Articles on Medical Diseases and Conditions

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  • Managing Your Cholesterol Level

    Cholesterol, also called blood cholesterol, is a natural waxy sub- stance that occurs in all your body cells. It is one of several types
    of fats (lipids) that circulate in your bloodstream. Your body uses it to form cell membranes and to make certain hormones, and therefore at healthy levels it is an essential component of cells and blood. Your liver makes as much cholesterol as your body needs—about 1,000 milligrams (mg) per day.
    You consume cholesterol (dietary cholesterol) in the foods you eat, especially animal products such as meats, eggs, and dairy foods. If cho- lesterol levels are high, cholesterol can be deposited in the blood vessel walls as a major component of plaque (a fatty deposit). A buildup of plaque restricts the blood ?ow, a process called atherosclerosis, and puts you at greatly increased risk of heart disease.
    Triglycerides are the true blood fat that exists in the body as well as in food. Triglycerides circulate in your blood along with cholesterol and are fuel for your body’s energy production. Together, cholesterol and triglycerides in the blood are called plasma lipids. Excess calories that you consume in foods are converted to triglycerides and are carried to fat cells for storage. In between meals, hormones control the release of triglycerides to meet your body’s need for energy. Like cholesterol, triglycerides can build up in the blood and contribute to atherosclerosis.

    Because neither cholesterol nor triglycerides can dissolve in the blood, they have to be moved to and from cells by carriers called lipoproteins. The two most common types, the ones you hear the most about, are low-density lipoproteins (LDL), the “bad cholesterol,” and high-density lipoproteins (HDL), the “good cholesterol.” LDLs have a lower density of protein (about 25 percent) and more cholesterol. HDLs have a higher density of protein (about 50 percent) and less cholesterol.
    If too much LDL accumulates in your blood, it causes fatty plaque to collect on your arterial walls, and the process of atherosclerosis begins. If the buildup reduces blood ?ow in the arteries that supply your heart, you may experience the chest pains known as angina. If a blood clot forms near the plaque and stops the blood ?ow, you have a heart attack. If a clot blocks blood ?ow to your brain, you have a stroke. Your LDL levels increase when you consume foods that contain lots of fat, choles- terol, or both. Foods rich in saturated fats and trans fats, such as butter fat, cheese, red meat, processed meats, and bakery goods, are the most harmful, along with tropical oils found in some products like crackers (see also pages 27–29).
    High-density lipoproteins carry cholesterol back from your cells to your liver, where it can be passed out of the body. Most doctors think that HDL can actually slow down the development of plaque by remov- ing cholesterol from it. A high level of HDL seems to protect against heart attack, and a low level places you at greater risk of heart attack and stroke.

    Cholesterol transport
    5Your liver produces blood cholesterol, a waxy substance that your body uses to build cells and make hormones, and you consume additional cholesterol in foods. Cholesterol is trans- ported to cells through the bloodstream on carrier particles called lipoproteins. Low-density lipoprotein (LDL) consists of
    less protein and more cholesterol, and it can be harmful at high levels when it builds up on the walls of your arteries as plaque. Very low-density lipoprotein (VLDL) is another form of choles- terol that can convert to LDL and cause problems. High-density lipoprotein (HDL; shown as smaller units), which consists of more protein and less cholesterol, can absorb some of the cho- lesterol in plaque and return it to the liver to be excreted. So you need to try to reach a high enough level for HDL in your bloodstream to help protect against heart attack and stroke.

  • Risk Factors for Heart Disease

    Some risk factors for heart disease are within your control, while others are not. The number of risk factors that affect you may change over the course of your lifetime. Having one or more of the major, proven risk factors doesn’t mean that you will develop cardiovascular disease or die of it. But generally, the more of these factors that apply to you, the more likely you are to develop the disease at some point. By knowing your own constellation of risk factors, you can control as many as possible and reduce your risk. These are the factors you can’t control:

    •Gender. Men are more likely than women to have a heart attack at a younger age. Women are generally protected from heart disease by their sex hormones until menopause. Cardiovasculardisease is still the leading cause of death for women, however. After menopause, a woman’s risk of heart disease starts to rise. After the age of 65, a woman’s chance of having coronary artery disease is about the same as a man’s, and after 75, a woman is at even greater risk than a man is.
    • Increasing age. Your risk of disease increases as you grow older.
    More than 80 percent of people who die from heart disease are over 65. As you age, your heart’s function tends to weaken. The heart is less able to pump blood, the walls of the heart may thicken, and the walls of the arteries may stiffen and narrow. In addition to atherosclerosis, other conditions such as hypertension may compound the problem. Clearly this process is affected by lifestyle, including diet and exercise.
    • Heredity. Cardiovascular disease runs in families, and you are more likely to develop it if your parents or siblings have coronary artery disease. Increased risk is linked to a family history of death from heart disease at a young age. Speci?cally, this is de?ned as coronary artery disease in men before age 55 and women before age 65. Your racial or ethnic background is another aspect of your heredity. In the United States, blacks are at higher risk than whites, in part because of higher rates of high blood pressure. The risk of heart disease is also somewhat higher in Mexican Americans and native Hawaiians. You can’t change your heredity, but it gives you strong motivation to manage other factors that you can change.
    The major proven risk factors for heart disease that you can modify, control, or treat are:
    • High blood cholesterol. High blood cholesterol directly increases your risk of heart disease. Cholesterol is a fatlike sub- stance that is carried in your blood, but excess cholesterol enters your body through foods derived from animals (meat, eggs, dairy products).
    • High blood pressure (hypertension). High blood pressure increases your risk of several forms of cardiovascular disease: coro- nary artery disease, heart attack, kidney failure, congestive heart failure, and stroke. Other factors, such as obesity, alcohol abuse, unhealthy diet, or physical inactivity can contribute to high blood pressure, but you can also have it independent of those other in?u- ences. (See chapter 3.)

    Obesity and overweight. Excess body fat contributes to the risk of heart dis- ease, independent of other risk factors, because it increases the heart’s work- load. It also raises blood pressure, adversely affects cholesterol levels, and contributes to the development of dia- betes.
    • Physical inactivity. An inactive lifestyle increases the risk of becoming overweight and developing high blood cholesterol levels, high blood pressure, and diabetes. Even moderate amounts of regular exercise will lower your risk of heart disease.
    • Type 2 diabetes. Having diabetes puts you at serious risk; about 65 to 75 per- cent of people with diabetes die from some form of cardiovascular disease. Controlling your diabetes may help control your risk of heart problems.
    • Smoking. If you smoke, you are more likely to develop cardiovascular disease than a nonsmoker is—in addition to the

    Heart Disease and Genetics

    Because heart disease tends to run in fami- lies, having parents or siblings with the dis- ease is a major risk factor. But there is no single gene for cardiovascular disease; in fact, geneticists think that more than a thousand separate genes may influence the overall cardiovascular system. There are separate genes for obesity, high blood pressure, and diabetes, all risk factors for heart disease. Scientists are still identifying these genes and studying how they interact with one another—and with other influences such as diet—in an individual or a family. Many geneticists believe that one of the most effec- tive approaches for a person at high genetic risk of heart disease is to ensure that the per- son follows a healthy lifestyle.
    Other avenues of research include devel- oping drugs that target a specific genetic pre- disposition, along with developing genetic tests that can screen for high-risk patients. The ultimate implications of genetic research for testing and treatment of heart disease are still far in the future.

    risk of lung cancer. Smoking increases your heart rate, constricts your arteries and contributes to their obstruction with plaque, and can cause irregular heartbeat. It also increases your risk of blood clots, which cause heart attack or stroke. Even exposure to other people’s smoke increases a person’s risk of heart disease.
    • Early menopause. Women who have early menopause, whether naturally or as a result of surgery, have a higher risk of coronary artery disease.
    Other in?uences, called contributing factors, are linked to heart dis- ease, but their signi?cance is not fully understood or measured yet. These factors are:
    • Stress. Stress, particularly in some people, appears to increase the risk of heart problems, perhaps because it raises your heart rate and blood pressure, damaging your arteries over time. It may also

    contribute to other harmful behaviors such as overeating, smok- ing, or drinking too much.
    • Alcohol. Drinking more than a moderate amount of alcohol can raise blood pressure, negatively affect cholesterol and triglyceride (blood fats) levels, and cause irregular heartbeats. However, mod- est amounts of alcohol may actually reduce the risk of heart dis- ease. Since so many Americans drink to excess, doctors are reluctant to recommend moderate drinking to improve heart health, for fear that “moderate” usage will change to “excessive” use. Alcohol, whether wine, beer, or liquor, but only in moderate amounts, may be helpful to your health.
    • Birth control pills. If you smoke or have high blood pressure, and especially if you are over 35, birth control pills may increase your risk of heart disease. Today’s birth control pills contain much lower levels of hormones than early ones and are generally consid- ered safe, independent of other risk factors. You should not smoke and take birth control pills, especially over age 35, due to the increased risk of heart attack and blood clots.

  • Preventing Heart Disease

    Cardiovascular disease is the leading cause of death of men and women in the United States. Cancer, the second most common killer, accounts for the deaths of only half as many people. Heart and blood vessel dis- ease takes many forms: high blood pressure, coronary artery disease, valvular heart disease, congestive heart failure, atherosclerosis, and stroke. Because of the enormous toll that the burden of these diseases has taken on the nation’s health, extensive research has focused on preventing these problems. Over a period of decades, numerous studies involving hundreds of thousands of people have identi?ed the major risk factors that indicate an individual’s chances of developing cardiovascu- lar disease. Understanding these risk factors and how you can control them gives you a good chance to prevent or modify heart disease in your own body. Even though cardiovascular disease is still a major threat, the death rates today are substantially lower than they were because so many people have been able to make effective changes in their lifestyle that prevent the development or the worsening of the disease.
    These preventive changes—including how we eat, how physically active we are, and how we approach risky habits like smoking or drinking—make common sense in part because of the nature of heart disease and its treatment. Cardiovascular disease develops slowly and often without symptoms. Factors such as cholesterol buildup or rising blood pressure can start in childhood but may not become apparent as disease for decades, so prevention is the best answer.
    About half the deaths from heart disease are sudden—an unexpected fatal occurrence that leaves little opportunity for intervention. Many treatments—for instance, the coronary artery bypass procedures that have become so common—can have side effects and are inappropriate to perform on every person at risk. Other technologies, such as balloon angioplasty or drugs, can treat a problem, but they cannot stop the underlying disease process.
    Most positively, the picture that emerges from decades of research is that the healthy lifestyle choices that prevent heart disease also reduce the risk of other major diseases such as cancer and diabetes.

  • The Heart and Other Body Systems

    Your heart beats and your blood circulates with little or no conscious awareness on your part. Even though circulation is an involuntary function, it is a dynamic one. Your cardiovascular system is constantly adjusting to changes in the external environment or to demands you place on it. It adapts quickly, or directs other systems to adapt to chang- ing conditions in order to maintain a constant ?ow of blood to body tis- sues. Even the simple act of standing up requires increased blood ?ow to the legs, because the heart must work harder to counteract the effects of gravity. This means that either blood ?ow to other parts of the body must be decreased or the heart must pump blood faster or in greater volume to accommodate the activity.
    The two main systems that help regulate cardiac function are ?rst, the brain and the nervous system, and second, the kidneys.

    The Brain and the Nervous System

    Nervous system receptors throughout your body constantly gather information about factors such as stretching of the arterial walls or the amount of oxygen in the blood. This information is relayed to the brain by chemicals called neurotransmitters. In the brain stem, at the base of the brain, regulatory centers involved with automatic body functions including heart rate, blood pressure, and respiration receive the mes- sages and formulate a response. Neurotransmitters such as adrenaline carry messages back that direct a response in the target tissue, such as commands to constrict the blood vessels or increase the rate of respira- tion to deliver more oxygen to your lungs.

    The Kidneys

    The kidneys in?uence the volume of ?uids in the body, so they can change the volume of circulating blood. In this way, they signi?cantly affect blood pressure. They release enzymes that can raise blood pres- sure by constricting blood vessels, raising sodium levels, and increasing water retention. The kidneys can adapt to changing environmental conditions by, for instance, concentrating your urine if your body is dehydrated. If, on the other hand, you eat a lot of salty foods and start to retain water, your kidneys will produce less urine.

  • Bowel function

    Even for people without Multiple Sclerosis, constipation is a very common problem, as evidenced by the number of remedies available in chemist shops, but there are some special issues that may make constipation worse, more frequent, more continuous or, indeed, more problematic for people with MS.
    Until a few years ago problems with bowel function were thought to be relatively minor; however, recent research studies, as well as the views of people with MS, have clearly indicated that these can be a real problem. The most common issue is constipation – that is infrequent, incomplete or difficult bowel movements. There may also difficulties with bowel urgency, where there is a need to pass a stool immediately or urgently, or with bowel incontinence, where control of defaecation is ef fectively reduced or lost.

    Constipation

    Constipation is problematic in MS because it can make other symptoms, such as spasticity and urinary difficulties, worse as well as producing pain or discomfort. Constipation may result from several causes in MS:

    • Demyelination may reduce the speed with which the movement passes through the bowel; as moisture is drawn from the stool continuously, the lower the speed, the more the movement becomes dry and hard and difficult to pass.
    • You may have decreased sensation in your bowel or rectal area thus not realizing that a bowel movement is needed, and therefore the stool is left in your bowel for a very long time.
    • You may have too low a fluid intake thus making the stool dry and hard.
    • You may have weakened those muscles that push the stool out and thus have difficulty in this respect.
    • In some cases drugs for other symptoms or for the MS itself may affect either the dryness of the stool, or the capacity to push it out.

    When MS becomes more severe, it is much more likely that people with the disease will have difficulty evacuating their bowels, as various
    body systems linked to this process become less efficient. You may need to undergo detailed medical investigation and get help for this problem.
    For most people with Multiple Sclerosis who have constipation, especially in the earlier stages of the disease, the advice is very similar to that for other people with the same problem. In particular:

    • Your diet should be high in fibre (e.g. bran, cereals, fruit and vegetables), which allows stools to pass more easily through the intestinal tract.
    • Fluid intake should also be increased for the same reason.
    • Getting as much exercise as possible can help, although clearly this particular advice will be less easy to follow by those who are bed- bound or using wheelchairs. In this latter case seek advice from your physiotherapist.
    • Proprietary bulking agents (such as Fibogel, Metamucil, Mucasil), and stool softeners, can help produce regular motions.
    • You could use laxatives, suppositories or enemas occasionally if all else fails, but be careful about using any of these too regularly, because they can actually increase constipation if overused, by slowing down natural bowel function still further.
    • Finally, make time for regular daily bowel habits (see below).

    As medical and related products are often readily available and may be recommended by some to deal with various problems associated with constipation, it is important to describe briefly some of these products.

    • Bulk formers. These are useful when there is inadequate bulk in the motion. They add moisture and content to the stool. The bulk formers should be taken with a couple of glasses of water. They distend the gastrointestinal tract making the passage of stools easier. Motions should pass through in a day or so after their use. Bulk formers are not habit forming and can be used regularly.
    • Stool softeners. If the cause of the constipation is a hard stool, which is difficult to pass, then a stool softener can draw increasing moisture into the stool from body tissues therefore softening it and helping elimination. Again these are not habit forming and can be used regularly
    • Laxatives. These should be used only occasionally; they are not only very habit forming, but also lead to a weakening of the remaining muscular control of the bowel. Harsh laxatives in particular should be avoided, because basically they are chemical irritants of the bowel tract. Softer laxatives, which should only be taken occasionally, can lead to passing motions in 10–12 hours.
    • Suppositories. These, placed in the rectum, both provide chemical stimulation and lubrication. They may be used occasionally to stimulate a bowel movement.
    • Enemas. These should be used only very occasionally because the bowel may become dependent on them if they are used frequently.

    You may have to be patient to try and find the right combination of strategies that works for you. It is likely that a successful overall strategy will consist of a good fluid intake, a diet with high fibre, as much exercise as possible, and a regular time for a bowel movement – 30 minutes after a meal is usually the most opportune time.

    Faecal incontinence

    This has been a neglected area in Multiple Sclerosis. Recent research has revealed that something like two-thirds of people with MS have some bowel problems and, over several months, nearly half, in one study, had some degree of what is described as ‘faecal’ or ‘bowel incontinence’. Of course, what appears to be an involuntary release of faeces produces a very unpleasant situation. There may be a link between urinary and bowel incontinence (from weakened muscles, from spasms in the intestinal area induced by MS, or from a full bowel pressing on the bladder), but the link is not always clear.
    The exact causes of bowel incontinence are not always easy to find, even in the few centres with special facilities for investigating these issues, but there are several pointers to what may be happening in many cases. Involuntary spasms in the muscles affecting the bowel area are probably the most common causes of such incontinence. Sensation may be reduced in the bowel area and you may not be aware that there has been a build-up of faecal material, until an involuntary movement of the anal sphincter occurs. Prior constipation might lead to this build-up and release of faecal material, as well as a lack of coordination in the muscles controlling bowel movements.
    There are a number of ways in which the problems of faecal incontinence may be helped. It is important to ensure that you have bowel movements (and thus bowel evacuation) on a regular basis. You should avoid substances that irritate the bowels such as alcohol, caffeine, spicy foods, and any other triggers to involuntary bowel action that you can identify. For such a symptom, antibiotics may be a trigger, thus you need to avoid their unnecessary use. It is also important to eliminate the possibility that the faecal incontinence is caused by a bowel infection – to test for this possibility you will need to consult your doctor.

    Spasms


    Stabbing pains in your midrif f may be caused by ‘bowel’ or ‘colon spasms’. These are due to either Multiple Sclerosis directly or changes in bowel function and regularity. Changes in diet and supplementary bulking agents may be all that is required to deal with this problem. If it persists, then antispasmodic drugs may calm your bowel or colon.

    Management techniques

    Although constipation and bowel incontinence may look like two separate problems, often they may be linked, so initially it is a good idea to try similar management. This involves establishing what is often known technically as a ‘bowel regimen’. In addition to checking your diet, making a regular time of day in which you try and have a bowel movement can be very helpful. Once this regular time is established, it is important that you stick to it – even though you may not feel the urge to go. You may find that drinking some warm liquid, such as tea, coffee or water, will help. This ‘retraining’ is not an easy task and may take some weeks or even months to achieve, but there is some evidence that it can reduce both constipation and bowel incontinence.
    You can undergo some complex tests for difficult problems with bowel incontinence, but there are still relatively few specialist centres to assess and help manage these problems. Thus for most people with MS, a tried and tested combination of everyday techniques will probably be a good first step.

  • Related problems

    For most younger people (those in their 50s and below), the urinary symptoms caused by Multiple Sclerosis will probably be far more significant than those arising from other causes, and thus the focus should mainly be on these. However, there are some circumstances that may be associated with an increased likelihood of urinary problems.

    Men and prostate problems
    As men get older, some have problems from prostate gland enlargement. This gland surrounds the neck of the bladder and the beginning of the urethra. By the age of 60, it is enlarged in some 60% of men, and the proportion increases even more with age. Very often, the symptoms of an enlarged prostate develop slowly, but as they can echo some urinary symptoms caused by MS – particularly increased urinary frequency, urgency and nocturia – it may be difficult to separate the causes without investigation. As with other symptoms, it is important that specific causes are found, if possible, so that they can be appropriately managed. As the life expectancy of people with MS increases, more men may find that an enlarged prostate gland makes some of their urinary symptoms worse.

    Childbirth
    Recent research has also shown that urinary problems may occur earlier in life for some women following a difficult or problematic childbirth. The control of urination is a frequent minor problem following childbirth. It is not clear how such problems interact with
    those of MS. However, many techniques of management indicated in this section can be used, although it would be wise for women who feel their pregnancy and childbirth has affected their bladder control to seek professional help and advice.

  • Managing urinary symptoms

    The management of urinary symptoms can take various forms, depending on the diagnosis of the problem. In most cases initially this can result in a combination of strategies including:

    • lifestyle changes (changing your everyday routines)
    • specific exercises and bladder training
    • using a continence product (e.g. absorbent pads) occasionally or regularly
    • taking appropriate prescribed drugs.

    In relation to more serious urinary symptoms, additional measures may be necessary including:

    • catheterization – either intermittent self-catheterization, or on occasions a more permanent indwelling catheter
    • surgical intervention.

    Problems of frequency and urgency
    These are two of the most troubling symptoms for people with MS. The issue of urinary urgency, often combined with wanting to urinate more frequently is one of the most difficult problems for people with MS earlier in the disease. It is usually caused by the bladder not storing the urine properly, or a lack of coordination between the storage and emptying process. It is wise to plan ahead whenever you leave home, and ensure that there are always toilet facilities within easy reach, but there are other aids.
    As a self-management technique, pelvic floor exercises help to tone the muscles in and around your urinary system. This is sometimes called
    ‘bladder squeezing’ and helps to decrease frequency and urgency problems in some people. As a general rule, exercising your pelvic floor muscles is a very good idea, although other help may well be required. If the frequency and urgency continues to be a problem, which they may well do so, you may have to turn to drugs.
    In effect many of the drugs which are used ‘slow’ the bladder by decreasing the transmissions to the nerves causing the bladder to empty. Oxybutin chloride (Ditropan) is an ‘anticholinergic’ drug that, in effect, blocks the nerve signals that trigger the muscles to release urine. This can be very effective, but is also associated with side effects, such as a dry mouth, because the drug blocks the nerve signals to the salivary glands as well. Indeed, without a dry mouth, it may be that the dose is too low. Unfortunately, you may become constipated, and at very high doses there may be problems with your sight. Often you have to experiment under the guidance of your doctor to find the most appropriate dose level controlling frequency and urgency with minimal other side effects. Another anticholinergic drug, propantheline, can be used, although trials have shown it to be slightly less effective than oxybutin. An antidepressant such as imipramine (Tofranil) may also be prescribed – not for depression, but because it has been found to have an effect in controlling urgency.
    More recently, a drug called capsaicin – derived from red chilli peppers
    – has been found effective in people with MS with relatively serious incontinence, who might find the side effects of the anticholinergic drugs unacceptable. Although this drug is still under evaluation for long-term safety and effectiveness, it appears to provide good control for quite long periods of time, i.e. 3 or 4 months from one administration usually in a hospital. It is not yet widely available, and it appears initially to make symptoms worse rather than better, before it takes full effect. So some people have to be ‘catheterized’ (see below) for the first few days after the administration. So far, people who have used it have found it sufficiently beneficial to come back for further administrations of the drug. Other natural products like ginger have also been tried. There is a vast amount of information on the internet that can be perused, but many of the studies have not been proven scientifically.
    You may not need to take one of these drugs continuously, but you could use it for a particularly important event or journey when you need to avoid urinating for some time. For peace of mind on particular occasions, you could use a protective pad to absorb urine, in case you have ‘an accident’. As a final point, people who have urinary problems often also have mobility problems – the nerves controlling both legs and the urinary system are situated close together – so the difficulties experienced through frequency and urgency are often compounded.

    Nocturia
    Another problematic symptom for many people with MS is that they may have to get up to urinate several times in the night. Nocturia, as this problem is known, is quite common. The usual medication for nocturia is desmopressin (DDAVP Nasal Spray) which reduces urine formation. There are some circumstances where the drug should be used only very cautiously, or not at all – for example, in people with kidney or heart disease, or in older people. The antidepressant, imipramine (Tofranil), mentioned above in relation to treating urgency and frequency, taken just before going to bed, has also been found to be effective in many cases.

    Incontinence
    Incontinence, what appears to be the involuntary release of urine, may be a slight and an occasional problem in MS, or it may prove to be a continuous problem. However, in each case it provokes anxiety and concern, for socially as much as physically it can be a difficult and embarrassing symptom to have occur unexpectedly. This can be caused by a number of separate problems. Bladder spasms may be causing this difficulty – technically called ‘incontinence’ – or your bladder muscle
    may be so weak that you have released urine before realizing it. In addition, sometimes you might not at first realize that you are wet because of reduced sensations in your pubic area.
    The first step where minor and occasional incontinence is concerned is, as a means of ‘insurance’, to use a protective pad. Sanitary protection (absorbent pads) can be used, even if only for maintaining confidence when you are not near a convenient toilet. Pads and liners are available in a wide variety of shapes and styles to suit different people and different clothing styles, but there is much less choice when they are supplied on prescription. Waterproof undersheets and absorbent bed sheets can also be very convenient, to minimize the effect of occasional accidents.
    If these procedures and/or the drugs mentioned above in relation to urgency and frequency do not work, other professional investigations may well be needed to determine the cause of the problems, and how best they might be managed.

    Catheterization
    Although your major concern may be incontinence, there may also a problem with urine retention in the bladder as well – for the bladder may not completely empty, which can lead to serious infection. Thus as an extra precaution, if one of the causes of the incontinence is retention of urine in your bladder, the use of ‘intermittent self-catheterization’ (ISC) might help (Figure 4.1).

    Self-cetheterization

    Figure 4.1 Self-catheterization.

    ISC is used to ensure that the retained urine is regularly voided. Although you can do it yourself, a carer can also help you. A catheter (a thin plastic tube) is threaded through your urethra – the opening at tip of the penis, or just above the vagina – into your bladder, and this drains any remaining urine. You will need to wash yourself thoroughly before using this technique, and you may need to use a lubricant (something like K-Y Jelly) to assist the access of the tube, but modern catheters are low friction types and need no lubricant (such as
    ‘Lofric’ and ‘Speedicath’ types). You withdraw the catheter as the urine begins to stop. You should not use a catheter (tube) which appears to be worn, stiff or damaged in any way. You can do it while sitting on the toilet, or lying down. Undertaken regularly, several times a day, this method usually helps substantially. A nurse or doctor will explain how to undertake this procedure, and how to clean the catheter thoroughly. For the most part, although the procedure may seem very difficult, many people adapt well to it, as long as it is seen as a routine process. If you are able to write and to feed yourself, even if you have some eyesight problems, ISC should be possible. There is another reason why ISC can be of value, in that regularly undertaken, it is a means of ‘training’ the bladder to fill and empty as the urine is released: the bladder muscle contracts, expanding again as urine fills the bladder.

    Urine retention and voiding problems
    As we have noted above, many people with MS have problems not only with urgency or frequency, but also with some urine retention in the bladder. If this is the case, do not reduce your fluid intake substantially, because this will increase the risk of urinary infection (urine as a waste product is not being diluted). A useful rule of thumb is the color of your urine: if it is dark yellow to brown in colour, then almost certainly you are not taking in enough fluid.
    There are some useful guidelines which should help you:

    • Drink at least 2 litres (or just over 3 pints) of liquid a day.
    • In general, an acid urine helps keep infections at bay.
    • Decrease your intake of citrus fruits/juices.
    • Foods and substances that neutralize acidity, including antacid preparations, such as sodium bicarbonate, should be eaten less often, as should dried vegetables.
    • Increase your intake of proteins.
    • Drink cranberry juice, and eat plums and prunes regularly.
    Cranberry juice will also help to provide the vitamin C lost through reducing the intake of citrus fruits/juices.

    Hesitancy and ‘full bladder’ feeling
    Although this is a frustrating problem, often urination will start after a couple of minutes, so be patient! Sometimes tapping very lightly on your lower abdomen – but not too hard – will help; this often produces a reflex reaction of urination.
    There have recently been trials of a hand-held vibrating device which, when held against your lower abdomen if you are still sensitive in this area, seems to work quite well by increasing urinary flow and leaving less urine in your bladder. It is probably most useful for people with relatively mild MS.
    Of course, other time-honoured techniques may work, including turning a tap on and hearing the sound of running water! A more direct method is to stimulate the urethra gently, at the tip of the penis or just above the vagina, with a clean finger or damp tissue.
    If you have the feeling that your bladder is still full, this may need further investigation. It is important that your bladder is as empty as possible after you have urinated, not least to try and avoid an infection. Intermittent self-catheterization (ISC) may help, as may anticholinergic drugs. If you need further advice, make an appointment to see your doctor or, if possible, your neurologist or continence nurse/advisor.

    Urinary tract infection
    If urination is painful or associated with a burning sensation, and even more so if it smells unpleasant and is cloudy, the chances are that you have a urinary infection. In this case seek medical advice as soon as possible. In the meantime you should try and increase your fluid intake.
    Kidney infections are particularly worrying in MS: they may be associated with both abdominal pain and a high fever, and require a tougher drug approach, perhaps with intravenous antibiotics. The problem is that, once infections get a hold in the kidneys, there is a substantial risk that they pass unchecked into the bloodstream, and cause major, even on occasions life-threatening, difficulties. You may also experience increased frequency and urgency with an infection. On the other hand some urinary infections in MS can be almost symptomless, and thus periodically – and especially if you feel that you suffer from some problems of urine retention – ask your doctor if you could have a urine test for infections just to make sure.
    For people who seem particularly liable to urinary tract infections, a long-term low-dose antibiotic might be given occasionally to eliminate or suppress bacteria.

    General precautionary steps to prevent bladder infection could include:

    • Attempting to empty to bladder as often as possible – holding urine in the bladder for long periods should be avoided.
    • Women should be careful to wipe from front to back and to avoid underclothes made of synthetic materials, which can trap infection. It is also a wise precaution to empty your bladder both before and after sexual intercourse.
    • You need to ensure that you take adequate amounts of fluid (see above).
    • You might also consider taking substantial does of vitamin C because this will make your urine more acid and less liable to bacterial growth.

    Indwelling catheterization
    When urinary difficulties become a real problem, a permanent catheter can be fitted. Although some may think this is more convenient, it is not an easy step to take for many others; some actually think of it as the hidden equivalent of being in a wheelchair. Furthermore, medically, it is best if some other way can be found to manage urinary problems. An indwelling catheter opens up the inside of the body to the continual possibility of infections from which it is normally protected, even during ISC, and it can be particularly dangerous if you have a weakened immune system. Therefore, in principle, the less time that people with MS use an indwelling catheter, the better. If the MS becomes more severe, there may be no option, particularly when you cannot undertake ISC, or when drugs or other strategies do not appear to deal with the problem.
    How it works. An indwelling catheter can be inserted through the urethra (like ISC), or through a specially constructed surgical opening in the lower abdomen, above the pubic bones (‘suprapubic catheterization’). Whichever route is chosen, the catheter is inserted into the bladder, and then a small attached balloon is inflated (which you won’t feel) and filled with sterile water in the bladder itself. Through the other end, on the outside of the body, urine is continuously drained into a collection bag.
    Increasingly, the medical preference is to insert the catheter through the special opening in the lower abdomen. This is because a permanent catheter through the urethra may enlarge, change or disrupt the urethral opening, and make it difficult to maintain control of the urine. An indwelling catheter like this can cause problems with sexual activity and we deal with this elsewhere in Chapter 5. Even if a catheter is inserted through the lower abdomen, there are still likely to be some problems:

    • Infection can occur around the site of the insertion.
    • The catheter can periodically become blocked.
    • The catheter needs to be changed every few weeks, and sometimes more frequently.
    • Kidney stones can form.
    • Catheters can sometimes become detached or loosened and thus require monitoring; this has to be done by someone else if your MS is severe.

    It is important to increase fluid intake if you have an indwelling catheter to help prevent infections – these occur more frequently if you don’t drink enough.
    An indwelling catheter can be used on a temporary basis, or for particular occasions when other means of urinary control are difficult, but you need to discuss all this with your doctor or continence nurse. Each insertion runs a risk of introducing infection and it has to be undertaken as meticulously as possible.

    Surgery and urinary problems in Multiple Sclerosis
    Surgery is very rarely performed to ensure urinary control in MS – indeed it seems to offer no major improvement in such control. Several procedures are possible, but are only undertaken on rare occasions when almost all else has failed, and a more or less intractable problem remains. There is another factor here: MS, over time, is a progressive disease, and it is possible that once you have undergone some surgery, other surgical procedures may then be needed later, to manage further problems that might arise.

    Other management techniques
    In addition to trials of further drugs that may be of value to people with MS, some other procedures or techniques may help. Research has suggested that bladder training – involving working out a schedule of regular urination on the basis of ultrasound assessments – together with ISC, may be helpful. Because of the association between CNS control of leg function and urinary function, an appropriate exercise regime may help the urinary function indirectly.
    Bladder training generally involves a series of educational and training exercises. It is important to note that some substances such as caffeine and alcohol can cause additional urgency with frequency, as can one of the common artificial sweeteners – Nutrasweet. Eliminating these products may help substantially. Training may involve you resisting or trying to slow down the urge to urinate so that urination
    can be undertaken more on a kind of timetable, perhaps every 1–2 hours. Urination can also be partly controlled by how and when drinks are taken.
    Electrical stimulation of various kinds comes into vogue from time to time to help with urinary control. A few of these techniques, some of which use small portable instruments, may prove to be of some value:

    • TENS (transcutaneous electrical nerve stimulation)
    • DSCS (dorsal spinal cord stimulation)
    • ESES (epidural spinal electrostimulation), and
    • SES (spinal electrostimulation).

    There is considerable energy being devoted to developing and testing some of these procedures. All these can be discussed with your continence nurse.

  • The Lungs and the Respiratory System

    The story of oxygen transport to body cells is not complete without a look at the respiratory system, which brings oxygen from the air into the body, transfers it to the blood, and then rids the body of the waste products of cellular energy. When you breathe, the organs of your res- piratory system perform the physical job of bringing air into the body and expelling it. The same organs are the site of the more complex biochemical process of respiration, the oxygenation of blood at a cellu- lar level.
    When you inhale air, it passes down your trachea, into the tubular bronchi that branch into your lungs, and through a system of subdivid- ing air passages that end deep in lung tissue as microscopic tubes called bronchioles. The bronchioles open into tiny, elastic air sacs called alveoli.
    Parallel to these branching air passages, a network of blood vessels brings blood into lung tissue. Minute capillaries cover the surface of the alveoli, and through the walls of these capillaries oxygen passes from the air sacs into the blood. Carbon dioxide molecules, carried in the blood from body tissues, pass into the alveoli. The oxygen-laden blood ?ows back into the heart, where it then can be circulated throughout the body, while the carbon dioxide moves back through the lungs to be exhaled.

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    When you inhale, you bring air into your lungs via the trachea, or windpipe. In the lungs, branching air passages (bronchi) end deep in lung tissue in microscopic clusters of air sacs called alveoli. In these clusters, networks of tiny blood vessels (capillaries) cover the air sacs. Oxygen exchange takes place through the walls of the alveoli and capillaries, as oxygen passes from lung tissue into the bloodstream and waste products (such as carbon dioxide) pass from the bloodstream into the lungs to be exhaled out of your body.

  • The Circulatory System

    Your systemic circulation is the vast highway system that carries blood from your heart to every part of your body, and then returns it to the heart. The vessels that carry blood away from the heart are the arteries; the vessels that carry blood back to the heart are veins. Like a system of roads, your circulatory system keeps branching off into successively smaller vessels that carry blood to and from the smallest structures and ?nally individual cells in body tissues. At a cellular level, single red blood cells exchange oxygen and nutrients with single body cells through the walls of microscopic capillaries.

    The Arteries and the Capillaries

    The aorta, the largest artery in your body, emerges from the left side of your heart. About 1 inch in diameter, it ascends from your left ventri- cle engorged with oxygen-rich blood, then arches down the chest into the abdomen. Major arteries branch off it to supply different areas of your body. The carotid and vertebral arteries travel to your head and neck. The subclavian arteries supply the arms. The abdominal (descending) aorta provides branches to your stomach, liver, kidneys, and intestinal tract. The aorta then divides into the iliac arteries and then the femoral arteries of the legs.
    The pulmonary artery carries blood from your heart to your lungs. Exiting from your right ventricle, it transports oxygen-depleted blood into your lungs to replenish the oxygen. This pulmonary circulation functions similarly to your systemic circulation but is limited to the lungs, where oxygen exchange occurs at a cellular level.
    The arteries subdivide into smaller vessels called arterioles. The arteries and arterioles have flexible muscular walls that can dilate (widen) and contract, with a critical impact on directing blood ?ow. Blood ?ows more easily to areas where there is less resistance, so arter- ies that widen increase the circulation to that area, while a constricted artery reduces blood ?ow. Branching off from the arterioles are the smallest vessels, the capillaries. Most capillary walls are only one cell thick. Specialized capillaries in different types of body tissue allow the passage of different types of molecules through their walls. In the lungs, for example, molecules of carbon dioxide (a waste product) pass into the tissue to be breathed out, while molecules of oxygen pass into the blood cells. In your intestinal system, nutrients from digested food pass through the capillary walls into the blood.

    The Veins

    At the level of individual cells throughout your body, the capillaries receive spent blood from body tissue that has a lower level of oxygen. The capillaries ?ow into larger vessels called venules, which converge and form still larger veins. The pressure in veins is signi?cantly lower than the pressure in arteries, and the walls are thinner, which is why blood samples are typically taken from a vein. As with arteries, the walls of veins can expand or contract. Any tensing of your muscles squeezes the veins, helping to counteract gravity and keep blood ?owing toward your heart. Larger veins also have a system of one-way valves that keep the returning blood ?owing the right way.
    Venous blood from the body enters the heart via two major vessels: the superior vena cava, bringing blood from the upper part of the body, and the inferior vena cava, returning blood from the lower part. These large veins enter the right atrium, where the blood is sent into the pul- monary circulation for oxygen pickup.

    Blood

    Blood is the ?uid vehicle by which oxygen, enzymes (proteins that pro- mote body processes), and other life-sustaining nutrients are brought to body cells in order to maintain an optimal environment for growth. Blood is composed of specialized blood cells—red blood cells, white blood cells, and platelets—and of plasma, the ?uid in which the blood cells are suspended.
    The vast majority of blood cells are red blood cells, also called ery- throcytes or red corpuscles, which do the work of oxygen transport. An individual red blood cell is saucer-shaped to maximize its surface area for ef?cient oxygen exchange. Chemically, a red blood cell contains large quantities of hemoglobin, an iron-rich protein that is the body’s oxygen transport carrier molecule. As red blood cells travel through the lungs, where oxygen levels are high, the hemoglobin readily combines with oxygen. When the blood cells reach body tissues where oxygen levels are relatively low, the hemoglobin just as effectively releases oxy- gen. The red blood cells also pick up the waste product carbon dioxide and carry it back to the lungs, where it is released and then exhaled out of the body. Red blood cells are formed in the bone marrow at the rate of about 8 million a second, or many billion in a single day. They live from 3 to 4 months.
    White blood cells, or leukocytes, play a critical role in protecting the body against infection. One type of white blood cell, called a lympho- cyte, identi?es invading microorganisms or other harmful substances in the body and triggers the body’s immune response. The number of white blood cells increases when your body is ?ghting infection. Also suspended in the plasma are cell fragments called platelets, which initi- ate a blood-clotting response when you are injured or a blood vessel is damaged. White blood cells and platelets make up about 1 to 2 percent of blood volume.
    About 55 percent of the blood volume is plasma, a yellowish, watery substance that contains proteins, glucose (sugar), cholesterol, and other components. Proteins in the plasma perform varied roles such as carrying nutrients, contributing to the clotting factor, and acting as infection-?ghting antibodies in an immune response.

  • Your Heart’s Performance

    Both the rate at which your heart beats and the volume of blood your heart moves in a single beat determine how ef?ciently your heart pumps blood. Cardiologists calculate cardiac output to measure your heart’s
    ef?ciency. Cardiac output is, quite simply, the amount of blood your heart pumps through your circulatory system in one minute. It is calcu- lated by multiplying how much blood the left ventricle squeezes out in a single contraction (stroke volume) by the number of times the heart contracts in a minute (heart rate).
    Most typically, when your body needs more blood (for instance, when you are running up stairs) the heart increases its output by beat- ing faster. If your heart beats at a fast rate for very long, the muscle begins to tire and the resting phase of the heartbeat becomes too short for the chambers to ?ll adequately. If you are physically ?t, your heart muscle is stronger and can pump more blood with each contraction. That is, your stroke volume is higher, so your heart can deliver adequate blood to your body without tiring as quickly. A physically ?t person may actually have a low resting heart rate, because he or she has strength- ened the heart muscle so that it can pump more blood, delivering adequate oxygen to the body with fewer strokes. When a ?t person exercises, he or she may have the same heart rate as someone who is less ?t, but the ?t person is able to do more work, such as run longer with- out tiring.
    A healthy resting heart rate is usually between 50 and 75 beats per minute. When you exercise, your heart rate may increase to as much as
    165 beats or more. Age plays a role in determining your maximum heart rate; the maximum number of beats per minute can be very roughly predicted by the formula 220 minus your age. A number of other factors can cause your heart rate to increase, including stress, some medica- tions, caffeine, alcohol, and tobacco. When a healthy person sleeps, his or her heart rate may dip to as low as 40 beats per minute. As you age, your heart rate may decrease somewhat.
    Stroke volume in most people is about 3 ounces. That means that the ventricles pump out about half the blood they contain. A good athlete may be able to increase his or her stroke volume by 5 percent or more. A diminishing stroke volume is one of the ?rst signs of a fail- ing heart.
    A pregnant woman’s body demands more blood ?ow and oxygen for the developing placenta. Stroke volume increases early in preg- nancy, and later the heart rate increases to maintain a cardiac output 40 to 50 percent above normal. These changes reverse after the baby is delivered.