Occasional patients with spasticity benefit from cyclobenzaprine, clonidine, or opiates. Alcohol or phenol blocks of the obturator nerve may be considered for bed-bound patients whose nursing care is hindered by severe adductor tone. Fatigue, the most pervasive and disabling symptom of MS, must be differentiated from spasticity, weakness due to neuromuscular impairment and excessive effort, medication effects, medical illness or fever, and depression. Nonpharmacologic management of fatigue includes resting or napping and avoiding elevated temperature by exercising only to subfatigue levels. They tend to have an activating effect on MS-related fatigue as well as having little or no undesirable anticholinergic effects, which aggravate urinary retention or constipation.
Patients also benefit from supportive psychotherapy and problem-focused support groups.
When the episodes are socially disruptive, amitryptiline or imipramine are usually effective at low doses. Bladder dysfunction is common and involves either a failure to store or to empty urine, or both. Three patterns of bladder dysfunction are recognized on urodynamic studies. A small, hyperreflexic bladder empties at small volumes and causes urge incontinence. Detrusor-sphincter dyssynergia is caused by reflex contractions of the urethral sphincter opposing detrusor activity, and usually leads to urinary urgency with small volumes and a persistent feeling of incomplete emptying.