The neurogenic bladder in multiple sclerosis: review of the literature and proposal of management guidelines

Open label feasibility study evaluating D-mannose combined with home-based monitoring of suspected urinary tract infections in patients with multiple sclerosis

OBJECTIVE

To assess the feasibility of using D-mannose, a natural food supplement, in patients with multiple sclerosis (MS) reporting recurrent urinary tract infections (UTIs) as a preventative.

METHODS

A single-center, open-label, feasibility study enrolled patients with MS, using and not using urinary catheters, experiencing recurrent UTIs (≥3/year or ≥2/6 months). Participants were given D-mannose powder 1.5 grams twice daily for 16-weeks and were instructed to monitor suspected UTIs at home using urine dipsticks. Diaries were used to record compliance, number of prescriptions of antibiotics received for UTIs, results of urine dipsticks and cultures.

RESULTS

Overall, 22 patients with MS, median age 50 years (46-59) were enrolled: 10 were not using catheters and 12 were using catheters. The compliance rates for using D-mannose and dipsticks for testing suspected UTIs were 100% and 90.2%, respectively. Sixty-one episodes of suspected UTIs were recorded, 19/61 (31.1%) were confirmed UTIs and 29/61 (47.5%) prescriptions of antibiotics were made. The number of monthly proven UTIs decreased both in catheter users and non-users (P < 0.01). No adverse effects were reported.

CONCLUSION

Using D-mannose in patients with MS experiencing recurrent UTIs and self-monitoring for infections is feasible and safe. Further studies are required to establish efficacy. CinicalTrials.gov (identifier NCT02490046).

Secondary and tertiary treatments for multiple sclerosis patients with urinary symptoms

Multiple sclerosis patients with refractory urinary symptoms after treatment with behavioral therapy and medications still have treatment options. Prior to starting treatments, baseline symptoms should be assessed and treatment goals thoroughly discussed. Catheterization, botulinum toxin, and reconstructive surgery all can play a role in improving both safety and quality of life for these patients. Newer modalities, such as neuromodulation, may also have an increasing role in the future as more data develop regarding efficacy. Risks need to be weighed against any perceived benefit and disease status before more aggressive therapy is initiated.

Antibiotic prophylaxis may not be necessary in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections for neurogenic detrusor overactivity

Many of the patients undergoing intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity (NDO) present with chronic bacteriuria. In these patients, antibiotic prophylaxis has been widely recommended since bacteriuria might impair treatment efficacy and cause urinary tract infections (UTI) but the evidence is limited. The aim of this study was to evaluate if an antibiotic prophylaxis is needed in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections. Between 06/2012 and 12/2014, a consecutive series of 154 patients undergoing a total of 273 treatment cycles were prospectively evaluated. Before treatment urine samples were collected, patients with no clinical signs for UTI underwent onabotulinumtoxinA injections, no antibiotic prophylaxis was given. Asymptomatic bacteriuria was found in 73% (200/273 treatments). Following treatment, UTI occurred in 5% (9/200) and 7% (5/73) of patients with and without bacteriuria, respectively. Intradetrusor onabotulinumtoxinA injections were clinically and urodynamically successful in 70% (192/273). There was no association between bacteriuria and treatment-related adverse events (odds ratio 0.64, 95% CI 0.23–1.81, p = 0.4) nor between bacteriuria and therapy failure (odds ratio 0.78, 95% CI 0.43–1.43, p = 0.4). Thus, we conclude that antibiotic prophylaxis needs to be critically reconsidered in patients undergoing intradetrusor onabotulinumtoxinA injections, especially taking into account the alarming antibiotic resistance worldwide.

Barriers experienced by patients with multiple sclerosis in seeking care for lower urinary tract symptoms

AIM

The Actionable Bladder Symptom and Screening Tool (ABSST) is used to identify multiple sclerosis (MS) patients in possible need of evaluation for urinary symptoms. The primary objective of this study was to identify barriers experienced by MS patients in seeking evaluation for urinary symptoms. We also assessed the utility of ABSST tool in identifying patients that will follow up with urologic evaluation.

METHODS

This was a prospective observational study where 100 patients with MS were enrolled from an MS center. Patients completed demographic information, questions to assess barriers to care, a short form of the ABSST, and incontinence questionnaires. An ABSST score >3 met criteria for referral and evaluation. One year after enrollment, follow up calls assessed whether patients had seen a urinary specialist.

RESULTS

The most common barriers to seeking care included "Doctor never referred" (16%) and "Doctor never asked" (13%). Thirty-eight percent (n = 8/21) of men stated "Doctor never referred" compared to 10% (n = 8/79) of women (P = 0.002). Twenty-seven patients had an ABSST Score ≥3 and were more interested in seeing a specialist compared to those scoring <3 (88.9%, n = 24/27 vs. 26%, n = 19/73; P = <0.001). After 1 year, 70 patients were reached for follow up. A total of 57.9% (n = 11/19) patients who followed up for evaluation screened positive on the ABSST.

CONCLUSIONS

The ABSST is a valuable tool to identify MS patients with urinary symptoms who will likely follow up for genitourinary evaluation. However, other barriers beyond awareness exist and prevent patients from being evaluated.

Prospective evaluation of antibiotic treatment for urological procedure in patients presenting with neurogenic bladder

OBJECTIVES

Patients presenting with neurogenic bladder often require urological procedures (urodynamic testing and botulinum toxin injections) and a preventive antibiotic therapy. We aimed to assess the efficacy of this little known strategy in a cohort of patients.

PATIENTS AND METHODS

All patients presenting with neurogenic bladder who underwent urological procedure were included in the study. They received an antibiotic therapy in accordance with the urine cytobacteriological examination results. The antibiotic therapy was initiated two days before the procedure and prolonged up until two days after the procedure if the culture was positive. Patients were treated with a single dose of fosfomycin-trometamol in case of a negative culture. The main study outcome was the occurrence of urinary tract infection (UTI), defined by a positive urine culture and symptoms, up until 14 days after the procedure.

RESULTS

A total of 80 urological procedures were performed. Mean patient age was 47±13.1 years (sex ratio 1.22); 59 (73.8%) presented with asymptomatic bacteriuria before the procedure. Nine (11.1%) UTIs were recorded on Day 14, of which one (1.2%) was febrile. Two patients required an additional curative antibiotic therapy. No patient was hospitalized. Overall, 77.8% of UTIs were cured without antibiotic therapy.

CONCLUSION

Screening and treating asymptomatic bacteriuria before urological procedures seems unnecessary and vainly exposes this population at high risk of infectious diseases to antibiotic therapies. This data should be confirmed by a randomized clinical trial.

Management of neurogenic lower urinary tract dysfunction in multiple sclerosis patients

Multiple sclerosis (MS) can be a debilitating neurological condition that attributes significant morbidity to bladder dysfunction. Although many effective treatment options exist, symptomatic patients are often underdiagnosed and undertreated. The purpose of this article is to give an overview of the current literature including new screening tools to identify symptomatic patients and updates on treatment options including medications, botulinum toxin, and neuromodulation.

Overactive bladder symptoms in patients with multiple sclerosis: Frequency, severity, diagnosis and treatment

OBJECTIVE

To determine the frequency and severity as well as the diagnosis and treatment of overactive bladder problems in patients with multiple sclerosis (MS) followed up at five centers in Turkey.

DESIGN

Survey study.

SETTING

Outpatient tertiary clinics of physical medicine and rehabilitation and neurology.

PARTICIPANTS

Consecutive MS patients scheduled for outpatient follow-up (n = 309).

INTERVENTION

MS patients were asked to complete a questionnaire regarding the frequency and severity, as well as the diagnosis and treatment of their overactive bladder problems.

RESULTS

The mean age ± SD was 39.3 ± 10.6 years. Urinary urgency was the most common urinary symptom (62%), followed by frequency (50.4%), urge incontinence (44.7%) and nocturia (33%). Residual urine volume was measured using a portable ultrasound instrument in 13.3% of the patients and by catheterization in 16.2% of them. Urodynamic investigations and urinary tract ultrasound were performed on 26.5% and 35.3% of the patients, respectively. Anticholinergic medications were prescribed for 27.5% of the patients. Intermittent catheterization and indwelling catheterization were used on 8.1% and 1.9% of the patients, respectively. The overactive bladder symptom score (OABSS) was significantly higher in patients who had had residual urine measurement (P < 0.001), upper urinary tract assessment by ultrasound (P < 0.001), urodynamic assessment (P < 0.001), admitted to a doctor for urinary symptoms (P < 0.001), and current or past catheter use (P = 0.002).

CONCLUSION

Urgency was the most common urinary symptom followed by frequency, urge incontinence and nocturia in MS patients. The patients with lower OABSS had detailed urological assessments less frequently than the patients with higher OABSS.

Diagnostic tools for assessment of urinary dysfunction in MS patients without urinary disturbances

Many guidelines are available for the management of lower urinary tract symptoms (LUTSs) in multiple sclerosis (MS) patients, but no agreement exists on the best approach for subjects without LUTSs. The objective of this study was to evaluate whether LUTSs can be detected in MS patients asymptomatic for urinary dysfunction, comparing three different tools [measure of post-void residual volume (PRV), bladder diary (BD), a focused questionnaire (IPSS)], and whether disability, disease duration and signs of pyramidal involvement are linked to their subclinical presence. 178 MS patients (118 women) have been included (mean age 41.2 years, mean disease duration 11.3 years, mean EDSS 2.2), and tested with the above-mentioned tools. PRV was abnormal in 14 subjects (7.8%), associated to abnormal findings at IPSS in 3 cases, at BD in 2 cases, at both in 1. BD was abnormal in 37 subjects (20.8%), with concomitant abnormal PRV in 2, abnormal IPSS in 10 cases, abnormal IPSS and BD in 1. IPSS was ≥ 9 in 43 subjects (24.1%). At least one test was abnormal in 76 patients (42.7%): 1 in 57 patients (32.0%), 2 in 17 (9.5%), and 3 tests in 2 (1.1%). Patients with at least one abnormal urinary variable, compared to patients without urinary abnormalities, had a more frequent pyramidal involvement (69.5 vs. 16.8%, χ(2) = 48.6, p < 0.00001), a more frequent occurrence of EDSS ≥2 (83.1 vs. 23.5%, χ(2) = 56.9, p < 0.00001), and a longer disease duration (15.7 ± 7.3 vs. 9.1 ± 7.1, t = 5.7, p < 0.00001). Asymptomatic LUTS were frequent but none of the tests used permitted to better identify asymptomatic patients.

Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies

Detrusor sphincter dyssynergia (DSD) is the urodynamic description of bladder outlet obstruction from detrusor muscle contraction with concomitant involuntary urethral sphincter activation. DSD is associated with neurologic conditions such as spinal cord injury, multiple sclerosis, and spina bifida and some of these neurogenic bladder patients with DSD may be at risk for autonomic dysreflexia, recurrent urinary tract infections, or upper tract compromise if the condition is not followed and treated appropriately. It is diagnosed most commonly during the voiding phase of urodynamic studies using EMG recordings and voiding cystourethrograms, although urethral pressure monitoring could also potentially be used. DSD can be sub-classified as either continuous or intermittent, although adoption of this terminology is not widespread. There are few validated oral pharmacologic treatment options for this condition but transurethral botulinum toxin injection have shown temporary efficacy in reducing bladder outlet obstruction. Urinary sphincterotomy has also demonstrated reproducible long term benefits in several studies, but the morbidity associated with this procedure can be high.

Urinary tract infections in multiple sclerosis

Background:

Urinary tract infections (UTIs) are commonly reported by people with multiple sclerosis (PwMS) and significantly impact quality of life.

Objective:

To provide an overview of the problem of UTIs in PwMS and offer a practical approach for the diagnosis and management.

Methods:

A review of the literature through a Pubmed search up to October 2015 was performed using the following keywords: multiple sclerosis, neurogenic bladder, urinary tract infections, relapse, dipsticks, culture, recurrent and prevention.

Results:

Noteworthy topics include the definition of a confirmed symptomatic UTI as a positive urine culture defined by >105 colony-forming units (CFU)/mL or >104 CFU/mL if a urethral catheter urine sample is taken, or any count of bacteria in a suprapubic bladder puncture specimen, both in addition to symptoms including fever, pain, changes in lower urinary tract symptoms or neurological status. Urinalysis is useful to exclude a UTI; however, on its own is insufficient to confirm a UTI, for which urine culture is required. Experts advise asymptomatic UTIs should not be treated except in the context of an acute relapse. From international guidelines, there is no validated strategy to prevent recurrent UTIs in PwMS.

Conclusion:

This review provides an overview of the diagnosis, treatment and prevention of UTIs in the setting of multiple sclerosis (MS).

Association Between the Neurogenic Bladder Symptom Score and Urodynamic Examination in Multiple Sclerosis Patients With Lower Urinary Tract Dysfunction

PURPOSE

To determine the relationship between the neurogenic bladder symptoms score (NBSS) and urodynamic examination in patients affected by multiple sclerosis (MS) and related lower urinary tract dysfunction (LUTD).

METHODS

We recruited 122 consecutive patients with MS in remission and LUTD from January 2011 to September 2013 who underwent their first urodynamic examination. Neurological impairment was assessed using the Expanded Disability Status Scale (EDSS) and bladder symptoms were studied with the NBSS.

RESULTS

Median NBSS was 20.0 (interquartile range, 12.75-31.0). Neurogenic detrusor overactivity (NDO) was discovered in 69 patients (56.6%). The concordance between patients with NDO and maximum detrusor pressure during involuntary detrusor contraction (PdetmaxIDC)≥20.0 cm H2O was 0.89 (κ-Cohen; P<0.05). Patients with EDSS scores of ≥4.5 had a greater NBSS (25.41 vs. 20.19, P<0.05), NBSS-incontinence (8.73 vs. 4.71, P<0.05), NBSS-consequence (4.51 vs. 3.13, P<0.05) and NBSS-quality of life (2.14 vs. 1.65, P<0.05). The NBSS was not associated with PdetmaxIDC≥20 cm H2O (P=0.77) but with maximum cystometric capacity<212 mL (odds ratio, 0.95; P<0.05).

CONCLUSIONS

The NBSS cannot give adequate information the way urodynamic studies can, in patients with MS and LUTD.

Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: Final results of a long-term extension study

AIMS

To present final efficacy/safety results from a prospective, long-term extension trial of onabotulinumtoxinA for urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO); patients received treatment for up to 4 years.

METHODS

Patients who completed a 52-week, phase III trial of onabotulinumtoxinA for NDO were eligible to enter a 3-year, multicenter, open-label extension study of intradetrusor onabotulinumtoxinA (200U or 300U). Patients were treated "as needed" based on their request and fulfillment of prespecified qualification criteria (≥12 weeks since previous treatment and a UI episode threshold). Assessments included change from study baseline in UI episodes/day (primary efficacy measure), volume/void, and Incontinence Quality of Life (I-QOL) total score (week 6); duration of effect; adverse events (AEs); and initiation of de novo clean intermittent catheterization (CIC). Data are presented for up to six treatments.

RESULTS

OnabotulinumtoxinA 200U consistently reduced UI episodes/day; reductions from baseline ranged from -3.2 to -4.1 across six treatments. Volume/void consistently increased, nearly doubling after treatment. I-QOL improvements were consistently greater than twice the minimally important difference (+11 points). Overall median duration of effect was 9.0 months (200U). Results were similar for onabotulinumtoxinA 300U. Most common AEs were urinary tract infections and urinary retention. De novo CIC rates were 29.5, 3.4, and 6.0% (200U), and 43.0, 15.0, and 4.8% (300U) for treatments 1-3, respectively; de novo CIC rates were 0% for treatments 4-6.

CONCLUSIONS

OnabotulinumtoxinA treatments consistently improve UI, volume/void, and QOL in patients with UI due to NDO in this 4-year study, with no new safety signals. Neurourol. Urodynam. 36:368-375, 2017. © 2015 The Authors. Neurourology and Urodynamics Published by Wiley Periodicals, Inc.

Neurogenic lower urinary tract dysfunction in the early disease phase of paediatric multiple sclerosis

Neurogenic lower urinary tract dysfunction (LUTD) in multiple sclerosis (MS) is highly prevalent in adults, but has not previously been described in paediatric MS. A total of 24 consecutive children with newly diagnosed MS were prospectively assessed for bladder and bowel problems early after diagnosis. Five of 24 children (21%) showed LUTD during assessment. One of these patients did not report voiding complaints. This high prevalence of LUTD indicates that all recently diagnosed patients with paediatric MS should be evaluated early in their disease and treated for urinary problems in order to prevent potential damage to the upper urinary tract.

Multiple Sclerosis and Risk of Infection-Related Hospitalization and Death in US Veterans

BACKGROUND

This study estimated the risk of infection-related hospitalizations and death in patients with and without multiple sclerosis (MS).

METHODS

We identified adults with MS in the US Department of Veterans Affairs (VA) system between 1999 and 2010. Each veteran with MS was matched, on age and sex, with up to four veterans without MS. Multivariable Cox proportional hazards regression models were performed to assess the influence of MS on the development of serious and fatal infections.

RESULTS

The cohort included 7743 veterans with MS and 30,972 veterans without MS. Mean (SD) age was 53.8 (13.3) years, and 80.8% were male. The incidence per 1000 person-years of overall serious infections was 19.2 (95% confidence interval [CI], 17.6-20.8) for those with MS and 10.3 (95% CI, 9.8-10.9) for those without MS. Fatal infection incidence rates were 1.2 (95% CI, 0.8-1.7) for patients with MS and 0.5 (95% CI, 0.3-0.6) for patients without MS. Regression models showed that veterans with MS were at greater risk for overall serious (hazard ratio [HR] = 1.52, P < .01) and fatal (HR = 1.85, P = .03) infections and serious respiratory (HR = 1.31, P = .01), urinary tract (HR = 4.44, P < .01), and sepsis-related infections (HR = 2.56, P < .01).

CONCLUSIONS

This study provides evidence that VA patients with MS are more likely than those without MS to be hospitalized and die of infection.

Metaboreflex activity in multiple sclerosis patients

PURPOSE

The muscle metaboreflex activation has been shown essential to reach normal hemodynamic response during exercise. It has been demonstrated that patients with multiple sclerosis (MS) have impaired autonomic functions and cardiovascular regulation during exercise. However, to the best of our knowledge, no previous research to date has studied the metaboreflex in MS patients. The purpose of this study was to investigate the hemodynamic response to metaboreflex activation in patients with MS (n = 43) compared to an age-matched, control group (CTL, n = 21).

METHODS

Cardiovascular response during the metaboreflex was evaluated using the post-exercise muscle ischemia (PEMI) method and during a control exercise recovery (CER) test. The difference in hemodynamics between the PEMI and the CER test was calculated and this procedure allowed for the assessment of the metaboreflex response. Hemodynamics was estimated by impedance cardiography.

RESULTS

The MS group showed a normal mean blood pressure (MBP) response as compared to the CTL group (+6.5 ± 6.9 vs. +8 ± 6.8 mmHg, respectively), but this response was achieved with an increase in systemic vascular resistance, that was higher in the MS with respect to the CTL group (+137.6 ± 300.5 vs. -14.3 ± 240 dyne · s(-1) cm(-5), respectively). This was the main consequence of the MS group's incapacity to raise the stroke volume (-0.65 ± 10.6 vs. +6.2 ± 12.8 ml, respectively).

CONCLUSION

It was concluded that MS patients have an impaired capacity to increase stroke volume (SV) in response to low level metaboreflex, even if they could sustain the MBP response by vasoconstriction. This was probably a consequence of their chronic physical de-conditioning.

Association Between Urinary Symptoms and Urinary Tract Infection in Patients With Multiple Sclerosis

Background & Objective:

Urinary dysfunctions occur in the majority of MS patients and these patients are at higher risks of developing UTI due to multiple reasons. We determined to study the association between different urinary symptoms and UTI in MS patients.

Material & Method:

Eighty seven MS patients that referred to our medical care center with an acute attack of the disease, from November 2012 to April 2014, were included in the study. Patients were classified into two groups based on their urine culture results UTI positive and non-UTI patients. The prevalence of different types of urinary symptoms was then compared among the two groups.

Result:

The mean age of our patients was 36.8 years old. From the total 87 patients, 83 (95.4%) were female. Overall 56.3% of patients displayed urinary symptoms. The most prevalent urinary problems were urinary incontinence and frequency (25.3% and 24.1%, respectively). A positive urinary culture was seen in 71.3% of the patients. The prevalence of urinary problems was significantly higher in UTI patients in comparison to non-UTI patients (64.5% and 40% in UTI and non-UTI patients, respectively; p=0.036). Separately none of the different urinary symptoms displayed a significant difference between UTI and non-UTI patients (p>0.05).

Conclusion:

Not a single symptom can be diagnostic of UTI, but MS patient with urinary tract infections do present more urinary symptoms and this can be an indication for further urine analysis and screening measures for MS patients who display more urinary symptoms.

Symptomatic management in multiple sclerosis

Multiple sclerosis (MS) is the commonest cause of disability in young adults. While there is increasing choice and better treatments available for delaying disease progression, there are still, very few, effective symptomatic treatments. For many patients such as those with primary progressive MS (PPMS) and those that inevitably become secondary progressive, symptom management is the only treatment available. MS related symptoms are complex, interrelated, and can be interdependent. It requires good understanding of the condition, a holistic multidisciplinary approach, and above all, patient education and empowerment.

Lower urinary tract dysfunction in the neurological patient: clinical assessment and management

Lower urinary tract (LUT) dysfunction is a common sequela of neurological disease, resulting in symptoms that have a pronounced effect on quality of life. The site and nature of the neurological lesion affect the pattern of dysfunction. The risk of developing upper urinary tract damage and renal failure is much lower in patients with slowly progressive non-traumatic neurological disorders than in those with spinal cord injury or spina bifida; this difference in morbidity is taken into account in the development of appropriate management algorithms. Clinical assessment might include tests such as uroflowmetry, post-void residual volume measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the indication. Incomplete bladder emptying is most often managed by intermittent catheterisation, and storage dysfunction by antimuscarinic drugs. Intradetrusor injections of onabotulinumtoxinA have transformed the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. An individualised, patient-tailored approach is required for the management of LUT dysfunction associated with neurological disorders.

Electrical management of neurogenic lower urinary tract disorders

Management of lower urinary tract dysfunction (LUTD) in neurological diseases remains a priority because it leads to many complications such as incontinence, renal failure and decreased quality of life. A pharmacological approach remains the first-line treatment for patients with neurogenic LUTD, but electrical stimulation is a well-validated and recommended second-line treatment. However, clinicians must be aware of the indications, advantages and side effects of the therapy. This report provides an update on the 2 main electrical stimulation therapies for neurogenic LUTD - inducing direct bladder contraction with the Brindley procedure and modulating LUT physiology (sacral neuromodulation, tibial posterior nerve stimulation or pudendal nerve stimulation). We also describe the indications of these therapies for neurogenic LUTD, following international guidelines, as illustrated by their efficacy in patients with neurologic disorders. Electrical stimulation could be proposed for neurogenic LUTD as second-line treatment after failure of oral pharmacologic approaches. Nevertheless, further investigations are needed for a better understanding of the mechanisms of action of these techniques and to confirm their efficacy. Other electrical investigations, such as deep-brain stimulation and repetitive transcranial magnetic stimulation, or improved sacral anterior root stimulation, which could be associated with non-invasive and highly specific deafferentation of posterior roots, may open new fields in the management of neurogenic LUTD.

Summary of European Association of Urology (EAU) Guidelines on Neuro-Urology

CONTEXT

Most patients with neuro-urological disorders require life-long medical care. The European Association of Urology (EAU) regularly updates guidelines for the diagnosis and treatment of these patients.

OBJECTIVE

To provide a summary of the 2015 updated EAU Guidelines on Neuro-Urology.

EVIDENCE ACQUISITION

Structured literature searches in several databases were carried out to update the 2014 guidelines. Levels of evidence and grades of recommendation were assigned where possible.

EVIDENCE SYNTHESIS

Neurological disorders often cause urinary tract, sexual, and bowel dysfunction. Most neuro-urological patients need life-long care for optimal life expectancy and quality of life. Timely diagnosis and treatment are essential to prevent upper and lower urinary tract deterioration. Clinical assessment should be comprehensive and usually includes a urodynamic investigation. The neuro-urological management must be tailored to the needs of the individual patient and may require a multidisciplinary approach. Sexuality and fertility issues should not be ignored. Numerous conservative and noninvasive possibilities of management are available and should be considered before a surgical approach is chosen. Neuro-urological patients require life-long follow-up and particular attention has to be paid to this aspect of management.

CONCLUSIONS

The current EAU Guidelines on Neuro-Urology provide an up-to-date overview of the available evidence for adequate diagnosis, treatment, and follow-up of neuro-urological patients.

PATIENT SUMMARY

Patients with a neurological disorder often suffer from urinary tract, sexual, and bowel dysfunction and life-long care is usually necessary. The update of the EAU Guidelines on Neuro-Urology, summarized in this paper, enables caregivers to provide optimal support to neuro-urological patients. Conservative, noninvasive, or minimally invasive approaches are often possible.

Autonomic Dysregulation in Multiple Sclerosis

Multiple sclerosis (MS) is a chronic, progressive central neurological disease characterized by inflammation and demyelination. In patients with MS, dysregulation of the autonomic nervous system may present with various clinical symptoms including sweating abnormalities, urinary dysfunction, orthostatic dysregulation, gastrointestinal symptoms, and sexual dysfunction. These autonomic disturbances reduce the quality of life of affected patients and constitute a clinical challenge to the physician due to variability of clinical presentation and inconsistent data on diagnosis and treatment. Early diagnosis and initiation of individualized interdisciplinary and multimodal strategies is beneficial in the management of autonomic dysfunction in MS. This review summarizes the current literature on the most prevalent aspects of autonomic dysfunction in MS and provides reference to underlying pathophysiological mechanisms as well as means of diagnosis and treatment.

Tablet-based screening improves continence management in multiple sclerosis

Objective

To investigate whether electronic continence questionnaires aid early identification and optimizes management of sphincter dysfunction in a multiple sclerosis clinic.

Methods

A custom designed, tablet-based cross-platform software tool was designed to capture validated multiple sclerosis (MS) patient-reported outcomes. An unselected cohort of MS patients from a tertiary referral clinic completed electronic tablet-based versions of the Bladder Control Scale (BLCS) and the Bowel Control Scale in the waiting room. Data were captured wirelessly “on-the-fly” and stored in a deidentified, secure database; and individual questionnaire results were immediately available to the treating neurologist in the electronic medical record. Scores of ≥2 on either questionnaire generated an automated electronic referral to the clinic MS continence nurse (MS CN).

Results

One hundred and fifty-seven MS patients completed a total of 184 electronic continence test sets and on two occasions only the BLCS was completed. An automatic electronic referral for formal continence review was generated 128 times in 108 patients. Fifty-seven formal continence assessments were undertaken by the MS CN following automated referral. All reviews resulted in at least one clinical intervention being made.

Interpretation

Tablet-based data capture and automated continence referral using this software tool is an efficient, sensitive, and feasible method of screening MS patients for bladder and bowel dysfunction. Concordance with the results of formal continence assessment in this pilot study validates the use of this technology as a screening tool.

Chapter 1: The conditions of neurogenic detrusor overactivity and overactive bladder

Overactive bladder (OAB) is a symptom syndrome consisting of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence (UUI), in the absence of a causative infection or pathological conditions. The prevalence of OAB is approximately 11-19% in both men and women, and leads to a significant negative effect on a patient's health-related quality of life (HRQOL). OAB is also associated with comorbidities such as urinary tract infection (UTI) and an increased risk of falls. Following behavioral therapy, anticholinergic agents are commonly prescribed, but these often fail because of lack of efficacy and/or poor tolerability. Evaluation of treatment success in OAB should include pre-defined, patient-centered goals. Patients for whom oral therapy has failed to meet such goals may be considered refractory to oral therapy and candidates for minimally invasive therapy. Neurogenic detrusor overactivity (NDO) is a bladder dysfunction frequently observed in patients with conditions such as multiple sclerosis (MS) and spinal cord injury (SCI). Increased storage pressure can put the upper urinary tract at risk of deterioration and reducing this risk is a primary aim of therapy. Urinary incontinence (UI) is reported by approximately 50% of MS patients, and most SCI patients will develop some bladder dysfunction. NDO leads to a negative impact on HRQOL, independent of the impact of the primary condition. NDO patients in whom oral therapy has failed to normalize storage pressure may be considered refractory and are candidates for minimally invasive therapy.

Validation survey of the impact of urinary incontinence (IIQ-7) and inventory of distress urogenital (UDI-6) - the short scales - in patients with multiple sclerosis

Cross-cultural adaptation and validation of the Impact Questionnaire of Urinary Incontinence (IIQ-7) and Urogenital Distress Inventory (UDI-6) - short scale - in the Brazilian population with multiple sclerosis. The IIQ-7 and UDI-6 were translated into Portuguese, called IIQ-7-BR and UDI-6-BR. The questionnaires were administered in 211 individuals selected randomly. Of these, 140 had MS according to McDonald criteria and 71 were included in the control group. In both questionnaires, the Cronbach's alpha coefficient was above 0.7. The IIQ-7-BR showed 94.31% concordance between the evaluated studies and UDI-6-BR, 93.33%. Thus, the instruments of this study were presented according to the standards proposed by the Instrument Review Criteria, reliability, validity and sensitivity, maintaining the original scales characteristics.

[Study of the sensitivity of renal ultrasonography as an indirect means of assessing renal function in patients with neurogenic bladder, from a cohort of 103 patients]

OBJECTIVES

The assessment of renal function is essential to follow up the patients with neurogenic bladder. The objective of this study was to determine if renal ultrasonography would both evaluate the morphology of the urinary tract and renal function.

METHOD

In a retrospective study, all patients followed for neurogenic bladder were included, regardless of their neurological disease. Renal function was estimated by creatinine clearance (Cl24 h), the reference test in neurological patients, the glomerular filtration rate by the MDRD simplified (MDRDs) and CKD-EPI creatinine formula, and we identified renal abnormalities detected on ultrasonography.

RESULTS

One hundred and three patients were included (57 men-36 women), mean age 51±13 years. Fifty-nine patients had multiple sclerosis, 23 spinal cord injury. Depending on the method used (Cl24h, MDRDs, CKD-EPI creatinine) respectively 54, 49 and 39 patients had abnormal renal function; eleven patients had abnormal findings on renal ultrasonography. The sensitivity of ultrasonography as an indirect indicator of renal function depending on the method used (Cl24h, MDRDs, CKD-EPI creatinine) was equal respectively to 14%, 8% and 10%.

CONCLUSION

Renal ultrasonography, which is essential to follow up the neurogenic bladder, is not enough sensitive to detect abnormal renal function and should continue to be associated with an evaluation of renal function, which is suitable for neurological patients.

LEVEL OF EVIDENCE

4.

Relationship between urodynamic findings and sexual function in multiple sclerosis patients with lower urinary tract dysfunction

BACKGROUND AND PURPOSE

Sexual dysfunction (SD) is prevalent in multiple sclerosis (MS) patients and affects quality of life. Furthermore, lower urinary tract dysfunction (LUTD) is common in MS patients. Our aim was to determine the relationship between urodynamic findings and SD in a cohort of MS patients with LUTD.

METHODS

From January 2011 to September 2013, 135 consecutive patients with MS in remission phase and LUTD underwent a first urodynamic examination, according to the International Continence Society criteria. Neurological impairment was assessed using the Expanded Disability Status Scale and SD was investigated with the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-15). Multivariate logistic regression analysis was performed to identify predictors of female SD (FSFI < 26.55) or moderate-severe erectile dysfunction (ED) (IIEF-EF ≤ 16), after adjusting for confounding factors including urodynamic findings.

RESULTS

Subjects with maximum detrusor pressure during involuntary detrusor contraction (PdetmaxIDC) ≥20.0 cmH2 O had lower IIEF-EF, IIEF overall satisfaction (IIEF-OS), FSFI-Arousal, FSFI-Lubrication and FSFI-Orgasm. Subjects with maximum cystometric capacity (MCC) ≥135 ml had higher IIEF-EF, intercourse satisfaction (IIEF-IS), orgasmic function (IIEF-OF), sexual desire (IIEF-SD), FSFI-Arousal, FSFI-Lubrication, FSFI-Orgasm, FSFI-Satisfaction and FSFI-Pain. On multivariate logistic regression analysis, PdetmaxIDC ≥20 cmH2 O [odds ratio (OR) 6.7; P < 0.05] and MCC <135 ml (OR 6.80; P < 0.05) were predictors of moderate-severe ED. In a model including all previous variables, compliance ≤3 ml/cmH2 O was an independent predictor of moderate-severe ED (OR 14.49; P < 0.01). No relationship was found between the previous variables and FSFI <26.55.

CONCLUSIONS

Neurogenic bladder is associated with SD in MS patients. The presence of PdetmaxIDC ≥20 cmH2 O, MCC <135 ml and compliance ≤3 ml/cmH2 O may significantly predict the presence of moderate-severe ED.

Concept Analysis and Content Validation of Risk of Injury to the Urinary Tract: Nursing Diagnosis

PURPOSE

To elaborate, propose, and validate risk for urinary tract injury as a nursing diagnosis.

METHODS

Methodology was divided into three phases: analysis of the concept of urinary tract injury, elaboration of the diagnosis, and validation by a group of specialists.

FINDINGS

Diagnosis label, definition, and inclusion in taxonomy were validated. In 15 risk factors proposed, 12 were validated.

CONCLUSIONS

Risk of urinary tract injury was validated as a nursing diagnosis to contemplate the vulnerability of patients using urinary catheters.

IMPLICATIONS FOR NURSING PRACTICE

Identification of these risk factors contributes to the elaboration of care plans to improve quality of care.

Alterations in nerve-evoked bladder contractions in a coronavirus-induced mouse model of multiple sclerosis

BACKGROUND

Patients with neurodegenerative diseases such as multiple sclerosis, Parkinson's, and Alzheimer's often present with lower urinary tract symptoms (LUTS, urinary frequency, urgency, nocturia and retention) resulting from damage to the peripheral and central nervous systems. These studies were designed to examine the changes in the function of the bladder that may underlie neurogenic bladder dysfunction using a mouse model of demyelination in the CNS.

METHODS

Bladders from 12 week old male C57BL/6J mice with coronavirus-induced encephalomyelitis (CIE, a chronic, progressive demyelinating disease model of human MS), and age-matched controls, were cut into 5-7 strips and suspended in physiological muscle baths for tension measurement in response to agonists and electric field stimulation (EFS). Experiments were performed on intact and denuded (with mucosa removed) bladder strips.

RESULTS

The maximum effect of EFS was not significantly different between CIE and control bladders. Nerve-evoked EFS contractions (tetrodotoxin-sensitive) were blocked by a combination of atropine (cholinergic antagonist) and α,β-methylene ATP (an ATP analog that desensitizes purinergic receptors). In response to EFS, the α,β-methylene ATP-resistant (cholinergic) component of contraction was significantly reduced, while the atropine-resistant (purinergic) component was significantly increased in CIE bladders. Removal of the mucosa in CIE bladders restored the cholinergic component. Bethanechol (muscarinic receptor agonist) potency was significantly increased in CIE bladders.

CONCLUSIONS

Our data demonstrate a deficit in the nerve-evoked cholinergic component of contraction that is not due to the ability of the smooth muscle to respond to acetylcholine. We conclude that neurodegenerative bladder dysfunction in this model of multiple sclerosis may be due, in part, to pathologic changes in the mucosa that causes suppression of muscarinic receptor-mediated contractile response and augmentation of purinergic response of the underlying muscle. Further studies utilizing CIE mice should help elucidate the pathological changes in the mucosa resulting from demyelination in the CNS.

Determinants of sexual impairment in multiple sclerosis in male and female patients with lower urinary tract dysfunction: results from an Italian cross-sectional study

INTRODUCTION

Sexual dysfunction (SD) is prevalent in multiple sclerosis (MS) patients and affects quality of life. Furthermore, lower urinary tract dysfunction (LUTD) is common in MS patients.

AIMS

This study aims to evaluate the relationship between SD, neurological disability, depression, anxiety, and urodynamic alterations in patients with MS and LUTD.

METHODS

From January 2011 to September 2013, 135 consecutive patients with MS in remission phase and LUTD underwent first urodynamic examination, according to the International Continence Society criteria. Depression and anxiety were evaluated with the Hamilton Depression Scale (HAM-D) and the Hamilton Anxiety Scale (HAM-A), neurological impairment was assessed using the Expanded Disability Status Scale (EDSS), and SD was investigated with the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-15).

MAIN OUTCOME MEASURES

Multivariate logistic regression analyses were carried out to identify variables for predicting female sexual dysfunction (FSD) (FSFI < 26.55), male SD (IIEF-15 < 60), or moderate-severe erectile dysfunction (IIEF-EF ≤ 16), after adjusting for confounding factors.

RESULTS

Total IIEF-15 and all subdomains (all P < 0.01), total FSFI, FSFI-arousal, FSFI-lubrication, and FSFI-orgasm (all P < 0.05) were lower in subjects with EDSS ≥ 4.5. We found inverse relationship between IIEF-15 and relative subdomains with EDSS (all P < 0.01) and between FSFI and relative subdomains with EDSS (all P < 0.01), HAM-D (all P < 0.01), and HAM-A (all P < 0.01). Continuous EDSS (odds ratio [OR] = 1.54; P = 0.03) and categorical EDSS (≥4.5) (OR = 6.0; P = 0.03), HAM-D (OR = 4.74; P = 0.03), and HAM-A (OR = 4.10; P = 0.02) were significantly associated with FSD (FSFI < 26.55). Detrusor overactivity (DO) was an independent predictor of moderate-severe ED (IIEF-EF ≤ 16) (OR = 2.03; P < 0.01), and of FSD (OR = 9.73; P = 0.04).

CONCLUSIONS

Neurological disability, depression and DO are significantly predictive of SD in MS patients, irrespective of gender. An EDSS ≥ 4.5 may significantly predict the presence of SD.

Coronavirus-induced demyelination of neural pathways triggers neurogenic bladder overactivity in a mouse model of multiple sclerosis

In the present study, we aimed to determine whether mice with coronavirus-induced encephalomyelitis (CIE) develop neurogenic bladder dysfunction that is comparable with the neurogenic detrusor overactivity observed in patients with multiple sclerosis. Adult mice (C57BL/6J, 8 wk of age, n = 146) were inoculated with a neurotropic strain of mouse hepatitis virus (A59 strain) and followed for 4 wk. Inoculation with the virus caused a significant neural deficit in mice with an average clinical symptom score of 2.6 ± 0.5 at 2 wk. These changes were accompanied by 25 ± 5% weight loss at 1 and 2 wk postinoculation (P ≤ 0.001 vs. baseline) followed by a recovery phase. Histological analysis of spinal cord sections revealed multifocal sites of demyelinated lesions. Assessment of micturition patterns by filter paper assay determined an increase in the number of small and large urine spots in CIE mice starting from the second week after inoculation. Cystometric recordings in unrestrained awake animals confirmed neurogenic bladder overactivity at 4 wk postinoculation. One week after inoculation with the A59 strain of mouse hepatitis virus, mice became increasingly sensitive to von Frey filament testing with responses enhanced by 45% (n = 8, P ≤ 0.05 vs. baseline at 4 g); however, this initial increase in sensitivity was followed by gradual and significant diminution of abdominal sensitivity to mechanical stimulation by 4 wk postinoculation. Our results provide direct evidence showing that coronavirus-induced demyelination of the central nervous system causes the development of a neurogenic bladder that is comparable with neurogenic detrusor overactivity observed in patients with multiple sclerosis.

Clinical and urodynamic evaluations of urinary disorders in multiple sclerosis

Urinary dysfunction is a major clinical problem and a significant cause of disability in multiple sclerosis (MS) patients. Indeed, the bothersome symptom of urinary dysfunction may adversely affect social relationships and activities in MS patients. Since many causes of urinary dysfunction are described, a thorough evaluation including history, clinical examination and evaluation of quality of life is necessary. Generally, diagnosis of urinary disorders is complex with intricated pathophysiologic factors. In these cases, urodynamic investigations are necessary to better understand symptoms pathophysiology and choose the best treatment.

OnabotulinumtoxinA and multiple sclerosis

Lower urinary tract dysfunction is present in two of three patients with multiple sclerosis five years after the diagnosis. Most frequent symptoms are related to neurogenic detrusor overactivity, often associated with detrusor-sphincter dyssynergia. From the end of the 1990s, there is growing evidence that neurogenic detrusor overactivity can be effectively managed by intradetrusorial injections of botulinum toxin type A. This treatment has shown, in different randomised placebo-controlled trials, to be safe and effective on clinical and urodynamic parameters with significant improvement in quality of life. The median duration of effect is in mean nine months. The vast majority of studies have been conducted with onabotulinumtoxinA. The dose of onabotulinumtoxinA commonly used to treat neurogenic detrusor overactivity in patients with multiple sclerosis is 200 UI, even if in selected patients lower doses can be preferred. To be considered eligible for treatment, all patients should accept and be instructed to perform clean intermittent self-catheterisation, since the risk of increased post-void residual volume and/or urinary retention after injection is high, especially with 200 UI of onabotulinumtoxinA. However, quality of life and patient satisfaction seem not to be affected by the need of intermittent catheterisation. The risk of urinary infection after the procedure is to be kept in mind, mainly in patients with multiple sclerosis, so that adequate antibiotic prophylaxis is highly recommended.

Therapeutic strategies of urinary disorders in MS. Practice and algorithms

OBJECTIVE

Review the literature on therapeutic strategies and guidelines for the treatment of neurogenic bladder in multiple sclerosis.

MATERIAL AND METHOD

A search on available articles on consensus, recommendations guidelines and algorithm of treatment of urinary tract dysfunction in multiple sclerosis.

RESULTS

Five national consensus guidelines were recently published and proposed guidelines for the first and second line treatments.

CONCLUSION

Multiple sclerosis patients suffering from lower urinary tract disorders must benefit from an early diagnosis and simple first line evaluation and treatment. More complex and invasive evaluation in the neuro-urology unit is appropriate for patients who failed to first line treatment or in case of complications.

Detrusor underactivity: Pathophysiological considerations, models and proposals for future research. ICI-RS 2013

AIMS

Detrusor underactivity, resulting in either prolonged or inefficient voiding, is a common clinical problem for which treatment options are currently limited. The aim of this report is to summarize current understanding of the clinical observation and its underlying pathophysiological entities.

METHODS

This report results from presentations and subsequent discussion at the International Consultation on Incontinence Research Society (ICI-RS) in Bristol, 2013.

RESULTS AND CONCLUSIONS

The recommendations made by the ICI-RS panel include: Development of study tools based on a system's pathophysiological approach, correlation of in vitro and in vivo data in experimental animals and humans, and development of more comprehensive translational animal models. In addition, there is a need for longitudinal patient data to define risk groups and for the development of screening tools. In the near-future these recommendations should lead to a better understanding of detrusor underactivity and its pathophysiological background. Neurourol. Urodynam. 33:591-596, 2014. © 2014 Wiley Periodicals, Inc.