Continence Issues in
Multiple Sclerosis
Gillian Nottidge
Continence Nurse Specialist
Bradford and Airedale tPCT
Incontinence
“Urinary incontinence is not
a joke for the thousands
of mainly older people
affected with this
embarrassing and lifedestroying condition,"
Dr Adrian Wagg, chairman of the
Continence Working Party, Royal
College of Physicians
Some statistics
• NHS estimates that 3-6 million people in
UK have some degree of urinary
incontinence. (NHS 2006)
• Women more likely to suffer stress incont
than men
• 32% of women in UK have symptoms of
UI (Lose et al 2003)
Physical impact
• Increased risk of
falls
• Skin problems
• Pressure ulcers
• Urinary tract
infections
• Delayed discharge
from hospital
Emotional impact
• Work
• Exercise
• Travelling
• Socialising / relationships
• Anxiety
• Depression
Remember
• Not necessarily attributable to MS
• MS does not preclude individual from
other causes/conditions
• Lifestyle
• Prostate
• Prolapse
• Menopause
• Don’t miss the obvious
However…..
• 85,000 MS sufferers in UK (Fowler et al 2008)
• 3:1 women:men (Fowler et al 2008)
• 90% will have bladder dysfunction (McClurg
2006). 75% (Bladder & Bowel Foundation 2008)
Also….
• 68% bowel dysfunction – constipation/
incontinence (Hinds et al 1990)
• 50% incontinent of faeces in past 3
months
• 20-30% incontinent of faeces at least once
a week. (Krogh & Christensen 2009)
From some MS sufferers
“Of all the problems associated with my MS, the bladder and bowel problems are
the ones which are the most debilitating for me.”
“People think it’s just your legs that don’t work properly. Nobody realises the extent
of my problems.”
“Within a few minutes of meeting another MS sufferer the subject of bladder
problems usually crops up!”
“I want to go swimming with my daughter but I daren’t because of my incontinence.”
The worst MS related problem is often incontinence
Neurogenic bladder
•
•
•
•
•
•
Frequency
Urgency
Urge incontinence
Nocturia
Enuresis
Stress incontinence
•
•
•
•
•
•
Incomplete emptying
Overflow
Passive incontinence
Dribbling
Recurrent UTI
Bladder/sphincter
dyssynergia
Neuronal control of the bladder
Assessment
•
•
•
•
•
Medical history
Current symptoms
Acute/insidious onset
Medication
Post-void residual
scan
• Urinalysis
•
•
•
•
•
•
Bladder diary
Bowels
Vaginal examination
Rectal examination
Sexual function
Mobility and dexterity
Bladder Management
•
•
•
•
•
•
•
Diet and fluid advice
Avoidance of caffeine
Pelvic floor exercises
Bladder retraining
Physiotherapy
Biofeedback
Electrical stimulation
Bladder Management
•
•
•
•
•
•
•
Avoid and/or treat constipation
Double voiding
Timed voiding
Bladder stimulator
Medication
ISC
Long-term catheter
Medication
•
•
•
•
•
•
Anti-muscarinics
Oxybutinin
Solifenacin
Tolterodine
Fesoterodine
Trospium XL
Darifenacin
•
•
•
•
•
Alpha-blockers
Tamsulosin
Doxazosin
Alfuzosin
Others
Desmopressin
Duloxetine
Investigations
• Urodynamics in patients refractory to
conservative treatments (Fowler et al 2008)
• Cystoscopy if indicated
• Treat symptomatically
Intermittent Catheterisation
Intermittent catheterisation is
recognised as a safe and
effective procedure
(Bakke et al 1997) and
carries a reduced risk of
infection compared to
indwelling urinary
catheterisation (Wyndaele 1990;
Bakke 1991)
NHS Quality Improvement Scotland 2004
Before the EPIC2 guidelines!
Found in Pompeii !
How they have improved!!
•
•
•
•
•
•
Single use
Well lubricated
Sterile
Readily available on prescription
Huge variety available
Horses for courses
Advantages
• Improves quality of life
• Minimise incontinence episodes
• Less infection risk than indwelling (Wyndaele, 1990;
Bakke, 1991)
•
•
•
•
Body image
Sexuality
Promotes normal bladder function and emptying
Routine urine testing not recommended (Fowler et
al 2008)
Disadvantages
•
•
•
•
•
•
•
May find it distasteful
May not have dexterity if high lesions
Disposal – no bins in men's toilets
Travel and carrying catheters
Public facilities
Hand washing facilities
UTI
Aids and adaptataions
Botox
• Significant improvement in
detrusor-sphincter
dyssynergia
• Decreased urge
incontinence
• Reduced frequency (Game et al
2008)
• Reduced incidence of UTI
(Fowler et al 2008)
But…
• May have to perform ISC
• Not a one-off treatment
• Not yet licensed for intra-vesical use, but
widely used
• May involve hospital admission, but can
be done as outpatient
Sacral Nerve Stimulation
Placement of an
electrode through one of
the naturally-occurring
holes in the sacrum. The
electrode lies alongside
the sacral nerves. These
nerves supply the organs
in the pelvis and the
pelvic floor muscles.
Regular, gentle pulses of
electricity are passed
along the electrode from
a battery pack.
Cannabis!
• Cannabinoid receptors in the bladder and
nervous system are potential pharmacological
targets (Brady et al 2004)
• Patient self-assessment of pain, spasticity and
quality of sleep improved significantly
• Significant improvement in LUTS
• Few troublesome side effects
• Cannabis has a positive clinical effect on MS
patients with urinary incontinence. (Freeman et al
2006)
Bowel Problems
• 68% bowel dysfunction – constipation/
incontinence (Hinds et al 1990)
• 50% incontinent of faeces in past 3
months
• Demyelination along the CNS pathway
responsible for bowel symptoms
Faecal Incontinence
• Reduced anal
sensitivity
• Affects anal sampling
causing incontinence
• Slow transit –
constipation and
overflow
Incontinence
• Anal tone – resting pressure affected by
spinal lesions
• Loss of voluntary control of external anal
sphincter
• Rectal hyperactivity
Constipation
•
•
•
•
•
•
•
Weakened abdominal muscles
Slow transit
Medications used to treat concomitant problems
Inadequate fluid intake
Insufficient dietary bulk
Decreased mobility
Reduced rectal tone – faecal impaction and
rectal distension
Assessment
• Good assessment
• Good rapport with
client
• Diet and fluids
• Bladder diary
• Rectal examination
• Stool type
•
•
•
•
•
•
Current bowel habit
Digitation
Manual removal
Enemas
Suppositories
Medication
Medication
• Antihypertensives
• Analgesics/narcotics
• Tricyclic
antidepressants
• Antacids
• Iron supplements
• Anti-muscarinics
• Sedatives/
tranquilizers
• Some antibiotics
• Diuretics
Bowel management
•
•
•
•
•
•
•
Diet
Fluids
Lifestyle
Exercise – may be limited
Medication
Containment
Other methods
Medication
Laxatives
– Stimulants
– Osmotic laxatives
Bulking agents
Suppositories
Enemas
Constipating
agents
• Clear constipation
with osmotic
laxative
• Give bulking agent
to maintain good
bowel movement
Management
•
•
•
•
Anal stimulation
Manual removal
Anal plugs
Continence products
Anal Irrigation
•
•
•
•
Clean
Quick
Natural
Promotes
independence
• Cost consideration
In summary
• Don’t assume all symptoms due to MS
• Bladder and bowel problems very common in
MS
• Treat conservatively where possible
• Many treatments and products are available
• Know how to access help
• Contact your local continence service
Thank You
Gillian Nottidge
Continence Nurse Specialist
01274 322210
Gillian.nottidge@bradford.nhs.uk
