Neurogenic Bladder

+ Conservative Options - Timed voiding, Double Voiding and Avoiding Bladder Irritants

Management of bladder symptoms, especially overactivity or frequency, with conservative measure of timed voiding and double voiding is often successful.

Timed voiding is where the patient voids at specific hours of the day (for example every 2-3 hours) whether the sensation to void is there or not. The idea is that keeping the bladder relatively empty prevents leakage or over-acitvity that would otherwise only happen at high volumes.

Double voiding is where the patient voids then waits for several seconds to minutes then initiates the void again. The idea behind double voiding is, again, to keep the bladder empty and to drain any residual urine that may be left in the bladder

In addition ot using these techniques, avoiding bladder irritants such as caffeine, alcohol and spicy foods is useful.

+ Management of Constipation

Management of constipation is critical in controlling bladder symptoms. Many MS patients have problems with bowel controlling, principally constipation; however, diarrhea and fecal incontinence can also be common.

The mainstays of constipation management are appropriate fluid intake and fiber in the diet along with regular exercise. For the majority of patients, adhering to good fiber and fluid intake as well as a daily exercise regimen will keep them regular.

However, bowel that is affect by MS is often slow and adding fiber to an already full bowel can actually worsen the problem. As a result, using a stool softener such as Polyethylene glycol (PEG) such as Restorolax can clear the bowel and allow fiber to gradually be added back into the diet for regular bowel movements. Often starting at 1/2 or 1/4 of the recommended starting dose of Restorolax will allow MS patients to start the process of having more regular bowel movements.

A moderate dose of PEG for adults would be 17-34 grams per day.

One tablespoon has 15 grams of PEG.

One capful is 17 grams.

1 packet is 17 grams.

Recommended fiber intake for adults is 25-30 grams of fiber per day.

Bran Buds are a good source of fiber with 1/3 of a cup of cereal providing over 44% of the daily fiber.

Other fiber rich foods include beans, legumes, fruits and vegetables

+ Pelvic Floor Physiotherapy

Pelvic floor physiotherapy is a main-stay of therapy for urgency and frequency symptoms. Physiotherapists traing patients to control muscles in the pelvic floor. This helps with control of these bothersome symptoms and can aid in continence as well

+ Medications

Antimuscarinic agents can be used for patients that have bladder (detrussor) overactivity and are experience frequency, urgency and incontinence.

Successful use medications requires some input from you. The goal of medication is to improve your symptoms of urinary urgency, frequency and leakage while minimizing the side effects (mainly dry mouth, dry eyes and constipation). This requires picking the medication that has the best fit for you and making sure you are taking the right dose at the right time.

1. Picking the right strength. Most of the medications come in different strengths. You may increase the dose up to the maximum dose, but do not increase it beyond that with out consulting your urologist.
2. Regular vs. on-demand dosing. These medications generally work best if taken continuously, but there is no reason why you cannot take them 'on demand' - only when you need them. You may find that your symptoms are really only a problem when travelling or out at social events, for example, and manageable other times. You may take them only at these times.
3. Timing of dosing. Many of the medications are once-daily formulations. If so, they are usually best taken before bed to minimize side-effects. However, they may be taken at any time during the day.

4. Frequency of dosing. Most OAB medications are once-daily dosing so frequency is simple. There are 2 medications, however, where the frequency and amount can be varied significantly.

   1. Ditropan (oxybutyinin), however, is short acting and can be taken up to 3 times per day. Each pill is usually 5 mg and these can be easily split into 2.5 mg tablets since they are scored. The dosage you take should not exceed 15 mg per day (3 full pills) without discussion with a urologist. You may take any amount less than that at a frequency of your chosing. For example, the best dose for one person might be 5 mg three times per day. For another, it may be 2.5 mg twice daily. Others might do best with 5 mg first thing in the morning. Basically, you can mix whatever dose and frequency works best for you, so long as you do not exceed 15 mg per day. This may require some trial and error to find what works best.
   2. Oxytrol patch. This is a skin patch which is applied every 3-4 days. It can sometimes remain effective for up to 5 days. The patch can also be cut in half. Therefore, anywhere from 1/2 to a full patch can be used. In some circumstances, more than a full patch will be prescribed.

   Medication	Pill size	Usual dose	Maximum Daily Dose*
   Ditropan (oxybutyinin)	5 mg	2.5-5 mg tid	15 mg
   Ditropan XL	10 mg	10 mg daily	10 mg
   Uromax	15 mg	15 mg daily	15 mg
   Detrol LA (tolterodine)	2 mg, 4 mg	4 mg daily	4 mg
   Detrol (tolterodine)	2 mg	2 mg bid	4 mg
   Enablex (darifenacin)	7.5mg, 15mg	7.5mg daily	15 mg daily
   Vesicare (solifenacin)	5 mg, 10 mg	5 mg daily	10 mg daily
   Oxytrol patch	3.9 mg	3.9 mg every 3-4 days	3.9 mg every 3-4 days
   Sanctura (trospium)	20 mg	20 mg bid	40 mg daily
   Sanctura XR	60 mg	60 mg daily	60 mg daily
   Toviaz	4 mg, 8 mg	4-8 mg daily	8 mg daily

bid = twice daily; tid = three times per day; * do not exceed without consulting your physician

Mirabegron or Mybetriq is a medication known as a beta-agonist. It works slighly differently than the medications above; however, the goal is also to reduce bladder overactivity symptoms. The dosing for mirabegron is 25-50 mg daily.

If you find that a higher dose of a once daily medication works best for you and are taking 2 pills of the lower dose, make sure you let your doctor know since they can prescribe the higher dose as a single pill. The cost will be much less.

Most importantly, these medications are designed to help your symptoms. If the side-effects outweight the benefit, you may stop them after consulting your urologist. There are exceptions to this guideline - especially in those patients with neurogenic bladder (e.g. from stroke, spinal cord injury or other neurological conditions). In these cases, the medications may be necessary to maintain the health of your kidneys. As always, consult your urologist or family physician first.

+ BOTOX

Injection of Botox into the bladder wall is highly effective for treating certain types of over-active bladder symptoms. Generally reserved for patients who do not tolerate oral medication or have over-active symptoms despite taking these medications (i.e. medication failures).

The procedure can be done on an outpatient basis, usually taking no more than 5 minutes, is usually uncomplicated and are not associated with the most bothersome side-effects which anticholinergic medications are (dry mouth and constipation).

+ Neuromodulation/Posterior Tibial Nerve Stimulation

Posterior tibial nerve stimulation has shown good response in MS patients. Up to 85% of patients had improvement in urgency, frequency and incontinence with daily 20 mintue sessions of tibial nerve stimulation.

+ Clean Intermittent Catheterization (CIC)

For patients with a bladder that does not empty (i.e. a hypo or atonic bladder) often catheters are used to drain the bladder. Ideally a patient can learn how to place a catheter in the bladder themselves for drainage. The is called clean intermittent catheterization.

Alternately, a indwelling or suprapubic catheter can be used.