Multicenter Observational Study for the Evaluation in Clinical Practice of Urinary Disorders in Multiple Sclerosis

Study Overview
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Brief Summary
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The major part of people with multiple sclerosis (pwMS) experiences Low Urinary Tract Symptoms (LUTS) secondary to neurogenic Low Urinary Tract Dysfunctions (n-LUTDs) during the course of MS, reaching almost 100% after about 10 years. N-LUTDs represent an important issue for pwMS, especially for their negative impact on Quality of Life (QoL), as they are mainly youngs in the prime of their life. Moreover n-LUTDs can lead to serious complications on the urinary tract as infections or renal failure. Therefore, the neurologist in daily clinical practice must intercept the possible presence of LUTS as soon as possible so that he can promptly initiate optimal management. To do this, it is essential to provide neurologists with validated, reproducible and sensitive tools that are, above all, easy to use in an outpatient setting. Our clinical research seeks, for the first time, to show whether pwMS get any improvement after the initial LUTS management, whether this improvement, if any, is related to the professional figure takes care about LUTS (neurologist vs urologist) and if there is an objective improvement of voiding performances on standardized measures.

Detailed Description
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The investigators will conduct a multicenter observational no-profit study to investigate the impact of Low Urinary Tract Symptoms (LUTS) management on subjective measure of patient global impression of improvement. Initial management of LUTS in MS should address both voiding and storage deficiency symptoms and is determined by the severity of symptoms and the risk of developing upper urinary tract damage. First-line treatments include behavioral / physical ones, such as rehabilitation of the pelvic floor, and pharmacological ones (antimuscarinics, alpha-lytics, beta3 agonists); second-line treatments are represented by intradetrusorial (or intrasphinteric) injection of botulinum toxin and by non-invasive (percutaneous and transcutaneous tibial nerve stimulation) and invasive (sacral neuromodulation) neuromodulation techniques; third-line treatments consist of surgical approaches. According to the various consensus and recommendations available for MS, the initial approach in most cases should be the prerogative of the neurologist, while the neurourologist should intervene when the initial treatment has been ineffective or there are pathologies of the urinary tract that require a non-postponable specialist evaluation. As regards the effectiveness of any initial management of LUTS in pcSM, there are, to the best of our knowledge, no studies in the literature that have analyzed the phenomenon, both in terms of subjective perception of clinical improvement and in objective terms of objective improved voiding performance. This study was developed with the primary intention of measuring, through the observation of real clinical practice, the presence and extent of improvement (through the PGI-I scale) of the subject with LUTS after at least three months of any type of initial management. A subgroup analysis will help us to assess whether the neurologist's management of LUTS is different from that of the urologist in terms of perceived improvement. A patient reported outcome assessing quality of life (Qualiveen-SF), a three-day frequency / volume chart, and post-voiding residual volume (PVR) will be used as secondary outcomes to reveal the effectiveness of the two approaches on quality of life and data objective measures of urinary disorders. The study also aims to 1) evaluate the prevalence of LUTS through a new diagnostic algorithm that consists of two questionnaires (the Urinary Bothersome Questionnaire-MS and the Actionable Bladder Symptoms Screening Tool-ABSST) and an objective measure of voiding dysfunction-the PVR and 2) analyze the influence of the more common risk factors on the presence of LUTS as thus diagnosed.

Official Title
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A Multicentre Observational Study for the Evaluation in Clinical Practice of the Initial Diagnostic-therapeutic Path of Urinary Disorders in Multiple Sclerosis

Conditions
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Multiple Sclerosis, Urinary Bladder, Neurogenic

Intervention / Treatment
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* Other: Initial management of the urinary disorder/s identified during the screening phase


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: People with MS (relapsing-remitting, secondary progressive, primary progressive phenotype) or clinically isolated demyelinating disease syndrome-CIS) according to McDonald's 2001 criteria, consecutively afferent to the outpatient clinic or hospitalized after study approval by the ethics committee. They: have never been previously evaluated and/or treated for LUTS secondary to MS; are between 18 and 80 years old; have given written consent to study part. Exclusion Criteria: analphabetism; severe cognitive impairment; severe psychiatric pathologies; EDSS> 7; clinical relapse of MS within the previous 30 days; history of urinary fevers > 2 in the last 6 months or > 3 in the last year; indwelling catheter; renal failure (creatinine> 1.2 mg / dL); presence of hydronephrosis, mono or bilateral vesicoureteral reflux; presence of urinary stones; history of urological surgery, neoplasms of the urogenital system and / or pelvic radiotherapy; therapy/treatment for LUTS secondary to MS or other diseases.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Intervention/Treatment |
| --- |
|Other: Initial management of the urinary disorder/s identified during the screening phase|Intervention can be defined as the initial management of the LUTS identified during the screening phase; management lasts at least three months. As observation of routine clinical practice, no specific intervention is included, but any counseling/drug/rehabilitation included as first line management.|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient global impression of Improvement (PGI-I) questionnaire | In participants with recorded LUTS, it will be measured the subjective impression of improvement after at least three months of stable urinary disorder management, by means of the PGI-I questionnaire. The PGI-I is a 1-item questionnaire designed to assess the patient's impression of change with values ranging from 1 to 7; higher scores mean a worse outcome. Patient is required to Check the one number that best describes how you feel now by entering his answer on a 7-point scale scored as: (1) very much better, (2) much better, (3) a little better, (4) no change, (5) a little worse, (6) much worse, or (7) very much worse. For this study, investigators will evaluated as primary outcome measure the percentage of patient gave a response to PGI-I equal to or less than 2. | at the end-of-study visit named Visit 2, corresponding at week 12-16 from Visit 1, that is the management start-up visit | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Qualiveen-Short Form (SF) questionnaire | In participants with recorded LUTS, it will be measured the patient reported urinary-related quality of life by means of the Qualiveen-Short Form (SF) questionnaire. It's a specific health related quality of life (HRQOL) with questionnaire for urinary disorders in patients with neurological conditions, such as Multiple Sclerosis. The Qualiveen-SF is an 8-items questionnaire. Response options are framed as 5-point Likert-type scales with 0 indicating no impact of urinary problems on HRQOL and 4 indicating a high adverse impact of urinary difficulty on HRQOL. Qualiveen domain scores are calculated as an average of the scores on items in that domain and, thus, the range is 0 to 4 with an overall score representing the mean of the 4 domains, which also ranges from 0 to 4. Higher scores mean worse outcome. For this study investigators will evaluated whether three-months (max 4 months) of urinary disorder stable management may change HRQOL in terms of Qualiveen-SF scores. | at the end of screening period named Visit 0, and at Visit 2 (weeks 12-16 from Visit 1, that is the management start-up visit) | 
| Post-void residual volume (PVR) assessment | The post-void residual volume (PVR) measured in ml is the urine volume remaining in bladder after a physiological micturition. It will be measured by ultrasound scans and calculated by the radiologist subtracting post-void bladder volume from pre-void bladder volume. For this study, the investigators will evaluate whether three months (max 4 months) of urinary disorder stable management may change the amount of PVR. Lower volume values mean better outcome. | at visit 0 and Visit 2 (weeks 12-16 from Visit 1, that is the management start-up visit) | 
| Micturitions' frequency and episodes of urgency/incontinence at three days frequency/volume chart | In participants with recorded LUTS, it will be measured the number of daily micturitions and episodes of urgency or incontinence signed on a three days frequency/volume chart. Frequency/volume chart is a brief diary where patients are asked to record for three days how many times they urinate and the volume of each micturition; they are also asked to record each episode of urinary urgency and incontinence. Higher numbers mean worse outcome. As secondary outcome, it will be evaluated whether three months (max 4 months) of urinary disorder stable management may change the numbers of micturitions and numbers of urinary urgency and/or incontinence. | at visit 0 and Visit 2 (weeks 12-16 from Visit 1, that is the management start-up visit) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Patient global impression of improvement, management, treatment, low urinary tract symptoms, diagnostic tools, prevalence