Wednesday, December 24, 2014

Clinic Speak: urinary symptoms in CISers

Urinary symptoms an early marker of damage in CISers. #ClinicSpeak #MSBlog #MSResearch

"You may get tired of me banging on
about the early impact of damage in MS and how the damage begins early
and in some cases before the first attack. Well I need to bang on a bit
more about this isssue. The study below looks at urinary symptoms in
CISers; i.e. people with only one clinical attack suggestive of MS. From
a practical perspective this is the earliest we as neurologists and
researchers can study this disease clinically. This study, albeit small,
scarily shows that over half of CISers studied had urinary symptoms and
this was backed up by hard or objective findings on testing. The latter
is called urodymanic studies; these studies test the bladders function.
For example how it deals with increasing pressure and does it empty
properly at the correct flow rates."

"Urinary symptoms in the majority of
CISers is giving you the same message as cognitive dysfunction in
CISers. Damage occurs early therefore if you are eligible for DMTs you
should take up the option. A lot of my colleagues tell me that if you
treat all CISers you will be treating a lot of people who will end up
with benign disease. Isn't that the point. Aren't we trying to convert
all MSers disease course into a benign course? The truth is in natural
history studies the proportion of MSers who have benign MS drops off
with time and the vast majority of MSers become disabled with time.
Having urinary symptoms early in the course of the disease is simply
another indicator that you don't have benign MS."

"Do you have urinary symptoms? I
view bladder dysfunction in MSers as integrator of damage and
potentially an early read-out of a poor prognosis. I therefore take this
symptom in MSers seriously as it has implications for prognosis and
treatment. Over the years I have observed that MSers who develop bladder
dysfunction tend to do worse than MSers who don't have bladder
symptoms. Why? The bladder is a complicated organ with several
neurological components that can be affected by MS and hence is
sensitive to damage."

"Why is the bladder an integrator of
MS damage? The descending nerve fibres that travel from the brain to the
lower spinal segments are very long and hence have a greater chance of
being affected by MS lesions in their path to the bladder centre in the
lower spinal cord. The same is true for motor fibres that control
movement in the lower legs. The bladder, unlike the motor fibres to the
leg, is more complicated because of the need to coordinate the different
muscular functions in the bladder. Therefore any progressive MS damage
is more likely to manifest with bladder dysfunction early on. This is
why I now include bladder problems in my list of poor prognostic factors
in MS."

"The bladder has two muscles that need to coordinated;
the detrusor or balloon and the sphincter or valve muscles. When the
bladder is filling up the detrusor muscle has to relax to allow the
bladder to expand with urine and the sphincter has to contract to keep
the urine in the bladder. The opposite occurs when you pass urine; the
sphincter or valve opens and the detrusor contracts to empty the

"What happens if the two muscles are not coordinated?
This causes the symptom of hesitancy, i.e. when you try and pass urine
the sphincter won't open and you have to wait for the bladder to open;
MSers find this very frustrating. The sphincter can also close as you
are passing urine, which breaks up the urine stream or prevents you from
emptying your bladder completely. The latter also causes dribbling. The
medical term for incoordination of the bladder muscles is dyssynergia
or more correctly detrusor-sphincter-dyssynergia (DSD). The drug
treatment for DSD includes the so called alpha-blockers ( prazosin,
indoramin, tamsulosin, alfuzosin, doxazosin and terazosin). Other
strategies include small bladder stimulators or vibrators; these are
place over the pubic area and work by blocking signals that inhibit the
sphincters. The vibrators work in some MSers and may help relax the
sphincter. It is also important to try and relax when passing urine;
this often helps improve hesitancy. The sound of running water, for
example from a tap, may trigger relaxation of the sphincter. This can be
a problem in public toilets when opening a nearby tap may not be
possible or inappropriate. Some MSers find pressing on the lower abdomen
helps. If all else fails regarding hesitancy intermittent
self-catheterisation (ISC) may be the only option."

"In MS the commonest bladder
problem is spasticity, or irritability, of the detrusor muscle. The
detrusor can't relax and this prevents the bladder filling to its
maximum capacity. Frequent spasms of the detrusor muscle tell the brain
that it is full and you need to go to the toilet. This causes frequency;
i.e. the need to go the toilet many times during the day and night.
Frequency often goes with the symptom of urgency, the need to get to the
toilet as quickly as possible to prevent yourself from being
incontinent. Incontinence occurs as you often lose the ability to
suppress or ignore the signals from the detrusor muscle and the
sphincter relaxes or opens as part of spinal cord reflex. We treat this
problem with the so called anti-cholinergic drugs, for example
oxybutynin, solifenacin or tolterodine. The older generation
anticholinergics such as oxybutynin cross the blood-brain-barrier and
enter the brain where they can exacerbate cognitive problems in MSers.
This is why I avoid using them. The commonest side-effect of
anticholinergics is dryness of the mouth and they can make constipation
worse. There is also a risk that they will relax the bladder too much
and precipitate urinary retention. All MSers must be warned about the
this problem when starting anticholinergics; I have had several MSers
under my care go into retention on starting anticholinergics."

urgency is a problem try some distraction techniques such as breathing
exercises and mental tricks (for example, counting) to take your mind
off the bladder; some MSers find this helpful. If frequency is the main
problem you may want to try and retrain your bladder by holding on for
as long as you can each time before passing urine. The aim is to train
the detrusor muscle to expand more so that it can hold on for longer
when you need to go to the toilet. In my experience these behavioural
techniques rarely work for long; MS is a relapsing and/or progressive
disease and in all likelihood the bladder pathways will simply be
affected by new MS lesions."

"If you fail to respond to
anticholinergics and behavioural techniques you need to have your
bladder scanned to see if you have a raised residual volume. The
residual volume is the amount of urine left behind after you have
emptied your bladder. If the residual volume is greater than 80-100mL
you may need to consider intermittent self-catheterisation or ISC. ISC
serves two purposes; it increases your so called functional residual
bladder volume allowing more storage space for urine in the bladder;
this reduces frequency and urgency. This is can help you if you have to
take a long trip or or to get through a social activity without having
to pass urine. It also helps reduce nocturia, or having to get up
frequently to pass urine at night. You will be surprised how much better
you feel if you get a good nights sleep. Reducing nocturia and
improving sleep reduces daytime fatigue."

"Another treatment that
is becoming more common is botox of the detrusor muscle. This paralyses
the muscle turning it into a flaccid bag for urine storage. Almost all
MSers who have detrusor botox are using ISC. In the past, before botox
was available, there were surgical techniques that could be used to
denervate or remove the nerve supply to the bladder that had the same
effect; these surgical techniques are rarely used nowadays."

also removes urine from the bladder. This is important if you are
having recurrent bladder infections. The residual urine acts as a
culture medium for bacteria and by clearing your bladder you can prevent
bladder infections. The opposite can occur. If you don't do ISC
technique correctly  you can introduce bacteria into the bladder, which
can cause infections."

"I have already posted on the potential
link between bladder infections and disease progression. The more
infections you have, in particular severe infections, the more likely it
is your MS will progress. Therefore if you have recurrent bladder
infections you should try and prevent them occurring. How do you do
this? Drink lots of liquids; flushing the bladder reduces infection
rates. Also acidifying your urine by drinking cranberry juice or citric
acid (citrasoda or lemonade) also helps. Increasing the frequency of ISC
may also help. Finally using urinary antiseptics may help reduce
infection rates. Urinary antiseptics are antibiotics that are
concentrated in the urine; they are given in low concentrations so they
have little impact on the rest of the body. I tend to cycle their use,
every 3-4 months, to prevent the bacteria in the bladder becoming
resistant to them. The agents I use currently are trimethoprim,
cephalexin, nalidixic acid and nitrofurantoin."

"If nocturia is
your main problem using agents to concentrate the urine at night might
help. There is a hormone called DDAVP that works on the kidney to reduce
it making urine. You can take DDAVP as a nasal spray or tablets. DDAVP
can only be taken once a day; if you use it continuously your kidneys
will retain water and that can be very dangerous. The latter is called
water intoxication; it presents as swelling of the feet and reduces the
salt or sodium levels in your blood. If blood sodium level become too
low it can cause problems. This is why when you start using DDAVP you
need to have your sodium levels checked about 4-6 weeks after starting
therapy. I am not sure why, but some neurologists are reluctant to
prescribe DDAVP. This is a shame as it is a very good drug and can make
the difference between getting a good nights sleep or waking feeling
awful. You can use DDAVP intermittently and you can use it the day, for
example when you need to go on a trip or when you need to go out. Please
remember you can only use DDAVP once a day; so if you use in the day
you can't use that day at night. The most common side effect is swelling
of the feet; it happens in approximately a third of MSers and is more
common in MSers who are less mobile."

"Other advice I give to
MSers is that if you are a smoker then stopping smoking may
significantly improve your bladder symptoms, as nicotine irritates the
bladder. Similarly, reducing alcohol and caffeine consumption may also
help; both these agents affect the kidney and cause it make more urine.
Medically this is referred to as a diuresis and these agents act as
diuretics. Try to anticipate times when urinary frequency and urgency
are likely to be most inconvenient; reducing the amount that you drink
beforehand may help. For example, when you go out, don't drink much for
2-3 hours before you go out. However, do not reduce your total fluid
intake to less than 1.5 litres each day. After you have finished passing
urine, go back to the toilet again after a few minutes to try to pass
some more urine. This is called the double micturition technique, which
aims to make sure the bladder is emptied completely."

if all else fails some MSers may need to be catheterised. This can be
done via the urethra or the lower abdominal wall. The latter is called a
suprapubic catheter. Being permanently catheterised sounds awful, but
in some MSers this drastically improves their quality of life. I have
several MSers who have let bladder dysfunction control their lives as a
result they have become socially isolated. They are typically anxious
about being incontinent in public. To avoid this possibility they choose
to stay at home. This is clearly unnecessary and with the strategies
highlighted above adequate bladder control should be the norm in MS. In
my experience the biggest hurdle to achieving adequate bladder control
is MSers accepting their bladder symptoms as being part of the disease
and living with them. Why? If you have problems tell your nurse or
neurologist; they will be able to help you."

Epub: Di Filippo et al. Lower urinary tract symptoms and urodynamic dysfunction in clinically isolated syndromes suggestive of multiple sclerosis. Eur J Neurol. 2014 Jan.

Urinary symptoms associated with MS are common and negatively impact on
quality of life, representing a considerable psychosocial and economic
burden, often requiring care and hospitalization. Although the
importance of identifying and adequately treating urinary symptoms in MS
is now well recognized, there is no information, to date, about the
real prevalence and impact of bladder symptoms in patients with
clinically isolated syndromes (CISs) suggestive of MS.

The aim of the present study was to investigate, in a cohort of
patients with a diagnosis of CIS suggestive of MS, the prevalence of
urinary tract symptoms, their impact on quality of life measures and
their association with functional urodynamic dysfunctions. CISers
underwent a complete neurological and urological visit, urodynamic
investigation and the MSQoL-54 questionnaire.

Twenty-eight consecutive CISers were enrolled in the study; 53.6% of
CISers reported urinary symptoms, 46.7% reporting irritative symptoms,
33.3% both irritative and obstructive symptoms and 20% obstructive
symptoms alone. Urodynamic abnormalities were observed in 57.1% of the
CISers. In 17.9% of the CISers urodynamic dysfunctions were
asymptomatic. The presence of urinary symptoms was associated with lower
scores on specific quality of life domains, particularly in women with
obstructive symptoms.

CONCLUSIONS: A high prevalence of
urinary symptoms and urodynamic dysfunctions in CISers and an
association of urinary symptoms with quality of life measures were
found. These results highlight the importance of identifying and
optimally treating urinary symptoms also at the very early stages of MS.