Symptoms of Multiple Sclerosis (MS)- Balance/dizziness , bladder, and bowel dysfunction

Symptoms of MS are unpredictable and vary greatly from person to person and can fluctuate within the same person from one time to the next.

What causes symptoms in MS?

MS attacks the protective covering — myelin — of the brain and spinal cord, causing inflammation and often damaging the myelin in patches. When this happens, the usual flow of nerve impulses along nerve fibres (axons) is interrupted or distorted. The result may be the wide variety of MS symptoms, depending upon what part or parts of the central nervous system are affected. Not all people with MS will experience all symptoms and often times the symptoms will improve during periods of remission.

There are a variety of ways to manage symptoms, ranging from pharmacological treatments to non-medicinal strategies such as physiotherapy, occupational therapy, exercise programs and alternative and complementary treatments.

Some of the most common symptoms include:?

? Balance and dizziness?

? Bladder dysfunction?

? Bowel dysfunction?

? Cognitive impairment?

? Depression?

? Fatigue?

? Gait?

? Pain?

? Paroxysmal symptoms?

? Sensory impairment?

? Sexual dysfunction?

? Spasticity?

? Uhthoff’s phenomena?

? Weakness?

Other MS symptoms:?

? Dysarthria?

? Dysphagia?

? Dry mouth?

? Hormonal influences for women with MS?

? Inappropriate Affect (pseudo bulbar affect, emotional incontinence, involuntary emotional expression disorder-IEED)

? Poor coordination or incoordination?

? Mood lability /bipolar affective disorder?

1- Balance/dizziness.?

Balance, and vertigo, or dizziness problems are common in MS and their management can be difficult. These symptoms are caused by lesions in the areas that coordinate visual, spatial, and other input needed to produce and maintain equilibrium. Balance and dizziness may present as symptoms of a relapse, or may be permanent, and can pose increased safety risk for falls. People with MS may feel off balance or lightheaded. Much less often, they have the sensation that they or their surroundings are spinning. Other conditions that may cause dizziness include middle ear inflammation and benign tumors of the acoustic nerve that connects the ear and the brain. To effectively treat dizziness or vertigo, it’s important to know the cause.

Management: Some balance problems can be overcome with a walking aid. Walking aids should only be used with the instruction of a trained professional to ensure proper gait alignment. A home assessment for safety conducted by an occupational therapist can be helpful to identify potential hazards and to suggest strategies for a safe approach to activities of daily living.?

Also, vertigo symptoms may improve with the aid of anti-motion sickness medications. Referral to occupational therapist may be needed for vestibular rehabilitation. New onset of Vertigo may be treated with high dose Corticosteroids.?

2- Bladder dysfunction.?

People with MS (PwMS) may find that bladder symptoms prevent them from fully interacting with their community, friends, and family. It doesn’t need to be that way. Once diagnosed, these common MS symptoms are manageable and treatable. However, the trigger is MS lesions in the brain or spinal cord can disrupt the normal bladder process by interfering with the transmission of signals between the brain and urinary system. This occurs in at least 80% of people living with MS.?

Healthy bladder function is essential for long-term kidney health, prevention of infection, personal independence, self-confidence, and overall quality of life. Untreated bladder issues can cause:

o Worsening of other MS symptoms, such as weakness and spasticity

o Repeated bladder or urinary tract infections (UTI), or kidney stones that can cause serious pain and compromise overall health

o Challenges with work, home, and social activities

o Loss of independence, self-esteem, and self-confidence

Early medical evaluation is important to determine the cause of the bladder symptoms and choose the appropriate management and treatment strategies. At their most serious, untreated urinary problems can lead to infections in the blood (urosepsis) and skin breakdown — two factors that can shorten life in someone with MS.

Some bladder symptoms may include: Urgency, frequency, burning sensation, abdominal and/or lower back pain, fever, increased spasticity and dark-coloured, foul-smelling urine

They can usually be managed successfully with lifestyle modifications, medications, physical therapy and/or nerve stimulation procedures.

Lifestyle changes may include:

o diet modifications,

o adequate fluid intake up to a few hours before bedtime,

o bladder training or planned voiding, among others.

Pharmacological options may include the following, depending on type of bladder dysfunction:?

onabotulinumtoxin A, desmopressin, tolterodine, oxybutynin, tamsulosin, mirabegron, oxybutynin, imipramine, and solifenacin succinate.?

Patients and healthcare professional should work together to select the best treatment option after a thorough assessment of bladder symptoms.

Other options are available, like intermittent self-catheterization (ISC), and surgical interventions.?

3- Bowel dysfunction:?

Bowel dysfunction in MS most commonly presents as constipation but can include diarrhea and incontinence. Constipation is in MS is caused by interruption of neural pathways. Decreased mobility and poor hydration can also aggravate bowel problems. As with urinary problems, bowel problems can stem from MS damage in the brain and spinal cord, which causes miscommunication between the central nervous system and the intestines. Sometimes, other factors, such as medications, impaired mobility or diet are the culprits. It’s common, too, for bowel problems to occur when an individual attempts to manage urinary symptoms by limiting his or her fluid intake. Without adequate fluids, the stool becomes dry and hard, leading to constipation. Overall, people with MS experience problems with their bladders more often than with their bowels. But because the organs for urination and bowel evacuation are linked anatomically—they form sort of a figure eight in the pelvis—a problem in one system often leads to a problem in the other, so they must be addressed together.?

Bowel problems won’t go away on their own, and may make other problems, such as spasticity and walking difficulties, worse. For these reasons, it’s crucial to address bowel problems when they arise. Most people find that their quality of life improves dramatically once their bowel issues have been treated.?

Constipations and MS: MS can cause loss of myelin in the brain or spinal cord, that may prevent or interfere with the signals from the bowel to the brain indicating the need for a bowel movement, and/or the responding signals from the brain to the bowel that maintain normal functioning. Common MS symptoms such as difficulty in walking and fatigue can lead to slow movement of waste material through the colon. Weakened abdominal muscles can also make the actual process of having a bowel movement more difficult. Some people may have problems with spasticity. If the pelvic floor muscles are spastic and unable to relax, normal bowel functioning will be affected. Some people also may not have the usual increase in activity in the colon following meals that propels waste toward the rectum. Finally, some people try to solve bladder problems by reducing their fluid intake. Restricting fluids makes constipation worse.

The first step to take may be to get medical help for your bladder problems so that adequate fluid intake, which is critical to bowel functions, will be possible. A long-term delay in dealing with bowel problems is not an option. Besides the obvious discomfort of constipation, complications can develop. Stool that builds up in the rectum can put pressure on parts of the urinary system, increasing some bladder problems.?

Diarrhea and MS: Diarrhea is less of a problem for people with MS than is constipation. Yet when it occurs, for whatever reasons, it is often compounded by loss of control. Reduced sensation in the rectal area can allow the rectum to stretch beyond its normal range, triggering an unexpected, involuntary relaxation of the external anal sphincter, releasing the loose stool. MS may cause overactive bowel functioning leading to diarrhea or sphincter abnormalities that can cause incontinence. The condition can be treated with prescription medications. Diarrhea might indicate a secondary problem, such as gastroenteritis, a parasite infection, or inflammatory bowel disease. It is never wise to treat persistent diarrhea without consulting your healthcare team. When bulk-formers are used to treat diarrhea instead of constipation, they are taken without any additional fluid. The objective is to take just enough to firm up the stool, but not enough to cause constipation. If bulk-formers do not relieve diarrhea, your doctor may suggest medications that slow the bowel muscles. These remedies are for short-term use only.

Irritable bowel syndrome: Also known as spastic colon, is an umbrella term for several conditions in which constipation and diarrhea alternate, accompanied by abdominal cramps and gas pains. Your doctor can determine if you have a health condition causing these symptoms or simply a syndrome associated with stress.?

Medical tests: After age 50, all people should have periodic examinations of the lower digestive system. The methods include a rectal exam or a sigmoidoscopy or colonoscopy. These last two tests, in which the bowel is viewed directly with a flexible, lighted tube, are increasingly routine as early diagnostic exams. The colonoscopy, which examines the entire large intestine, is widely considered the better choice.

Good bowel habits: It is much easier to prevent bowel problems by establishing good habits than to deal with impaction, incontinence, or dependency on laxatives. If your bowel movements are becoming less frequent, act. You may be able to prevent worsening problems by establishing good habits now.

Drink enough fluids: Each day, drink two to three quarts of fluid (8-12 cups) whether you are thirsty or not. Keep in mind any bladder issues that need to be resolved first to avoid urgency or loss of bladder control.?

More fibre in diet: Fibre helps keep the stool moving by adding bulk and by softening the stool with water. Incorporate high-fibre foods into your diet gradually to lessen the chances of gas, bloating, or diarrhea

Regular exercise: Kegel exercises can strengthen the sphincter muscles and pelvic floor. This can help you have better control. Also, staying active helps keep the intestinal contents moving.?

Establish a regular time of the day: The best time of day is about a half hour after eating, when the emptying reflex is strongest. It is strongest of all after breakfast. Set aside 20 or 30 minutes for this routine. Stick to the routine of a regular time for a bowel movement, whether you have the urge or not.

Pharmacological options for constipation: Bulk forming laxatives, saline laxatives, stimulant laxatives, suppositories, Enemas, and manual stimulation.

Always check with your pharmacist which one is the best for you and how to use.?

Impaction and incontinence:?

Impaction refers to a hard mass of stool that is lodged in the rectum and cannot be eliminated. This problem requires immediate attention. Impaction can usually be diagnosed through a simple rectal examination, but symptoms may be confusing because impaction may cause diarrhea, bowel incontinence, or rectal bleeding. Your doctor may want you to have a series of tests to rule out the chance of other more serious health conditions. Impaction leads to incontinence when the stool mass presses on the internal sphincter, triggering a relaxation response. The external sphincter, can be weakened by MS and may not be able to remain closed, leaking watery stool from behind the impaction. Loose stool as a side effect of constipation is not uncommon.

Incontinence:

Total loss of bowel control happens only rarely. It is more likely to occur, as mentioned above, as an occasional incident. Some people with MS report that a sensation of abdominal gas warns them of impending incontinence. If incontinence is even an occasional problem, see your doctor but don’t be discouraged. It can usually be managed. Dietary irritants such as caffeine and alcohol should be considered contributing factors and reduced or eliminated. In addition, certain medications may be contributing to the problem and their dose or scheduling may need to be adjusted. Protective pants can be used to provide peace of mind. An absorbent lining helps protect the skin, and a plastic outer lining contains odours and keeps clothing from becoming soiled.

To be continued …...?

References:?

https://mssociety.ca/aboutms/symptoms?gclid=Cj0KCQjwrs2XBhDjARIsAHVymmSN9EBAf5VthE7Y1aC0IkOpnuus7JDvn-Rk-ZesohKhCJ7ebECvl_0aAp_CEALw_wcB

https://mssociety.ca/uploads/files/2085-naep-2015-book-english.pdf?

https://www.nhs.uk/conditions/multiple-sclerosis/symptoms/?

https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Dizziness-and-Vertigo?

https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Bowel-Problems?

https://www.nationalmssociety.org/Treating-MS/Medications?

?https://mssociety.ca/library/document/PRS27klmdTGCbg1zLiZJ9eOKXxYMrFpN/original.pdf?

https://mssociety.ca/managing-ms/treatments/medications/symptom-management#bladder?

https://www.hopkinsmedicine.org/health/conditions-and-diseases/bladder-and-bowel-dysfunction