Bladder dysfunction is a common problem for patients with multiple sclerosis. The severity of symptoms often correlate with the degree of spinal cord involvement and, hence, the patient’s general level of disability. The emphasis of management is now mainly medical and is increasingly offered by nonurologists. Treatments can be highly effective, relieving patients of what are otherwise very troublesome symptoms that would compound their neurological disability. This article gives an overview of the neural control of the bladder, followed by an explanation of the pathophysiology of detrusor overactivity secondary to neurological disease. A review of methods available for treating bladder dysfunction in multiple sclerosis then follows. The treatment options for this disorder are largely medical and include established first-line measures such as anticholinergics, clean intermittent self-catheterization and the use of desmopressin, as well as potential second-line agents, such as cannabinoids, intravesical vanilloids and intradetrusor botulinum neurotoxin type A. The diminishing role of surgical intervention is also discussed.
INTRODUCTION
The estimated prevalence of urogenital symptoms in multiple sclerosis (MS) has varied, depending on the populations studied. Estimates of between 52% and 97% have been cited,1 but, since these problems result mainly from spinal cord involvement,2, 3 figures that show an occurrence similar to that of lower limb dysfunction (75%)4 or to the MRI estimate of incidence of spinal cord lesions (74%)5 seem more realistic. There is a clear gender difference in the prevalence of MS, with females being more commonly affected than males, on average by a ratio of 2:1.6 The nature of micturition complaints and lower urinary tract symptoms also differ between sexes. Obstruction complaints, such as hesitation, interrupted or weak urine flow and incomplete emptying, are found more frequently in men, whereas incontinence complaints (involuntary loss of urine) are more frequent in women. Irritative complaints of urgency, frequency, nocturia and pain are found equally between sexes.7Urogenital symptoms in patients with MS are therefore common, and are clearly recognized to have significant adverse effects on the quality of life of this group of patients.8, 9Fortunately, this is an area where therapeutic intervention can be highly effective, as will be described in this review.
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NEUROLOGICAL CONTROL OF THE BLADDER
Functional brain imaging studies are adding to our understanding of the contribution of higher centers and signal processing involved in bladder control, so that voiding can be achieved in a socially appropriate time and place. Such studies have shown that a complex of brain networks is involved in the two processes of bladder storage10, 11 and voiding,12,13 but that the final result of these processes is either activation or inhibition of the pontine micturition center (PMC). Direct pathways from the PMC project to the sacral segments of the spinal cord (S2–S4) (Figure 1), and determine parasympathetic outflow to the detrusor and reciprocal activity of the motor neurons innervating the striated urethral sphincter.14
Figure 1 Illustration of the pathways involved in micturition.
PAG, periaqueductal gray; PMC, pontine micturition center.
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