There’s no one-size-fits-all therapy. “Every patient has unique issues and a unique set of treatment goals,” Dr. Shapiro says. Your doctor can help tailor a treatment plan to your specific concerns—such as an overactive bladder or difficulty emptying (or some combination thereof)—as well as the way your body responds to the various treatment options. So the first step is a thorough exam and testing to get to the root of the problem.
“Do not be embarrassed,” Claire advises. “Healthcare professionals cannot help you unless you tell them everything. The right doctors with the right information can improve your life dramatically!”
Most likely, your doctor will start with a simple urinalysis to test for a possible UTI, which is common in people with MS. If it’s positive, you’ll likely get antibiotics. If it’s negative, the next step is urodynamics, an evaluation of your bladder function in real-time that allows doctors to observe how your pelvic floor and bladder work together (or not so much, as the case may be). Your doctor may also use a catheter to check how much urine remains in your bladder, which could signal problems with emptying. Your doctor may also check your kidneys.
Whatever testing reveals, many promising treatment options are now available. “Up until five years ago, I had only medication and surgery options; there were no intermediate steps,” Dr. Murphy says. “Now I have lots of tools in my toolbox that help people avoid major reconstructive surgery and give them back their quality of life.”
- Medication. Drugs known as anticholinergics (such as Ditropan, Detrol, Vesicare, Enablex, Gelnique, Oxytrol and Toviaz) suppress involuntary bladder contractions to help with urgency, frequency and urgency-related leakage. Anticholinergics are available as a pill, a patch or a topical gel. Side effects can include cognitive impairment, dry eye, dry mouth and constipation, leading some 80 percent of people to quit the medications.A newer treatment called Myrbetriq, which is a type of medication called a beta-agonist, aims to avoid the side effects. Approved by the FDA in 2012, it works by reducing muscle contractions, which promotes greater retention in the bladder to reduce urgency, frequency and incontinence. A bump in blood pressure is a possible side effect. Most medications are covered by insurance, but, as Dr. Murphy notes, out-of-pocket expenses can reach $100 a month.Expect some trial and error when it comes to finding the right medications. Claire notes that she started out on one drug and had to switch a few years later when the first one lost its effectiveness.
- Pelvic floor rehabilitation. Though people can do Kegel exercises on their own, working with a specialized therapist to learn other ways to manipulate the muscles of the pelvic floor can help control urgency and leakage. Using a pelvic probe fitted with sensors, people try to contract and relax their pelvic floor muscles while looking at the results—a rising and falling bar graph—on a computer screen. “It shows how well you’re recruiting different muscles,” says Connecticut-based pelvic floor physical therapist Matthew Durst.In a 2007 study, patients who used biofeedback pelvic floor muscle training saw a 76 percent improvement in their symptoms, with less severe frequency and urgency, and less retention. After just six weekly one-hour sessions, some patients improve enough to stop taking their meds, Dr. Murphy says. There are no known side effects and it’s generally covered by insurance.
- Botox. Yep, the same treatment that relaxes wrinkles is FDA approved (as of 2011) to treat urge incontinence that doesn’t respond to medication or physical therapy. This in-office procedure—involving some 20 injections into the detrusor muscle (the muscle on your bladder wall that contracts to expel urine)—takes just five to 10 minutes, with results lasting six to 12 months. It works by calming some of the nerve activity connected to bladder muscles, so they’re less rigid and more elastic.“Botox can work very well for patients who already catheterize but continue to leak urine,” Dr. Shapiro says. A 2013 study from Case Western University that reviews current data on Botox reported excellent results for symptoms of overactive bladder: incontinence, UTIs and use of incontinence pads decreased by more than 50 percent in many of the findings. Side effects, though rare, include pain at the injection site, UTIs, blood in the urine, and an increase in post-void residual urine that may require catheterization. Insurance typically covers Botox treatment (with authorization) when previous therapies have failed.
- Sacral nerve stimulation. Approved by the FDA in 1997, sacral nerve stimulation (SNS) involves surgically implanting a stopwatch-sized device that acts as a kind of pacemaker for the bladder. The device sends mild electrical pulses to the sacral nerves, just above the tailbone, which control muscles and organs involved in voiding—the bladder, sphincter and pelvic floor muscles. For people with MS who have urinary retention or urinary or bowel incontinence, the device can help improve communication between the brain and the bladder, allowing messages—hey, time to pee!—to come through more clearly.A 2012 study of the procedure on people with MS, published in the World Journal of Urology, showed a significant increase in voiding volume and number of voids per day, and a decrease in incontinence episodes. Side effects include pain and soreness at the incision site for up to two weeks, as well as possibly a slight tingling, tapping or pulling sensation. Complications, though rare, include pain, infection and technical problems with the device.Medicare and many other private insurance companies cover this therapy. Out-of-pocket costs vary by insurance plan.
- Percutaneous tibial nerve stimulation (PTNS). This low-risk, in-office procedure—for people with urinary urgency, frequency or incontinence—involves placing a fine needle electrode on a spot along the inside of the ankle to stimulate the tibial nerve. That, in turn, sends an electrical pulse up to the sacral plexus, which regulates bladder and pelvic floor muscle function. “This treatment helps the nerves learn how to talk to each other instead of waiting for disrupted signals from the brain,” Dr. Murphy says. “It tells the sacral nerves, ‘You’re in charge now.’”“I was very skeptical that this would work,” says Claire. “But this simple procedure has changed my life! Now instead of getting up three to four times a night to use the bathroom, I might get up once.”The FDA-approved treatment, which is usually covered by insurance, reduces symptoms by 50 to 80 percent, according to Durst. “You’ll need half-hour weekly treatments for 12 weeks, and will begin to see improvement by the sixth treatment.” The most common side effects are minor bleeding, mild pain and swelling. For needle-phobes, there’s a version of the treatment that uses electrode pads.
- Surgery. In the most severe cases, or if all other options fail, the final step is surgical reconstruction—to make the bladder bigger or to divert urine out through the abdomen (to an external collection bag). “My goal is to protect the kidneys, prevent infection and provide patients with the best possible quality of life,” Dr. Murphy says. “Bladder dysfunction is a fixable symptom in every case.”
Aviva Patz is a freelance writer in Montclair, New Jersey. She has written for Health, Prevention, Redbook and other major periodicals.
Read more about bladder problems on the National MS Society resource pages.