Multiple sclerosis (MS) is a chronic progressive neurological disease that is more likely to affect young adults. In addition to sensory disturbances, spasticity, weakness, depression and cognitive problems, MS is well known for having significant harmful effects on bowel, bladder and sexual function, worsening the quality of life. Although pelvic dysfunctions are common in patients with MS, they remain underdiagnosed. The aim of the study is to evaluate the prevalence of symptoms that characterize pelvic floor dysfunctions in patients with MS, to understand which symptoms are more common in this type of patients, the rehabilitation plan applied in this field and how they affect their quality of life.

We included patients aged between 18 and 65 screened from reading the medical records, with relapsing-remitting MS (RR) and secondarily progressive (SP) of mild group A (EDSS ≤ 3) and moderate grade group B (EDSS> 3-7). Cases with EDSS ≥ 7, primarily progressive MS (PP), progressive relapsing (PR) and clinically isolated syndrome (CIS) forms, bladder catheter, severe cognitive-behavioral disorders and dementia were excluded. The first 34 consecutive eligible patients were recruited. 
Patients must agree on informed consent to be included. The evaluation of pelvic floor symptoms was performed using the following assessment scales: IQOL and ICIQ-SF (>=1) for urinary incontinence (UI); OAB V8 for over active bladder (OAB); WEXNER Score (>=1) for fecal incontinence (FI); ODS Score (> 5) for obstructed defecation syndrome (ODS); MC.GILL PAIN Questionnaire, to evaluate chronic pelvic pain (CPP); WHODAS-12 for perceived health status. Furthermore, pelvic floor muscle assessment was performed, which includes: external evaluation of pelvic contraction (central fibrous nucleus) and PC test. The result was recorded using the PERFECT method and the OXFORD Scale (< 3).

The percentage of patients reporting symptoms of pelvic floor dysfunction was 99%: only 1 in 34 had no symptoms of pelvic floor dysfunction. 33 patients had a positive OAB V8 score; 11 reported persistent pelvic pain for more than 6 months, 2 of whom reported dyspareunia. As for FI, 11 subjects tested positive on the Wexner score. There is a linear correlation between ICIQ and IQOL, with relative impact on the quality of life (fig 1 and fig 2). Regarding ODS, 17 patients had an ODS score > 5. Muscle assessment was performed in 31 patients, of whom only 11 had an Oxford score ≥ 3, indicating a valid contraction, and there was no correlation between the Oxford score and the presence of pelvic floor symptoms, i.e. the patient with all negative rating scales did not present an Oxford score ≥ 3. Analyzing the WHODAS-12 results, there is a non-proportional correlation between perceived health status and clinical status. Of the 33 symptomatic patients, only 2 patients received a pelvic floor rehabilitation treatment in the past.

The study shows that although the diagnosis of these disorders is underestimated, the prevalence of pelvic floor symptoms in patients with MS is very high. Specifically a strong presence of OAB was highlighted (OAB-wet and OAB-dry 33 out of 34), UI (26 out of 34), IF (18 out of 34) and ODS (17 out of 34) has been found. There were less frequent symptoms of chronic pelvic pain. Although pelvic floor rehabilitation is strongly recommended in treating these symptoms, only 2 patients knew this type of rehabilitation. 
It is important to raise awareness among healthcare professionals and patients about these therapeutic opportunities to manage this kind of impairment.

The results of the study indicate that the analysis and treatment of pelvic dysfunctions is neglected although it should be part of the therapeutic priorities in patients with MS as important part of the rehabilitation plan. These kind of symptoms are often underestimated due to modesty or as shown by the Who-das results, because patients are more worried about motor dysfunctions that their related symptoms.
Untreated cases could generate clinical complications, increase the disability and strongly interfere with quality of life.

Bladder, Bowel and sexual Dysfunction in multiple sclerosis     Hawker KS, Frohman EM ;Curr Treat Options Neurol. 2001 May
Pathophysiology and management of bowel dysfunction in multiple sclerosis     Wiesel PH, Norton C, Glickman S, Kamm MA ; Eur J Gastroenterol Hepatol 2001 Apr
Pelvic floor rehabilitation in multiple sclerosis De Ridder , Vermeulen C, Ketelaer P, Van  Poppel H, Baert L.; Acta Neurol Belg. 1999 Mar;99(1):61-4