Bladder problems


Bladder problems can include needing the toilet urgently and frequently, having difficulty emptying your bladder, and bladder accidents. 

There's a range of effective treatments available for these bladder issues. Straightforward lifestyle changes can make a real difference too. Depending on your symptoms, treatment options may include medication, using a catheter and lifestyle changes.

What are bladder problems?

Bladder problems can be divided into two types; those relating to the storage of urine and those relating to the emptying of urine. Some people experience a combination of these symptoms.

Problems storing your urine (urgency and frequency) Storage problems can cause you to feel a sudden urge to go to the toilet (urgency) and to need the toilet very often (frequency). This can happen during the day and at night (nocturia). Bladder accidents (urinary incontinence) may also happen where bladder control is lost and urine leaks out.

Problems emptying your bladder (hesitancy, intermittency and retention) – Emptying problems can result in symptoms such as your urine flow being slow or interrupted (intermittency), it taking longer than normal to start passing urine (hesitancy), and feeling like your bladder hasn't completely emptied (retention).

If you're experiencing any of the bladder problems listed below, it might be time to contact a health professional for some help and support.

  • You're having bladder accidents, and you avoid important activities because of this.
  • You often feel an urgent need to urinate, but sometimes don't make it to the toilet in time.
  • You go to the toilet much more often than you used to, during the day and/or at night.
  • Going to the toilet is painful or your urine has an unusual smell.
  • You feel the need to urinate, but you're unable to.
  • You notice your urine stream is getting weaker, or you feel as if you haven't fully emptied your bladder.
  • You notice a red or brown tinge to your urine, or on toilet paper after wiping.

You may feel embarrassed or uncomfortable talking about bladder problems, but your health professionals will have lots of experience talking about these kinds of symptoms. 

With the right information and support, the majority of bladder problems can be successfully managed so they no longer impact, or have as much impact, on your daily life.

How common are they in MS?

Bladder issues are common in multiple sclerosis. It's thought around 75 in 100 people with MS experience them.

How are bladder symptoms diagnosed?

When you see your health professional they will take a full history of your symptoms and they might ask you to keep a detailed bladder diary for a short period of time. As different types of bladder problems are treated differently, health professionals need to find out the cause of your bladder problems so they can find the most appropriate treatment options for you. This will usually involve the following investigations.

  • Urine test – Your health professional may ask for a sample of your urine so they can test it for any infection – this is sometimes called a dipstick test. A small, chemically treated stick is dipped into your urine sample. If bacteria are present, it will change colour, indicating you may have a urinary tract infection (UTI).
  • Bladder ultrasound – The amount of urine left in your bladder after urinating will be measured. This is carried out with an ultrasound scanner which is applied to your lower abdomen and gently moved over the skin. This creates an image of your bladder and shows how much fluid is left inside. If there is less than 100ml left after your bladder has been emptied, then symptoms are more likely to be due to problems storing urine. If more than 100ml remains after emptying, then the symptoms are likely to be due to problems with emptying the bladder.

What causes bladder problems?

MS can cause nerve damage in the areas of your brain and spinal cord that play a part in controlling your bladder function and the symptoms you experience will depend on which areas have been affected.

Causes of storage problems

Problems storing urine (urgency and frequency) happen because messages are interrupted between the bladder emptying reflex in your spinal cord and the part of your brain that has control over when you empty your bladder. This can result in the reflexes telling the bladder muscle to contract as soon as it starts filling. The bladder can become overactive and spasm or tighten unpredictably, resulting in an immediate or frequent urge to go. This is also known as overactive bladder (OAB).

I feel as though my bladder has a life of its own.

Causes of emptying problems

Difficulties emptying your bladder (hesitancy, intermittency and retention) can have several possible causes. The area of your spinal cord that controls the bladder emptying reflex may be damaged by your MS. As there is no signal to urinate, your bladder becomes very full but you're unaware of how full it is, so leakage of urine may occur. Sometimes messages from the brain are confused, so when your bladder muscle contracts to start emptying, the valve which allows urine out of the bladder (the urethral sphincter) closes at the same time. This can block or interrupt the bladder's attempts to empty. For some people, MS damage can cause the bladder muscle to stop contracting before the bladder has been properly emptied, causing retention.

I can be absolutely desperate to go to the loo and once I get there - I can't go!

For some people, these symptoms may also be combined with feelings of needing to find a toilet quickly and often. This can lead to bladder accidents despite earlier efforts to empty the bladder.

Not all bladder issues are caused by MS nerve damage. Other causes include:

  • enlarged prostate in men
  • pregnancy and childbirth
  • fibroids (non-cancerous growths) in the womb
  • a vaginal prolapse (where pelvic organs drop because of weakened pelvic floor muscles)
  • infection in the urinary tract (the kidneys, ureters, bladder and/or urethra)
  • abdominal surgery
  • caffeine and alcohol consumption.

What can I do if I have bladder problems?

Speaking to a health professional – such as your MS nurse, GP or a bladder and bowel team – is an important first step in getting the right treatment for bladder problems. Alongside this, lifestyle changes can make a real difference.

Make lifestyle changes

Keep a bladder diary

A symptom diary gives you an overview of how your bladder problems affect you over time. You can share it with your health professionals to show them what your bladder patterns are. You could keep notes in a notebook or on your phone. Alternatively, there are apps available to help you monitor your bladder function. Make a note of what you eat and drink, and any medication you take. Keep track of when you go to the loo, any problems (such as urgency, frequency, hesitancy or retention), and whether you have any accidents. If you make any lifestyle changes (eg, reducing your caffeine intake) the diary can help you monitor how these changes affect your bladder.

Drink enough fluids

If you don't drink enough fluids and become dehydrated, your urine becomes more concentrated. This can irritate the bladder and create a good environment for infection. The general guidance is to drink at least 1.5 litres of fluid in 24 hours, or about six to eight glasses. Your urine should be pale or straw coloured. On the other hand, drinking too much can make bladder symptoms worse, increasing the number of visits to the toilet and the urgency to urinate, so getting the right balance is important.

Avoid food and drink that irritates your bladder

Some food and drink can irritate the bladder. This includes drinks containing caffeine, alcohol, fizzy drinks, acidic fruit and juices and spicy food. Reducing or cutting these out completely can help with bladder symptoms.

Changing little things can make a big difference.

Maintain a healthy weight

Maintaining a healthy weight through regular exercise and a healthy, balanced diet is important. Being overweight can increase the pressure on your pelvic floor muscles. This can result in stress incontinencewhere urine leaks out of your bladder when it's under pressure. Common examples of this are leaking when sneezing, coughing, exercising or standing up.

Stop smoking

Nicotine in cigarettes can irritate the bladder. Reducing how often you smoke, or stopping smoking completely, may improve your symptoms.

Strengthen your pelvic floor

Your pelvic floor is a sheet, or hammock, of muscles that extends from your tailbone (coccyx) at the bottom of your spine, to your pubic bone at the front. They form the floor to your pelvis and support your bladder and bowel. Pelvic floor muscles relax at the same time as the bladder contracts to let your urine out. 

Pelvic floor exercises can help improve urinary incontinence in women and men. Find your pelvic floor muscles by trying to stop the flow of urine when you go to the toilet. Once you've felt these muscles, you can strengthen them by squeezing the muscles 10–15 times in a row. You can try holding the squeeze for longer as your muscles get stronger. It helps to do them multiple times a day.

There are apps you can use to build an exercise plan and remind you to do your pelvic floor exercises, such as NHS Squeezy.

More about your pelvic floor exercises from the NHS

Avoid constipation

A full bowel can obstruct the flow of urine or affect the capacity of your bladder, increasing the number of times you need to empty.

Try bladder training

The aim of bladder training is to teach your bladder to hold more urine and increase the amount of time between going to the toilet. You gradually increase the time between urinating by waiting when you feel the urge to go – this can be by just five minutes. It may take weeks or months to be effective. Your bladder specialist or MS specialist nurse can put together a timetable to support you to achieve this. They can also teach you techniques to distract you from the urgent sensation, helping delay your need to use the toilet.

An interview on bladder symptoms with consultant nurse in urogynaecology, Angie Rantell

How are bladder problems treated?

Treatments for needing the toilet urgently or frequently

Medication

Antimuscarinic drugs

You may be offered drugs that block the messages that start bladder contractions and reduce how often you need to empty your bladder – these are called antimuscarinic drugs. These drugs can also reduce sensations of urgently needing to reach the toilet. They may be taken orally as tablets or through skin patches. 

Some examples of antimuscarinics include:

  • oxybutynin (Ditropan, Cystrin and Kentera)
  • tolterodine (Detrusitol, Detrusitol XL)
  • solifenacin (Vesicare)
  • fesoterodine (Toviaz)
  • trospium chloride (Regurin, Flotros)
  • darifenacin (Emselex).

You may experience side effects from these drugs, although not everybody does. Antimuscarinics can cause dry mouth, constipation and blurred vision. They can also affect cognition, cause confusion and increase the risk of falls, particularly in older people. These side effects are known as the anticholinergic burden. Studies show that newer antimuscarinic drugs (such as solifenacin, tolterodine and fesoterodine) are associated with a lower risk of experiencing these side effects, so these tend to be preferred. For people with advanced MS, or where cognition is more of a concern, darifenacin and trospium chloride may be more suitable.

Mirabegron (Betmiga)

Mirabegron may be tried if antimuscarinics haven't been effective for you or if the side effects were too difficult to tolerate. It's taken orally as a tablet and works by relaxing your bladder muscle, allowing your bladder to fill and store urine more effectively.

Mirabegron can be used in combination with an antimuscarinic drug, or as an alternative.

Desmopressin

Desmopressin reduces the amount of urine the body produces. It's used to treat day and night time frequency. It may be offered to you if other drugs don't work well. It may be given as a nasal spray or tablets.

Botulinum toxin (Botox) injections

Botulinum toxin type A injections (Botox) are sometimes used if antimuscarinic treatments haven't been effective. They work by stopping nerve messages to your bladder muscle and freezing its contraction. This can improve urinary continence and significantly reduce symptoms of overactive bladder.

Botulinum toxin is injected into your bladder wall from the inside. The procedure is usually carried out under local anaesthetic. A fine tube, containing a very small telescope, is inserted into your bladder via the urethra. Then, around 20–30 injections are administered. The benefits generally last between 6 and 12 months, after which the procedure can be repeated.

Following treatment with Botox injections, your bladder may no longer be able to empty itself. You may, therefore, need to be prepared for the possibility of using a catheter.

Tibial nerve stimulation

If antimuscarinic medications haven't been effective and you don't want to try botulinum toxin, percutaneous tibial nerve stimulation (PTNS) may be offered. PTNS can also be used in combination with antimuscarinic medication.

The procedure involves having a small needed inserted near a nerve just above your ankle. A mild electric current is then passed through the needle. This relaxes the nerves in your lower back that control bladder function, reducing symptoms of overactive bladder.

You'll need at least 12 weekly sessions lasting 30 minutes each. Effects may not always last long after the sessions have stopped, so more sessions may be needed. But it's still a safe and effective treatment for some people.

Treatments for problems emptying your bladder

Catheters

If you have problems emptying your bladder, your health professional may suggest using a catheter. A urinary catheter is a thin, smooth, hollow tube that's used to drain urine from your bladder. There are a few different types of catheter available – intermittent, indwelling and suprapubic. They are all inserted and used in slightly different ways.

Read more about catheters

Using catheters means my bladder empties properly, and I get less of those awful water infections.

Suprapubic vibration

There is some limited evidence to suggest that a vibration device or buzzer, such as the Queen Square bladder stimulator, placed over the pubic area can help with bladder emptying. It's thought to work by helping the muscle at the bottom of the bladder (the urethral sphincter) to relax. This can improve emptying if hesitancy is a problem.

Find out more

References
National Institute for Health and Clinical Excellence.
Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease.
London: NICE; 2012. (Reviewed 2019)
Full guideline (link is external)
National Institute for Health and Clinical Excellence.
Percutaneous posterior tibial nerve stimulation for overactive bladder syndrome.
London: NICE; 2010.
Full guideline (link is external)
Thomas S, et al.
Expert opinion consensus document. Management of bladder dysfunction in people with multiple sclerosis.
London: British Journal of Nursing 2022; 31 (3 Suppl 3), S1–32.
Full article (link is external)
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Managing your bladder - book

Managing your bladder looks at why bladder problems can be part of MS and provides a practical approach to their management. It includes comments and tips from people with MS who know what it is like to live with bladder problems.