Kings College Hospital
MS Service
Fax:
02077133354
Consultants:
Dr Eli Silber & Dr Peter Brex
MS Nurse Specialists:
Lewisham
Pauline Shaw
Lambeth
Fiona Barnes
Southwark
Joan Regan
02077713317
02077713363
02077713389
Guidelines for the treatment of Neurogenic Bladder Problems in Multiple Sclerosis
MS patients commonly present with bladder problems. These may include urinary urgency, frequency, urge
incontinence, nocturia, hesitancy, interrupted stream and incomplete emptying
Mechanism of bladder dysfunction in MS
Normal voiding is achieved by contraction of the detrusor muscle and relaxation of the urethral sphincter
functioning together. Incoordination of this mechanism causes the urethral sphincter to remain contracted
resulting in an inability to void, or result in hesitancy or may lead to interrupted or incomplete voiding (detrusor
sphincter dyssynergia).
Lesions of the brain and spinal cord may result in excess reflex activity (detrusor hyper-reflexia) and cause an
increased urge to pass urine and possible incontinence.
Lesions affecting the lower cord and nerves may result in the bladder being unable to contract effectively. This
results in incomplete emptying and a large post void residual volume of urine. This may predispose to recurrent
urinary tract infections and renal damage from hydronephrosis.
Management
Collect MSU
A urine sample should be collected and a urine dipstick performed. If this is abnormal a specimen should be sent
for microscopy, culture and sensitivity.
Bladder Diary
The patient should keep a bladder diary for 3 days to identify symptoms of storage and emptying, assess the
frequency of voiding and identify any contributing causes, e.g. poor fluid intake.
Ultrasound Bladder Scan

If this demonstrates a post void residual volume of 150mls or less with no history of urinary tract
infection, bladder retraining can be commenced to improve a neurogenic overactive bladder. This
involves gradually increasing the time between voiding form as little as 5-10 minutes initially until a 3-4
hour pattern is achieved. Anti-cholinergic medication may assist with bladder retraining (see overleaf),
but should only be prescribed with caution if the post void residual volume of urine is in excess of 100mls
(a further bladder USS post-treatment should be considered). Patients should be advised of the common
side effects. Bladder emptying techniques, such applying pressure to the bladder and double voiding,
should be taught.

If the post void residual volume of urine is greater than 150mls intermittent self-catheterisation should
be advised. Those with a combination of storage and voiding problems may benefit from combining
intermittent self-catheterisation and anti-cholinergic medication.

If the post void residual volume of urine is greater than 400mls in a symptomatic individual, immediate
catheterisation should be considered (intermittent or permanent) whist an urgent specialist opinion is
sought.
For patients with significant on-going pain, incontinence or haematuria in the absence of infection
an early specialist opinion is advised.
Guidelines developed July 2006 by the South East Regional Multidisciplinary MS Group with advice from Sue Foxley,
Nurse Consultant, Continence Care, KCH and Prof Cardoza, Consultant Urogynaecologist, KCH
Current Anticholinergic Medication used in Neurogenic Bladder Problems
NAME
Tolterodine
(Detrusitol)
DOSE
1 – 2 mg twice daily
Tolterodine modified 4 mg daily
release
(Detrusitol XL)
Oxybutynin
(Ditropan)
2.5 – 20mg daily
ADVANTAGES AND COMMON SIDE EFFECTS
Adv: Reduces urgency and frequency.
SE: Mild dry mouth, constipation, blurred vision, dry
eyes, drowsiness, difficulty voiding, facial flushing,
dizziness, indigestion, fatigue, flatulence, chest pain,
peripheral oedema, parasthesia
As Tolterodine but better tolerated
Adv: Reduces urgency and frequency.
SE: Very dry mouth, constipation, blurred vision, dry
eyes, drowsiness, difficulty voiding, facial flushing,
dizziness
As Oxybutynin but better tolerated
Oxybutynin modified 5 – 30mg daily
release
(Lyrinel XL)
Oxybutynin
Transdermal patches
(Kentera)
3.9 mg/24hours applied As Oxybutynin, better tolerated, skin reactions
twice weekly
Solifenacin
(Vesicare)
5 – 10 mg once a day
Trospium chloride
(Regurin)
20 mg twice
(before food)
Adv: More selective for nerve endings in bladder,
reduces leakage.
SE: As Oxybutynin and gastro-oesophageal reflux,
altered taste, fatigue, oedema
daily Adv: Less effect on the brain; does not interact with
other drugs.
SE: As Oxybutynin and flatulence, chest pain,
dyspnoea, rash and asthenia
Drugs used to reduce urine output
10 – 40 micrograms
Desmopressin acetate
once a night
Nasal spray
(Desmospray, Nocutil
Desmopressin acetate
(Desmotabs)
200 – 400 micrograms
once a night
Caution: Limit fluid intake to minimum from 1 hour
before dose until 8 hours afterwards.
Periodic blood pressure and weight checks needed
SE: Fluid retention and hyponatraemia, stomach pain,
headache, nausea, vomiting, allergic reactions
Caution: Limit fluid intake to minimum from 1 hour
before dose until 8 hours afterwards.
Periodic blood pressure and weight checks needed
SE: Fluid retention and hyponatraemia, stomach pain,
headache, nausea, vomiting, allergic reactions
Guidelines for the treatment of Neurogenic Bladder Problems in Multiple Sclerosis
Troublesome urinary symptoms
(Hesitancy / incomplete voiding /
nocturia / incontinence / frequency /
urgency)
Dipstick Urine
(in line with MHRA guidance*)
Send for MSU and
treat with antibiotics
Abnormal
Normal
Address contributory factors, e.g. fluid
intake, caffeine / alcohol, constipation
Ongoing symptoms
Three day bladder diary and formulate
care plan. Reassess after one month
Ongoing symptoms
Post-micturition bladder USS
Residual less than 150 ml
Add
anticholinergics
Repeat bladder
USS if further
symptoms
Residual greater than 400ml
Consider
immediate
catheterisation
& urgent referral
as below
Residual 150 – 400ml
Teach double-voiding,
percussion, positioning,
vibration & association.
Reinforce life-style advice.
Rescan after 3 months
Ongoing symptoms
ICSC +/- anticholinergics
Ongoing
symptoms
Patient unable to manage ISC
Supra-pubic catheter with
flip-flow valve if suitable or
leg bag
Ongoing symptoms
Refer for specialist opinion (urology /
urogynaecological / continence services)
This is a guideline only. Management of an individual patient is a collaboration between MS nurse,
neurologist, continence nurse and urologists / urogynaecologist. Individual patient management will
vary depending on the facilities available in different geographical regions.
* MRHA / DoH (2006) Point of Care Testing, Urine Dipsticks Top Tips: Advise for health care professionals. dh@prolog.uk.com for copies