Hypothesis / aims of study
Background: Multiple Sclerosis (MS) is increasing in pediatric population. As in adults, symptoms vary among patients, but in children the first manifestations can overlap with acute neurological symptoms causing a missing diagnosis. Urological symptoms have not been much studied in childhood. We retrospectively reviewed our experience with MS considering urological manifestation in pediatric population.
Study design, materials and methods
We retrospectively reviewed clinical charts of all patients with MS diagnosis and urological symptoms evaluated at our pediatric urology division, in the last five years, from January 2019 to January 2024. We included all patients with MS and urological symp-toms onset before the age of 18 years. In accordance with our institutional guidelines, written consent was obtained from parents and Scientific/Ethical committee informed.
MS was diagnosed and classified according to Krupp criteria.We collected demographic and clinical data, including onset symptoms, magnetic reso-nance (MR) localization of demyelinating lesions, timing of onset and type of urological symptoms. We reviewed all data related to diagnostic pathway and clinical manage-ment to critically assess our approac
Results
About 81 patients with diagnosis of MS, 6 patients presented urinary symptoms and were referred to our division of pediatric urology. The incidence of lower urinary tract dysfunction (LUTD) in our series was 7.4%. 4 were females, 2 males. The median age at time of MS diagnosis was 14,55 years (range 11,4-17,3 years). Urinary symptoms were already present at time of MS diagnosis in 2 patients (one with worsening of known voiding problems during MS onset), in 4 patients symptoms appeared within 6 months and 5 years from MS diagnosis. Urinary symptoms were characterized by urinary incontinence in five patients (one also with enuresis) and urinary retention in one. Urinary ultrasound showed the absence of urinary tract dilatation in all patients.Three patients underwent invasive urodynamic exams that diagnosed an overactive bladder (OAB) in one case, acontractile detrusor in another and detrusor-sphincter dys-synergia in the remaining one. Two patients underwent non-invasive urodynamic evaluations only, due to lack of patients’ collaboration.Regarding the management of LUTD, 1 patient refused any urological therapy and was lost at follow-up. The remaining 5 patients were initially managed with standard uro-therapy; 1 of these resolved completely the urological manifestations due to the change of MS therapy and standard urotherapy. Three patients needed clean intermittent cathe-terization (CIC), 2 of them were also on pharmacological therapy with oxybutynin and intradetrusor Onabotulinum Toxin A (BTX-A) injection.
Three patients reported constipation, and one of these was the boy with previous spinal dysraphysm. Two of these were managed with TAI (trans-anal irrigation); one declined therapy. No patients reported fecal incontinence.
Interpretation of results
In pediatric population, MS generally appears with focal deficits such as unilateral weakness, numbness or paresthesia but also visual loss, ataxia, and transverse myelitis.An important differential diagnosis, is with the Acute Disseminated Encephalomyelitis (ADEM). ADEM is characterized by focal symptoms too, but it is more common in children than MS. Differentiating between ADEM and MS poses significant challenges.Clinical history can be helpful for differentiation: ADEM typically manifests as a monophasic demyelinating disease with seizures or behavioural disorders.The localization of demyelinating lesions doesn’t seem to be correlated with the onset of urological manifestations.Since MS affects multiple central nervous system regions and it is a progressive disease, a wide spectrum of urodynamic diagnosis can be recorded. LUTD is reported in about 50-90% of patients with MS . Frequency and urge incontinence, are present with a prevalence of 37-99%, representing neurogenic OAB which is the most frequent report in MS patients, ranging from 34 to 99% of these UD exams, while Detrusor underactivity is described in a mean of 25% of MS urodynamic tests (ranging from 0 to 40%). There is limited data about urological manifestation in MS pediatric patients. Scheepe et al described presence of LUTD in children affected by MS, especially in those with a higher Disability Status. In our series, five patients exhibited urinary incontinence and one showed retention symptoms. We encountered initial resistance to urodynamic evaluation and/or starting CIC from patients and their parents; these events could therefore delay urological diagnosis and/or the related treatment , increasing the risk of chronic renal failure.
Particular attention should be paid to pediatric patients with MS, because often under-report urological symptoms due to prevalence of others neurological symptoms. In case of urological anomalies detection, the evaluation must be in-depth by the neuro-urologist, including questionnaires, bladder diaries, urinary tract ultrasound and assessment of post-void residual, urinalysis, blood exam to assess renal function, urodynamic tests (inva-sive and/or non-invasive exams), cystoscopy.
Concluding message
Although considered a rare diagnosis in pediatric age, MS must be suspected in adolescents with LUTD associated with some neurological manifestations.Pediatric population diagnosed with MS are highly vulnerable to cognitive impairment, that beyond physical disability may be a cause of depression or other psychological disturbances, that may contribute to patients' low functional outcomes . For these reasons, a multidisciplinary management is suggested, involving neurologist, physical re-habilitation, physician, psychologist, urologist, to define individualized rehabilitative treatment, improving MS complications management, quality of life, psychosocial care. We advocate that an early urological evaluation after the diagnosis of MS could be useful in all.