Control your bladder, control your life

Treatment for bladder issues can help people with MS take back their freedom.

by Aziza Patz

For many people with multiple sclerosis, having to dash to the bathroom is an-all-too-familiar occurrence.

In fact, some 80% of people with MS experience bladder problems, according to the National Multiple Sclerosis Society. “It’s a very common symptom,” explains Kelly Casperson, MD, a urologist with Pacific Northwest Urology Specialists. “The same demyelination that causes issues with everything else in MS does the same thing to the bladder.”

Understanding what causes bladder issues and how to manage and treat them can go a long way toward helping people with MS live their best lives.

Causes of bladder issues

In healthy bladder function, kidneys make urine that travels down to the bladder, a sac that expands as urine collects. Once it’s full — with 4 to 8 ounces of fluid — it signals the spinal cord to alert the brain that it’s bathroom time. At the toilet, the brain and spinal cord work together to initiate voiding: The bladder muscle contracts to push out the urine, and the external sphincter opens to let urine out.

In MS, those normal signals are delayed or disrupted, according to urologist Rebecca Lavelle, MD, of Knoxville, Tennessee.

How people with MS experience bladder problems

Storage problems are the most common type of dysfunction, causing symptoms of overactive bladder (OAB), including increased urgency (needing to run to the bathroom), increased frequency (needing to go more than around five to seven times a day), nocturia (waking up to go at night) and incontinence.

The second type of dysfunction is a bladder that won’t empty properly, leading to hesitancy (a delay in the ability to initiate urine) and retention. “You try to go to the bathroom, but instead of the sphincter opening, it stays closed, and you need to strain to empty and may not empty completely,” explains Lavelle, adding that incomplete emptying can make you more prone to bladder infections.

You can also sometimes have both hesitancy and retention at the same time, according to Casperson. “You’re leaking but you can’t empty your bladder all the way,” she explains.

Treating bladder problems

Kelly Casperson, MD, urologist at Pacific Northwest Urology Specialists, recommends pelvic floor physical therapy to people with bladder issues.

First, evaluate their impact. “It’s a quality-of-life issue,” Lavelle says. “I tell patients: If we don’t see anything dangerous within the urinary system, and if you’re not bothered by it, then I’m not bothered by it.”

But it can be emotionally and socially isolating and can disrupt sleep, sex and daily activity. Lavelle describes people who are scared to go to church or who won’t take hikes with their friends for fear of accidents. “If your life is being ruled by your bladder,” Lavelle says, “it’s time to consider therapeutic options.”

Bladder health is also tied to overall health. “The emptying issue in particular can affect kidney function, increase risk of infection and cause chronic kidney scarring,” Lavelle says. Plus, any infections that are not addressed can lead to worsening of MS symptoms such as weakness and spasticity and even progression of MS.

“Some young people may not feel the burning of the urinary infection because of nerve disruption,” Lavelle adds, “but they notice that they’re falling down more.”

Treatment options for bladder issues

Once your provider determines your type and severity of dysfunction, there are a range of treatments available:

Antispasmodic medications help control urgency, frequency and leakage. There are two classes: anticholinergics, and Myrbetriq and Gemtesa.

“Both work on the bladder receptors,” Lavelle says, and both improve symptoms by around 50%. “The anticholinergics have a higher side effect profile — they’ve been linked to cognitive issues with long-term use — but they’re cheap and generic. The newer medications have fewer side effects but a higher cost.”

Botox, the neurotoxin known for relaxing facial muscles, can reduce spasticity when injected directly into the bladder (under local anesthesia) about every six months. It’s been FDA approved for decades, but it can make emptying more difficult.

Pelvic floor physical therapy uses noninvasive tools such as biofeedback, neuromuscular stimulation and other exercises to help “retrain the brain-bladder connection,” as Casperson explains, for improved control. She recommends it to everyone with bladder issues. It’s usually covered by insurance.

Percutaneous tibial nerve stimulation involves inserting a very small needle electrode into the ankle to send signals to the bladder and pelvic floor nerves. The 30-minute treatment — weekly for 12 weeks, then monthly for maintenance — is approved by the FDA for overactive bladder but not for incomplete emptying. Intermittent self-catheterization involves inserting a tiny tube into the urethra to empty the bladder one or more times a day.

InterStim is a pacemaker-like device that’s surgically implanted under the skin to stimulate the nerves to the pelvic floor and bladder and help with storage and emptying issues. It’s recently become MRI-compatible, but it’s FDA approved only for overactive bladder, not for neurologic bladder issues.

Practical tips for managing bladder issues

You can minimize bladder symptoms in MS with the following lifestyle strategies:

• Limit coffee, tea, soda and alcohol, which are all bladder irritants that increase urgency.
• Sip fluids gradually throughout the day instead of guzzling huge amounts at once.
• Use “timed voiding,” in which you plan bathroom breaks every one to three hours to help prevent urgent trips to the toilet and accidents.
• Wear clothing that’s easy to remove in a hurry.
• Use absorbent pads, adult diapers or washable underwear when bathroom access may be limited.
• Carry a change of clothes as backup.

“There are a lot of tools to help people take control of their bladder,” says Lavelle. “There’s no need to let bladder issues rule their life.”

Aviva Patz is a writer in Montclair, New Jersey.