Next question - bladder and CNS

Quix and anyone else -

I'm wondering - I know incontinence is a common MS symptom, but just what is the connection (or lack of connection)  between the Central nervous system and the bladder? Why is this symptom so common when others appear to be so random?

Depending on your answer,
Laura

[wishforchange]

I know this isn't the answer you're seeking but just have a question you may want to keep the answer to private.  It's regarding the menopause.  If you have not yet reached that stage there is a hormonal connection to incontinence too, which is why some women have this symptom around the time of their menses.  

As a little help to the neurological side, the urge to urinate is controlled by spinal nerves, and any interruption or damage to these signals can result in either chronic retention or incontinence.  The bladder is generally under some voluntary control which is why we can after early childhood generally choose when to empty our bladder and relax the muscle to achieve this, or tense it if voiding is not watned.  I cannot answer why this is a common symptom in MS, but it is a common symptom in women generally.  In the medical world this is a surprisingly new area of research, particularly retention, which can be linked with incontinence. I would recommend apart from talking to  your neurologist also trying to find a good uro-gynaecologist or uro-neurologist who works with MS issues.  Three is an expert forum here and you may want to post your question there too.

I am not being much help I know, but having continence issues myself I can only empathize.  My issues are more of retention, such that I self-catheterize, but I have ocassional incontinence too.  It has been confirmed as a neurological deficit, but no-one has told me why.  I do not have diagnosed MS.  My route to diagnosis was via a hospital admission in severe retention, followed by a urodynamic study, and then referral to a uro-neurologist.  There are things that can be done to replace the damaged signal of the nerve, eg. through a surgical implant, but this is something that needs careful evaluation by you.  I opted not to have the implant.  But bear in mind the implant was for retention issues, whether it works for incontinence I do not know.  Hope you get more answers here!

[Fluffysmom]

I saw a MS specialist this week who is basically dismissing my brain lesions and discounting my symptoms.  After careful and respectful questioning by me, she is sending me to a urologist who will do testing to see if my urgency/frequency/weird buzzing sensation/slow or stop and start urine stream are neurogenic.

She didn't say that she was a uro-neurologist, but since she works in concert with the neurology clinic often, I'd say she has some knowledge and experience in the matter.

If you want to find out personally about such matters, maybe a good uro gynecologist or uro-neurologist, as WFC mentioned, would be something to consider looking into.  I've been to two old-fogey urologists, and neither of them seemed to really GET the female urology scene.  I decided that my next urologist would be a female, and, low and behold, I'm being referred to a female urologist!

I wish you well.

Kathy

[Quixotic1]

The neurologic connections to the bladder and it's role in initiating the urge to urinate, tehn the mental and voluntary decision to urinate, followed by the contraction of the bladder wall (detrusor) muscle, followed by the relaxation of the inner sphincter and then relaxation of the external sphincter.  All of these signals and muscles must work in harmony to acheive correct urination.  So there are several ways in which the sequence can be messed up.

A lesion originating in the brain, the brainstem, or the spinal cord can knock one part out of the sequence.

Incontinence isn't the only urinary problem people can have.  

If the baldder detrusor muscle is weak, it may overfill and a person may have retention.  In men this may lead to backward flow up the ureters and eventually cause kidney damage.  Or they may fill normally, but the nerve taking the signal that the bladder is full may be interrupted and the signal doesn't reach the brain.  No sensation of fullness and no urge.  This causes retention also.  Any retention predisposes to urinary infections.

The bladder muscle cans spasm causing inappropriate and early urges to urinate.

The sphincters may lose their signal causing leaking.  Or the sphincters may spasm shut causing an inability to begin urinating or to finish emptying the bladder.

A common problem is when all the signals get mixed up in their sequence.  The most common is called detrusor-sphincter dyssynergia (dyssynergia = not working together).  The bladder sends the signal, the person tries to urinate, but the sphincter doesn't relax and allow it.

This last causes hesitation in initiating the urine stream, a weak stream, a stop-and-start stream and/or failure to be able to completely empty the bladder.

I also recommend trying to see a uro-gynecologist.  My MS clinic has two of them, both female, who run a continence clinic,  They are so patient and compassionate and make the exam so easy.  I saw one last year for some urege incontinence.  They recommended peovic msucle physical therapy.  I deferred, but not the problem isn't leaking just a few drops.  I periodically lose the whole shebang.  

Also, the proper function of the urinary system may be influenced by dysfunction by the bowels whcih occurs in a good 50% of all people with MS.  Because of the female anatomy, constipation can cause urinary retention or incomplete emptying because of pressure of the stool in the rectum directly on the bladder sphincters.  Other have the opposite problem of having the pressure of the backed up stool pressing into the bladder itself, so that it can't fill enough  and the person has frequency.

Finally, many of the meds we use for other symptoms of MS affect the bladder and the ease with which we urinate or our ability to hold it properly.

Urinary retention is the most serious of the problems.  the longer the urine sits in the bladder, the more likely we are to develop a urine infection.  UTIs, besides being potential threats to our lives, trigger relapses, increase spasticity and do damage to our organs.  Catheterization is often used to handle this problem.  Intermittent self catheterizing is much preferable to having to have an indwelling catheter.  The reason for this is that indwelling catheters always become infected.

Well, maybe that is more than anyone wanted to know.  Hope it helps.

Quix

[wishforchange]

Just a thank you for such a great explanation.  My consultant is terrific but has never fully helped me understand what is going on.  I keep re reading your post as it is like the talk I should have had.  If my printer was working would like to print it.  
My kidneys have been partially damaged from years of endless infections from retention, and I agree it is a serious symtpom.  I was very fortunate to find the person I did.  When I was admitted in retention of over a litre I was also very constipated, and they initially just put it down to that.  It was only a very observant nurse who pushed for the urodynamic test and then got me seen by the right people.  I remember being annoyed at being referred to a neurologist rather than a urologist.  But I had already had a cystoscopy and apart from severe inflammation of the bladder there was no obvious pathology.  I nearly just got sent away and declared better.  I do believe I would have eventually gone into kidney failure.  I now mostly have no sensation of fullness and am often amazed when I catheterize at the quantity.  My only symptom of bladder fullness is abdominal pain, and only when it is extreme.  This is why I was told to catheterize every day at least twice, regardless of how I felt.  Slowly the infection rate is reducing.  Sometimes the problem flips and I get such a powerful urge to void I cannot reach the toilet in time.  The whole lot just comes out in one go, the opposite to the weak or non-existent stream of the rest of the time.  Nobody has followed through where the damage is in the neural route.  It is too new a part of medicine here.  A lot of women with these problems have been dismissed by their doctors as suffering anxiety, and yet the muscles and nerves involved are not under voluntary control.  That is my only grumble, there are so few consultants working on this problem here that it is very hard to get an appointment, and as yet they are still learning themselves, so treatments are not developed fully and all the consultant can really do is watch and observe changes.  The catheters I use turned my life around, maybe even saved it.  Now I never get into the situation where my bladder is holding over a litre, and as my technique and products for sterilizing the area improve, infections are becoming just one or two a year, rather than before, where they were practically permanent.  The incontinence is very concerning, and only happens with my menses, but maybe I need to take this back to the specialist, when I eventually see them.  From what you are saying somewhere in the neural route there must be damage.  Strange thing with this consultant is they are not too bothered about investigating the source of the problem, they are more concentrating on trying to treat it.
Apparently there is a link with general anaesthesia, in that some people develop this neural malfunction after this, and it continues.  I worked for a tie in anaesthetics and know how little is understood about how these drugs work, but there is apparently in the literature a clear link, so my consultant told me.  Just fyo.

[Lulu54]

What great information in a way that I can understand!  I am well past menopause - did that in my mid-40's and no one has questioned it! The incontinence problem is becoming an issue and I couldn't find the physical connection, so again, thank you all for your input.

Be well,
Laura

[AMO]

hi  laura,

how ar eyou today?
i see you   have gotten very good  answwers.
i too    am incontent, rare a day goes by i do not change close     more thna onnce. Even with caathing 4-6x.  I have mixed sigsnals.... both over activity and flaccid.

I did have a triiiial of inter stimm    implant for three w eeks, but my results not warrant th epermanant implant.
I was haoppy to have had the chance even though  my uro had not tried this before in a neuro patient.

i am sorry you have developed this symtpom. try not to let it stop you from doing things. Just be prepared.
be well, amo