Neurourology and Urodynamics 35:39–43 (2016)
Voiding Dysfunction in Patients With Neuromyelitis Optica Spectrum Disorders Fabricio Leite de Carvalho,1 Cristiano Mendes Gomes,1* Samira L. Apostolos-Pereira,2 Jose Bessa Jr,1 Marcello Pinheiro,1 Paulo E. Marchiori,2 Homero Bruschini,1 Miguel Srougi,1 and Dagoberto Callegaro2 1
Division of Urology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil Department of Neurology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
Aims: We assessed the lower urinary tract symptoms (LUTS) and urodynamic findings in patients with neuromyelitis optica spectrum disorders (NMO-SD), a recently defined neurological disease. Methods: We prospectively evaluated seven men and 23 women (mean age 41.1 13.5 years) with an established diagnosis of NMO-SD who were invited to participate irrespective of the presence of LUTS. Neurological evaluation was assessed with the Expanded Disability Status Scale (EDSS) and LUTS were evaluated with the Overactive Bladder questionnaire (OAB-V8) and the International Prostate Symptom Score (I-PSS). All patients underwent videourodynamics, transabdominal urinary tract sonography, urine culture, and serum creatinine levels. Results: The mean time of disease duration was 33.8 30.8 months. Neurological evaluation showed a mean EDSS score of 5.3 1.8. The most frequent videourodynamic findings were detrusor-sphincter dyssynergia (DSD) and detrusor overactivity (DO) in 11 (36.6%) patients, DSD without DO in seven (23.3%) and DO without DSD in six (20.0%) patients. Voiding dysfunction assessed by I-PSS and OAB-V8 increased with the degree of neurological impairment (P ¼ 0.018; r ¼ 0.42 and P ¼ 0.006; r ¼ 0.48 respectively). Patients with DSD had higher I-PSS (18.5 11.4 vs 7.0 9.2; P ¼ 0.029) and OAB-V8 scores (22.8 15.8vs 9.1 7.8; P ¼ 0.008), and worse neurological impairment (mean EDSS 5.9 1.8 vs 4.5 1.5; P ¼ 0.027). Conclusions: Most patients with NMO-SD have LUTS and voiding dysfunction, with DSD and DO as the main urodynamic findings. The severity of the neurological disease is a predictive factor for the occurrence of voiding dysfunction and detrusor-sphincter dyssynergia. Neurourol. Urodynam. 35:39–43, 2016. # 2014 Wiley Periodicals, Inc. Key words: bladder dysfunction; demyelinating diseases; lower uinary tract symptoms; neuromyelitis optica; urodynamics
Neuromyelitis optica (NMO) is a severe inflammatory disease of the central nervous system (CNS) which preferentially affects the optic nerves and the spinal cord and frequently follows a relapsing course with severely disabling episodes of Optic Neuritis (ON) and Longitudinally Extensive Transverse Myelitis (LETM).1 Traditionally, NMO was considered a severe form of multiple sclerosis (MS). Currently, substantial evidence including clinical, laboratory, neuroimaging, and immunopathological data indicate they are different diseases. A serum reactivity that targets aquaporin-4 (AQP-4), the most abundant water channel in the CNS, has been described in patients with NMO and distinguishes neuromyelitis optica from other demyelinating disorders.2 It is termed aquaporin-4 immunoglobulin G (AQP4-IgG) and is detectable in 60–90% of patients with NMO and, with lower frequency, in patients with limited forms such as those with a first episode of LETM.3 The presence of serum AQP4-IgG in these patients support the existence of a continuum of neuromyelitis optica related disorders often referred to as NMO spectrum disorders (NMOSD).4 According to recently revised diagnostic criteria, the presence of two major criteria are necessary: (i) optic neuritis; and (ii) acute myelitis associated with at least two minor criteria: (i) contiguous spinal cord magnetic resonance imaging (MRI) lesion extending over three or more vertebral segments; (ii) brain MRI not meeting diagnostic criteria for multiple sclerosis or (iii) AQP4-IgG seropositive status.5 Prompt diagnosis and treatment are very important to reduce the morbidity of NMO-SD since only early immunosuppressive therapy seems effective in NMO-SD.6 #
2014 Wiley Periodicals, Inc.
Lower urinary tract symptoms (LUTS) have been widely studied in patients with MS, but not in patients with NMO-SD.7 The aim of this study was to assess the prevalence and characteristics of LUTS and urodynamic findings in patients with NMO-SD. In addition, we analyzed clinical factors associated with voiding dysfunction and QOL. MATERIALS AND METHODS
In a cross sectional study from February 2010 to February 2011, we evaluated 30 consecutive patients with NMO-SD recruited from our Neurology Clinic. Inclusion criteria were patients with an established diagnosis of NMO-SD,4 irrespective of the presence of LUTS. Fourteen (46.7%) patients had NMO and Abbreviations: AQP4-IgG, aquaporin-4 immunoglobulin G; CNS, central nervous system; DO, detrusor overactivity; DSD, detrusor sphincter dyssynergia; EDSS, expanded disability status scale; I-PSS, international prostatic score symptoms; LETM, longitudinally extensive transverse myelitis; LiSat-9, life satisfaction questionnaire; LUTS, lower urinary tract symptoms; MRI, magnetic resonance imaging; MS, multiple sclerosis; NMO-SD, neuromyelitis optica spectrum disorders; NMO, neuromyelitis optica; OAB-V8, overactive bladder-validated 8question Screener; ON, optic neuritis; OSMS, optic-spinal multiple sclerosis; QOL, quality of life; STUI, stress urinary incontinence. Eric Rovner led the peer-review process as the Associate Editor responsible for the paper. Potential Conflict of Interest: Nothing to disclose. *Correspondence to: Cristiano M. Gomes, M.D, Hospital das Clinicas da Universidade de Sao Paulo, Divisao de Clinica Urologica, Caixa Postal: 11273-9, CEP: 05422-970 Sao Paulo, SP BRAZIL E-mail: [email protected]
Received 16 April 2014; Accepted 14 July 2014 Published online 11 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22667
de Carvalho et al.
16 (53.3%) had LETM. Exclusion criteria were prostate volume 30 g at transabdominal sonography, previous history of pelvic or prostate surgery, previous pelvic radiotherapy, presence of bladder stones and genital prolapse. This study was approved by the Institutional Review Board of our hospital. Patients agreed to participate after full disclosure of its purposes and written consent was obtained from all participants or their legal representatives. A total of 23 (76.7%) women and seven (23.3%) men with an average age of 41.1 13.5 years (ranging from 13 to 70 years) were evaluated. Female to male ratio was 3.2:1. Sixteen (56.7%) patients were Caucasian and 13 (43.3%) African-Brazilians. All patients were evaluated during remission of the disease. Neurological Evaluation
The severity of neurological impairment was assessed with the Expanded Disability Status Scale (EDSS ranging from 0 to10) which was performed by neurologists specialized in demyelinating diseases.8 All patients underwent serum AQP4-IgG testing by tissue-based indirect immunofluorescence as previously described.9 MRI of the brain and spinal cord was performed on a 1.5 tesla device, with 5 mm cuts in heavily weighted T1, T2 and multiplane imaging before and after the administration of paramagnetic contrast. The time interval between the start of neurological symptoms and the evaluation date for inclusion in this study was used as the duration of the disease. Urologic Evaluation
LUTS were evaluated using two symptom score questionnaires: Overactive Bladder-Validated 8-question Screener (OABV8) and the International Prostate Symptom Score (I-PSS).10,11 Patients who scored 8 in at least one of these tests were considered symptomatic. Only patients with scores of