SECTION 12: BLADDER

Bladder problems are common in MS, and result from demyelination in the nervous system pathways that control the muscles of the bladder and the sphincters of the urinary tract. The three categories of bladder problems are usually referred to as "failure to store," "failure to empty," and a "combination" of the two. They can usually be managed successfully, once the cause is identified.

A. FAILURE TO STORE

This problem results from a hyperactive or spastic bladder, and is the most common type of bladder dysfunction in MS. Symptoms include increased urgency and frequency of urination, incontinence, and the need to urinate during the night (nocturia).

NON-PHARMACOLOGIC MANAGEMENT

Dietary and Fluid Management

Changes in your diet combined with timing urination - rather than waiting to feel the urge - may be effective. Your nurse or other healthcare provider can help you to develop an effective management plan. Meanwhile, don't restrict your water intake! Dehydration and constipation will only add to your problems.

PHARMACOLOGIC MANAGEMENT

Ditropan® and Ditropan XL®(oxybutynin)

This medication may be taken orally, and it is also available through a patch, which is replaced every 3 to 4 days. The dose for regular release is 5 mg two times per day; XL is 5 to 10 mg once daily; and a new patch is usually applied two times per week. This medication decreases the spasms associated with failure-to-store bladder problems, reducing urge and frequency of urination.

A study now recruiting participants, sponsored by Astellas Pharma Inc., will compare the effects of oxybutynin against solifenacin (brand name: Vesicare ®; please see individual listing on next page for more information about this drug).

Side effects include dry mouth, constipation, headache, and blurred vision.

Detrol® and Detrol LA®(tolterodine tartrate)

This is an oral medication in tablet form. The dose ranges from 2 to 4 mg per day. It reduces the frequency and severity of the bladder spasms that result in many of the symptoms associated with failure-to-store problems.

Side effects include dry mouth, headache, and gastrointestinal symptoms.

Vesicare®(solifenacin)

This is an oral medication in tablet form. The dose ranges from 5 to 10 mg per day.

As mentioned earlier, a study now recruiting participants, sponsored by Astellas Pharma Inc., will compare the effects of oxybutynin against solifenacin in MS.

Side effects include dry mouth, constipation, and blurred vision.

Enablex®(darifenacin)

This is an oral medication in tablet form. The dose ranges from 7.5 to 15 mg per day. Its actions are similar to those of Detrol ® and Ditropan®.

Side effects include dry mouth, constipation, and blurred vision.

Levsinex®(hyoscyamine)

This is an oral medication in tablet form. The dose ranges from 1 to 2 mg per day.

Side effects include dry mouth and difficulty swallowing.

Flomax®(tamsulosin) and Other Antihistamines

This is an oral medication in capsule form. The dose ranges from 0.4 to 0.8 mg per day. Flomax ®was originally developed to treat enlargement of the prostate. It acts by relaxing the muscles of the bladder.

Side effects include low blood pressure, dizziness, and sleepiness.

Hytrin® (terazosin); Minipress®(prozosin)

These are oral medications in tablet form. The dose for either drug is 1 mg once to twice daily. These medications were developed to treat high blood pressure. They are also effective in relaxing the muscles of the bladder.

Side effects include dizziness, weakness, and nausea.

DDAVP (desmopressin)

This drug is administered as a nasal spray, as directed, and is also available as an oral formulation. The nasal spray is usually taken once in the evening, as a treatment for nocturia (nighttime urgency). The dose is one squirt (spray) or 0.2 mg (oral), both given at bedtime. Desmopressin is a hormone that controls frequent urination by its action on the kidneys.

Side effects include runny or stuffy nose and headache.

Botulinum Toxin (Botox®)

Botox injections into the bladder wall and sphincters decreases spasticity and may permit increased retention of urine. However, this technique is still somewhat experimental.

B. FAILURE TO EMPTY

This condition is the result of the muscles of the bladder being flaccid due to a loss of ability for the bladder muscles to adequately contract. Symptoms include urgency followed by difficulty in starting the stream of urine, incomplete emptying, and increased frequency of urination - often the result of incomplete emptying.

NON-PHARMACOLOGIC MANAGEMENT

Catheterization

The most common management strategy is intermittent catheterization, usually done every few hours. In some cases, an indwelling catheter that remains in place for a period of time is needed, especially in people with significant disability.

Pharmacologic Management

Medications are generally not effective for this type of bladder dysfunction. Urecholine has been used by some doctors. The dose is usually 50 mg twice daily.

C. COMBINATION BLADDER DYSFUNCTION

As its name suggests, this problem results from a failure of the muscles of the urinary tract system to act together in a normal pattern, so that bladder contraction and the release of urine occur together.

NON-PHARMACOLOGIC MANAGEMENT

Catheterization

As with the failure-to-empty situation, intermittent catheterization or an indwelling catheter is often effective.

PHARMACOLOGIC MANAGEMENT

The medications noted earlier for use with failure-to-store difficulties, in combination with catheterization, is often effective. Baclofen may also be of help to some patients; please refer to the Spasticitysection (page 11) for details on this drug.

D. BLADDER INFECTIONS

Bladder infections are relatively common in people with MS. They are treated with antibiotics, the most common of which are listed below. The specific antibiotic depends on the type of bacteria causing the infection. Increasing the urine 's acidity may reduce the risk of infection. Cranberry juice in moderation is commonly used for this purpose.

PHARMACOLOGIC MANAGEMENT (THROUGH ANTIBIOTICS)

Bactrim® (sulfamethoxazole/trimethoprim) and Septra®(sulfamethoxazole/ trimethoprim)

These are oral medications in tablet form. The usual doses are 80 mg of trimethoprim and 400 mg of sulfamethoxazole. These medications are used in combination, administered either as a single dose twice a day or a double dose once a day.

Side effects include dizziness, headache, and gastrointestinal symptoms.

Cipro®(ciprofloxacin)

This is an oral medication in tablet form. The dose ranges from 500 to 1000 mg per day.