Urologic Complications of Neurologic Disease, Focus on the Patient with Multiple Sclerosis - Lysanne Campeau

(Length of Discussion: 12 min)

A conversation with Lysanne Campeau and Ben Brucker on treatment options for Multiple Sclerosis patients who present with neurologic disease. In this at-risk population, clinicians must consider comorbities, polypharmacy and the level of disability for each patient. The role of counseling appropriately to include the patient in the treatment decision plan is a routine practice for these providers.

Biographies:

Lysanne Campeau, MDCM, Ph.D, FRCSC, Assistant Professor, Urology, McGill University, Montreal, Quebec, Urologist, Jewish General Hospital, Clinical Researcher, Lady Davis Institute

Benjamin M. Brucker, MD



Dr. Ben Brucker: Hi. I'm Ben Brucker, and I'm joined today on UroToday with Lysanne Campeau. Lysanne is a basic scientist but also clinician. She had done her Ph.D. in neuro-urology and now has a neuro-urology practice. Lysanne, why don't you just tell us a little bit about yourself and then we'll get started talking about neuro-urology.

Dr. Lysanne Campeau: All right. I am an assistant professor at McGill University in the division of urology and a Urologist at the Jewish General Hospital. I also do some research both at a basic and at a clinical level.

Dr. Ben Brucker: The patient population I wanted to talk about specifically with you, given your expertise, are the MS patients, and the lower urinary tract symptoms that affect MS patients. For those that are watching that may not be as familiar with the different presentations of MS, the patients that you're seeing, are these ambulating patients? Are they bed bound and institutionalized patients? Who is it that as a Urologist now you're actually clinically treating that has MS who's presenting with LUTS?

Dr. Lysanne Campeau: There's such a wide variety of presentation for these patients. We know that a large proportion of these patients will develop lower urinary tract symptoms at one point or another in their condition. I think what's important to assess when you see these patients is what kind of MS do they have? Establish their disability from their MS and then based on that, you can dwell or spend a lot more time looking at how much the MS actually affects their urinary symptoms and causes problems, either quality of life or other things.

I think one thing to consider is that there are other conditions besides their neurogenic urinary tract dysfunction that can present in these patients, and a lot of them are women. They can develop stress urinary incontinence. They can develop overactive bladder syndrome, as well.

Dr. Ben Brucker: It's a great point. Again, we sometimes see in men, for example, neurologic conditions that they have concomitant BPH or another cause for their outlet obstruction. You mentioned the idea that women can have stress incontinence. If you had a 50-year-old multiparous woman who came in complaining of incontinence, who was not in an MS clinic or sent by a Neurologist, you'd sort of go down one pathway. I think sometimes we do overlook the possibility of other concomitant causes for incontinence.

Are there considerations you have or things that you do a little bit differently, perhaps, in a 50-year-old, maybe G3 woman who comes in complaining of incontinence and if you do elect to treat her?

Dr. Lysanne Campeau: I think if they're known to have MS, your evaluation has to be a lot more thorough. Your baseline evaluation before considering any surgical option for their stress urinary incontinence has to include a urodynamic study in my opinion. In order to assess, do they have any component of detrusor-external sphincter dyssynergia, how is their voiding ability before I consider treating your stress urinary incontinence with any surgical options. Whether they have MS or not, I have to go through a thorough evaluation, but I think that you have to look for other things in a patient with MS. 

Dr. Ben Brucker: Yeah. One of the challenging I guess patient groups are those stress incontinence patients that also have some incomplete bladder emptying. Thankfully, it's not super common in the women that I am seeing, but it does happen. Are those patients that you again put a sling in or sort of are you going to really just push the conservative therapies and hope that they don't want a surgical correction for their incontinence?

Dr. Lysanne Campeau: It's funny because we know based on the data that true external sphincter dyssynergia is not that common in this patient population; however, in my practice, I see a lot of patients complaining of voiding symptoms. Now, whether or not they have demonstrated the true external sphincter dyssynergia on urodynamic study is not always the case. I always consider this aspect before considering a Mid Urethral sling or a Pubovaginal sling. 

Dr. Ben Brucker: Are you pushing one way or the other because of the fear of potential catheterization or you think that it is reasonable to keep the morbidity low and just place a synthetic sling.

Dr. Lysanne Campeau: I think it goes back to counseling. I think if we counseled the patient appropriately and we let them know about the risks, and ultimately they are the ones making the decision of how effective they are by the conditions and what they are comfortable doing. I think that many of these women would benefit from an NT continence surgery. I do not think that we should just let them suffer from their condition, but I think you can consider other options, whether it be urethral blocking agents or more conservative options like we have right now, NT continence pessaries or other things. Really it depends on patient's preference and presentation.

Dr. Ben Brucker: I think I've actually in my practice have been very satisfied with outcomes, and again, it does come down to what you elude it to, which is a subtle, perhaps clinical judgment to sort of figure out what's right for the patient and what's bothering them. Certainly, we talk about in progressive neurologic conditions, what happens if something happens years down the road; but, I still think that if a patient comes in complaining of leakage and you can demonstrate stress incontinence, it certainly may be reasonable. 

What about your overactive bladder, sort of treatment paradigm? Is it any different in the MS patient versus the idiopathic patient for you, men and women alike?

Dr. Lysanne Campeau: I think there is a lot of commonality in terms of what medications we can use to treat these patients. A lot of different anticholinergic drugs are good options for these patients; Beta-3 agonist, a combination or botox. We have many different options that we use in the idiopathic overactive bladder population. You have to consider their comorbidities, their other medications that they are on, and also their level of disability from the condition, and are these patients going to be able to catheterize or not. Are you eventually going to need a suprapubic in this patient and you also have to consider that a good proportion of patients that we see are relapsed or remitting, but that these patients may progress to secondary progressive and will have a very different presentation at that point.

Dr. Ben Brucker: You brought up a topic that I think I have seen debated; the suprapubic tube for example versus urinary diversion, versus diaper and/or sphincterotomy and/or condom catheter. So specifically, does suprapubic tube in your practice is that a tool that you are comfortable using, do you use that? What are your thoughts on let's say the patient that is perhaps somewhat mobility, unable to get around, and you are not sure they can learn catheterization or they have vision issues and sort of dexterity. Is suprapubic tube a next step, is it the final step? How does that factor into your practice?

Dr. Lysanne Campeau: I'm quite liberal about the use of suprapubic catheter. I have had very good outcomes. Patients do very well most of the time and I find that the morbidity is quite low. Depending again on patient preferences and the stability, I find that a certain group of patients would do very well with a suprapubic catheter. 

When you are deciding between a suprapubic or a more reconstructive surgery, I think you have to take into consideration the morbidity involved in a large reconstructive procedure. As long as you follow these patients well with the suprapubic catheter and you are managing their possible complications, whether it be stones or infections, I think they can do very well for a prolonged period of time.

Dr. Ben Brucker: I think that it does come down again, that counseling piece, that I think has been a common theme when you think about it and talk to people about neuro-urology no different than anything else certainly; but, there are certain complexities and even a decision to place a suprapubic tube, I think I rarely make the first time you meet the patient, these are patients that you begin to develop a bit more of a relationship and rapport with to understand when to utilize. 

More I guess short term treatments or may be even specific to nocturia. Nocturia issue for these patients, any special consideration for the MS patient who may be somewhat mobility limited?

Dr. Lysanne Campeau: I think nocturia can present in any lower urinary tract symptom presentation. I can't see the majority of them necessarily have nocturia, I think I see nocturia a lot more commonly in other neurogenic lower urinary tract dysfunction like Parkinson's disease for example. A good proportion of them will have nocturia and you have to consider that they may a decreased bladder capacity that's likely contributing to that problem.

Dr. Ben Brucker: You mention the suprapubic tube having a role and one of the therapies that we have available, onabotulinum toxin. Have you used that at all as an add-on therapy for that suprapubic tube patient that still has leakage, and if so, how is its success with that?

Dr. Lysanne Campeau: It's interesting, we have very little data available on that subject, but I think that it can be an adjunct to the management during incontinence. It could be either adjunct to if they have persistent urinary incontinence per urethra or I have used it in certain patients who have I know a decreased bladder capacity, they have a recurring blockage or recurrent urinary tract infection really, but without any significant data to rely on.  I have had good outcomes on some of these patients. I think it is an additional tool that we have to control their neurogenic bladder, and it can definitely be used in a context of a suprapubic catheter.

Dr. Ben Brucker: Sort of backing off maybe before we get into some other reconstructive procedures, when we are dealing with patients with MS, and let's say your ambulating population that is able to catheterize if they needed to, botox, or onabotulinum toxin, how do you use it? What doses do you use and what's your outcomes with that clinically.

Dr. Lysanne Campeau: I think there is a very good role of onabotulinum toxin for patients with neurogenic bladder related to MS. I consider MS a very heterogeneous group and there are patients that are as you mentioned ambulatory but maybe not necessary catheterizing, they are still voiding on their own, but they have significant overactive bladder. In those patients who have a more presentation of idiopathic then I will use 100 units. I will do a urodynamics study beforehand and determine their voiding ability, is there is any component of the detrusor-external sphincter dyssynergia that may make them at a little higher risk for requiring catheterization. That's involving the counseling of these patients, but if these patients are already catheterizing, and they have significant urinary incontinence related to their condition, then I may push the dosage to 200 units. 

Dr. Ben Brucker: I think starting with 100 units certainly again and idiopathic, I think you laid it out nicely. Interestingly, I have not found the urodynamics as useful in some of those ambulating idiopathic looking patients. I do see a little bit of signal I think in the Parkinson's patients that do void with higher pressures and perhaps they do a little bit worse with onabotulinum toxin, but I think it is interesting food for thought as we take some of these therapies and use them in these heterogeneous populations. 

Fast-forwarding a little bit now, we talked about suprapubic tube. We backtracked and talked a little bit about onabotulinum and some of the affects it can have on bladder emptying. What about reconstructions, so whether it is an augmentation cystoplasty, pubovaginal sling, ileal loop, or continent catheterizable channel. You have a preference in your MS patients and I guess the little asterisk will say, we will quote you on saying that a lot of these patients will develop secondary progressive disease, so with that loaded question what do you think?

Dr. Lysanne Campeau: I have to say that the patients with MS that require reconstructive surgery are few and far between. There are not that many that will eventually need reconstructive surgery, or at least the more major ones. I am not necessarily referring to the Pubovaginal sling, but the ileal conduits and the continent diversions. 

In my experience, I find that when they get to the point where either suprapubic catheter is no longer an option because their bladder has contracted too much or they are not candidates obviously for intermittent catheterization, botox is just not doing it. I find that the only option in the patient population are an ileal conduit and usually because the disability level has progressed significantly. At that point, I don't think they are a candidate for continent diversion, so most of the patients with MS that I have to do reconstruction, usually when were ileal conduit, non-continent diversion.

Dr. Ben Brucker: It does sound like our practices are somewhat similar in terms of the types of patients we see. I know that in some parts of the world, the MS patients that are seen are much more debilitated and more progressed diseased, or they are coming to urology later and certainly then reconstruction becomes more of an issue. I think it sounds pretty similar.

I would like to thank you for taking some time to talk about neurologic, I guess urologic complications of neuro-urology or neurologic diseases. I think that the MS population is as you mention sort of a population that is an at risk population for issues, and I think the great work that you do and all of your basic science research will hopefully continue to shed light on this patient population. Thanks again for joining us.

Dr. Lysanne Campeau: Thank you.
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