Author:Anika Biel
Multiple sclerosis (MS) is a condition that can have many different symptoms, including fatigue, spasticity, pain, speech difficulties and bladder problems. Several studies have demonstrated a prevalence of 65–95% for bladder dysfunction in MS [1]. Urological symptoms in MS include overactive bladder and bladder voiding dysfunction. These symptoms can be grouped together under neurogenic lower urinary tract dysfunction (NLUTD). The consequences for patients can be unpleasant and can lead to a severe impairment of health as well as having a negative impact upon the patient’s social life. Despite the common occurrence of bladder dysfunction, diagnosis is often poorly performed [2].
MS typically progresses in different phases, and symptoms can also vary greatly. One common dysfunction is an overactive bladder. This leads to an (uncontrolled) urge to urinate when the bladder is not yet completely full, sometimes combined with involuntary loss of urine (urge incontinence). Another common symptom is the formation of residual urine (i.e., the inability to completely empty the bladder) which can occur throughout the course of MS [3].
If symptoms of bladder dysfunction are left untreated, this can have consequences for the patient. Incomplete bladder emptying can be the breeding ground for urinary tract infections (e.g., cystitis) and inflammation of the kidneys (pyelonephritis). These, in turn, can be responsible for a new MS episode or a relapse when symptoms have already subsided [4]. Urosepsis due to urinary tract infections is the most common cause of death associated with MS [5].
Furthermore, residual urine formation left untreated for a long period of time can also lead to urine build up in the kidneys. Ultimately, this can result in renal failure and should be prevented at all costs.
In addition, people with MS often find bladder problems distressing and socially restrictive [6]. The subject is often perceived as taboo and is not always adequately addressed by the medical community.
There is currently no European standard for the diagnosis or screening of bladder problems in people with MS. As a result, the situation across different countries can vary from no screening at all to regular examinations using sonography or urodynamics [7].
An important element to consider is the comprehensive and regular education of people with MS concerning potential urologic complaints and the recognition of these symptoms. This can help to ensure that people with MS report any symptoms they experience to their treating neurologist. The neurologist can then initiate further evaluation or specialist urologic diagnosis and treatment. Although this patient education is important, it is not sufficient on its own. Studies have demonstrated that therapy based solely on patient-reported symptoms covered only ~50% of sufferers, partly because many sufferers are unaware of their bladder problems [8]. If diagnosis and therapy of urologic problems was based only on reported symptoms, up to 50% of patients with a urologic disease component would not be accessed. Therefore, patient awareness combined with structured diagnostics is critical for improved urologic care.
One way for a more accurate detection of bladder problems is via regularly performed bladder screening and Domurath et al recently validated a potential screening instrument [9]. The final tool was a patient questionnaire with eight multiple choice questions concerning bladder and urologic symptoms. Warning signals in the responses provided by the patient were identified using yellow and red flags.
Following a yellow flag response, a sonographic residual urine measurement and uroflowmetry is scheduled. With a red flag response, further neuro-urological diagnostics are necessary, e.g., urodynamics. In this way, important, and potentially otherwise undetected symptoms are systematically recorded and can be further processed.
Urological symptoms are more common in MS than generally assumed. Due to the potentially serious risks, as well as the high psychosocial burden of non-treatment, it is important to both educate people with MS and perform regular bladder screening. This also applies to supposedly asymptomatic patients.
[1] Khalaf, K.M. et al, 2015. Lower Urinary tract symptom prevalence and management Among patients with multiple sclerosis. Int. J. MS Care 17 (1), 14–25. https://doi.org/10.7224/1537-2073.2013-040.
[2] Mahajan. S.T. et al, 2010. Undertreatment of overactive bladder symptoms in patients with multiple sclerosis. An ancillary analysis of the NARCOMS Patient Registry. Neurology 1 3:1432–7. DOI: 10.1016/j.juro.2009.12.029
[3] Litwiller, S.E. et al, 1999 Multiple Sclerosis and the Urologist. The Journal of Urology 161, 743–757. DOI: 10.1016/S0022-5347(01)61760-9
[4] Correale, J. et al, 2006 The risk of relapses in multiple sclerosis during systemic infections. Neurology, 67:652-659. DOI: 10.1212/01.wnl.0000233834.09743.3b
[5] Harding K. et al, 2020 Multiple cause of death analysis in multiple sclerosis: A population-based study. Neurology 25;94(8):e820–e829. DOI: 10.1212/WNL.0000000000008907
[6] Nortvedt. M.W. et al, 2001 Reduced quality of life among multiple sclerosis patients with sexual disturbance and bladder dysfunction. Multiple Sclerosis 7, 231–235. DOI: 10.1177/135245850100700404
[7] Domurath, B. et al, 2021 Aktuelles zu neurogenen Dysfunktionen des unteren Harntraktes bei Multipler Sklerose. Der Nervenarzt; DOI: https://doi.org/10.1007/s00115-020-01046-0
[8] Blaivas, J.G., 1980. Management of bladder dysfunction in multiple sclerosis. Neurology 30 (7 Pt2), 12–18. https://doi.org/10.1212/wnl.30.7_part_2.12.
[9] Domurath, B. et al, 2020 Neurourological assessment in people with multiple sclerosis (MS): a new evaluated algorithm; DOI: https://doi.org/10.1016/j.msard.2020.102248
