Multiple sclerosis (MS) is a chronic, progressive neurological disease of the central nervous system, which appears to have both inflammatory and degenerative components (Johns Hopkins University, 2021). It is characterised by areas of demyelination (or damage to the coating around nerve fibres) and the formation of plaques along the nerve pathways (Johns Hopkins University, 2021). It may be triggered by either environmental factors or appear in genetically susceptible individuals, and is associated with severe side effects and disabling symptoms (Alshammari et al, 2019).
There are several types of MS, including relapsing and remitting (relapses of symptoms with periods of partial or complete remission), primary progressive (symptoms gradually get worse), secondary progressive (sustained build-up of disability), and progressive relapsing (Alshammari et al, 2019). All are life-changing forms of the disease that affect about 2.5 million people globally, with its incidence on the increase (Lin et al, 2019).
Prevalence rates across the UK vary, with the MS Trust (2020) estimating that there are about 130 000 people in the UK with MS, 105 450 of whom are in England, 5600 in Wales, 4830 in Northern Ireland and 15 750 in Scotland. Within the UK a little over 6700 people are diagnosed with MS each year, or about 100-130 new diagnoses per week (MS Trust, 2020; Public Health England, 2020).
MS mostly affects young individuals aged 20–40 years (Alshammari et al, 2019). Research suggests that the proportion of women with MS is increasing and it is estimated that there two to three women with MS for every man with the condition (MS Trust, 2020).
The impact of MS is profound, affecting an individual physically, mentally and financially. It is associated with a reduced quality of life and has considerable costs to both the individual and the community. The clinical course and presentation of MS varies from person to person and depends on the location of lesions or plaques. Common symptoms include muscle weakness, stiffness, tremors, pain and spasms, balance and co-ordination problems, impaired sensation and motor function, visual disturbances, problems with speech/swallowing, memory impairment, fatigue, and bladder and/or bowel dysfunction (Lakin et al, 2021).
Bladder and bowel dysfunction
Bladder and/or bowel dysfunction in MS can occur at the onset of the disease or any time during its course. It can impact either the bladder or bowel directly, through plaques damaging the areas of the central nervous system that control voiding/defaecation, or indirectly, due to immobility/poor dexterity or cognitive ability.
Bladder symptoms are reported by 80% or more of people with MS and bowel symptoms by more than 50% (Multiple Sclerosis International Federation, 2014). This is about three times more common than in the general population (Lakin et al, 2021). However, it is important to remember that factors, such as pregnancy, the normal ageing process and other risk factors for incontinence, can also affect bladder/bowel function.
Bladder problems
The main bladder problems experienced by individuals with MS are categorised by the International Continence Society (ICS) (Abrams et al, 2002) into storage, voiding and postmicturition symptoms (Al Dandan et al, 2020).
Storage problems include failure to store urine, which may lead to overactive bladder that can present as urgency (a sudden and strong desire to pass urine), frequency (going to the toilet too often ie more than eight times in 24 hours) and nocturia (waking up at night to void usually more than once) (Al Dandan et al, 2020).
Voiding problems include failure to empty the bladder, which can present as hesitancy, poor stream, intermittent flow, straining, after-dribble, pain on voiding, and sensations of needing to immediately to void again.
Postmicturition symptoms present as after-dribble and feelings of incomplete emptying, which may be associated with a urinary tract infection (UTI).
Al Dandan et al (2020) stressed that early diagnosis, assessment and investigation of symptoms are all important in preventing possible complications and to guide the professional to the right treatment/management pathway for the individual patient.
Bowel problems
Bowel dysfunction in individuals with MS usually falls into two categories: faecal incontinence and constipation (Johns et al, 2021). The Royal College of Nursing (RCN, 2019) defines faecal incontinence as the involuntary loss of liquid or solid stool that is a social or hygienic problem, and constipation as the infrequent passage of stools, difficulty in passing stools or passage of hard stools.
These symptoms may have numerous causes in MS, eg poor transit/motility through the gut, use of constipating medication, poor mobility, and damage that impedes signals to bowel and bowel control mechanisms. Long-term constipation increases the risk of faecal impaction, in which dry, hard faeces collect in the rectum and anus, which can lead to individuals suffering from overflow faecal incontinence.
Treatments
Conservative therapies
Routine conservative treatments and management options can initially improve the continence status of people with MS. These could include simple measures such as reviewing the individual's intake of fluid, identifying that they are drinking the correct amount of adequate fluids, ideally water (about 6–8 glasses daily or 1.5–2 L), and discouraging the consumption of caffeine-based fluids, fizzy drinks and alcohol (Multiple Sclerosis Limited, 2021). If patients have nocturia, they can be advised not to drink excess fluid about 2 hours before bedtime, while ensuring that their total consumption of fluid is not reduced over a 24-hour period.
Patients should be advised to eat a healthy, balanced diet with adequate fibre to prevent bowel dysfunction. The patient should be advised to respond to their natural reflexes, such as gastric colic reflex, and to try to empty their bowels 30 minutes after a meal. The patient should be provided with guidance on the correct sitting position on the toilet to ensure effective evacuation and on the use of the brace and bulge breathing technique.
Pelvic floor rehabilitation (including bladder/bowel retraining) under the guidance of a competent health professional will improve both bladder and bowel urgency and leakage. It is important to encourage individual programmes and monitor progress.
Medications
Medication may also be used to treat bladder and bowel symptoms. For example, antimuscarinics/anticholinergics, such as darifenacin, oxybutynin, solifenacin, tolteradine, fesoterodine, trospium and mirabegron, may be used to prevent spasms of the bladder and assist in reducing urgency and frequency. However, they are not suitable for all patients and should be used sparingly in the older person (Bladder and Bowel Community, 2021).
Medication used to relieve constipation and overflow faecal incontinence includes different types of laxatives, such as bulk-forming agents (ispaghula, methycellulose, sterculia), which are available in powder, granule or tablet form and used with patients with mild symptoms (RCN, 2019).
Stimulants, such as bisacodyl, senna and sodium picosulphate, are drugs that enhance colonic activity and mucus secretion. They usually work within 8–12 hours of taking them and aim to improve stool frequency and consistency.
Osmotic laxatives, such as lactulose, act by retaining fluid in the bowel by osmosis and help soften stool. These agents may take up to 48 hours to act and should be given with plenty of water. Macrogol, when mixed with water and drunk in solution, remains in the colon via osmotic action. This increases colonic peristalsis, and the increase in stool volume promotes defaecation.
Some of these preparations are licensed to treat faecal impaction.
Rectal preparations
Rectal preparations, including suppositories and enemas, may be used in the following cases (RCN, 2019):
- When oral laxatives are insufficient/ineffective/or the patient is unable to take
- For chronic conditions, when normal bowel emptying is disrupted
- To create a timed bowel movement to prevent faecal incontinence.
If these treatments fail, transanal irrigation (TAI) may be an option to consider (Yates, 2019). However, professionals need to be aware of the range of devices available to undertake the procedure, how they are used and what type would be of benefit in addressing an individual's bowel problem (Yates, 2019).
Catheterisation
Many people with MS will be required to undertake intermittent catheterisation as a method of emptying the bladder to address voiding and post-micturition bladder symptoms (Bladder and Bowel Community, 2021).
This can be carried out either by the individual or by a carer trained in the procedure. Frequency will depend on presenting symptoms and residual bladder volume, and can vary from once daily to 5-6 times in 24 hours.
If the patient is unable to perform intermittent catheterisation or no carer is available, an indwelling catheter may be the only clinical option available. This could be either a urethral catheter or, if the patient has been assessed for long-term use, a suprapubic catheter may be more appropriate.
Management products
Management products may be required even if treatment methods have been instigated. Products come in a variety of forms and include a range of pad products and pants, which are available for both urinary and faecal leakage. These may be available via the local continence/bladder and bowel home delivery service or purchased by patients themselves.
Commodes and urinals come in various shapes and may be used if a patient's mobility or access to a toilet are an issue. Men with MS may have access to urinary sheaths or pubic pressure devices to assist with bladder leakage, and these are available on prescription. To manage faecal leakage, there are devices such as anal plugs which are available either on prescription or patients can purchase themselves.
Conclusion
Patients will encounter health professionals who will not be knowledgeable in MS and the symptoms of bladder/bowel dysfunction that are associated with the condition. It is vital that they understand how MS affects the bladder and bowel, and that they are aware of the treatments/management options available that can improve the presenting factors.
Patients with MS must be reviewed on a regular basis because presentation of the disease can alter, meaning that treatments must be adjusted to reflect the current presentation. MS is a complex disease, and bladder and bowel dysfunction are prevalent within the condition. It is important that professionals are aware of this in order to offer patients appropriate treatment.
‘Management products may be required even if treatment methods have been instigated. Products come in a variety of forms and include a range of pad products and pants, which are available for both urinary and faecal leakage’