By W. Tufail. Westminster College, New Wilmington Pennsylvania. 2018.
It is important to remember that the bladder does not make urine—urine is made by the kidneys buy minocycline 50mg without prescription antimicrobial use density. It only occurs if infection of the blad- der is uncontrolled discount 50 mg minocycline antibiotics for sinus infection during first trimester, and is surprisingly uncommon in MS, which makes the routine kidney X-ray (intravenous pyelogram, or IVP) for the most part unnecessary. However, the risk of urine backing up from the bladder toward the kidney is increased in a man with a dyssynergic bladder (women usually do not experience this prob- lem because the pressures within the female bladder are lower). Management of Bladder Problems Bladder problems often may be managed with medications and/or other approaches. To determine the most appropriate mode of treat- 72 CHAPTER 10 • Bladder Symptoms ment, it first is necessary to distinguish between the spastic (failure to store), flaccid (failure to empty), and dyssynergic bladder. This is easily done by carefully recording the frequency of urination and the amounts of fluid urinated over a 48-hour period, followed by deter- mining how much urine remains in the bladder after voiding. The amount of this "residual" urine is measured by inserting a catheter into the bladder or by ultrasound technology after urination; a residual of less than 5 ounces (150 cc) indicates either a normal bladder or a small spastic bladder, whereas a larger amount indicates a flaccid bladder. The small spastic bladder is best treated with medications that "slow" the bladder by decreasing transmission in the nerves to the bladder that cause it to empty. These include oxybutynin (Ditropan®, Ditropan XL®), tolterodine tartrate (Detrol®, Detrol LA®), hyoscyamine (Levsinex®, Levbid®, Cystospaz®), flavoxate hydrochloride (Urispas®), imipramine (Tofranil®), and several medications that are used for the "runny" nose of a cold. These medications lengthen the intervals between urination and decrease urgency, thus allowing for more time to reach the bathroom and avoiding dribbling and incontinence. Treatment of the flaccid bladder is not as simple, and manage- ment frequently relies on alternative techniques for bladder emp- tying rather than on medication. One common method that facili- tates more complete bladder emptying is the Credé technique of bladder massage. This technique involves applying downward pres- sure to the lower abdomen with both hands while bearing down after as much urine as possible has been voided naturally; it is nec- essary for men to sit while using the technique. This technique should not be used in the dyssynergic bladder because the urine may back up into the kidneys. This mainly is a problem in men because pressure is much lower in the female bladder. If the bladder cannot be emptied sufficiently by the Credé tech- nique, intermittent self-catheterization may be used for more com- plete bladder emptying. A small tube, or catheter, is inserted through the urethra into the bladder to allow the urine to drain out. This may seem rather complicated, but actually it is simple to learn and it poses no risk. It allows a person to empty the bladder at planned 73 PART II • Managing MS Symptoms intervals, thus avoiding dribbling or incontinence. The frequency of self-catheterization varies from person to person but generally need not be done more frequently than every four to six hours. Medications such as oxybutynin frequently are used in conjunction with self-catheterization to allow the bladder to fill more complete- ly and to decrease the need to urinate between catheterizations. As mentioned previously, conflict or dyssynergia often is com- bined with either a spastic bladder or a flaccid bladder. Initial treat- ment based on the 48-hour diary is aimed at either spasticity or flaccidity; if the previously described techniques do not provide adequate control, it becomes apparent that the bladder wall and the sphincter are not functioning in a coordinated fashion. Occasionally, formal testing with a "bladder analysis machine’’ (cystometer) is needed to accurately pinpoint the source of the problem. The problem may be helped by the addition of an alpha blocker to the treatment regimen. Most alpha blockers were devel- oped to aid in the treatment of high blood pressure, but they also help the bladder work in a more coordinated manner. Phenoxybenzamine (Dibenzyline®), clonidine, and terazosin (Hytrin®) are alpha blockers that improve coordination and increase bladder control. One approach to this problem involves the use of a medica- tion called DDAVP (desmopressin), a hormone that slows the pro- duction of urine by the kidneys. One or two pills decrease urine formation during the night and decrease the chances of a wet bed.
If this recognition process goes wrong minocycline 50mg for sale antibiotic resistance zoology to the rescue, then an ‘autoimmune’ attack of the body’s own tissue is likely to occur discount minocycline 50 mg amex bacterial chromosome, as in MS. The genes under investigation here that perform this recognition function – ‘histocompatibility genes’ – are usually RESEARCH 199 either HLA (human leukocyte antigen) genes, or MHC (major histocompatibility) genes. Although there is much detailed research still to be undertaken, it appears likely that a combination of genes controlling these lymphocytes and related immune activity produces a susceptibility in people with MS to the disease, although other triggering factors, perhaps environmentally determined, may be necessary for the onset of the disease. Research on viruses and MS The relationship of viruses to MS has been the subject of much research over the past two decades, and causes an equal amount of controversy. Almost every year, it has been claimed that a virus speciﬁc to the cause of MS has been discovered. However, none of these claims has been sustained after further extensive investigation. Does a virus cause MS, or does a weakened immune system have the effect of making the body more susceptible to attack by viruses? Most researchers believe the latter to be the case, but an existing faulty recognition process in the immune system may either also fail to recognize (and thus attack) an invading virus, or such a virus may, through the same process, accelerate the body’s own attack on itself. In this respect recent work on viruses is being linked to other research on malfunctioning immune systems, and genetic research is also continuing. Regeneration of myelin This research area – trying to regenerate myelin – has been signiﬁcant over the past few years. The cells that produce myelin are called ‘oligodendrocytes’, one of a family of what are described as ‘glial cells’. If the life of oligodendrocytes could be fully understood, as well as their role in the formation and repair of myelin, then an attempt to encourage their revitalization in MS could be made. This research process has also involved investigating exactly how the nervous system responds to myelin damage and how scar tissue is formed, as well as estimating what effects regeneration of myelin might have. Research on myelin damage and possible regeneration is yet another story of an initially hopeful scientiﬁc development followed by major disappointment. For some time it was thought that myelin could not be 200 MANAGING YOUR MULTIPLE SCLEROSIS regenerated at all, and then more sophisticated techniques indicated that myelin repair did occur in MS, although it was very slow and weak – and was not enough to compensate for the original damage. Now scientists are concentrating on seeing whether and how this process of repair might be made more effective. The importance of this research is the knowledge that, even if myelin has been lost (and thus messages along the nerves are malfunctioning), the underlying nervous tissue is almost certainly still intact, at least in the early stages of MS; thus, if it was reinsulated (remyelinated), it may well be able to function normally. Animal models have suggested that remyelination is possible in such a way as to restore some functions originally lost. Strategies have included: • using substances called growth factors to enhance the actions of myelin-producing cells; • trying to inhibit other processes that weaken the actions of those cells, or • in a more adventurous way, investigating the possibility of transplanting cells to produce myelin. There are a number of substances being tested on humans to assist remyelination, although the lessons of the disappointments of equally promising possibilities arising from animal work with EAE (see above) are important to bear in mind. It is also important to say that most of the remyelinating strategies are essentially compensatory ones, i. In addition for those with long-standing MS, the underlying nervous tissue will probably have been damaged, as well as the myelin coating of that tissue. The most important source of reliable and accurate scientiﬁc research on MS is that contained in the peer-reviewed scientiﬁc, and especially neurological, journals. Usually these are not obtainable directly except in specialist medical libraries, but recent key issues and ﬁndings on MS from the journals can be obtained through computer searches, often through ordinary libraries, using one of the major medical databases such as RESEARCH 201 ‘Medline’. Increasingly the MS Society in Britain, and the MS Society in the United States are putting out press statements and information on major current research issues, often highlighting advances in their regular Newsletters. If you have access to the World Wide Web, there are now all sorts of possibilities of keeping track of new research. These include: • the websites of the MS Society in Britain and the United States; • the website of MS Trust, which is fast, efﬁcient and up to date; • using one of the ‘search engines’ on the Web to trawl for updates on MS, and other sources of information; • joining ones of the growing number of Newsgroups in which people exchange information about new developments and other issues about MS. These latter groups are particularly important in terms of contact with other people with MS, and are often likely to be amongst the ﬁrst sources of information about all kinds of developments, both scientiﬁc and non-scientiﬁc. Web addresses are currently changing too fast to permit any sensible listing here, but one source which is likely to be with us for sometime is the Usenet News Group at news://alt.
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