In the present study, urodynamic abnormalities were observed in 85 patients (67.5%). However, 41 patients with MS (32.5%) had a normal bladder. For MS patients, detrusor overactivity was the predominant bladder dysfunction. The other urodynamic abnormalities include DSD, detrusor hypocontractility, and poor compliance bladder [Table 2]. Fifty-eight of 81 patients (71.6%) with urgency were diagnosed as detrusor overactivity.
CIS patients had significantly lower EDSS and OABSS than relapsing–remitting MS (P < 0.01) or progressive MS (P < 0.01). However, there was no statistically significant difference between relapsing–remitting MS and progressive MS (P = 0.155) [Table 3].
For CIS patients, the differences in the OABSS, Qmax, and bladder volume at the first desire to voiding and maximum bladder volume before and after the treatment were statistically significant (P < 0.05). However, there was a weak change in the PVR, bladder compliance, and the PdetQmax. For relapsing–remitting MS patients, the differences in the OABSS, Qmax, and bladder volume at the first desire to voiding, maximum bladder volume and bladder compliance before and after the treatment were statistically significant (P < 0.05). The differences in the PVR and the PdetQmax were not statistically significant. For progressive MS patients, the differences in the bladder volume at the first desire to voiding, the PdetQmax and bladder compliance before and after the treatment were statistically significant (P < 0.05). The differences in the OABSS, Qmax, maximum bladder volume, and PVR were not statistically significant [Table 4].
MS is a disabling neurologic condition disease. It has protean neurologic manifestations and follows varying clinical stages. MS is characterized by focal demyelinating lesions that can occur at different levels in the central nervous system (CNS), resulting in genitourinary system dysfunction. The etiology of MS is unclear, but current reports are in favor of an autoimmune origin involving CNS antigens. The spinal cord controls the urine storage function, and the spinal cord and brainstem govern voiding function. For MS patients, LUTD is sustained by a complex alteration of the neurological control of the detrusor-sphincter function, resulting in detrusor over activity, detrusor hypocontractility, and/or DSD. The results of the present study suggest that major patients with a diagnosis of MS present have urinary symptoms. DasGupta and Fowler reported that approximately 75% of all MS patients would develop voiding dysfunction and LUTS during the disease. For MS patients, urgency and frequency were the predominantly reported irritative symptoms observed, and obstructive symptoms were hesitancy and feeling of incomplete emptying. The results were similar to the reports from Western countries, which revealed that storage symptoms such as urgency, frequency were the predominant urinary symptoms in MS. Moreover, the presence of urinary symptoms was associated with more severe disability as measured with EDSS. In some studies reported, no correlation between videourodynamics finding and severity of MS was found, but in others a direct link between EDSS and urologic complaints was reported. Araki et al. found that storage symptoms correlated well with EDSS but voiding symptoms did not. The variability of relationship between urinary symptoms and EDSS probably relates to the clinical type of MS, which is characterized by exacerbations and remissions.
The result of our urodynamic parameters is more solid proof of diversity of LUTD and urinary symptoms in patients with MS. The results of the present study are comparable with those of other reported series. Both detrusor overactivity and DSD were the major urodynamic diagnoses in the present study. Suprasacral plaques will cause varying degrees of detrusor hyperreflexia with associated signs and symptoms, and sacral plaques will result in detrusor hypocontractility and, possibly, pudendal neuropathy. Urodynamic parameters can also objectively divide the contractility of the detrusor muscle into different levels by the pressure-flow rate diagram, allowing an intuitive and objective understanding of the detrusor function in MS patients. Urodynamic parameters examined are currently the most effective methods in identifying the type of voiding dysfunction in patients with MS. Therefore, urodynamic parameters examined should repeat at regular intervals in symptomatic patients to diagnose and optimize clinical management. Urodynamics may be helpful in providing an accurate diagnosis, guiding management decisions, and potentially, offering prognostic information on risk for upper tract deterioration. However, the universal recommendation of obtaining urodynamics in MS patients with minimal to moderate urologic symptom burden seems flawed.
The treatments for MS patients include immunomodulatory therapy, hormonotherapy, behavioral therapy, and medical therapy, such as anticholinergic drugs and alpha-1 receptor blockers. Acting on the detrusor muscle, anticholinergic drugs can relieve muscle spasms, reduce bladder pressure, and relieve symptoms in the urine storage period. The alpha-1 receptor blockers not only reduce urethral resistance but also relieve voiding symptoms. Behavioral therapies include bladder training, delaying urination, and increasing the urine volume for a single time. For MS patients with urinary retention or excessive residual urine volume, the approach of intermittent catheterization was applied.
In approximately 85% of the patients who develop MS, CIS is characterized by an acute or subacute episode of neurological problems due to a single lesion within the CNS. The patient has a relatively short duration of disease, and the illness is lighter. If CIS is accompanied by MRI-detectable focal white matter abnormalities at clinically unaffected sites, the chance of a second attack of demyelination, and thus of a diagnosis of clinically defined relapsing–remitting MS increases significantly. For the early stage of MS patients, the improvement of the storage urine symptoms is more obvious than that in other subgroups. OABSS, bladder volume at the first desire to voiding, maximum bladder volume, and Qmax were significantly increased after the treatment. PVR, bladder compliance, and the PdetQmax were a weak change because it was normal before the treatment. Accordingly, even at early stages of the disease, i.e., in CIS patients, the presence of urinary symptoms may be used to guide treatment decisions. Because of the potential long-term predictive value of urinary symptoms, future prospective studies should be aimed at investigating the role of LUTS to predict the conversion of CISs in clinically defined MS and to predict future disability.
Relapsing–remitting MS is the predominant subtype, makes up 80% of the MS patients. It is characterized by repeated relapses and remissions as benign MS. The symptoms can be acute attack or exacerbation and followed by remission with no new signs of disease activity. For relapsing–remitting MS patients, the OABSS, Qmax, and bladder volume at the first desire to voiding, bladder compliance, and maximum bladder volume were significantly increased after the treatment. However, the improvement in the PVR and the PdetQmax was not statistically significant.
Patients in progressive period are major with serious illness which is more progressive and no longer remitted, and poorly reacted for varieties of treatments. It is not obvious for the improvement of urine symptoms and maximum bladder volume and PVR. Patients in this stage are major with detrusor overactivity, detrusor hypocontractility, and DSD. The bladder volume at the first desire to voiding the PdetQmax and bladder compliance could be improved after neurology treatment. We suggest that comprehensive urodynamic parameters examined of bladder function are the keys to determine the therapy. We should give a proactive treatment to patients to relieve urinary symptoms, reduce the risk of complications, and enable these patients to cope better with their lifelong disability.
Some limitations in the present study must be pointed out. First, a weakness of the present study was that our data were collected retrospectively. Second, the number of patients enrolled was limited. Hence, we cannot make the statistical analysis between different treatment periods. In addition, many factors may lead to a system bias in the result of our urodynamic parameters. OABSS and EDSS are greatly influenced by patients’ subjective opinions. However, we believe that our results provide a useful insight for clinicians when counseling patients with MS. More high-quality trials with larger samples are proposed to learn more about the evaluation and urological management of MS. Future studies in larger cohorts of patients will aim at clarifying the specific clinical and MRI factors associated with urodynamic dysfunction in symptomatic and asymptomatic subjects with MS.
In conclusion, both urinary symptoms and urodynamic dysfunctions are more prevalent in patients with MS. These results suggest that urinary symptoms are correlated significantly with MS patients’ disability status. Moreover, according to the MS’ different clinical stages, the therapeutic effect of urinary symptoms is diversified. Urodynamic parameters examined are important in evaluation and urological management of MS. Urodynamics is helpful in providing an accurate diagnosis, guiding management decisions. Early and effective treatment may improve the bladder function and the quality of life at the early stage of MS.
Financial support and sponsorship
This work was supported by a grant from Beijing Municipal Science and Technology Commission (No. z151100004015163).
Conflicts of interest
There are no conflicts of interest.
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Edited by: Li-Shao Guo
Keywords:© 2016 Chinese Medical Association
Lower Urinary Tract Dysfunction; Multiple Sclerosis; Urinary Symptoms; Urodynamic