Multiple sclerosis (MS) is an immune mediated neurological disease of the central nervous system; its symptoms are variegate and often include lower urinary tract (LUT) dysfunctions: around 80% of these patients manifest neuro-urological symptoms after 10 years from the diagnosis, and 10% may present with LUT symptoms (LUTS) at disease onset. The most frequent urinary dysfunctions reported by these patients are storage symptoms, compatible with neurogenic overactive bladder (nOAB), but also voiding symptoms due to detrusor underactivity (DU) are well represented. As a consequence, health-related quality of life is often impaired and the upper urinary tract might be at risk for damage(1). According to EAU guidelines, antimuscarinics are strongly recommended as first-line medical treatment for neurogenic OAB, alpha-blockers works well to decrease bladder outlet resistance; whenever a pathological post-void residual (PVR) is found, clean intermittent catheterisation (CIC) should be started. In case of failure of antimuscarinics, botulinum toxin injection in the detrusor can be suggested. Despite guidelines recommendations, there are only few studies on MS patients’ satisfaction on the use of these drugs, and there are even less reports about patients’ compliance. The aim of this retrospective study was to investigate MS patients’ response and adherence to different medical treatment for LUTS.

Patients with a diagnosis of MS and nOAB at their first visit in a single neuro-urology centre were included in this study. Age, sex, type of symptoms complained were recorded; previous treatment and data related to clean intermittent catheterisation regime were also recorded. Recommended treatment was recorded and a database was built, and data analysed. A simple Likert-type psychometric scale (from 1 to 5, being 1 = very unsatisfied and 5 = very satisfied) was used to register patient’s feedback on every kind of treatment suggested, both at the first visit and at subsequent follow ups. Whenever patients refused or dropped a treatment, reason and motivation were recorded.

A total of 47 patients (age range 26-59 years; average age 48 years; M=16, F=31) with a previous diagnosis of MS visited in a single neuro-urology clinic between April 2018 and January 2020 were evaluated. Average follow up was 11 months (min 1 month, max 15 months). At the first visit, 15 (32%) patients had already tried unsuccessfully medical treatment, mostly alpha-blockers, for LUT dysfunction, while 32 (68%) had no history previous treatment. Figure 1 illustrates what kind of treatment were suggested and the percentages of patients who agreed to that; 9% of the patients preferred not to start any kind of medical treatment. Patients who had used medical treatment for OAB were fully satisfied with the treatment in 7 cases (18%) and partially satisfied in 12 (30%), whilst 6 (15%) did not notice any change, 7 (18%) reported a not satisfactory improvement and 8 (20%) were very unsatisfied. No significant differences between males and females were found.
At follow up, almost 60% of the cohort were not following the recommended therapy (Figure 2). Causes for dropping out from therapy were: 30% reported side effects and dropped the therapy after less than a month of treatment; 19% reported no efficacy and therefore decided to stop the treatment in 3 to 6 months from the start; 26% reported to have stopped the treatment for financial reasons and for reducing the drug intake; 26% decided to refuse any kind of medical treatment. In all comparative analysis, no significant difference between the males and females were found.

Antimuscarinics seem to be the most common treatment for OAB in MS patients, followed by mirabegron, PTNS and alfa-blockers; we tried to avoid combined therapy, considering that in our country these drugs are paid by the patient out of pocket. Our data show that even though the majority of the MS patients suffering from OAB is willing to improve their urinary symptoms, after one year from the first visit, around 40% of patients are satisfied with the therapy and still undergoing medical treatment for LUTS. The reason for this very low compliance appears to be related in the first place to the presence of side effects, that leads to an early drop out (30% of patients evaluated dropped the therapy after less than 1 month). Also the intolerance towards medical treatment in general seem to have a role: 26% of our patients reported they preferred to cut the numbers of drug they take every day, even though the therapy seemed to work, and 26% of the patients decided not to take any drug, and therefore did not attempt the therapy in the first place. Only 19% found the treatment completely ineffective, interrupting it after an average of 2 months. Also, the costs of the drugs may affect patients’ decision.

There are many different strategies for improving urinary symptoms in MS but a satisfactory outcome seems hard to obtain for these patients: many effective therapies may come with side effects which discourage the patient and the therapy itself may represent a burden, even in presence of positive results. These results highlight the need of designing a tailored therapy for each patient; in order to further improve the compliance, closer follow up visits may also be indicated.

Tornic, J. & Panicker, J. N. The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis. Curr. Neurol. Neurosci. Rep. (2018).