A 36-year-old schoolteacher was referred for consideration of disease-modifying therapy for MS. Onset of first symptoms was 10 years earlier, with subacute onset of visual loss in the right eye that had recovered spontaneously and without treatment. A diagnosis of optic neuritis had been made at that time. The disease was then clinically quiescent until 8 years later, when he noticed that on bending his neck, shock-like sensations would shoot down his back and into both legs. This had persisted for 3 months and resolved spontaneously. Twelve months ago, he had experienced visual loss in the left eye, and now, despite having his vision recovered, he was no longer able to go jogging or cycling, because after a short period of such exercise he would experience visual loss in both eyes that would settle promptly but only with a period of rest.

and walk, but spastic limbs may actually allow a degree of weight bearing because of the involuntary contraction of antigravity muscles. It is notable how many MS patients with very weak limbs "use" their spasticity to execute transfers.

Muscle wasting is not commonly seen in MS and, if noted at time of presentation or early in the clinical course, alternative diagnoses usually should be considered. However, relatively debilitated patients may be vulnerable to pressure palsies, and wasting of the hand and thigh muscles may be noted in those with advanced disease.

Sphincter Disturbance Disturbances of micturition are the presenting feature in approximately 5% of cases of MS, but problems with bladder function eventually affect the majority of patients to some extent. In view of the common etiology within the spinal cord, bowel and sexual function problems often co-exist; few male patients who have significant micturition problems do not have erectile dysfunction.

Patients with bladder problems will have a variety of symptoms including frequency, urgency, incontinence, hesitancy, retention, and nocturia. In detrusor muscle hyper-reflexia, impaired bladder storage is pres ent, caused by rises in intravesical pressure that are disproportionate to bladder volume; this gives rise to the sense of urgency and frequency experienced by the patient and may result in the inadvertent leakage of urine. In detrusor sphincter dyssynergia, opposing mechanisms occur simultaneous-ly—those that precipitate bladder emptying and those that close the sphincter. Consequently, patients experience hesitancy and retention with a significant post-voiding bladder residual.

The estimated prevalence of bowel problems varies, but figures of 46% to 68% for bowel symptoms in general, and 43% for constipation in particular, have been documented. Constipation is clearly not unique to MS, but commonly is seen in disabling neurologic disorders. It results from a variety of factors, including spinal cord involvement with slowed passage of the stool through the bowel, increased water absorption, and desiccation. There are also present the negative effects of weakness of abdominal muscles, reduced activity, poor diet, drugs, and an understandable but counterproductive desire to limit fluid intake because of concurrent bladder problems. As with the bladder, frequency and urgency may occur, but the most distressing problem is that of faecal incontinence. This may occur as a result of lost rectal sensation, but may also be triggered by drugs or arise from a spurious diarrhoea with loose bowel bypassing an impacted stool.

The occurrence of sexual dysfunction correlates closely with bladder impairment. It is a major cause of distress, relationship strain, misunderstanding, and marital breakdown. Although not commonly a feature at presentation, again, apart from those with primary progressive disease, it is a significant issue even in the relatively able-bodied patient. Erectile dysfunction has been found to affect up to 91% of men, and between 56% and 72% of women with MS report sexual difficulties. The problems experienced do not simply reflect the autonomic disturbances that occur in MS but are multifactorial and may involve issues related to fatigue, loss of libido, low mood, spasticity, unpredictable loss of bladder control, and loss of normal sensation.

Fatigue Fatigue is considered the most disabling symptom by many patients with

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