Understanding Bladder Problems in MS

In about 80% of people living with MS, messages between the brain and bladder are affected, leading to bladder problems that can greatly affect quality of life, including social participation, emotional well-being, and overall health. 

Even though these symptoms are common, many people may not feel comfortable sharing them with their healthcare team. However, early diagnosis and treatment can make a big difference to improve your quality of life.

The bladder stores urine from the kidneys. Muscles in the bladder wall expand to store urine, and the muscles in the urethra contract to hold urine in. When it’s full, the bladder sends signals to the brain through the spinal cord, telling the bladder muscles to squeeze and the urethra muscles to relax, so that the urine is released.

In MS, inflammation and lesions can weaken or block the signals between the bladder, spinal cord, and the brain. Depending on where the damage is in the central nervous system, different bladder problems can happen.

The three most common bladder problems caused by damaged or blocked signals are:

• Overactive bladder
• Urinary retention  
• Mixed symptoms (a combination of both overactivity and retention)

With overactive bladder, you may feel the need to urinate more often than usual. This happens when the bladder muscles squeeze more often than they should.

Sometimes, the urethra muscles are not strong enough and let urine pass before you’re ready to go the bathroom. Symptoms can include: 

• An urgent need to urinate 
• Waking up to urinate 2 or more times at night
• Having accidents 
• Passing small amounts of urine

Urinary retention happens when the bladder doesn’t fully empty, which can make you feel like you still need to go. This can happen when lesions on the spine interrupt the signals that tell your bladder when to empty. This means your bladder fills, but you may not realize it. MS can also cause the bladder muscles to stop squeezing too soon, so the bladder doesn't empty all the way.

Your MS healthcare team can help find the cause of your bladder problems and recommend treatment options. They might look at:

• Mobility and access to restrooms:
  • Are your accidents from mobility changes that make it hard for you to physically get to a restroom? 
• Diet and fluid intake: 
  • Some foods and drinks can irritate your bladder (e.g., caffeine, alcohol, fizzy drinks, acidic fruit and juices and spicy food).
• Medications:
  • Some medication can cause bladder issues, like making your body produce more urine and weakening your bladder’s ability to hold it. 
• Urinary tract infections (UTIs):
  • When you don’t drink enough fluids, you can become dehydrated, which makes your urine more concentrated. Concentrated urine may irritate the bladder and increase the risk of a UTI. To help prevent this, try to drink at least 1.5 liters of fluid per day—about six to eight glasses.

Keeping a bladder diary to track how often and how much you’re urinating can also be helpful.

Up to about 80% of people diagnosed with MS will have a UTI at some point. UTIs can often be the first sign of bladder problems and may also lead to relapses or more serious health complications.

Signs for a UTI can be similar to bladder problems (for example, frequent urge to urinate, or only passing small amounts of urine at a time), but be on the lookout for other symptoms like: 

• Painful or burning sensation when urinating 
• Cloudy urine that smells unusual
• Fever

Watch for worsening of symptoms like vision problems, cognitive changes, pain, weakness, and spasticity. These symptoms can be caused by a pseudo-relapse. This happens when a fever or infection raises your body temperature and temporarily makes old MS symptoms appear, but it’s not a new relapse. It usually gets better once your fever or body temperature goes back to normal.

There are different treatments and management options that vary depending on the type of bladder problem you have. From behavioural changes to medications and medical devices, there’s lots of options available so let’s break it down.

Start with Simple Changes

Behavioural changes are small things you can do every day to help your bladder work better:

• Drink less at one time (not more than 4–6 ounces of fluid per hour).
• Reduce caffeine and alcohol, these can irritate your bladder.
• Stop drinking fluids 2–3 hours before bedtime.
• Talk to your doctor or pharmacist about the best way to take medications that cause bladder problems.
• Bladder training with scheduled urination times can avoid urgency and help increase the time between urination.

Pelvic Floor Muscle Therapy

Some people are referred to a physical therapist who specializes in the pelvic floor. The pelvic floor is a group of muscles that support your bladder, bowel, and reproductive organs. Both men and women can use pelvic floor exercises (Kegel exercises) to strengthen pelvic floor muscles, which can help control the flow of urine from the urethra.

Electromagnetic and magnetic stimulation is a treatment that helps strengthen your pelvic floor muscles. You sit on a special chair that sends gentle pulses to make your pelvic floor muscles contract.

Medications 

Medications are usually the next step if behavioural changes and pelvic floor physiotherapy do not help. Depending on your specific bladder problem, different medications can be prescribed. Because all drugs have possible side effects, it’s important to discuss the risks and benefits of any medication with your healthcare team.

When medications don’t work for certain bladder problems, Botox may be used. It’s injected into the bladder muscles to help reduce bladder activity. This treatment usually lasts 6 months to a year.

Talk with your healthcare provider about what’s best for you, including what’s covered under your health benefits plan. 

Electrical Stimulation

Electrical stimulation (neuromodulation) is another way to treat an overactive bladder. Here, an electric current is used to stimulate the nerves of the pelvic floor muscles, causing them to contract. 

In PTNS (Percutaneous Tibial Nerve Stimulation) a very small electrode is inserted through the skin of the lower leg. The electrode is connected to an electrical stimulator (outside your body). The stimulator sends pulses to the electrode, which stimulates the tibial nerve in your leg. That electrical current then affects the nerve in your lower back that controls the bladder and pelvic floor.

SNM (Sacral Neuromodulation) is like the PTNS but the electrical stimulator is placed under your skin near your lower back. 

Management Tools

There are many products you can consider for managing ongoing symptoms.

Absorbent liners, pads, briefs, disposable underwear, and reusable underwear can provide a sense of security and protect clothing from leaks.

Catheters are another option that help with bladder emptying. External and internal options are available and are designed for both males and females.

Catheters

• Female external catheters are soft devices that sit outside the body and use gentle suction to pull urine into a collection container. These catheters are designed to help manage overactive bladders or bladder leakage, not urinary retention.
• Males have the option of condom catheters or external male catheters. 
  • A condom catheter fits over the penis like a condom and drains urine into a drainage bag or a bag worn on the leg.
  • Some male external catheters stick around the base of the penis and use gentle suction to pull urine into a collection container.
• An intermittent catheter is a thin, flexible tube inserted through the urethra several times a day to empty the bladder for people who can’t fully empty the bladder on their own.
• A Foley catheter is a thin, flexible tube inserted through the urethra into the bladder to drain urine. A small balloon at the tip holds it in place, and urine flows into a drainage bag. It’s used for people who can’t fully empty the bladder on their own.

Talk to your healthcare team about what treatment and management options might work best for you. You may need to see a urologist, a doctor who specializes in bladder problems. They can help you explore more treatments, and in some cases, surgery might be an option.

We’d like to thank Becton Dickinson for their support of this content, and their commitment to advancing education for Canadians affected by MS.