Why do women with MS get so many bladder infections, and what can
they do about it?
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.”