MS ECHO Session 8: Neurogenic bladder and
Neurogenic bowel
Gary Stobbe, MD Medical Director, MS Project ECHO
Clinical Assistant Professor, UW Neurology
Conflicts of Interest
• Dr. Stobbe has no conflicts of interest to disclose
Instructional Objectives • Review screening and symptoms of bladder
and bowel dysfunction • Describe medical and self-management
strategies for bladder and bowel problems • Discuss the social and emotional impact of
bladder and bowel problems
Overview • Bladder and bowel dysfunction - commonly
limit MS patients in their activities in the community – Fear of social embarrassment
• Bowel and bladder issues are very treatable with current therapies
• Not always aware their bladder and bowel issues are related to MS so screening is important
Patient Case • 65 yo male businessman with progressive MS • Wheelchair and walker • Rare UTIs in the past; urinary frequency/urgency • Rare bowel incontinence/chronic constipation • Business trip to Alaska – decreased urine
output/intractable suprapubic pain/nausea/increased LE weakness
Patient Case (cont.) • WBC – 13K; BUN – 48; Cr – 5.2 • RUA – turbid, >100 WBC • Blood Cx neg • CT abd/pelvis – hydronephrosis/hydroureter • Foley – drained 3.5 L urine
Urinary Tract Infections • Urinary tract infections (UTIs)
– common in people with a neurogenic bladder – common reason for a pseudorelapse in MS (e.g.
generalized fatigue and increased spasticity)
• May not be aware of UTI because of sensory loss
• Always first step in evaluating new bladder symptoms
Detrusor Hyperreflexia
• “failure to store” • Frequency, urgency,
incontinence, nocturia • Most common early
bladder change
Detrusor Hyperreflexia • PVR to rule out retention • Management
– Minimize bladder stimulants (caffeine) – Scheduled voiding – Reduce HS fluids (too great of a reduction may
increase infection risk and constipation) – Pelvic floor PT may be helpful – Trial of anti-cholinergic/anti-muscarinic therapy – Negative med trial - consider botox
Detrusor Hyperreflexia – Medications to reduce detrusor activity
• Oxybutynin (anti-muscarinic) • Tolterodine (selective anti-M) • Hyoscyamine (anti-cholinergic) • Propantheline (anti-cholinergic) • Trospium (Sanctura; anti-cholinergic/anti-spasmodic) • Solifenacin (Vesicare; M3 selective) • Darifenacin (Enablex; M3 selective) • Fesoterodine (Toviaz; tolterodine prodrug) • Mirabegron (Myrbetriq; beta-3 adrenergic agonist) • Imipramine (tricyclic class)
– Botulinum toxin A injections
Bladder Botulinum toxin injections • Botulinum toxin A
injections to reduce detrusor muscle overactivity
• Urologist injects numerous areas of the detrusor muscle with botox via a cystoscope
Neurogenic bladder with retention
• “failure to empty” • Urgency, hesitancy,
double voiding, feeling incomplete emptying
• Urinary retention due to – Detrusor-sphincter dyssynergia – loss of sensation – poor contractility
Case • Example: 40 yo male presents to clinic complaining that
he often has trouble voiding. He has the urge to go but when he tries, he cannot urinate. He has occasional accidents that are embarrassing for him. He is not having UTIs. No BPH.
• Management: – PVR: >200ml and/or having leaking, UTIs, or high voiding
pressures on urodynamics; a catheterization program is recommended
– PVR >200ml without leaking, UTIs, or high voiding pressure may monitor annually with renal US and creatinine
– Consider Flomax trial if BPH is considered – Urology consultation often helpful in this setting
Collaborative Decision Making for Bladder Management
• Meet patient “where” he or she is • Help patient define desired outcome • Discuss the pros and cons of medical and non-
medical interventions, including impact of some meds on cognition
Neurogenic Bowel Case: 45 year-old male with PPMS presents to
clinic due to bowel difficulties. Notes he is always constipated but when he does go it is unexpected and he has had a few accidents in public. He has since been more leery of leaving the house.
Case: 40 yo female presents to clinic due to bowel difficulties. She works full time. She is struggling with bowel urgency and incontinence. She has come close to having an accident at work
Neurogenic Bowel – Constipation Predominant
• Lifestyle – Bowel regimen – same time daily or every other (2-7 days
to see effect) – Minimize meds that worsen constipation (i.e. opioids) – Adequate hydration/fruits/vegetables/fiber – Physical exercise
• Medications – Polyethylene glycol (GlycoLax, MiraLax) – osmotic laxative – Psyllium (Metamucil) – stool bulkener – Docusate (Dulcolax, Colace) - stool softener – Bisacodyl (Dulcolax) – laxative/stimulant – Lubiprostone (Amitiza), linaclotide (Linzess) - stimulants
Neurogenic Bowel - Other Types • Fecal impaction
– Manual disimpaction
• Diarrhea – typically resulting from constipation – Disimpaction and relief of constipation
• Fecal incontinence – Bowel program – Anti-cholinergic medication
Resources • Bladder Self-Assessment Questionnaire (pdf) • Bladder Dysfunction in MS • Bowel Dysfunction in MS • Talking with Your MS Patient about
Elimination Problems
Dr. Sheri Howell’s case • 37 yo caucasian male, no prior med hx • 9/2014 – shooting pains, LLE into calf/top of foot;
dragging L foot at times • Hx LBP 1995 – “different pain” • Exam unremarkable • Medrol dosepak – no effect • Lumbar MRI – mild bulging L2-3/L3-4 • EMG/NCS unremarkable • 2/15 – notes shooting pain if turns head
Dr. Sheri Howell’s case
• C-spine MRI without contrast (2/2015) – Mild degen changes C6-7 – “increased T2 signal in the spinal cord C7”
Brain MRI – 2/2015 • Periventricular lesions highly suggestive of MS • Largest R frontal lesion with slight contrast
enhancement • Smaller corpus callosal lesions
Dr. John Schaeffer Case
• 28 yo female • Hx bipolar on lamictal • Onset L side scalp/ear pain – constant ache • Exam normal/MRI unremarkable • ENT – Ramsay Hunt? (no vesicular lesions) • Poor response to gabapentin, good response
to carbamazepine
Dr. Schaeffer Case (cont.)
• 6 mos later – neuropathic pain distal BLEs • Exam – reduced PP/temp distal to mid-calf B • EMG/NCS – mild axonal polyneuropathy • Serology – neg except B12 low (229) • Tx – B12 replacement; increase
carbamazepine (pain improved)
Dr. Schaeffer Case (cont.) • 20 mos later – R temporal/ocular pain with blurry
vision • Ophtho – dx R optic neuritis – tx with IV steroids with
prednisone taper – symptoms resolved • Neuro exam normal • Vit D – 18; anti-SSA/SSB, anti-gliadin, SPEP, lyme, TSH,
B12, ESR, ANA, anti-Hu, anti-Yo, anti-Ri all negative • Brain/cervical/thoracic WNL (8/2014 and 12/2014) • CSF – positive OCBs, elevated IgG index
12/2014 – Axial T2
12/2014 – Axial T2 FLAIR
12/2014 – Axial T2 FLAIR
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