UTIs: The Bladder and MS

Why do women with MS get so many bladder infections, and what can

they do about it?


MS Insight’s fascinating new video, titled “Urinary Tract Infections:

The Bladder and MS,” provides answers from several experts. Although

this can be a sensitive area to discuss, it’s a major issue for many

women. Incontinence can be terribly isolating and dramatically change

women’s quality of life. And due to anatomical differences, women are

more prone to UTIs than men.


Anna Wechta, who holds a B.S. in nursing and is Clinical Research

Coordinator in Female Urology at the University of Pittsburgh Medical

Center (UPMC), furnished some key insights on the video. Wechta has

extensive experience in nursing, including five years in female urology.

Shirley Nedzesky, an MS Insight volunteer, is one of Wechta’s patients

and talked about her own personal experience with UTI.


Wechta made the following points:


- Urine retention. If you retain urine when you void—from MS or

any other underlying cause—you’re more likely to get UTIs. If

you hold onto urine that should be expelled, “it’s a perfect place

for bacterial proliferation—warm, dark and moist,” explained

Wechta.


- Cathing and bacterial colonization. If you’re not cathing well

enough to empty your bladder completely several times a day,

you’re leaving urine there, which creates a perfect opportunity

for a colony of bacteria to grow.


- The bladder is not perfectly round like a balloon. Due to age

and underlying disease, the bladder can have little pockets and

divots. So Wechta and her team recommend teaching women to

place a catheter both to the right and left and reposition it to “get

as empty as you can each time.” She explained: “Pull the catheter

back and slowly you may hit another pocket of urine which needs

to be emptied.”


- Prevalence of overactive—versus underactive--bladder in

women with MS. For underactive bladders, which have ceased

to function, the only therapy is an artificial empty bladder, said

Wechta. Incontinence due to an overactive bladder is the main

complaint which brings women into the urology clinic. Wechta

said there are two types:


- “urge” incontinence, where urine leaks right out of you.

Typically managed with oral medications, but can

sometimes be solved surgically;

- “stress” or “mixed” incontinence, which is leakage caused

by running, jumping, laughing, etc. and is often an affliction

of younger women who have had children.


- Bladder Botox as treatment. If women fail to respond to two or

three oral medications for overactive bladder, the preferred

treatment is bladder Botox injections. These are tiny injections

(10 to 30, depending on the dose) into the bladder wall. This

creates a lot of relief. “It calms the overactivity of the bladder,”

explained Wechta. Generally, treatments are done every 6 to 9

months. However, for some women, Botox makes the bladder too

calm, so they have to cath for a period of time until the botox

wears off. For people with MS, the course of treatment will

depend on where they are in the disease progression. As

symptoms worsen, treatment moves from oral medication to

advanced therapies, one of which is Botox, said Wechta.


- Super-pubic catheter. For patients who are unable to use a

catheter four or five times a day, there is a super-pubic catheter

which serves as a passive drain for the bladder.


- Incontinence is a major problem for women 70 and

older—whether they have MS or not. Many older women have

“urge” incontinence and bladder weakening as they age. Oral

agents help with that. Some elect to use bladder Botox.


- Isolation is a major problem with this condition. Many feel

women like they can’t go out, be with friends or travel, said

Wechta. They tell her: “’Everywhere I go, I know every bathroom

available in this particular place.’” They have a hyper-focus on

that. Still others can’t go out, even with bladder Botox. Dr.

Jonathan Merril, M.D., Director of Education at MS Insight and

moderator of the discussion, pointed out that UTIs can be very

isolating and debilitating for women with MS, because their

doctor typically does not focus on that during an exam, and

instead is focused on the progression of the patient’s MS.


- If you think you have a UTI, get a culture from a lab. The

reason, explained Wechta, is medical practitioners want to know

what bacteria the culprit and which antibiotic is might be

resistant to it.


- A PVR (Post-Void Residual) is an important test. Clinicians

scan the bladder. They often find, to the patient’s surprise, that

their bladder is partially full. Because of underlying neurological

symptoms, patients may have decreased awareness of bladder

symptoms. “People are shocked. You feel like you’re empty, but

you’re not,” explained Wechta. “It’s a perfect area for bacteria to

grow and proliferate.”


- Keep a void-cath diary. You can do this at home. Sit down and

void and measure; immediately cath; then measure the post-void

residual. For example, you void and get 50 cc’s, then you

immediately cath and get 300 or 400. That means your bladder is

not doing a very good job of emptying. Conversely, if you void

300 and cath for 50, your bladder is doing very well.


- Other treatments for persistent UTIs. Wechta said a select

group of patients “can’t shake UTIs,” no matter what treatments

they try. So, a cranberry supplement called Ellura is

recommended. It’s scientifically tested and shown to be effective.

She also recommended using Gentamicin solutions in the end of

your catheter. It stays in your bladder and doesn’t travel around

the body. Shirley Nedzesky said she used it and it resembled a

“turkey baster.”


- Women get more UTIs than men due to anatomical

differences. The urethra is quite short in women, so not far for

bacteria to travel.


- Rural areas tend to be underserved. Wechta said some patients

drive 4 hours to Pittsburgh to get treatment at their clinic. Merril

said he hoped MS Insight’s videos would provide a national

platform for MS patients to learn about beneficial new treatments.


BENEFITS OF PHYSICAL THERAPY


Sue Kushner, who holds a doctorate of physical therapy (DPT) and

works as a physical therapist with a number of MS patients in

Pittsburgh, was another speaker in the video.


“Many people do not know physical therapists can assist with these

problems,” she noted. Physical therapists (PTs) are highly trained to

work with pelvic floor exercises, do manipulations and assist with

strengthening for women with MS who have incontinence problems.


Kushner advised finding relevant PTs through your local MS Society, PT

Support Group or friends. “They can change your world,” she said.

Physical therapists can work with patients one-on-one and prescribe

different exercises to do at home. Kushner concurred with the other

speakers that incontinence was very isolating for patients, who feel they

can’t exercise, go to a movie or go on a date.


Shirley Nedzesky, who has utilized PT for her UTIs, recommended that

physical therapists explain to women what the procedure is beforehand,

so they’ll know what to expect.


Nedzesky is a 6 th -grade teacher who said that she used to suffer

embarrassing incontinence—an urgent need to urinate that would

cause her to wet herself in class and conceal it from students. She

wouldn’t drink enough water to prevent herself from urinating and this

would lead to dehydration—a treacherous cycle. If she drank too much

water before bed, she would “pee all night.”


“I used to have two beers at night, but if I took a sip of beer before

bed, I had to run to the bathroom,” she recounted.


But then she tried bladder Botox and had excellent results.

Wechta stressed that women need to continue to do exercises at

home, taught to them by a pelvic floor therapist. Internal myofascial

release is key to getting those muscles to relax. It’s similar to a

massage, she explained. A therapist will insert a gloved hand into a

woman’s vagina and put pressure on these muscles until they release, if

women have spastic pelvic floors.


EXERCISE IS KEY


Wendy Booker, another speaker, is a celebrated author, speaker and

advocate on the global MS community, who has relapsing remitting MS.

She is an active athlete who has climbed mountains and run marathons.

Booker said bladder issues are the biggest reason that a lot of MS

athletes stop participating in events. If you like to run or go on long

walks, she recommended knowing where all the porta potties are, or the

woods or other area where you can take discreetly relieve yourself.

“Dehydration is a serious topic,” she added. “MS athletes need to have

water or a sports drink.” Booker said this was the number one topic in

MS chat groups.


Merril noted that 20 years ago, doctors recommended that MS patients

not exercise because of muscle spasticity—but in recent years, exercise

has been shown to slow down the disease progression and is

recommended by clinicians.


Booker recommended choosing a sport you love and sticking with it.

She and members of her running group wear large shirts tied around

their waists. If they have an accident while running, they use the large

shirt to conceal it.


Kushner said that in her Can Do Workshops for MS patients, women do

exercises using a big ball, laugh and play like children. “They have a ball,

literally and figuratively,” she said.


The final speaker was Mindy Eisenberg, an expert in Mindfulness

Based Stress Reduction (MSRB). She advised MS patients to get to know

their bodies and empower themselves. Finding an exercise buddy or a

walking buddy could be a great start.


“Find movement—whatever it is,” summarized Booker. “Find the joy.

Then go back to it.”

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