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LONDON—Many patients with multiple sclerosis (MS) suffer from bladder dysfunction, however, few of these patients have their symptoms managed, according to an overview presented at the 32nd Congress of the European Committee for Treatment and Research in MS.
If a patient reports bladder symptoms, most often those bladder symptoms will persist and increase, said Jalesh Panicker, MD, DM, Consultant Neurologist and Clinical Lead in Uroneurology at the University College London Institute of Neurology in Queen Square, London. Symptoms of urinary frequency, urgency, incontinence, and nocturia, which are collectively called overactive bladder syndrome, increase with increased duration of MS and tend to correlate with the neurologic disability, especially lower limb parameter weakness. 
In a large survey of 3,000 patients with MS, 90% rated bladder complications as one of the top five common symptomatic problems. Seventy percent of the group reported that bladder issues had a moderate or high impact on them. Only one-third of patients surveyed reported improvement after starting disease-modifying therapies.
Bladder symptoms in MS occur, on average, six years into the illness. Lower urinary tract symptoms are present in 10% of patients at first diagnosis. To help address this issue, the Actionable eight-item questionnaire was developed to help make it easier for doctors to assess bladder problems, said Dr. Panicker.
Lesion location plays a significant role in urinary tract dysfunction. Patients with suprapontine lesions present predominantly with overactive bladder, whereas patients with spinal lesions tend to report voiding symptoms such as hesitancy and poor stream. Plaques in the cerebral cord can also alter the pattern of lower urinary tract dysfunction.
Measuring post-void residue is critical for bladder dysfunction management. Unlike in urgency and incontinence, patients tend to have difficulties expressing voiding and voiding dysfunction symptoms. A high post-void residue can cause urinary tract infections and lead to devastating effects on patients, Dr. Panicker said. Using a bladder scanner to detect high post-void residuals may help reduce urinary tract infections.
Oral Agents
The three most commonly used treatments for bladder dysfunction in patients with MS are oral agents, botulinum toxin, and neuromodulation. Oral antimuscarinics work through the muscarinic receptors of the bladder, reducing bladder sensation and intrusive pressures, inhibiting detrusor overactivity, and improving bladder capacity. Oxybutynin, for example, can cause dry mouth and dry eyes, whereas newer antimuscarinics such as tolteradine, solifenancin, or fesoteradine are less likely to cause dry eyes, dry mouth, or constipation, Dr. Panicker noted.
Anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. The higher the anticholinergic burden, the greater the risk of cognitive impairment, impaired functional performance, mortality, and brain atrophy. The Anticholinergic Burden Scale (ACB) grades medications according to their anticholinergic burden—mild (ACB1), moderate (ACB2), and severe (ACB3). Total ACB score is the sum of each medication the patient is on; any ACB score over 3 is considered clinically relevant.
Beta 3 agonists are another class of oral agents used to control bladder symptoms. Beta 3 agonists inhibit intrusive muscle contractions and increase relaxation by acting on the beta 3 receptors present on the wall of the bladder. Unlike antimuscarinics, beta 3 agonists are devoid of side effects like dry mouth, dry eyes, and constipation; however, these oral agents are associated with cardiovascular side effects. Currently, there are pivotal phase III studies on the efficacy of mirabegron in the UK, however, there is limited evidence from neurologic patients and there is a need for more long-term data, Dr. Panicker said.
Botulinum Toxin
Botulinum toxin is effective for bladder management. Evidence shows that patients with MS experienced significant improvement in urinary incontinence, frequency, and urgency as early as four weeks after injections, and this beneficial effect is not lost with repeated injections. Three pivotal phase III studies have demonstrated the efficacy of onabotulinumtoxinA for improving incontinence. Studies suggest that onabotulinumtoxinA significantly improved incontinence at week 12. The median duration of retreatment was 42 weeks.
Neuromodulation
Stimulating the tibial nerve is beneficial in managing overactive bladder symptoms such as urinary frequency and incontinence. Percutaneous tibial nerve stimulation is one of the few treatments that does not tend to worsen voiding dysfunction. It is also potentially a treatment for patients who are retaining urine or experiencing incomplete bladder emptying.
“With several disease-modifying therapies over the last few years, it is clear that the number of MS relapses in patients is coming down. There is evidence to suggest that the neurologic disability that accumulates is also either halted or possibly even reversed. Whether the nonmotor symptoms of MS, such as urinary tract dysfunction, also would get halted or reversed with these treatments is an area for further research,” said Dr. Panicker.
—Erica Tricarico
Suggested Reading
Ginsberg D, Gousse A, Keppenne V, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. J Urol. 2012;187(6):2131-2139.
Jongen PJ, Blok BF, Heesakkers JP, et al. Simplified scoring of the Actionable 8-item screening questionnaire for neurogenic bladder overactivity in multiple sclerosis: a comparative analysis of test performance at different cut-off points. BMC Urol. 2015;15:106.
Wintner A, Kim MM, Bechis SK, Kreydin El. Voiding dysfunction in multiple sclerosis. Semin Neurol. 2016;36(1):34-40.
LONDON—Many patients with multiple sclerosis (MS) suffer from bladder dysfunction, however, few of these patients have their symptoms managed, according to an overview presented at the 32nd Congress of the European Committee for Treatment and Research in MS.
If a patient reports bladder symptoms, most often those bladder symptoms will persist and increase, said Jalesh Panicker, MD, DM, Consultant Neurologist and Clinical Lead in Uroneurology at the University College London Institute of Neurology in Queen Square, London. Symptoms of urinary frequency, urgency, incontinence, and nocturia, which are collectively called overactive bladder syndrome, increase with increased duration of MS and tend to correlate with the neurologic disability, especially lower limb parameter weakness.
In a large survey of 3,000 patients with MS, 90% rated bladder complications as one of the top five common symptomatic problems. Seventy percent of the group reported that bladder issues had a moderate or high impact on them. Only one-third of patients surveyed reported improvement after starting disease-modifying therapies.
Bladder symptoms in MS occur, on average, six years into the illness. Lower urinary tract symptoms are present in 10% of patients at first diagnosis. To help address this issue, the Actionable eight-item questionnaire was developed to help make it easier for doctors to assess bladder problems, said Dr. Panicker.
Lesion location plays a significant role in urinary tract dysfunction. Patients with suprapontine lesions present predominantly with overactive bladder, whereas patients with spinal lesions tend to report voiding symptoms such as hesitancy and poor stream. Plaques in the cerebral cord can also alter the pattern of lower urinary tract dysfunction.
Measuring post-void residue is critical for bladder dysfunction management. Unlike in urgency and incontinence, patients tend to have difficulties expressing voiding and voiding dysfunction symptoms. A high post-void residue can cause urinary tract infections and lead to devastating effects on patients, Dr. Panicker said. Using a bladder scanner to detect high post-void residuals may help reduce urinary tract infections.
Oral Agents
The three most commonly used treatments for bladder dysfunction in patients with MS are oral agents, botulinum toxin, and neuromodulation. Oral antimuscarinics work through the muscarinic receptors of the bladder, reducing bladder sensation and intrusive pressures, inhibiting detrusor overactivity, and improving bladder capacity. Oxybutynin, for example, can cause dry mouth and dry eyes, whereas newer antimuscarinics such as tolteradine, solifenancin, or fesoteradine are less likely to cause dry eyes, dry mouth, or constipation, Dr. Panicker noted.
Anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. The higher the anticholinergic burden, the greater the risk of cognitive impairment, impaired functional performance, mortality, and brain atrophy. The Anticholinergic Burden Scale (ACB) grades medications according to their anticholinergic burden—mild (ACB1), moderate (ACB2), and severe (ACB3). Total ACB score is the sum of each medication the patient is on; any ACB score over 3 is considered clinically relevant.
Beta 3 agonists are another class of oral agents used to control bladder symptoms. Beta 3 agonists inhibit intrusive muscle contractions and increase relaxation by acting on the beta 3 receptors present on the wall of the bladder. Unlike antimuscarinics, beta 3 agonists are devoid of side effects like dry mouth, dry eyes, and constipation; however, these oral agents are associated with cardiovascular side effects. Currently, there are pivotal phase III studies on the efficacy of mirabegron in the UK, however, there is limited evidence from neurologic patients and there is a need for more long-term data, Dr. Panicker said.
Botulinum Toxin
Botulinum toxin is effective for bladder management. Evidence shows that patients with MS experienced significant improvement in urinary incontinence, frequency, and urgency as early as four weeks after injections, and this beneficial effect is not lost with repeated injections. Three pivotal phase III studies have demonstrated the efficacy of onabotulinumtoxinA for improving incontinence. Studies suggest that onabotulinumtoxinA significantly improved incontinence at week 12. The median duration of retreatment was 42 weeks.
Neuromodulation
Stimulating the tibial nerve is beneficial in managing overactive bladder symptoms such as urinary frequency and incontinence. Percutaneous tibial nerve stimulation is one of the few treatments that does not tend to worsen voiding dysfunction. It is also potentially a treatment for patients who are retaining urine or experiencing incomplete bladder emptying.
“With several disease-modifying therapies over the last few years, it is clear that the number of MS relapses in patients is coming down. There is evidence to suggest that the neurologic disability that accumulates is also either halted or possibly even reversed. Whether the nonmotor symptoms of MS, such as urinary tract dysfunction, also would get halted or reversed with these treatments is an area for further research,” said Dr. Panicker.
—Erica Tricarico
Suggested Reading
Ginsberg D, Gousse A, Keppenne V, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. J Urol. 2012;187(6):2131-2139.
Jongen PJ, Blok BF, Heesakkers JP, et al. Simplified scoring of the Actionable 8-item screening questionnaire for neurogenic bladder overactivity in multiple sclerosis: a comparative analysis of test performance at different cut-off points. BMC Urol. 2015;15:106.
Wintner A, Kim MM, Bechis SK, Kreydin El. Voiding dysfunction in multiple sclerosis. Semin Neurol. 2016;36(1):34-40.
LONDON—Many patients with multiple sclerosis (MS) suffer from bladder dysfunction, however, few of these patients have their symptoms managed, according to an overview presented at the 32nd Congress of the European Committee for Treatment and Research in MS.
If a patient reports bladder symptoms, most often those bladder symptoms will persist and increase, said Jalesh Panicker, MD, DM, Consultant Neurologist and Clinical Lead in Uroneurology at the University College London Institute of Neurology in Queen Square, London. Symptoms of urinary frequency, urgency, incontinence, and nocturia, which are collectively called overactive bladder syndrome, increase with increased duration of MS and tend to correlate with the neurologic disability, especially lower limb parameter weakness.
In a large survey of 3,000 patients with MS, 90% rated bladder complications as one of the top five common symptomatic problems. Seventy percent of the group reported that bladder issues had a moderate or high impact on them. Only one-third of patients surveyed reported improvement after starting disease-modifying therapies.
Bladder symptoms in MS occur, on average, six years into the illness. Lower urinary tract symptoms are present in 10% of patients at first diagnosis. To help address this issue, the Actionable eight-item questionnaire was developed to help make it easier for doctors to assess bladder problems, said Dr. Panicker.
Lesion location plays a significant role in urinary tract dysfunction. Patients with suprapontine lesions present predominantly with overactive bladder, whereas patients with spinal lesions tend to report voiding symptoms such as hesitancy and poor stream. Plaques in the cerebral cord can also alter the pattern of lower urinary tract dysfunction.
Measuring post-void residue is critical for bladder dysfunction management. Unlike in urgency and incontinence, patients tend to have difficulties expressing voiding and voiding dysfunction symptoms. A high post-void residue can cause urinary tract infections and lead to devastating effects on patients, Dr. Panicker said. Using a bladder scanner to detect high post-void residuals may help reduce urinary tract infections.
Oral Agents
The three most commonly used treatments for bladder dysfunction in patients with MS are oral agents, botulinum toxin, and neuromodulation. Oral antimuscarinics work through the muscarinic receptors of the bladder, reducing bladder sensation and intrusive pressures, inhibiting detrusor overactivity, and improving bladder capacity. Oxybutynin, for example, can cause dry mouth and dry eyes, whereas newer antimuscarinics such as tolteradine, solifenancin, or fesoteradine are less likely to cause dry eyes, dry mouth, or constipation, Dr. Panicker noted.
Anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. The higher the anticholinergic burden, the greater the risk of cognitive impairment, impaired functional performance, mortality, and brain atrophy. The Anticholinergic Burden Scale (ACB) grades medications according to their anticholinergic burden—mild (ACB1), moderate (ACB2), and severe (ACB3). Total ACB score is the sum of each medication the patient is on; any ACB score over 3 is considered clinically relevant.
Beta 3 agonists are another class of oral agents used to control bladder symptoms. Beta 3 agonists inhibit intrusive muscle contractions and increase relaxation by acting on the beta 3 receptors present on the wall of the bladder. Unlike antimuscarinics, beta 3 agonists are devoid of side effects like dry mouth, dry eyes, and constipation; however, these oral agents are associated with cardiovascular side effects. Currently, there are pivotal phase III studies on the efficacy of mirabegron in the UK, however, there is limited evidence from neurologic patients and there is a need for more long-term data, Dr. Panicker said.
Botulinum Toxin
Botulinum toxin is effective for bladder management. Evidence shows that patients with MS experienced significant improvement in urinary incontinence, frequency, and urgency as early as four weeks after injections, and this beneficial effect is not lost with repeated injections. Three pivotal phase III studies have demonstrated the efficacy of onabotulinumtoxinA for improving incontinence. Studies suggest that onabotulinumtoxinA significantly improved incontinence at week 12. The median duration of retreatment was 42 weeks.
Neuromodulation
Stimulating the tibial nerve is beneficial in managing overactive bladder symptoms such as urinary frequency and incontinence. Percutaneous tibial nerve stimulation is one of the few treatments that does not tend to worsen voiding dysfunction. It is also potentially a treatment for patients who are retaining urine or experiencing incomplete bladder emptying.
“With several disease-modifying therapies over the last few years, it is clear that the number of MS relapses in patients is coming down. There is evidence to suggest that the neurologic disability that accumulates is also either halted or possibly even reversed. Whether the nonmotor symptoms of MS, such as urinary tract dysfunction, also would get halted or reversed with these treatments is an area for further research,” said Dr. Panicker.
—Erica Tricarico
Suggested Reading
Ginsberg D, Gousse A, Keppenne V, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. J Urol. 2012;187(6):2131-2139.
Jongen PJ, Blok BF, Heesakkers JP, et al. Simplified scoring of the Actionable 8-item screening questionnaire for neurogenic bladder overactivity in multiple sclerosis: a comparative analysis of test performance at different cut-off points. BMC Urol. 2015;15:106.
Wintner A, Kim MM, Bechis SK, Kreydin El. Voiding dysfunction in multiple sclerosis. Semin Neurol. 2016;36(1):34-40.