The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis

Clinical and urodynamic benefit of adding antimuscarinics after a loss of efficacy of intradetrusor botulinum toxin in patients with multiple sclerosis

PURPOSE

The aim was to assess in real-life practice the effectiveness of adding antimuscarinics drug (AM) when facing a loss of efficacy of intradetrusor botulinum toxin A (IDBTX-A) in patients with multiple sclerosis (PwMS) on overactive bladder symptoms and urodynamic parameters.

METHODS

All PwMS who had IDBTX-A injections between January 2023 and December 2023 were screened. Patients with a loss of efficacy of IDBTX-A on bladder symptoms and/or detrusor overactivity, and who received AM as an add-on therapy were included. Data collected were urodynamic parameters (bladder capacity, filling volume of first detrusor overactivity (DO), maximal detrusor pressure at DO, area under curve of detrusor pressure (AUUC)), and clinical parameters (persistence of spontaneous voiding, number of self-catheterization, nocturia, persistence of urgency and/or urge incontinence, number of urinary tract infections (UTI)).

RESULTS

Thirty-four patients were included (mean age 49 ± 8.7; 20 (58%) women). The rate of patients with DO significantly decreased after AM addition (27 (81%) before AM addition vs. 11 (33%) patients after; p < 0.01). Bladder capacity increase from 311 ± 124 ml to 381 ± 70 ml (p < 0.01) was the only other significant change in urodynamics after AM. The only clinical change was a decrease in the number of patients reporting urgency from 23 (67%) to 11 (32%) (p < 0.01).

CONCLUSION

Adding antimuscarinics to intradetrusor botulinum toxin for treating DO in PwMS reduces the rate of patients with DO, improves bladder capacity and the occurrence of urgencies.

Sacral Neuromodulation in Multiple Sclerosis: The NEMISIS Study

Recent studies have shown promising sacral neuromodulation (SNM) results in neurogenic overactive bladder caused by multiple sclerosis. In the first half of 2025 we aim to start including patients in a multicentre, randomised controlled trial to test the hypothesis that SNM has a therapeutic benefit in this setting.

Innovative multidisciplinary tool for screening bowel and bladder symptoms in multiple sclerosis

INTRODUCTION

Bowel and bladder symptoms are frequent in people with Multiple Sclerosis (PwMS) and early diagnosis and treatment become crucial to improve their quality of life (QoL). The study aims to design a multidisciplinary questionnaire for screening bladder and bowel symptoms in PwMS.

MATERIALS AND METHODS

The Bowel and Bladder Symptoms Screening in Multiple Sclerosis (BBSS-MS) questionnaire for screening bowel and bladder symptoms was designed in Italian following a three-steps process. In the first step, a dedicated board of experts identified a pool of items, which will be analysed for content, clarity, and consistency during the second step. During the third step, the relevance of each item was evaluated through a two-round process following the Delphi method. For each round of the Delphi method, medians, the 25th and 75th percentiles, and the IQR of the score for each statement were calculated. Stata 16.1 software was used to conduct all analyses.

RESULTS

The Board identified 22 items to include in the BBSS-MS, based on existing questionnaire and clinical expertise. After discussing about the comprehensibility and clarity of items, the first version of the BBSS-MS composed of 22 items was proposed. Following, a Panel of 44 experts scored the relevance of each question and all the questions reached the score to be included in the questionnaire. The final 21-item version of the BBSS-MS was proposed.

DISCUSSION AND CONCLUSION

To our knowledge, the BBSS-MS represents the first self-reported hybrid questionnaire for screening bladder and bowel symptoms in an Italian MS population.

Lumbopelvic Muscle Mechanical Properties in Women with Multiple Sclerosis: A Cross-Sectional Case-Controlled Study

Background/Objectives: To compare the lumbopelvic muscle mechanical properties (MMPs) of women with and without multiple sclerosis (MS) and explore relationships between these properties and sociodemographic/clinical characteristics. Methods: This cross-sectional observational study included 22 women with MS and 22 age- and BMI-matched women without MS. MMPs (frequency, stiffness, decrement, relaxation, and creep) of pelvic floor and lumbar paravertebral muscles were assessed using a MyotonPRO device. Sociodemographic and clinical data related to pelvic floor health were also collected. Results: Women with MS showed significant differences in pelvic floor MMPs, including higher frequency (3.26 Hz; 95% CI [2.12, 4.41]), stiffness (90 N/m; 95% CI [55.09, 124.91]), and decrement (0.2; 95% CI [0.09, 0.31]), and lower relaxation (6.15 ms; 95% CI [8.26, 4.05]) and creep (0.24; 95% CI [0.34, 0.13]) compared to women without MS. For lumbar paravertebral muscles, differences were observed only on the right side, with lower frequency (2.15 Hz; 95% CI [0.28, 4.02]) and stiffness (62.17 N/m; 95% CI [10.7, 113.65]) in women with MS. Correlation patterns between MMPs and clinical characteristics differed by group, with moderate correlations found only in the MS group (e.g., EDSS: r = 0.57; p = 0.006; PFDI-20: r = 0.47; p = 0.026). Conclusions: Women with MS exhibit altered pelvic floor MMPs, characterized by reduced tone and stiffness and increased elasticity and viscoelasticity, while lumbar paravertebral differences are minimal. These findings highlight the need for objective MMP assessments in women with MS to guide preventive and therapeutic interventions.

Algorithms for the first-line management of bladder, bowel and sexual dysfunction in multiple sclerosis: Present and future

INTRODUCTION

Neurogenic lower urinary tract (NLUTD), bowel (NBD), and sexual dysfunction (SD) are commonly observed in patients with (pw) multiple sclerosis (MS) and diminish the patients' quality of life (QoL). This systematic review aim to evaluate and discuss the current algorithms for the management of these issues.

METHODS

A systematic review was conducted on the PubMed in June 2024. The primary search criterion was the presence of the term 'algorithm/s' or 'management/ing' in the title and/or abstract, followed by the MeSH term 'multiple sclerosis' and a combination of free-text keywords referring to NLUTD, NBD or SD.

RESULTS

Fifteen articles regarding NLUTD were considered eligible, only one regarding SD while none addressed NBD.

DISCUSSION

Numerous studies emphasize the profound impact of urinary and bowel symptoms on the QoL and morbidity in pwMS. Few algorithms addressing NLUTD are designed for first-line physicians and addresses the key priorities in MS care. Specific approaches to NBD management in pwMS are lacking. Screening for SD requires a structured assessment to deliver appropriate solutions.

CONCLUSION

NLUTD, NBD, and SD are underdiagnosed and undertreated. The implementation of straightforward algorithms for first-line physicians could enhance the management of these common issues, improve the QoL, reduce costs, and ensure appropriate referral to specialists.

Wearables for the Bladder: Stakeholder Perspectives on Moving Multiple Sclerosis Bladder Dysfunction Interventions Into the 21st Century

BACKGROUND

Bladder dysfunction (BD) is common in people with multiple sclerosis (MS) and can reduce participation in daily life. Detecting BD early allows for effective prevention-focused treatments such as pelvic floor physical therapy. Pairing neurotechnology with patient-reported outcomes to remotely measure BD could significantly improve monitoring and treatment of BD. Therefore, we describe the process and findings of stakeholder engagement from a human-centered design process to assemble a wearables for the bladder (WeB) kit.

METHODS

Four people with MS with varying BD severity, and 5 MS clinical/research experts had 4 virtual meetings. Commercially available bladder tools were graded for ability to evaluate, monitor, or treat BD. The Health Information Technology Usability Evaluation Scale (utility, usability, feasibility) was used for evaluation. Scoring was performed individually and as a group.

RESULTS

Of the 11 devices, 5 obtained mean scores of greater than 6 of 10 for likability, usability, and device utility. The 2 highest scoring (9/10) devices were selected for the pilot. One device measures bladder urine levels, reporting the number/frequency of voids/leaks; the other guides pelvic floor exercises by pairing games on an app with biofeedback from intravaginal sensors. We uncovered critical differences in experts' and patients' appreciation of the tools, and the collaborative engagement led to substantial revisions of initial tool scores.

CONCLUSIONS

This process underscores the critical role of stakeholder engagement in the selection of digital tools, especially in sensitive domains like pelvic function. Ongoing clinical validation of the selected tools will yield a validated, user-friendly WeB kit that is able to fill gaps in our ability to evaluate BD treatments in people with MS, ultimately reducing the impact of BD on quality of life.

White Matter Magnetic Resonance Diffusion Measures in Multiple Sclerosis with Overactive Bladder

BACKGROUND

Lower urinary tract (LUT) symptoms are reported in more than 80% of patients with multiple sclerosis (MS), most commonly an overactive bladder (OAB). The relationship between brain white matter (WM) changes in MS and OAB symptoms is poorly understood.

OBJECTIVES

We aim to evaluate (i) microstructural WM differences across MS patients (pwMS) with OAB symptoms, patients without LUT symptoms, and healthy subjects using diffusion tensor imaging (DTI), and (ii) associations between clinical OAB symptom scores and DTI indices.

METHODS

Twenty-nine female pwMS [mean age (SD) 43.3 years (9.4)], including seventeen with OAB [mean age (SD) 46.1 years (8.6)] and nine without LUT symptoms [mean age (SD) 37.5 years (8.9)], and fourteen healthy controls (HCs) [mean age (SD) 48.5 years (20)] were scanned in a 3T MRI with a DTI protocol. Additionally, clinical scans were performed for WM lesion segmentation. Group differences in fractional anisotropy (FA) were evaluated using tract-based spatial statistics. The Urinary Symptom Profile questionnaire assessed OAB severity.

RESULTS

A statistically significant reduction in FA (p = 0.004) was identified in microstructural WM in pwMS, compared with HCs. An inverse correlation was found between FA in frontal and parietal WM lobes and OAB scores (p = 0.021) in pwMS. Areas of lower FA, although this did not reach statistical significance, were found in both frontal lobes and the rest of the non-dominant hemisphere in pwMS with OAB compared with pwMS without LUT symptoms (p = 0.072).

CONCLUSIONS

This study identified that lesions affecting different WM tracts in MS can result in OAB symptoms and demonstrated the role of the WM in the neural control of LUT functions. By using DTI, the association between OAB symptom severity and WM changes were identified, adding knowledge to the current LUT working model. As MS is predominantly a WM disease, these findings suggest that regional WM involvement, including of the anterior corona radiata, anterior thalamic radiation, superior longitudinal fasciculus, and superior frontal-occipital fasciculus and a non-dominant prevalence in WM, can result in OAB symptoms. OAB symptoms in MS correlate with anisotropy changes in different white matter tracts as demonstrated by DTI. Structural impairment in WM tracts plays an important role in LUT symptoms in MS.

The impact of bladder problems on well-being in multiple sclerosis - A cross-sectional study

BACKGROUND

Persons with multiple sclerosis (pwMS) frequently suffer from bladder problems that are not identified and managed optimally, reducing quality of life and increasing risk of health consequences.

OBJECTIVE

This study aimed to investigate associations between bladder problems and well-being of pwMS.

METHODS

The study included 1872 pwMS from France, Germany, Italy, and the UK self-reporting on demographics, MS status, bladder problems and management, and well-being. Logistic regression analyses were performed to investigate associations with self-reported well-being.

RESULTS

Population mean age was 51 years and 79 % were women. Among pwMS, 55 % reported bladder problems indicating overactive bladder (OAB), and 40 % reported self-experienced urinary retention. Self-management of bladder problems was reported by 32 %, 33 % were yet to have problem resolution, and 45 % reported a wish to receive bladder management help. Additionally, 35 % of pwMS reported that bladder problem onset preceded awareness of a link to MS. OAB, problem self-management, and urinary complications were significantly associated with lower well-being.

CONCLUSION

Bladder problems affect pwMS across disease subtypes and many attempt self-management. Consequently, pwMS with bladder problems are more likely to experience lower well-being, suggesting an unmet need. Raising awareness of the link between bladder problems and well-being could benefit pwMS living with bladder problems.

Etiology, presentation and management of urinary tract infections in multiple sclerosis patients: A review of the current literature

Urinary tract infections (UTIs) present a formidable challenge in the care of individuals affected by multiple sclerosis (MS). Lower urinary tract dysfunction is a prevalent issue among MS patients, predisposing them to an elevated risk of UTIs. When left untreated, UTIs can further exacerbate the already compromised quality of life in individuals with MS. The diagnosis and management of UTIs in MS patients necessitate a careful clinical evaluation. The objective of this review is to delineate preventive strategies and current and developing therapeutic approaches for preventing and treating UTIs associated with urinary dysfunction, catheterization, and upper urinary tract infections in patients with MS. Effectively addressing UTIs and urinary tract dysfunction in individuals with multiple sclerosis calls for a comprehensive, interdisciplinary approach.

Voiding Phase Dysfunction in Multiple Sclerosis: Contemporary Review of Terminology, Diagnosis, Management, and Future Directions

Lower urinary tract symptoms (LUTS) are highly prevalent in individuals with multiple sclerosis (MS). However, assessment of these symptoms is often hindered by vague definitions or absence of screening in asymptomatic patients. It is crucial to exercise caution when applying the non-neurogenic definition of urinary retention in this population. For men with MS experiencing persistent and treatment-resistant LUTS, urodynamic studies should be used to identify the underlying causes of symptoms. Although numerous therapies are presently accessible for managing LUTS in MS, there is a need for further investigation into emerging treatments such as percutaneous tibial nerve, and noninvasive brain stimulation.

Z-nucleic acid sensor ZBP1 in sterile inflammation

Z-DNA binding protein 1 (ZBP1), a cytosolic nucleic acid sensor for Z-form nucleic acids (Z-NA), can detect both exogenous and endogenous nucleic acids. Upon sensing of self Z-NA or exposure to diverse noxious stimuli, ZBP1 regulates inflammation by activating nuclear factor kappa B and interferon regulating factor 3 signaling pathways. In addition, ZBP1 promotes the assembly of ZBP1 PANoptosome, which initiates caspase 3-mediated apoptosis, mixed lineage kinase domain like pseudokinase (MLKL)-mediated necroptosis, and gasdermin D (GSDMD)-mediated pyroptosis (PANoptosis), leading to the release of various damage-associated molecular patterns. Thereby, ZBP1 is implicated in the development and progression of diverse sterile inflammatory diseases. This review outlines the expression, structure, and function of ZBP1, along with its dual roles in controlling inflammation and cell death to orchestrate innate immunity in sterile inflammation, especially autoimmune diseases, and cancers. ZBP1 has emerged as an attractive therapeutic target for various sterile inflammatory diseases.

Posterior Tibial Nerve Stimulation for the Treatment of Detrusor Overactivity in Multiple Sclerosis Patients: A Narrative Review

Bladder dysfunction, particularly neurogenic detrusor overactivity (DO), poses a substantial challenge in multiple sclerosis (MS) patients, detrimentally impacting their quality of life (QoL). Conventional therapies often fall short, necessitating alternative approaches like posterior tibial nerve stimulation (PTNS) for effective management. This narrative review critically examines the application of PTNS in treating DO among MS patients, aiming to provide a comprehensive synthesis of its efficacy, underlying mechanisms, and clinical outcomes. By evaluating a spectrum of studies, including randomized controlled trials and long-term follow-up research, the review elucidates PTNS's role in enhancing bladder control and ameliorating symptoms of urgency and incontinence, thereby improving patient well-being. Despite its potential, the review acknowledges the limited scope of existing research specific to MS-induced neurogenic DO and calls for further investigation to optimize PTNS protocols and understand its long-term benefits. Highlighting PTNS's minimal invasiveness and favorable safety profile, the review advocates for its consideration as a viable third-line treatment option in MS-related bladder dysfunction management. Through this analysis, the review contributes to the broader narrative of seeking effective, patient-centered therapeutic strategies for MS-related complications, underscoring the importance of personalized care in improving patient outcomes.

Dehydration associates with lower urinary tract symptoms in progressive multiple sclerosis

BACKGROUND

Lower urinary tract symptoms (LUTS) are common in persons with progressive multiple sclerosis (pwPMS), who may consequently limit their fluid intake. We aimed to investigate the hypothesis that LUTS associate with objective evidence of inadequate hydration status in pwPMS.

METHODS

In this prospective study, 55 pwPMS were studied over 2 years. A 6-monthly first-morning urine specimen was analysed for urinary osmolality and sodium as hydration markers. LUTS symptom severity in three categories (urgency, voiding and discomfort) was assessed and quantified using a questionnaire. Correlation between LUTS severity and hydration was assessed within subjects and between subjects, controlling for age.

RESULTS

Some 274 urine samples with accompanying LUTS data from 55 participants were analysed. Biochemical data showed the expected loss of urine-concentrating capacity with increasing age. Inadequate hydration was observed in 47% of participants. LUTS were very common (87% reported urgency and 89% voiding symptoms). Voiding and discomfort, but not urgency severity, were correlated with hydration markers, both within and between participants.

CONCLUSIONS

LUTS are very common in pwPMS, and associate with inadequate hydration. The causes and consequences of inadequate hydration in MS need further study, since (i) this will focus greater attention on LUTS management in pwPMS and (ii) dehydration has been associated with reversible cognitive dysfunction and physical underperformance.

The Prevalence and Impact of Urinary Incontinence on Multiple Sclerosis Patients in Taif City, Saudi Arabia

Introduction Multiple sclerosis (MS) is a chronic inflammatory disease that results in demyelination and progressive loss of nerve cells within the central nervous system. Multiple sclerosis, as well as other neurological diseases that impact brain structures and spinal pathways involved in sphincter control, may cause lower urinary tract symptoms (LUTS) Our aims are to determine the prevalence, severity, and impact on the quality of life of urinary incontinence among MS patients in Taif, Saudi Arabia, as well as its potential association with demographics and clinical features. Method A cross-sectional study included 150 of MS patients aged 18 years and older who completed the validated Arabic versions of both the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). In addition, other clinical parameters were collected from the medical records of patients. The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 26 (IBM Inc., Armonk, New York). Qualitative data were expressed as numbers and percentages, and the Chi-squared test (χ2) was employed. Quantitative data were expressed as means with standard deviation (mean ± SD). Result 67.3% of the participants were female; the mean ICIQ UI and ICIQ OAB scores in these MS patients were found to be 6.30 ± 6.26 and 5.32 ± 3.76, respectively. They were significantly higher in progressive MS patients compared to relapsing-remitting MS patients (p<0.05). There was a high positive correlation obtained between ICIQ UI and ICIQ OAB scores (rho=0.801, p<0.001). Conclusion The findings of this study showed that urinary incontinence was a common and distressing symptom experienced by individuals with MS. The severity of UI symptoms was significantly more in progressive multiple sclerosis compared to relapsing-remitting multiple sclerosis.

MS bladder check tool: Development and validation of a patient awareness tool to facilitate timely management of lower urinary tract dysfunction due to multiple sclerosis

BACKGROUND

Lower urinary tract dysfunction impacts quality of life of people with MS; often, symptoms are 'lived with' or deprioritised by healthcare providers (HCPs). Consequently, patients must be given the skills they need to become confident in managing their illness and enhance their involvement in the process.

OBJECTIVE

To develop and validate a self-assessment tool to help people with MS become more aware of their bladder symptoms and prompt contact with their HCP to facilitate timely management and specialist referral, if required.

METHODS

The 'MS bladder check tool' was developed by a multidisciplinary panel of specialist advisors. Consensus meetings and pilot testing were conducted to design and evolve the tool into a series of nine questions, using population-appropriate language, and covering all aspects of bladder dysfunction in MS. The tool was then validated by an international, multidisciplinary team of experts.

RESULTS

Validity was rated 'excellent' for all questions indicating that the MS bladder check tool is an appropriate method of highlighting bladder problems in people with MS.

CONCLUSION

The MS bladder check tool is simple, easy-to-use, and empowers patients to take charge of their urinary tract health, aiming to improve the management of MS and, ultimately, patient quality of life.

A comprehensive review of the advances in neuromyelitis optica spectrum disorder

Neuromyelitis optica spectrum disorder (NMOSD) is a rare relapsing neuroinflammatory autoimmune astrocytopathy, with a predilection for the optic nerves and spinal cord. Most cases are characterised by aquaporin-4-antibody positivity and have a relapsing disease course, which is associated with accrual of disability. Although the prognosis in NMOSD has improved markedly over the past few years owing to advances in diagnosis and therapeutics, it remains a severe disease. In this article, we review the evolution of our understanding of NMOSD, its pathogenesis, clinical features, disease course, treatment options and associated symptoms. We also address the gaps in knowledge and areas for future research focus.

The relationship between bladder functions, pelvic floor muscle strength, fall, and fatigue in multiple sclerosis

BACKGROUND

The aim of this study was to determine the relationship between the severity of bladder functions, fatigue, quality of life (QoL), fall, and pelvic floor muscle strength in patients with Multiple Sclerosis (PwMS).

METHODS

Patients were divided into two groups according to their Expanded Disability Status Scale (EDSS) bladder scores as Group 1 (EDSS bladder score 0-1, mildly affected group, n = 25) and Group 2 (EDSS bladder score 2-3-4, moderate and severely affected group, n = 21). Pelvic floor muscle (PFM) strength (EMG-Biofeedback device), fear of fall (Fall Efficacy Scale (FES-1)), fatigue (Fatigue Severity Scale (FSS)), QoL (Urogenital Distress Inventory-short form (UDI-6), and Incontinence Impact Questionnaire-short form (IIQ-7)) were evaluated.

RESULTS

46 female patients diagnosed with MS were included in this study. No significant differences in baseline characteristics were seen between the groups except age. EDSS bladder score were 1 (0-1) and 3 (2-4), EMG-Biofeedback score were 79,5 ± 8,11 and 41,7 ± 5,48, FSS score were 38,7 ± 2,80 and 54±2,20, FES-I score were 16,9 ± 2,15 and 40,2 ± 7,39, UDI-6 score were 4,24±0,47 and 8,42±0,64, IIQ-7 score were 3,64±0,86 and 18,2 ± 1,42 in Group 1 and Group 2. As a result of statistical analysis, significant differences were found in less fatigue and fall, higher PFM strength and better QoL with mildly affected PwMS (p<0,05).

CONCLUSION

There was a significant difference in terms of bladder function level in PFM strength, fall, fatigue and QoL between the mildly affected group and the moderate and severely affected group.

Scientometric Analysis and Mapping of Scientific Articles on Multiple Sclerosis-Related Neurogenic Lower Urinary Tract Dysfunction

OBJECTIVE

Patients suffering from multiple sclerosis (MS) frequently experience lower urinary tract (LUT) dysfunction, which significantly impacts their quality of life. This study's objective was to conduct a scientometric analysis of the literature on MS-induced neurogenic LUT dysfunction.

METHODS

Using bibliometric methods, we examined the literature on neurogenic lower urinary tract dysfunction (NLUTD) in MS patients without restricting it to prevalence studies or specific management methods. We considered contributions from authors, organizations, nations/regions, as well as the evolution of theoretical frameworks, research subtopics, and influential papers. In January 2023, we searched the complete Scopus database, without imposing any language or date constraints, identifying relevant documents related to urology clinical investigations of MS-induced NLUTD. The original articles were categorized into 4 groups: narrative reviews, systematic reviews and meta-analyses, research of levels 1-4, and case reports/series.

RESULTS

On January 1, 2023, our search yielded 72 sources published between 1977 and 2022, including journals and books. The average time before publication was 11.2 years. Each document received an average of 18.1 citations, totaling 1.299 citations per year. The author's analysis explored relationships, productivity, and coauthorship networks among authors and institutions based on bibliographic records. Chartier-Kastler E, Karmonik C, and Khavari R ranked highest with 8 publications each. The University of Catania claimed the top position, followed by Houston Methodist Hospital and Paris University, recognized as the leading institutions in this field.

CONCLUSION

An analysis of diagnosis, therapy, and rehabilitation of MS-related NLUTD may be helpful for future bibliometric research in the field to better direct output.

Assessment of the Impact of Lower Urinary Tract Dysfunction on Quality of Life in Multiple Sclerosis Patients in Saudi Arabia-A Cross-Sectional Study

BACKGROUND

Lower urinary tract dysfunction (LUTD) is caused by neurogenic factors that could lead to permanent injury in affected patients, and therefore result in substantial annual healthcare expenses. LUTD is very prevalent in multiple sclerosis (MS) patients and has a drastic impact on their quality of life (QOL). This study aimed to assess the effect of LUTD on the QOL of Saudi MS patients.

METHODS

A cross-sectional study was carried out in Saudi Arabia using a self-administered questionnaire that included the World Health Organization Quality of Life (WHOQOL-BREF) and LURN Symptom Index (LURN SI-29). Data were analyzed and presented as frequencies and percentages.

RESULTS

There were 428 patients who participated in this study; 270 were females and 158 were males. Most of the patients received a low score in all sections of the LURN part of the questionnaire. The highest scores (urgent need to urinate and excessive urination at night) were recorded in the urgency domain (47.20 ± 36.88) rather than the nocturia domain (44.74 ± 32.91). Meanwhile, the lowest score (complete control of bladder) was recorded in the incontinence domain (22.80 ± 26.80). For the WHOQOL-BREF score, the highest score (more social stability) was in the social domain (65.07 ± 21.16 for females, 60.41 ± 21.54 for males), and the lowest score (less psychological stability) was in the psychological domain (46.36 ± 9.84 for females, 46.20 ± 10.03 for males). However, there was no significant association between the four domains of the WHOQOL-BREF and the gender of the MS patients.

CONCLUSIONS

LUTD is significantly associated with a lowered quality of life. Therefore, patients are recommended to consult with and be evaluated by appropriately experienced healthcare providers and clinicians. This ensures that the patients receive the best advice, accurate and effective treatment, and long-term analysis that can lead to an improvement in their quality of life.

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.

Cannabis and Cannabinoids in Multiple Sclerosis: From Experimental Models to Clinical Practice-A Review

BACKGROUND

As far as 80% of people diagnosed with multiple sclerosis (MS) experience disabling symptoms in the course of the disease, such as spasticity and neuropathic pain. As first-line symptomatic therapy is associated with important adverse reactions, cannabinoids have become increasingly popular among patients with MS. This review intends to provide an overview of the evidence of the role of cannabinoids in treating symptoms related to MS and to encourage further research on this matter.

AREAS OF UNCERTAINTY

To date, the evidence supporting the role of cannabis and its derivatives in alleviating the MS-related symptoms comes only from studies on experimental models of demyelination. To the best of our knowledge, relatively few clinical trials inquired about the therapeutic effects of cannabinoids on patients with MS, with variable results.

DATA SOURCES

We conducted a literature search through PubMed and Google Scholar from the beginning until 2022. We included articles in English describing the latest findings regarding the endocannabinoid system, the pharmacology of cannabinoids, and their therapeutic purpose in MS.

RESULTS

Evidence from preclinical studies showed that cannabinoids can limit the demyelination process, promote remyelination, and have anti-inflammatory properties by reducing immune cell infiltration of the central nervous system in mice with experimental autoimmune encephalomyelitis. Moreover, it has been established that experimental autoimmune encephalomyelitis mice treated with cannabinoids experienced a significant reduction of symptoms and slowing of the disease progression. Given the complexity of human immune and nervous systems, cannabinoids did not have the anticipated effects on human subjects. However, data obtained from clinical trials showed some beneficial results of cannabinoids as a single or as add-on therapy in reducing the spasticity and pain related to MS.

CONCLUSION

Considering their various mechanisms of action and good tolerability, cannabinoids remain an interesting therapy for spasticity and chronic pain related to MS.

Autonomic nervous system disorders in multiple sclerosis

Multiple sclerosis (MS) is a chronic progressive demyelinating disease of the central nervous system (CNS), which also affects the autonomic nervous system (ANS). Manifestations of MS in the ANS include urological, sexual, gastrointestinal, cardiovascular, and thermoregulatory disorders as well as increased fatigue. These problems are common yet are often underestimated due to the non-specificity of the symptoms and the limited evaluation of the ANS in the usual clinical practice. Most of these symptoms seem to be related to localized lesions in the CNS. However, the mechanisms by which these disorders are caused in MS have not been fully investigated, thus preventing any focused etiological treatment. The most common disorders of the ANS in MS represent a challenge for clinicians due to the variability of the clinical picture and our minimal data on their diagnosis and treatment. Early diagnosis and initiation of individualized treatment regimens, often in need of multiple approaches, seem to yield the best results in managing ANS dysfunction in MS patients.

Efficacy of Tibial Nerve Stimulation in Neurogenic Lower Urinary Tract Dysfunction Among Patients with Multiple Sclerosis: A Systematic Review and Meta-analysis

OBJECTIVE

This study was performed to systematically review the current literature on the effects of transcutaneous tibial nerve stimulation and percutaneous tibial nerve stimulation on multiple sclerosis-induced neurogenic lower urinary tract dysfunction.

MATERIALS AND METHODS

Medical databases including PubMed, Scopus, Embase, and Web of Science were systematically searched from inception to September 2022. Metaanalysis was carried out using the comprehensive meta-analysis tool.

RESULTS

Our inclusion criteria were met by 12 studies evaluating the effects of percutaneous tibial nerve stimulation/transcutaneous tibial nerve stimulation on multiple sclerosis-induced neurogenic lower urinary tract dysfunction. Comparing the postintervention results to the baseline showed that the rate of frequency was decreased in both percutaneous tibial nerve stimulation and transcutaneous tibial nerve stimulation groups after intervention. The overall mean change of tibial nerve stimulation on frequency was -2.623 (95% CI: -3.58, -1.66; P < .001, I 2 : 87.04) among 6 eligible studies. The post-void residual was decreased after treatment in both methods of tibial nerve stimulation, with an overall mean difference of -31.13 mL (95% CI: -50.62, -11.63; P=.002, I 2 : 71.81). The other urinary parameters, including urgency (mean difference: -4.69; 95% CI: -7.64, -1.74; P < .001, I 2 : 92.16), maximum cystometric capacity (mean difference: 70.95; 95% CI: 44.69, 97.21; P < .001, I 2 : 89.04), and nocturia (mean difference: -1.41; 95% CI: -2.22, 0.60; P < .001, I 2 : 95.15), were improved after intervention, too. However, the results of subgroup analysis showed no effect of transcutaneous tibial nerve stimulation on urinary incontinence (mean difference: -2.00; 95% CI: -4.06, 0.06; P=.057, I 2 : 95.22) and nocturia (mean difference: -0.39; 95% CI: -1.15, 0.37; P=.315, I 2 : 84.01). In terms of mean voided volume, the evidence was related to only percutaneous tibial nerve stimulation with a mean change of 75.01 mL (95% CI: -39.40, 110.61; P < .001, I 2 : 85.04).

CONCLUSION

Although the current literature suggests that tibial nerve electrostimulation might be an effective method for treating neurogenic lower urinary tract dysfunction, the evidence base is poor and derived from small, mostly nonrandomized trials with a high risk of bias and confounding.

Solifenacin versus posterior tibial nerve stimulation for overactive bladder in patients with multiple sclerosis

Introduction

Overactive bladder (OAB) is one of the most common complications in patients with multiple sclerosis (MS). Choosing the effective treatment is very important in improving their quality of life (QOL). Therefore, the aim of this study was to compare solifenacin (SS) and posterior tibial nerve stimulation (PTNS) treatment effects in the MS Patients with OAB.

Materials and methods

In total, 70 MS patients suffering from OAB enrolled in this clinical trial study. Patients with a score of at least 3 according to the OAB questionnaire were randomly divided into two groups (35 patients in each group). In one group, patients received SS (5 mg daily for 4 weeks and 10 mg/day for another 8 weeks) and in a second group, patients were treated by PTNS (12 weekly session, 30 min).

Results

The mean (SD) age of patients participating in this study was 39.82 (9.088) and 42.41 (9.175) years for the SS group and the PTNS group, respectively. Patients in both groups showed statistically significant improvements in urinary incontinence, micturition, and daytime frequency (p < 0.001). Patients in the SS group had a better response for urinary incontinence after 12 weeks compared to the PTNS group. Also, patients in the SS group reported higher satisfaction and less daytime frequency compared to the PTNS group.

Conclusion

SS and PTNS were effective for improving the OAB symptoms in patients with MS. However, patients demonstrated a better experience with SS in terms of daytime frequency, urinary incontinence, and treatment satisfaction rate.

Disruption of specific white matter tracts is associated with neurogenic lower urinary tract dysfunction in women with multiple sclerosis

OBJECTIVE

To identify specific white matter tracts (WMTs) whose disruption is associated with the severity of neurogenic lower urinary tract dysfunction (NLUTD) in two independent cohorts of women with multiple sclerosis (MS) and NLUTD.

METHODS

Cohort 1 consisted of twenty-eight women with MS and NLUTD. The validation cohort consisted of 10 women with MS and NLUTD. Eleven healthy women served as controls. Participants of both MS cohorts had the same inclusion and exclusion criteria. Both MS cohorts and the healthy controls underwent the same clinical assessment and functional MRI (fMRI) protocol, except that the validation MS cohort underwent 7-Tesla fMRI scan. Fifteen WMTs (six coursing to relevant brainstem areas) involved in bladder control were a priori regions of interest (ROI). Spearman's correlation test was performed between each the Fractional Anisotropy (FA) and mean diffusivity (MD) of each WMT and the clinical parameters.

RESULTS

Overall, we found a very high degree of overlap (100% of a priori ROI) in the tracts identified by our correlation analysis as having the greatest contribution to NLUTD symptoms in MS women. The right inferior cerebellar peduncle, left posterior limb of internal capsule, and left superior cerebellar peduncle displayed significant associations to the greatest number of clinical parameters.

CONCLUSIONS

Our correlation analysis supports the role of specific WMT disruptions in the contribution of symptoms in women with MS and NLUTD, as confirmed in two independent MS cohorts.

Differential transcriptomic changes in the central nervous system and urinary bladders of mice infected with a coronavirus

Multiple sclerosis (MS) often leads to the development of neurogenic lower urinary tract symptoms (LUTS). We previously characterized neurogenic bladder dysfunction in a mouse model of MS induced by a coronavirus, mouse hepatitis virus (MHV). The aim of the study was to identify genes and pathways linking neuroinflammation in the central nervous system with urinary bladder (UB) dysfunction to enhance our understanding of the mechanisms underlying LUTS in demyelinating diseases. Adult C57BL/6 male mice (N = 12) received either an intracranial injection of MHV (coronavirus-induced encephalomyelitis, CIE group), or sterile saline (control group). Spinal cord (SC) and urinary bladders (UB) were collected from CIE mice at 1 wk and 4 wks, followed by RNA isolation and NanoString nCounter Neuroinflammation assay. Transcriptome analysis of SC identified a significantly changed expression of >150 genes in CIE mice known to regulate astrocyte, microglia and oligodendrocyte functions, neuroinflammation and immune responses. Two genes were significantly upregulated (Ttr and Ms4a4a), and two were downregulated (Asb2 and Myct1) only in the UB of CIE mice. Siglec1 and Zbp1 were the only genes significantly upregulated in both tissues, suggesting a common transcriptomic link between neuroinflammation in the CNS and neurogenic changes in the UB of CIE mice.

The neurogenic bladder: developing a consensus bladder and bowel management pathway for people with MS

This article outlines how the bladder can be affected in neurological conditions such as multiple sclerosis (MS) and the impact this has on patient quality of life and NHS resources. A group of MS and bladder and bowel nurse specialists has developed consensus bladder pathways in the hope that all nurses in contact with patients who are likely to have neurogenic bladder symptoms become 'bladder aware'.

Impact on quality of life in multiple sclerosis patients: Which urinary symptoms are to blame?

AIM

To evaluate the correlation between the Expanded Disability Status Scale (EDSS) in multiple sclerosis (MS) subjects, and the severity of lower urinary tract symptoms (LUTS), the bother caused by these symptoms and subjects' quality of life (QoL).

MATERIAL AND METHODS

This cross-sectional study included 50 subjects with persistent LUTS secondary to MS who were recruited from the registry of a national NGO, between October 2017 and November 2019. Subjects with a history of any disease besides MS that could otherwise explain the presence of LUTS, as well as those with other neurological conditions were excluded. Information including MS duration, subjects' EDSS, voiding and storage LUTS, voiding symptoms' subscore of the International Prostate Symptom Score (IPSS-V), Overactive Bladder Symptom Scores (OABSS), Urinary Bothersome Questionnaire in Multiple Sclerosis (UBQMS), and urologic QoL (SF-Qualiveen) was gathered. Correlations between these scores were assessed using Spearman's bivariate correlations. Wilcoxon's signed rank test was used to evaluate the difference of impact between voiding and storage LUTS on bother of subjects.

RESULTS

The median disease duration was 7±5.8years and the predominant lower urinary symptom was urgency (82%). Median OABSS and IPSS-V were respectively 8±3.8 and 8±3. Subjects were significantly more bothered from storage than voiding symptoms (2 vs. 1.6; P=0.03), and their QoL was directly affected by storage LUTS. Urgency urinary incontinence had the highest positive correlation with SFQ (r=0.542; P<0.01). MS duration and urologic QoL measured by SF-Q were negatively correlated (r=-0.345; P=0.01).

CONCLUSION

In MS patients with LUTS, urologic QoL is mainly affected by storage urinary symptoms. Physicians should use a holistic approach to reduce the risk of complications in these patients, by controlling both voiding and storage symptoms, in particular urgency urinary incontinence that mostly affects patient's QoL.

LEVEL OF EVIDENCE: 3

Alterations of gut microbiota diversity, composition and metabonomics in testosterone-induced benign prostatic hyperplasia rats

BACKGROUND

Studies had shown many diseases affect the stability of human microbiota, but how this relates to benign prostatic hyperplasia (BPH) has not been well understood. Hence, this study aimed to investigate the regulation of BPH on gut microbiota composition and metabonomics.

METHODS

We analyzed gut samples from rats with BPH and healthy control rats, the gut microbiota composition and metabonomics were detected by 16S rDNA sequencing and liquid chromatography tandem mass spectrometry (LC-MS/MS).

RESULTS

High-throughput sequencing results showed that gut microbiota beta-diversity increased (P < 0.01) in the BPH group vs. control group. Muribaculaceae (P < 0.01), Turicibacteraceae (P < 0.05), Turicibacter (P < 0.01) and Coprococcus (P < 0.01) were significantly decreased in the BPH group, whereas that of Mollicutes (P < 0.05) and Prevotella (P < 0.05) were significantly increased compared with the control group. Despite profound interindividual variability, the levels of several predominant genera were different. In addition, there were no statistically significant differences in several bacteria. BPH group vs. control group: Firmicutes (52.30% vs. 57.29%, P > 0.05), Bacteroidetes (46.54% vs. 41.64%, P > 0.05), Clostridia (50.89% vs. 54.66%, P > 0.05), Ruminococcaceae (25.67% vs. 20.56%, P > 0.05). LC-MS/MS of intestinal contents revealed that differential metabolites were mainly involved in cellular processes, environmental information processing, metabolism and organismal systems. The most important pathways were global and overview maps, lipid metabolism, amino acid metabolism, digestive system and endocrine system. Through enrichment analysis, we found that the differential metabolites were significantly enriched in metabolic pathways, steroid hormone biosynthesis, ovarian steroidogenesis, biosynthesis of unsaturated fatty acids and bile secretion. Pearson correlation analysis (R = 0.94) showed that there was a strong correlation between Prevotellaceae, Corynebacteriaceae, Turicibacteraceae, Bifidobacteriaceae and differential metabolites.

CONCLUSION

Our findings suggested an association between the gut microbiota and BPH, but the causal relationship between the two groups is unclear. Thus, further studies are warranted to elucidate the potential mechanisms and causal relationships between BPH and gut microbiota.

Antimuscarinics for neurogenic overactive bladder in multiple sclerosis: real-life data

Background:

Antimuscarinics (AMs) represent the mainstay of treatment for storage lower urinary tract symptoms (LUTS) but few data are available on their impact in multiple sclerosis (MS) patients.

Objective:

To assess effectiveness and tolerability of AMs in MS patients with neurogenic detrusor overactivity (NDO).

Methods:

Sixty consecutive outpatients, who started treatment with AMs at one centre, were recruited. The primary endpoint was change in Patient’s Perception of Intensity of Urgency Scale (PPIUS) at 6 months; secondary endpoints were post-void residual urine (PVR) and pads used daily. Incidence and severity of adverse events (AEs) were recorded.

Results:

Significant reduction (p < 0.001) of mean PPIUS and pads use were detected, as well as a significant increase (p < 0.001) of PVR (143 ± 42 ml).

AEs, recorded in 53% of patients, were frequently multiple and caused suspension of AM in 10% of cases, mainly for xerostomia, which has been the commonest AE (26.6%). Neurological AEs appeared in 11.7% of subjects, mostly with oxybutynin. Worsening/onset of voiding LUTS, reported by 8.3% of MS, resulted to be the unique AE correlated to AM dosage.

Conclusion:

This study suggests that AMs are effective in MS patients, but their use should be tailored on every patient as even low dosages can be poorly tolerated. AEs, including neurological ones, are common.

Effects of behavioural therapy versus interferential current on bladder dysfunction in multiple sclerosis patients; a randomised clinical study

Objectives

This study examines the effect of behavioural therapy (biofeedback) and interferential current on bladder dysfunction in multiple sclerosis patients.

Methods

Fifty patients with secondary progressive type multiple sclerosis (SPMS) suffering from bladder dysfunction were divided equally into two groups randomly. Group A (GA) received behavioural therapy (biofeedback training), while Group B (GB) received interferential current training. Both groups were assessed by urodynamics for detrusor pressure and maximum flow rate before and after eight weeks of behavioural therapy and interferential training.

Results

Both groups, GA and GB, showed significant increase in the detrusor pressure and maximum flow rate after eight weeks of training. There was no significant difference between both methods. However, GA showed more improvement by close observation.

Conclusions

Both behavioural therapy and interferential current training effectively managed bladder dysfunction in patients with SPMS, with more evident effects in behavioural therapy patients by close observation.

Rehabilitation in Dementia

Dementia is an eurodegenerative disorder, which causes significant disability, especially among the elderly population worldwide. The affected person shows a progressive cognitive decline, which interferes with the independence in performing the activities of daily living. Other than the cognitive domain, the patient tends to have neuropsychiatric, behavioral, sensorimotor, speech, and language-related issues. It is expected that the global burden of the disease will rise with more people entering the geriatric age group. By 2050 close, to 140 million people will be living with one or the other type of dementia. Alzheimer's disease contributes to more than 60% of cases worldwide, followed by vascular dementia. Pharmacotherapy has a limited role to play in the treatment, and at present, no drug is available, which can halt or reverse the progress of the disease. World Health Organization has mandated rehabilitation as a core recommendation in the global action plan on the public health response to dementia. Rehabilitation services are widely recognized as a practical framework to maximize independence and community participation in dementia care. The rehabilitation program is customized to achieve the desired goals, as each person has different experiences, preferences, motivations, strengths, and requirements based on type, course, and severity of the illness. It is an interdisciplinary-team approach with the involvement of several health care professionals. This article reviews the existing literature and outlines the effective rehabilitation strategies concisely in dementia care.

Clinical course of neurogenic bladder dysfunction in human T-cell leukemia virus type-1-associated myelopathy/tropical spastic paraparesis: a nationwide registry study in Japan

BACKGROUND

Most patients with human T-cell leukemia virus type 1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) develop neurogenic bladder dysfunction. However, longitudinal changes and treatment effects remain poorly understood. This study aimed to characterize the clinical course of urinary dysfunction in this population.

METHODS

This prospective observational study included 547 patients enrolled in HAM-net, a nationwide registry for HAM/TSP in Japan. Urinary dysfunction severity was evaluated using the HAM/TSP-bladder dysfunction symptom score (HAM-BDSS) and the HAM/TSP-bladder dysfunction severity grade (HAM-BDSG). These specific measures were recently developed for assessing urinary dysfunction in HAM/TSP. We analyzed longitudinal changes over a 6-year follow-up period, associations between urinary and gait dysfunction, and treatment efficacy of urinary catheterization and mirabegron (a β3-adrenergic agonist for overactive bladder symptoms).

RESULTS

The mean (standard deviation [SD]) age and disease duration at enrollment were 61.9 (10.7) years and 16.6 (11.6) years, respectively, and 74.6% of patients were women. Only 8.0% were free from urinary symptoms (HAM-BDSG 0), 65.4% had urinary symptoms or were on medication (HAM-BDSG I), and 23.2% and 3.3% used intermittent and indwelling catheters (HAM-BDSG II and III), respectively. HAM-BDSG and BDSS were worse in patients with greater gait dysfunction (p < 0.001 for both). During the 6-year follow-up, 66.7% of patients with HAM-BDSG 0 developed new urinary symptoms. Of those with HAM-BDSG I at enrollment, 10.8% started using urinary catheters. Importantly, HAM-BDSS significantly improved after initiating catheterization (mean [SD] change, - 8.93 [10.78], p < 0.001). The number of patients receiving mirabegron increased in the fourth year. Multivariable linear regression analysis significantly associated mirabegron with improvement in HAM-BDSS (- 5.82, 95% confidence interval - 9.13 to - 2.51, p = 0.001).

CONCLUSIONS

Urinary dysfunction affected 92% of patients and progressed over the 6-year follow-up. Urinary symptoms were more severe in patients with poorer gait function. Urinary catheterization and mirabegron were effective in relieving symptoms. Effective utilization of real-world data is key to establishing evidence for rare diseases, such as HAM/TSP.

Disorders of the enteric nervous system - a holistic view

The enteric nervous system (ENS) is the largest division of the peripheral nervous system and closely resembles components and functions of the central nervous system. Although the central role of the ENS in congenital enteric neuropathic disorders, including Hirschsprung disease and inflammatory and functional bowel diseases, is well acknowledged, its role in systemic diseases is less understood. Evidence of a disordered ENS has accumulated in neurodegenerative diseases ranging from amyotrophic lateral sclerosis, Alzheimer disease and multiple sclerosis to Parkinson disease as well as neurodevelopmental disorders such as autism. The ENS is a key modulator of gut barrier function and a regulator of enteric homeostasis. A 'leaky gut' represents the gateway for bacterial and toxin translocation that might initiate downstream processes. Data indicate that changes in the gut microbiome acting in concert with the individual genetic background can modify the ENS, central nervous system and the immune system, impair barrier function, and contribute to various disorders such as irritable bowel syndrome, inflammatory bowel disease or neurodegeneration. Here, we summarize the current knowledge on the role of the ENS in gastrointestinal and systemic diseases, highlighting its interaction with various key players involved in shaping the phenotypes. Finally, current flaws and pitfalls related to ENS research in addition to future perspectives are also addressed.

Perspectives on urological care in multiple sclerosis patients

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system. Lower urinary tract dysfunction due to MS includes a dysfunction of the storage phase or dysfunction of the voiding phase or a detrusor-sphincter dyssynergia. Baseline evaluation includes a voiding chart, an ultrasound scan of the urinary tract, urine culture, and an urodynamic study. For storage symptoms, antimuscarinics are the first-line treatment, and clean intermittent catheterization (CIC) is indicated if there is concomitant incomplete bladder emptying. Intradetrusor injections with botulinum toxin A (BTX-A), are recommended for refractory cases. Urinary diversion is rarely indicated. For patients with voiding symptoms, CIC and alpha-blockers are usually offered. Sexual dysfunction in patients with MS is multifactorial. Phosphodiesterase type 5 inhibitors are first-line therapies for MS-associated erectile dysfunction in both male and female patients. This review summarizes the epidemiology, pathogenesis, risk factors, genetic, clinical manifestations, diagnostic tests, and management of MS. Lastly, the urologic outcomes and therapies are reviewed.

Transcranial magnetic stimulation (TMS) and repetitive TMS in multiple sclerosis

Multiple sclerosis (MS) is the most well-known autoimmune disorder of the central nervous system, and constitutes a major cause of disability, especially in young individuals. A wide array of pharmacological treatments is available, but they have often been proven to be ineffective in ameliorating disease symptomatology or slowing disease progress. As such, non-invasive and non-pharmacological techniques have been gaining more ground. Transcranial magnetic stimulation (TMS) utilizes the electric field generated by a magnetic coil to stimulate neurons and has been applied, usually paired with electroencephalography, to study the underlying pathophysiology of MS, and in repetitive trains, in the form of repetitive transcranial magnetic stimulation (rTMS), to induce long-lasting changes in neuronal circuits. In this review, we present the available literature on the application of TMS and rTMS in the context of MS, with an emphasis on its therapeutic potential on various clinical aspects, while also naming the ongoing trials, whose results are anticipated in the future.

The effect of pelvic floor exercise program on incontinence and sexual dysfunction in multiple sclerosis patients

PURPOSE

Multiple sclerosis (MS) is a chronic neuroinflammatory disease of the central nervous system that involves different neurological areas. In addition to lower urinary tract symptoms (LUTS), sexual dysfunction (SD), and psychopathological effects, MS sometimes seriously impairs the quality of life (QoL). We hypothesize that the pelvic floor exercise program (PFEP) could improve bladder, sexual function, depression, and QoL in MS patients.

METHODS

Patients diagnosed with MS completed the Incontinence Questionnaire Short Form (ICIQ-SF), the Beck Depression Inventory (BDI), the Multiple Sclerosis Quality of Life-54 (MSQoL-54) questionnaire, and either the Female Sexual Function Index (FSFI) or the Sexual Health Inventory for Men (SHIM). Maximum bladder volumes (MBV) and post-voiding residual (PVR) volumes were measured using ultrasonography. The patients who regularly completed the PFEP for 12 weeks were asked to fill out the questionnaires again, and their MBV and PVR were remeasured.

RESULTS

Seventy-two patients with relapsing-remitting multiple sclerosis (RRMS) were included in the study. Forty-two (58.3%) RRMS patients reached the end of the study. The patients' post-PFEP average MBV statistically increased (p = 0.01). In contrast, no statistically significant difference was found in the PVR (p = 0.2). After exercise, the FSFI values in women increased (p = 0.02), and ICIQ-SF and BDI values in all the RRMS patients statistically decreased (p = 0.004, p = 0.01, respectively), but there was no improvement in the MSQoL-54 score (p > 0.05).

CONCLUSION

PFEP, which causes a reduction in LUTS by enhancing the MBV of RRMS patients, can be seen as an investment in the future in terms of reducing depression in MS patients and preventing or delaying SD in women.

Management strategies for neurogenic lower urinary tract dysfunction: a qualitative study of the experiences of people with multiple sclerosis and healthcare professionals

PURPOSE

Urinary symptoms are highly prevalent among people with MS. This study aimed to explore the experiences of people with MS and HCPs in managing urinary symptoms and explore their views on using TTNS to treat urinary symptoms.

MATERIALS AND METHODS

Audio-recorded semi-structured, interviews were employed with people with MS and HCPs. All transcribed interviews were exported to NVivo software (Version 12) and analyzed using a reflexive approach to thematic analysis.

RESULTS

Four main themes were identified; The wide-ranging negative impacts of urinary symptoms ("It's limited everything else"), Gaps in urinary services ("Is there somebody like that, sort of specialized in that area?"), Management strategies ("I don't go too far from the toilet in case I need to use one"), and optimism about TTNS ("Are you giving Me Hope?").

CONCLUSION

Urinary symptoms are common and very troublesome for people with MS. Despite their prevalence, many people with MS continue to suffer in silence. People with MS require skilled multidisciplinary services guided by clinical care pathways to improve service provision and to address urinary symptoms. HCP's and people with MS are open to the use of TTNS for urinary symptoms and have clear preferences for location and duration of intervention delivery.Implications for rehabilitationUrinary symptoms are very common and troublesome for people with multiple sclerosis, yet many continue to suffer in silence.People with multiple sclerosis lack knowledge about treatment options for urinary symptoms.There is an on-going need for healthcare provider education on guidelines for screening and managing urinary symptoms in people with MS and the role of specialist urinary service providers.HCP's and people with MS are open to the use of TTNS for urinary symptoms.

Relationship between Lower Urinary Tract Dysfunction and Dementia

Lower urinary tract dysfunction (LUTD) is a common health challenge in dementia patients with significant morbidity and socioeconomic burden. It often causes lower urinary tract (LUT) symptoms, restricts activities of daily life, and impairs quality of life. Among several LUT symptoms, urinary incontinence (UI) is the most prominent storage symptom in the later stages of dementia. UI in patients with dementia results not only from cognitive impairment, but also from urological defects such as detrusor overactivity. Management of LUTD in patients with dementia is based on multiple factors, including cognitive state, functional impairment, concurrent comorbidities, polypharmacy and urologic condition. Behavioral therapy under caregiver support represents appropriate treatment strategy for UI in these patients. Pharmacological treatment can be considered in patients refractory to behavioral therapy, but it is more effective when combined with behavioral therapy. Antimuscarinics and mirabegron, a beta-3 receptor agonist, are effective for managing storage symptoms involving the LUT. However, anticholinergic side effects in elderly subjects are a concern, particularly when there is a risk of exacerbating cognitive impairment with prolonged use of antimuscarinics. Proper recognition and treatment of LUTD in dementia can improve quality of life in these patients.

Transcutaneous tibial nerve stimulation for the treatment of bladder storage symptoms in people with multiple sclerosis: Protocol of a single-arm feasibility study

Background: Neurogenic lower urinary tract dysfunction (NLUTD) is common among people with multiple sclerosis (MS) with a pooled prevalence of 68.41% using self-report measures and 63.95% using urodynamic studies. Transcutaneous tibial nerve stimulation (TTNS) is a non-invasive option to manage bladder storage symptoms; however, the potential efficacy of TTNS among people with MS is based on a small number of studies with the absence of high-quality evidence relating to efficacy, and lack of clarity of the optimal electrical stimulation parameters and frequency, duration and number of treatment sessions. This study aims to assess whether TTNS is feasible and acceptable as a treatment for bladder storage symptoms in people with MS. Methods: We will use a single-arm experimental study to explore the feasibility and acceptability of TTNS in the treatment of bladder storage symptoms in MS. The CONSORT extension for pilot and feasibility studies will be followed to standardise the conduct and reporting of the study. The recruitment plan is twofold: 1) Open recruitment for people with MS through MS Ireland's communication channels; 2) recruitment from a convenience sample of people with MS who have previously participated in a qualitative interview study of urinary symptoms. We will assess recruitment/retention rates, the urinary symptoms changes and the effect on quality of life pre and post intervention using ICIQ-OAB, 3-day bladder diary, King's Health Questionnaire and collect self-reported data on adherence and adverse events. Acceptability of using TTNS will be evaluated at the end of intervention. This study has been reviewed and approved by the Education and Health Science's Faculty Research Ethics Committee, University of Limerick [2020_06_07_EHS].  Conclusion: It is anticipated that assessing the feasibility and acceptability of TTNS for storage bladder symptoms in MS will inform the development of a definitive randomised trial. Trial registration: ClinicalTrials.gov NCT04528784 27/08/2020.

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.

Lower urinary tract dysfunction in common neurological diseases

The lower urinary tract has the main function of urine storage and voiding. The integrity of the lower urinary tract nerve supply is necessary for its proper function. Neurological disorders can lead to lower urinary tract dysfunction (LUTD) and cause lower urinary tract symptoms (LUTS). Common causes of neurogenic LUTS or LUTD include spinal cord injury, multiple sclerosis, Parkinson's disease, cerebrovascular accidents, cauda equina syndrome, diabetes mellitus, and multiple system atrophy. The pathophysiology is categorized according to the nature of the onset of neurological disease. Assessment requires clinical evaluation, laboratory tests, imaging, and urodynamic studies. Impaired voiding is most often managed by clean intermittent self-catheterization if the postvoid residual urine exceeds 100 ml, whereas storage symptoms are most often managed by antimuscarinic medications. Intradetrusor injection of botulinum toxin type A is emerging as an effective treatment for managing refractory neurogenic detrusor overactivity. This review provides an overview of the clinical characteristics, diagnosis, and management of LUTD in patients with central and peripheral common neurological diseases.

Management of Multiple Sclerosis Symptoms and Comorbidities

PURPOSE OF REVIEW

This article discusses the prevalence, identification, and management of multiple sclerosis (MS)-related symptoms and associated comorbidities, including complications that can present at all stages of the disease course.

RECENT FINDINGS

The impact of comorbidities on the outcome of MS is increasingly recognized. This presents an opportunity to impact the course and outcome of MS by identifying and treating associated comorbidities that may be more amenable to treatment than the underlying inflammatory and neurodegenerative disease. The identification of MS-related symptoms and comorbidities is facilitated by brief screening tools, ideally completed by the patient and automatically entered into the patient record, with therapeutic suggestions for the provider. The development of free, open-source screening tools that can be integrated with electronic health records provides opportunities to identify and treat MS-related symptoms and comorbidities at an early stage.

SUMMARY

Identification and management of MS-related symptoms and comorbidities can lead to improved outcomes, improved quality of life, and reduced disease activity. The use of brief patient-reported screening tools at or before the point of care can facilitate identification of symptoms and comorbidities that may be amenable to intervention.

Management strategies for lower urinary tract symptoms (LUTS) among people with multiple sclerosis (MS): a qualitative study of the perspectives of people with MS and healthcare professionals

Background: Neurogenic lower urinary tract dysfunction (NLUTD) is defined as a lower urinary tract dysfunction secondary to confirmed pathology of the nervous system. NLUTD is common in people with multiple sclerosis (MS), with prevalence estimates ranging from 49% to 92%. Managing NLUTD is complex and can be comprised of pharmacological and non-pharmacological interventions. Qualitative research exploring perspectives of people with MS and healthcare professionals on living with and managing NLUTD symptoms is sparse. This study aims to explore the perspectives of people with MS and healthcare professionals on managing NLUTD symptoms. Methods: A qualitative descriptive approach will be applied in this study using audio-recorded semi structured interviews for people with MS and healthcare professionals. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardize the conduct and reporting of the research. People with MS will be recruited through a gatekeeper at MS Ireland. Healthcare professionals will be recruited through gatekeepers at Irish Practice Nurses Association, Continence Foundation of Ireland, Irish Society of Chartered Physiotherapists, and Physiotherapists Interested in MS Group. Interviews will be transcribed and exported to NVivo software package (Version 12) for analysis. Data will be collectively synthesised using thematic analysis. Conclusion: It is anticipated that exploring perspectives of people with MS and healthcare professionals on managing symptoms (including current practice) of NLUTD in MS will assist in the development of an evidence-based and stakeholder informed intervention for NLUTD in people with MS.

CoQ10 ameliorates monosodium glutamate-induced alteration in detrusor activity and responsiveness in rats via anti-inflammatory, anti-oxidant and channel inhibiting mechanisms

Background

Competent detrusor muscles with coordinated contraction and relaxation are crucial for normal urinary bladder storage and emptying functions. Hence, detrusor instability, and subsequently bladder overactivity, may lead to undesirable outcomes including incontinence. Multiple mechanisms may underlie the pathogenesis of detrusor overactivity including inflammation and oxidative stress. Herein, we tested the possibility that CoQ10 may have a potential therapeutic role in detrusor overactivity.

Methods

Forty adult male Wistar albino rats weighing 100-150 g were used in the present study. Rats were divided (10/group) into control (receiving vehicles), monosodium glutamate (MSG)-treated (receiving 5 mg/kg MSG daily for 15 consecutive days), MSG + OO-treated (receiving concomitantly 5 mg/kg MSG and olive oil for 15 consecutive days), MSG + CoQ10-treated (receiving concomitantly 5 mg/kg MSG and 100 mg/kg CoQ10 daily for 15 consecutive days) groups.

Results

MSG resulted in significant increase in bladder weight and sensitised the bladder smooth muscles to acetylcholine. MSG has also resulted in significant increase in bladder TNF-α, IL-6, malondialdehyde, nerve growth factor and connexion 43, with significant decrease in the antioxidant enzymes superoxide dismutase and catalase. Olive oil had no effect on MSG induced alterations of different parameters. Treatment with CoQ10 has resulted in a significant restoration of all the altered parameters.

Conclusion

Taken together, our results suggest that CoQ10 antagonizes the deleterious effects of MSG on detrusor activity. We propose that CoQ10 could be a therapeutic strategy targeting urinary bladder dysfunction.

Is baseline routine renal ultrasound indicated for all MS patients?

BACKGROUND

Most patients with multiple sclerosis (MS) develop multiple urological complaints due to hyperactive or hypoactive bladder, and may have detrusor-sphincter dyssynergia. Routine renal ultrasound (RUS) screening has been recommended for both symptomatic and asymptomatic MS patients; however, there is little data to support this practice.

METHODS

Prospectively screened consecutive MS clinic patients in 2016-2017 with functional systems scores (FSS) indicating moderate to severe neurogenic bladder symptoms (FSS bladder ≥2) were sent for RUS. We also screened for history of urinary tract infections.

RESULTS

872 patients were screened between 3 September 2016 and 13 April 2017. 58 patients met inclusion criteria for RUS. 6 were excluded due to non-compliance with testing or unavailability of results; 52 patients were imaged. Only 3/52 patients were found to have renal pathology requiring follow-up. Of those three, one had known symptomatic nephrolithiasis, and one had subsequently normal findings, leaving one patient newly found to have valid abnormal upper urinary tract (UUT) findings. Multiple incidental findings were also discovered.

CONCLUSION

The minimal yield for significant UUT pathology found in this enriched group of symptomatic MS patients indicates that RUS screening for asymptomatic MS patients without clear risk factors is not indicated. Red flags for high risk of UUT complications should be used as triggers for baseline RUS screening in MS patients.

Validation of the Turkish version of the eight-item actionable bladder symptom screening tool in multiple sclerosis

AIMS

This study aimed to translate the eight-item Actionable Bladder Symptom Screening Tool (ABSST) and determine its psychometric properties in Turkish speaking subjects.

METHODS

The study was conducted at the multiple sclerosis (MS) outpatient clinic of the Istanbul Faculty of Medicine, Istanbul University. First, the ABSST was translated into Turkish by an expert panel. We employed the back translation method for linguistic validation. Cronbach's α and test-retest analysis were performed for reliability analysis. The overactive bladder-v8 (OAB-v8) questionnaire was also administered for concurrent validation, and expanded disability status scale (EDSS) and multiple sclerosis quality of life scale-54 (MSQL-54) were used to evaluate construct validity.

RESULTS

One hundred and five patients (84 females; mean age, 39.5 ± 11.6 years; mean EDSS score, 3.2 ± 1.8) participated in the study. Mean duration of MS was 9.7 ± 8.3 years, and most (n = 96; 91.5%) had relapsing-remitting MS. The mean ABSST score was 9.7 ± 5.8 (range, 0-21). Highest scores were obtained from urgency and frequency, and the lowest from psychosocial effects of lower urinary tract (LUT) symptoms. The Cronbach's α coefficient was 0.856, and item-total score correlations ranged between 0.485 and 0.845. Correlations of ABSST scores with OAB-v8, EDSS, and MSQL-54 scales were significant (P < .001). According to the questionnaire, 38.1% (n = 40) of the patients needed a referral to a urologist or gynecologist for their LUT symptoms.

CONCLUSIONS

The Turkish version of the ABSST is a valid and reliable screening tool that can be used to identify LUT symptoms in an MS clinic.

Differential neurodegenerative phenotypes are associated with heterogeneous voiding dysfunction in a coronavirus-induced model of multiple sclerosis

Patients with multiple sclerosis (MS) develop a variety of lower urinary tract symptoms (LUTS). We previously characterized a murine model of neurogenic bladder dysfunction induced by a neurotropic strain of a coronavirus. In the present study, we further study the role of long-lasting neurodegeneration on the development of neurogenic bladder dysfunction in mice with corona-virus induced encephalitis (CIE). Long-term follow up study revealed three phenotypes of neurodegenerative symptom development: recovery (REC group), chronic progression (C-PRO group) and chronic disease with relapsing-remitting episodes (C-RELAP group). The levels of IL-1β in REC group, IL-10 in C-RELAP group, and IL-1β, IL-6, IL-10 and TNF-α in C-PRO group were diminished in the brain. The levels of TNF-α in REC group and INF-γ, IL-2, TGF-β and TNF-α in the C-PRO group were also diminished in the urinary bladder. Mice in C-RELAP group showed a delayed recovery of voiding function. In vitro contractility studies determined a decreased basal detrusor tone and reduced amplitude of nerve-mediated contractions in C-RELAP group, whereas C-PRO group had elevated muscle-mediated contractions. In conclusion, mice with CIE developed three phenotypes of neurologic impairment mimicking different types of MS progression in humans and showed differential mechanisms driving neurogenic bladder dysfunction.