While the spastic bladder is still quite accessible to drug therapies, more complex bladder dysfunctions, which mainly characterize later stages of MS, are no longer so easy to treat.In advanced stages, a so-called Detrusor-Sphincter Dyssynergia is often encountered. This means: Due to the damage caused by MS lesions, the bladder emptying muscle (detrusor) and the bladder sphincter (sphincter) no longer work together in a coordinated manner. In simple terms, this can be imagined as the bladder emptying muscle contracting without the sphincter opening adequately. This then leads to constant urge to urinate, delayed bladder emptying, incontinence and the feeling of not being able to completely empty the bladder. Indeed, higher residual urine volumes often remain in the bladder (normal is a residual urine volume of 0 ml – max. 30 ml), which then provide an ideal breeding ground for bladder germs and lead to the occurrence of urinary tract infections.
To complicate matters, MS patients with a bladder dysfunction often avoid drinking enough and thus flushing the bladder to counteract the constant urge to urinate. However, this behavior promotes the occurrence of urinary tract infections. Some patients then find themselves in a vicious circle, as urinary tract infections can in turn worsen bladder function.
Drug intervention is difficult and should definitely be carried out in close consultation with urologists – ultimately, a urodynamic examination is also necessary to determine what the Detrusor-Sphincter Dyssynergia looks like in the individual case and how high the residual urine volumes are.
The principle of drug therapy is to dampen the contraction of the bladder emptying muscle (with anticholinergics, see post: The spastic bladder) and at the same time to reduce bladder outlet resistance by inhibiting the bladder sphincter. For this purpose, so-called alpha-receptor blockers can be used – these are drugs that bind to alpha-adrenoceptors of the sympathetic nervous system and lead to a relaxation of the smooth muscles (this includes the bladder muscle). A well-known representative of this group is Tamsulosin (Alna®, Omnic® etc.).
Another drug strategy that has gained importance in recent times is the endoscopic injection of Botox into the bladder muscle – very good results are often achieved here. However, the indication must be clarified individually. I often advise against the implantation of a bladder pacemaker, since MS is a dynamic disease and therefore one can never say whether a surgical measure will really last.
The problem with drug therapies, however, is that they can lead to a further increase in residual urine volumes and an increase in the risk of infection. As a rule of thumb, drug therapy is no longer targeted when the residual urine volume is > 100 ml.
In this case, especially if the patient has good hand function, intermittent self-catheterization should be discussed. There are now very sophisticated disposable catheter systems that are very easy to use. The procedure should be clean but not sterile and is almost complication-free. The bladder can be completely emptied as needed, which means effective prevention of urinary tract infections. Against the background that recurring urinary tract infections not only pose the risk of causing kidney damage, but also worsen other MS symptoms in addition to bladder dysfunction and are even capable of triggering relapses due to general immune activation, the avoidance of urinary tract infections by mastering bladder function is an absolute priority. And here intermittent self-catheterization is actually indispensable.
Inserting a permanent catheter should be the last resort. The indwelling catheter is always colonized with bacteria, as the bacteria adhere to the plastic, which increases the risk of (poorly controllable) urinary tract infections. In addition, the insertion site of the catheter can also repeatedly be the starting point for infections, which in turn can lead to a deterioration of MS symptoms.
Finally, it should be mentioned here that acidifying the urine is a means of reducing bacterial colonization when the residual urine volume is lower. Acimethin (Methionin®) is the most effective for this at a dosage of 3 x 500 – 1000 mg per day. Less effective, but perhaps more sympathetic, is the intake of lingonberry or cranberry juice.
Even though all of this sounds complicated and perhaps a bit frustrating for some, I would like to strongly advocate keeping an eye on bladder function and making efforts to optimize it – which in many cases is achieved by introducing intermittent self-catheterization. Control of bladder dysfunction is extremely important and successful results often result in a significant increase in quality of life.
