Additionally, a patient should not be committed to a bladder management regimen that makes her dependent on someone else for bladder emptying. For example, a tetraplegic patient should not be started on self catheterization. The mode of bladder management should be consistent with the patient's physical and mental capacities. After obtaining a urinary history and performing a genitourinary physical exam, one of the most important determinants of bladder management is the post void residual volume. This can be measured with an ultrasound or with bladder catheterization after voiding. How efficiently a bladder empties (i.e., how much urine is left behind after a void) will help the practitioner decide on treatment and management. Several common scenarios exist:
Keep in mind that there is no “cookbook” method of determining which combination of behavioral modifications, medications and/or catheter use is applicable to a particular patient; each person requires an individual assessment. If an initial trial of bladder management fails to alleviate symptoms or infections, then a referral to a urologist is needed. Many persons with bladder dysfunction will require supplemental items such as medications, pads or other absorbent garments, catheters and other urine collection devices. These items are available in most VA pharmacies. Bladder Management Links: NMSS Brochures Date Posted: July 2004 |