Bowel and Bladder Dysfunction in MS. Tracy Walker, WOCN, MSCN, FNP C Nurse Practitioner MS Institute at Shepherd Center. Bladder Dysfunction

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1 Bowel and Bladder Dysfunction in MS Tracy Walker, WOCN, MSCN, FNP C Nurse Practitioner MS Institute at Shepherd Center Bladder Dysfunction Approximately 75% of people with MS experience bladder problems Can have a huge impact quality of life 1

2 Cause of Bowel and Bladder Dysfunction Interruption of nerve pathways = Dysfunction Spinal Cord Lesions cause most of the problems Brain lesions can affect voluntary control Bowel and Bladder Dysfunction and Disability There is a definite correlation with bowel and bladder dysfunction and disability 2

3 Why is management so important? Elimination dysfunction greatly impacts quality of life Affects social interactions and self esteem Risk of other medical complications: Urinary Tracy Infections, Kidney damage, Bowel Impaction and perforation Goals of Bladder Management 1. Maintain Renal Function and Prevent Secondary Complications 2. Mimic normal voiding patterns and provide means for adequate bladder emptying 3. Reduce Symptoms and Improve Quality of Life 3

4 Normal Bladder Function Bladder Filling>>>Storage>>> Bladder distention/spasm(=urge)>>> Signals brain>>> Brain maintains continence and delays emptying until appropriate>>> when appropriate brain initiates voiding>>>sphincter relaxes>>> bladder contracts>>> Urination/ bladder emptying occurs Types of Bladder Dysfunction in MS Failure to Store Failure to Empty Combination of above 4

5 Diagnostic Tests Urinalysis Urine Culture and Sensitivity Video Urodynamics Post Void Residual Video Urodynamics Video Urodynamic tests can determine: 1. Presence or absence of Bladder Sensation 2. Detrusor response to bladder filling 3. Sphincter response to any contractions elicited 4. Type of bladder dysfunction and potential for complications 5

6 Failure to Store Most common problem in MS "Urinary Urgency / Frequency Urge Incontinence Irritable Bladder Cause: Normal inhibition during bladder filling is lost Basic reflex takes over Causes Bladder spasms/ contractions signal the brain that the bladder needs to empty even before it is full Failure to Store: Prevention and Treatment 1. Avoid Bladder Irritants: Caffeine Alcohol Aspartame Infection Constipation Concentrated Urine 6

7 Failure to Store: Prevention and Treatment 2. Voiding Schedules 3. Pelvic Floor Muscle Exercises Keigels 4. Biofeedback and Electrical Stimulation Failure to Store: Prevention and Treatment 5. Medications: Antispasmodics Ditropan (oxybutinin chloride) Detrol ( tolterodine tartrate) Oxytrol Patch, Sanctura, Urospaz, Vesicare, Enablex DDAVP (desmopressin acetate) 7

8 Failure to Empty "Urinary Retention or "Neurogenic Bladder" Less common in MS but more dangerous Cause: Bladder does not contract or sphincter doesn't open Medications can contribute to retention Symptoms: Failure to Empty Urinary Tract Infections Leakage or overflow incontinence Hesitancy, slow stream Sensation of incomplete emptying Urgency, frequency, leakage or repeat urge immediately following voiding 8

9 Failure to Empty Prevention and Treatment Post Void Residual If Low ( < 100) conservative management and ongoing monitoring Double Voiding Techniques Timed Voiding Fluid management Failure to Empty Prevention and Treatment Post Void Residual If High ( > 100) Urology Consult / Video urodynamics Clean Intermittent Catheterization Medications to relax sphincter and reduce resistance to emptying( Flomax) 9

10 Failure to Empty Management Options Catheterization: Intermittent Indwelling Foley, Suprapubic External Condom Caths Absorptive pads and garments Combination Failure to Store and Failure to Empty "Dyssnergia" Cause: Sphincter doesn't open when bladder contracts Management : Flomax, Intermittent Catheterization, Indwelling Cath 10

11 Bowel Dysfunction in MS Normal Bowel Function Not as well understood Involves many factors : Bowel Motility Distention of rectal vault produces urge Relaxation of Sphincter Increased abdominal pressure Evacuation 11

12 Types of Bowel Dysfunction in MS 1. Constipation 2 or less bowel movements per week Hard stool consistency Frequent use of laxatives/medications 2. Fecal Incontinence Involuntary loss of stool Constipation Causes and Contributing Factors Decreased Bowel Motility Nutrition and Fluid intake Reduced Mobility Medications Reduced or Ignored Sensation/ Urge 12

13 Treatment and Prevention : Bowel Programs 1. Increase Fluid Intake 2. Add Fiber 3. Use Stool Softners (if needed) 4. Stimulant or Laxative if no bowel movement every 3 rd day Treatment and Prevention : Bowel Programs Keys to success: Use the Gastro colic Reflex Protein loading Regular mealtimes and toileting visits Positioning: Elevate knees above hips 13

14 New and Emerging Therapies Peristeen Bowel irrigation device Coloplast P.I.E Pulsed Irrigation Evacuation system P.I.E. Med LLC Fecal Incontinence Causes and Contributing Factors: Constipation / Impaction Decreased Rectal Sensation Diet Medications Sphincter Dysfunction Comorbid Conditions ie: Irritable Bowel 14

15 Fecal Incontinence Treatment and Prevention 1. Establish Bowel Program 2. Fiber Loading 3. Medical evaluation to rule out other possible causes ie: irritable bowel, infection, etc. 15