| Voiding complaints are frequently found in patients with multiple sclerosis and have a devastating impact on quality of life. In an unselected study population 52% of the multiple sclerosis (MS) patients had voiding complaints (Koldewijn et al. 1995). The most common voiding complaints are urgency, frequency and urge incontinence. Even a more striking finding is that lower urinary tract dysfunction exists in more than half of the patients without voiding complaints (Bemelmans et al 1991). Since a poor correlation exist between voiding complaints and lower urinary tract dysfunction, a careful urological examination is mandatory in every MS patient with indications of urinary tract problems. Therapy should be based on facilitating bladder emptying and increase of bladder capacity. A variety of therapeutic options are available for the treatment of lower urinary tract dysfunction. For the treatment of detrusor hyperreflexia anticholinergic medication is first line treatment. In case of bladder emptying problems, intermittent clean catheterization should be started. Most patients can be treated with conservative measures. However, a significant number of patients do not respond to standard therapy. For this group of patients invasive, irreversible surgery, like augmentationcystoplasty, bladder replacement or urinary diversion is sometimes the only solution. Neuromodulation by sacral nerve stimulation (SNS) can serve as an intermediary between conservative and radical surgical treatment options. Neuromodulation is a reversible minimal-invasive surgical treatment with proven efficacy in patients with refractory urge-incontinence, urgency frequency or urinary retention (Bosch et al 1995, Bemelmans et al 1999, Hassouna et al 2000, Jonas et al 2001). It has a very low morbidity and a short operation time. These features make it a surgical procedure that is extremely suited for MS patients. If the treatment would be successful in patients with MS they would gain an important increase in quality of life. Chartier-Kastler, Bosch et al (2000) showed in 5 patients the efficacy and the feasibility of this treatment in MS patients with detrusor hyperreflexia during 55 months follow-up. Unfortunately, because there are only 2 small studies, it is still impossible to predict which patient will benefit from this treatment and to what extent the benefit will be. In this study neuromodulation as a treatment for voiding problems in MS patients will be studied. The impact on quality of life will be studied. Neurological and urological factors will be studied in MS patients with urgency, frequency and urge incontinence complaints in order to try to define predictive success factors, although Koldewijn et al (1994) failed to demonstrate predictive urological factors for success of the treatment in patients with non-neurogenic bladder dysfunction. Since the stimulation of the sacral roots with neuromodulation also affects bowel functions and neuromodulation is also used nowadays for fecal incontinence, the effect on bowel functioning will also be studied. SNS is a reversible, minimal invasive and efficacious treatment for voiding dysfunction. Therefore it seems extremely suited for MS patients. Beneficial results were found in a small number of patients, as was pointed out by Chartier-Kastler, Bosch et al. At the moment the momentum exists to investigate the feasibility of this expensive treatment in MS because four involved partners already are committed to invest a major amount of money in this project. A fifth partner would complete the project. |
