Bladder dysfunction

Approximately 80% of patients with MS experience some type of bladder dysfunction. The primary problems are failure to store urine in the bladder and inability to empty the bladder normally. Symptoms of failure to store urine in the bladder include urinary urgency, frequency, incontinence, and nocturia. Symptoms associated with failure to empty the bladder include urgency, hesitancy, and a sensation of incomplete bladder emptying. Being unable to control bladder function poses significant psychosocial implications. For example, the patient may avoid drinking liquids, may experience anxiety over loss of bladder control, may become homebound due to fear of not being close to a bathroom, may fear incontinence during sexual activities, and experience increased fatigue due to interrupted sleep.

Both non-pharmacological and pharmacological interventions can be used to help bladder dysfunction. Patients should be advised to avoid using substances such as caffeine and alcohol that have a diuretic effect. Bladder modification techniques, such as timed or scheduled voiding, may also be used. Some patients empty their bladders regularly using intermittent catheterization. Using this technique, the patient or a caregiver inserts a straight catheter into the bladder every few hours to drain urine and prevent urinary retention. Medications that can improve bladder dysfunction include oxybutynin (Ditropan ®), hyoscyamine sulfate, propantheline bromide (Banthine ®), and tolterodine (Detrol ®).

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Timed voiding and intermittent catheterization, in conjunction with medications, can help decrease bladder problems in people with MS.

Bowel dysfunction

Bowel dysfunction occurs in approximately 60% of patients with MS. The most common bowel complaint is constipation; the most distressing is involuntary bowel emptying. Slow colon transit times, pelvic floor spasticity, and poor perianal sensation cause constipation, fecal impaction, flatulence, and paralytic ileus. Diarrhea may occur as a result of bowel impaction. Bowel dysfunction creates embarrassment, and anxiety about leaving home and interferes with participation in normal social activities.

Interventions for constipation include increasing daily fluid intake to 1.5 to 2 liters, adding fresh fruits and vegetables to the diet, increasing bulk and fiber in the diet by adding bran and whole grain breads, and increasing physical exercise. Bulk forming agents, stool softeners, mild laxatives, anticholinergic drugs, and suppositories or mini-enemas can also be used to help treat constipation.

Cognitive dysfunction is common in persons with MS. It is estimated that up to 60% of patients with MS demonstrate abnormalities on mental status examinations. Symptoms of cognitive dysfunction include:

• Memory impairment
• Impaired attention and concentration
• Slowed processing speed
• Impaired executive functions, such as being able to plan and organize
• Difficulty learning new information
• Mood alterations, such as depression and/or euphoria
• Impaired spatial relations abilities
• Impaired word-finding abilities
  

Cognitive impairment can have a profound effect on quality of life for the person with MS. The individual with symptoms of cognitive dysfunction often experiences anxiety, loss of self-esteem, depression, and impaired ability to perform self-care activities. On an interpersonal level, cognitive dysfunction may produce family and marital strain, impaired communication, and role shifts within the family. Cognitive impairment is a major cause of the high unemployment rate among people with MS. Cognitive problems may also affect the patient’s ability to communicate with his or her healthcare providers and may have a negative impact on treatment compliance.

Cognitive rehabilitation shows promise as an approach to help patients with cognitive impairment. A restorative approach to cognitive rehabilitation focuses on restoring impaired function through direct retraining exercises. A compensatory approach helps to improve cognitive function by using specific strategies and tools to substitute for the impaired functions. This approach teaches patients how to substitute specific strategies and tools for the impaired cognitive functions. For example, memory books, and electronic reminders can help an individual with cognitive impairment with daily living skills. Denepezil hydrochloride (Aricept ®), a drug currently approved for use in Alzheimer’s disease, may be used to treat cognitive dysfunction in MS patients. There is also some evidence that treatment with disease modifying agents may play a modest role in the treatment of cognitive impairment.

Medication for Symptom Management

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