Clinical and urodynamic risk factors for recurrent urinary tract infections in patients with multiple sclerosis

Castro-Díaz D M1, Vírseda-Chamorro M2, Salinas-Casado M3, Méndez-Rubio S4, Esteban-Fuertes M2, Moreno-Sierra J3

Research Type

Clinical

Abstract Category

Neurourology

Abstract 505
Open Discussion ePosters
Scientific Open Discussion Session 28
Friday 31st August 2018
13:20 - 13:25 (ePoster Station 1)
Exhibition Hall
Multiple Sclerosis Infection, Urinary Tract Urodynamics Techniques
1. Urology Department Hospital Universitario de Canarias Tenerife (Spain), 2. Urology Department. Hospital Nacional de Parapléjicos. Toledo (Spain), 3. Urology Department. Hospital Clínico de San Carlos. Madrid (Spain), 4. Urology Department. Hospital Sanitas-La Moraleja. Madrid (spain)
Presenter
Links

Poster

Abstract

Hypothesis / aims of study
Our hypothesis is that urodynamic alterations due to neurogenic lower urinary tract dysfunction (NLUTD) are risk factors for recurrent urinary tract infections (rUTIs) in patients with Multiple sclerosis (MS). Consequently the aim to this study is to identify the clinical and urodynamic risk factors for  rUTIs in a cohort of patients with MS.
Study design, materials and methods
Study designg 
Prospective cohort study

Materials and methods 
In this prospective study between January 2015 and September 2017, we recruited 170 patients with MS who underwent a videourodynamic study with selective sphincter EMG  due to lower urinary tract symptoms (LUTS). A follow-up of a year was carried out and finally 114 patients  (84 women [74%] and 30 men [26%]; mean age (± standard deviation) 49 ± 10.0 years, finished the study.  

Sample size was calculated based on the data provided by Wiedemann et al. [1] and Bemelmans et al. [ 2]. Assuming an Expanded Disability Status Scale (EDSS) score difference of 1.5 points, a standard deviation (SD) of 2.36 points, an alpha level of 5%, and a statistical power of 80%, the minimum sample size was calculated at 37 patients per group.

MS was diagnosed by the Hospital’s Neurology Department. We comprehensively reviewed patients’ clinical histories, recording data on demographic, neurological (including level of disability, measured using the EDSS and urological variables (including presence and type of LUTS and rUTIs). Recurrent urinary tract infections were diagnosed according to the criteria of the European Association of Urology. Thirty-seven patients (32%) had rUTIs.

The videourodynamic study and selective sphincter EMG were performed in accordance with the specifications of the International Continence Society (ICS) and guidelines for Good Urodynamic Practice.

For statistical analysis we used the Fisher exact text and the chi-square test for qualitative variables and the t-test to compare the means of parametric data. Quantitative data were tested for normal distribution using the Kolmogorov-Smirnov test. Statistical significance was set at P < 0.05.
Results
Relationship between clinical variables and rUTI occurrence. 
Statistically significant differences were observed for symptom progression time (longer in patients with rUTIs), MS duration (longer in patients with rUTIs), EDSS score (higher in patients with rUTIs), and MS type (greater rUTI frequency in primary progressive MS  and secondary progressive MS).

 Relationship between videourodynamic findings and rUTI occurrence. 
Significant differences were observed in maximum flow rate (lower in patients with rUTIs), voided volume (lower in patients with rUTIs), bladder voiding efficiency (greater post-void residual volume in patients with rUTIs), Stress Urinary Incontinence (SUI) (greater rUTI frequency in patients with SUI), detrusor pressure at maximum flow (lower in patients with rUTIs), and BCI score (lower in patients with rUTI).
	
No statistically significant differences were observed between between neurourological findings and rUTI occurrence
Interpretation of results
Our study identified a series of clinical and urodynamic risk factors for rUTIs. 

Clinical risk factors were symptom progression time (longer in patients with rUTIs), MS duration (longer in patients with rUTIs), EDSS score (higher in patients with rUTIs), and MS type (greater rUTI frequency in patients with PPMS and SPMS). 

Regarding to urodynamic risk factors, reduced flow rate and bladder voiding efficiency may be secondary to impaired detrusor contractility or to bladder outlet obstruction. The fact that patients with rUTIs had lower detrusor pressure at maximum flow, similar BOOI to those of patients without rUTIs, and significantly lower BCI suggests that impaired detrusor contractility is the main functional risk for the voiding phase.

We also observed that patients with SUI displayed a significantly higher frequency of rUTIs. This is probably also related to detrusor contractility. Valentini et al. [3] observed a direct correlation between detrusor contractility and urethral resistance (which is related to SUI); patients with SUI would have lower urethral resistance and therefore impaired detrusor contractility. Therefore, the greater frequency of rUTIs in patients with SUI would also be explained by impaired detrusor contractility.
Concluding message
Our data suggests that greater severity and longer duration of MS and impaired detrusor contractility are risk factors for rUTIs in patients with MS, whereas the presence of NLUTDs is not a specific risk factor.
References
  1. Wiedemann A, Kaeder M, Greulich W, et al. Which clinical risk factors determine a pathological urodynamic evaluation in patients with multiple sclerosis? An analysis of 100 prospective cases. World J Urol. 2013; 31:229-33.
  2. Bemelmans BL, Hommes OR, Van Kerrebroeck PE, Lemmens WA, Doesburg WH, Debruyne FM. Evidence for early lower urinary tract dysfunction in clinically silent multiple sclerosis. J Urol. 1991; 145:1219-24.
  3. Valentini FA, Nelson PP, Zimmern PE, Robain G. Detrusor contractility in women: Influence of ageing and clinical conditions. Prog Urol. 2016; 26:425-31.
Disclosures
Funding None Clinical Trial No Subjects Human Ethics Committee Hospital Clínico de San Carlos Helsinki Yes Informed Consent Yes
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