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Bove R, Chitnis T, Houtchens M. Menopause in multiple sclerosis: therapeutic
considerations. J Neurol. 2014;261(7):1257-1268.
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C H A P T E R 1 6
Urologic Issues in the
Multiple Sclerosis Patient
Philip J. Aliotta
Introduction
Multiple sclerosis (MS) is an autoimmune inflammatory
disease that results in damage to the myelin sheaths of the
nerves in the central nervous system. 1 It presents with a broad
spectrum of clinical presentations that are time and disease
course related. MS plaque (intracranial and/or spinal) location
is a key feature in the pathophysiology of disease-related
lower urinary tract symptoms (LUTS). 2 It is commonly
diagnosed between the ages of 20 and 40 years, with a female
predominance of 3:1.
1,2
The prevalence in the United States is
57.8 per 100,000 and is twice as common in the north as
compared with the southern United States. 3 About 80% to
96% of all patients with MS will seek urologic care because of
bothersome LUTS at some point in their disease course, and as
many as 12% have symptoms before the actual diagnosis.
4,5
If
a patient has ambulatory difficulties, the prevalence of lower
urinary tract complaints is close to 100%.
6,7
The 2005 North
American Research Committee on Multiple Sclerosis
(NARCOMS) reported that 65% of patient responders
experienced at least one moderate to severe urinary symptom.
8
Patients with bladder dysfunction have lower scores on
quality-of-life scales. 9 There is also noted to be a greater
burden on professional or family caregivers associated with
urinary disorders. 10 Access to treatment is uncertain and varies
from country to country. 11 The MS Barometer 2015—
European Multiple Sclerosis Platform, 12 which has measured
and compared well- being and quality of life for people living
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with MS in 33 European countries, including 26 EU member
states, shows huge disparities in terms of access to treatment,
therapies, and employment. Furthermore, according to the MS
Barometer 2015, the average percentage of the total costs for
symptomatic treatments and therapies reimbursed over a
period of 12 months vary; the Western countries enjoy a
generally high level of reimbursement, whereas the Eastern
ones reported very different national policies on this topic.
Only 50% of the 9702 patients of the NARCOMS cohort used
medications despite severe symptomatology; 47% benefitted
from urological evaluation.
7,8,13
Physiology of Micturition
Bladder storage (Figure 16.1A) occurs through sympathetic
nervous system stimulation of alpha adrenergic receptors,
which results in closure of the bladder neck, and betaadrenergic receptor stimulation, which relaxes the detrusor
muscle. 14 Bladder contraction and emptying occurs by
parasympathetic muscarinic receptor stimulation. 15 Sensory
afferent information is carried through myelinated A-delta and
unmyelinated C fibers through pelvic and pudendal nerves at
S2 to S4 nerve roots. 16 The spinothalamic tract sends sensory
impulses to the periaqueductal gray (PAG) region in the
midbrain. The PAG inhibits the pontine micturition center in
the brainstem allowing for bladder filling. Sympathetic nerve
fibers from T10 to L2 via the hypogastric nerve cause the
bladder to relax and the bladder neck to close. 17 Awareness of
bladder fullness occurs through medial prefrontal cortex and
hypothalamic modulation of the PAG area (Figure 16.1).
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FIGURE 16.1 Mechanism of storage (A) and voiding reflexes
(B).
Reprinted from Chai TC, Birder LA. Physiology and
Pharmacology of the Bladder and Urethra. In: Wein AJ , ed.
Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Saunders;
2016:1631-1684. Copyright © 2016 Elsevier. With permission.
Bladder emptying (Figure 16.1B) occurs through
parasympathetic nervous system efferent activation of the
pelvic nerve from sacral nerve roots S2 to S4. Increased
parasympathetic activity inhibits sympathetic stimulation, and
the bladder neck relaxes. The pelvic plexus ganglia stimulate
the detrusor muscle, and voiding occurs. 18 MS plaques occur
in the cortex, brainstem, and spinal cord. Corticospinal and
reticulospinal tract plaques (innervate bladder detrusor muscle
and external sphincter) affect voiding. Sacral plaque
involvement has been reported to be 18%, but the exact
pathologic role is uncertain owing to imaging limitations and
the concomitant presence of multiple plaque lesions
throughout the nervous system. Suprasacral lesions occur in
80% of cases and are seen most commonly in cervical lesions
and are associated with detrusor hyperreflexia due to loss of
descending inhibition. Reticulospinal tract involvement is
associated with detrusor-sphincter dyssynergia, incomplete
sphincteric relaxation, or sphincter paralysis. Intracranial
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plaques are commonly encountered in patients with MS, but
their clinical significance is unclear. Pontine lesions have been
reported to be associated.
19
Clinical Presentation
Case Study
A 37-year-old white female was diagnosed with Relapsing
Remitting MS 1.5 years ago after initially presenting with
visual problems and lower extremity weakness and gait
disturbance over a 6-month period. She presents with
complaints of frequency, urgency, urge incontinence, and
complaints of suprapubic pressure making her believe she
has a full bladder but is only voiding small-volume voids
with an erratic weak stream. She has nocturia ×4. There are
no stress- or activity-related complaints of incontinence.
Before the diagnosis of MS, there was no history of urinary
tract infections, but since the diagnosis, she has had at least
three infections, the last one severe enough to exacerbate her
MS symptoms requiring hospital admission. She has
irregular bowel habits, suffering constipation with associated
bowel movements as long as 5 to 6 days apart, culminating
in the occurrence of uncontrollable large bowel movements
with fecal incontinence occurring occasionally. Oftentimes,
after a bout of severe constipation, she will experience
frequent loose stools and diarrhea. After one such
occurrence, she developed a urinary tract infection, which
was treated effectively with an antibiotic.
Between 50% and 90% of patients with MS report LUTS with
the prevalence of incontinence as low as 37% and as high as
72%.
20-22
Lower urinary tract symptomatology is directly
related to the severity of the disability caused by the MS. Up
to 15% of patients who go on to be diagnosed with MS have as
an initial presentation symptom attributable to lower urinary
tract involvement, that is, acute urinary retention or as an acute
onset of urgency and frequency. 20 The most common urinary
tract symptom in patients with MS is urgency, as part of the
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overactive bladder syndrome comprising urgency, urinary
frequency, and/or urge incontinence.
21
LUTS fall into two categories, irritative and obstructive.
Irritative symptoms include frequency, urgency, nocturia, and
urge incontinence, and obstructive symptoms include
hesitancy or difficulty initiating the stream, straining to void, a
reduced flow, an intermittent stream, or a sensation of
incomplete emptying. However, the presence or absence of
symptoms remains an unreliable indicator of the extent or type
of bladder dysfunction.
23
The bladder has two functions, to store urine without leaking
and to empty/void without a residual.
24,25
Bladder storage
requires low intravesical pressures, a compliant viscoelastic
bladder with intact sensation. Efficient and effective bladder
emptying requires no evidence of pathologic outlet obstruction
(benign prostatic hypertrophy and bladder outlet obstruction),
urethral stricture, meatal stenosis, etc., and relaxation of the
external striated sphincter with coordinated relaxation of the
smooth muscle sphincter at the bladder neck and proximal
urethra leading to opening and funneling of the bladder neck,
accompanied by the simultaneous coordinated bladder
contraction.
25
Overactive bladder (OAB)—The Standardization
Subcommittee of the International Continence Society now
recognizes OAB as a “symptom syndrome suggestive of lower
urinary tract dysfunction.” It is specifically defined as
“urgency, with or without urge incontinence, usually with
frequency and nocturia, in the absence of proven infection or
other obvious pathology.” When neurological conditions affect
the OAB, it is called neurogenic bladder (NGB).
26,27
The presence of an indwelling catheter, highdetrusor/intravesical filling pressures, and striated sphincter
dyssynergia in men, are causes of serious urologic
complications experienced by patients with MS.
28
Storage Symptoms Experienced During
the Storage Phase of the Bladder
29
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Increased daytime frequency is the complaint by the patient
who considers that he or she voids too often by day. This term
is equivalent to pollakisuria used in many countries.
Nocturia is the complaint that the individual has to wake at
night one or more times to void. The term nighttime frequency
differs from that for nocturia, as it includes voids that occur
after the individual has gone to bed but before he or she has
gone to sleep and voids that occur in the early morning, which
prevent the individual from getting back to sleep as he or she
wishes.
Urgency is the complaint of a sudden compelling desire to
pass urine that is difficult to defer.
Urinary incontinence is the complaint of any involuntary
leakage of urine (Table 16.1).
Table 16.1
Types of Incontinence
29,30
Stress urinary
incontinence
Involuntary leakage on effort, exertion, or sneezing
or coughing
Urge urinary
incontinence
The complaint of involuntary leakage accompanied
by or immediately preceded by urgency
Mixed urinary
incontinence
The complaint of involuntary leakage associated
with urgency and with exertion, effort, sneezing or
coughing
Enuresis Any involuntary loss of urine
If it is used to denote incontinence during sleep, it
should always be qualified with the adjective
“nocturnal”
Continuous urinary
incontinence
The complaint of continuous leakage
Functional incontinence Occurs when physical disabilities, external
obstacles, or cognitive and/or communication
problems prevent the person from getting to the
bathroom to urinate
Transient incontinence A temporary form of incontinence, usually caused
by a short-lived medical condition—or the treatment
for the condition
Reflex
incontinence/unconscious
incontinence
Occurs when a person is unaware of the need to
urinate
Voiding Symptoms Experienced During
the Voiding Phase
29
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Slow stream is reported by the individual as his or her
perception of reduced urine flow, usually compared with
previous performance or in comparison with others.
Splitting or spraying of the urine stream may be reported.
Intermittent stream (intermittency) is the term used when the
individual describes urine flow that stops and starts, on one or
more occasions, during micturition.
Hesitancy is the term used when an individual describes
difficulty in initiating micturition resulting in a delay in the
onset of voiding after the individual is ready to pass urine.
Straining to void describes the muscular effort used to either
initiate, maintain, or improve the urinary stream.
Terminal dribble is the term used when an individual
describes a prolonged final part of micturition, when the flow
has slowed to a trickle/dribble.
Postmicturition Symptoms Experienced
Immediately After Micturition
29
Feeling of incomplete emptying is a self-explanatory term for
a feeling experienced by the individual after passing urine.
Postmicturition dribble is the term used when an individual
describes the involuntary loss of urine immediately after he or
she has finished passing urine, usually after leaving the toilet
in men or after rising from the toilet in women.
Symptoms Associated With Sexual
Intercourse
29
Dyspareunia, vaginal dryness, and incontinence are among the
symptoms women may describe during or after intercourse.
These symptoms should be described as fully as possible.
Define urine leakage as during penetration, during intercourse,
or at orgasm.
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Symptoms Associated With Pelvic Organ
Prolapse
29
The feeling of a lump (“something coming down”), low
backache, heaviness, dragging sensation, or the need to
digitally replace the prolapse to defecate or micturate, are
among the symptoms women may describe who have a
prolapse.
The Goals of Managing the Multiple
Sclerosis Neurogenic Bladder
25
Upper urinary tract preservation or improvement
Absence or control of infection
Adequate storage at low intravesical pressure
Adequate emptying at low intravesical pressure
Adequate control
No catheter or stoma (depending on the degree of
disability)
Social acceptability and adaptability
Vocational acceptability and adaptability
Urologic Evaluation
20,21,29-33
Patient assessment should include the following:
History
31
Mental status/cognitive function
Functional status activities of daily living, walking,
transfer ability
Diet
Fluid intake habits and bladder diary
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Bowel habits
a. Constipation
b. Diarrhea
c. Irritable bowel syndrome
Type of incontinence
a. Stress
b. Urge
c. Mixed
d. Functional
Recurrent urinary tract infections
Postvoid residual (PVR)
Urinary frequency and urgency
Concurrent medical history
Surgical history
a. Gynecologic history—pelvic surgeries: cystocele,
rectocele, sacrospinous fixation, vaginal vault
surgery; pelvic malignancy, pelvic radiation, bladder
cancer surgery, bowel surgery
b. Obstetric history—parity, C-sections
c. Male pelvic history—urethral surgery or history of
stricture disease, benign prostate surgery
(transurethral resection prostate), radical
prostatectomy, radiation therapy for pelvic
malignancy, bowel surgery
Associated medications, over the counter, homeopathic,
and/or phytotherapeutic products/remedies 30 (Table 16.2)
Table 16.2
Medications Used in Multiple Sclerosis Management With Potential
Urologic Adverse Effects
54
Type of Medication Examples Potential Effects on Continence
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