First-Line Treatment for Urinary Urgency in Multiple Sclerosis

Treatment Algorithm

Behavioral therapies, including bladder training, pelvic floor muscle training, and fluid management strategies, should be offered as first-line treatment for urinary urgency in multiple sclerosis patients, as recommended by the American Urological Association 1
Weight loss is recommended for patients with obesity, as it can reduce urgency urinary incontinence episodes, according to the American Urological Association 1
Fluid management with appropriate intake reduction, typically 25% reduction, is recommended for patients with urinary urgency, as suggested by the American Urological Association 1

Mirabegron is recommended as the preferred second-line pharmacological option due to its lack of impact on cognitive function, which is important in multiple sclerosis patients, as stated by the European Association of Urology 2, 3
Mirabegron has a lower risk of urinary retention compared to antimuscarinics, according to the European Association of Urology 3
Regular blood pressure monitoring is required when using mirabegron, especially during initial treatment, as recommended by the European Association of Urology 3
Antimuscarinic medications should be used with extreme caution in multiple sclerosis patients due to the risk of urinary retention, especially in patients with neurogenic bladder, as warned by the American Urological Association 2, 4
Antimuscarinic medications can cause potential cognitive impairment, which can worsen existing multiple sclerosis-related cognitive issues, according to the American Urological Association 2, 5

Post-void residual volume should be assessed before starting treatment, especially with antimuscarinic medications, as recommended by the European Association of Urology 4, 6
Antimuscarinic medications should be avoided in patients with post-void residual volume greater than 150 ml, as advised by the European Association of Urology 6

Combination approaches, such as adding beta-3 agonists to antimuscarinic therapy, may be considered for patients with inadequate response to monotherapy, as suggested by the American Urological Association 5, 7
Behavioral therapies should be continued alongside pharmacological treatments, as recommended by the American Urological Association 2, 5

Bladder diaries should be used to document voiding behavior and treatment efficacy, as recommended by the American Urological Association 1
Validated symptom questionnaires can help quantify bladder symptoms and treatment response, according to the American Urological Association 1
Regular assessment of post-void residual volume is necessary, especially in patients on antimuscarinic therapy, as recommended by the European Association of Urology 6

Initiating antimuscarinic therapy without checking post-void residual volume should be avoided, as warned by the American Urological Association 4, 6
Using antimuscarinic medications in patients with cognitive impairment or at high risk for dementia should be avoided, as advised by the American Urological Association 2
Mirabegron should not be used in patients with severe uncontrolled hypertension, as warned by the European Association of Urology 3

Urodynamic studies should be performed in MS patients with storage symptoms that place their upper tracts at risk, as recommended by The American Urological Association 8
Posterior tibial nerve stimulation (PTNS) may be offered to select MS patients with urgency, frequency, and/or urgency incontinence who can spontaneously void, according to The American Urological Association 8

Antimuscarinic medications should be used with extreme caution in MS patients due to high risk of urinary retention, especially in patients with neurogenic bladder, and potential cognitive impairment, as reported by The American Urological Association 9
Antimuscarinic medications should be avoided in patients with narrow-angle glaucoma, as recommended by The American Academy of Ophthalmology 9, 10
Antimuscarinic medications should be avoided in patients with impaired gastric emptying, as reported by The American Gastroenterological Association 9
Options for antimuscarinic medications include oxybutynin, darifenacin, fesoterodine, solifenacin, tolterodine, or trospium, as listed by The American Urological Association 10

Sacral neuromodulation (SNS) may be offered as third-line treatment in carefully selected patients with severe refractory symptoms, as recommended by The American Urological Association 10
Intradetrusor botulinum toxin injection may be offered to patients with inadequate response to or intolerable side effects from pharmacotherapy or behavioral therapy, as reported by The American Urological Association 9

Repeat urodynamic studies at appropriate intervals following treatment in patients with impaired storage parameters, as recommended by The American Urological Association 8
If initial therapy is ineffective at reducing elevated storage pressures, additional interventions should be offered, according to The American Urological Association 8