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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. Jones: Diabetes and the bladder, you never think of these two things going hand in hand. You think of a cupcake and diabetes, not the bladder and diabetes, but today we're talking about diabetes, the bladder. This is Dr. Kirtly Jones and this is The Scope.

Here in The Scope studio, we have Dr. Sara Lenherr, who is a urologist by training, but subspecialty trained in neurology. Today we're talking about diabetes because diabetes is a complex disease. It affects every part of the body and the bladder is the final common pathway of both nerves and sugar and trouble. Welcome to The Scope, Sara.

Dr. Lenherr: Thank you for having me.

Dr. Jones: I think in my own practice sometimes I diagnose diabetes because of women's urinary frequency. So can you tell us a little bit about how the first signs of diabetes might affect the bladder?

Dr. Lenherr: Sometimes women with poorly controlled diabetes end up having a bladder that spasms too frequently, and that can be very bothersome. It makes them feel like they have to go more frequently and urgently.

Dr. Jones: Also, sometimes people who don't know they have diabetes yet, their sugars are high, the kidney is trying to dilute that sugar, and they just pee a lot.

Dr. Lenherr: Yes, frequently these patients make too much urine because their kidney function is affected, and so they just make more urine than the bladder can handle, and it makes them feel like they need to go more frequently, and they do.

Dr. Jones: So peeing a lot in large volumes, for me, I remember that from medical school, was you better make sure they don't have diabetes.

Dr. Lenherr: Exactly.

Dr. Jones: Over the long term, though, diabetes affects your nerves in your feet and affects other parts of your brain, but talk about the bladder in long-term diabetes.

Dr. Lenherr: Diabetes in patients that have had it for a long time can affect the fingers and toes, and all that sensation also affects all of the nerves that go to the bladder, and so the bladder doesn't necessarily contract at the right time. Either it's overactive, or it's underactive. It doesn't contract well enough, and so therefore it doesn't squeeze when you want it to and you don't empty your bladder completely.

Dr. Jones: So in terms of diabetes, we certainly want people to be in good control, because that might help early on a lot of their bladder symptoms, meaning if their sugars are in good shape, their bladder will probably be in good shape. But for people who have been diabetic for a long time and they weren't in such great control and now they have more permanent damage, how do you make that diagnosis?

Dr. Lenherr: Usually, we check and see whether or not the bladder empties completely, so once you go, we can then check and see if you have a residual left over in your bladder, and then we can also check bladder function tests where we measure the pressures inside the bladder and see how your bladder behaves with filling and then trying to empty your bladder.

Dr. Jones: Is that very comfortable? Reassure me that that's not going to be a painful test.

Dr. Lenherr: It's a very simple test that's done in the office. We put a very small catheter that's smaller than the mouse cord that goes to your computer, and we place that inside your bladder, and we place also a very similar small one inside the rectum. This helps us look at how the bladder behaves with filling and emptying to measure those pressures and see whether or not your bladder nerves are not working properly.

Dr. Jones: Okay, maybe I would have this test. Okay, I'll have this test. So, I had this test and my bladder isn't contracting very well. What are you going to do? What can you do to help me with this?

Dr. Lenherr: Depending on how much your bladder is injured, sometimes we have to have patients actually just pass a small catheter every four hours while they're awake to empty their bladder as opposed to trying to pee it out. But if you have a little bit of bladder function, then sometimes we can actually give you a bladder pacemaker that helps your bladder contract in a much more efficient manner, and therefore you're able to empty without having to use that catheter.

Dr. Jones: How about as people get older? I think of the elderly patient with what we call comorbidity, so they're older, they have diabetes, they have heart disease because it's affected their heart, maybe they had a stroke. Urinary incontinence is the number one reason to be admitted to a nursing home. So what do we do for older people? Can they do their own catheterizations, or is this something a family can help them with?

Dr. Lenherr: The complex patient with incontinence is definitely some of the more challenging cases that we have, and it's a balance between figuring out what the goals of care are. Some patients are very happy to have family help them catheterize if they need that to be done. Sometimes patients would rather not have their family members be going down there and helping them pass a catheter, and depending on how the bladder works, it can be a very good option to leave a chronic catheter in place.

Usually we try to place that in a suprapubic location, so right above the pubic bone below the belly button, and that helps drain the bladder and improves quality of life in a lot of patients. But these are really specialized conversations that we have with both the patients and their families to determine who is going to help out the patient and who is going to be able to help keep the patient safe and happy.

Some of the more rewarding conversations are having these discussions where you have patients understand these are my choices and this is what my goals of care are, and it's not always a quick fix, and it's not always the most complicated solution. Sometimes it just needs to be something simple that everyone agrees this is what I want to have my life be like, and I'm there to offer those solutions for them.

updated: November 24, 2021
originally published: December 23, 2015

Dr. Jones: Wait, can we stop at the next gas station? Yes, I know we stopped at the last one but this is your bladder speaking and maybe it's time to get some help. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is your bladder on The Scope.

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

Dr. Jones: Urinary incontinence is common in women, as many as 30% of women have incontinence for one reason or another. Babies moved your bladder around or you have an overactive bladder. Incontinence pads are a billion dollar business. But if your primary care provider can't help or you have more complicated medical issues maybe you need to see a urologist.

Today in The Scope Radio studio we'll be talking to Dr. Sara Lenherr. Dr. Lenherr is a urologist at the University of Utah and she's going to help us understand some of the more complicated reasons for bladder problems. She has a special interest in neurology, let's talk about how our brain and our bladder communicate.

Dr. Lenherr: The brain and the bladder have a really important communication process that needs to occur and basically the bladder is designed to store urine as a vessel until your brain tells it that it's okay to go to the bathroom, like when you're near a bathroom. And then the sphincter is designed to hold urine in place. Again, when you're able to get to the bathroom in time.

Sometimes in some medical conditions and other things that have happened with pelvic surgery or other types of vaginal deliveries with babies, that communication can get disrupted and so we need to pay special attention to that type of communication.

Dr. Jones: I always admired dogs who could put a little here and put a little there and do exactly what they wanted and when. But when that's not working I thought only men went to urologists. You know, for their prostate problems or those guy things. So urology for girls? For women?

Dr. Lenherr: So that is a really common perception and actually women have bladders too and they need to be pee too and urologists are specially trained to take care of the bladders pretty much exclusively and so we're here to help both men and women.

Dr. Jones: Great. So I'm an OBGYN and in our department we see a lot of women with urinary problems and we can fix a lot of them. But we're not very good for those women with complex medical problems. So can you talk a little bit about that?

Dr. Lenherr: So women have many different sorts of disorders that can disrupt the way the bladder works. The common ones are ones that disrupt the signals that go back and forth between the bladder and the brain. And also there are signals that make too much urine, so some women have heart disease which causes their kidneys to actually make urine and shift that around at the wrong time, and so they need to go more frequently and urgently because they're just making more urine.

There are many different types of conditions that affect the way the bladder works and really with an in-depth evaluation with a specialized urologist is really useful in order to figure out do we need to work on the bladder squeezing too much at the wrong time? Or is it a problem with the sphincter being too leaky, causing you to leak when you don't want to?

Dr. Jones: Well I can see that really takes some specialty training and you did a specialty fellowship in this area?

Dr. Lenherr: Yes, so there's a new specialty that came out a couple of years ago called, "Female Pelvic Medicine Reconstructive Urology" and we specialize in basically bladder function and how the bladder and the brain communicate. In order to evaluate how the bladder and the brain communicate frequently we perform what's called, "urodynamic evaluation" where we study the bladder pressures and the sphincter pressures, the urethral pressures, and figure out how they coordinate and communicate with different sensations.

Dr. Jones: Well we're really glad you're here at the University of Utah for all of us who are getting a little older, having a few more medical problems, and don't have the bladder that we want. Voluntary control of the bladder is a beautiful thing, but if it's not working for you, we and Dr. Lenherr can help.

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