What are the treatment options for multiple sclerosis (MS) patients experiencing urinary urgency and retention?

Treatment Options for Urinary Urgency and Retention in Multiple Sclerosis Patients

For MS patients with urinary urgency and retention, beta-3 agonists like mirabegron should be offered as first-line pharmacological therapy due to their lower risk of urinary retention and lack of cognitive side effects, while antimuscarinic medications should be used with extreme caution due to increased risk of urinary retention in this population. 1

First-Line Treatment Options

Behavioral Therapies

• Behavioral therapies should be offered as first-line treatment for all MS patients with urinary urgency 1
• These include bladder training, pelvic floor muscle training, and fluid management strategies 1
• Fluid management with appropriate intake reduction (typically 25%) is recommended for patients with urinary urgency 1
• Weight loss is recommended for patients with obesity, as it can reduce urgency urinary incontinence episodes 1

Assessment Before Treatment

• Post-void residual volume should be assessed before starting any pharmacological treatment, especially with antimuscarinic medications 1
• Urodynamic studies should be performed in MS patients with storage symptoms that place their upper tracts at risk 2
• Bladder diaries should be used to document voiding behavior and treatment efficacy 1

Pharmacological Management

Beta-3 Adrenergic Agonists

• Mirabegron is the preferred second-line pharmacological option for MS patients with urinary urgency 1
• Advantages include:
  • Lower risk of urinary retention compared to antimuscarinics 1
  • No impact on cognitive function, which is important in MS patients 1
  • FDA-approved for overactive bladder and neurogenic detrusor overactivity 3
• Regular blood pressure monitoring is required when using mirabegron, especially during initial treatment 1
• Should not be used in patients with severe uncontrolled hypertension 1

Antimuscarinic Medications

• Should be used with extreme caution in MS patients due to:
  • High risk of urinary retention, especially in patients with neurogenic bladder 1, 2
  • Potential cognitive impairment, which can worsen existing MS-related cognitive issues 1, 2
• Should be avoided in patients with:
  • Post-void residual volume greater than 150 ml 1
  • Narrow-angle glaucoma 2
  • Impaired gastric emptying 2
• If used, options include:
  • Oxybutynin, darifenacin, fesoterodine, solifenacin, tolterodine, or trospium 2
  • Oxybutynin has shown efficacy in reducing OAB symptoms in MS patients but has side effects like dry mouth in about 35% of patients 4

Minimally Invasive Treatments

Neuromodulation Therapies

• Posterior tibial nerve stimulation (PTNS) may be offered to select MS patients with urgency, frequency, and/or urgency incontinence who can spontaneously void 2
• Daily transcutaneous tibial nerve stimulation (TTNS) has shown good performance in reducing clinical symptoms and improving quality of life in MS patients with overactive bladder, with no side effects 4
• Sacral neuromodulation (SNS) may be offered as third-line treatment in carefully selected patients with severe refractory symptoms 2

Botulinum Toxin Injections

• Intradetrusor botulinum toxin injection may be offered to patients with inadequate response to or intolerable side effects from pharmacotherapy or behavioral therapy 2

Combination Therapy Options

• Combination approaches, such as adding beta-3 agonists to antimuscarinic therapy, may be considered for patients with inadequate response to monotherapy 1
• Behavioral therapies should be continued alongside pharmacological treatments 1

Common Pitfalls to Avoid

• Initiating antimuscarinic therapy without checking post-void residual volume 1
• Using antimuscarinic medications in patients with cognitive impairment or at high risk for dementia 1
• Treating asymptomatic bacteriuria with antibiotics, which can create antimicrobial resistance 5
• Using indwelling catheters instead of clean intermittent catheterization, as the former is associated with higher UTI rates 5

Follow-up and Monitoring

• Repeat urodynamic studies at appropriate intervals following treatment in patients with impaired storage parameters 2
• Regular assessment of post-void residual volume is necessary, especially in patients on antimuscarinic therapy 1
• If initial therapy is ineffective at reducing elevated storage pressures, additional interventions should be offered 2