Bladder Dysfunction

Among the more common complaints heard from MS patients are frequency and urgency of urination. Hesitancy and incontinence rank right up there as well. Apparently, because the nerve tracts to the bladder traverse long distances and are very myelinat-ed, bladder irritability is very common in MS. Bladder continence varies from patient to patient. Many MS bladders are small and do not store urine well. These bladders have uncontrolled contractions and very low residual urine. Some bladders are almost the opposite. These bladders contain a large volume, do not empty well, and have a large residual urine. Separately, a dyssynergia of the bladder and the urinary sphincter may be present, in which the bladder wants to empty against a closed, spasming sphincter.

The treatment must fit the situation. Working up bladder problems begins with checking for infection. Obviously, infection can influence urinary function and must be treated with appropriate antibiotics. That being remedied, a residual urine (either by catheterization or by ultrasound) helps determine a large from a small bladder.

Small bladders often are treated easily with anticholinergic medications. Oxybutynin and tolterodine are among the most popular, but imipramine and propantheline bromide function in a similar manner. Dosing should be such to decrease the bladder spasms, allowing for increased bladder capacity, while not interfering with other cholinergic functions (e.g., sweating, salivation, or tearing).

Large bladders are more difficult to treat. Urecholine may help stimulate the bladder to empty but often is ineffective. Catheterization techniques may be necessary to allow for appropriate elimination. Self-catheterization may be taught using a clean technique as opposed to a sterile technique. This procedure takes fairly good hand and sensory function. Incoordination or intense numbness may make this technique impossible for some MS patients to master. Chronic Foley catheterization often leads to chronic infection, but may be a necessary evil if self-catheterization is impossible. Asking a family member to perform intermittent catheterization will almost certainly change the personal relationship of that family member to the person with MS, and this usually is not desirable.

Dyssynergic bladders may respond to ablockade with medication (Hytrin, Cardura). Often, self-catheterization is necessary to accompany those treatments. The dyssyner-gic bladder is best diagnosed using urody-namics. Although many opt for urodynamics at the front end of the work-up, it is more practical to reserve these studies for situa tions in which the initial evaluations and treatments have not produced the desired results.

Just how much residual urine to accept is somewhat dependent on the situation. The normal residual is zero to 20 cc. Less than 100 cc is clearly acceptable. In MS, it is not unusual to see a residual of 200 cc to 400 cc without much discomfort. It all depends on individual symptoms. If high pressures exist in the bladder (dyssynergic type), it is potentially possible to push urine up the ureters toward the kidneys, although, surprisingly, upper tract disease is quite rare in MS. If chronic infections have been present, an ultrasound of the kidneys and ureters is appropriate; cystoscopy may be necessary to find bladder stones that result from chronic bladder infections.

Urinary production is increased in the supine position during the night. This can result in frequent urination, causing a significant increase in fatigue. The production of urine can be decreased by the administration of antidiuretic hormone (desmopressin) at night. This may allow for less nocturia, a better night's sleep, and less daytime fatigue.

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