Multiple Sclerosis is characterized by a number of different symptoms ranging from mild sensory symptoms such as tingling, burning and itching to major symptoms such as weakness, paralysis, and bladder and bowel control. Learning how to live with these symptoms is an important part of managing the condition and living an active life with MS.

Many people with MS experience bladder control issues due to problems with the muscles that help hold or release urine. Urinary incontinence in among the most common types of bladder control conditions. Incontinence effects women two times more often than men and is treatable.

Urinary incontinence refers to the involuntary passage of urine, or loss of bladder control. The body stores urine in the bladder, which is a balloon-like organ. Urine leaves the body through the urethra, a tube connected to the bladder. During urination, bladder muscles contract, forcing urine into the urethra. Urine flows out of the body when the sphincter muscles surrounding the urethra relax. Incontinence occurs when the bladder muscles contract suddenly or when the urethra muscles relax suddenly.

People who experience incontinence when they laugh, sneeze, cough or perform other movements that put pressure on the bladder are experiencing "stress incontinence." Physical changes such as pregnancy and childbirth can lead to stress incontinence. Stress incontinence occurs due to the weakening of pelvic floor muscles that support the bladder. When weakened, the bladder tends to move down preventing the muscles that shut the urethra from squeezing as tight as they should. The week before a woman’s menstrual cycle can also lead to stress incontinence due to lowered estrogen levels which in turn lowers muscle pressure around the urethra causing leakage.

"Urge incontinence" is marked by the loss of urine while suddenly feeling the need to urinate. This is caused by inappropriate bladder contractions. Urge incontinence is also referred to as "spastic bladder", "unstable bladder", or "overactive bladder." People who experience urge incontinence can lose urine during sleep, after drinking a small amount of water, when they touch water or when they hear water running. These involuntary actions of the bladder muscles occur due to damage to the nerves of the bladder, to the nervous system or to the bladder muscles themselves. MS patients are especially susceptible, as are people who have Parkinson’s disease and Alzheimer’s disease.

Urinary incontinence can be treated with exercises called Kegel exercises. These strengthen the pelvic floor muscles and sphincter muscles and take just a few minutes a day. A health care professional can teach these exercises. Electrical stimulation works in the same way as exercises by strengthening the muscles in the lower pelvis. Electrodes placed in the vagina or rectum stimulate the muscles and can correct stress incontinence and urge incontinence.

Biofeedback and timed voiding or bladder training are treatments that work together. Biofeedback involves the use of electrical measuring devices to track when bladder and urethral muscles contract, allowing the patient to gain better control. Timed voiding and bladder training (also known as muscle conditioning) rely on biodfeedback. During timed voiding, a patient fills in a chart of voiding and leaking episodes. Patterns indicate when a patient should empty the bladder to avoid incontinence. Biofeedback and bladder training are used to alter the bladder’s schedule for storing and eliminating urine.

Medications can be effective in treating incontinence. Medications can work by inhibiting the contractions of an overactive bladder or by relaxing the muscles allowing for complete bladder emptying during urination. Other medications work by tightening the muscles at the bladder neck or urethra, preventing leakage. Some medications have proved to have side effects when used over a long period of time. Patients should be aware of the risks and long-term effects of medications for incontinence.

All incontinence conditions are treatable. While many patients find urinary incontinence embarrassing, overcoming the embarrassment and talking to a healthcare provider is the first step in solving the problems.

PARIS, FRANCE -- July 2, 2001 -- Results of two studies evaluating the safety and efficacy of extended-release oxybutynin (Ditropan XL) to treat overactive bladder in patients with spinal cord injury (SCI) and multiple sclerosis (MS) were presented today at the World Health Organization Second International Consultation on Incontinence in Paris, France.

Michael B. Chancellor, M.D., professor of urology and director of neuro-urology at the University of Pittsburgh Medical Center, served as author and lead investigator for the studies.

These are the first reported results of the drug's efficacy in MS and SCI patients. "Results of these studies show that extended-release oxybutynin can safely and effectively treat patients diagnosed with MS or SCI that experience symptoms of overactive bladder or neurogenic bladder," said Dr. Chancellor. "Through these studies physicians should be encouraged that treating overactive bladder as a secondary condition is an effective measure in improving quality of life for these patients."

Conditions in which the bladder becomes overactive due to lesions on the nervous system, or due to damage to the nervous system are referred to as neurogenic bladder. Extended release oxybutynin is one of the leading medications for overactive bladder, reducing incontinence episodes and frequency of urination, with minimal side effects. Both studies were conducted by researchers at the University of Pittsburgh Medical Center and led by Dr. Michael Chancellor.

Dr. Chancellor, et. al., presented data on an investigational study designed to evaluate the effectiveness of extended-release oxybutynin, inpatients who experienced detrusor hyperrerflexia (DH) or overactive bladder and had some type of SCI.

It was found that up to 30mg of extended-release oxybutynin greatly reduced their frequency of urination or catheterization by an average of two episodes per day. "Patients who are diagnosed with SCI already have difficult challenges in every day life," said Dr. Chancellor. "By treating their overactive bladder symptoms effectively with extended-release oxybutynin, we are allowing them increased freedom, as catheterization and trips to the bathroom decrease."

The results were based on an ongoing 12-week study in which 14 patients with complete or incomplete SCI were enrolled. Eighty percent of the patients were women and the mean age of the patients was approximately 38 years.

The dosing was initiated at 10 milligrams of extended-release oxybutynin per day, and was adjusted weekly by five milligrams, up to 30 milligrams per day. All 4 patients had a dosing regimen over 10 milligrams per day, with six patients using 30 milligrams per day. At one week, a decrease of two voids or catheterizations per day was recorded.

No patients experienced serious adverse events during the study, nor was there a relationship between dosing quantity and severity of side effects, such as dry mouth.

Results of a study involving 40 adult MS patients with neurogenic bladder and a mean age of approximately 43 years indicated that high doses of extended-release oxybutynin can greatly reduce frequency of urination and incontinence episodes in patients with MS. "This study demonstrates that extended-release oxybutynin is safe and effective in decreasing frequency of urination and incontinence episodes, without significantly increasing residual urine volume," said Dr. Chancellor." This is important to MS patients as not only does this treatment increase their quality of life but it does so without compromising their overall bladder health, as increased volume could lead to urinary infections."

In the 12-week study, patients were started with 10 milligrams per day of extended-release oxybutynin. Dosing was increased weekly by five milligrams, up to 30 milligrams per day. More than 80 percent of patients had a final dosing regimen of over 10 milligrams per day, with 20 percent at 30 milligrams per day. At one week, a decrease of two voids or catheterizations per day was recorded.

No patient experienced serious adverse events during the study, nor was there a relationship between dosing quantity and severity of side effects such as dry mouth.

The medical condition known as overactive bladder affects approximately 17 million Americans, making it more prevalent than many commonly discussed conditions, such as diabetes (seven million) and Alzheimer's disease (four million). With symptoms of urinary urge incontinence, involuntary loss of bladder control; urgency, urgent need to urinate; and micturition frequency, urinating more than eight times a day, overactive bladder is one of the most under-diagnosed and under-treated conditions in the United States.

SOURCE: ALZA Pharmaceuticals

Botulinum Toxin Improves Urinary Continence in Multiple Sclerosis Patients with Overactive Bladder

By Ed Susman
Special to DG News

ORLANDO, FL -- May 28, 2002 -- Botulinum toxin injection appears to return bladder control to patients with urinary incontinence secondary to multiple sclerosis, according to researchers.

"Botulinum toxin injections are an effective and promising treatment for patients with incontinence due to problems in controlling their bladder," said Michael Chancellor, MD, professor of urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. He presented the results of two studies here Monday at the 97^th annual meeting of the American Urological Association (AUA).

Dr. Chancellor described his use of botulinum toxin-commonly known as Botox-in 25 patients with multiple sclerosis and 50 patients with overactive bladder. He said patients with multiple sclerosis frequently suffer urinary problems because nerve damage caused by the disease prevents signals from reaching the external sphincter muscle. Injection of botulinum relaxed the external sphincter, and the internal sphincter at the neck of the bladder prevented unwanted leakage of urine.

For patients with overactive bladder, Dr. Chancellor located the bladder through a fiber optic scope and injected the bladder with 100 to 300 units of botulinum toxin, which calmed the bladder spasms.

"People with these conditions have to wear diapers[or] are fitted with catheters and urine bags," he said. "Some of these people are almost hopeless."

Dr. Chancellor said about two-thirds of the study patients experienced enough relief to discard their catheters and diapers, and many were able to discontinue medicine used to control overactive bladder.

The injections are effective for about six months, but the treatments are not curative and must be repeated.

"I haven't seen any unwanted side effects with the treatment," he said.

"The use of botulinum for treating overactive bladder sounds reasonable," said Thomas Brady, MD, head of the AUA's media committee and a faculty member at the University of Nevada, Reno. "The treatment is quite feasible as well. We can get needles into the bladder to make all kinds of injections, so this would not require any greater amount of expertise that doctors already have."

Dr. Chancellor said the downside of the treatment is its cost. A vial of botulinum toxin costs about $400 for 100 units of the drug. A single bladder procedure can use one to three vials. And while the treatment may be the only thing that works for these patients, insurance companies often will not pay for the injections because botulinum toxin does not have FDA approval for this indication.

Dr. Chancellor said he has urged the manufacturers of botulinum toxin to fund a study to prove its worth as a treatment for incontinence, but so far the companies have not responded favorably.

The studies were institutionally sponsored.