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Transcript
Continence Issues in Multiple Sclerosis Gillian Nottidge Continence Nurse Specialist Bradford and Airedale tPCT Incontinence “Urinary incontinence is not a joke for the thousands of mainly older people affected with this embarrassing and lifedestroying condition," Dr Adrian Wagg, chairman of the Continence Working Party, Royal College of Physicians Some statistics • NHS estimates that 3-6 million people in UK have some degree of urinary incontinence. (NHS 2006) • Women more likely to suffer stress incont than men • 32% of women in UK have symptoms of UI (Lose et al 2003) Physical impact • Increased risk of falls • Skin problems • Pressure ulcers • Urinary tract infections • Delayed discharge from hospital Emotional impact • Work • Exercise • Travelling • Socialising / relationships • Anxiety • Depression Remember • Not necessarily attributable to MS • MS does not preclude individual from other causes/conditions • Lifestyle • Prostate • Prolapse • Menopause • Don’t miss the obvious However….. • 85,000 MS sufferers in UK (Fowler et al 2008) • 3:1 women:men (Fowler et al 2008) • 90% will have bladder dysfunction (McClurg 2006). 75% (Bladder & Bowel Foundation 2008) Also…. • 68% bowel dysfunction – constipation/ incontinence (Hinds et al 1990) • 50% incontinent of faeces in past 3 months • 20-30% incontinent of faeces at least once a week. (Krogh & Christensen 2009) From some MS sufferers “Of all the problems associated with my MS, the bladder and bowel problems are the ones which are the most debilitating for me.” “People think it’s just your legs that don’t work properly. Nobody realises the extent of my problems.” “Within a few minutes of meeting another MS sufferer the subject of bladder problems usually crops up!” “I want to go swimming with my daughter but I daren’t because of my incontinence.” The worst MS related problem is often incontinence Neurogenic bladder • • • • • • Frequency Urgency Urge incontinence Nocturia Enuresis Stress incontinence • • • • • • Incomplete emptying Overflow Passive incontinence Dribbling Recurrent UTI Bladder/sphincter dyssynergia Neuronal control of the bladder Assessment • • • • • Medical history Current symptoms Acute/insidious onset Medication Post-void residual scan • Urinalysis • • • • • • Bladder diary Bowels Vaginal examination Rectal examination Sexual function Mobility and dexterity Bladder Management • • • • • • • Diet and fluid advice Avoidance of caffeine Pelvic floor exercises Bladder retraining Physiotherapy Biofeedback Electrical stimulation Bladder Management • • • • • • • Avoid and/or treat constipation Double voiding Timed voiding Bladder stimulator Medication ISC Long-term catheter Medication • • • • • • Anti-muscarinics Oxybutinin Solifenacin Tolterodine Fesoterodine Trospium XL Darifenacin • • • • • Alpha-blockers Tamsulosin Doxazosin Alfuzosin Others Desmopressin Duloxetine Investigations • Urodynamics in patients refractory to conservative treatments (Fowler et al 2008) • Cystoscopy if indicated • Treat symptomatically Intermittent Catheterisation Intermittent catheterisation is recognised as a safe and effective procedure (Bakke et al 1997) and carries a reduced risk of infection compared to indwelling urinary catheterisation (Wyndaele 1990; Bakke 1991) NHS Quality Improvement Scotland 2004 Before the EPIC2 guidelines! Found in Pompeii ! How they have improved!! • • • • • • Single use Well lubricated Sterile Readily available on prescription Huge variety available Horses for courses Advantages • Improves quality of life • Minimise incontinence episodes • Less infection risk than indwelling (Wyndaele, 1990; Bakke, 1991) • • • • Body image Sexuality Promotes normal bladder function and emptying Routine urine testing not recommended (Fowler et al 2008) Disadvantages • • • • • • • May find it distasteful May not have dexterity if high lesions Disposal – no bins in men's toilets Travel and carrying catheters Public facilities Hand washing facilities UTI Aids and adaptataions Botox • Significant improvement in detrusor-sphincter dyssynergia • Decreased urge incontinence • Reduced frequency (Game et al 2008) • Reduced incidence of UTI (Fowler et al 2008) But… • May have to perform ISC • Not a one-off treatment • Not yet licensed for intra-vesical use, but widely used • May involve hospital admission, but can be done as outpatient Sacral Nerve Stimulation Placement of an electrode through one of the naturally-occurring holes in the sacrum. The electrode lies alongside the sacral nerves. These nerves supply the organs in the pelvis and the pelvic floor muscles. Regular, gentle pulses of electricity are passed along the electrode from a battery pack. Cannabis! • Cannabinoid receptors in the bladder and nervous system are potential pharmacological targets (Brady et al 2004) • Patient self-assessment of pain, spasticity and quality of sleep improved significantly • Significant improvement in LUTS • Few troublesome side effects • Cannabis has a positive clinical effect on MS patients with urinary incontinence. (Freeman et al 2006) Bowel Problems • 68% bowel dysfunction – constipation/ incontinence (Hinds et al 1990) • 50% incontinent of faeces in past 3 months • Demyelination along the CNS pathway responsible for bowel symptoms Faecal Incontinence • Reduced anal sensitivity • Affects anal sampling causing incontinence • Slow transit – constipation and overflow Incontinence • Anal tone – resting pressure affected by spinal lesions • Loss of voluntary control of external anal sphincter • Rectal hyperactivity Constipation • • • • • • • Weakened abdominal muscles Slow transit Medications used to treat concomitant problems Inadequate fluid intake Insufficient dietary bulk Decreased mobility Reduced rectal tone – faecal impaction and rectal distension Assessment • Good assessment • Good rapport with client • Diet and fluids • Bladder diary • Rectal examination • Stool type • • • • • • Current bowel habit Digitation Manual removal Enemas Suppositories Medication Medication • Antihypertensives • Analgesics/narcotics • Tricyclic antidepressants • Antacids • Iron supplements • Anti-muscarinics • Sedatives/ tranquilizers • Some antibiotics • Diuretics Bowel management • • • • • • • Diet Fluids Lifestyle Exercise – may be limited Medication Containment Other methods Medication Laxatives – Stimulants – Osmotic laxatives Bulking agents Suppositories Enemas Constipating agents • Clear constipation with osmotic laxative • Give bulking agent to maintain good bowel movement Management • • • • Anal stimulation Manual removal Anal plugs Continence products Anal Irrigation • • • • Clean Quick Natural Promotes independence • Cost consideration In summary • Don’t assume all symptoms due to MS • Bladder and bowel problems very common in MS • Treat conservatively where possible • Many treatments and products are available • Know how to access help • Contact your local continence service Thank You Gillian Nottidge Continence Nurse Specialist 01274 322210 [email protected]
