Asking the Embarrassing Questions: My Interview with a Urologist
I have struggled with bladder symptoms since being diagnosed with MS, and I know I am far from being alone! I not only live it firsthand, but as an MS specialist I spend a lot of time talking about bladder frequency, urgency, hesitancy, infection, and incontinence with my patients. Bladder dysfunction can hold us back, and keep us isolated from the activities we once enjoyed, yet many people are afraid to face their symptoms head on. I recently interviewed a colleague of mine who is a fantastic urologist, Dr. Dana Rice, to get her take on MS related bladder issues, and what we should be doing about them.
Q: Why does MS affect the bladder?
The bladder is a surprisingly complex organ that requires nerves, neurotransmitters, and muscles to work in synch. Urination requires complex communication between neural circuits in the brain and the spinal cord and the muscles in the bladder and urethra.1 Neurogenic bladder is a term we use when a person has bladder dysfunction because of a neurological issue, like MS.
Q: What are the most common symptoms of MS related bladder dysfunction?
Common symptoms can include:
- Recurrent urinary tract infections (UTI)
- Incomplete bladder emptying
- Urinary frequency
- Urinary urgency
- Urinary hesitancy
- Urinary incontinence
- Urinary retention
Bladder issues can present in many ways and have devastating medical and social consequences. As many as 52-97% of MS patients experience bladder symptoms, and 37-72% of people with MS experience incontinence at some point.2 That is a significant portion of the MS community! Additionally, many people have asymptomatic bladder issues, which can be dangerous because they are unaware there is an issue. In fact, one study demonstrated that 100% of MS patients studied with urodynamics (a test that can diagnose bladder issues) had positive findings, despite only 52% of the patients reporting urologic symptoms.3
Many early signs and symptoms of multiple sclerosis (MS) are overlooked or minimized by patients. As a urologist, I see a wide variety of patients with urinary dysfunction. Occasionally I will see a patient for a seemingly common issue that turns out to be a symptoms of an undiagnosed neurological disease, like MS. It is important for patients to recognize and be evaluated early for bladder issues.
Q: What should people with bladder dysfunction do?
I was really surprised to learn just how common bladder symptoms are, and often they can go unnoticed. It really is nice to know that I'm not alone in this. If a person living with MS suspects they have bladder dysfunction, what should they do?
Early diagnosis and prevention strategies should be a goal for all MS patients. Speak to your neurologist about your concerns, and schedule an appointment with a urologist. Establishing a baseline for your urinary health is an essential first step. The doctor will help determine what, if any, bladder problems you have. Your urologist will then determine what testing is necessary. A general work up may consist of obtaining a urine sample, getting pictures of the kidney and ureters, urodynamics (explained below), and/or cystoscopy (using a scope to look into the bladder).
Q: What are urodynamics? Does the testing hurt?
Urodynamics are important because they help determine the type of problem, if any, you are having. Bladder dysfunction in MS can occur for different reasons including overactivity of the bladder muscle (neurogenic detrusor overactivity), being unable to relax the sphincter that allows urine to flow out of the bladder (detrusor-sphincter dyssynergy), or lack of nerve signaling by the bladder muscle (areflexia).1 It is critical to find the underlying issue, so that we can treat it effectively.
The test itself involves a small catheter into your urethra and anus. The bladder is then filled and and urination is monitored with small stickers similar to those used for EKG (heart tests). Urodynamics is more awkward then painful. Please be aware that we perform these tests frequently and will try our best to make you comfortable at all times. If you are feeling uncomfortable please let us know.
Q: What treatments are available for bladder issues?
Once patients have a diagnosis of bladder dysfunction, treatment is tailored for optimal medical health and ease of care. Medications and behavioral management are often first steps. It is important to discuss lifestyle habits and goals with your physician to establish long-term care plans. There are also a variety options ranging from clean intermittent catheterization to surgical interventions. Surgical intervention such as permanent catheter (suprapubic tube), urinary diversion or neuromodulation procedures can also help certain people.
Q: What happens when the dysfunction is left untreated?
I was initially very hesitant to see a urologist, but ultimately I'm very glad that I did. What could have happened if I didn't seek treatment?
Just like MS can be a progressive disease, bladder dysfunction can become worse and change over time, especially if left untreated. Establishing a baseline and having regular follow-ups will allow your doctor to help implement care strategies early, which can help prevent many long-term issues.
Complications of untreated bladder dysfunction include:
- Frequent UTIs
- Drug resistant UTIs
- Urinary incontinence
- High pressure voiding
- Kidney disease
- Kidney stones
- Non-compliant bladder
Q: What can those of us with MS do to prevent long-term problems?
Just like every person with MS is different, every bladder is different. Establishing a good health care team is crucial for long-term health in chronic illnesses. There are many urologic interventions and strategies that can be utilized to help prevent UTIs, incomplete bladder emptying and more serious complications. Individual strategies should be reviewed with your practitioner, but may include timed voiding, avoiding antibiotics for asymptomatic infections, good bowel regimens, urinary catheterization, and pelvic floor exercises.
Q: Are there any tools to help me control my symptoms?
Most of my patients have a smartphone, so I recently developed a mobile app that can help people track and minimize their bladder symptoms and infections. The UTI Tracker has an alarm to remind you to empty your bladder regularly, a voiding diary to help record intake and output, an education center to review urinary health issues and prevention, as well as a daily symptom tracker for voiding dysfunction symptoms and antibiotic use. You can learn more about it here.
Q: What other resources do you recommend?
Does anyone else in your family have MS?