Consensus guidelines on the neurologist's role in the management of neurogenic lower urinary tract dysfunction in multiple sclerosis

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.

Astrocyte Activation and Drug Target in Pathophysiology of Multiple Sclerosis

Multiple sclerosis (MS) is a neurodegenerative disease, which is also referred to as an autoimmune disorder with chronic inflammatory demyelination affecting the core system that is the central nervous system (CNS). Demyelination is a pathological manifestation of MS. It is the destruction of myelin sheath, which is wrapped around the axons, and it results in the loss of synaptic connections and conduction along the axon is also compromised. Various attempts are made to understand MS and demyelination using various experimental models out of them. The most popular model is experimental autoimmune encephalomyelitis (EAE), in which autoimmunity against CNS components is induced in experimental animals by immunization with self-antigens derived from basic myelin protein. Astrocytes serve as a dual-edged sword both in demyelination and remyelination. Various drug targets have also been discussed that can be further explored for the treatment of MS. An extensive literature research was done from various online scholarly and research articles available on PubMed, Google Scholar, and Elsevier. Keywords used for these articles were astrocyte, demyelination, astrogliosis, and reactive astrocytes. This includes articles being the most relevant information to the area compiled to compose a current review.

Communication between persons with multiple sclerosis and their health care providers: A scoping review

OBJECTIVES

This study undertakes a scoping review of research about communication between persons with MS and their health care providers.

DESIGN

PubMed, PsycInfo, Communication Source, Socindex, Sociological Abstracts, Cinahl, and Proquest Dissertations and Theses were used to identify studies since each database's inception. Research team members engaged in study selection, coding for communication issues, and data extraction for descriptive information.

RESULTS

Of the 419 empirical articles identified, 175 were included. Codes represented all elements of ecological and pathway models, emphasizing emerging technologies for facilitating communication, uncertainty and anxiety for persons with MS, and communication issues surrounding diagnosis, information seeking, and decision making.

CONCLUSION

This review synthesizes and organizes influences on communication, communication processes, and health outcomes of communication for persons with MS and their providers. Findings extend the ecological model with illness context and the pathway model with communication breakdowns and provider outcomes.

PRACTICE IMPLICATIONS

Health care providers should consider the complexity of communication when interacting with persons with MS, including the larger context in which it occurs, communication processes and their purposes, and short-term and long-term consequences of interactions. Ecological and pathway models can be frameworks for developing educational materials, as they succinctly capture key communication issues and outcomes.

Neurologic Urinary Incontinence, Lower Urinary Tract Symptoms and Sexual Dysfunctions in Multiple Sclerosis: Expert Opinions Based on the Review of Current Evidences

Objective: To resume each specialist’s role in the management of neurologic urinary tract symptoms (nLUTS) and sexual dysfunctions (SD) in patients suffering from multiple sclerosis (MS). Material and Methods: We asked a neurologist, a urologist and a gynecologist, experts on neuro-urology and sexual dysfunction at our hospital, to resume their role in the management of nLUTS and SD in MS patients based on the review of current evidence. PubMed was used to review literature with a focus on nLUTS and SD in MS patients. Conclusions: The difference in symptomatology in MS patients is very wide. The more the CNS is involved, the more the variations and severity of nLUTS is present. SD have numerous causes and should always be assessed. Urologists play the director’s role in evaluating and treating these patients. Neurologist should play an important role, they must evaluate the potential mutual interactions between disease manifestations of MS and their treatments. Additionally, gynecologists play an important information sharing role in the management of patients with multiple sclerosis.

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.

Genetic diseases mimicking multiple sclerosis

Multiple sclerosis (MS) is an inflammatory neurodegenerative disorder manifesting as gradual or progressive loss of neurological functions. Most patients present with relapsing-remitting disease courses. Extensive research over recent decades has expounded our insights into the presentations and diagnostic features of MS. Groups of genetic diseases, CADASIL and leukodystrophies, for example, have been frequently misdiagnosed with MS due to some overlapping clinical and radiological features. The delayed identification of these diseases in late adulthood can lead to severe neurological complications. Herein we discuss genetic diseases that have the potential to mimic multiple sclerosis, with highlights on clinical identification and practicing pearls that may aid physicians in recognizing MS-mimics with genetic background in clinical settings.

[Current aspects of neurogenic dysfunctions of the lower urinary tract in multiple sclerosis]

BACKGROUND

In the clinical management of patients with multiple sclerosis (MS), the challenge is to make an early diagnosis and initiate adequate treatment of neurogenic disorders of the lower urinary tract (NLUTD). Various national guidelines provide practical recommendations which are sometimes discordant.

OBJECTIVE

To develop a simple evidence-based algorithm for detecting NLUTD in patients with MS that could be taken as a principle for deriving therapeutic consequences.

MATERIAL AND METHODS

A prospective multicenter study was initiated as a direct result of two multidisciplinary conferences. The aim was to identify statistically and clinically relevant parameters for the routine diagnosis of NLUTD in patients with MS. Urodynamic abnormalities served as the gold standard. At three subsequent consensus conferences, the results of the study were discussed, a diagnostic algorithm was developed and consensus was reached on a first-line treatment.

RESULTS AND DISCUSSION

The proposed algorithm enables the detection of NLUTD in patients with MS with the help of four statistically significant predictors: 1) the residual urine volume, 2) the number of urinary tract infections (UTI) within the last 6 months, 3) the standardized micturition frequency and 4) the presence/absence of urinary incontinence. The newly developed algorithm has proved to be efficient with the following results: approximately 75% of the patients do not need a urodynamic examination for a first-line treatment decision. In 25% of cases, urodynamic examinations are essential for an adequate treatment decision. Routine assessments include the patient medical history, residual urine volume measurement, a micturition diary and a uroflowmetry (optional).

B3 agonists or anticholinergics in the treatment of the lower urinary tract dysfunction in patients with multiple sclerosis?-A randomized study

INTRODUCTION AND OBJECTIVE

Multiple sclerosis (MS) is the most frequent autoimmune demyelinating disease of the central nervous system. MS patients usually present with lower urinary tract dysfunction (LUTD). Objective of this study is to evaluate and compare the efficacy and safety of treating MS patients with LUTD with either a b3 agonist (mirabegron) or anticholinergics. The study's primary outcome is the LUTD symptom improvement.

MATERIAL AND METHODS

This is a multi-center, single-blinded, comparative study including 91 MS patients with LUTD. At baseline, patients underwent thorough clinical examination, urine cultivation and abdominal ultrasound and completed urination diaries and specific, validated questionnaires (NBSS, MusiQoL). At second visit, patients were administered either mirabegron or anticholinergics. Treatment was always carried out alongside with MS treatment. Reevaluation was performed 3 months after first visit. Patients underwent the same clinical and imaging tests that were carried out at first visit.

RESULTS

We compared several clinical and imaging parameters between the two groups at first visit and month 3 after treatment. Νo statistical difference was noted between the mirabegron group and the anticholinergic group in terms of LUTD improvement. In both groups, improvement from baseline regarding LUTD was recorded. Statistical analysis was performed using the paired and unpaired t test method. No patient discontinued either medication due to side effects.

CONCLUSIONS

MS patients receiving either mirabegron or anticholinergic therapy for LUTD showed improvement. Nevertheless, no statistical difference was noted between the two cohorts at 3 months in terms of drug efficacy in all the statistically significant parameters.

Managing Urological Disorders in Multiple Sclerosis Patients: A Review of Available and Emerging Therapies

Multiple sclerosis (MS) is a progressive neurological autoimmune disease with a diverse range of urological symptomatology, and most MS patients experience 1 or more moderate to severe urinary symptoms, as well as bladder and/or sexual disorders. Urologists play the director's role in evaluating and treating these patients. Therefore, identifying the proper evaluation tools and the most suitable therapeutic options for specific patients requires a thorough understanding of this disease process.

Consensus document on the multidisciplinary management of neurogenic lower urinary tract dysfunction in patients with multiple sclerosis

AIM

Neurogenic lower urinary tract dysfunction (NLUTD) is very common in multiple sclerosis (MS) patients. Early diagnosis and treatment are crucial to avoid irreversible damage and improve quality of life. Our aim was to develop recommendations to improve NLUTD identification in MS patients, along with their referral and management.

METHODS

A multidisciplinary group of 14 experts in the management of patients with MS and NLUTD (nine urologists, three neurologists, and two rehabilitators) was selected. A comprehensive review of the literature was undertaken and a set of recommendations was generated and submitted to a Delphi panel of 114 experts. Recommendations were presented according to the grade of agreement (GA).

RESULTS

Early diagnosis in asymptomatic patients with risk factors for complications is recommended (GA 94%). Postvoid residual volume should be measured if changes in urinary symptoms (GA 87%), preferably ultrasound-guided (GA 86%). Early referral to urologist is recommended if urinary incontinence (GA 91%), significant post-void residual volume (94%), quality of life impairment (GA 98%) and recurrent urinary infections (GA 97%). The initial evaluation should include physical examination (GA 99%) and urodynamics including cystometry (GA 89%), pressure-flow study (90%) and electromyography (GA 70%). The panel recommends multidisciplinary collaboration (GA 100%) with a rehabilitation specialist and trained nurses in the management of NLUTD (GA 99%).

CONCLUSIONS

Multidisciplinary management for patients with NLUTD due to MS is advised, including urologists, neurologists, rehabilitation, and nurses. Panel recommends early diagnosis with post-void residual volume in symptomatic patients before referring to urologist and urodynamics when referred.

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.

Assessment of Renal Deterioration and Associated Risk Factors in Patients With Multiple Sclerosis

OBJECTIVE

To evaluate predictors of renal deterioration (RD) in patients with multiple sclerosis (MS) at a tertiary referral center.

METHODS

We reviewed adult patients with MS presenting for evaluation of lower urinary tract symptoms, with baseline urodynamic study (UDS) and either serum creatinine (SCr) or renal ultrasound, from a prospectively maintained database, and excluded patients with abnormal renal function. RD was defined as doubled SCr, new hydronephrosis, or renal atrophy on follow-up ultrasound. Demographic and UDS parameters were evaluated in multivariable models of RD.

RESULTS

From 1999 to 2016, 660 patients were evaluated, and 355 met criteria with median follow-up of 79 months. SCr doubled in 8 patients, 4 had decline by renal ultrasound, and 1 by both (3%). Overall, 46 patients met less strict criteria of decrease in estimated glomerular filtration rate by ≥30%. Using the less rigid criterion, detrusor overactivity (DO) remained associated with RD on multivariable analysis. Eleven of 355 patients had RD by either imaging or doubled Cr, with which only history of diabetes mellitus and nephrolithiasis were associated.

CONCLUSION

By strict criteria, the rate of RD in patients with neurogenic bladder due to MS was low (3%) at intermediate-term follow-up and was not associated with UDS parameters. Using more liberal criteria, DO was associated with deterioration, suggesting that study of the impact of more aggressive control of DO in this population may be warranted.

The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis

PURPOSE OF REVIEW

Multiple sclerosis (MS) is the most frequent neuroinflammatory disease of the central nervous system and is commonly associated with lower urinary tract (LUT) dysfunction. As a consequence, health-related quality of life is often impaired and the upper urinary tract might be at risk for damage. The aim of this review is to give an overview of current treatment options for LUT dysfunction in patients with MS.

RECENT FINDINGS

The treatment is tailored to the type of dysfunction-storage or voiding dysfunction-beginning with conservative treatment options and ending with invasive therapies and surgery. Additionally, alternative options, e.g., different intravesical therapies or cannabinoids, have been evaluated in recent years with promising results. Current available therapies offer different possible treatments for LUT dysfunction in patients with MS. They address either voiding or storage dysfunction and therefore ameliorate LUT symptoms improve quality of life and protect the upper urinary tract.

Treatment of lower urinary tract symptoms in multiple sclerosis patients: Review of the literature and current guidelines

Multiple sclerosis (MS) is a unique neurological disease with a broad spectrum of clinical presentations that are time- and disease course-related. Lower urinary tract symptoms (LUTS) are highly prevalent in this patient population, with approximately 90% showing some degree of voiding dysfunction and/or incontinence 6-8 years after the initial MS diagnosis. Major therapeutic goals include quality of life improvement and the avoidance of urological complications Owing to the wide divergence of clinical symptoms and disease course, evaluation and treatment differ between patients. Treatment must be customized for each patient based on disease phase, patient independence, manual dexterity, social support, and other medical- or MS-related issues. Ablative or irreversible therapies are indicated only when the disease course is stable. In most cases of "safe" bladder, behavioural treatment is considered first-line defense. Antimuscarinic drugs, alone or in combination with intermittent self-catheterization, are currently the mainstay of conservative treatment, and several other medications may help in specific disease conditions. Second-line treatment includes botulinum toxin A injection, neuromodulation, indwelling catheters, and surgery in well-selected cases.

Evaluation of lower urinary tract symptoms in multiple sclerosis patients: Review of the literature and current guidelines

Multiple sclerosis (MS) is a unique neurological disease with a broad spectrum of clinical presentations that are time- and disease course-related. MS plaque location (intracranial and/or spinal) is a key feature in the pathophysiology of disease-related lower urinary tract symptoms (LUTS). The prevalence of these symptoms in MS patients is very high, with nearly 90% of them experiencing some degree of voiding dysfunction and/or incontinence. LUTS rarely present as primary MS manifestations and usually appear 6-8 years after the initial diagnosis. Symptom severity usually correlates with the disability status of patients. Patient assessment comprises clinical and advanced investigations. Each patient should be evaluated uniquely, after taking into account his/her symptoms, disease course and length, comorbidities, physical status, and medications. Basic investigation includes detailed history-taking, physical examination, and post-void residual volume measurement. Advanced evaluation consists of imaging and specific testing, with pivotal importance on urodynamic study.

Cognitive Motor Interference in Multiple Sclerosis: Insights From a Systematic Quantitative Review

OBJECTIVE

To synthesize the evidence for differences in cognitive motor interference (CMI) between persons with multiple sclerosis (MS) and those without MS by using systematic review and meta-analysis.

DATA SOURCES

EMBASE, PubMed, ScienceDirect, Scopus, SPORTDiscus, and Web of Science. Our focused literature search was informed by past systematic reviews of CMI during walking in MS.

STUDY SELECTION

The key terms searched included Multiple sclerosis and synonyms of motor function (eg, Gait disorders, Gait, Walking, Balance, or Fall) and motor and cognitive functions (eg, Cognitive motor interference or Thinking).

DATA EXTRACTION

From the 116 abstract-identified articles, 13 experimental studies were selected for the final analysis and were rated using the Quality Assessment of Diagnostic Accuracy Studies tool. A meta-analysis was performed for all considered outcomes.

DATA SYNTHESIS

The results yielded a small overall effect size (ES) of .08 (SE=.17; 95% confidence interval, -.25 to .40; z=.49; P>.05), which indicated a nonsignificant minimal difference in CMI between persons with MS and those without MS. The moderator analysis for motor task (mobility task: ES, .22; postural task: ES, -.11) was not significantly different between persons with MS and those without MS. The moderator analysis for cognitive task (verbal fluency task: ES, .66; mental tracking task: ES, .04; discrimination and decision-making task: ES, -.30) resulted in a significant difference in CMI between persons with MS and those without MS (P<.05).

CONCLUSIONS

We provide evidence that overall there is a minimal difference in CMI between persons with MS and those without MS.

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

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

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

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

Autonomic Dysregulation in Multiple Sclerosis

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

Current and future drugs for treatment of MS-associated bladder dysfunction

A majority of patients diagnosed with multiple sclerosis (MS) will develop lower urinary tract symptoms (LUTS) during the course of the disease. Even if antimuscarinic (anticholinergic) treatment is currently the mainstay of conservative treatment of neurogenic detrusor overactivity (NDO), including MS-induced NDO, extensive data regarding their effectiveness and safeness are lacking. When antimuscarinic medications fail to prove efficacious, a further option is intradetrusor injections of onabotulinumtoxin A. In several studies, more than half (and up 76%) of the patients treated with onabotulinumtoxin A experienced significant improvement in symptoms or even achieved complete continence. Cannabis extracts have shown some promise but has still not gained wide acceptance as an effective treatment. Over the last few years many new disease-modifying drugs that have been approved and introduced for treatment of MS. These drugs may have effects not only on the MS disease process, but also on the disease symptoms, including LUTS. However, MS is not primarily a bladder disease and treatment of the underlying pathophysiology should be the main goal of treatment. Since most of the urology drugs are targeting LUTS, these drugs should be regarded as "adds on" to treatments modifying the underlying disorder. Considering that most of these drugs have not been studied specifically with respect to efficacy on LUTS, and since they are not without significant side effects, it seems important that if and when they are going to be used for treatment of bladder symptoms should be a joint decision between the neurologist and urologist taking care of the patient.

Deep brain stimulation and multiple sclerosis: Therapeutic applications

Deep brain stimulation is a neurosurgical technique that can be used to alleviate symptoms in a growing number of neurological conditions through modulating activity within brain networks. Certain applications of deep brain stimulation are relevant for the management of symptoms in multiple sclerosis. In this paper we discuss existing treatment options for tremor, facial pain and urinary dysfunction in multiple sclerosis and discuss evidence to support the potential use of deep brain stimulation for these symptoms.

Multiple sclerosis: diagnosis, differential diagnosis, and clinical presentation

The diagnosis of multiple sclerosis (MS) is based on demonstrating evidence of inflammatory-demyelinating injury within the central nervous system that is disseminated in both time and space. Diagnosis is made through a combination of the clinical history, neurologic examination, magnetic resonance imaging and the exclusion of other diagnostic possibilities. Other so-called "paraclinical" tests, including the examination of the cerebrospinal fluid, the recording of evoked potentials, urodynamic studies of bladder function, and ocular coherence tomography, may be helpful in establishing the diagnosis for individual patients, but are often unnecessary. Differential diagnosis in MS must be guided by clinical presentation and neurologic localization. While the list of conditions that can mimic MS clinically or radiologically is long, in clinical practice there are few conditions that truly mimic MS on both fronts. A positive test for a putative MS "mimic" does not unto itself exclude the diagnosis of MS. Typical symptoms of MS include discrete episodes ("attacks" or "relapses") of numbness, tingling, weakness, vision loss, gait impairment, incoordination, imbalance, and bladder dysfunction. In between attacks, patients tend to be stable, but may experience fatigue and heat sensitivity. Some MS patients go on to experience, or only experience, an insidious worsening of neurologic function and accumulation of disability ("progression") that is not associated with discrete relapse activity. Progression accounts for most of the long-term disability in MS. Diagnostic criteria for MS have evolved over the past several decades, with each revision impacting the apparent prevalence and prognosis of the disorder - the result has been to encourage earlier diagnosis without compromising accuracy.