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

Unraveling the complex relationship: Multiple sclerosis, urinary tract infections, and infertility

BACKGROUND

Multiple sclerosis (MS) is an immune system disorder that affects the central nervous system (CNS) and progressively damages nerve fibers and protective myelin. People with MS often experience a wide range of complications, including lower urinary tract dysfunction, urinary tract infections (UTIs) and sexual dysfunction. MS is common in young people and can lead to sexual dysfunction (SD) and infertility, which becomes more pronounced as the disease progresses.

RESULTS

Over the past two decades, significant advances have been made in the management of MS, which may slow the progression of the disease and alter its course. However, UTI and SD remain significant challenges for these patients. Awareness of the underlying complications of MS, such as UTIs and infertility, is crucial for prevention, early detection and appropriate treatment, as there is a causal relationship between UTIs and the use of corticosteroids during an attack.

CONCLUSION

This article provides an overview of potential microbial pathogens that contribute to the development of MS, as well as an assessment of people with MS who report UTIs and infertility.

Multiple sclerosis and lower urinary tract symptoms: A survey of prevalence, characteristic and urological evaluations

Objective

Most multiple sclerosis patients have urological complications such as lower urinary tract symptoms. This study was conducted to evaluate the prevalence of these symptoms and whether they result in a urological evaluation.

Methods

A cross-sectional study of 517 multiple sclerosis patients at Tehran's referral multiple sclerosis center and neurology clinics between 2018 and 2022 was performed. Data were collected through interviews after patients completed informed consent forms. Urological examinations, including urine analysis and ultrasonography, were evaluated as final assessments. The data were analyzed using descriptive and inferential statistical tests in Statistical Package for Social Science.

Results

Among all participants, the prevalence of lower urinary tract symptoms was 73% (n = 384), with urgency (44.8% n = 232) being the most common symptom. The prevalence of intermittency was significantly higher among women (p = 0.004). There was no gender-significant difference in terms of the prevalence of other symptoms (p > 0.050). Lower urinary tract symptoms were significantly correlated with age, clinical course, disease duration, and disability (p < 0.001). Additionally, 37.3% and 18.7% of patients with lower urinary tract symptoms, as well as 17.9% and 37.5% of patients with multiple sclerosis attacks, respectively, had undergone urine analysis and ultrasonography.

Conclusion

Multiple sclerosis patients rarely undergo urological evaluations during the course of their disease. Proper assessment is essential as these symptoms are among the most detrimental manifestations of this disease.

Urinary tract infections in patients with multiple sclerosis and different methods of bladder evacuation

INTRODUCTION AND OBJECTIVES

To evaluate the incidence and course of urinary tract infections (UTI) in patients with multiple sclerosis (MS) and their relationship to the method of bladder evacuation.

MATERIALS AND METHODS

Patients with neurogenic bladder dysfunction due to MS (n=111) were enrolled in the study. During one-year follow-up, clinical examination with urine culture was performed every 4 months or whenever symptoms occurred. The control group included patients with symptomatic UTI, without neurological or autoimmune disease. Incidence of symptomatic and asymptomatic bacteriuria, the effect of urine drainage on UTI incidence, and the effect of antibiotics were statistically evaluated.

RESULTS

54 MS patients completed the protocol. The mean incidence of symptomatic and asymptomatic bacteriuria in the MS group was 12.5% and 29.6%, respectively. A decreasing trend in the incidence of symptomatic, and an increasing trend in the incidence of asymptomatic bacteriuria was observed. Eradication of UTI in symptomatic MS patients was significantly lower than in controls (37.75% vs. 92.93%, P<0.05). Causative agents significantly differed in both groups (P=0.0005). The hypothesis that the incidence of UTIs in MS patients is independent of the method of bladder evacuation was not rejected (P>0.99 at visit 0, 1 and 3, P=0.078 at visit 2).

CONCLUSIONS

There is a significant difference between the causative agents of UTI in both groups. Eradication of bacteriuria in symptomatic MS patients is difficult when compared to the normal population. We have insufficient evidence to confirm the relationship between the incidence of UTI and the method of bladder evacuation.

Postoperative Outcomes Following Posterior Lumbar Fusion in Patients With Multiple Sclerosis

SUMMARY OF BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory disease that can cause physical and neurological dysfunction. Patients with MS are living longer and undergoing more orthopedic procedures, but the risk of patients with MS undergoing posterior lumbar fusion (PLF) has not been studied in literature before.

OBJECTIVE

This study aims to (1) analyze the rates of postoperative complications of MS patients undergoing primary PLF and (2) analyze the economic burden associated with these surgeries in the MS population compared with patients without MS.

METHODS

A retrospective review of the Medicare database was conducted on all patients who underwent PLF and/or posterior lumbar interbody fusion between the years of 2006 and 2013. Cases involving same-day anterior or revision procedures and patients with a history of spine, infection, and trauma, or neoplasm were excluded from the study. Demographics, comorbidities, 90-day postoperative complications, cost, and length of stay were calculated. All outcomes of interest were analyzed using multivariate logistic regression, adjusting for age, sex, and comorbidity burden. Significance was defined as P-value <0.05.

RESULTS

There were 2363 patients with MS and 23,569 matched controlled patients. We found a significant increase in the risk of sepsis [odds ratio (OR)=1.85, P=0.034], urinary tract infection (OR=1.89, P<0.001), deep vein thrombosis (OR=1.4, P=0.044), 90-day emergency room visit (OR=1.14, P=0.027), and 90-day readmissions (OR=1.20, P=0.011) compared with patients without a history of MS. Patients with MS also incurred $4379 extra in total hospital charge, a $1679 increase in the cost of hospitalization, and an increase in length of stay (4.05 vs. 3.61, P<0.001).

CONCLUSIONS

A diagnosis of MS is associated with a significant increase in postoperative complications and higher costs after hospitalization. It is imperative for physicians to understand the risk factors of patients undergoing PLF and/or posterior lumbar interbody fusion with MS to better counsel them about postoperative complications before surgery.

LEVEL OF EVIDENCE

Level III.

Temporal changes in extra-axial brain hematoma's signal intensity in magnetic resonance images of trauma patients: A preliminary, technical study

INTRODUCTION

Dating the exact or estimated time of trauma is an important issue facing forensic medicine. Several clinical and radiological methods were used to achieve this purpose. In the recent study, we aimed to track the changes in the signal intensity of the extra-axial brain hematoma using magnetic resonance imaging (MRI) conventional sequences as well as diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC).

MATERIALS AND METHODS

Considering inclusion and exclusion criteria, all patients with blunt head trauma were involved. After proper management., stabilization, and resuscitation, the participants were assessed using conventional sequences of MRI and DWI twenty-four hours, forty-eight hours, and three weeks after the injury. Temporal changes of signal intensity were compared by Wilcoxon ranged test.

RESULTS

Sixteen patients sustaining blunt head trauma were included in this study. The study showed that during the time, diffusion restriction could be seen in an extraaxial hematoma. At the first 24 hours, the signal of hematoma was void in 87.5% of DWI and 100% of ADC. On the second day, they were hypo-signal in 75% of DWI and 100% 0f ADCs, and after three weeks, 100% of cases were hyper-signal in DWI and hypo-signal ADCs.

CONCLUSION

This preliminary study has shown that the DWI can be used to detect and track the extra-axial hematoma. The signal intensity was void during the first twentyfour hours, although it became hypo-signal after 48 hours. Of note, the diffusion restriction is noted after three weeks.

Evaluation of Treatment Practices for Urinalyses and Urine Cultures at an Outpatient Multiple Sclerosis Clinic

Background

Patients with multiple sclerosis (MS) experience disease flares that can be precipitated by the presence of infection. Discerning asymptomatic bacteriuria from urinary tract infection (UTI) in patients with MS is complicated by lower urinary tract dysfunction, leading to potentially inappropriate antimicrobial use. In this study the antimicrobial treatment practices for positive urine cultures in patients with MS were evaluated.

Methods

In this single-center, retrospective study, positive cultures in patients with MS were included. The primary outcome was the proportion of patients appropriately treated with or without antimicrobial therapy. Secondary end points included antimicrobial selection and urinalysis positivity.

Results

Two hundred thirty-six cultures from 139 patients were evaluated. Treatment was inappropriate in 81 of 201 treated cultures (40%). Frequency, nocturia, dysuria, and foul-smelling urine were reported by patients in 54 (23%), 10 (4%), 25 (11%), and 14 (6%) cultures, respectively. The antimicrobial selected was too broad in spectrum for 35 of 201 (17%). Of those, fluoroquinolones were the agents used in 33 of 35 cases (94%). A urinalysis was sent in 203 cases (86%), with 197 (84%) positive for at least one predefined positivity criteria.

Conclusions

Urinalyses and urine cultures are performed frequently in patients with MS, often independent of symptoms. Patients with MS could be treated for asymptomatic bacteriuria at higher rates than the general population, and traditional urinary symptoms may not be appropriate indicators of infection. Empirical therapy for UTI is frequently used in this population, often resulting in inappropriate and/or too broad of antimicrobial therapy.

Serum inflammatory markers in patients with multiple sclerosis and their association with clinical manifestations and MRI findings

Inflammation in a myelinated portion of the nervous system is the mainstay of multiple sclerosis (MS). Elevation of inflammatory markers such as procalcitonin, ESR and hs-CRP is suspected to occur in MS patients. However, their prognostic role and their relationship with the severity of clinical symptoms of MS and MRI evidences has remained unnoticed in the literature. Hence, we aim to evaluate the serum level of inflammatory markers in the acute attack of MS patients and demonstrate the potential prognostic role of these inflammatory markers. This study was carried on case and control groups of definite MS patients. The cases were patients with active MS and were further allocated into four subgroups, while as control group included patients with non-active MS. Furthermore, all the participants underwent brain and cervical magnetic resonance imaging (MRI) using a contrast agent. A significant difference was detected in hs-CRP level (p = 0.009) across the subgroups of the cases. The highest level of hs-CRP was reported in patients with cerebellar and brain stem symptoms (mean = 6998.13 ± 3501.16), while the lowest in patients with pyramidal and urinary incontinence symptoms (mean = 1958.91 ± 2662.16). Moreover, correlation coefficient between values of MRI contrast-enhanced lesions and ESR level was statistically significant (Rs = 0.503 and p = 0.001). Elevation of ESR serum level positively correlates with disease activity evidenced by values of contrast-enhanced plaques of MRI in relapsing-remitting MS patients which may predict the disease activity. In addition, MS relapse with cerebellar and brain stem symptoms is associated with a high concentration of hs-CRP plasma level.

Evaluation of Urinary Tract Infection following Corticosteroid Therapy in Patients with Multiple Sclerosis Exacerbation

The first treatment for multiple sclerosis exacerbation is usually short-term intravenous methylprednisolone (IVMP), with or without a regimen of oral prednisone taper (OPT). This study aims to evaluate the effects of IVMP and OPT in comparison with IVMP alone in raising the risk of urinary tract infection (UTI) and posttreatment improvement of urinary tract symptoms in patients with relapsing-remitting multiple sclerosis. This double-blind randomized clinical trial was conducted on 56 people with multiple sclerosis relapse who had undergone methylprednisolone for 5 days. Patients were randomly split into two groups: oral prednisolone and placebo (tapering for 20 days). Demographic data, duration of multiple sclerosis, urinary tract symptoms, the Expanded Disability Status Scale (EDSS) score, and urine data were analyzed. The incidence of UTI in the intervention and control groups did not differ significantly ( $p=560$ ). However, the improvement of urinary tract symptoms in the intervention group was significantly more favorable than in the control group ( $p\le 0.001$ ). Furthermore, administering OPT after IVMP did not increase the risk of UTI occurrence in patients with multiple sclerosis exacerbation. The urine analysis results did not show any differences at baseline and after the corticosteroid tapering regimen. Due to the risk of infection by corticosteroids, it is no longer necessary to do further urinary screening in this group of patients.

Urinary tract infections and multiple sclerosis: Recommendations from the French Multiple Sclerosis Society

OBJECTIVES

Establish recommendations for the management of UTIs in MS patients.

BACKGROUND

Urinary tract infections (UTIs) are common during multiple sclerosis (MS) and are one of the most common comorbidities potentially responsible for deaths from urinary sepsis.

METHODS

The recommendations attempt to answer three main questions about UTIs and MS. The French Group for Recommendations in MS (France4MS) did a systematic review of articles from PubMed and universities databases (01/1980-12/2019). The RAND/UCLA appropriateness method, which has been developed to synthesize the scientific literature and expert opinions on health care topics, was used for reaching a formal agreement. 26 MS experts worked on the full-text review and a group of 70 multidisciplinary health care specialists validated the final evaluation of summarized evidences.

RESULTS

UTIs are not associated with an increased risk of relapse and permanent worsening of disability. Only febrile UTIs worsen transient disability through the Uhthoff phenomenon. Some immunosuppressive treatments increase the risk of UTIs in MS patients and require special attention especially in case of hypogammaglobulinemia. Experts recommend to treat UTIs in patients with MS, according to recommendations of the general population. Prevention of recurrent UTIs requires stabilization of the neurogenic bladder. In some cases, weekly oral cycling antibiotics can be proposed after specialist advice. Asymptomatic bacteriuria should not be screened for or treated systematically except in special cases (pregnancy and invasive urological procedures).

CONCLUSION

Physicians and patients should be aware of the updated recommendations for UTis and MS.

Urinary tract infection in patients with multiple sclerosis: An overview

INTRODUCTION

Multiple sclerosis (MS) is a demyelinating, chronic, inflammatory, and autoimmune disease of the central nervous system (CNS) with axonal degeneration, presenting a progressive and variable course. MS patients usually have complications, such as bladder dysfunction, presence of urinary symptoms, and Urinary Tract infection (UTI), which is one of the three most common non-neurological complications in MS patients.

OBJECTIVE

Analyze the most diverse aspects of UTI in MS patients, focusing on risk factors, prevalence, hospitalization, mortality rates, diagnosis, and treatment of UTIs in this group.

METHODS

A non-systematic review of articles published on PubMed in the last 10 years with the search terms "Urinary Tract Infection" AND "Multiple Sclerosis".

DISCUSSION

MS patients have a high UTI prevalence, mainly due to the occurrence of urinary disorders in these patients. The most common symptoms of UTI in MS patients are urinary urgency, polyuria, nocturia, urinary retention, and incontinence. Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most found organisms and treatment is based on antibiotic therapy. Moreover, UTIs can precipitate outbreaks, worsen the disease, causing more damage and a severe neurological condition deterioration. In addition, UTIs in this group are associated with a high hospitalizations rate and a high mortality rate. Therefore, patients in MS outbreaks with urinary symptoms or positive urinalysis must keep corticosteroid therapy and Disease-Modifying Treatments (DMTs). Whether clinically stable or MS relapse patients, the urinalysis and the presence of symptoms must guide the treatment in each group. Moreover, the pharmacological treatment of asymptomatic bacteriuria has no evidence of clinical efficacy. As the treatment of asymptomatic bacteriuria induces a significant increase in more resistant bacterial strains, it is recommended exceptionally in cases of recurrent acute UTIs, prior to handling of the UTI, pregnancy or patients in need of immunosuppression.

CONCLUSION

UTI represents a great risk and concern in MS patients. The high prevalence, hospitalization rate, and mortality rate of UTI in MS is worrying, such as the cause-consequence relationship between UTIs and the use of corticosteroids in outbreaks. Therefore, it is important to be aware of a UTI in this group to make early diagnoses, adequate management, and new infections prevention. Thus, further studies are needed to thoroughly analyze each nuance of this important comorbidity for MS patients.

Screening for urinary tract colonisation prior to corticosteroid administration in acute multiple sclerosis relapses: Validation of an updated algorithm

INTRODUCTION

To evaluate an updated algorithm in the detection of urinary tract infection (UTI) prior to high-dose corticosteroid treatment in acute relapses in multiple sclerosis (MS). This updated algorithm aimed to decrease the unnecessary use of antibiotics, whilst maintaining accuracy and safety.

METHODS

Prospective cohort study of 471 consecutive patients with MS relapses in a hospital-based outpatient acute relapse clinic. 172 patients met exclusion criteria, leaving 299 patients for analysis. Patients underwent urine dipstick and were treated for UTI if 2 or more of: nitrites, leukocyte esterase and cloudy urine were positive. Patients with confirmed acute MS relapse were treated with high dose intravenous or oral methylprednisolone.

RESULTS

Significant bacteriuria (>10⁵ colony forming units/mL) was present in 33 (11%, 95% CI 8-15) patients. The algorithm sensitivity and specificity was 24% and 94% respectively; the negative predictive value was 91%. The overall accuracy of the algorithm was 87%. No adverse sequelae were identified in 25 patients who received high dose methylprednisolone in the presence of an untreated UTI.

CONCLUSION

With an improved specificity, this updated algorithm addresses previous issues concerning the unnecessary prescription of antibiotics, whilst improving accuracy and maintaining safety.

Triaging Patients with Multiple Sclerosis in the Emergency Department: Room for Improvement

Background

Patients with multiple sclerosis (MS) present to the emergency department (ED) for various reasons. Although true relapse is rarely the underlying culprit, ED visits commonly result in new magnetic resonance imaging (MRI) and neurology admissions. We studied ED visits in patients with MS and evaluated decision making regarding diagnostic/therapeutic interventions and visit outcomes. We identified potential areas for improvement and used the data to propose a triaging algorithm for patients with MS in the ED.

Methods

We reviewed the medical records from 176 ED visits for patients with MS in 2014.

Results

Ninety-seven visits in 75 patients were MS related (66.6% female; mean ± SD age, 52.6 ± 13.8 years; mean ± SD disease duration, 18.5 ± 10.5 years). Thirty-three visits were for new neurologic symptoms (category 1), 29 for worsening preexisting symptoms (category 2), and 35 for MS-related complications (category 3). Eighty-nine visits (91.8%) resulted in hospital admission (42.7% to neurology). Only 39% of ordered MRIs showed radiographic activity. New relapses were determined in 27.8% of the visits and were more prevalent in category 1 compared with category 2 (P = .003); however, the two categories had similar rates of ordered MRIs and neurology admissions.

Conclusions

New relapse is a rare cause of ED visits in MS. Unnecessary MRIs and neurology admissions can be avoided by developing a triaging system for patients with MS based on symptom stratification.

Comparison of diffusion-weighted imaging and enhanced T1-weighted sequencing in patients with multiple sclerosis

Introduction The purpose of this study was to assess whether demographic, brain anatomical regions and contrast enhancement show differences in multiple sclerosis (MS) patients with increased diffusion lesions (ID group) compared with diffusion restriction (DR group). Method MRI protocol comprised T1- and T2-weighted sequences with and without gadolinium (Gd), and sagittal three-dimensional FLAIR sequence, DWI and ADC maps were prospectively performed in 126 MS patients from January to December 2015. The investigation was conducted to evaluate differences in demographic, cord and brain regional, technical, and positive or negative Gd contrast imaging parameters in two groups of ID and DR. Statistical analysis was performed by using SPSS. Results A total of 9.6% of patients showed DR. In the DR group, 66.6% of the patients showed contrast enhancement of plaques, whereas 29.2% of the IR group showed enhancement of plaques. The most prevalent group was non-enhanced plaques in the ID group, followed by Gd-enhanced plaques in the ID group. Patients in the ID group (90.4%) were significantly more than in the DR group (9.6%). Out of the 40 patients with Gd-enhanced plaques, 80.5% was from the ID group and 19.5% from the DR group. Conclusion MRI of the brain, unlike of the cord, with Gd demonstrates significant difference in enhancement between the two groups ( p < 0.05). No significant difference was seen in demographic, cord and brain regional, and technical parameters, EDSS, disease duration, and attack rate as well as demographic and regional parameters between the ID and decrease diffusion groups ( p > 0.05).