Bladder Bowel and Sexual Disturbances

Disturbances of defecation and especially micturition are among the most disabling features of MS, occurring in up to 78% during the course of the illness (134). Patients may complain of urinary frequency, urgency, and incontinence. Alternatively, the urge to urinate may be accompanied by an inability to voluntarily initiate urine flow. History alone is an unreliable indicator of the physiological status of micturition and must be supplemented by further investigation (135,136). Usually, this requires only a determination of voided volume followed by measurement of residual urine volume, either by direct catheterization or by some other method for estimation, such as ultrasonography or radionuclide study (137). Disturbances of micturition may be divided into failure to store urine, failure to empty the bladder adequately, or a combination of both. In some patients, good contraction of the bladder detrusor is inappropriately associated with contraction of the external ure-thral sphincter, rather than relaxation. This condition, known as detrusor-external sphincter dyssynergia, may then lead to retention of urine and, particularly in males, to vesicoureteral reflux, with the threat of hydronephrosis and progressive renal failure (138). Retention of urine also increases the risk of urinary tract infection which, in turn, may suddenly precipitate urinary symptoms.

Bowel dysfunction in MS has received less attention than disturbances of micturition. However, studies have shown a prevalence rate of constipation ranging from 39% to 53% (139-142). The suggested causes include slow colonic transit due to autonomic dysfunction, abnormal rectal function, and intussuception (141-143). The problem is often compounded by a tendency of patients to reduce fluid intake in an attempt to decrease urinary frequency and urgency. In a recent survey of unselected outpatients, Hinds et al. (139) found that 51% of patients had experienced bowel incontinence at least once in the preceding three months, whereas 25% had experienced the symptom at least weekly. Fecal incontinence appeared to correlate with degree of disability, duration of disease, and the presence of urological symptoms.

Sexual symptoms are also common among MS patients. Men most often experience erectile dysfunction, but may also suffer from problems with ejaculation (135,144). These symptoms typically accompany abnormal micturition. Women most typically experience difficulty in achieving orgasm, but may also complain of problems with lubrication (145). Both men and women may also complain of diminished libido. In contrast, a recent case of episodic hyperlibidinism has been reported (146).

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