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Bladder problems are very common among MS patients. In fact, 70 – 80% of patients with MS may experience problems with bladder function.

 

Symptoms of Neurogenic Bladder include:

  • Frequency and/or urgency of urination
  • Hesitancy in starting urination
  • Incontinence (the inability to hold in urine)
  • Frequent nighttime urination (nocturia)
  • Inability to empty the bladder completely and/or double voiding

 

Other causes of bladder dysfunction:

  • Urinary tract infections (UTIs)
  • Pelvic floor relaxation in women
  • Benign prostatic hyperplasia (BPH) in men

 

What can I do on my own to help with my bladder problems?

The Do’s and Don’ts of Bladder Dysfunction In MS

 

DO:

  • Do drink at least 48-64oz of fluid a day (1.4-2 liters) to keep well hydrated. Water is always best.
  • Do limit the amount of caffeinated beverages you consume. It’s ok to have a cup of coffee or tea, but remember, caffeine can cause increased bladder activity and can exacerbate symptoms, including urgency and frequency, as well as increased incontinence.
  • Do limit alcohol intake. Yes, alcohol is also a bladder irritant.
  • Do limit carbonated beverages. The fizz in carbonated beverages can potentially aggravate bladder symptoms.
  • Do try to limit fluid intake past 7:00pm to avoid frequent trips to the bathroom overnight

 

DON’T:

  • Don’t Smoke! Smoking irritates the bladder muscle, and spasms caused by smoker’s cough can result in further urine leakage.
  • Don’t try to self-treat your bladder problems by drinking less fluid!  Don’t let yourself become dehydrated. This can lead to constipation and sometimes urinary tract infections.
  • Don’t wait for the urge! Drink 6-8oz of fluid at regular intervals and then urinate on a regular schedule. It usually takes about 1.5 hours for fluid that you drank to get to the bladder, so try to void every 1.5-2 hours.

 

What are the potential pharmacologic treatments for bladder dysfunction?

Commonly used medications for urgency, frequency and incontinence include a class of drugs called anticholinergic/antimuscarinic agents.

 

Examples of these medications include:

  • Oxybutynin (Ditropan/XL®)
  • Oxybutynin transdermal
  • Tolterodine (Detrol®/LA)
  • Solifenacin succinate (VESIcare®),
  • Darifenacin (Enablex®)
  • Fesoterodine fumarate (Toviaz®)

 

Other medications used for bladder problems include:

  •  Mirabegron (Myrbetriq®) – This drug works by a different mechanism of action than the medications listed above. It is a beta-3 adrenergic receptor agonist.
  •  DDAVP (desmopressin)
  •  Flomax® (tamsulosin)
  •   Hytrin® (terazosin)
  •  Minipress® (prazosin)

 

 

Other Treatments:

  • Botulinum Toxin (Botox®)
    Botox can be injected into the bladder wall to help with bladder spasticity and relax bladder muscles. Botox has been used to treat urinary incontinence for many years. It acts to decrease the muscular contractions of the bladder and improved the bladder carrying capacity.This is often a short procedure that takes place in a urology clinic or operating room.  The effect from the injections can last up to about 6 months.
  • Intermittent self-catheterization or indwelling catheter.
    This can be particularly helpful for patients that have difficulty emptying their bladder.

 

Referral to urology

  • You may be referred to a urologist for urodynamic testing. Urodynamics is a study that assesses how well the bladder and urethra are storing and releasing urine.
  • A urologist is the person who administers Botox injections

Many patients with MS may experience problems with their bowels.

Normal bowel functioning can range from 3 bowel movements a day to 3 a week. While you may have heard that “one movement a day,” is the norm, such frequency is not necessary. The medical definition of “infrequent” bowel movements is “less often than once every 3 days.”

Constipation is the most common bowel complaint in MS.

In addition to the disease itself, other contributing factors to constipation in MS patients may include, inactivity; difficulty in walking and fatigue which can slow movement of waste material through the colon. Medications such as calcium supplements or antacids containing aluminum or calcium can also contribute to constipation. Additionally, other drugs such as some antidepressants, diuretics, opiates, and antipsychotic drugs may also lead to constipation. Finally, some people with MS try to solve bladder problems by reducing their fluid intake.  However, restricting fluids can make constipation worse.

Besides the obvious discomfort of constipation, complications can develop. Stool that builds up in the rectum can put pressure on parts of the urinary system, increasing some bladder problems.

 

Forming Good Bowel Habits

 

  • Drink enough fluids:  Each day, drink 8–12 cups of liquid whether you are thirsty or not. Water, juices, and other beverages all count

 

  • Put fiber into your diet: Fiber is plant material that holds water and is resistant to digestion. It is found in whole-grain breads and cereals as well as in raw fruits and vegetables. Fiber helps keep the stool moving by adding bulk and by softening the stool with water

 

  • Get your regular physical activity: Walking, swimming, and even chair exercises help

 

Medications/tools that can help

 

  • Stool softeners: Examples are Colace® and Surfak. These medications often contain docusate, a surfactant that helps to “wet” and soften the stool.

 

  • Bulk-forming supplements: Natural fiber supplements include Metamucil®, Benefiber, FiberCon, Citrucel®, or Fiberall.  These supplements are often taken daily with 1-2 glasses of water. They are generally safe to take for long periods.

 

  • Saline laxatives: Milk of Magnesia, Epsom salts, and sorbitol are all osmotic agents. They promote secretion of water into the colon. They are reasonably safe, but should not be taken on a long-term basis.

 

  • Stimulant laxatives:  Some brands include Ex-Lax, Senokot, Correctol, Dulcolax, These medications provide a chemical irritant to the bowel, which stimulates the passage of stool. Peri-Colace includes senna plus a stool softener. Note: Don’t use stimulant laxatives daily or regularly. This type of laxative may weaken the body’s natural ability to defecate and cause laxative dependency. One more caveat: the stimulant laxatives may cause cramping and diarrhea.

 

  • Suppositories: If oral laxatives fail, you may be told to try a glycerin suppository half an hour before attempting a bowel movement. Dulcolax® suppositories stimulate a strong, wave-like movement of rectal muscles.

 

  • Enemas: Enemas should be used sparingly, but they may be recommended as part of a therapy that includes stool softeners, bulk supplements, and mild oral laxatives.

 

Bowel Incontinence:

Accidents can happen.  This can be embarrassing and stressful. Try to keep a regular bowel regimen to prevent an uncomfortable situation.

 

If you know you might be in a situation where you’ll be at risk for an accident, you can try to induce a bowel movement on your own beforehand with the help of enemas or suppositories.

Depression is very common among MS patients. Depression in MS may be due to the disease itself which may affect the signals in the brain that affect mood. Depression can also a side effects of some the drugs that treat MS, such as steroids or interferon.

More than half of all people with MS are likely to experience a depressive episode over their lifetime compared to 20% of the general population.

Anxiety, difficulty controlling emotions (mood swings), pseudobulbar affect (inappropriate or uncontrollable laughing and weeping), and euphoria also occur in MS.

It is not uncommon for family members to also become depressed and anxious as they struggle to cope with the challenges of the illness affecting their loved one. MS affects the whole family.

 

What are the symptoms of Depression?

Depression is characterized by:

  • Depressed mood or loss of interest or pleasure
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness
  • Sleep disturbances: trouble falling or staying asleep, early morning awakening, sleeping too much (this can be confused with sleep disturbances caused by MS)
  • Diminished appetite with weight loss or increased appetite with weight gain
  • Decreased energy, increased fatigue, and feeling “slowed down” (this can be easily confused with MS-related fatigue)
  • Restlessness or agitation and/or irritability
  • Diminished ability to think, concentrate, or make decisions (this can be easily confused with MS-related cognitive impairment)
  • Thoughts of suicide or death or a suicide plan or attempt

 

 

When are MS patients most vulnerable to depression?

People with MS can become depressed at any time, but certain times and experiences are associated with greater risk:

  • The time at diagnosis
  • During an exacerbation or relapse
  • Noticing increasing disability
  • A transition point to greater dependence – i.e. the need for a cane, transitioning to a wheelchair
  • Any major life change or loss, such as retiring for disability-related reasons

 

What are some of the medications for depression?

  • Prozac (Fluoxetine) 10mg-40mg daily

Side Effects: Weight gain, sexual side effects, agitation, insomnia

  • Sertraline (Zoloft) 50mg-200mg daily

Side Effects: Sexual side effects, loss of appetite, GI side effects, agitation, insomnia

  • Escitalopram citrate (Lexapro) 10mg-20mg daily

Side Effects: Sexual side effcts, nausea, diarrhea, agitation, insomnia

  • Citalopram (Celexa) 20mg-60mg daily

Side Effects: syncope, lightheadedness, tremor, hallucinations, sexual side effects

  • Venlafaxine (Effexor) 37.5mg-225mg long-acting forms given once daily

Side Effects: tachycardia, hypotension, sexual side effects, nausea, weight loss

  • Bupropion (Wellbutrin) 100mg-300mg in divided doses

Side Effects: lowers seizure threshold, nausea, constipation, headache, insomnia, rare Stevens-Johnson syndrome

 

 

What you can do:

  • Talk to your neurologist or primary care doctor about finding a mental health provider who can help you.
  • Psychiatrists, psychologists, social workers, and psychiatric nurses all work with patients and families in psychotherapy.
  • Chapters of the National Multiple Sclerosis Society (1-800-344-4867) can provide names of mental health professionals in the community who are experienced with treating the emotional disturbances associated with MS.
  • The chapters also offer educational programs, support groups, and other resources to support patients’ coping efforts and help them deal with MS-related emotional changes.

 

 

Recommended Books:

  • Feinstein A. The Clinical Neuropsychiatry of Multiple Sclerosis (2nd ed.). New York: Cambridge University Press, 2007.
  • Kalb R (ed.). Multiple Sclerosis: The Questions You Have; The Answers You Need (4th ed.). New York: Demos Medical Publishing, 2008.
  • Kalb R (ed.). Multiple Sclerosis: A Guide for Families (3rd ed.). New York: Demos Medical Publishing, 2006.
  • Kalb R, Holland N, Giesser B. Multiple Sclerosis for Dummies. Hoboken, NJ: Wiley Publishing, 2007
  • Minden S. Pseudobulbar Affect (Uncontrollable Laughing and/or Crying) https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Clinical-Bulletin-Pseudobulbar.pdf
  • Pitzele S. We Are Not Alone: Learning to Live with Chronic Illness. New York: Workman Press, 1986.

Fatigue in MS may be due to certain lesions affecting specific parts of the brain. It is the most common symptom of MS. As many as 75% to 95% of all people with MS have fatigue; 50% to 60% say that it’s one of their worst problems. No one quite understands what causes MS related fatigue, but we do know some things that can help.

MS related fatigue may have some unique characteristics that make it different from the normal feeling of being tired.  MS patients may notice some of the following features associated with their fatigue:

  • Generally occurs on a daily basis
  • May occur early in the morning, even after a restful night’s sleep
  • Tends to worsen as the day progresses
  • Tends to be aggravated by heat and humidity
  • Comes on easily and suddenly
  • Is generally more severe than normal fatigue
  • Is more likely to interfere with daily responsibilities

 

Some Strategies for Dealing with Fatigue Include:

  •  Physical therapy: May learn energy-saving ways of walking (with or without assistive devices) and performing other daily tasks, and to develop a regular exercise program.
  • Sleep regulation: May involve treating other MS symptoms that interfere with sleep (e.g., spasticity, urinary problems) and using sleep medications on a short-term basis.
  • Psychological interventions: Stress management, relaxation training or Cognitive Behavioral Therapy
  • Heat management: Find ways to avoid overheating and how to cool down quickly.
  • Rest and Conserve: Take short breaks throughout the day. Rest before you get tired! Take advantage of using that handicapped permit and park close to the building. That does not mean you’re giving in; it means you’re being smart.
  • Exercise: This seems counterintuitive, but exercising boosts energy by strengthening easily tired muscles
  • Ask for help: It’s ok to delegate some work to others.  Be specific about what you need.  

 

Medications that can help:

    Drug name      Dose in MS      Drug profile

 

     Amantadine     100 mg morning and early afternoon      Antiviral agent typically used in influenza or Parkinson’s disease treatment—has also shown fatigue relief for some with MS
     Modafinil (Provigil)

 

    100-200 mg a day      Wakefulness-promoting agent for treating narcolepsy that a study has shown reduces self-reported fatigue for some people with MS
     Methylphenidate (Ritalin)

     Amphetamine & Dextroamphetamine (Adderall)

     10–20 mg early morning and at noon      A central nervous system stimulant indicated for treatment of attention deficit disorders but also helpful for MS fatigue in some people

 

Source: National MS Society Medical Advisory Board

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