Here is My Question:
Can a persistent cough, especially at night, be a symptom of MS, and if so is there anything that can be done to treat it?

Answer:
Lesions in/near the area postrema (the area where the brainstem and spinal cord meet) can cause nausea, hiccups, and cough.  Such a symptom is unusual in MS and more common in rarer neurologic disease that can mimick MS.  When this part of the nervous system is affected, it can cause intractable symptoms throughout the day as well.

More common explanations for persistent coughing include certain medications (called ACE inhibitors), seasonal allergies, post-nasal drip, acid reflux disease, asthma, etc.  The cause of your symptom can't be diagnosed over a blog (requires a clinic evaluation and examination).  I would suggest speaking with your PCP first.  Treatment varies depending on the identified cause of your cough.

-ASN, MD

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

Here is My Question:
I haven't had feeling in my feet in over 9 years. Why is it that I get horrible foot cramps that clench my muscles up for several painful minutes when I do something as simple as apply pressure to a certain part of my upper thigh or even scratch an itch in my lower back?! Am I weird?

Answer:
You are not weird at all. Foot cramps and spasms can be caused my abnormal reflexes in your spinal cord that create spasms in the muscles of your feet (common in MS) or irritability of the muscles on the bottom of your feet (arch muscles) often spreading to your big toe. Foot cramps are very common even in people without MS. These can and often do occur even when an individual has no sensation in their feet. This is because the parts of your nervous system responsible for sensation (peripheral nerves and sensory pathways in the spinal cord) are separate from those areas responsible for cramping and spasms (muscles and motor pathways).

There are many causes and many treatments of cramps and spasms, so contact your doctor to get evaluated and find a solution.

-Rip Kinkel, MD

Question: 
I've been diagnosed with PPMS, why do my symptoms wax and wane or disappear and others take their place?

Answer: 
Primary progressive MS is differentiated from relapsing remitting MS by two clinical features:
1. The slow temporal course of symptom development
2. The lack of significant improvement

Both relapsing remitting and primary progressive MS patients experience fleeting symptoms that come and go or symptoms that worsen with certain activities, illnesses or even the time of day; these signify neither a relapse nor progression. I have written previous blogs that explain the reason for these symptoms that come and go. Please refer to these blogs for an explanation.

Let’s look at each of the characteristics that differentiate relapsing remitting and progressive MS more closely...

Relapses are the acute or subacute development of new symptoms or worsening of old symptoms without improvement over hours to days usually with corresponding findings on examination by a neurologist; 80% of patients reach their worst deficits within 2 weeks and more than 90% within one month. At times the symptoms are so dramatic in onset that a relapse can be confused with a stroke.

Symptoms and findings develop very slowly in primary progressive MS. They also tend to wax and wan considerably at the beginning but the overall pattern is one of continued worsening. The most typical symptom is a slowly developing abnormality in the way a person walks. One typical story we hear from patients and families at the time they are first seen by a neurologist sounds something like this:

“I was always active until last year when I began to drag my right leg. Its been getting slowly worse and I finally agreed to see the doctor when I could no longer hide the problem and people at work were beginning to think I had a drinking problem.  I thought it was just a bad hip but my primary doctor could find nothing wrong with my hip. I’ve actually been a little concerned for at least two years or at least since our family reunion 2 years ago last summer; we had a game of touch football and I started to stumble and trip after playing for about an hour. I just figured this was due to the hot weather and deconditioning. After this I began to notice decreasing endurance with my morning jogs and began to trip or drag my right leg after a few miles; eventually I stopped running altogether about a year and half ago"
 
Contrast this description with a relapsing remitting MS description:
   
“When I woke up last monday my right leg felt heavy and my right foot was tingling. At first I thought the right leg was still asleep but the symptoms persisted. Later in the day I noticed that the numbness and tingling had moved up the right leg to about thigh level and I kept tripping over my right leg when I walked too fast. It seemed a little better with rest that evening. The next day when I got out of bed I stumbled to the bathroom because of my right leg weakness and imbalance and could barely walk without assistance. Of course, this is when I decided to come to the emergency department. The symptoms continued to get worse and spread to the left leg over the next few days. Once they determined I had MS they treated me with IV steroids. I noticed some improvement by the following day and was ready to return to work 4 weeks later. I felt almost completely normal within 3 months”

-Rip Kinkel, MD

Question:  I am very frustrated with my need to get up to urinate at least 3 times a night sometimes after wetting the bed.  I currently take oxybutynin XL 15mg, catheterize before bedtime and drink no caffeinated beverages. This only cut me down from 6 times a night to 3 times a night and I am exhausted during the day. Help please?

Answer:  This is a frustrating problem and there are several potential solutions. First, it would be useful to know the rest of your history, but I am guessing you experience significant urinary frequency, urgency, hesitancy and urge incontinence during the day as well. The first thing you should do, if not done already, is see a urologist, preferably one with expertise in neurogenic disorders of the bladder and MS. Your constellation of symptoms and lack of response to therapy suggests a low capacity bladder, possibly under high pressure, with overactivity of urinary sphincter that helps control the release of urine. This type of problem often does not respond adequately to standard treatment with high doses of oxybutynin (called anti-muscarinic treatment) or even self catheterization. If this is the problem, effective treatment often involves botox injections into the bladder neck or even neuromodulation with the InterStim device made by Medtronics. As a temporizing measure, your physician may consider prescribing DDAVP (desmopressin) at bedtime to help decrease the production of urine, but this treatment should not replace a thorough evaluation by a urologist. To learn more about urination and MS, you might want to read this http://www.healthcarejourney.com/10/post/2014/03/the-idiots-guide-to-urination-and-ms.html

Good luck.

--Dr. Rip Kinkel

Q:  I am 18 years old. A few years ago my vision started getting bad and I started to get a lot of floaters in both eyes. I went to a retina specialists and he said it was probably caused by some type of auto immune disease because I had a lot of inflammation in my eye, so we did a bunch of tests for stuff like Lyme disease and a few others. They all came back negative and he said that it could possibly be MS but I didn't have other symptoms so we just kind of figured there is really nothing we could do. In the past few months I've experienced a lot of weird symptoms. A big change was bladder problems. I had to pee way too much and especially at night. And I had a feeling of it not being completely empty and also a hesitancy to urinate. Another symptom was one of my legs felt very weak and just felt really strange,and this lasted about 3-4 weeks. I also have found that my speech has changed, I tend to have trouble saying stuff or articulating my words, sometimes even slurring them. I am planning on getting an MRI when I go home for spring break from college but my question is do you believe that these symptoms are an indication that I could possibly have MS?

Answer:  Those are great questions. I can certainly understand why you would be concerned about MS. In fact there are many things that could be causing your symptoms. An MRI scan of the head and spinal cord as well as a trip to see a neurologist are definitely the first steps and should be done during your Spring Break. Keep us posted. We’d be happy to see you if you are anywhere near San Diego

--Dr Kinkel

PLEASE NOTE:  The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.