Neurogenic Bladder in MSASymptoms and Treatments
The ability to store urine for several hours at a time and release it at convenient intervals relies on a complex coordination of nervous system feedback loops to and from the bladder, spinal cord, and brain. Many junctures along these feedback loops are vulnerable to the effects of injury or illness. As such, urinary dysfunction is a common feature of neurologic conditions. In MSA, urinary problems usually arise from degeneration in a part of the brainstem that controls urination. Symptoms such as incontinence, leakage, urinary frequency and urgency affect up to 96% of MSA patients and are often one of the first signs to appear. (1)Urinary problems that go untreated can lead to infections, kidney damage, and kidney stones. Chronic urine leakage that is poorly managed can also cause skin damage and pressure sores around the genital area. Accurate diagnosis and prompt treatment can help prevent urinary problems from progressing.
One of the ways bladder control malfunctions is by failing to allow complete emptying of the bladder. Patients may be unaware that their bladder is not emptying fully and only suspect a problem when they find themselves having to void again within minutes. An ultrasound study can determine whether the bladder is retaining urine and how much is being retained.
Another problem associated with inability to void urine is lack of control of the urinary sphincter, the circular muscle at the opening of the bladder that contracts to retain urine and relaxes to allow emptying of the bladder. This lack of control is a prevalent condition in MSA patients, affecting up to 77% of patients who have urinary symptoms. (1)Similarly, the muscle in the wall of the bladder, called the detrusor muscle, which normally contracts to expel urine from the bladder, can become overactive. In MSA, detrusor overactivity results in sudden urgency and leakage of urine, a condition known as urge incontinence.
The pattern of urinary symptoms forms an important distinguishing feature that helps doctors differentiate between MSA and Parkinson’s disease. In PD, 58% of patients experience urinary problems, whereas urinary symptoms affect the overwhelming majority of MSA patients. The majority of affected Parkinson’s patients have difficulty with the storage of urine more so than voiding, and symptoms appear later in PD than they do in MSA – usually 5 or more years after diagnosis, compared to less than 2 years post-diagnosis in MSA patients (4). MSA patients generally experience problems with both urine storage and voiding. (2)
Non-Pharmacological Treatment Options
If ultrasound evaluation reveals that there is residual volume of 100 mL, or more than one-third of your bladder capacity, your doctor may recommend intermittent self-catheterization. For this procedure, the patient or a caregiver will insert a flexible plastic tube, called a catheter, into the urethra and up into the bladder to allow residual urine to drain. A regular schedule of catheterization immediately upon awakening in the morning, every 3 to 4 hours throughout the day and evening, and just before retiring for the night. It is important to perform catheterizations at regular intervals to prevent infection that may occur due to residual urine being present in the bladder for prolonged periods of time.
A urologist’s training staff will demonstrate sterile technique for self-catheterization and the patient will be asked to show proficiency with the method. A red rubber catheter, a sterile wipe, gloves, and lubricant jelly are all that is needed. Be aware that there are self-lubricating, individually packaged commercial products available for use when away from the home. Multiple types of catheter units are available. Find the one that the patient is most comfortable using. These are more convenient than nonlubricated catheters, but they tend to be more expensive and insurance may not cover the cost.
Permanent (Foley) Catheter
Patients might require a permanent, indwelling catheter, known as a Foley catheter, if intermittent self-catheterization becomes ineffective or inconvenient. Foley catheters have a balloon at the end that is inserted into the bladder. When the catheter is properly positioned, the balloon is filled with sterile water to keep the catheter in place. The part of the catheter tube that passes along the inside of the thigh is then taped to the thigh to prevent the catheter from shifting.
Maintenance of a Foley catheter requires careful attention to hygiene and optimal catheter function. It is important to visually check the collection bag to make sure there is no blockage and that the urine remains clear. The urine may contain sediment after prolonged catheterization. Patients will need to wash the area of the catheter so that it remains clean. The catheter may be changed at intervals recommended by a doctor. This procedure can be performed at home or at the doctor’s office by a nurse or trained caregiver. The doctor may order a full urinary work-up, which may include an ultrasound and periodic X-rays to monitor bladder health while using a Foley catheter.
To help ensure that the self-catheterization program is successful, patients will likely be advised to keep accurate records of fluid intake, voiding schedule, and amount of urine collected. It is recommended to consume about 1.8 L (61 fluid ounces) of fluid and to void approximately 1.6 L (54 fluid ounces) of urine per day. Patients can accomplish these goals by drinking 400 mL with each meal and an additional 200 mL at 10 a.m., 2 p.m., and 4 p.m.. To avoid the need for catheterization during the night, restrict fluid consumption after dinner to sips. This may pose a dilemma.(2)Patients must make sure to stay adequately hydrated so as to avoid NOH, so be cautious. If it is necessary to get up during the night to cath, hydrate with a sip of water before moving to an upright position. Otherwise, you are at risk for a syncopal or fainting episode.
In some instances, an overactive bladder wall muscle can be retrained by carefully timing catheterization intervals. If you doctor recommends trying this technique, after taking initial recordings of time and urine volume collected, you will gradually lengthen the intervals between catheterization so that your bladder holds more urine with fewer inappropriate contractions of the bladder wall.(2)A physical therapist trained in urodynamics can help with bladder retraining and pelvic strengthening. Patients might start by setting the interval time for 15 minutes longer than the previously established interval time. If the urge to urinate occurs before the extra 15 minutes is up, attempt to distract yourself by contacting the pelvic floor muscles. These contractions, known as Kegel exercises, stop the flow of urine and also inhibit the detrusor muscle. Start by contracting these muscles for 3 to 5 seconds. Gradually build up to 10-second contractions. Crossing of the legs and focusing on taking slow, regular breaths can also help patients reach the goal interval time.
If intermittent self-catheterization becomes problematic or ineffective, doctors may recommend a permanent form of catheterization known as a suprapubic catheter. In this procedure, a catheter is inserted into the bladder through an incision made just above the pubic bone. The bladder will drain through the catheter into a collection bag.(3)The patient or a caregiver will need to replace this catheter at home every 4 to 6 weeks. Particular attention to proper care of the skin around the catheter is important in order to prevent infection. Patients will need to clean and bandage the catheter site daily and monitor for signs of infection, such as redness, pain, or swelling. The collection bag should be placed below the incision level so that gravity prevents urine from backing up into the bladder and should be situated so that the tube does not become kinked.
Pharmacological Treatment Options
A member of the anticholinergic family of drugs, propiverine works by blocking the activity of the neurotransmitter acetylcholine, which signals muscles to contract. In neurogenic bladder patients, propiverine decreases overactivity of the detrusor muscle, thereby increasing bladder capacity. In men with neurogenic bladder who also have benign enlarged prostates, propiverine combined with certain prostate medications has proven effective for improving urine storage capacity.(6)
An anticholinergic drug, oxybutynin, brand name Ditropan, decreases an overactive detrusor muscle and can be used in conjunction with an indwelling or permanent urethral catheter.(7)Oxybutynin helps prevent bladder leakage and backup of urine into the kidneys. It is available in immediate-release tablet form, which is more cost-effective but is associated with more side effects than other anticholinergic drugs, or in extended-release form. Patients can also take oxybutynin as a transdermal patch, from which the drug is absorbed through the skin. The patch form of oxybutynin causes fewer side effects than the oral form.(8)
Other anticholinergic drugs used for neurogenic bladder include:
- Tolterodine (Detrol), a drug that is highly specific to the bladder, giving it a lower overall side effect profile than other anticholinergic drugs.(12)
- Solifenacin (Vesicare), an increasingly popular newer-generation anticholinergic for use in women and also particularly effective in elderly patients and those with cognitive dysfunction.(13)
- Darifenacin (Enablex), a drug that is safe for patients with heart problems or cognitive impairment.(8)
The most common side effect associated with anticholinergic drugs – and one of the major reasons patients discontinue taking these drugs – is dry mouth. (9)In general, extended-release forms of these drugs are associated with lower incidence of dry mouth due to lower peak blood levels compared to the immediate-release forms. A comparison study between properivine and oxybutynin found that properivine was less likely to cause dry mouth. (11)Other anticholinergic side effects include urinary retention (affecting men more than women), dry eyes, and constipation.
This chemical messenger, mostly known for its role in blood vessel dilation, also controls nerve pathways of the urinary tract. An animal study reported that raising levels of nitric oxide increases bladder capacity and improves the ruination reflex in spinal nerve injury.(14)In another study, nitric oxide was found to relax the muscle of the bladder neck. (15)
- Certain drugs used for erectile dysfunction are thought to work by influencing nitric oxide levels in the prostate. These drugs, known as phosphodiesterase type 5 (PDE-5) inhibitors, include sildenafil(trade name Viagra)(16),tadalafil(trade name Cialis) (16), and vardanafil(trade name Levitra) (17). They are useful for improving both urinary and erectile dysfunction in men with benign prostatic enlargement.
- Vardenafil might improve sensory nerve transmission from the bladder to the spinal cord and brain and inhibit the bladder from contracting at times other than during urination.
- Tadalafil in combination with tamsulosin(trade name Flomax) – a drug used to treat benign prostatic hypertrophy or enlargement of the prostate – demonstrated a synergistic effect that relaxed the prostate and the bladder neck to a greater degree than either drug alone in a preliminary study(16). Tamsulosin has been shown to help alleviate urge incontinence, decrease residual urine in the bladder, decrease overactive detrusor muscle, and increase speed of urine flow and bladder storage capacity in neurodegenerative bladder dysfunction. (19)
- A clinical trial of tamsulosin found that it increased urine flow rate by an average of 45% and decreased residual urine volume by 30% in patients with intact detrusor muscle function (20). However, the drug was not as effective in patients with detrusor muscle atrophy. Potential side effects of tamsulosin include cough, fever or chills, lower back pain, or difficult or painful urination. Tamsulosin may also cause chest pain, dizziness, fainting, and prolonged or painful erections (23).
- Potential side effects of PDE-5 inhibitors include headache, flushing, stomach upset, and nasal congestion. There have also been occurrences of sudden, irreversible hearing loss following use of these drugs.(22)
This GABA-promoting drug has been found to help calm overactive bladder, improve urinary sphincter function, and increase bladder capacity(7). Baclofen (trade name Lioresa)l can be taken in pill form or as an injection into the space around the spinal cord via a pump, a delivery method known as intrathecal injection. A small clinical trial found that baclofen significantly slowed progression of urinary symptoms. (20)Potential side effects include allergic reactions, such as skin rash or swelling of the lips or tongue, chest pain, hallucinations, and seizure. Patients may also experience sleeping problems, headache, or nausea
If medication proves ineffective, your doctor may recommend an injection of botulinum toxin (trade name Botox) into the bladder wall as an alternative. This therapy calms an overactive detrusor muscle and increases bladder capacity.(21)Potential side effects include urinary tract infection and retention of urine, though it is considered safe and is associated with a low rate of occurrence of side effects. (9)Botulinum toxin may also be recommended in patients unable to perform self-catheterization. The injections temporarily paralyze the external sphincter and help with bladder emptying. Each injection lasts 3 to 9 months. This simple procedure is less invasive than surgery and there are minimal side effects associated with it. (7)
MSA - What You Need to Know
- MSA Overview
- Types and Symptoms
- Treatment of MSA
- Prognosis and Outlook
- Differential Diagnosis
- Evaluation Methods
- Neurogenic Orthostatic Hypotension (nOH)
- Neurogenic Bladder
- MSA-P (Parkinsonian)
- MSA-C (Cerebellar Ataxia)
- Breathing Disorders
- REM Sleep Behavior Disorder
- Depression and Cognitive Impairment
- Neuroprotective Diet
- Advanced Planning
- What is the ANS
- History of MSA