Search for tag: "multiple sclerosis"

Dr. Jones: Multiple sclerosis is a disease that's more common in women than men. It's a complicated disease, it's a neurologic disease, but it affects many parts of the body and today we're going to talk about the bladder, and MS, and your health, on The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Today in The Scope studio, we have Dr. Sara Lenherr, who is a specialist in neurology, she's trained as an urologist, but she's pretty clearly interested in the way the brain talks to the bladder. And today we're talking with her about MS, patients with MS, and problems they might have with their bladder, and what might be done. So talk a little about the brain talking to the bladder and multiple sclerosis.

Dr. Lenherr: In normal patients that don't have neurological problems, the brain is designed to tell the bladder to store urine for as long as is reasonable, and then when you're near a bathroom, then you volitionally go ahead and void out your urine. Unfortunately in multiple sclerosis and a lot of different types of neurological disorders, the communication between the brain and the bladder is disrupted by the nervous system problems that happen in MS.

And so specifically, sometimes that bladder becomes over-active and receives too many signals from the brain, and then it also, the sphincter that's supposed to keep you from leaking doesn't necessarily relax when you want to go ahead and pee.

Dr. Jones: So what happens? So a woman who has MS and has neurologic symptoms in her bladder, what would she experience?

Dr. Lenherr: So usually they'll present with urinary frequency and urgency, but sometimes they just don't empty their bladder at all, so they'll feel like they have to go, they try to go, and then they can't empty out their bladder completely. Either just a little bit comes out or none comes out at all, and interestingly, sometimes we catch these cases of multiple sclerosis before they're even diagnosed by a neurologist, because women will present when they're a little bit younger, and they have no reason to be in urinary retention to not empty their urine.

Dr. Jones: So let's back up, so urinary retention. You mean if they go a little bit, then their bladder gets fuller, and fuller? I see a balloon in my head.

Dr. Lenherr: Exactly.

Dr. Jones: How full is too full and what happens?

Dr. Lenherr: Well, if you have too much urine in your bladder, especially for women, usually when you have too much in your bladder and you're a female, you have what's called overflow incontinence, where the urine just comes out even though the sphincter is nice and tight. And so those women will notice that they just leak, and they can't empty out all the way. They feel full.

Dr. Jones: Well, so a lot of women leak, so how would you know that it's overflow? What test would you do?

Dr. Lenherr: So we can do either a catheterized volume to see if there's urine left over after you pee. Or we can just do a little bed side ultrasound to evaluate whether or not there's any urine leftover in your bladder.

Dr. Jones: So a urologist might actually pick up MS before the patient shows the other neurologic signs of MS.

Dr. Lenherr: That's correct.

Dr. Jones: And these are young women.

And young women being wet all the time is devastating, well it's what, it's devastating for any woman of any age, but for young women in particular, they don't want to be wearing pads, and Depends. So what kinds of things do you have to offer for women with MS?

Dr. Lenherr: So once we identify the problem, then we need to discuss with the patient what drives their quality of life, and what is a safety issue. So safety issues would be if your bladder doesn't empty all the way, and it ultimately causes the bladder to stretch out and cause damage, and sometimes could impact kidney function.

Dr. Jones: Oh, so it backs up and backs up?

Dr. Lenherr: It can back up all the way and it could cause the kidneys to have damage which is a bigger issue. The other thing that can happen with the urine sitting in the bladder for a long time, it can lead you to get urinary tract infections. So there's multiple things that we can address with a safety issue, and then we need to look at quality of life, so quality of life is impacted by leaking all the time, or having to go to the bathroom all the time.

Dr. Jones: So do women have to empty their own bladder with a tube? I mean do you give them medication to make their bladder squeeze a little harder?

Dr. Lenherr: So depending on how their bladder works when we evaluate it, we frequently have to have these patients go use a small catheter to empty their bladder on a timed basis. And that generally treats them very well because it empties the urine when they want to, and they're able to control risks of urinary tract infections and kidney damage, and then they also don't have the overflow incontinence that we discussed before.

That's one good strategy, sometimes if the over-activity is really bothersome, and they still have irritation even though there's a small amount of urine in their bladder, we put them on other types of medication and we also can offer them chemodenervation, which is called botox, which is similar to the botox that you put on your forehead for wrinkles, we can inject that in the bladder to relax it.

And we can also put in nerve stimulators that help act like a bladder pacemaker. So there are multiple different options we can offer women with multiple sclerosis to help them manage their bladders better.

Dr. Jones: Well that's great news, because for MS it's a condition that waxes and wanes through a life time. It often begins in women's early 20s, or 30s. So giving somebody the qualify of life so they can be the persons that they want to be, is a really important service that you guys can offer.

And I think for many women with MS, they feel like their life and their agency has been taken away, and empowering them to have a little more control.

Dr. Lenherr: Exactly, and also considering that we follow them for the rest of their lives, and sometimes their bladder conditions change, so we need to adjust the strategies that were working five years ago.

Dr. Jones: And here at the University of Utah, we have a medical record that helps our doctors talk to each other so you're not doing this just in the urology clinic. You talk to their other MS doctors.

Dr. Lenherr: Exactly.

Dr. Jones: Because often they're on a lot of meds.

Dr. Lenherr: We coordinate all their care and make sure that we're all working together to improve the quality of life and keep them safe.

Dr. Jones: That's great to know because I've had a lot of patients over the years with MS. It's very discouraging. Knowing that there's things that they can do is very helpful, and Sara thank you for joining us on The Scope.

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Dr. Miller: MS or multiple sclerosis. What is it and what can you do about it? We're going to talk about that next on Scope Radio. This is Dr. Tom Miller.

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Dr. Miller: I'm here today with Dr. Dana Dewitt who is a professor of neurology and a specialist in multiple sclerosis care. Dana, what is multiple sclerosis? I think we've heard the term but what is it and how does it present and when should somebody be concerned that they might have it?

Dr. Dewitt: Everybody seems to know about the term "multiple sclerosis," but many people really don't understand what it is. It's certainly a neurologic disease. It is a disease that occurs because the immune system is activated and attacks the myelin in the brain and the spinal chord.

Dr. Miller: And we don't know why that occurs, is that true?

Dr. Dewitt: We don't know why that occurs. We know that there's a genetic input. We know that it may have something to do with Vitamin D levels, but we also don't know what actually is the spark that sets it off.

Dr. Miller: So if it's "set off," what does one experience? What are some of the symptoms that might arise?

Dr. Dewitt: There are some classic symptoms with MS. The attack on the nervous system can be on the optic nerve and can cause something that we call "optic neuritis."

Dr. Miller: Which changes vision, I guess?

Dr. Dewitt: Which changes vision. It causes, sometimes, a painful, kind of gritty feeling in the eye and then dimming of vision over time in one eye. The other thing that can happen is that the spinal chord can be attacked and you can end up with numbness or weakness of an arm and a leg or both legs, bladder and bowel dysfunction. Other parts of the brain can be affected that can cause double vision, vertigo, imbalance, those kinds of things.

Dr. Miller: But sometimes it can come on subtly. I mean, I've had a patient in the past who developed multiple sclerosis. His first time was running. He couldn't quite run as far. He had a weakness in one of the legs and then that sort of progressed.

Dr. Dewitt: That's true and there are different forms of MS, the most common type being relapsing/remitting disease. The beginning symptom can sometimes come on over days or a week or two and just get worse and worse. The interesting thing with relapsing/remitting disease is the nervous system has a way of healing itself in MS and so sometimes the symptoms get better and the patient ends up not coming to the attention of a physician early enough, until they've had a few events. At that point, we discover that they've probably had MS for a few years.

Dr. Miller: Now you can have numbness, I guess, on one leg or arm and then maybe weakness on the other and it could alternate back and forth. It could have some sort of strange presentations I think, is that right?

Dr. Dewitt: Exactly and you can have different things occur at different times.

Dr. Miller: Presenting with some of the symptoms that you've just talked about, how do you make the diagnosis and then what do we do about it?

Dr. Dewitt: Probably referral to a neurologist who would listen to your symptoms and do a complete neurologic exam to see what they think is happening. Then one of the ways MS is diagnosed is with an MRI scan and MRI is very, very good at showing the what we call plaque-like lesions that can occur in MS.

Dr. Miller: These little spots on the brain that are tell-tale signs of multiple sclerosis.

Dr. Dewitt: Exactly.

Dr. Miller: So does that mean that we don't have to do this lumbar puncture anymore, to take spinal fluid out and look at it under the microscope?
Most of the time I like doing a lumbar puncture. It tells me how much inflammation there is. It rules out what we call MS mimickers or other unusual things that can look like MS. If an MRI is absolutely classic for MS, occasionally, a lumbar puncture might not be necessary.

Dr. Miller: So you might still need that?

Dr. Dewitt: Yes.

Dr. Miller: Okay. Now, in the not-too-distant past the main treatment was steroids prednisone but there are a lot of new treatments now.

Dr. Dewitt: Most of the initial FDA treatments actually date back to about 1995. So, we've had treatments for quite some time. The major treatments are an interferon or something called glatiramer acetate. Those are all given by injections, which has been a bit problematic for some patients along the way, but they are very effective. They've been around so long we know what to expect and we know how safe they are and they really work. What's been shown in clinical trials is that getting on the drug early and staying on the drug makes an enormous amount of difference.
Now, we do have three new FDA approved oral agents that become options as well. So, the whole armamentarium of treatment for MS now has grown enormously. We still know the important thing is being diagnosed early, getting on treatment, staying on treatment.

Dr. Miller: What looks great in the future? Do you see any treatments on the horizon that you're excited about?

Dr. Dewitt: Well, we're hoping. We're actually doing a clinical trial here now for a new treatment for secondary progressive and what's called primary progressive MS, which are two different presentations for MS different from relapsing/remitting disease. And there really have not been good treatments for those forms of the disease. So we're very excited that we're actually doing this clinical trial here to look at this agent.
I think the other developments are there are a couple of clinical trials looking at potential remyelinating type agents where damage that has occurred in the past can actually be repaired and I think that's what we really want more than anything. The other thing is we're learning more and more with MRI in that we're able to do special MRIs looking at brain volume and we're able to look at certain agents to see if we can prevent degeneration and progression of disease in different ways than what we have available now.

Dr. Miller: You know, it's interesting. With the advent of MRI, which is a magnetic way of looking at the brain. That's allowed this field to progress in its ability to treat people, I think, because now you can actually see inside the brain on these images and look at the plaques and sort of figure out if there are more of them or if they're growing, right? So that's been key.

Dr. Dewitt: Exactly. It's been huge. Part of it is that once a plaque forms it will stay on the MRI as a scar and so we can differentiate between old lesions, new lesions, lesions that enhance with contrast agents. And now we're able to do these brain volume measurements to see how well some of the new medications are working to prevent progression.

Dr. Miller: This allows us a way to really see if the drugs are working and treatment's working. I had heard that stem cell transplant or bone marrow transplant was being tried in the past. Has that been effective at all?

Dr. Dewitt: Yes, there are some places where there are still clinical trials and there are places where bone marrow transplants are being done. There are different kinds of bone marrow transplants. The traditional bone marrow transplant where patients are given high-dose chemotherapy to totally eradicate the bone marrow. The question has always remained in those cases whether the high-dose chemotherapy actually treated the disease effectively enough that it's not really the bone marrow transplant, but those questions are still up in the air.
There are other types of bone marrow transplants now. Something called a mesenchymal transplant or multi-stem, which are these actual intravenous infusions which is a different kind of mode of stem cell transplant which, I think, is the major excitement for the future because I think they're going to turn out to be immune regulators that are far safer than the traditional way of doing a stem cell transplant.

Dr. Miller: Now treating multiple sclerosis is one of your areas of expertise. Would you recommend that people with multiple sclerosis seek a neurologist who have experience with multiple sclerosis?

Dr. Dewitt: I strongly do for a couple of reasons. One is I think making the diagnosis is important and sometimes it can be not so clear. So I think you need a specialist to make the diagnosis. The second thing is now that we have so many treatments, it's important for someone with experience who follows a lot of these patients to be able to choose the proper treatment for you, monitor you to know whether you're responding to that treatment, and then decide whether you need to be changed to something else and follow you over time and just see how you're doing.

Dr. Miller: So it sounds to me like early diagnosis, early treatment, and rigorous follow-up by a specialist who's an expert in multiple sclerosis can make a great difference in the health of these patients.

Dr. Dewitt: Exactly.

Dr. Miller: Any final thoughts?

Dr. Dewitt: We have so many developments for treating MS that it's changed the scope of the disease. It's always hard to give someone the diagnosis at the beginning because people do have a preset idea of what it means and they look down the road and they're very worried about having a chronic condition. I think what I'd like to say is that the treatments that we have available now are really excellent treatments and as long you're followed closely and you know you're on a medication that works, most people with MS live an absolutely normal life.

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