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Q) My patient has multiple sclerosis and complains of feeling weaker, but denies urinary symptoms. Why have I been told to check for urinary tract infection and not just administer steroids?
Bladder complications are extremely common in patients living with multiple sclerosis (MS), occurring in around 80% of this population.1 These complications—which include urinary urgency, failure to fully empty the bladder, incontinence, and difficulty getting to a toilet in time—can increase risk for urinary tract infection (UTI). And because many patients with MS also have sensory problems (eg, neurogenic bladder), they do not always present with the hallmark UTI symptoms of burning or pain with urination.
Often, presenting symptoms include generalized weakness, increased spasticity, or intensified neurologic issues. These can lead patients to believe they are having a relapse, when in fact, a UTI is causing a pseudoexacerbation of their baseline neurologic issues. In addition, frequent nocturia can disrupt sleep and further contribute to MS-related fatigue. Patients may self-induce dehydration by limiting their daytime fluid intake in an effort to avoid bathroom visits.1
In partnership with urology colleagues, you can help mitigate bladder complications in patients with MS; this can entail use of medication or interventions such as in-and-out or straight catheterization, timed voids, Botox, or pelvic floor physical therapy. Behavior modifications—ie, minimizing caffeine intake, limiting alcohol consumption, and stopping fluids early in the evening—can also be beneficial.1,2
Before initiating bladder medication, it is important to review potential adverse effects with the patient. It’s also crucial to ensure that patients are fully emptying their bladders before starting anticholinergic medications, as these can worsen retention.
Which treatment should you choose? Insurance companies tend to prefer generic, older-generation anticholinergics, but bear in mind that these can cause or contribute to cognitive issues (which many patients with MS already have).3 Another medication, such as mirabegron, may be preferable; it’s less likely than anticholinergics to cause dry mouth, which may help with compliance. Also, be aware that anticholinergics can cause blurred vision, which might lead patients to believe they are having optic neuritis or another MS-related visual change.4
That said, it is possible for patients to have a relapse and a UTI simultaneously. Due to potential adverse effects, it is essential to balance the risks and benefits of steroid therapy. Steroids could worsen an untreated infection and may not be appropriate for the patient’s symptoms or chief complaint.
Addressing bladder symptoms can not only help prevent UTIs but can also improve skin integrity, sleep quality, independence, and overall quality of life. A thorough exam and history-taking can alleviate secondary and tertiary urinary complications, as well as avoid unnecessary use of corticosteroids. -DRB
Denise R. Bruen, MSN, APRN-BC, MSCN
University of Virgina, Charlottesville
1. Sheehan J. Coping with MS bladder dysfunction. www.everydayhealth.com/multiple-sclerosis/symptoms/coping-with-bladder-dysfunction/. Accessed November 18, 2017.
2. Mayo Clinic. Bladder control: medications for urinary problems. www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problems/art-20044220. Accessed November 18, 2017.
3. Staskin DR, Zoltan E. Anticholinergics and central nervous system effects: are we confused? Rev Urol. 2007;9(4):191-196.
4. Geller EJ, Crane AK, Wells EC, et al. Effect of anticholinergic use for the treatment of overactive bladder on cognitive function in post-menopausal women. Clin Drug Investig. 2012;32(10):697-705.
Clinician Reviews in partnership with
MS Consult is edited by Colleen J. Harris, MN, NP, MSCN, Nurse Practitioner/Manager of the Multiple Sclerosis Clinic at Foothills Medical Centre in Calgary, Alberta, Canada, and Bryan Walker, MHS, PA-C, who is in the Department of Neurology, Division of MS and Neuroimmunology, at Duke University Medical Center in Durham, North Carolina. This month's responses were authored by Denise R. Bruen, MSN, APRN-BC, MSCN, who is with the University of Virginia in Charlottesville, and Maureen A. Mealy, BSN, MSCN, who is Neuromyelitis Optica Clinical Research Program Manager, Senior Research Nurse of the Transverse Myelitis & Multiple Sclerosis Centers, and PhD candidate at Johns Hopkins School of Nursing in Baltimore.
Clinician Reviews in partnership with
MS Consult is edited by Colleen J. Harris, MN, NP, MSCN, Nurse Practitioner/Manager of the Multiple Sclerosis Clinic at Foothills Medical Centre in Calgary, Alberta, Canada, and Bryan Walker, MHS, PA-C, who is in the Department of Neurology, Division of MS and Neuroimmunology, at Duke University Medical Center in Durham, North Carolina. This month's responses were authored by Denise R. Bruen, MSN, APRN-BC, MSCN, who is with the University of Virginia in Charlottesville, and Maureen A. Mealy, BSN, MSCN, who is Neuromyelitis Optica Clinical Research Program Manager, Senior Research Nurse of the Transverse Myelitis & Multiple Sclerosis Centers, and PhD candidate at Johns Hopkins School of Nursing in Baltimore.
Clinician Reviews in partnership with
MS Consult is edited by Colleen J. Harris, MN, NP, MSCN, Nurse Practitioner/Manager of the Multiple Sclerosis Clinic at Foothills Medical Centre in Calgary, Alberta, Canada, and Bryan Walker, MHS, PA-C, who is in the Department of Neurology, Division of MS and Neuroimmunology, at Duke University Medical Center in Durham, North Carolina. This month's responses were authored by Denise R. Bruen, MSN, APRN-BC, MSCN, who is with the University of Virginia in Charlottesville, and Maureen A. Mealy, BSN, MSCN, who is Neuromyelitis Optica Clinical Research Program Manager, Senior Research Nurse of the Transverse Myelitis & Multiple Sclerosis Centers, and PhD candidate at Johns Hopkins School of Nursing in Baltimore.
Q) My patient has multiple sclerosis and complains of feeling weaker, but denies urinary symptoms. Why have I been told to check for urinary tract infection and not just administer steroids?
Bladder complications are extremely common in patients living with multiple sclerosis (MS), occurring in around 80% of this population.1 These complications—which include urinary urgency, failure to fully empty the bladder, incontinence, and difficulty getting to a toilet in time—can increase risk for urinary tract infection (UTI). And because many patients with MS also have sensory problems (eg, neurogenic bladder), they do not always present with the hallmark UTI symptoms of burning or pain with urination.
Often, presenting symptoms include generalized weakness, increased spasticity, or intensified neurologic issues. These can lead patients to believe they are having a relapse, when in fact, a UTI is causing a pseudoexacerbation of their baseline neurologic issues. In addition, frequent nocturia can disrupt sleep and further contribute to MS-related fatigue. Patients may self-induce dehydration by limiting their daytime fluid intake in an effort to avoid bathroom visits.1
In partnership with urology colleagues, you can help mitigate bladder complications in patients with MS; this can entail use of medication or interventions such as in-and-out or straight catheterization, timed voids, Botox, or pelvic floor physical therapy. Behavior modifications—ie, minimizing caffeine intake, limiting alcohol consumption, and stopping fluids early in the evening—can also be beneficial.1,2
Before initiating bladder medication, it is important to review potential adverse effects with the patient. It’s also crucial to ensure that patients are fully emptying their bladders before starting anticholinergic medications, as these can worsen retention.
Which treatment should you choose? Insurance companies tend to prefer generic, older-generation anticholinergics, but bear in mind that these can cause or contribute to cognitive issues (which many patients with MS already have).3 Another medication, such as mirabegron, may be preferable; it’s less likely than anticholinergics to cause dry mouth, which may help with compliance. Also, be aware that anticholinergics can cause blurred vision, which might lead patients to believe they are having optic neuritis or another MS-related visual change.4
That said, it is possible for patients to have a relapse and a UTI simultaneously. Due to potential adverse effects, it is essential to balance the risks and benefits of steroid therapy. Steroids could worsen an untreated infection and may not be appropriate for the patient’s symptoms or chief complaint.
Addressing bladder symptoms can not only help prevent UTIs but can also improve skin integrity, sleep quality, independence, and overall quality of life. A thorough exam and history-taking can alleviate secondary and tertiary urinary complications, as well as avoid unnecessary use of corticosteroids. -DRB
Denise R. Bruen, MSN, APRN-BC, MSCN
University of Virgina, Charlottesville
Q) My patient has multiple sclerosis and complains of feeling weaker, but denies urinary symptoms. Why have I been told to check for urinary tract infection and not just administer steroids?
Bladder complications are extremely common in patients living with multiple sclerosis (MS), occurring in around 80% of this population.1 These complications—which include urinary urgency, failure to fully empty the bladder, incontinence, and difficulty getting to a toilet in time—can increase risk for urinary tract infection (UTI). And because many patients with MS also have sensory problems (eg, neurogenic bladder), they do not always present with the hallmark UTI symptoms of burning or pain with urination.
Often, presenting symptoms include generalized weakness, increased spasticity, or intensified neurologic issues. These can lead patients to believe they are having a relapse, when in fact, a UTI is causing a pseudoexacerbation of their baseline neurologic issues. In addition, frequent nocturia can disrupt sleep and further contribute to MS-related fatigue. Patients may self-induce dehydration by limiting their daytime fluid intake in an effort to avoid bathroom visits.1
In partnership with urology colleagues, you can help mitigate bladder complications in patients with MS; this can entail use of medication or interventions such as in-and-out or straight catheterization, timed voids, Botox, or pelvic floor physical therapy. Behavior modifications—ie, minimizing caffeine intake, limiting alcohol consumption, and stopping fluids early in the evening—can also be beneficial.1,2
Before initiating bladder medication, it is important to review potential adverse effects with the patient. It’s also crucial to ensure that patients are fully emptying their bladders before starting anticholinergic medications, as these can worsen retention.
Which treatment should you choose? Insurance companies tend to prefer generic, older-generation anticholinergics, but bear in mind that these can cause or contribute to cognitive issues (which many patients with MS already have).3 Another medication, such as mirabegron, may be preferable; it’s less likely than anticholinergics to cause dry mouth, which may help with compliance. Also, be aware that anticholinergics can cause blurred vision, which might lead patients to believe they are having optic neuritis or another MS-related visual change.4
That said, it is possible for patients to have a relapse and a UTI simultaneously. Due to potential adverse effects, it is essential to balance the risks and benefits of steroid therapy. Steroids could worsen an untreated infection and may not be appropriate for the patient’s symptoms or chief complaint.
Addressing bladder symptoms can not only help prevent UTIs but can also improve skin integrity, sleep quality, independence, and overall quality of life. A thorough exam and history-taking can alleviate secondary and tertiary urinary complications, as well as avoid unnecessary use of corticosteroids. -DRB
Denise R. Bruen, MSN, APRN-BC, MSCN
University of Virgina, Charlottesville
1. Sheehan J. Coping with MS bladder dysfunction. www.everydayhealth.com/multiple-sclerosis/symptoms/coping-with-bladder-dysfunction/. Accessed November 18, 2017.
2. Mayo Clinic. Bladder control: medications for urinary problems. www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problems/art-20044220. Accessed November 18, 2017.
3. Staskin DR, Zoltan E. Anticholinergics and central nervous system effects: are we confused? Rev Urol. 2007;9(4):191-196.
4. Geller EJ, Crane AK, Wells EC, et al. Effect of anticholinergic use for the treatment of overactive bladder on cognitive function in post-menopausal women. Clin Drug Investig. 2012;32(10):697-705.
1. Sheehan J. Coping with MS bladder dysfunction. www.everydayhealth.com/multiple-sclerosis/symptoms/coping-with-bladder-dysfunction/. Accessed November 18, 2017.
2. Mayo Clinic. Bladder control: medications for urinary problems. www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problems/art-20044220. Accessed November 18, 2017.
3. Staskin DR, Zoltan E. Anticholinergics and central nervous system effects: are we confused? Rev Urol. 2007;9(4):191-196.
4. Geller EJ, Crane AK, Wells EC, et al. Effect of anticholinergic use for the treatment of overactive bladder on cognitive function in post-menopausal women. Clin Drug Investig. 2012;32(10):697-705.
