What is the best treatment for urinary incontinence (UI) or urinary retention in an 80-year-old patient with Multiple Sclerosis (MS) and no Urinary Tract Infection (UTI)?

From the Guidelines

For an 80-year-old with multiple sclerosis (MS) experiencing urinary bypassing without a urinary tract infection, I strongly recommend onabotulinumtoxinA injections as the most effective treatment to improve bladder storage parameters, decrease episodes of incontinence, and improve quality of life measures, as supported by the latest guideline from 2021 1. This approach is based on the strong recommendation from the AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction, which suggests that onabotulinumtoxinA injections can significantly improve bladder function and quality of life in patients with MS refractory to oral medications. Some key points to consider when using onabotulinumtoxinA injections include:

• The dose of 200 U or 300 U can be effective, but there is an increasing dose-dependent relationship regarding the risk of retention and need for clean intermittent catheterization (CIC) 1.
• Regular follow-up is necessary to assess the effectiveness of the treatment and adjust the dose as needed.
• It is essential to rule out other causes of urinary bypassing and to address any underlying neurogenic bladder dysfunction.
• Behavioral interventions, such as timed voiding and pelvic floor exercises, can be used in conjunction with onabotulinumtoxinA injections to optimize treatment outcomes. The use of onabotulinumtoxinA injections is supported by high-quality evidence from recent studies, including the 2021 guideline from the AUA/SUFU 1, which provides a strong recommendation for its use in patients with MS and neurogenic lower urinary tract dysfunction.

From the FDA Drug Label

to treat leakage of urine (incontinence) in adults with overactive bladder due to neurologic disease when another type of medicine (anticholinergic) does not work well enough or cannot be taken The best treatment for bypassing urine in an 80-year-old with MS and no UTI is onabotulinumtoxinA (IM), as it is indicated for the treatment of leakage of urine (incontinence) in adults with overactive bladder due to neurologic disease when another type of medicine (anticholinergic) does not work well enough or cannot be taken 2.

• Key considerations:
  • The patient has MS, which is a neurologic disease
  • The patient has no UTI, which is a contraindication for onabotulinumtoxinA (IM) treatment for urinary incontinence
  • OnabotulinumtoxinA (IM) is a suitable alternative to anticholinergic medications, which may have adverse effects in the elderly or in patients with certain medical conditions.

From the Research

Treatment Options for Bypassing Urine in 80-Year-Old with MS and No UTI

• Clean intermittent catheterization (CIC) is a recommended treatment for patients with multiple sclerosis (MS) who have urinary retention or incomplete bladder emptying 3, 4.
• However, CIC may increase the risk of urinary tract infections (UTIs) in MS patients, as shown in a study where the CIC group had 7 times greater odds of having at least one UTI within 1 year compared to the pharmacologic treatment group 5.
• Other treatment options for urinary symptoms in MS patients include pelvic floor muscle therapy, pelvic floor electrical stimulation, anticholinergics, desmopressin, sacral nerve neuromodulation, posterior tibial nerve stimulation, cannabinoids, and intravesical therapy with vanilloids, as well as botulinum toxin 3.
• Indwelling transurethral catheterization should be avoided due to the high risk of infection 3.
• Urinary tract infections are a common complication in MS patients, and can exacerbate the disease, causing more damage and a severe neurological condition deterioration 6, 7.

Considerations for Treatment

• The treatment of urinary symptoms in MS patients should be individualized, taking into account the patient's symptoms, complications, and ability to perform self-catheterization 4.
• The teaching of self-catheterization should consider the patient's physical and cognitive impairment 4.
• Regular assessment of the patient's ability to perform self-catheterization and the need for treatment adjustments is necessary due to the progressive nature of MS 4.