Symptom Management

Help for Urinary Incontinence

By Dr. Sardar Ali Khan and Yiji Suh
Help for Urinary Incontinence

By Dr. Sardar Ali Khan and Yiji Suh

MS can decrease quality of life through a variety of symptoms. Certain ones, such as fatigue and gait impairment, receive a great deal of attention, but one of the less-talked-about symptoms is urinary incontinence – an inability to store or empty urine within the bladder, often resulting in the involuntary leaking of urine. This is a serious symptom that can result in poor physical and emotional health, as well as embarrassment and withdrawal from social interaction. Because of the highly negative effects of urinary incontinence, awareness of available testing and treatment options is incredibly important.
 
Testing for incontinence
 
  The two most frequent causes of incontinence are the weakening of the
urinary sphincter and incomplete bladder emptying. If you experience urinary incon-tinence to any degree, it is important to see a urologist. They can perform several tests that may identify the underlying cause and extent of issues. The tests they perform may include:
 
• A urine culture – where urine is collected and tested.
 
• A blood test – to establish proper kidney function.
 
• Cystoscopy – where a small camera is inserted into your bladder.
 
• Video urodynamics – the study of pressure and flow in the lower urinary tract.
 
• A renal (kidneys) and bladder ultrasound – which can determine if the bladder is completely emptying or retaining urine.
 
• Post-void residual urine volume – measuring the amount of urine left in your bladder after urination.
 
Finding the right treatment for you
 
  Finding a suitable treatment option is important, because urinary incontinence can lead to several serious conditions in addition to the discomfort and embarrassment you may experience. Women in a postmenopausal state can leak urine into the vagina, which may cause recurrent vaginitis. Falling can occur in situations where the floor may become wet, resulting in serious physical injury. Leakage, or the fear thereof, may interfere with healthly sexual expression.
 
  In many cases, disturbances in the nerve signals sent to the bladder or sphincter are the cause behind MS-related incontinence. However, a number of other MS symptoms can be contributing factors. Decreased mobility may be factor – especially when combined with speech limitations that may make it difficult to convey needs to one’s caregiver. However, even for those who remain mobile, other symptoms can play a part. For example, symptoms such as chronic fatigue, pain, or blurred vision may make it difficult for someone to respond to the need to urinate in a timely way.
 
  There are several options that medical professionals use to treat urinary incontinence. Oral medication is a popular first-step treatment (see box on page 35). But, if it proves to be
ineffective, urologists may discuss other options, including:
 
• Acupuncture
• Botox injections
• Tibial nerve stimulation
• Pelvic floor muscle training
• Medical marijuana
 
  Botox injections can improve urodynamic function; however, it is important to note that a side effect of Botox injection may include urinary retention. Botox injections can be repeated every three to four months if it is successful in managing urinary incontinence.
 
  Tibial nerve stimulation involves the insertion of an electrode needle into the lower leg. Then, electrical signals are sent up through the leg. The procedure is often done once a week for 12 weeks, and has proven to be an effective alternate to medications.
 
  Pelvic floor muscle training involves doing exercises that will strengthen the muscles that support your bladder and urinary tract. Kegel exercises are the most common form of training and can be done discreetly at any time.
 
  Studies suggest that cannabis may alleviate lower urinary tract symptoms. This treatment may help decrease urinary urgency, number of incontinence occurrences, and incidents of nocturia, when you wake up from sleep with an urgency to urinate.
 
Other options
 
  If these treatments do not show improvement in incontinence symptoms, others are available, but are not often recommended until all other options have been exhausted.
 
  There are several, partially invasive nerve stimulation therapies available. Intravaginal neuromuscular electrical stimulation, which involves placement of an electrode on or into the vagina, may strengthen vaginal muscle by electrical stimulation to allow greater control of the vaginal wall and improve urinary incontinence. Sacral neuro modification (known as InterStim® therapy) sends electrical stimulation through the bladder nerves, which can improve bladder hyperactivity and urinary leakage. However, with these procedures, a neurologist will not be able to monitor MS progress with MRIs because of metal implants in the body.
 
  Clean self-intermittent catheterization (known as CIC) can be performed for urinary retention by the patient, if they retain dexterity in their arms, or by their caregiver after proper training. Catheterization involves inserting a tube into the urethra for the purpose of draining urine from the bladder.
 
  Several surgical options also exist. A urethral sling can be surgically implanted to assist with CIC. Suprapubic cystotomy with closure of the urethra to drain urine from the bladder is also a surgical option to explore. Augmentation cystoplasty is a procedure designed to increase bladder capacity in
patients with small bladder capacity secondary to MS. Permanent urinary diversion is a surgical procedure (called ileal loop) to control urinary incontinence and protect renal function that may be considered for last stages of urinary issues in patients with end stage bladder disease secondary to MS. Ileal loop involves providing an alternative pathway for urine to flow and be collected in a bag. It is only for patients with severe disability.
 
  Future possible solutions to treating urinary MS-related incontinence are being explored. Functional MRI, regarding brain mapping of lower urinary tract dysfunction in MS patients, is a new avenue being considered to improve diagnosis of urinary incontinence.
 
  To safeguard function of the urinary tract and improve quality of life in MS patients with urinary incontinence, a multi-disciplinary team approach – consulting with a neurologist, gynecologist, urologist, physiotherapist, psychiatrist, pharmacologist, nursing staff and caregiver – may improve
options managing urinary incontinence and bladder dysfunction in patients with multiple sclerosis.
 
Urinary incontinence is not a symptom that many people want to discuss, but the severe physical and
emotional burdens of it are not something to be ignored. There are a variety of available treatments that have proven effective for others with MS, and, if you suffer from this symptom, might be able to help you, too.
 
MS Focus is a member of the Bladder Alliance.
 
Medication Options
 
  Several methods for treating patients with MS experiencing urinary incontinence
include anticholinergic medications such as:
 
  • Oxybutynin                                     • Tolterodine
  • Propantheline                                • Propiverine
  • Fesoterodine                                  • Solifenacin
 
  Many, however, cannot tolerate the anticholinergic drugs because of side effects including dry mouth, blurred vision, and hallucinations. As an alternative, antimuscarinic medication, such as trospium chloride or darifenacin, or other medicine, such as
L-Arginine, may be utilized.