Management of bladder dysfunction in multiple sclerosis: a systematic review and meta-analysis of studies regarding bladder rehabilitation

Abstract

Introduction: The aim of the study was to investigate the efficacy of rehabilitation programs for bladder disorders in patients with multiple sclerosis (MS) and to guide physicians in delineating therapeutic tools and programs for physiatrists, using the best current strategies.

Evidence acquisition: A search was conducted on PubMed, EMBASE, the Cochrane Library and Web of Science. Studies were eligible if they included adults with bladder disorders related to MS and described specific treatments of rehabilitation interest. The search identified 190,283 articles using the key words "multiple sclerosis" AND "rehabilitation" AND "urinary" OR "bladder," of which the reviewers analyzed 81 full-texts; 21 publications met the criteria and were included in the systematic review.

Evidence synthesis: The systematic review identified the specific rehabilitation treatments reported in the current literature. The meta-analysis compared the scores and scales used to quantify bladder disorders due to MS, both before and after rehabilitation or in a comparison with a control group.

Conclusions: The present study suggests the need of a specific therapeutic protocol, based on the degree of disability and symptom complexity in patients with MS-related neurogenic lower urinary tract dysfunction (NLUTD). Particularly, the meta-analysis shows the effectiveness of peripheral tibial nerve stimulation (PTNS) and pelvic floor muscle training (PFMT) for neurogenic detrusor overactivity (NDO). However, the goal of physiotherapy is to treat incontinence without making urinary retention worse and vice-versa, reducing the loss of urine urgency, while ensuring the emptying of the bladder.

Figure 1

—Flowchart of the process for the literature search and extraction of studies meeting the inclusion criteria.

Figure 2

—Forest plot of Supplementary Table V: A) effectiveness of 3 months of peripheral tibial nerve stimulation in daytime frequency before and after treatment; B) effectiveness of 3 months of peripheral tibial nerve stimulation in nocturia before and after treatment; C) effectiveness of 3 months of peripheral tibial nerve stimulation in urge incontinence before and after treatment; D) effectiveness of 3 months of peripheral tibial nerve stimulation in voided volume before and after treatment; and E) effectiveness of 3 months of pelvic floor muscle training in voided volume before and after treatment.^{20, 21, 23, 26, 30, 33}

Figure 3

—Forest plot of Supplementary Table VI: effectiveness of 3 months of pelvic floor muscle training in PERFECT scheme (P power, E endurance, R repetitions, F fast contraction, ECT every timed contraction) versus no treatment.^{25, 26, 33, 39}

Figure 4

—Forest plot of Supplementary Table VII: effectiveness of 3 months of peripheral tibial nerve stimulation in maximum cystometric capacity before and after treatment.^{22, 23, 26, 27}