The prevalence of urinary incontinence in women who have multiple sclerosis (MS) is dramatic, according to research recently published in the International Neurourology Journal. The authors conducted the study within a treatment center that is dedicated to the care of patients with MS. Out of the 143 women surveyed, stress UI occurs in 55.9%, urge symptoms in 70.6%, and 44.8% had both stress and urge symptoms, also known as mixed incontinence. The authors report that the condition of UI significantly impacts quality of life (QOL.) The Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) were utilized to collect data about both stress and urge urinary symptoms and QOL impact. Women in the study ranged in age from 20-72 years of age, and the subjects who reported stress urinary incontinence were older and tended towards a higher body mass index (BMI). The women with complaints of stress UI also scored higher on the Incontinence Impact outcomes survey as it related to physical activity. This article is available for free in full-text format by clicking here.
One of the challenges for the patients who have MS and for the providers who work with them is the potential fluctuation in symptoms. This chronic neurologic disease is characterized by "flare-ups" that usually require a period of medical intervention followed by a time of recovery in which the patient often has to gradually return to prior levels of function. Neurologic lesions of MS can occur in varied levels of the nervous system, thereby influencing the neurologic control of the urinary system to a varying extent. If a patient is going through a flare-up it may be best to limit the amount of intervention such as strengthening of pelvic muscles until the exacerbation has eased. Some patients are fortunate to experience periods of relative stability in symptoms, even so, fatigue and the risk of increasing fatigue through overactivity is significant. During your subjective history taking, you can inquire of the patient how the disease has tended to manifest for him or her, and then inquire about stability of symptoms and the patient's warning signs for fatigue. It is also important to screen for signs of a urinary tract infection (UTI), as UTI's frequently occur in this patient population. Regarding objective examination, it is imperative to assess the patient's current level of pelvic muscle awareness, strength, sensation, coordination, and endurance. The patient may return for another bout of care at a different time and present with very significant differences in level of function, therefore it is not safe to assume that the patient has a similar baseline to the last bout of therapy.
In my clinical experience, patients who have MS often experience both urge and stress symptoms. For clarification of this terminology, please click here. Utilization of electrical stimulation for either strengthening or neuromodulation of urge symptoms can be a useful adjunct to education and home program management. You can use the knowledge that you have regarding application of electrical stimulation for any patient population, with the consideration that significant fatigue should be avoided. This requires that your exercise prescription skills are applied carefully to the patient's current level of strength and endurance, with close follow-up prior to any increase in home program strengthening. An earlier study by McClurg et al. (2008) suggested that electrical stimulation in addition to pelvic muscle training and biofeedback should be offered as a first-line treatment for lower urinary tract dysfunction in MS. Sacral nerve stimulation is also an option that your patient may have utilized or is interested in discussing. Information about sacral nerve stimulation can be found here. The National MS Society in the US has a clinical bulletin published regarding many medical topics for both health care professionals and patients. The bulletin regarding urinary incontinence can be accessed here, and although it does not discuss the use of rehabilitation, there is a useful algorithm that medical providers are utilizing for the treatment of UI, and the bulletin also emphasizes that early referral to an urologist is important. The study referenced in the first paragraph of this posting points out that the majority of patients in their study were consulting with a neurologist, but not a urologist. It is also significant to remember that urinary symptoms may be one of the first signs of a neurologic disease or condition, and that medical evaluation must be completed prior to rehabilitation commencing so that conditions may be identified and treated early in the process.