Managing bladder issues

Nicola: Welcome to the MS Education Podcast series. Thank you for joining me. I'm Nicola Graham, and in each episode we're going to be joined by an expert to discuss strategies for living well with MS.

Today we're looking at bladder issues and how you can best manage your symptoms. I'm delighted to be joined by our resident MS expert, Bridie Phillips, who's a nurse advisor with our MS nurse advisor service.

Welcome, Bridie.

Bridie: Hi Nicola. Thanks for inviting me along to this podcast. Yes, I'm an MS nurse with 33 years’ experience and the last 10 years I've dedicated to community health and I'm really pleased we're chatting about the important topic of bladder issues today.

Some people manage these symptoms well and for others they may feel out of control and embarrassed and also find it difficult achieving everyday life outside the home, especially social isolation. There's so much that can be done to support a better quality of life for those who are struggling to manage bladder symptoms and I'm hoping today we can provide some tips and strategies that will be useful for some of the common issues experienced by people with MS.

Nicola: That's fantastic, Bridie. And I'm going to get started with some of the most common questions that I know you get asked. So, the first one on my list is, why do people with multiple sclerosis have bladder issues in the first place?

Bridie: Yes, that's a great question, Nicola. And I guess the best way to answer that is to try and understand a little bit what normal bladder function looks like. If we're looking at the urinary tract, it's divided into the upper urinary tract, which is the kidney and the ureters, and the lower urinary tract, which is the bladder and the urethra. So the bladder is a hollow muscular organ that sits in the pelvic cavity.

And in general, MS mostly affects the function of the lower urinary tract. Normally the bladder function is controlled by the brain, so it uses a spinal cord to communicate with the bladder and the urethra, and then during urine storage, pressure receptors in the walls of the bladder sense the degree of bladder filling and causes the bladder to stretch.

So this information is relayed to the brain via the spinal cord and then it stimulates the firing of nerves in charge of that bladder storage and then that causes relaxation of the bladder. Now we're very, very clever as human beings, and at the same time, closure of the urethra is maintained by a contracting sphincter muscle therefore, preventing leakage of that urine when the bladder fills. So when the bladder is filling with urine, the bladder remains relaxed and stretches to hold the urine. And when it's time to urinate, or void, or pass water, however you like to say it, the bladder contracts to allow the urine to come out.

Now, just an interesting fact on there is that we actually produce about 2.5 litres of urine a day and most people will get to about 300 ml in the bladder, when they get this feeling that they need to pass water. But in MS, there can be several dysfunctions of the lower urinary tract due to the alteration of nerves and of the brain and spinal cord pathways.

So the main urinary problems in MS are the storage of urine, voiding issues or a combination of both. As with many MS symptoms, it's not unusual for bladder function symptoms to vary greatly from one person to another. And it's what we call a neurogenic bladder. And surveys actually indicate 60 to 90 percent of people with MS will have bladder dysfunction at some time during their disease.

Nicola: So it's quite a common concern for people with MS, Bridie.

Bridie: Absolutely. And, it is also so varying degrees in how it impacts people. It can come and go, and there's obviously varying factors that can affect the bladder function as well.

Nicola: Bridie, you've indicated that it's different for every everybody. Saying that, what are the typical range of symptoms that people with MS bladder issues might experience?

Bridie: The main sort of things are like bladder urgency, frequency, which means having to go to the toilet more often. Normally we'd go five to six times a day and maybe one at night. So if you're going more often than that, then we could consider that you may have a neurogenic bladder.

Nocturia, which means passing a lot of urine at night. Incontinence, changing in the flow or hesitancy, which, you know, so you can have a difficulty in starting the stream, more prone to UTIs. It can be a failure to storage. so in, in other words, an overactive bladder frequency, urgency, maybe incontinence involved in when you, um, can't store the urine, you might have a failure to.

empty the bladder properly. So you get a bit of a urine retention. So that's where it's difficult to actually get all of the urine out of the bladder in one part. Um, so you end up with some of the urine actually still sitting in your bladder and that kind of leads to you wanting to sort of go to the toilet more often.

And you can also get a variable stream. So you might go to the toilet and find you're passing just little bits at a time or you know you might get a stop start. You can also get an in coordination between the sphincters and the bladder, so you get a combination of retention and overactivity. And not to mention with the poor old men with their prostates, that can often impact the bladder as well.

Nicola: Okay. And Bridie, just to clarify, when you said more UTIs, what's a UTI?

Bridie: What does that stand for? Oh, sorry. That's a urinary tract infection and I'm sure a lot of people have potentially had one of those in the past. Um, so, you know, it's really important that if you do have any sort of signs that you get that checked out because urinary tract infections can make you be particularly unwelcome.

build up the sort of toxins in your, in your body and start having sort of a general effect. And I guess the big thing is that it can actually impact your MS and it can backflow to the kidneys and cause some more serious kidney dysfunction.

Nicola: Right, so really important that people get on top of any bladder infection promptly.

Absolutely. Okay, and I think it's also interesting to note 10 percent of women who haven't had a baby, 33 percent of women who have had a baby will have some bladder incontinence. So it is quite a common symptom for many women, isn't it?

Bridie: Absolutely, absolutely. And that's, you know, yeah, it is and tend to be more so, um, and you know, as I mentioned with the men, if you've got an enlarged prostate or something going on as well, that's certainly going to impact, but you know, there, there are things that can be done.

Nicola: Sorry Bridie, so on that note, what are your top tips if a person is experiencing bladder

Bridie: issues? Absolutely, number one, go to the GP. So if you have any change in your habits of going to the toilet, particularly with your bladder, you need to eliminate a urinary tract or a UTI as a cause. And as I mentioned, if it's not detected and treated early, it can impact other MS symptoms, particularly stiffness, spasm and fatigue.

And they can sort of present as what we call a pseudo relapse. So your symptoms can flare up. And as I mentioned, more importantly, the bacteria that's still in the, in the bladder. can backflow to the kidneys and cause more serious kidney problems. Secondly, you need to speak to a medical professional about your continence issues so that they can investigate the cause and put an appropriate management plan in place.

You know, that might be surgical, non surgical, could be pharmaceutical, could be behavioural methods, um, you know, training the bladder and it's talking about bladder health. And I guess One of the big messages here is not to be embarrassed about speaking to your health professionals. You've got to remember that the doctor has to pee as well.

So, you know, when you're, when you're actually sort of, you know, confronting them, just remember they do it too. And it's a very vital, um, process that our bodies need to be able to do and do well. My next tip would be to keep a diary of your input and output and triggers to changes in your bladder habits and times of toileting, so that when you do go and see someone, um, about your problems, um, you can immediately give them a good history.

And if you've already got that diary in place, it can sort of streamline the process and they can form a management plan a lot easier. The other thing is when you're out and about, Make sure you've got protection with you. So, you know, it's easy to stuff a little, you know, nappy bag, nappy wipes, change of underwear, those sort of things in your bag, so that if you are caught out, you have everything, and hand sanitiser, of course.

Always know where the toilet is when you're out in the shopping centre of something, so that you know. Take regular toilet stops, because we do Expect that we would go five to six times a day. So if you're out in the shops and you haven't been for a few hours, just take yourself and go to eliminate any risks of incontinence.

Keep up your fluid intake to maintain hydration and kidney function, but sort of stop drinking fluid sort of just before bedtime and empty your bladder before going to bed. And another one that I've added here, which is really important is to avoid constipation. So it's important that you look after your bowel.

Um, if your bowel is full and blocked, it will impact the amount of times that you need to go to the toilet. So it's the pressure from the, the bulging from the bowel, so really important that you look after your bowel as well. And I'm

Nicola: interested to note Bridie as well where you say keep up the fluid intake because I know a lot of people when they have a bladder continence issue tend to not drink as much and so it's, that's a really important message for people I think.

And we hear also a lot about pelvic floor, especially for women. Can pelvic floor exercises help with bladder issues?

Bridie: Yeah, they can. There are exercises that strengthen the pelvic floor. So it's a sheet of muscle that runs from your pubic bone at the front to the base of your spine at the back, and it supports the bladder and bowel.

It looks a bit different between men and women. Um, but in women, particularly, you know, when you've had babies and that we know that we can weaken the pelvic floor, but they've been found to have significant results in reducing incontinence. And that's including the amount of leakage, the number of leakages, the frequency, the feelings of urgency.

and it has a significant influence on the confidence and quality of life. The great thing about it is that you can sit at a traffic light and do these pelvic floor exercises and no one actually knows that you're doing it. So it's not like a time consuming or a, you know, something that, um, you need a lot of effort to do.

So absolutely. And I do know that there are a number of physios around that specifically deal with pelvic floor exercises. So. You can source them.

Nicola: Fantastic. And Bridie, in terms of a healthy lifestyle, what do you suggest people eat and drink to best support a healthy bladder?

Bridie: Okay, so absolutely number one, maintain your fluid intake and try to get you know, 1.

5 to 2 litres. That's about six to eight glasses of fluid each day. Um, and to spread your drinks evenly throughout the day. So, you know, they say to limit or avoid drinks that contain caffeine, such as tea, coffee, hot chocolate, cola, energy drinks, some soft drinks, because they actually irritate the bladder and it's a diuretic.

So that means it will increase how often you need to empty your bladder. and will generally increase the amount of urine you produce. So you end up getting a dehydrating effect. So what we want to do is balance that with enough water as well so that your, um, body is uptaking the amount of fluid it needs to, um, function properly.

So if you can cut down your daily coffee intake from three to one, it might help see a reduction in the frequency. Um, and similarly, if you drink tea, um, reducing that as well, because the tea has tannins, which can also affect your frequency to the bathroom. Um, as mentioned, alcoholic drinks, they're dehydrating and they stimulate the bladder, um, which sort of make you want to go to the toilet more often.

Apparently, white wine is the worst. of all of them. Avoid acidic drinks, um, like fruits and juices. So if you think acid and spices, they can make bladder irritation worse. So when we're talking about spices, we're talking about chilies and cayenne pepper and curries and things like that. Keep a bladder and food and drink diary to discover what your specific triggers are.

Um Biggest thing, don't reduce your fluid intake if you've got bladder control problems, as it will concentrate your urine and make the problems worse. And particularly, if, if your urine is really thick and it's been sitting in your bladder and you haven't been able to pass it because your blood is not allowing you to do that, it's kind of a bit like having a stagnant pool in your bladder that will grow bacteria.

Avoid constipation. So it's really good to get your bowel health in order. Probiotics are great, especially if you've had a lot of antibiotics. Cranberry helps stop E. coli bacteria adhering to the urethral wall. So, um, you can get that in ural sachets. You can get cranberry capsules on their own and you can also buy juice.

And exercise is really important. It gets the circulation going. Promotes bowel motions, kidneys filtering and helps to limit that urine stasis. And one of the biggest thing is don't suffer in silence. This is a normal body function, a vital body function. You need to make an appointment and see your GP, a continence nurse, a neurologist or your treating team because there's so much that can be done.

Nicola: That's great to know, Brady. Could you talk us through what can happen in a typical bladder assessment,

Bridie: please? Absolutely. So you can be referred for a bladder assessment from a GP and MS nurse neurologist. There's also a national continence Um, line, which is a free, uh, phone service. There's local community services in Victoria.

We've got the Victorian Continence Resource Centre. So there are places. And for some of those, um, you don't actually need a referral. But, um, it depends where you want to go. And some people will go straight to a urologist. But you're probably better if you can just sort of get a bladder assessment. first and then be armed with the information.

There's no reason to feel embarrassed about discussing these problems. Um, we know that most people with MS will experience urinary symptoms at one time or another and prompt open discussions are the fastest, safest, and most effective way to manage urinary dysfunction. So the assessment can take up to a couple of hours.

It's basically. an information collections session. So they look at things like getting your surgical and medical history, your dietary habits, alcohol consumption. They look at your mobility. So some, some people might have a bit of control over their bladder, but it could be their mobility that's actually affecting their Um, ability to get to the toilet fast enough.

So they look at that. They look at your fine motor skills. So, you know, if, if you don't have fine motor skills, you're not going to be able to self catheterize very easily. So what are the other options? You know, you might have trouble actually managing, you know. Cleaning, cleaning yourself after you've been to the toilets and things like that if that fine motor isn't.

So they look at all of that. They commence the bladder diary. So if you've already got one of those started, you're kind of ahead of the thing. They might do a 24 hour urine collection. They look at your sleep, your lifestyle, history of urinary tract infections and current medications. They also look at the type of MS you have and the history of what, how your MS has been presenting.

And then they might. send you for an ultrasound diagnostic for residual urine or bladder pressure, um, so that they can have a look at what's actually happening. And sometimes further investigation may be required and then they might sort of send you off for a urologist if needed. Um, but the clinic staff can also advise, order continence products, arrange NDIS, my age care, or as I said, you know, the support of a urologist.

So, um, it's a very comprehensive assessment, hence the reason it takes so long. And they may ask for you to come back.

Nicola: Okay, that's great. Thank you, Bridie. If you have tried all of the above and you're still struggling, are there any other supports available or where to

Bridie: next? Yeah, so, so absolutely, um, GP number one.

First thing. As I mentioned, you really need to make sure this isn't because of a urinary tract infection and that can be sorted out so quickly. Um, you need your continence nurse, your neurologist, your urologist and you do that full continence assessment and get a management plan. Excuse me. You can go to Continence Clinics in public hospitals, local community.

The National Continence line is a free phone service and it's very good. Their phone number 1 800 330 066. It's online. Please look it up. Continence aids are available online, delivered and locally. So if you're living rural, Independence Australia, for example, is one of those places that, you know, you can buy things in bulk and have it delivered.

Um, National toilet maps. Perfect. And a universal key, so if you're out and about you can access, um, disabled toilets. Look at the CAP scheme, which is the Continence Aid Payment Scheme. That's through Centrelink. And, um, like NDIS and, you know, your My Aged Care, you might be able to get continence assessment and products through them as well.

Um, Now the other thing is that your GP will have a look first, but they might actually be able to initiate treatment. So there's a lot of prescription medications that we know have really good therapeutic effects used in the right context. You know, and obviously if you do have a UTI, they can get you onto antibiotics pretty quickly.

So absolute GP first.

Nicola: Okay, fantastic. And Bridie, any last thoughts for people as we bring the podcast to a close?

Bridie: You know, look, no one needs to struggle with bladder symptoms and allow them to impact your quality of life. There's help available and If I really encourage you to speak up and get some professional advice, often people with bladder problems may also have presenting bowel problems and some sexual dysfunction.

It kind of all sort of kind of goes together but never feel embarrassed to talk about them. As I mentioned before, remember your health professional. Also, does all of those things, goes to the toilet, you know, all, you know, so don't look at it that way. And if you really want to be cheeky, even think the queen does it.

So, you know, um, just, just, you know, have this really open conversation because this is your body. This is your quality of life. And, um, there is no need for you to be socially isolated and feeling embarrassed about a perfectly normal function that, um, can be managed a lot better.

Nicola: Thank you so much, Bridie.

And I think exactly like you say, the more we talk about it, the easier it gets to talk about it. So, Bridie, thank you for your knowledge and wisdom that you've shared with us today. I hope that everybody listening feels that there are things that you can do that will make a difference, that you're not alone grappling with these symptoms, and that there is support available.

Bridie: Thanks for having me, Nicola.

Nicola: My pleasure. Thank you, Bridie.

For more information on anything we've covered today, please get in touch with MS Connect on free call 1 800 042 138 or email msconnect at ms. org. And don't forget to find the MS Podcast on your favourite podcast player such as Apple, Google Play, Spotify, Overcast, or you can access the podcast directly from our website, ms.org. au.