Barriers to care


Barriers to care include patient embarrassment about their condition, lack of awareness that serious complications can result from mismanagement of incontinence, the perception that bladder issues are not life-threatening, fear of needing invasive surgical intervention, a lack of awareness that effective treatment options are available, and a lack of access to treatment options covered under insurance-plan benefits. Patients and clinicians need to be aware of the potentially detrimental effects of poorly managed or unmanaged NDO on disease outcomes.


Patient satisfaction with treatment 


Patient perceptions, expectations, and satisfaction with treatment can affect adherence,38 as can costs 7,10 and reimbursement issues. To ensure treatment adherence and a successful outcome, patients and clinicians need to be informed of available options and any training as well as the day-to-day requirements and long-term expectations for treatment. Ideally, bladder management strategy should be adapted to the underlying disease. 



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Patient satisfaction with treatment in the NGB population has been inadequately studied, using tools developed for idiopathic overactive bladder.39,40 The Actionable MS Urinary Function Screening Tool is a new measurement instrument developed to assess the impact of NGB dysfunction on quality of life in patients with MS.41 Until study results are available, clinicians cannot accurately assess patient satisfaction with treatment.


Case Study: Managing Urinary Incontinence in Multiple Sclerosis

K.A. is a 52-year-old woman with multiple sclerosis (MS) that was diagnosed at the age of 37 years. She has had to take a medical leave of absence from her job as an elementary schoolteacher because of fatigue, lack of adequate bladder control, and urinary incontinence (UI) that impaired her ability to teach. She can walk 50 feet without a cane but must watch her balance, and going up and down stairs is difficult for her. K.A. is currently on beta interferon for her MS and has not had a flare-up for more than 2 years. Her overall health is otherwise stable, with only borderline hypertension and normal lipid profiles.

Approximately 3 years ago, K.A. presented with urge UI and was prescribed extended-release oral oxybutynin 15 mg/day. At her initial follow-up, she noted a moderate degree of dry mouth but no other complications. She decided to continue with this medication, as she believed it increased her health-related quality of life by decreasing episodes of UI.

One year ago, K.A. admitted she was increasingly constipated and often felt dizzy if she stood up too quickly. Her clinician determined she was having involuntary detrusor contractions starting at 79 mL and had a maximal detrusor pressure of approximately 40 cm H20. She did not have stress incontinence or pelvic prolapse on examination. Several options were suggested, including switching to a different anticholinergic agent, clean intermittent catheterization, and a suprapubic catheter, since increasing her current oxybutynin dose was not a viable alternative.

She agreed to switch to a different anticholinergic and was placed on tolterodine tartrate extended-release tablets 4 mg/day. At her 2-week follow-up, postvoid residual (PVR) was 75 mL, symptoms had improved, and incontinence was 75% better.

However, at her 10-month follow-up, K.A. asks her clinician to discuss any other options, as treatment with this anticholinergic has resulted in blurred vision and drowsiness, interfering with her ability to walk up and down stairs without fear of falling, and her UI seems to be worse. At this visit, her PVR is 35 mL, her incontinence has returned to baseline, and her urgency symptoms have returned.

Three suggested treatment modalities are neuromodulation, bladder injection of botulinum toxin, or augmentation. The efficacy and safety of each of the options are explained. K.A. opts for treatment with intradetrusor injection of onabotulinumtoxinA 200 U because she does not want to undergo a surgical procedure. She understands that the treatment with onabotulinumtoxinA will last approximately 10 months.

Conclusion


Successful treatment of the patient with NGB dysfunction encompasses satisfaction with therapy as well as meaningful improvement in symptoms. Optimal management can result in improved patient outcomes, and a consistent effect on bladder control can result in sustained improvement in quality of life.


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