​Here is My Question:
I am working through these thoughts and would appreciate any expert opinion/explanation that might be shared. The questions is based on the premise that 80% of people with MS experience some form of bladder/bowel dysfunction. Thanks for any insight you can share.

As 80% of people with MS have these Bowel and Bladder issues it would be expected that the same effected area could be identified on a MRI scan on whatever machine is used and for all the 80% of people scanned.

Do 80% of MSer’s have lesions on the spine at the same position? Does any research identify the reason why an attack on that nerve in the spine for 80% of people with MS, occurs? 

If the bladder and bowel are controlled in the frontal lobe of the brain, it appears unlikely that MSer’s would have lesion activity in that particular location. I believe lesions are generally not found in the lower section of the thoracic and lumbar spine where you would expect activity would affect bowel and bladder function.

The spinal cord at C3, C4, C5 has 31 pairs of nerves. What are the chances that lesions in 80% of people with MS affects the bowel and bladder function?

What is the commonality among people with MS that causes so many to have this problem?


​Answer:
​These are excellent questions on bladder control and relatively easy to answer.

It helps to understand that the control of urine and fecal storage and elimination (i.e. bladder and bowel control) is an essential function involving large areas of the central and peripheral nervous system stretching from the most anterior part of your frontal lobes to the very end of your spinal cord and the plexus of nerves that supply the organs of elimination. This provides a very large territory for any potential neurological disease to cause problems with elimination. This is one of the reasons why almost any multifocal neurological disease can, and often dose, cause problems with elimination control at some point in the illness. This is particular true of diseases like MS that create demyelination and axon loss in white matter tracts involved in the control of bladder function. In fact there is a fairly good correlation between involvement of the spinal cord or brainstem pathologically by MS and symptoms of bladder dysfunction;  both occurring, as you mentioned, in about 80 % of patients.

However, many of the neural pathways that control urination are in regions of the brainstem and spinal cord that are difficult to see on standard imaging techniques; this is due to the location of these pathways in or near the gray matter of the cord or cerebral aqueduct and fourth ventricle of the brainstem or the lower parts of the spinal cord, all areas more difficult to image on MRI. We also know that very small lesions, below the resolution of imaging, can create bladder symptoms because some of the important pathways are small and condensed. Lastly is far more common for bladder problems to occur with bilateral involvement of the spinal cord or brainstem but this bilateral involvement does not need to occur at the same level or location.

There is no single or common location for lesions to cause bladder symptoms and the urination symptoms created are the same (usually urinary urgency and hesitancy with variable amount of incontinence) regardless of the location of lesion anywhere between the brainstem and the sacral spinal cord.

I hope this helps.

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
Professor of Clinical Neurosciences
University of California San Diego

 Question:
Is insomnia a common issue with MS patients? I can't sleep to save my soul at night. Also, how common is bowel incontinence? Seem to have "troubles" at night when I can sleep. Not sure what to do about it?

Answer:
We written a great deal on insomnia in MS. Please try our search engine (upper right corner of this page) to look for prior blogs and answers to user questions on this issue. Just search for sleep problems or insomnia. This will help you get started on addressing this issue. You will need to have your doctor or a sleep specialist take a good sleep history and possibly do some diagnostic studies to determine the main cause of your insomnia. http://www.healthcarejourney.com/apps/search?q=sleep

Bowel incontinence is far less common that urinary incontinence in MS and tends to occur in more disabled patients. You need to see you doctor for a good history and exam that includes a rectal exam. Occasionally, your doctor will need to send you to a gastroenterologist who specializes in gastric motility problems. http://www.healthcarejourney.com/bowel-dysfunction.html

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Question:
Are MS patients good candidates for interstim bladder pacemakers? My new gynecologist wonders why my urologist never recommended this to me. 

Answer:
In general the bladder stimulators have been helpful to many MS patients, but a large number have reported a ‘wearing off’ of the benefit over two years. Thus, several urologists have cut back on using them.

Benjamin M. Greenberg, MD, MHS
Director, Transverse Myelitis, Neuromyelitis Optica and Pediatric Demyelinating Disease Programs
Director, Neurosciences Clinical Research Center
UT Southwestern Medical Center
Childrens Medical Center
Dallas, Texas

Question:
To my absolute horror I had bowel incontinence twice in the last week. I have suffered from IBS for many years. I am 71 and functional with no aids. Is this the beginning of a new MS symptom? Super scary. Suddenly in the middle of a walk, no control.

Answer:
Bowel dysfunction due to MS tends to manifest mainly as constipation, but some can also experience fecal incontinence (accidents).  When a scar of MS involves the part of the nervous system that helps coordinate signaling to the bowels to evacuate (located primarily in the spinal cord--especially the lowest segment), these bowel symptoms emerge.  Other contributors to bowel problems that are related to MS include:  immobility or sedentary lifestyle, dehydration (ie, avoiding liquids because of bladder problems), poor dietary intake of fiber, and the acknowledgement that many different medications prescribed to treat other MS symptoms can cause bowel dysfunction as a side effect.  All the more reason to review your symptoms with the MS specialist.

Here is a blog I wrote that goes into further detail as well as management strategies. Hope this helps.

http://www.healthcarejourney.com/q--a-for-virtual-ms-center/bowel-problems-and-ms

A. Scott Nielsen MD MMSc
Virginia Mason Multiple Sclerosis Center

#bowelincontinence #multiplesclerosis

Here is My Question:
With my MS I have frequent bouts of irritable bowel syndrome and it causes interference with daily abilities, sometimes by making frequent trips to bathroom. What I am wondering is how do I decide if it is the irritable bowel syndrome or MS related?! I know there are bowel problems with MS but not fully educated on the symptoms and what not. I do avoid eating red meat and other foods that can trigger it.... but it seems to be more occasional lately.

Answer:
This is a great question and one that I think many patients with MS have on their mind when they see their neurologist, but may be too embarrassed to bring up at the clinic visit.  

Bowel symptoms are fairly common in MS and can lead to social isolation and to other health problems.  There are many potential causes of bowel dysfunction and it is important to make the doctor aware of the issue so it can be properly evaluated and addressed.  This is an expansive topic, and one that is impossible to fully answer in a blog post; however, I'll outline general principles about the symptoms of these conditions as well as initial steps a patient with MS can take to try and alleviate the problem.

Irritable bowel syndrome (IBS) is a functional bowel problem which means that extensive medical evaluation cannot identify another cause for abdominal discomfort, pain, and variable symptoms of diarrhea/constipation.  IBS is a prevalent condition in the general population and tends to affect younger patients and preferentially affects women more than men (similar demographic as MS), which makes the co-occurrence of these diseases common.  

Bowel dysfunction due to MS tends to manifest mainly as constipation, but some can also experience fecal incontinence (accidents).  When a scar of MS involves the part of the nervous system that helps coordinate signaling to the bowels to evacuate (located primarily in the spinal cord--especially the lowest segment), these bowel symptoms emerge.  Other contributors to bowel problems that are related to MS include:  immobility or sedentary lifestyle, dehydration (ie, avoiding liquids because of bladder problems), poor dietary intake of fiber, and the acknowledgement that many different medications prescribed to treat other MS symptoms can cause bowel dysfunction as a side effect.  All the more reason to review your symptoms with the MS specialist.

For patients primarily experiencing constipation who are mobile and able to walk, general strategies include increasing fiber in the diet (men= 30 to 40 grams/day and women=21 to 25 grams/day), keep well hydrated (while avoiding caffeine and sugary alcohol), and establish a consistent exercise routine (check with your doctor first about exercise).  Implementing this strategy is generally effective but should be done with patience because it can take a few weeks for the bowels to respond.  If this does not improve bowel function, or you are not mobile, then the next step would be to set up an appointment with your MS specialist to specifically discuss the problem.  Depending on how problematic your symptoms are, you may want to alert the doctor early on in the visit that this is your main problem (and other problems may need to take a back seat or be addressed at a future clinic visit).  

Occasionally, these symptoms are more difficult to manage with conservative strategies alone or your symptoms may suggest another problem other than MS that requires the help of a gastroenterologist (digestive system expert).  The gastroenterologist can evaluate for inflammatory bowel diseases (which are seen in patients with MS more often than the general population), food allergies, and infections of the digestive tract which cause bowel symptoms as well.

If you go see your doctor about bowel problems, you may want to print up this article published in the International Journal of MS Care (CLICK HERE TO DOWNLOAD) and take it with you to the appointment or provide it to your physician in advance so they can review it ahead of time.  This article is a good reference for the doctor to help facilitate a productive clinic visit.

I hope this helps.

ASN