Relationship between neurological and urological status in patients with multiple sclerosis

Smooth muscle of the bladder in the normal and the diseased state: pathophysiology, diagnosis and treatment

The smooth muscle of the normal bladder wall must have some specific properties. It must be very compliant and able to reorganise itself during filling and emptying to accommodate the change in volume without generating any intravesical pressure, but whilst maintaining the normal shape of the bladder. It must be capable of synchronous activation to generate intravesical pressure at any length to allow voiding. The cells achieve this through spontaneous electrical activity combined with poor electrical coupling between cells, and a dense excitatory innervation. In the diseased state, alterations of the smooth muscle may lead to failure to store or failure to empty properly. The diseased states discussed are bladder instability and diabetic neuropathy. Bladder instability is characterised urodynamically by uninhibitable rises in pressure during filling, and is seen idiopathically and in association with bladder outflow obstruction and neuropathy. In diabetic neuropathy, many of the smooth muscle changes are a consequence of diuresis, but there is evidence for alterations in the sensory arm of the micturition reflex. In the unstable bladder, additional alterations of the smooth muscle are seen, which are probably caused by the patchy denervation that occurs. The causes of this denervation are not fully established. Nonsurgical treatment of instability is not yet satisfactory; neuromodulation has some promise, but is expensive, and the mechanisms poorly understood. Pharmacological treatment is largely through muscarinic receptor blockade. Drugs to reduce the excitability of the smooth muscle are being sought, since they may represent a better pharmacological option.

Urodynamics and multiple sclerosis

Multiple sclerosis is an enigmatic and devastating neurologic disease. Voiding dysfunction is common and the irritative and obstructive symptoms can be disabling to the patient. Voiding symptoms alone are unreliable predictors of bladder and urethral dysfunction secondary to multiple sclerosis. This article focuses on the central role played by urodynamic studies in the initial assessment and management of the lower urinary tract. Detrusor hyperreflexia is the most common urodynamic finding. However, a variety of urodynamic patterns can be seen and voiding function may change over time with this chronic neurologic disorder.

Urinary incontinence in brain injury

In the rehabilitation of severely brain-injured patients, solving urinary incontinence poses a therapeutic challenge. From this study it appears that incontinence does not always result from impaired neuropsychological functioning. If habituation procedures fail, an underlying organic cause (usually detrusor hyperactivity with synergic sphincter action) for persistent urinary incontinence can be demonstrated in a large number of patients. In patients with a severe pelvic fracture a pudendal nerve lesion must be ruled out.

Upper urinary tract abnormalities in multiple sclerosis patients with urinary symptoms

OBJECTIVE

To determine the prevalence of upper urinary tract complications in multiple sclerosis (MS) patients with urinary symptoms, and to determine if an association exists between degree of physical impairment and upper urinary tract complications.

DESIGN AND SETTING

A cohort study of MS patients seeking treatment at a freestanding, university-affiliated rehabilitation hospital.

PARTICIPANTS

A referred sample of 48 patients with MS, exacerbation-free for 6 months with symptoms of neurogenic bladder dysfunction. For each patient, demographic data, disease characteristics, and urologic history was obtained. Using the Kurtzke Expanded Disability Status Scale (EDSS), participants were divided into a control (EDSS < 7) and study (EDSS >/= 7) group.

INTERVENTION

Ultrasound examination of the upper urinary tract.

MAIN OUTCOME MEASURE

Significant MS-related abnormalities of the upper respiratory tract.

RESULTS

Ten of 48 patients (21%) had significant MS-related upper urinary tract abnormalities, which were evenly distributed between control and study groups. In the more disabled study group, abnormalities were associated with the symptom of urinary hesitancy (p < .05) and form of bladder management (p < .05).

CONCLUSIONS

Routine screening for upper urinary tract complications appears indicated in a select group of MS patients with urinary symptoms.

Fate of the upper urinary tract in multiple sclerosis

Urologic problems are a major source of morbidity for patients with multiple sclerosis (MS). Fifty-four to 78% of patients experience bladder symptoms which are due to spinal lesions interrupting neural pathways that control micturition. MS patients could have upper or lower motor neuron lesion type bladders. Both obstructive and irritative symptoms may be present. Although lower urinary tract dysfunction has been well described in MS, few studies have investigated the fate of the upper urinary tract. Thirty-two patients with MS were referred for urodynamic evaluation. Twenty-six of the 32 patients had upper urinary tract studies performed. Only 1 of the 26 patients had evidence of upper urinary tract deterioration. It is our impression that upper tract deterioration occurs infrequently in these patients. We discuss clinical clues that may predict deterioration.

Long-term follow-up of transvaginal urethral closure and suprapubic cystostomy for urinary incontinence in women with multiple sclerosis

OBJECTIVE

To assess the long-term success, in terms of continence and patient satisfaction, of transvaginal urethral closure and suprapubic cystostomy in women with multiple sclerosis and urinary incontinence.

PATIENTS AND METHODS

The group under study comprised 50 severely disabled women with multiple sclerosis who were undergoing suprapubic cystostomy and transvaginal urethral closure to manage urinary incontinence refractory to conservative measures and urethral catheterization. Follow-up was by patient interview and Catheter Change Clinic records.

RESULTS

An initial continence rate of 78% was achieved and secondary revision was attempted in 10%. Urinary diversion was performed in 4% and a return to urethral catheterization in 2%. Long-term follow-up (mean length 6.5 years) showed that 79% of patients remained completely dry and were managed by regular catheter change. Six per cent of women with continued leakage around the suprapubic site were managed by conservative local methods. The major complications of urethral closure and suprapubic cystostomy (recurrent calculi and encrustation blockage) related to the presence of the catheter.

CONCLUSIONS

The lack of major complications associated with transvaginal urethral closure and suprapubic cystostomy, and the high rates of continence and patient satisfaction suggest that this technique could be more widely used. Particularly, it could be employed at an earlier stage in multiple sclerosis and thus offer patients a better quality of life for a longer period of time. Modifications in catheter design may overcome problems of calculi and encrustation blockage.

Urinary symptoms and the neurological features of bladder dysfunction in multiple sclerosis

One hundred and seventy patients with multiple sclerosis and bladder dysfunction were evaluated. Emphasis was placed on the relationship between their neurological features and urinary symptoms. The severity of the urinary symptoms was related to the degree of pyramidal impairment in the lower limbs so that both problems are thought to reflect the extent of spinal involvement. No other neurological features correlated with bladder dysfunction. Detrusor hyperreflexia was the commonest finding on cystometry and no patient had areflexia. More than half of the patients had a significantly raised post-micturition residual volume but symptoms were largely unreliable in predicting poor bladder emptying. In this series only two patients had evidence of upper tract disease: both men with severe, longstanding neurological disease who had indwelling catheters. Detrusor hyperreflexia can be anticipated in patients with MS who have irritative urinary symptoms and pyramidal signs in their lower limbs. After measurement of the residual volume appropriate treatment can be instituted.

Lower urinary tract dysfunction in multiple sclerosis

Previous investigators have shown that in multiple sclerosis failure to empty the bladder was secondary to detrusor-distal sphincter dyssynergia or areflexia. However, our urodynamic evaluation of 46 female and 43 male patients with multiple sclerosis revealed that 63 percent of patients failed to empty their bladders because of a hypocontractile detrusor, and only 6 percent had areflexia. Detrusor-distal sphincter dyssynergia (6%) and bladder neck obstruction (6%) were present in only 12 percent of patients. Hyperreflexia was common (78%) and was associated with hypocontractility in 63 percent of patients. Urgency incontinence was significantly more common in females and voiding difficulty significantly more common in males. Sensation was also reduced in 74 percent of female and 77 percent of male patients. In conclusion, failure to empty the bladder in multiple sclerosis is most commonly associated with hypocontractility, and the combination of hyperreflexia and hypocontractility produces the symptoms of urgency and incomplete emptying.

Neurophysiology of the striated urethral sphincter in multiple sclerosis

Urethrovesical dysfunction is common in patients with multiple sclerosis. We present the results of urodynamic and neurophysiological studies in a series of 24 patients with multiple sclerosis associated with urinary symptoms. Urethral sphincter electromyography showed only minor abnormalities but studies of central conduction demonstrated abnormal sensory conduction in 88% and abnormal motor conduction in 80% of the patients studied. These abnormalities of central conduction correlated well with the urodynamic findings.

Evidence for early lower urinary tract dysfunction in clinically silent multiple sclerosis

The occurrence of micturition complaints as late sequelae of multiple sclerosis is well studied and documented. However, no reports exist on urologically asymptomatic patients with a relatively short disease duration. In a prospective study of 40 patients with definite multiple sclerosis (mean disease duration 5 years), urodynamic investigations (cystometry and pressure-flow study) were combined with neuro-urophysiological measurements (cortical evoked potentials and sacral reflex latencies). Patients with (13) and without (27) micturition complaints were investigated. Neurourodynamic abnormalities were seen in 35 of 40 patients (88%). The lower urinary tract proved to be afflicted by multiple sclerosis at an early stage of the disease. Early neurourodynamic investigations had clinical implications. All of the complaining and half of the noncomplaining patients showed urodynamic abnormalities upon which the need for further followup and eventual therapeutic intervention was based. We conclude that neurourodynamic testing of a urinary functional system can be worthwhile as part of the initial diagnostic evaluation in patients with proved multiple sclerosis.

Role of urologist in diagnosis of multiple sclerosis

This report presents 7 patients with confirmed cases of multiple sclerosis (MS) in whom the diagnosis of MS was first suspected by the urologist. Review of these 7 cases identifies three factors that increased the suspicion of MS at the time of urologic evaluation: a history of neurologic symptoms, abnormalities on a brief neurologic examination, and abnormal basic urodynamic evaluation. Urologists attuned to the possible diagnosis of MS in patients who present with symptoms of voiding dysfunction can facilitate the proper diagnosis with a basic office evaluation.

Neuropeptide immunoreactivity and choline acetyltransferase activity in the mouse urinary bladder following inoculation with Semliki Forest Virus

The effect of Semliki Forest Virus, a known central demyelinating agent and a proposed model for multiple sclerosis, on the innervation of the mouse urinary bladder has been examined 3, 6, 9 and 12 weeks after inoculation. Three weeks after Semliki Forest Virus inoculation, vasoactive intestinal polypeptide content of the bladder was reduced and the density of vasoactive intestinal polypeptide-immunoreactive nerves was decreased in the smooth muscle, but not in the mucosa. Choline acetyltransferase activity and neuropeptide Y and substance P content was normal, as was the pattern of innervation by acetylcholinesterase-containing and neuropeptide Y- and substance P-immunoreactive nerve fibres. Six weeks after Semliki Forest Virus inoculation, the choline acetyltransferase activity was significantly reduced. Between 6 and 9 weeks the level of vasoactive intestinal polypeptide in the bladder of Semliki Forest Virus-infected mice significantly increased, so that at 9 weeks it was higher than the control value. However, by 12 weeks both choline acetyltransferase activity and vasoactive intestinal polypeptide content were normal. At this time, the substantial age-related increase in substance P content of the bladder was more pronounced in the Semliki Forest Virus-treated animals. Thus there are transitory changes in the innervation of the mouse bladder by vasoactive intestinal polypeptide-containing and cholinergic nerve fibres after exposure to a central demyelinating agent which may reflect changes in bladder dysfunction seen in multiple sclerosis patients.

Oxybutynin versus propantheline in patients with multiple sclerosis and detrusor hyperreflexia

Hyperreflexia is the most common urological finding in patients with multiple sclerosis. A prospective randomized study was done to compare the effectiveness of 2 commonly used drugs, oxybutynin and propantheline. Of the 34 patients entered into the trial 19 were treated with oxybutynin and 15 with propantheline. The urological symptoms (frequency, nocturia, hesitancy, urgency and urge incontinence) were graded according to severity from 0 to 3. Patients with urinary infection were excluded. Urodynamic examination, consisting of cystometrography and electromyography, was performed in all patients before treatment. Both groups of patients had comparable neurological, urological and urodynamic status before treatment. In 4 patients (21 per cent) treated with oxybutynin and in 4 (27 per cent) treated with propantheline side effects were so severe that the treatment had to be discontinued. Symptomatic response to oxybutynin was good in 10 patients (67 per cent), fair in 2 (13 per cent) and poor in 3 (20 per cent). Propantheline produced good symptomatic results in 4 patients (36 per cent), fair in 1 (9 per cent) and poor in 6 (55 per cent). The mean increase in maximum cystometric capacity on cystometrography was significantly larger in the oxybutynin group than in the propantheline group (144 +/- 115 versus 35 +/- 101). Our results indicate that oxybutynin is more effective than propantheline in the treatment of detrusor hyperreflexia in patients with multiple sclerosis.