What is the best approach to manage urinary urgency in men with multiple sclerosis?

Management of Urinary Urgency in Men with Multiple Sclerosis

The first-line approach for managing urinary urgency in men with multiple sclerosis should be a combination of anticholinergic medications and clean intermittent catheterization, supplemented with pelvic floor muscle training. 1

Initial Assessment

• Perform a thorough bladder function assessment including measurement of urinary frequency, volume, control, and assessment for dysuria 1
• Evaluate post-void residual volume using bladder scanner or in-and-out catheterization to determine the degree of urinary retention 1
• Consider urodynamic testing if empiric anticholinergic therapy is planned, as symptoms alone do not reliably predict obstructive findings in men with neurological conditions 1

Pharmacological Management

First-Line Medications

• Anticholinergic medications are recommended as first-line pharmacological treatment for storage symptoms in neurogenic lower urinary tract dysfunction (NLUTD) 1
• Beta-3 adrenergic receptor agonists (like mirabegron) may be used alone or in combination with anticholinergics to improve bladder storage parameters 1
• Combination of alpha-1 blockers with antimuscarinic agents is effective for men with both storage and voiding symptoms 1

Important Considerations

• Monitor post-void residual (PVR) volume during treatment with anticholinergics 1
• Avoid antimuscarinic medications in men with PVR volume >150 ml 1
• Be aware that combination therapy with alpha-1 blockers and antimuscarinic agents is associated with higher rates of adverse events than monotherapy 1

Catheterization Techniques

• Intermittent catheterization is the gold standard for treating voiding disorders associated with neurogenic bladder 1
• Implement clean intermittent catheterization on a regular schedule (every 4-6 hours) to keep urine volume below 500 ml per collection 1
• Use hydrophilic catheters if possible, as they are associated with fewer urinary tract infections and less hematuria 1
• Avoid indwelling catheters due to higher risk of urinary tract infections, bladder stones, and poorer quality of life 1
• If catheterization is required, use silver alloy-coated catheters to reduce infection risk 1

Pelvic Floor Rehabilitation

• Pelvic floor muscle training (PFMT) is effective for improving urinary symptoms and quality of life in MS patients 2, 3
• Physiotherapist-guided PFMT programs show significant improvements in urinary incontinence severity, quality of life, and lower urinary tract symptoms in both men and women with MS 3
• PFMT combined with electrical stimulation of the pelvic floor is particularly effective in male MS patients 2
• Regular pelvic floor exercises should be continued for at least six months to maintain benefits 2

Bladder Management Program

• Implement a comprehensive bladder management program that enables regular emptying while preventing leakage and maintaining low bladder pressures 1
• Teach proper hand hygiene (using antibacterial soap or alcohol-based cleaners) before and after catheter insertion 1
• Ensure adequate fluid intake but avoid excessive fluid consumption that may worsen urgency 1
• Consider prompted voiding techniques to improve continence 1
• Develop an individualized bladder-training program for patients with urinary incontinence 1

Follow-up and Monitoring

• Regularly monitor urinary symptoms, post-void residual volumes, and urinary tract infections 4
• Perform periodic ultrasound of the upper urinary tract to detect any complications 1
• Adjust treatment based on disease progression and changing mobility status 4
• Consider referral to a urologist if first-line treatments fail 5

Pitfalls and Caveats

• Avoid treating asymptomatic bacteriuria with antibiotics in MS patients with neurogenic bladder 1
• Do not rely on urine dipstick testing alone for diagnosis of UTI; symptoms must be present to warrant antibiotic treatment 1
• Be aware that cranberry products, methenamine salts, and urinary acidification/alkalinization agents have not shown effectiveness in preventing UTIs in patients with neurogenic bladder 1
• Recognize that management strategies must adapt as MS progresses and mobility decreases 4, 5
• Quality of life is significantly impacted by urinary symptoms in MS patients and should be regularly assessed 3, 6