Let’s talk about urinary incontinence! I know, you may not want to talk about it, but I bet you are curious to learn about it. Urinary incontinence (UI), or bladder leakage, is all too common in those with Multiple Sclerosis (MS). There are areas in the brain, brain stem and spinal cord which work together to control urinary function, so if MS affects any of these specific areas, then communication regarding urination is disrupted, and urinary dysfunction results. Urinary dysfunction is seen in up to 90% of persons with MS¹, and 80-100% of those with urinary dysfunction, report UI symptoms². It’s common, it’s frustrating, it significantly impacts your quality of life³, and if experiencing any balance or vision difficulties, then rushing to the bathroom to prevent leakage may increase your risk for fall related injuries⁴. I often hear that patients feel this is a difficult topic to discuss with their healthcare providers, so I wanted to bring it up for you in order to demystify, destigmatize, clarify and bring a bit of confidence to seek out the help you need and deserve. 

Did you know that there are physical therapists (PT) out there who specialize in the treatment of UI? That’s where I come in. I am a pelvic health physical therapist, and I specialize in the treatment of neuromuscular and musculoskeletal dysfunction in the abdominal and pelvic areas. This includes bladder dysfunction.

Here is a simplified version of what should occur without interruption during normal urinary function:

• Blood circulates through your kidneys, and the product of this normal filtration process is urine.
• The urine is then emptied from the kidneys into the bladder, a hollow organ that sits behind the pubic bone, via the ureters.
• The bladder happily fills with urine without us even sensing it, but at a certain threshold, usually around 200 mL of urine, neurologic signals are sent up the spinal cord to a control center in the brain stem, the Pontine Micturition Center (PMC), and you start to feel like maybe you could go to the bathroom. This “first sensation” is usually easily ignored, and the brain tells the bladder to keep quiet, keep filling for now, and sends a signal back down the spinal cord to do so.
• Once your bladder has filled to about 400 mL, it becomes a lot harder to ignore. The signal is once again sent up the spinal cord, to the brain stem, and you and your brain agree not to put it off any longer. You make your way to the bathroom, sit down, relax your pelvic floor muscles (more on those late), and then unconsciously the urethral sphincters relax, the muscle around your bladder (detrusor) contracts, and urine is eliminated via the urethra, out of the body.
• The process continues all day, every day.

Urinary Incontinence and Multiple Sclerosis

When there is a wrench in this system somewhere, UI can occur. Urinary incontinence is the involuntary loss of urine. It is by far the most commonly seen urinary dysfunction in physical therapy. There are three main categories of UI depending on the symptoms you may have: stress urinary incontinence (SUI), urge urinary incontinence (UUI) or mixed urinary incontinence (MUI). Each type of UI may have different contributory factors, aggravating factors and treatment approaches. 

• Stress urinary incontinence: The involuntary loss of urine because of pressure/physical exertion. For example, urine is lost after sneezing, coughing, laughing, jumping, running, etc. 
• Urge urinary incontinence: The involuntary loss of urine associated with a strong urge to urinate. This can be a small amount of leakage, or a total loss of the bladder contents⁵.
• Mixed urinary incontinence: The involuntary loss of urine associated with stress and/or an urge⁵.

The causes of SUI can be multifactorial. Common contributing factors include pelvic floor muscle weakness, poor pelvic muscle coordination, urethral deficiencies, detrusor muscle overactivity, poor diet or hydration, constipation, or bad lifestyle habits which make leakage worse. When you have MS, the disease process can complicate these factors. When MS leads to damage of the myelin in the parts of the brain, brain stem, or spinal cord which contribute to urinary function, then the messages regarding urination get disrupted. Your physician is always the first line of defense for examining what medically is contributing to urinary dysfunction, when you have multiple sclerosis. There are many wonderful treatment options including medications, intermittent self-catheterization, nerve stimulation and surgical interventions⁶. The National MS Society is a good resource for further information on these treatment options, and can be found here. In addition to the neurologic dysfunction that is contributing to bladder symptoms there are behavioral and lifestyle factors, and/or muscle dysfunctions that can worsen bladder symptoms. This is where physical therapy can be really helpful. 

How Physical Therapy Can Help Your Bladder:

There are important muscles and nerves that help your bladder function. With urinary incontinence, we are typically taking a closer look at the function of the muscles and nerves in the abdomen and pelvic floor.

The pelvic floor refers to the group of muscles, nerves and fascia which form a basket at the base of the pelvis. These muscles make up several layers, and run from the pubic bone to the tailbone, left and right between the two sit bones, and encircle and support the bladder, the bowel, the uterus and the vagina in cis females, and the prostate and penis in cis males. When contracted, the pelvic floor muscles draw up and provide a “lift” of your organs towards your head, and they bring the tailbone and pubic bone inwards towards your center, assisting in closure of the pelvic openings (urethra, vagina and rectum), and stability to your pelvic bones. 

Since these muscles are so important in the support and closure of bladder and urethra, then their optimal function is important to prevent urinary leakage. These muscles need to have sufficient strength, length and coordination to help support the complex function of urination. Pelvic physical therapists will work with you to accomplish this. For more information on the pelvic floor, check out this blog.

A pelvic physical therapist will examine the pelvic floor muscles in order to determine what is going on with each patient’s muscles. A good summary of what this examination may entail can be found here. Depending on the findings, physical therapists use a variety of techniques and exercises to decrease the impairments in the muscles and nerves that are affected. Some of the interventions you may see in physical therapy may include:

• Pelvic floor muscle strengthening exercises: These exercises are more commonly knowns as Kegels but may also include strengthening exercises for muscles in the abdomen, hips, and thighs as imbalance in the muscles in the surrounding areas of the pelvic floor muscles, may also have an adverse effect on urinary incontinence.
• Neuromuscular Electrical Stimulation (NMES): Electrical stimulation is provided to the pelvic floor muscles, either trans-vaginally or trans-rectally. The exact mechanism of how NMES improves UI is not known, but it is thought that the stimulation either helps to encourage pelvic floor muscle contraction or curbs the detrusor contractions to reduce the overactivity of the bladder⁷.
• Electromyography (EMG) Biofeedback: An instrument-based tool that teaches a person how effectively they are using the muscles, using auditory and visual feedback⁸. In EMG Biofeedback, the muscle activity is measured using external sensors, and displayed for the person to see. This can be helpful in teaching a person how to contract or relax a muscle, depending on what is needed for that individual⁹.
• Hydration and diet management: Typically, this consists of optimizing hydration status since drinking too much or too little can make incontinence worse, and diet modification since certain foods can irritate the bladder leading to increased leakage as well.
• Constipation management
• Lifestyle strategies: This may include bladder training, techniques to modulate the autonomic nervous system

In persons with MS and urinary incontinence, it is common to see either pelvic floor muscles that are weak and underactive, tight and overactive, muscles that lack coordination, a bladder muscle (detrusor muscles) that is over reactive, or any combination of these¹⁰. Physical therapy has been found to provide substantial decreases in urinary leakage, and significant improvements in the quality of life in persons with MS⁹. Physical therapy interventions such as those described are easy to do, have little to no side effects, and the rewards are significant⁹. So why not try it!

For more information on how pelvic health physical therapy can help you, check out these websites:

The Academy of Pelvic Health Physical Therapy

Pelvic Rehab

For help finding a qualified pelvic health physical therapist, you can find people in your area here and here.

Resources:

1. Aharony MS, Lam O, Corcos J. Evaluation of lower urinary tract symptoms in multiple sclerosis patients: Review of the literature and current guidelines. Can Urol Assoc J. 2017; 11(1-2): 61–64. Doi:  10.5489/cuaj.4058
2. Tubaro A, Puccini F, De Nunzio C, Digesu GA, Elneil S, Gobbi C, Khullar V. Treatment of lower urinary tract symptoms in patient with multiple sclerosis: a systematic review. Curr Urol Rep. 2012; 13(5):335-42. Doi: 10.1007/s11934-012-0266-9 
3. Litwiller SE, Frohman EM, Zimmern PE. Multiple sclerosis and the urologist. J Urol. 1999; 161(3):743-5.7.
4. Block V, Rivera M, Melnick M, Allen D. Do physical therapy interventions affect urinary incontinence and quality of life in people with multiple sclerosis. International Journal of Ms Care. 2015; 17(4): 172-80. Doi: 10.7224/1537-2073.2014-031.
5. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Van Kerrevroeck P, Victor A, Wein A. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the international continence society. Urology.  61: 37-49. Doi: 10.1016/S0090-4295(02)02243-4.
6. National Multiple Sclerosis Society. Bladder Dysfunction. National Multiple Sclerosis Society. Accessed 4/10/2021. https://www.nationalmssociety.org/For-Professionals/Clinical-Care/Managing-MS/Symptom-Management/Bladder-Dysfunction. 
7. vanBalken MR, Vergunst H, Bemelmans BLH. The use of electrical devices for the treatment of bladder  dysfunction: a review of methods. J Urol. 2004; 172: 846-851.
8. Lee HJ, Jung KW, Myung SJ. Technique of functional and motility test: how to perform biofeedback for constipation and fecal incontinence. J Neurogastroenterol Motil. 2013; 19: 532-537. 
9. Alfarra N, Aldosary H, Almefleh S. Do physical therpay interventions improve urinary incontinence and quality of life in patient with multiple sclerosis: A systematic literature review. Phys Med Rehabil Res. 2019. 4:1-6. Doi: 10.15761/PMRR.1000204.
10. DeRidder D, Vermeulen C, DeSmet F, et al. Clinical assessment of pelvic floor dysfunction in multiple sclerosis. Neruourol Urodyn. 1998;17:337-542.