This is the ninth of our MS Society Awareness talks available to watch on the internet.

Page contents:

• Interview of prof Fowler on the management of bladder problems
• Online Q&A board
• Transcript
• PDF of interview transcript and Q&As

 

Interview

In the two parts of this film, Professor Clare Fowler, a uro-neurologist answers questions regarding the management of bladder problems.

She explains why bladder problems can happen in MS, what the main problems encountered are, what the best first-line treatment is, what new treatments are coming, and much more.

Online question and answer session

  Professor Fowler will also be answering questions on the management of bladder problems from Monday 29 September to Sunday 5th October in one of our online question and answer sessions. Please use the link above to login.

You will need a free MS Society Discussion board account to send your question in. If you don't have an account, please use the following link to set one up:

• Register now for a free discussion board account

 

Transcript

Please note that the transcript is not a word-for-word transcription. Repetitions, hesitations etc have been removed.


Part 1

• Q1 - Why do many people with MS experience bladder control problems? 
  Many people with MS are going to have trouble with their bladder. We think that that’s because of the involvement of the spinal cord in multiple sclerosis. You very, very, badly need to have the connections between your brain and the bottom end of the spinal cord, to work your bladder. So if the disease is affecting your mobility, affecting the use of your legs, it’s a sign that it is affecting the spinal cord. And whatever that trouble is it is going to interrupt those connections between those two critical sites. So the bottom line really is that you need your spinal cord to be working perfectly to work your bladder perfectly. If it doesn’t work the consequences are that your bladder function is going to be disrupted.
  
  Now the bladder really does two things, it only does two things. It stores up urine and then at a well chosen moment you empty your bladder out. And to be able to do that you need to make those connections, and if something goes wrong you can neither store properly, nor often can you empty properly either.
  
  
• Q2 - What are the main problems encountered?
  What patients with MS usually complain of is that they find that they become unable to hold on. They say as soon as they get the urge to pass urine they must reach the toilet or, if they are unlucky, they will leak. And the severity of that depends to a large degree on how bad their spinal cord is. Such that it’s an unhappy fact that as you become less able to run, to run to the loo, your bladder is – that urgency is worse, so it’s really a double whammy there. So that’s the thing that they actually come complaining of, the fact that they have urgency and they can’t wait long enough to reach a toilet.
  
  What’s happened is that a new reflex has opened up that is making their bladder contract involuntarily, and that reflex is fired off at a low volume. So they have a small capacity bladder, so that means that they’re going to have frequency, because as soon as they reach that capacity they’re going to empty. So they have urgency, and they have frequency, and if they’re unlucky they’re going to have urgency incontinence, and if they’re very unlucky they’re going to have night time frequency, possibly being wet in the night as well. But fortunately that’s a bit less common.
  
  So those are all the signs and symptoms which are due to having an overactive bladder, and that’s what people usually complain of. The other thing you need your bladder to do is to empty properly, and that process is affected also. So in spinal health you hold on, you then go to the loo, you relax your sphincter, and then you contract the muscle wall of the bladder, it’s called the detrusor, and you contract that down, and you empty your bladder nicely. So you have a good flow rate and you empty your bladder completely. If your spinal cord doesn’t work properly what happens is that the bladder tends to contract and the muscle at the outlet of the bladder, the sphincter, contracts at the same time. So you don’t have a good flow rate, and you don’t empty properly. So the other problem people get is incomplete emptying. So the extent to which you have both these problems is unpredictable and variable, but the majority, particularly if they’re not walking well, have a combination of bladder over-activity, and incomplete emptying.
  
  
• Q3 - What is the best first-line treatment?
  The treatment that people are given for having an overactive bladder is a medication that blocks the transmission between the nerves that innovate the bladder and the bladder wall. And these tablets are generally known as – they used to be called anti-cholinergics, they’re not called anti-musclerinics. There’s a group of seven of them and they all work in much the same way, they block the, in fact they block the receptor, that’s the bit that the molecule locks into on the bladder muscle, and thus prevents its effective contraction. At least that’s what they were said to do, they probably actually work in a much more complicated way but that’s quite a helpful way of thinking about it. So they reduce the tendency of the bladder to contract when you don’t want to, they lessen urgency, which can’t actually be explained by that mechanism that I’ve just outlined to you, which is why we think it’s more complicated. And that’s why people take them in the first instance, because they reduce urgency and frequency. And, as I say, there are seven of them, and the one that the patients are prescribed is usually determined often by financial constraints, but quite often by the use of medicines committee for their local trust, or some other arrangement with their GP. I don’t think I’ll go into the different names now.
  
  But that’s only one side of the treatment because, as I already explained to you, the other thing that can happen is that you may not empty your bladder. The symptoms of not emptying your bladder are actually much more subtle and it’s not something that you get a good indication from, from the history. And so, before you have the treatment if there’s any reason to think that you’re not emptying your bladder, you need to pass your urine and have the residual volume measured with an ultra sound device. This is a very simple non invasive investigation, but it shows you how much is left behind after you’ve passed urine. Something that is difficult to guess at from the history unless patients say I can pass urine and then five minutes later I can go and pass the same amount again. And then you begin to suspect that that’s what they’ve got. So that’s the most important investigation if the doctor thinks that any investigations are needed before a prescription is given.
  
  And very recently we had a consensus meeting between neurologists, the nurses, and urologists, and we all agreed that in this country the top investigation is actually to just do a dip stick to check that the patient hasn’t got an infection in their urine. And then after that to get them to pass urine, measure the residual volume, and then prescribe the anti-cholinergic. If you’re not emptying your bladder you then need to learn to do intermittent self catheterization, which is a technique that is best taught by a urology nurse or a continence advisor. This business of intermittent catheterisation is something that understandably alarms patients. I’ve never met a patient who said they wanted to do it, and really the most encouraging thing is for a patient to have met another patient who tells them how helpful it is. But unless you empty your bladder the tablets can’t work because you always are going to have urine in your bladder that’s going to stimulate the bladder to contract involuntarily.
  
  So in somebody who’s not emptying and who has an overactive bladder, they need to learn how to do self catheterisation, and this is something that is probably best taught by somebody who comes to your home, but can be taught as a hospital outpatient. This is a catheter as used by, for a man, and it’s lubricated and put through the penis into the bladder, and the bladder is drained and then the catheter is removed. Very fine soft catheter, because the patient does it themselves, they don’t hurt themselves. It obviously takes practise, it takes quite a bit of instruction, it takes encouragement, but the people who come back and say they’re really better are the people who have mastered this, if they weren’t emptying their bladder. This is the one that can be used by women, and as you can see, it’s about the size of a lipstick, and it undoes in this way here, and it pulls out and there is the catheter, introduced into the bladder through the urethra. Obviously for women it’s difficult for them to learn where to insert it. It’s not as obvious as in men, goes without saying. But they learn to put this into the bladder, empty the bladder out, and then take the catheter out, and that’s the way of doing intermittent catheterisation. And once that is established then it’s a good idea if they still, the patient still has overactive symptoms, to take one of the anti- musclurinic medications.
  
  So that, actually, is the first line treatment. It’s quite complicated and a lot of patients, when they’re told about the catheter they forget about the tablets. A lot of patients don’t need to do the catheter, but that’s the test we would be doing as they came to a department, that’s the test we’d want to know do they need to do that as well as take the tablet.
  

Part 2

• Q4 - What new treatments are available?
  What I’ve described to you is the first line treatments, but there were always patients who didn’t respond sufficiently well, and needed something more doing. And, in fact, there was a big gap between those simple things and offering the patient surgery. And, in fact, I’ve spent most of my working life looking for things to fill the gap, and happily in the last seven or eight years, a truly excellent treatment has become available. This is something that was discovered in Germany and Switzerland. You can inject the muscle of the bladder, it’s called the detrusor muscle, with botulinum toxin, otherwise known as botox. There are two different types of botulinum toxin, botox and dysport, but botox is used notoriously for wrinkle treatment, so it’s the same stuff. And that’s something that has actually been developed in this department and is now available in a number of different departments. I’ll just describe that a little bit to you.
  
  After some assessment, which includes looking to see how well the bladder is working or is not, you need to agree to do, that you will do or are willing to learn to do, intermittent self catheterisation. Because what we know is that all the patients with MS who have had botox injected into their bladder are unable to empty their bladders afterwards, so that’s a requirement of going forward for this treatment. You then come as an outpatient, lie on this couch, and the doctor injects using a flexible cystoscope and a very fine needle. This needle here, extremely fine, through a channel in the flexible cystoscope, the telescope that’s looking into the bladder, injects into the wall of the bladder in 30 different sites, under local anaesthetic. And it can be monitored on this screen here, and you can see the needle going into the bladder wall, and the little bled being raised, of the injection going in. This is a remarkable treatment. It very rapidly, within a week, abolishes urgency. It does make the bladder empty even less efficiently, hence the need for intermittent self catheterisation. But we know that it lasts for something like nine or ten months before it has to be repeated, and the really good news is that it seems to be as effective, the second, third, fourth, fifth, or even up to six or seven times, that it’s reinjected. It’s as effective when it kicks in on those occasions as it was the first time. And patients are absolutely delighted.
  
  As with any treatment there are adverse effects. I mean, the commonest is a bit of bleeding or urinary tract infection. There are some more, some much rarer side effects, adverse effects that you would have to be warned about before you agree to have this treatment. The tricky bit about this is that it’s unlicensed; the manufacturers are in the process of getting all the drug trials together to get it a licence for this indication. But at the moment it’s not licensed and so it can only be given in centres where the hospitals have agreed their doctors can use it as a treatment, and that’s certainly something that we have set up here at UCLH. But there are a lot of the trusts where that isn’t in place.
  
  The detrusor injection of botulinum toxin is not available everywhere in the UK yet, it is still unlicensed, and so for a doctor to use this treatment they have to have special permission from their hospital, and not all hospitals have given this permission. Here at UCLH we do have that permission but if it’s something that you were interested in you would have to ask your GP to refer you to a hospital where they’d got the treatment set up. And that’s what it would depend on.
  
  5 - Can drinking more help with bladder problems?
  The answer is not definitely yes. I think that what happens is that if you have an unreliable bladder you avoid drinking. Indeed there’s lots of patients who, that’s their mode of management, they just cut down on drinking, and ever so many patients, when they come to see me say, well, I haven’t had a cup of tea yet this morning because I knew I’d have urgency on the train. So they tend not to drink enough, and that in turn leaves them susceptible to get urinary tract infections. So that’s the circumstances in which you need to encourage people to drink more. So the answer is not simply, yes. There are circumstances if patients are not drinking enough, they will be getting infections, and therefore they should drink more. But they’re unlikely to do that unless their bladder is under better control, and so if they’re in a condition of managing their bladder by reducing their fluid intake they really ought to go and seek some sort of help. Perhaps have the tablets, possibly the tablets and the intermittent catheterisation. If they embark on the intermittent catheterisation then it’s really very necessary to drink plenty, to wash the bladder out, because the catheter can introduce germs and it’s important that those are washed out by plenty of throughput through the bladder. So the answer is not a simple, yes.
  
  6 – Is professional help always necessary?
  I think probably people who have troublesome bladder symptoms, and it’s up to them to decide if they’re troublesome, but if it’s disrupting their work or their social life, or stopping them sleeping, or limiting them in some way, then it’s worth going to seek advice. As you gather, the treatments can be very simple, just a tablet, or the more complicated intermittent self catheterisation as well. But usually in the first instance the tablets are adequate and a lot of patients find those make a tremendous difference. So I think, yes, I think a visit to the GP in the first instance is appropriate.
  
  7 – How does the future look for treating these problems?
  Well, I think the fact that this injection of botulinum toxin has arrived has really transformed patient’s quality of life, who have bladder troubles. I think that more research needs to be done; we need to see if it’s actually suitable in lower doses, for people who simply have urgency, rather than in combination with self catheterisation. And that’s something that we don’t know, and that would avoid taking the tablets, possibly. That’s something to look at in the future. I’m sure that other tablets will become available. I said to you that at the minute all the tablets are of the same group, the anti-musclurinics. The drug companies are working very hard to find alternative ways of treating over active bladders, which is something that affects large numbers of the general population as well as patients with multiple sclerosis.
  
  I think that there should be an improvement in the accessibility for patients who have this problem. We’ve just concluded a UK consensus view, for management of bladder dysfunction in multiple sclerosis, and everybody who took part in that was adamant that there should be easy access, for patients who have troubles, to people who are interested in bladder problems. And access, if necessary, from there on to urologists who have a particular interest in this. So I think the logistics and management will improve, the treatments that we have on offer have improved, and will probably improve further.

END

 

Awareness Talk Film and Q&A
Download a pdf document of the interview transcript and the answers from Prof Fowler in our online question and answer sessions between Monday 29 September to Sunday 5th October 2008.