Conservative bladder management in advanced multiple sclerosis

Lower urinary tract disorders in multiple sclerosis patients: prevalence, clinical features, and response to treatments

Aims

Lower urinary tract symptoms are common in multiple sclerosis (MS) and have a great impact on quality of life. We evaluated prevalence and characteristics of urological symptoms in a cohort of patients with MS.

Methods

This is a cross‐sectional study conducted on consecutive patients with MS attending our Center in 2018. We evaluated prevalence, clinical features, and response to symptomatic treatments of lower urinary tract disorders; we investigated the relationship between them and clinical and demographic features. Data of urodynamic studies were also collected.

Results

In our cohort of 806 patients, the overall prevalence of urological symptoms was 52.9% and urgency was the most frequent symptom (59.4%). Symptomatic patients had a higher disability, a longer disease duration, a later age at onset, and a greater mean age at the time of evaluation. Urinary disorders were more frequent in patients with progressive disease and in women. About 41.8% of patients were under treatment for the urological disorder and 81.5% of them reported an improvement of symptoms.

Conclusion

Urinary disorders in patients with MS have a high prevalence. An early and correct characterization of types of symptoms and an early and targeted therapeutic strategy are essential to improve the patient's quality of life and avoid future complications.

Pharmacotherapeutic management of lower urinary tract symptoms in Multiple Sclerosis patients

INTRODUCTION

Multiple Sclerosis (MS) manifests with a plethora of signs and symptoms affecting brain structures and spinal pathways. The multitude of lesions in MS patients makes difficult to establish the relative role of each of them to lower urinary tract symptoms (LUTS). Generally, the subcortical white-matter lesions result in detrusor overactivity, whilst lesions of the spinal cord result in the combined occurrence of detrusor overactivity and detrusor-sphincter dyssynergia (DSD). It has been estimated that 80-90% of patients with MS will suffer from some form of LUTS over the course of the disease. Among LUTS, the most reported is detrusor overactivity which includes urinary urgency, frequent urination, nocturia, and urge urinary incontinence.

AREAS COVERED

The authors review the management of lower urinary tract symptoms in MS patients providing their expert opinions on the subject matter.

EXPERT OPINION

LUTS affect the quality of life substantially and are associated with a significantly increased mortality. The adequate management is an important challenge for both patients and caregivers with a multidisciplinary approach likely necessary.

Urodynamic changes in mice with experimental autoimmune encephalomyelitis correlate with neurological impairment

AIMS

Neurogenic bladder dysfunction is a major issue in Multiple Sclerosis (MS). High intravesical pressure should be treated early. Available therapies are insufficient and there is need for drug development and investigation of pathogenesis. Experimental Autoimmune Encephalomyelitis (EAE) in rodents is a well validated model to study MS. Previous research has shown that these animals develop urinary symptoms. However, from clinical studies, we know that symptoms do not necessarily reflect changes in bladder pressure. This paper aims to provide a complete overview of urodynamic changes in a model for detrusor overactivity in MS.

METHODS

Female C57Bl/6J mice, injected with MOG35-55 and control mice, injected with vehicle (Complete Freund's adjuvant), were monitored daily for neurologic symptoms. Within 1 month after symptom development, mice were used for cystometry or histology of the bladder.

RESULTS

Increasing disease score correlated with increased micturition frequency, basal pressure, and average pressure, and with a decrease in functional bladder capacity, voiding amplitude, and maximum pressure.

CONCLUSIONS

This paper provides a detailed description of bladder function in C57Bl/6J mice with Myelin Oligodendrocyte Glycoprotein peptide (MOG35-55 ) induced EAE. This EAE model induces detrusor overactivity in close relationship to neurological impairment. EAE in mice is a suitable model to study detrusor overactivity in MS. Neurourol. Urodynam. 35:450-456, 2016. © 2015 Wiley Periodicals, Inc.

TRP channels in lower urinary tract dysfunction

Lower urinary tract dysfunction (LUTd) represents a major healthcare problem. Although it is mostly not lethal, associated social disturbance, medical costs, loss of productivity and especially diminished quality of life should not be underestimated. Although more than 15% of people suffer from a form of LUTd to some extent, pathophysiology often remains obscure. In the past 20 years, transient receptor potential (TRP) channels have become increasingly important in this field of research. These intriguing ion channels are believed to be the main molecular sensors that generate bladder sensation. Therefore, they are intensely pursued as new drug targets for both curative and symptomatic treatment of different forms of LUTd. TRPV1 was the first of its class to be investigated. Actually, even before this channel was cloned, it had already been targeted in the bladder, with clinical trials of intravesical capsaicin instillations. Several other polymodally gated TRP channels, particularly TRPM8, TRPA1 and TRPV4, also appear to play a prominent role in bladder (patho)physiology. With this review, we provide a brief overview of current knowledge on the role of these TRP channels in LUTd and their potential as molecular targets for treatment.

Caregiver burden among informal caregivers assisting people with multiple sclerosis

Multiple sclerosis (MS) burdens not only patients but also their informal or family caregivers. This study was conducted to identify characteristics of caregivers, caregiving, and MS patients receiving informal care that are associated with caregiving burden. Data were collected through a national survey of informal MS caregivers and analyzed using an ordered logistic regression model to identify factors associated with burden. Burden was found to be significantly greater among male caregivers than among female caregivers. Moreover, greater burden was associated with more frequent patient bladder dysfunction, more hours per week spent providing assistance, and greater restriction on the caregiver's ability to perform daily activities because of caregiving responsibilities. A strong association was found between the mental health status of the caregiver and burden. Health professionals should be sensitive to the impact of caregiving on the mental health of MS caregivers. The results of this study suggest that treating patient bladder dysfunction and facilitating respite care may reduce burden and improve the mental health of informal caregivers of people with MS. Future research should identify programs and services designed specifically to reduce burden experienced by male caregivers.

Pannexin 1 involvement in bladder dysfunction in a multiple sclerosis model

Bladder dysfunction is common in Multiple Sclerosis (MS) but little is known of its pathophysiology. We show that mice with experimental autoimmune encephalomyelitis (EAE), a MS model, have micturition dysfunction and altered expression of genes associated with bladder mechanosensory, transduction and signaling systems including pannexin 1 (Panx1) and Gja1 (encoding connexin43, referred to here as Cx43). EAE mice with Panx1 depletion (Panx1^−/−) displayed similar neurological deficits but lesser micturition dysfunction compared to Panx1^+/+ EAE. Cx43 and IL-1β upregulation in Panx1^+/+ EAE bladder mucosa was not observed in Panx1^−/− EAE. In urothelial cells, IL-1β stimulation increased Cx43 expression, dye-coupling, and p38 MAPK phosphorylation but not ERK1/2 phosphorylation. SB203580 (p38 MAPK inhibitor) prevented IL-1β-induced Cx43 upregulation. IL-1β also increased IL-1β, IL-1R-1, PANX1 and CASP1 expression. Mefloquine (Panx1 blocker) reduced these IL-1β responses. We propose that Panx1 signaling provides a positive feedback loop for inflammatory responses involved in bladder dysfunction in MS.

Sacral neuromodulation in patients with multiple sclerosis

PURPOSE

We present a case series of patients with multiple sclerosis (MS) and neurogenic lower urinary tract dysfunction treated by sacral neuromodulation (SNM).

METHODS

We reviewed charts of 25 patients who were treated for refractory lower urinary tract symptoms; during the SNM testing phase, patient management included evaluation of number of daily voiding, number of episodes of incontinence, residual urine and quality of life score. Patients who experienced greater than 50% improvement in symptoms of frequency and incontinence episodes and/or a greater than 50% decrease in the number of catheterizations and a greater than 50% increase in voided volumes were offered placement of the permanent InterStim(TM) .

RESULTS

Fifteen patients were implanted with InterStim(TM); mean duration of MS was 13.66 years; mean follow-up of patients was 49.4 months. Nine patients were on clean intermittent catheterization, and in all of them, a significant decrease in residual volume with increase in voided volume and number of voiding per day; in 6 patients, the main problem was incontinence, and in them incontinence, episodes decreased and voided volume increased. Sixty-six per cent of patients have a functioning device after a mean follow-up of 61.2 months.

CONCLUSIONS

SNM is a good option in the treatment of voiding dysfunction in patients with MS in a medium to long-term follow-up. Urinary retention due to detrusor underactivity is not a good indication for SNM; it should be offered to MS patients with refractory urgency urinary incontinence and MS patients with urinary retention due to detrusor-sphincter dyssynergia (DSD).

Contemporary management of the neurogenic bladder for multiple sclerosis patients

Urinary symptoms related to multiple sclerosis (MS) present a complex challenge for the treating physician. However, several treatment options are available for the symptomatic patient once the physician understands basic MS disease epidemiology and pathophysiology. Depending of disease status and symptoms, MS urinary symptoms may respond to directed behavioral, pharmacologic, intravesical, neuromodulation, or surgical therapies.

The symptomatic management of multiple sclerosis

The management of multiple sclerosis (MS) revolves around disease management, symptom management, and person management. Of these, symptom management takes up the bulk of the time of the practicing physician. Some symptoms are easily managed whereas others are more difficult. Decisions have often to be made on whether to treat or to wait and watch. This article discusses the varied symptoms of MS and the approaches to management, which involves rehabilitation, pharmacological treatments, and surgical procedures. The skilled physician managing MS should be familiar with the multiple approaches to improving the quality of life of those with MS. After the diagnosis has been established and the decisions regarding treatment approaches have been made, the talk in a typical office appointment for MS usually turns to symptom management. Thus, the majority of management decisions made by the clinician revolve around that important topic. It is symptom management that will determine quality of life for those with MS, It is the basis for improving function, and, up until twenty years ago, it was the only basis for treating MS. Now, however, we can approach treatment by disease management, symptom management, and person management. The MS specialist must be well versed in all three areas.

Urogenital dysfunction in patients with multiple sclerosis

The occurrence of urogenital dysfunction as an isolated early symptom in multiple sclerosis (MS) is rare, but the prevalence thereof becomes high with progression of disease. Lower urinary tract dysfunction may add to the cause of death (particularly through urinary infections), but both urinary and sexual dysfunction significantly affect quality of life of patients. Both storage and evacuation of urine may be affected by MS, and ultimatively the functional diagnosis can only be made by urodynamic testing. As upper urinary tract affection is, however, rare (and can be prevented by timely ultrasound imaging), a first stage diagnostics in the MS center by the neurologist and specialized nurse is appropriate. History, urine tests and post void residual urine determination (preferably by ultrasound) should provide necessary data for treatment of infections, and also symptomatic management of frequency, urgency and incontinence by bladder training, anticholinergics, and intermittent self catheterization (as indicated); the referral to urologist may be reserved for patients who fail first line treatment. Treatment in the late stages of MS is as yet little researched, but eventually a suprapubic catheter is the preferred method of bladder emptying. Sexual dysfunction should be actively sought in MS patients (in men erectile and ejaculation dysfunction, in women deficient lubrication and genital hyper- or hyposensitivity are frequent). Clinical examination contributes little to clarification of neurogenic sexual dysfunction, but defines the extent of other deficits due to MS, which may be relevant for sexual counseling (spasticity, sensory loss). Sildenafil has been demonstrated to be effective in treatment of men, but not in women. Other management options exist, and the doctor and nurse in the MS center should be proactive in providing first line counseling and management.