Urodynamic Findings and Long-Term Outcome Management of Patients with Multiple Sclerosis-Induced Lower Urinary Tract Dysfunction

0022-534'//84/ L-i24-G'7~3$02 "OC/0 THE JOlJRNAL GF UROLOGY

Copyright

1984 by The V/itiarns & ·Wilkins Co.

URODY1·,JAivnc LONG-TERrvI MANAGENIENT PATIENTS vVITH Iv1ULTIPLE INDUCED LOVIER URINARY TRACT DYSFUNC'I'ION E. J. McGUIRE

AND

J. A. SAVASTANO

From the Sections of Urology, University of Michigan, Ann Arbor, Michigan, and Yale University, New Haven, Connecticut

ABSTRACT

We studied urodynamically 46 patients between 20 and 74 years old with multiple sclerosis and uncomfortable bladder symptoms. The response to treatment was recorded during a followup of 1 to 10 years (mean 3½ yearn). Lack of response to appropriate therapy predicated on urodynamic testing appeared to be related to progression of multiple sclerosis. As many as 90 per cent of the patients with multiple sclerosis will complain of lower urinary tract symptoms at some time. Management of the lower urinary tract is a medical, social and nursing problem of considerable magnitude. Urodynamic findings in patients with multiple sclerosis include abnormalities of detrusor control, abnormalities of detrusor-sphincter coordination and urethral continence function but there are few reports on long-term responses to treatment predicated on urodynamic findings. 1 - 4 We have followed 46 patients with multiple sclerosis for 1 to 10 years after initial urodynamic evaluation. METHODS

Urodynamic evaluation consisted of residual urine determinations, simultaneous bladder and urethral pressure recordings, and external sphincter electromyography during bladder filling and voiding under fluoroscopic control. These studies were repeated at monthly intervals in patients with continued symptoms or yearly in asymptomatic patients. Monthly urodynamic studies were done until the symptoms were controlled or catheter drainage, condom catheter or diversion was necessary. Patient population. There were 14 men and 32 women between 20 and 74 years old. The patients were referred from neurologists, urologists, gynecologists and general practitioners for incontinence or uncomfortable bladder symptoms. The diagnosis of multiple sclerosis in each patient had been made by a neurologisto Patients with questionable or tentative u.w, 5 uvo,,0 were excluded. Urodynamic evaluation was prompted nary incontinence in every instance, even in those with detrnsor areflexia. RESULTS

Initial urine cultures were positive in 10 per cent of the patients and 4 patients had a symptomatic tract infection following urodynamic testing, a high rate for this laboratory (the usual incidence is 1 symptomatic infection per 200 such studies). Results of urodynamic testing showed 3 discrete patterns of bladder dysfunction (see table). Pattern 1 was characterized detrusor areflexia with poor subjective sensation of bladder events, and inability to relax the external sphincter and initiate voiding. Symptoms included a slow urinary stream, poor voiding, pressure sensation, urgency, incontinence and enuresis (fig. 1). Pattern 2 consisted of simple bladder instability without significant residual urine and relaxation of the external sphincAccepted for publication June 27, 1984. Supported in part by Eastern Paralyzed Veterans Association. 713

ter at the time of micturition. Symptoms included pressure sensation, urgency, incontinence and enuresis (fig. Pattern 3 involved detrusor-sphincter dyssynergia during micturition and difficulty with volitional relaxation of the sphincter (fig. 3). Symptoms included inability to void voluntarily, pressure, urgency and incontinence. Treatment and response to treatment Areflexic bladder function: Two patients with bladder areflexia were treated bethanechol chloride and timed voiding in combination with phenoxybenzamine and dantroline sodium: 1 m,w,m~,,., while 1 did not and was managed by intermittent Eleven patients were treated by intermittent catheterizationo Uncontrollable incontinence developed gradually in 2 patients owing to detrusor hyperreflexia with detrusor-sphincter dyssynergia (1 was treated with a Foley catheter, and 1 external sphincterotomy and condom catheter drainage). Of these 13 patients 10 have been managed satisfactorily for 1 to 6 years by intermittent catheterization, with a mean followup of 3.2 years. Detrusor instability: Of 12 patients with detrusor alone vvho were treated with anticholinergic agents (imipramine hydrochloride and/or oxybutynin chloride) 11 became tomatic and remained so for 1 to 10 years, with a mean of 5 years. The remaining patient suffered intractable incontinence related to detrusor hyperre:flexia and detrusor-sphincter dyssynergia, and was converted to condom catheter drainage after external sphincterotomy. Detrusor-sphincter !'""""''''"" with detrudyssynergia ~'§P"'"~ ...... residual urine volumes were treated by intermittent catheterization and antichoor a combination of pnten,oxyoenzam1ne, diazepam sodium, Of intermittent catheterization and cn,uv.Huc;,. 5 fered intractable incontinence and were rrYnv,c>1·Y.PC1 to Foley or condom catheter UUAm,u5,v following external sphincterotomyo Of the 6 patients by medication alone 4 failed and currently are being managed by suprapubic tube or condom catheter drainage following external sphincterotomy. Follo'l'.rup of the patients who responded to any method of management ranged from 1 to 7 years, with a mean of 3.5 years. The symptoms of multiple sclerosis progressed during the observation interval in only 1 of 18 women who did well with treatment, 2 of 4 who improved but still had occasional difficulty with urinary incontinence and 8 of 10 with a poor treatment response. Among the men studied multiple sclerosis progressed in 3 of 11 with a good response to treatment, while rapid progression occurred in all 3 with no response to treatment or gradual worsening of lower urinary tract dysfunction with treatment.

714

MCGUIRE AND SAVASTANO

Urodynamic findings and results of treatment Response to Treatment

Detrusor areflexia Detrusor instability with relaxation of external sphincter Detrusor-sphincter dyssynergia

9

cHmO

2

ol

Total No. Pts.

Residual Urine

(%)

13 (28) 12 (26)

21 (46)

DISCUSSION

Mean (range)

Asymptomatic and Stable No.(%)

Worse No.(%)

600 (340-1,400) 30 (0-40)

10 (76) 11 (92)

3 (24) 1 (8)

12 (57)

9 (43)

(ml.)

90 (50-120)

lmin

Isl

1----i

Discomfort

1-------------------

...

Vo Ium e

,

350ml

700ml

attempts to void

&'II I

1J

1• • + •s +

a J,._

Urethral EMG

FIG. 1. Areflexic bladder. Bladder filling induces no change in pressure ( Pdet) and no increase in electromyographic (EMG) activity. First sensation of filling (/sf) is delayed and even with some discomfort efforts to void are not accompanied by sphincter relaxation. Equally common urodynamic finding in this group is attempt to void by straining.

90

fsf

i Volume

200ml

Urethral EMG FIG. 2. Detrusor instability with sudden bladder contraction elicited at small volume with no warning occurred at first sensation of filling (ts/). Patient tried to stop wetting but could not. At mid flow electromyographic (EMG) activity is not measurable. Pdet, bladder pressure.

Volume

Progressive symptoms were associated with the development of detrusor-sphincter dyssynergia and intractable incontinence.

200ml

Urethral EMG FIG. 3. Detrusor-sphincter dyssynergia, which was not associated with micturition in this patient but only sensation of painful bladder contraction and inability to release urine. EMG, electromyography. Pdet, bladder pressure.

Progression in this context involved gross deterioration in mobility and ability to perform activities of daily living, and not of mental status. A patient who was ambulatory when first seen and who became confined to a wheelchair had progression.

The results of urodynamic testing indicate that when bladder . symptoms prompt urological referral, about half of the patients already will have established detrusor-sphincter dyssynergia with significant residual urine volumes. The remaining 50 per cent of the patients are divided evenly between those with detrusor areflexia and those with simple detrusor instability. The symptoms of incontinence, a pressure sensation, enuresis, and bladder and urethral irritative symptoms were of no differential value. However, 28 per cent of the patients presented with areflexic detrusor dysfunction even though detrusor instability was a more common problem. Multiple sclerosis patients cannot be assumed to have detrusor instability simply because they have the disease. Patients with areflexic detrusor dysfunction appear to be treated best by intermittent catheterization. Of the 13 patients in the areflexic group 10 remained asymptomatic and stable on intermittent catheterization, while 2 became worse with that method of management. Worsening of symptoms was owing to the development of detrusor hyperreflexia with sphincter dyssynergia. When urological symptoms increased they frequently were associated with progression of the neurological disease. Simple detrusor instability without significant residual urine volume responded predictably to anticholinergic agents. Of the patients so treated 92 per cent remained stable for protracted intervals while taking relatively small doses of anticholinergic agents. Detrusor-sphincter dyssynergia with significant residual urine is the most common expression of lower urinary tract dysfunction in patients with multiple sclerosis. Only 57 per cent of the patients with this type of lower urinary tract dysfunction were treated satisfactorily. The best response to treatment was attained by vigorous anticholinergic therapy, combined with intermittent catheterization. Anticholinergic agents given without institution of intermittent catheterization precipitated urinary retention. The 50 per cent of the patients who had deterioration with treatment often had progression of the generalized neurological disease. These findings suggest that a cystometrogram that demonstrates reflex bladder contractility is a useful urodynamic study in the majority of patients with multiple sclerosis. Patients with significant residual urine volumes and reflex bladder contractility almost invariably have detrusor-sphincter dyssynergia. Roughly 40 per cent of these patients demonstrate progression of neurological disease and a poor response to urological treatment. The best long-term method of management of this patient group was a combination of anticholinergic agents and intermittent catheterization. On the other hand, patients with unstable reflex bladder contractility without sphincter discoordination and who have no or minimal residual urine volumes can be expected to do well if they are treated with anticholinergic agents alone. Only 1 of the 12 patients with detrusor instability alone showed progression of IJlultiple sclerosis and failure of response to treatment. Thr!le of every 4 patients with detrusor areflexia can be treated 'effectively Qy intermittent catheterization, while 1 will suffer incontinence unresponsive to anticholinergic agents and ultimately may require catheter drainage or sphincterotomy and conversion to a condom catheter appliance as a result of detrusor hyperreflexia and sphincter discoordination. Intermittent catheterization clearly is a problem for patients with multiple sclerosis but we used that method preferentially since catheter drainage or diversion led to problems more serious than the inconvenience of intermittent catheterization. When feasible, the patient performed the catheterization and, when not, a family member, caregiver or visiting nurse did the procedure. One of the problems that emerged during this study was

URODYNA1V1IC FII~D!]\JG~:_; Al~D IvIAI~AGElVIE~T CF' PATIENTS V/ITl-1 f'iiULTIPLE SCLEROSIS

related to the of the agement of the neurological disease of the Patients who initially did well with a method of urological treatment often appeared for a followup study with a Foley catheter in place. This generally occurred when sudden incontinence was reported to another physician or a visiting nurse and was treated promptly the institution of catheter drainage. Foley catheter drainage in patients with reflex detrusor activity and detrusor-sphincter dyssynergia is only transiently effective in relieving incontinence, and may further impair lower urinary tract function and make subsequent conversion to an areflexic bladder by drugs and intermittent catheterization difficult or impossible. The tendency of other medical care providers to use Foley catheter drainage to achieve a ~,>Jov;,o,,o

715

short-term solution to a long-term problem can be circumvented providing the patient with a regular followup appointment that should be within 1 week to 10 days after the institution of therapy. REFERENCES

K B.: Vesicourethral dysfunction in multiple sclerosis. J. Urol., 122: 342, 1979. 2. Andersen, J. T. and Bradley, W. K: Bladder and urethral innervation in multiple sclerosis. Brit. J. UroL, 48: 239, 1976. 3. Goldstein, I., Siroky, M. B., Sax, D. S. and Krane, R. J.: Neurourologic abnormalities in multiple sclerosis. J. Urol., 128: 541, 1982. 4. Schoenberg, H. W. and Gutrich, J. M.: Management of vesical dysfunction in multiple sclerosis. Urology, 16: 444, 1980. 1. Blaivas, J. G., Bhimani, G. and Labib,