Urologic Issues in the Multiple Sclerosis Patient
Philip J. Aliotta
Introduction
Multiple sclerosis (MS) is an autoimmune inflammatory disease that results in damage to the myelin sheaths of the nerves in the central nervous system.1 It presents with a broad spectrum of clinical presentations that are time and disease course related. MS plaque (intracranial and/or spinal) location is a key feature in the pathophysiology of disease-related lower urinary tract symptoms (LUTS).2 It is commonly diagnosed between the ages of 20 and 40 years, with a female predominance of 3:1.1,2 The prevalence in the United States is 57.8 per 100,000 and is twice as common in the north as compared with the southern United States.3 About 80% to 96% of all patients with MS will seek urologic care because of bothersome LUTS at some point in their disease course, and as many as 12% have symptoms before the actual diagnosis.4,5 If a patient has ambulatory difficulties, the prevalence of lower urinary tract complaints is close to 100%.6,7 The 2005 North American Research Committee on Multiple Sclerosis (NARCOMS) reported that 65% of patient responders experienced at least one moderate to severe urinary symptom.8 Patients with bladder dysfunction have lower scores on quality-of-life scales.9 There is also noted to be a greater burden on professional or family caregivers associated with urinary disorders.10 Access to treatment is uncertain
and varies from country to country.11 The MS Barometer 2015—European Multiple Sclerosis Platform,12 which has measured and compared well-being and quality of life for people living with MS in 33 European countries, including 26 EU member states, shows huge disparities in terms of access to treatment, therapies, and employment. Furthermore, according to the MS Barometer 2015, the average percentage of the total costs for symptomatic treatments and therapies reimbursed over a period of 12 months vary; the Western countries enjoy a generally high level of reimbursement, whereas the Eastern ones reported very different national policies on this topic.
and varies from country to country.11 The MS Barometer 2015—European Multiple Sclerosis Platform,12 which has measured and compared well-being and quality of life for people living with MS in 33 European countries, including 26 EU member states, shows huge disparities in terms of access to treatment, therapies, and employment. Furthermore, according to the MS Barometer 2015, the average percentage of the total costs for symptomatic treatments and therapies reimbursed over a period of 12 months vary; the Western countries enjoy a generally high level of reimbursement, whereas the Eastern ones reported very different national policies on this topic.
Physiology of Micturition
Bladder storage (Figure 16.1A) occurs through sympathetic nervous system stimulation of alpha adrenergic receptors, which results in closure of the bladder neck, and beta-adrenergic receptor stimulation, which relaxes the detrusor muscle.14 Bladder contraction and emptying occurs by parasympathetic muscarinic receptor stimulation.15 Sensory afferent information is carried through myelinated A-delta and unmyelinated C fibers through pelvic and pudendal nerves at S2 to S4 nerve roots.16 The spinothalamic tract sends sensory impulses to the periaqueductal gray (PAG) region in the midbrain. The PAG inhibits the pontine micturition center in the brainstem allowing for bladder filling. Sympathetic nerve fibers from T10 to L2 via the hypogastric nerve cause the bladder to relax and the bladder neck to close.17 Awareness of bladder fullness occurs through medial prefrontal cortex and hypothalamic modulation of the PAG area (Figure 16.1).
Bladder emptying (Figure 16.1B) occurs through parasympathetic nervous system efferent activation of the pelvic nerve from sacral nerve roots S2 to S4. Increased parasympathetic activity inhibits sympathetic stimulation, and the bladder neck relaxes. The pelvic plexus ganglia stimulate the detrusor muscle, and voiding occurs.18 MS plaques occur in the cortex, brainstem, and spinal cord. Corticospinal and reticulospinal tract plaques (innervate bladder detrusor muscle and external sphincter) affect voiding. Sacral plaque involvement has been reported to be 18%, but the exact pathologic role is uncertain owing to imaging limitations and the concomitant presence of multiple plaque lesions throughout the nervous system. Suprasacral lesions occur in 80% of cases and are seen most commonly in cervical lesions and are associated with detrusor hyperreflexia due to loss of descending inhibition. Reticulospinal tract involvement is associated with detrusor-sphincter dyssynergia, incomplete sphincteric relaxation, or sphincter paralysis. Intracranial plaques are commonly encountered in patients with MS, but their clinical significance is unclear. Pontine lesions have been reported to be associated.19
 Figure 16.1. Mechanism of storage (A) and voiding reflexes (B). Reprinted from Chai TC, Birder LA. Physiology and Pharmacology of the Bladder and Urethra. In: Wein AJ, ed. Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Saunders; 2016:1631-1684. Copyright © 2016 Elsevier. With permission. |
Clinical Presentation
Case Study
A 37-year-old white female was diagnosed with Relapsing Remitting MS 1.5 years ago after initially presenting with visual problems and lower extremity weakness and gait disturbance over a 6-month period. She presents with complaints of frequency, urgency, urge incontinence, and complaints of suprapubic pressure making her believe she has a full bladder but is only voiding small-volume voids with an erratic weak stream. She has nocturia ×4. There are no stress- or activity-related complaints of incontinence. Before the diagnosis of MS, there was no history of urinary
tract infections, but since the diagnosis, she has had at least three infections, the last one severe enough to exacerbate her MS symptoms requiring hospital admission. She has irregular bowel habits, suffering constipation with associated bowel movements as long as 5 to 6 days apart, culminating in the occurrence of uncontrollable large bowel movements with fecal incontinence occurring occasionally. Oftentimes, after a bout of severe constipation, she will experience frequent loose stools and diarrhea. After one such occurrence, she developed a urinary tract infection, which was treated effectively with an antibiotic.
tract infections, but since the diagnosis, she has had at least three infections, the last one severe enough to exacerbate her MS symptoms requiring hospital admission. She has irregular bowel habits, suffering constipation with associated bowel movements as long as 5 to 6 days apart, culminating in the occurrence of uncontrollable large bowel movements with fecal incontinence occurring occasionally. Oftentimes, after a bout of severe constipation, she will experience frequent loose stools and diarrhea. After one such occurrence, she developed a urinary tract infection, which was treated effectively with an antibiotic.
Between 50% and 90% of patients with MS report LUTS with the prevalence of incontinence as low as 37% and as high as 72%.20,21,22 Lower urinary tract symptomatology is directly related to the severity of the disability caused by the MS. Up to 15% of patients who go on to be diagnosed with MS have as an initial presentation symptom attributable to lower urinary tract involvement, that is, acute urinary retention or as an acute onset of urgency and frequency.20 The most common urinary tract symptom in patients with MS is urgency, as part of the overactive bladder syndrome comprising urgency, urinary frequency, and/or urge incontinence.21
LUTS fall into two categories, irritative and obstructive. Irritative symptoms include frequency, urgency, nocturia, and urge incontinence, and obstructive symptoms include hesitancy or difficulty initiating the stream, straining to void, a reduced flow, an intermittent stream, or a sensation of incomplete emptying. However, the presence or absence of symptoms remains an unreliable indicator of the extent or type of bladder dysfunction.23
The bladder has two functions, to store urine without leaking and to empty/void without a residual.24,25 Bladder storage requires low intravesical pressures, a compliant viscoelastic bladder with intact sensation. Efficient and effective bladder emptying requires no evidence of pathologic outlet obstruction (benign prostatic hypertrophy and bladder outlet obstruction), urethral stricture, meatal stenosis, etc., and relaxation of the external striated sphincter with coordinated relaxation of the smooth muscle sphincter at the bladder neck and proximal urethra leading to opening and funneling of the bladder neck, accompanied by the simultaneous coordinated bladder contraction.25
Overactive bladder (OAB)—The Standardization Subcommittee of the International Continence Society now recognizes OAB as a “symptom syndrome suggestive of lower urinary tract dysfunction.” It is specifically defined as “urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of proven infection or other obvious pathology.” When neurological conditions affect the OAB, it is called neurogenic bladder (NGB).26,27
The presence of an indwelling catheter, high-detrusor/intravesical filling pressures, and striated sphincter dyssynergia in men, are causes of serious urologic complications experienced by patients with MS.28
Storage Symptoms Experienced During the Storage Phase of the Bladder29
Increased daytime frequency is the complaint by the patient who considers that he or she voids too often by day. This term is equivalent to pollakisuria used in many countries.
Nocturia is the complaint that the individual has to wake at night one or more times to void. The term nighttime frequency differs from that for nocturia, as it includes voids that occur after the individual has gone to bed but before he or she has gone to sleep and voids that occur in the early morning, which prevent the individual from getting back to sleep as he or she wishes.
Urgency is the complaint of a sudden compelling desire to pass urine that is difficult to defer.
Urinary incontinence is the complaint of any involuntary leakage of urine (Table 16.1).
Voiding Symptoms Experienced During the Voiding Phase29
Slow stream is reported by the individual as his or her perception of reduced urine flow, usually compared with previous performance or in comparison with others.
Splitting or spraying of the urine stream may be reported.
Intermittent stream (intermittency) is the term used when the individual describes urine flow that stops and starts, on one or more occasions, during micturition.
Hesitancy is the term used when an individual describes difficulty in initiating micturition resulting in a delay in the onset of voiding after the individual is ready to pass urine.
Straining to void describes the muscular effort used to either initiate, maintain, or improve the urinary stream.
Terminal dribble is the term used when an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/dribble.
Postmicturition Symptoms Experienced Immediately After Micturition29
Feeling of incomplete emptying is a self-explanatory term for a feeling experienced by the individual after passing urine.
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Postmicturition dribble is the term used when an individual describes the involuntary loss of urine immediately after he or she has finished passing urine, usually after leaving the toilet in men or after rising from the toilet in women.
Symptoms Associated With Sexual Intercourse29
Dyspareunia, vaginal dryness, and incontinence are among the symptoms women may describe during or after intercourse.
These symptoms should be described as fully as possible. Define urine leakage as during penetration, during intercourse, or at orgasm.
Symptoms Associated With Pelvic Organ Prolapse29
The feeling of a lump (“something coming down”), low backache, heaviness, dragging sensation, or the need to digitally replace the prolapse to defecate or micturate, are among the symptoms women may describe who have a prolapse.
The Goals of Managing the Multiple Sclerosis Neurogenic Bladder25
1. Upper urinary tract preservation or improvement
2. Absence or control of infection
3. Adequate storage at low intravesical pressure
4. Adequate emptying at low intravesical pressure
5. Adequate control
6. No catheter or stoma (depending on the degree of disability)
7. Social acceptability and adaptability
8. Vocational acceptability and adaptability
Urologic Evaluation20,21,29-33
Patient assessment should include the following:
History31
1. Mental status/cognitive function
2. Functional status activities of daily living, walking, transfer ability
3. Diet
4. Fluid intake habits and bladder diary
5. Bowel habits
a. Constipation
b. Diarrhea
c. Irritable bowel syndrome
6. Type of incontinence
a. Stress
b. Urge
c. Mixed
d. Functional
7. Recurrent urinary tract infections
8. Postvoid residual (PVR)
9. Urinary frequency and urgency
10. Concurrent medical history
11. Surgical history
a. Gynecologic history—pelvic surgeries: cystocele, rectocele, sacrospinous fixation, vaginal vault surgery; pelvic malignancy, pelvic radiation, bladder cancer surgery, bowel surgery
b. Obstetric history—parity, C-sections
c. Male pelvic history—urethral surgery or history of stricture disease, benign prostate surgery (transurethral resection prostate), radical prostatectomy, radiation therapy for pelvic malignancy, bowel surgery
12. Associated medications, over the counter, homeopathic, and/or phytotherapeutic products/remedies30 (Table 16.2)
TABLE 16.2 MEDICATIONS USED IN MULTIPLE SCLEROSIS MANAGEMENT WITH POTENTIAL UROLOGIC ADVERSE EFFECTS54 | |||||||||||||||||||||||||||||||||||||||||||||
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Bladder Sensation Can Be Defined During History Taking by Five Categories29
1. Normal
The individual is aware of bladder filling and increasing sensation up to a strong desire to void.
2. Increased
The individual feels an early and persistent desire to void.
3. Reduced
The individual is aware of bladder filling but does not feel a definite desire to void.
4. Absent
The individual reports no sensation of bladder filling or desire to void.
5. Nonspecific
The individual reports no specific bladder sensation but may perceive bladder filling as abdominal fullness, vegetative symptoms, or spasticity.
Physical Examination6,25,28,29
MS involvement in the cervical spinal cord is associated with lower extremity spasticity evidenced by hyperactive reflexes and bladder detrusor overactivity (DO) with or without detrusor external sphincter dyssynergia (DESD).6 General examination with urologic- and neurourologic-focused examination includes the following.28
1. Abdominal/pelvic examination/genital examination—prostate examination in men, vaginal vault examination in women
2. A sensorimotor assessment of L1 to S4 cord segments
3. Rectal tone—S2 to S4 sacral reflex assessment
4. Bulbocavernosus reflex—S2 to S4 sacral reflex assessment
5. Plantar response—pyramidal tract integrity
6. Cremasteric reflex—L1 root integrity
7. Deep tendon reflexes—reflect the integrity of the upper motor neuron and lower motor neuron function
Diagnostic Evaluation
The common causes of transient urinary incontinence can be easily remembered by the term “DIAPPERS” (Table 16.3).
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