Multiple Sclerosis (MS) is a chronic, inflammatory, and degenerative disorder of the central nervous system affecting more than 2 million individuals globally. While primarily known for its neurological symptoms, its systemic effects are extensive, significantly impacting the quality of life of affected individuals. Among the prevalent yet often overlooked complications in these patients are alterations in continence, which can range from urinary incontinence to fecal control issues.
Despite the high prevalence of these symptoms in MS patients, appropriate referral to specialized care remains challenging. Thus, it's crucial for healthcare professionals to understand when, how, and to which specialist to refer patients to ensure comprehensive care and optimize symptom management.
The aim of this study is to assess the implementation of a coordinated clinical pathway for MS patients with urinary or bowel dysfunction, developed by a multidisciplinary team in our center to standardize patient management.

A multidisciplinary unit was established in a tertiary hospital, comprising specialists from Neurology, Urology, Gastroenterology, Coloproctology, and Physical Medicine and Rehabilitation (PM&R), along with two nurses specialized in the care of MS patients with continence issues.
After reviewing evidence-based studies and international guidelines and identifying the existing care pathways, the multidisciplinary team developed an optimized clinical pathway with clear referral criteria. These guidelines aim to facilitate early identification of continence issues, ensuring prompt intervention, improving patient care, and optimizing treatment outcomes.
The clinical pathway is outlined in Figure #1.
An audit process was devised to evaluate adherence to this pathway. All referrals made from September 2023 to February 2024, from Neurology to the four relevant departments and between these departments, were retrospectively analyzed to assess compliance with the referral criteria outlined in the guidelines. Additionally, a random sample of patients evaluated in Neurology consultations during this period was analyzed to identify those meeting the referral criteria who had not been referred.

During the six-month period following the implementation of the pathway, 79 referrals were recorded. Figure 2 summarizes these referrals. The majority were directed to Urology, primarily for urge urinary incontinence. PM&R received the second-highest number of referrals, mainly for mild overactive bladder symptoms. While less common, referrals for fecal incontinence and chronic constipation were made, with patients referred to Coloproctology or Gastroenterology as needed. 
The number of referrals increased during the study period. All referrals during this time met the established criteria. 
Analysis of a random sample of 167 patients seen in MS-specific Neurology consultations did not identify any patients meeting the referral criteria who were not referred.

All referrals from Neurology and between departments met the established criteria, with no inadequate referrals identified. The analysis of the random sample did not reveal any symptomatic patients who were not referred appropriately. Therefore, we can conclude that the clinical pathway for MS patients with urinary or fecal dysfunction is effective in identifying symptomatic patients and providing them with appropriate medical care.

Multidisciplinary management of bladder and bowel disorders in MS patients is crucial. This standardized clinical pathway can enhance the care of patients with this complex neurological disorder.