Multiple sclerosis Bladder and Bowel issues

In MS, neurogenic bladder dysfunction causes urinary frequency and urgency, often worsened by infections. Treatment includes Oxybutynin for overactivity and Tamsulosin for sphincter dyssynergia, with botulinum toxin and neuromodulation as alternatives. Bowel issues are managed with diet, laxatives, and enemas, and severe faecal incontinence may require surgery.

Neurogenic Bladder Dysfunction in MS:

Neurogenic bladder dysfunction is common in MS. It could lead to urinary frequency, urgency and nocturia. Also, urinary tract infection is common in MS and may worsen bladder dysfunction as well. (1)

Causes of Bladder Problems:

Bladder problems are caused by either failure of the bladder to store urine (detrusor overactivity), which manifests as urinary frequency, urgency and incontinence; or failure of the bladder to empty (detrusor sphincter dyssynergia) with symptoms of urinary retention, interrupted micturition and urinary frequency. Measurement of post void residual volume is advisable in bladder hypoactivity; and patients with high urine volume (>100 mL) are at risk of recurrent infections and hydronephrosis. (2)

Management Goals for Bladder Dysfunction:

The management of bladder dysfunction in MS has several goals; including preserving renal function, minimising urinary tract complications and attaining social continence. (3)

Treatment of Detrusor Overactivity:

For patients with detrusor overactivity, Oxybutynin 2.5- 5 mg one- three times daily is effective. Alternatively, patients who are refractory or intolerant to oxybutynin could benefit from Botulinum toxin injection in the form of (onabotulinumtoxinA 200- 300 IU into the detrusor muscle). Detrusor overactivity which is unresponsive to botulinum toxin may benefit from sacral neuromodulation with electrical stimulation of the S3 nerve root as well as peripheral nerve stimulation of the dorsal penile/ clitoral nerves and posterior tibial nerve which aims to inhibit the micturition reflex. (4, 5, 6)

Treatment of Detrusor Sphincter Dyssynergia:

For patients with detrusor sphincter dyssynergia, alpha antagonists, such as, tamsulosin (0.4 mg once daily), terazosin 1mg daily are beneficial. Nocturia can be treated with oral desmopressin (0.2 mg at bedtime) (7, 8)

Management of Recurrent UTIs:

Patients with recurrent urinary tract infections should be investigated by cystoscopy and ultrasound to rule out any underlying predisposing abnormalities. If no cause is identified, it is reasonable to them on prophylactic low dose antibiotics. (9)

Bowel Dysfunction in MS:

Bowel dysfunction is also common in MS and usually results from neurological disorders, decreased patient’s mobility, other comorbidities and adverse effects of medications. Common problems include constipation, poor evacuation and faecal incontinence. (10)

Treatment for Constipation and Poor Evacuation:

For constipation and poor evacuation, it is advisable to try dietary changes to increase fluid and fibre content and if no improvement, laxatives and enemas are beneficial. Among the laxatives, bulking agents include methylcellulose 2mg orally, wheat dextrin are considered as first- line treatment. Other laxative classes are also helpful. They include osmotic agents, such as, lactulose (10 ml twice daily as needed), GI stimulants including senna (1-2 tablets twice daily as needed) and stool softeners including docusate sodium (100 mg twice daily) (10)

Management of Faecal Incontinence:

For management of faecal incontinence, supportive measures and medical treatment are helpful. Supportive measures include avoiding foods known to provoke symptoms and improve perianal skin hygiene. Medical therapy includes the use of bulking agent (methylcellulose 1- 2 tablespoons daily) and antidiarrheal agent; loperamide 2mg orally three times daily as needed to reduce faecal incontinence. For refractory cases, additional evaluation with endorectal MRI should be performed to detect structural abnormalities causing faecal incontinence and surgical intervention (such as ileostomy or colostomy) is an option in severe refractory cases. (11)

GI Symptoms from Dimethyl Fumarate:

Among DMT, Dimethyl fumarate causes GI symptoms. It could cause diarrhea, nausea and abdominal cramps. Antimuscarinic agent (glycopyrrolate 1- 2 mg twice daily) could help to improve the problem. (12)

References

1-Phé V, Pakzad M, Curtis C, et al. Urinary tract infections in multiple sclerosis. Mult Scler 2016; 22:855.

2-Homma Y, Yoshida M, Seki N, et al. Symptom assessment tool for overactive bladder syndrome—overactive bladder symptom score. Urology. 2006;68:318–23.

3-Ghezzi A, Carone R, Del Popolo G, et al. Recommendations for the management of urinary disorders in multiple sclerosis: A consensus of the Italian Multiple Sclerosis Study Group. Neurol Sci. 2011;32:1223–31.

4-Bosma R, Wynia K, Havlíková E, et al. Efficacy of desmopressin in patients with multiple sclerosis suffering from bladder dysfunction: a meta-analysis. Acta Neurol Scand 2005; 112:1.

5-Chancellor MB, Patel V, Leng WW, et al. OnabotulinumtoxinA improves quality of life in patients with neurogenic detrusor overactivity. Neurology 2013; 81:841.

6-Fjorback MV, Rijkhoff N, Petersen T, et al. Event driven electrical stimulation of the dorsal penile/clitoral nerve for management of neurogenic detrusor overactivity in multiple sclerosis. Neurourol Urodyn 2006; 25:349.

7-Kragt JJ, Hoogervorst EL, Uitdehaag BM, Polman CH. Relation between objective and subjective measures of bladder dysfunction in multiple sclerosis. Neurology 2004; 63:1716.

8-Bosma R, Wynia K, Havlíková E, et al. Efficacy of desmopressin in patients with multiple sclerosis suffering from bladder dysfunction: a meta-analysis. Acta Neurol Scand 2005; 112:1.

9-Soljanik I. Efficacy and safety of botulinum toxin A intradetrusor injections in adults with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic review. Drugs 2013; 73:1055.

10-Frohman TC, Castro W, Shah A, et al. Symptomatic therapy in multiple sclerosis. Ther Adv Neurol Disord 2011; 4:83.

11-DasGupta R, Fowler CJ. Bladder, bowel and sexual dysfunction in multiple sclerosis: management strategies. Drugs 2003; 63:153.

12-Farez MF, Correale J, Armstrong MJ, et al. Practice guideline update summary: Vaccine-preventable infections and immunization in multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2019; 93:584.