Dehydration is not a good way to control your bladder symptoms.
Almost 30 years ago, while doing my PhD on a urine biomarker of inflammation, I noted that urinary concentration of creatinine, a muscle metabolite excreted in the urine, correlated with disability. I soon worked out that people with MS with worse disability (higher EDSS) were more likely to have bladder dysfunction and were dehydrating themselves to manage urinary frequency, urgency and nocturia. As I asked my study subjects to collect daily urine samples, it became clear that these people with MS (pwMS) were not intermittently dehydrating themselves but were doing it chronically.
We published a small letter in the Annals of Neurology on this issue in response to another paper suggesting urine levels of myelin basic protein-like material (uMBPLM) correlated with disability. It was clear to me that all this group were describing was the correlation of dehydration with disability, i.e. higher levels of uMBPLM were simply a marker of urine concentration and not linked to the biology underpinning disability.
This observation was highlighted again with the chronic cerebrospinal venous insufficiency (CCSVI) debacle. It was clear that many people with advanced MS had collapsed central veins because they were dehydrated, and when rehydrated with intravenous fluids, their veins opened spontaneously (see paper 2). I was vindicated as I had hypothesised this was the underlying problem in CCSVI in an earlier blog post (see ‘CCSVI: could dehydration be a possible confounding variable?’ 25-June-2011).
These findings were familiar. Professor Bryan Matthews, a neurologist in Oxford, had described dehydration as a strategy to manage urinary symptoms in the 1960s and highlighted the issue of pwMS dehydrating themselves to manage their bladder problems in his textbook on MS. Therefore, I was interested to read a recent paper from the Southhampton group describing the same findings (see paper 2 below). It is remarkable how the same things in medicine or neurology tend to be rediscovered for people to become aware of them.
I am frustrated that despite highlighting the issue of chronic dehydration in pwMS many times over the years, it is clear that it remains a persistent problem. My message is clear: don’t use dehydration to manage your bladder symptoms. The potential consequences of chronic dehydration should be enough to change your habits.
Chronic dehydration can have a significant impact on your overall health and well-being and can exacerbate many of your MS symptoms. Here are some of the potential effects of chronic dehydration:
1. Impact on Physical Performance: Dehydration can decrease physical endurance, cause muscle cramps, and exacerbate or cause fatigue. This can affect overall physical performance and make everyday tasks more challenging.
2. Cognitive Function: Dehydration has been linked to cognitive impairment, including issues with concentration, alertness, and short-term memory. Prolonged dehydration may even contribute to long-term cognitive decline.
3. Mood and Mental Health: Studies have shown that dehydration can affect mood and contribute to increased feelings of anxiety and irritability. In severe cases, it can even lead to symptoms resembling depression.
4. Kidney Function: Chronic dehydration can put a strain on the kidneys, potentially leading to the formation of kidney stones and urinary tract infections. It can also impair the kidneys' ability to filter waste from the blood effectively. It also makes you more susceptible to side effects of non-steroidal anti-inflammatory medications.
5. Digestive Problems: Dehydration can lead to constipation and other digestive issues. It may also contribute to an increased risk of developing peptic ulcers and acid reflux.
6. Skin Health: Inadequate hydration can lead to dry, flaky skin and exacerbate conditions such as eczema and psoriasis. Proper hydration is essential for maintaining overall skin health and elasticity.
7. Risk of Heat-Related Illnesses: Dehydration reduces your body's ability to regulate temperature, increasing the risk of heat exhaustion and heat stroke, particularly in hot and humid conditions. Please remember that pwMS, in particular people with more advanced MS, may already have a problem with thermoregulation, and dehydration will make things worse. Please note this problem is worsened by drugs that affect sweating, e.g. anticholinergics.
A better way of managing urinary symptoms is using a holistic approach, which I have written about many times before on MS-Selfie. Are you doing your pelvic floor exercises? Have you deconditioned your bladder by not training yourself to resist emptying your bladder whenever you get the urge to pass urine? The bladder is a muscle that needs to be trained. Are you avoiding bladder irritants or stimulants, for example, caffeine and nicotine? Have you tried peripherally acting anticholinergics or mirabegron? Have you had a post-micturition bladder scan to see if you are emptying your bladder? You may need to intermittently self-catheterise to increase your functional bladder volume. Do you have a chronic low-grade urinary tract infection? Do you have bladder stones? Have you tried DDAVP (Desmotabs or Desmospray) to help concentrate your urine without dehydrating yourself? DDAVP helps reduce urinary frequency and urgency for a defined period, for example, at night or when travelling. If you are a post-menopausal woman, have you tried HRT? Pelvic floor tone and bladder function often improve on HRT.
Please see:
To find out how many of you use dehydration to manage your bladder problems, I have set up a short MS-Selfie survey. If you have time, please complete it; it will take 2-3 minutes. Thank you.
Finally, please share any hacks or tricks you use to manage your bladder symptoms.
Paper 1
We sought to determine the effect of hydration on the criteria for chronic cerebrospinal venous insufficiency (CCSVI), a proposed hypothesis for the etiology of multiple sclerosis (MS). Sixteen subjects (11 MS and 5 controls) were asked to fast overnight. The following morning, 2 CCSVI ultrasound examinations were performed: 1 in the mildly dehydrated state, and another 30-45 minutes after rehydrating with 1.5 L of Gatorade. Seven subjects fulfilled CCSVI criteria in the dehydrated state. Of these, 5 (71%) no longer fulfilled CCSVI criteria after rehydration. One additional subject met CCSVI criteria only after rehydration. Hydration status has a substantial effect on CCSVI criteria, suggesting that the sonographic findings of CCSVI may represent a physiologic rather than pathologic state.
Paper 2
Background: Lower urinary tract symptoms (LUTS) are common in persons with progressive multiple sclerosis (pwPMS), who may consequently limit their fluid intake. We aimed to investigate the hypothesis that LUTS associate with objective evidence of inadequate hydration status in pwPMS.
Methods: In this prospective study, 55 pwPMS were studied over 2 years. A 6-monthly first-morning urine specimen was analysed for urinary osmolality and sodium as hydration markers. LUTS symptom severity in three categories (urgency, voiding and discomfort) was assessed and quantified using a questionnaire. Correlation between LUTS severity and hydration was assessed within subjects and between subjects, controlling for age.
Results: Some 274 urine samples with accompanying LUTS data from 55 participants were analysed. Biochemical data showed the expected loss of urine-concentrating capacity with increasing age. Inadequate hydration was observed in 47% of participants. LUTS were very common (87% reported urgency and 89% voiding symptoms). Voiding and discomfort, but not urgency severity, were correlated with hydration markers, both within and between participants.
Conclusions: LUTS are very common in pwPMS, and associate with inadequate hydration. The causes and consequences of inadequate hydration in MS need further study, since (i) this will focus greater attention on LUTS management in pwPMS and (ii) dehydration has been associated with reversible cognitive dysfunction and physical underperformance.
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Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Queen Mary University of London or Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.
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