Perspectives on urological care in multiple sclerosis patients

Abstract

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system. Lower urinary tract dysfunction due to MS includes a dysfunction of the storage phase or dysfunction of the voiding phase or a detrusor-sphincter dyssynergia. Baseline evaluation includes a voiding chart, an ultrasound scan of the urinary tract, urine culture, and an urodynamic study. For storage symptoms, antimuscarinics are the first-line treatment, and clean intermittent catheterization (CIC) is indicated if there is concomitant incomplete bladder emptying. Intradetrusor injections with botulinum toxin A (BTX-A), are recommended for refractory cases. Urinary diversion is rarely indicated. For patients with voiding symptoms, CIC and alpha-blockers are usually offered. Sexual dysfunction in patients with MS is multifactorial. Phosphodiesterase type 5 inhibitors are first-line therapies for MS-associated erectile dysfunction in both male and female patients. This review summarizes the epidemiology, pathogenesis, risk factors, genetic, clinical manifestations, diagnostic tests, and management of MS. Lastly, the urologic outcomes and therapies are reviewed.

Managing the Symptoms of Multiple Sclerosis

“…Up to 90% of patients experience incontinence or voiding dysfunction, although symptoms primarily occur 6-8 years after the initial diagnosis. 171 The topic is important to discuss during regular visits as prompt treatment can reduce feelings of social isolation, improve sleep quality, and prevent UTIs, which account for 30-50% of hospitalizations in patients with MS. 171 It is important to distinguish symptoms of storage failure, like urgency, frequency, and nocturia, from symptoms of voiding failure, like hesitancy, double-voiding, bladder-insensitivity, and poor force of stream. Most patients with MS have storage-phase symptoms, but some will eventually develop voiding phase symptoms as well.…”

“…Most patients with MS have storage-phase symptoms, but some will eventually develop voiding phase symptoms as well. 171 If symptoms remain persistent despite initial medical management, patients should be referred to urology for post-void residual measurement, urodynamic studies, and further symptom management.…”

“…Therapy for urinary dysfunction is preferably conservative and initially reversible due to the waxing and waning nature of symptoms. 171 Pelvic floor therapy provided exercises to enable relaxation or to defer urges to urinate. Patients should be started on lifestyle modifications to allow them to avoid situations of increased urgency and frequency, such as scheduled voiding, avoiding excessive fluid intake and caffeine, and bathroom mapping.…”

“…For patients with primarily voiding dysfunctions, such as the majority of patients with progressive MS, first line treatment includes alpha-1 antagonists like doxazosin, terazosin, and tamsulosin, which are specifically aimed towards improving detrusorsphincter dyssynergia, which can also contribute to increased rate of UTIs. 105,171 Side effects to be aware of in these patients are orthostasis, overflow urinary incontinence, and abnormal ejaculation. 103 These patients would also benefit from intermittent clean catheterization, and indwelling catheters should be avoided whenever possible.…”

“…103 These patients would also benefit from intermittent clean catheterization, and indwelling catheters should be avoided whenever possible. 171 Medications can be combined if there is concern for adverse effects of monotherapy at higher doses.…”