Bladder and Bowel Problems
Written by Marie A. Namey, APN, MSCN
Advanced Practice Nurse
Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic
Although the literature reports that many people with MS experience bladder and bowel disturbance, I’m not sure how many people with MS actually talk openly about these symptoms with their healthcare providers. Bladder and bowel symptoms, once assessed, can be very successfully treated. There are many excellent treatment options that are available for bladder and bowel dysfunction, as well as many behavioral and dietary approaches that can reduce your symptoms.
Please keep in mind that like other MS symptoms, bladder and bowel problems can vary from person to person. It’s important to have an assessment and develop a plan that addresses your particular symptoms and works for you.
Recent articles appearing in medical journals say that 80 percent of people with MS report bladder symptoms at the time of diagnosis and up to 90 percent of people with MS by 10 years after diagnosis. In one study that reviewed patients who share their MS experience in the NARCOMS database, only 43 percent of people with moderate to severe bladder symptoms had ever been evaluated by a urologist.
I know that many people don’t talk about elimination problems with their healthcare provider, so as a nurse with more than 25 years of experience providing care for people with MS, I wonder why this is so. Maybe it’s just too embarrassing to talk about with others. Maybe during a visit with your healthcare provider, the discussion of MRI or other medicines to treat MS take up most of the time. Maybe you think that bladder and bowel symptoms are a normal part of aging. Or maybe you think that there isn’t much help for these symptoms. Whatever the reason, I encourage you to find a way to discuss these symptoms openly.
Bladder and/or bowel disturbances due to MS can be very distressing and limiting. There is an association between bladder and bowel symptoms and quality of life. Bladder and bowel dysfunction often results in people avoiding opportunities to socialize and restricting their normal daily activities. Constantly leaking urine can result in skin breakdown and infection. Bowel dysfunction can cause a great deal of discomfort. First let me discuss what happens in MS that causes these symptoms to occur. Let’s start with the bladder.
Bladder Dysfunction
Bladder dysfunction in MS happens when nerve signals to the bladder and urinary sphincter (the muscles surrounding the opening to the bladder) are blocked or delayed because of MS lesions in the brain and/or spinal cord.
There are basically two major muscles involved in emptying the bladder: the detrusor muscle and the sphincter muscle. As a result of MS, the detrusor muscle in the wall of the bladder involuntarily contracts, increasing the pressure in the bladder and decreasing the volume of urine the bladder can hold. This causes symptoms of going frequently, urgently, leaking urine, or interfering with a good night’s sleep.
In other words, the inability to store or hold urine in the bladder occurs when the bladder is unable to retain urine when it accumulates. Instead of expanding when urine collects, the bladder involuntarily contracts, which can make you feel as if you have an urgent need to go to the bathroom much of the time – even when there isn’t much urine in the bladder.
The flow of urine is controlled by the sphincter in the bladder, the muscle which relaxes to open and contracts to close. An inability to empty means that even though a person senses that his bladder is full, the nerve impulse telling the muscle to open is interrupted and never reaches the urinary sphincter, and the sphincter muscle closes before all the urine is emptied from the bladder. If you’re not emptying your bladder completely, you might feel the urge to void often but have hesitancy when you try to void. You may also wake up at night often to void since the bladder is not completely empty during the day. Bladder infections or urinary tract infections (UTIs) can occur if urine, which is a waste product, sits in the bladder too long.
Leakage of urine can occur in some cases when the sphincter remains at least partially open, resulting in involuntary leaks. Sometimes the detrusor muscle and the sphincter muscle do not work in coordination and a person with MS can experience many bladder symptoms.
Many behavior modification techniques may be used to manage bladder symptoms. Here are a few suggestions:
- Drink 48 to 64 ounces of fluid a day (one and a half to two quarts) to keep well hydrated. Water is best.
- Drink six to eight ounces of fluid at regular intervals and then urinate on a regular schedule, rather than waiting for the urge. It takes about one and a half hours for fluid that you drank to get to the bladder, so try to void by the clock, every one and a half to two hours.
- Limit the amount of caffeinated beverages, alcohol, and orange juice. It’s okay to have one cup of coffee or tea, but remember that caffeine can cause you to void more frequently and more urgently. Alcohol is also a bladder irritant.
- Stop smoking (yes, smoking is a bladder irritant too).
- Don’t try to self-treat your bladder problems by drinking less fluid! This can lead to constipation and/or urinary tract infections.
Assessing how your bladder works first involves a simple screening for a urinary tract infection (UTI), which is very common in MS and can cause many of the symptoms mentioned. If you have an infection, you will be treated with antibiotics to clear up the infection and symptoms may improve.
If you do not have an infection, then further evaluation of how your bladder works is important before suggesting treatments. After proper assessment, medications might be prescribed to allow the bladder to hold more urine or empty better. There are many medication options on the market now, so don’t get discouraged if one doesn’t work or causes too many side effects.
Another intervention is to learn the technique of intermittent self-catheterization to allow the urine to flow and empty the bladder if you are not emptying completely. Intermittent catheterization (IC) is a safe procedure that can help bring your urinary symptoms under control. Many people self-catheterize and report that it has improved their quality of life. It will allow you to completely empty your bladder at regular intervals, protect your kidneys from infection and damage, lower the risk of distending (stretching) the bladder, and eliminate the need for wearing a continuously draining catheter. However, some individuals would benefit from an indwelling catheter (Foley catheter) for a short period of time.
Other interventions can be offered by a urologist, including a suprapubic catheter. This is another type of urine drainage catheter that is surgically inserted into the bladder so that urine can drain out. Instead of urine being passed through the urethra opening as usual, the suprapubic catheter is inserted through the abdominal wall just above the pubic bone and into the bladder.
There are also other surgical procedures that might be recommended by a urologist. More recently, Botox injections into the bladder have been approved by the FDA to help with managing symptoms.
Bowel Dysfunction
Bowel symptoms can affect nearly 70 percent of individuals with MS. Because MS interrupts or slows the transmission of signals to and from the brain and spinal cord, the electrical impulses to the muscles that are involved in emptying the bowel can become disrupted. MS may also prevent pelvic floor muscles from relaxing. These muscles are used to help void fecal matter. Also, MS may block the natural increase in activity of the colon following meals.
Most individuals experience constipation or slow bowel. Some people with MS have reported bowel incontinence (loss of bowel control) and diarrhea, although these latter symptoms are less common than constipation in individuals with MS.
Constipation is very common among people with MS. In general, inadequate daily fluid, not enough dietary fiber (less than 20 grams of fiber per day), and lack of physical activity all affect the digestive system. Medications and supplements may also contribute to constipation.
Constipation is characterized by infrequent bowel movements (usually fewer than three bowel movements per week), or by needing to strain to eliminate stool. Constipation can contribute to abdominal cramping, bloating, fullness, or discomfort.
A very distressing symptom, bowel incontinence is the loss of voluntary bowel control. This can range from occasionally leaking a small amount of stool and passing gas to completely losing control of bowels. Bowel retraining can help encourage normal bowel movements. Aspects of this routine may include setting aside time every day to try to empty the bowels, taking in enough daily fiber to keep stool formed, and avoiding foods that trigger loose stool for you.
Some individuals experience diarrhea. Diarrhea occurs when the bowel contents progress too rapidly along the digestive tract, resulting in frequent bowel movements that yield watery, loose stools. This is sometimes the result of allergies or sensitivity to spicy foods or dairy products, contaminated water or food, a change in activity level, or a stomach virus. Chronic diarrhea can also contribute to dehydration or poor nutrient absorption in people with MS.
Many behavior modification techniques may be used to manage bowel symptoms. Here are a few suggestions:
- Increase your fluid intake. Try to drink six to eight glasses of water daily.
- Drink something hot as the first beverage in the morning (tea, coffee, etc.) to stimulate a bowel movement (BM). Peristaltic activity (that moves food and waste through the intestines) is increased after a hot beverage or meal.
- Try to maintain regularity. Establish a regular time for emptying the bowels. Plan trips to the bathroom immediately after meals, since eating is a natural stimulus for having a bowl movement. Take your time in the bathroom, but if after 10-15 minutes you do not have a BM, try again later. Try to wait no more than two to three days between bowel movements.
- Increase your fiber intake. Eating plenty of fresh fruits and vegetables as well as whole grain breads and cereals is the best way to increase the amount of fiber you eat. High fiber cereal can be eaten dry or sprinkled over other foods. You might try a high fiber supplement but real food is best.
- Be sure to exercise. Activity such as walking helps normalize bowel function.
The message here is that bladder and bowel symptoms can be treated once these symptoms are discussed openly and proper assessment is completed. It’s important to share your concerns with your healthcare providers; if they are not able to help, ask for a referral to someone who can help. You may need a referral to a urologist to treat bladder symptoms or a gastroenterologist for bowel management.
The medications listed on the following page may be used to treat bladder and bowel problems (as listed on MSAA’s website at mymsaa.org under Symptoms). Please see MSAA’s website for more information about these drugs, such as prescribing information and side effects.
Bladder medications for failure to store:
- Ditropan® and Ditropan XL® (oxybutynin)
- Detrol® and Detrol LA® (tolterodine tartrate)
- Vesicare® (solifenacin)
- Enablex® (darifenacin)
- Levsinex® (hyoscyamine)
- Flomax® (tamsulosin) and other antihistamines
- Hytrin® (terazosin); Minipress® (prazosin)
- DDAVP (desmopressin)
- Botulinum Toxin (Botox®)
- Myrbetriq® (mirabegron)
- Toviaz® (fesoterodine fumarate)
Medications to treat bladder infections:
- Bactrim® (sulfamethoxazole/trimethoprim)
- Septra® (sulfamethoxazole/ trimethoprim)
- Cipro® (ciprofloxacin)
- Macrodantin®, Macrobid® (nitrofurantoin)
Medications for constipation:
- Stool softeners
- Colace® (docusate)
- Surfak®
- Chronulac®
- Bulk formers
- Metamucil® (psyllium hydrophilic mucilloid)
- Fibercon®
- Citrucel®
- Fiberall®
- Laxatives; oral medications
- Miralax®
- Pericolace®
- Milk of Magnesia® (magnesium hydroxide)
- Mineral oil
- Laxatives; rectal stimulants
- Glycerin suppositories
- Dulcolax® (bisacodyl) suppositories
- Enemeez® Mini Enema (docusate)
- Fleet® (sodium phosphate) Enema
Medications for diarrhea:
- Metamucil®
- Imodium® and related medications