Symptom Management

Waste Management as You Age

By Michelle Stern, M.D.

Bowel and bladder issues are common for people with multiple sclerosis at any age. But as one gets older, some of these issues may be directly related to the aging process itself and not to MS. Some of the causes can also be reversible. If you note a change in your bowel and bladder, don’t just chalk it up to the disease process or an irreversible cause from aging. This article will delve into issues affecting the bowel and bladder and help give understanding on a topic that most people are reluctant to ask their physician about.

Bladder Dysfunction

Bladder issues can be identified as a failure to store, a failure to empty, or some combination of both. In the general population, there are many adults over 60 who have urinary incontinence (twice as common in females). This is commonly because of anatomic or physiological changes that occur. Frequent urinary tract infections, obesity, and decreased mobility are also important risk factors.

Most people with MS have a failure to store because of the bladder muscles’ overactivity, which leads to frequent urination, urgency, and incontinence. This is commonly treated by using medications that help decrease the overactive muscles (anticholinergic agents commonly known by trade names Ditropan®, Detrol®, Sanctura®, Enablex®). As one ages, they are more likely to be prone to side effects associated with these medications, such as dry mouth, constipation, and confusion.

The use of a diuretic can also increase frequency. If one has urinary frequency, it is helpful to wear clothes that are easily removed, use timed voiding, limit fluid intake, limit caffeine and alcohol consumption, and use urinals or bedside commodes if mobility is an issue. For people without an indwelling catheter, the recommended fluid intake would be about 61 ounces in total, with only limited amount of water intake after dinner time. 

A failure to empty the bladder usually needs to be treated by using intermittent catheterization or having an indwelling catheter. As one ages, it may be more difficult to perform intermittent catheterizations due to changes in mobility, coordination, vision, and cognitive function. Medications that can increase urinary retention include anticholinergic agents (such as Benadryl), tricylcic antidepressants (such as Elavil®), and narcotics.

A combination of voiding dysfunction is commonly caused by sphincter dysnergia, which is a lack of coordination between the bladder muscle and the sphincter. Medications that can help relax the bladder sphincter can cause low blood pressure upon standing, and the older population should be monitored closely.

Constipation, diabetes, and urinary tract infections are common causes for developing new bladder symptoms. Heart failure or venous insufficiency can also cause an increase in urination, especially when lying down. In addition, women may develop atrophic vaginitis due to the lack of estrogen, while men may have difficulties related to an enlarged prostate.

Your doctor may recommend the following procedures:

• Measuring postvoid residuals, which is the amount of urine left in the bladder after voiding. 

• Urinalysis and urine culture looks for signs of an infection. This can also be used to diagnose diabetes if glucose is present.

• Urodynamic studies give information on how the muscles of the bladder are working.

• Chronic indwelling catheters can cause colonization of the urinary tract, renal stones, and squamous cell cancer, and should be monitored for these issues on a regular basis.

Bowel Disturbance

Bowel dysfunction can be divided into constipation or incontinence, while some may have a combination of the two. This topic has had limited studies compared to the bladder, therefore the true nature of this issue in people with MS is not yet fully understood.

Constipation is by far the most common issue in both the general population and people with MS. As one ages, the motility in the intestines is slowed down, with decreased contractions and a reduced ability to absorb certain vitamins and minerals, as well as a reduced tolerance of certain foods. Constipation can be exacerbated by the lack of mobility, weak abdominal muscles, and inadequate hydration (although hydration must be balanced with bladder issues and finding a balance can be challenging). 

Medications can also cause constipation, including narcotics, iron, calcium, antidepressants, and anticholinergic agents. It can also be related to other medical causes such as hypothyroidism, colon cancer, and diverticular disease. Treatment of constipation includes: fluid intake of eight to 10 cups of water daily, 15 grams of dietary fiber (wheat bran, fruits, vegetables) introduced slowly into the diet to reduce feeling bloated, and a bowel program.

A bowel program should be individually tailored, based on level of mobility and cognition. It needs to be monitored regularly for changes in ability and the program adjusted as needed. Commonly used medication in a bowel program includes stool softeners such as Colace, bulk formers (Metamucil, Citrucel and FiberCon, etc.), and laxatives (such as Senokot, which takes up to eight to 12 hours to work). If constipation persists, a suppository can be used (which typically works in 30 minutes to an hour).

For people with fecal incontinence, a timed toileting and bowel program can help reduce the risk of bowel accidents later in the day. Again, the program needs to take into account the mobility and cognitive status and be adjusted as needed. Diarrhea is not because of MS and should be investigated for other causes. Many medications can lead to diarrhea, such as antacids and antibiotics. Also antibiotic use can lead to an infection called clostridium difficile which can cause diarrhea.  This should be kept in mind, especially for those people with MS who have frequent antibiotic use due to urinary tract infections.  Also as one ages, caffeine, artificial sweeteners, spicy food, fatty food, and fruit juices can cause diarrhea.

Anyone older than 50, with MS or not, is recommended to have their stool tested regularly for blood and undergo routine colonoscopy. A sudden change in bowel habits or rectal bleeding also warrants investigation. Other medical causes of bowel dysfunction that should be investigated are diabetes, electrolyte disturbances, parathyroid disease, and thyroid disease.

Bowel and bladder issues can significantly affect one’s quality of life and need to be addressed. People with MS are encouraged to discuss these issues with their medical team at any age and be aware of the special challenges they may face as they reach an older age.

Michelle Stern, M.D., is a Board-Certified Physician in the field of Physical Medicine and Rehabilitation. Dr. Stern is the current Chair for the Department of Physical Medicine and Rehabilitation at the North Bronx Health Care Network and is an Associate Professor at the Albert Einstein College of Medicine. In addition to her advocacy work and speaking engagements at various national conferences, she also regularly contributes to the current medical literature. Dr. Stern has a special interest in aging with a neurological disease.

(Last reviewed 8/2012)