Can Multiple Sclerosis (MS) cause painful urination?

Can Multiple Sclerosis Cause Painful Urination?

Yes, Multiple Sclerosis can cause painful urination, though pain is not the most common urinary symptom in MS patients. MS primarily causes urinary dysfunction through spinal cord lesions that interrupt neural pathways controlling bladder function, leading to a spectrum of lower urinary tract symptoms including painful urination in some cases. 1, 2

Primary Urinary Symptoms in MS

MS-related bladder dysfunction typically manifests as:

• Irritative symptoms (most common): urgency, frequency, nocturia, and urinary incontinence 1, 2, 3
• Obstructive symptoms: urinary retention, incomplete bladder emptying, and hesitancy 1, 4
• Painful urination (dysuria) can occur but is less frequently reported as a primary symptom compared to urgency and incontinence 2

The prevalence of urinary symptoms in MS is substantial, affecting 54-78% of patients, with urinary incontinence being particularly common (67.3% in one recent study) 5, 4

Mechanisms Leading to Painful Urination

Spinal cord lesions in MS interrupt the neural pathways between the pontine micturition center and sacral spinal cord, causing detrusor hyperreflexia and incomplete bladder emptying 1. This neurogenic bladder dysfunction creates conditions that can lead to painful urination through:

• Urinary tract infections (UTIs): MS patients have high UTI prevalence due to urinary retention and incomplete emptying, with common organisms including E. coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae 2
• Detrusor-sphincter dyssynergia: uncoordinated bladder and sphincter function causing painful voiding 1
• Bladder overdistention: from incomplete emptying leading to discomfort during urination 4

Clinical Presentation Patterns

Progressive MS patients experience more severe urinary symptoms compared to relapsing-remitting MS patients, with significantly higher symptom scores on validated questionnaires 5. Patients with lower limb neurological deficits are particularly likely to develop bladder dysfunction 1.

The most common urinary symptoms reported by MS patients include:

• Urinary urgency (most frequent) 2
• Polyuria 2
• Nocturia 2
• Urinary retention 2
• Incontinence 2

Important Clinical Considerations

UTIs can precipitate MS relapses and worsen neurological deterioration, making prompt recognition and treatment essential 2. However, painful urination in MS patients should trigger evaluation for UTI rather than being attributed solely to neurogenic bladder dysfunction 2.

Upper urinary tract deterioration is uncommon in MS patients despite frequent lower urinary tract symptoms, occurring in less than 4% of cases in urodynamic studies 4. This distinguishes MS from other neurogenic bladder conditions where upper tract damage is more prevalent.

Evaluation Approach

When MS patients report painful urination, clinicians should:

• Obtain urinalysis and urine culture to identify UTI, as symptomatic UTI requires antibiotic therapy 2
• Assess post-void residual volume to identify incomplete emptying contributing to recurrent infections 1
• Perform urodynamic evaluation in patients with persistent symptoms or recurrent UTIs to characterize the specific bladder dysfunction pattern 4

Asymptomatic bacteriuria should not be treated in MS patients unless there are specific indications (recurrent acute UTIs, pregnancy, or need for immunosuppression), as treatment increases antibiotic-resistant bacterial strains without clinical benefit 2.