What are the treatment options for urinary urgency in Multiple Sclerosis (MS)?

Treatment Options for Urinary Urgency in Multiple Sclerosis

For patients with urinary urgency in Multiple Sclerosis (MS), behavioral therapies should be offered as first-line treatment, followed by pharmacologic options if behavioral approaches are unsuccessful. 1, 2

First-Line Treatment: Behavioral Therapies

• Bladder training should be recommended as the initial treatment for patients with MS experiencing urinary urgency, as it improves urinary symptoms and quality of life 1, 2
• Pelvic floor muscle training (PFMT) is particularly effective for MS patients with urinary urgency and has been shown to decrease urine leakage and neurogenic bladder symptoms 1, 3
• PFMT has demonstrated moderate to significant increases in both endurance and power of pelvic floor muscles in MS patients (standardized mean difference = 1.25 for endurance and 0.64 for power) 3
• For patients with mixed urinary symptoms, PFMT combined with bladder training is recommended 1
• The efficacy of behavioral treatments for urinary incontinence ranges from 57% to 86% reduction in frequency of incontinence episodes 4

Second-Line Treatment: Pharmacologic Options

If behavioral therapies are unsuccessful, pharmacologic treatment should be considered:

• Antimuscarinic medications (e.g., oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium) are recommended for urgency urinary incontinence and have shown efficacy in increasing continence rates 1
• Beta-3 adrenergic receptor agonists like mirabegron are indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 5
• Mirabegron has demonstrated effectiveness in reducing incontinence episodes and micturition frequency compared to placebo in clinical trials 5
• When choosing between medications, consider:
  • Tolterodine causes fewer adverse effects than oxybutynin with similar efficacy 1, 2
  • Solifenacin has the lowest risk for discontinuation due to adverse effects 1
  • Oxybutynin is associated with the highest risk for discontinuation due to adverse effects 1

Catheterization Considerations

• For MS patients with urinary retention in addition to urgency, intermittent catheterization should be recommended rather than indwelling catheters 1
• Intermittent catheterization has lower rates of UTI and urethral trauma compared to indwelling catheters 1

Additional Management Strategies

• Weight loss and exercise should be recommended for obese patients with urinary urgency 1, 2
• Avoiding bladder irritants in diet, such as caffeine and alcohol, can help reduce symptoms 2
• Treatment of constipation is essential as it can exacerbate urinary symptoms 2

Special Considerations for MS Patients

• MS patients have a high prevalence of urinary tract infections (UTIs), which can worsen MS symptoms and lead to increased hospitalization and mortality 6
• Common urinary symptoms in MS patients include urgency, polyuria, nocturia, retention, and incontinence 6
• UTIs can precipitate MS relapses and cause neurological deterioration, so prompt treatment is essential 6
• Patients using PFMT may have high dropout rates (36.8% in one study), suggesting that motivation and logistical factors play a significant role in treatment success 7

Common Pitfalls to Avoid

• Failing to identify medications that may cause or worsen urinary incontinence 2
• Overlooking conditions that may cause urinary symptoms, such as urinary tract infections and metabolic disorders 2
• Underdiagnosing urinary issues, as at least half of women with urinary incontinence do not report the issue to their physicians 2
• Treating asymptomatic bacteriuria in MS patients without clinical indication, which can lead to antibiotic resistance 6