Contemporary management of the neurogenic bladder for multiple sclerosis patients

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.

A Prospective Observational Study of Posterior Tibial Nerve Stimulation in Multiple Sclerosis

INTRODUCTION AND HYPOTHESIS

The objective was to examine the outcomes of posterior tibial nerve stimulation (PTNS) on bladder, bowel, and sexual health-related quality of life among a cohort of patients with multiple sclerosis (MS) with refractory lower urinary tract symptoms (LUTS).

METHODS

Patients with MS and refractory LUTS were recruited for a prospective, observational study using PTNS to treat their symptoms. Patients underwent 12 weekly 30-min PTNS sessions and bladder, bowel, and sexual symptoms were evaluated at baseline, 3, 12, and 24 months with voiding diaries, visual analog scales (VAS), and validated patient-reported questionnaires, including the American Urological Association Symptom Score (AUA-SS), Neurogenic Bladder Symptom Score (NBSS), Michigan Incontinence Symptom Index (M-ISI), Health Status Questionnaire, Sexual Satisfaction Scale, and Bowel Control Scale.

RESULTS

A total of 23 patients were recruited: 18 started PTNS and 14 completed 3 months of PTNS. Of the 18 who started PTNS, the mean age was 52 years (SD 12), 61% were female, 83% were white, and most patients had relapsing remitting (39%) MS. Baseline (n=18) and 3-month voiding (n=11) outcomes showed no significant change in number of voids or incontinence episodes. The median VAS symptom improvement was 49 (IQR 26.5, 26) and 9 (53%) patients elected for monthly maintenance PTNS. On paired analysis, there was a significant improvement in median change in NBSS, AUA-SS, and M-ISI. There was no significant change in bowel or sexual dysfunction.

CONCLUSIONS

This prospective, observational study of PTNS in patients with MS with refractory LUTS shows improvement in patient-reported bladder outcomes, but not in number of voids per day or bowel or bladder function.

Classification of multiple sclerosis women with voiding dysfunction using machine learning: Is functional connectivity or structural connectivity a better predictor?

Introduction

Machine learning (ML) is an established technique that uses sets of training data to develop algorithms and perform data classification without using human intervention/supervision. This study aims to determine how functional and anatomical brain connectivity (FC and SC) data can be used to classify voiding dysfunction (VD) in female MS patients using ML.

Methods

Twenty-seven ambulatory MS individuals with lower urinary tract dysfunction were recruited and divided into two groups (Group 1: voiders [V, n = 14]; Group 2: VD [n = 13]). All patients underwent concurrent functional MRI/urodynamics testing.

Results

Best-performing ML algorithms, with highest area under the curve (AUC), were partial least squares (PLS, AUC = 0.86) using FC alone and random forest (RF) when using SC alone (AUC = 0.93) and combined (AUC = 0.96) as inputs. Our results show 10 predictors with the highest AUC values were associated with FC, indicating that although white matter was affected, new connections may have formed to preserve voiding initiation.

Conclusions

MS patients with and without VD exhibit distinct brain connectivity patterns when performing a voiding task. Our results demonstrate FC (grey matter) is of higher importance than SC (white matter) for this classification. Knowledge of these centres may help us further phenotype patients to appropriate centrally focused treatments in the future.

Is EDSS Enough to Predict Risk of Upper Urinary Tract Damage in Patients with Multiple Sclerosis?

Lower urinary tract dysfunction is often observed in patients with multiple sclerosis (MS) and may be responsible for an increased risk of upper urinary tract (UUT) damage. Although there are well-known urodynamic risk factors for UUT damage, no clinical prediction parameters are clearly identified. We aimed to confirm the accuracy of the Expanded Disability Status Scale (EDSS) in predicting urodynamic risk factors for UUT deterioration and to assess other clinical parameters potentially predicting urodynamic risk factors. We retrospectively reviewed 201 patients with MS referred for primary neuro-urological work-up, including a video-urodynamic study (VUDS) from August 2009 to February 2020. Multivariate modeling revealed EDSS, male gender, and a number of LUTS as clinical parameters significantly associated with urodynamic risk factors for UUT damage (p = 0.06, p = 0.01, p = 0.02, respectively). A nomogram combining EDSS, male gender, and a number of different LUTS was created to predict the presence of at least one urodynamic risk factor for UUT damage. In conclusion, the presence of high EDSS combined with male gender and several different LUTS is significantly associated with urodynamic risk factors and can be used to stratify MS patients for further neuro-urological assessment and treatment.

Neurogenic Bladder in Dogs, Cats and Humans: A Comparative Review of Neurological Diseases

Lower urinary tract disease (LUTD) includes abnormalities in the structure and function of the bladder and the urethra. LUTD caused by neurological disease is defined neurogenic bladder (NB). The integrity of the central nervous system (CNS) and peripheral nervous system (PNS) is required to explicate normal micturition, maintaining the proper function of bladder and urethra. The location and type of neurological lesions influence the pattern of clinical manifestations, potential treatment, and prognosis. Though, in dogs and cats, spinal cord injury is considered mainly responsible for bladder and/or urethra incompetence, other disorders, congenital or acquired, involving CNS or PNS, could play a role in NB. In veterinary medicine, the information about the epidemiology, prevalence, etiopathogenesis, diagnosis and treatment of NB are scattered. The aim of this study is to provide an overview of the epidemiology, prevalence, clinical findings, diagnosis and prognosis for NB in dogs and cats compared with humans.

Preliminary Analysis of Brain Footprints in Multiple Sclerosis Females with Detrusor Sphincter Dyssynergia: A Concurrent Urodynamic and Functional Magnetic Resonance Imaging Study

Purpose

This study evaluates the grey and white brain matter characteristics in women with multiple sclerosis (MS) and detrusor sphincter dyssynergia (DSD). Grey matter is assessed via the functional connectivity (FC) of brain regions activated during voiding, using functional magnetic resonance imaging (fMRI). Two white matter tracts involved in bladder function, the anterior thalamic radiation (ATR) and superior longitudinal fasciculus (SLF), were evaluated using diffusion tensor imaging (DTI).

Methods

Twenty-seven women with MS (two groups: no-DSD (n=23) or DSD (n=4)), and eight healthy controls (HC) underwent concurrent urodynamic-fMRI evaluation with four cycles of bladder filling and emptying. A FC similarity measure (FC_sim) was calculated for each subject to express the similarity of individual FC at voiding initiation compared to all FC patterns. ATR and SLF tracts were traced and their fractional anisotropy (FA) and mean diffusivity (MD) were recorded.

Results

Mean FC_sim values were significantly different among the three groups indicating distinct FC patterns; however, no significant difference was found between DSD and no-DSD groups. DSD group showed trends of lower FA and higher MD - indicating loss of coherence - in all tracts compared to HCs, and in the left and right ATR when compared to MS women with neither DSD nor voiding dysfunction (VD), suggesting more damage in these tracts for MS women with DSD.

Conclusions

Women with MS show distinctly different FC patterns compared to HCs. There are trends showing more damage in the ATR in women with MS and DSD compared to those with neither DSD nor VD.

High spatial correlation in brain connectivity between micturition and resting states within bladder-related networks using 7 T MRI in multiple sclerosis women with voiding dysfunction

Background

Several studies have reported brain activations and functional connectivity (FC) during micturition using functional magnetic resonance imaging (fMRI) and concurrent urodynamics (UDS) testing. However, due to the invasive nature of UDS procedure, non-invasive resting-state fMRI is being explored as a potential alternative. The purpose of this study is to evaluate the feasibility of utilizing resting states as a non-invasive alternative for investigating the bladder-related networks in the brain.

Methods

We quantitatively compared FC in brain regions belonging to the bladder-related network during the following states: ‘strong desire to void’, ‘voiding initiation (or attempt at voiding initiation)’, and ‘voiding (or continued attempt of voiding)’ with FC during rest in nine multiple sclerosis women with voiding dysfunction using fMRI data acquired at 7 T and 3 T.

Results

The inter-subject correlation analysis showed that voiding (or continued attempt of voiding) is achieved through similar network connections in all subjects. The task-based bladder-related network closely resembles the resting-state intrinsic network only during voiding (or continued attempt of voiding) process but not at other states.

Conclusion

Resting states fMRI can be potentially utilized to accurately reflect the voiding (or continued attempt of voiding) network. Concurrent UDS testing is still necessary for studying the effects of strong desire to void and initiation of voiding (or attempt at initiation of voiding).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03599-4.

A prospective observational cohort study of posterior tibial nerve stimulation in patients with multiple sclerosis: design and methods

BACKGROUND

Posterior tibial nerve stimulation (PTNS) is a promising treatment for lower urinary tract symptoms (LUTS) in patients with MS. However, long term data focusing on PTNS impact on health-related quality of life (HRQOL), bowel and bladder symptoms are lacking. This paper describes a study protocol that examines the extended efficacy of PTNS on MS related bladder and bowel symptoms and resulting HRQOL.

METHODS/DESIGN

This is a single-centered, prospective, longitudinal, observational cohort study of patients with MS who suffer from LUTS and are refractory to two prior treatment modalities. Participants who have elected to pursue PTNS therapy for LUTS will be eligible. The primary outcome is the median number of urinary frequency and incontinence episodes on a 3-day voiding diary at 3, 12 and 24 months compared to baseline. Secondary outcome measures will include change in total AUA-SS, M-ISI, NBSS, SF-12, SSS and BCS scores from baseline The Expanded Disability Status Scale and magnetic resonance imaging will be evaluated at baseline and annually throughout the study.

DISCUSSION

This research protocol aims to expand on the existing literature regarding outcomes of PTNS in MS. Specifically, it will provide long term follow-up data on bladder, bowel, sexual and HRQOL outcomes. The completion of this study will provide longitudinal efficacy data of the impact of PTNS in MS patients.

TRIAL REGISTRATION

NCT04063852.

The effect of cortical versus sacral repetitive magnetic stimulation on lower urinary tract dysfunction in patients with multiple sclerosis

75% of multiple sclerosis (MS) patients have lower urinary tract symptoms. Moreover, up to 80% of asymptomatic patients show abnormalities on urodynamic examination. The objective of this study is to assess the effect of repetitive magnetic stimulation on the motor cortex versus sacral roots in MS patients with lower urinary tract dysfunction (LUTD). 40 MS patients with LUTD were divided according to urodynamic studies (UDS) into two groups (20 patients each): Group A (overactive bladder) and Group B (underactive bladder). Each group was further subdivided into Subgroup (A-I) and (B-I) which received cortical magnetic stimulation and Subgroup (A-II) and (B-II) which received sacral magnetic stimulation. UDS, pelvic ultrasound as well as Incontinence Quality of Life (I-QOL) questionnaire were compared before and after magnetic stimulation sessions in each group as well as between groups. UDS showed significant reduction in bladder capacity, improvement in bladder contractility in all groups and subgroups. Moreover, it showed improvement of urine flow rate only in Group B. Reduction of post-void residual urine was noted in all subgroups except in (Group A-II). I-QOL questionnaire showed improvement in patients with underactive bladder only. Intergroup comparison between A and B showed no difference. Cortical as well as sacral magnetic stimulation showed significant effect on lower urinary tract dysfunction that led to improvement in symptoms in MS patients with underactive bladder, rather than those with overactive bladder.

Worsening disability status in multiple sclerosis predicts urologic complications

PURPOSE

Multiple sclerosis (MS) causes voiding dysfunction and might predispose to urologic complications. However, long-term complications and risk factors for complications are unknown. We aim to assess long-term changes in voiding function and to determine risk factors for urologic complications during MS follow-up.

METHODS

We analyzed the records of MS patients and recorded baseline and follow-up voiding symptoms, urodynamic (UDS) findings, Expanded Disability Status Scale (EDSS), serum blood studies, imaging, and complications. T test and Chi-square test were used to determine statistical significance using a two-tailed p value < 0.05. We assessed complication-free survival using Kaplan-Meier curves and performed multiple variable Cox proportional hazard models to estimate hazard ratios predicting complications for various independent variables.

RESULTS

126 women and 35 men with MS were followed for a median of 9.7 years (IQR 4.3-13). Mean age at MS diagnosis was 36.7 with a mean EDSS of 3.2. During follow-up, EDSS progressed to a mean of 5.5. In addition, at least one complication occurred in 60.2% and major complications were present in 16.7%. After multivariable analysis, EDSS progression ≥ 2.0 (p = 0.003), follow-up EDSS ≥ 6.0 (p = 0.01), use of intermittent catheterization (p < 0.001) and urinary reconstruction with continent catheterizable stoma (p = 0.009) were significantly related to an increased hazard for any complications.

CONCLUSION

Upper tract changes and other major complications were uncommon. Complications were related to MS progression, resultant increase in total disability, and the need for intervention to maintain functional continence. Lower tract infections occurred more frequently in patients with the need for catheterization.

Identificação de fatores de risco para quedas em indivíduos com esclerose múltipla: uma revisão sistemática de estudos prospectivos

RESUMO O objetivo deste estudo foi identificar, a partir de uma revisão sistemática, variáveis clínicas, instrumentais e demográficas associadas com maior risco de queda em indivíduos com esclerose múltipla (EM), com base em dados prospectivos. A pesquisa foi conduzida nas bases de dados Medline, Web of Science, Bireme e CINAHL, utilizando os descritores “esclerose múltipla”, “quedas”, “quedas acidentais”, “risco de quedas”, “controle postural” e “equilíbrio”, seguido de buscas manuais. Foram considerados elegíveis estudos de coorte prospectivos, com período mínimo de acompanhamento das quedas de três meses, que avaliassem a associação de determinada variável demográfica, clínica ou instrumental em relação a maior risco de queda em indivíduos com EM. A escala de Newcastle-Ottawa modificada foi utilizada para avaliação da qualidade metodológica dos estudos incluídos. Foram identificados 357 estudos, 12 dos quais foram incluídos na revisão sistemática, com total de 1.270 pacientes incluídos. Destes, 740 (58,26%) pacientes apresentaram um ou mais episódios de queda, 396 (31,18%) apresentaram episódios de queda recorrentes (2≥quedas no período estipulado), e 530 (41,74%) não apresentaram nenhum episódio. Com exceção da espasticidade e do impacto da dupla tarefa na velocidade da marcha, todas as variáveis investigadas apresentaram resultados conflitantes quanto às suas associações a maior risco de quedas. São necessários mais estudos que apresentem homogeneidade dos fenótipos clínicos de indivíduos com EM, além da utilização de instrumentos de avaliação validados, a fim de estabelecer uma associação robusta de outras variáveis clínicas, instrumentais e demográficas com maior risco de queda.

Long-Term Complications of the Neurogenic Bladder

It is widely accepted that neurogenic lower urinary tract dysfunction, when left untreated, has a natural history that has a potential for causing deterioration of renal function over time. However, certain patient profiles are at risk for this and other complications. This can be linked to their underlying neurologic disease process. Identifying risk profiles allows the provider to determine what surveillance strategies might be adopted. Risk factors for upper urinary tract deterioration include loss of bladder compliance, repeated bouts of pyelonephritis, and chronic indwelling catheterization. Other long-term complications include nephrolithiasis, refractory urinary incontinence, and malignancy.

Associations Between Bladder Dysfunction and Falls in People with Relapsing-Remitting Multiple Sclerosis

BACKGROUND

Bladder dysfunction and falls are common in people with multiple sclerosis (MS), but associations between these problems are unclear. We sought to clarify the association between specific types of bladder dysfunction and prospectively recorded falls in people with MS.

METHODS

Fifty-one people aged 18 to 50 years with relapsing-remitting MS and mild-to-moderate disability (Expanded Disability Status Scale score ≤6.0) completed a self-report questionnaire regarding urinary incontinence, urgency, and frequency at baseline and then prospectively recorded their falls daily for 3 months using fall calendars. Participants were classified as recurrent fallers (two or more falls) or nonrecurrent fallers (fewer than 2 falls) for one regression model and then as fallers (one or more falls) or nonfallers (no falls) for another regression model. Associations between baseline bladder dysfunction and faller status were assessed using logistic regression adjusted for the potential confounders of age, sex, and disability.

RESULTS

Fifteen participants were recurrent fallers, 36 were nonrecurrent fallers, 32 were fallers, and 19 were nonfallers. After adjusting for age, sex, and disability, there was a significant association between urinary urgency with incontinence and recurrent falls in the 3 months after baseline (odds ratio, 57.57; 95% CI, 3.43-966.05; P = .005).

CONCLUSIONS

Urinary urgency with incontinence is associated with recurrent falls in people with relapsing-remitting MS with mild-to-moderate disability. Further research is needed to better understand the mechanisms underlying this association and to evaluate the effect of bladder management programs on falls.

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.

Secondary and tertiary treatments for multiple sclerosis patients with urinary symptoms

Multiple sclerosis patients with refractory urinary symptoms after treatment with behavioral therapy and medications still have treatment options. Prior to starting treatments, baseline symptoms should be assessed and treatment goals thoroughly discussed. Catheterization, botulinum toxin, and reconstructive surgery all can play a role in improving both safety and quality of life for these patients. Newer modalities, such as neuromodulation, may also have an increasing role in the future as more data develop regarding efficacy. Risks need to be weighed against any perceived benefit and disease status before more aggressive therapy is initiated.

Overactive bladder symptoms in patients with multiple sclerosis: Frequency, severity, diagnosis and treatment

OBJECTIVE

To determine the frequency and severity as well as the diagnosis and treatment of overactive bladder problems in patients with multiple sclerosis (MS) followed up at five centers in Turkey.

DESIGN

Survey study.

SETTING

Outpatient tertiary clinics of physical medicine and rehabilitation and neurology.

PARTICIPANTS

Consecutive MS patients scheduled for outpatient follow-up (n = 309).

INTERVENTION

MS patients were asked to complete a questionnaire regarding the frequency and severity, as well as the diagnosis and treatment of their overactive bladder problems.

RESULTS

The mean age ± SD was 39.3 ± 10.6 years. Urinary urgency was the most common urinary symptom (62%), followed by frequency (50.4%), urge incontinence (44.7%) and nocturia (33%). Residual urine volume was measured using a portable ultrasound instrument in 13.3% of the patients and by catheterization in 16.2% of them. Urodynamic investigations and urinary tract ultrasound were performed on 26.5% and 35.3% of the patients, respectively. Anticholinergic medications were prescribed for 27.5% of the patients. Intermittent catheterization and indwelling catheterization were used on 8.1% and 1.9% of the patients, respectively. The overactive bladder symptom score (OABSS) was significantly higher in patients who had had residual urine measurement (P < 0.001), upper urinary tract assessment by ultrasound (P < 0.001), urodynamic assessment (P < 0.001), admitted to a doctor for urinary symptoms (P < 0.001), and current or past catheter use (P = 0.002).

CONCLUSION

Urgency was the most common urinary symptom followed by frequency, urge incontinence and nocturia in MS patients. The patients with lower OABSS had detailed urological assessments less frequently than the patients with higher OABSS.

Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies

Detrusor sphincter dyssynergia (DSD) is the urodynamic description of bladder outlet obstruction from detrusor muscle contraction with concomitant involuntary urethral sphincter activation. DSD is associated with neurologic conditions such as spinal cord injury, multiple sclerosis, and spina bifida and some of these neurogenic bladder patients with DSD may be at risk for autonomic dysreflexia, recurrent urinary tract infections, or upper tract compromise if the condition is not followed and treated appropriately. It is diagnosed most commonly during the voiding phase of urodynamic studies using EMG recordings and voiding cystourethrograms, although urethral pressure monitoring could also potentially be used. DSD can be sub-classified as either continuous or intermittent, although adoption of this terminology is not widespread. There are few validated oral pharmacologic treatment options for this condition but transurethral botulinum toxin injection have shown temporary efficacy in reducing bladder outlet obstruction. Urinary sphincterotomy has also demonstrated reproducible long term benefits in several studies, but the morbidity associated with this procedure can be high.

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.

Non-pharmacologic options for the management of voiding dysfunction in multiple sclerosis

Multiple sclerosis is a neuroinflammatory condition that can cause significant bladder dysfunction manifesting either as overactive bladder or impaired bladder emptying. Patients will often complain of urgency, frequency, nocturia, urgency incontinence, hesitancy, straining to void, and incomplete bladder emptying. While these symptoms can be treated with pharmacologic agents, often patients will require more significant treatments. Patients should first be evaluated with urodynamics in order to adequately diagnose the pathologic condition causing their symptoms. These interventions include catheter use, injection of botulinum toxin, neuromodulation, urethral stenting, sphincterotomy, suprapubic catheter with bladder neck closure, bladder augmentation and urinary diversion. The purpose of this review is to examine the evidence supporting each of these treatment options so urologic providers can better provide for this unique and complex patient population.

Clinical and urodynamic evaluations of urinary disorders in multiple sclerosis

Urinary dysfunction is a major clinical problem and a significant cause of disability in multiple sclerosis (MS) patients. Indeed, the bothersome symptom of urinary dysfunction may adversely affect social relationships and activities in MS patients. Since many causes of urinary dysfunction are described, a thorough evaluation including history, clinical examination and evaluation of quality of life is necessary. Generally, diagnosis of urinary disorders is complex with intricated pathophysiologic factors. In these cases, urodynamic investigations are necessary to better understand symptoms pathophysiology and choose the best treatment.

The conceptualization and development of a patient-reported neurogenic bladder symptom score

Background

There is no single patient-reported instrument that was developed specifically to assess symptoms and bladder-related consequences for neurogenic bladder dysfunction. The purpose of this study was to identify and consolidate items for a novel measurement tool for this population.

Methods

Item generation was based on a literature review of existing instruments, open-ended semistructured interviews with patients, and expert opinion. Judgment-based item reduction was performed by a multidisciplinary expert group. The proposed questionnaire was sent to external experts for review.

Results

Eight neurogenic quality of life measures and 29 urinary symptom-specific instruments were identified. From these, 266 relevant items were extracted and used in the creation of the new neurogenic symptom score. Qualitative interviews with 16 adult patients with neurogenic bladder dysfunction as a result of spinal cord injury, multiple sclerosis, or spina bifida were completed. Dominant themes included urinary incontinence, urinary tract infections, urgency, and bladder spasms. Using the literature review and interview data, 25 proposed items were reviewed by 12 external experts, and the questions evaluated based on importance on a scale of 1 (not important) to 5 (very important). Retained question domains had high mean importance ratings of 3.1 to 4.3 and good agreement with answer hierarchy.

Conclusion

The proposed neurogenic bladder symptom score is a novel patient-reported outcome measure. Further work is underway to perform a data-based item reduction and to assess the validity and reliability of this instrument.

The diagnosis and management of lower urinary tract symptoms in multiple sclerosis patients

Sixty-five percent of multiple sclerosis patients have moderate to severe urinary symptoms and up to 14% initially present with urinary symptomatology. Urinary retention, neurogenic detrusor overactivity, and detrusor sphincter dyssynergia, all increase the risk for urinary tract infections in patients with multiple sclerosis, and these infections may exacerbate their immune response, leading to symptom progression. Fewer than half of the patients with urinary symptoms have seen a specialist and only half have been treated for their neurogenic detrusor overactivity. Several treatments including pelvic floor muscle therapy, pelvic floor electrical stimulation, anticholinergics, desmopressin, sacral nerve neuromodulation, posterior tibial nerve stimulation, cannabinoids, and intravesical therapy with vanniloids, as well as botulinum toxin, have all been shown to be effective in treating urinary symptoms in those with multiple sclerosis. Clean intermittent catheterization is invaluable in patients with persistent urinary retention to avoid infection and upper tract dysfunction. Indwelling transurethral catheterization should be avoided because of the high risk of infection. Identification and successful treatment of these urinary conditions will improve the health and quality of life for these men and women.

Bladder management in multiple sclerosis

This article reviews the basic principles and therapeutic options in the management of the neurogenic bladder due to multiple sclerosis (MS), written primarily for the non-urology provider. An algorithm for the initial management of the MS patient with lower urinary tract symptoms is provided.

First-line urological evaluation in multiple sclerosis: validation of a specific decision-making algorithm

BACKGROUND

Urinary disorders that lead to urological complications are frequent in multiple sclerosis, resulting in diminished quality of life. Urinary management guidelines are scarce and targeted to neuro-urology specialists.

OBJECTIVE

This study aimed to construct and validate an algorithm dedicated to neurologists and general practitioners to facilitate first-line evaluation and treatment of urinary disorders associated with multiple sclerosis.

METHODS

49 items concerning urological symptom evaluation and therapeutic strategies were derived from literature analysis and evaluated by an expert panel. The Delphi method established consensus between the experts and allowed development of the First-Line Urological Evaluation in Multiple Sclerosis (FLUE-MS) algorithm. Two questions from the Urinary Bothersome Questionnaire in Multiple Sclerosis were included and their validation to verify comprehensiveness and acceptability was also conducted.

RESULTS

Three rounds of expert review obtained consensus of all 49 items and allowed finalisation of the algorithm. Comprehension and acceptability of two Urinary Bothersome Questionnaire in Multiple Sclerosis questions were verified (mean comprehensiveness score: 1.99/2 [99.7% total comprehensiveness], mean acceptability score: 1.99/2 [99.1% complete acceptability]).

CONCLUSION

The FLUE-MS algorithm was designed for neurologists and general practitioners, enabling identification of 'red flags', timely patient referral to specialist neuro-urology units, and appropriate first-line therapy.