Disorders of bladder function may raise serious problems in management. Where the major disorder is one of urinary retention, bethanechol chloride is helpful. In this situation, monitoring and reducing the residual urinary volume are important means of preventing infection; volumes up to 100 mL are generally well tolerated. Some patients with severe bladder dysfunction, particularly those with urinary retention, benefit from intermittent catheterization, which they can learn to do themselves and which lessens the constant risk of infection from an indwelling catheter. More often the problem is one of urinary urgency and frequency (spastic bladder), in which case the use of propantheline (Pro-Banthine) or oxybutynin (Ditropan) may serve to relax the detrusor muscle (Chap. 25). These drugs are best used intermittently. Severe constipation is best managed with stool softeners and properly spaced enemas. Sexual dysfunction has been treated with sildenafil and similar drugs. When pain is a prominent symptom, its management follows the general principles of pain management outlined in Chap. 7. Carbamazepine or gabapentin are often helpful to reduce paroxysmal symptoms in MS, particularly truncal extensor spasms.
Oral baclofen or tizanidine are often used to reduce spasticity in patients with MS but the dose must be limited to avoid excessive sedation. In patients with severe spastic paralysis and painful flexor spasms of the legs, local injection of botulinum toxin can be very effective. In these cases, intrathecal infusion of baclofen through an indwelling catheter and implanted pump can also be considered. An alternative to oral baclofen is tizanidine.
The severe and disabling tremor that is brought out by the slightest movement of the limbs, if unilateral, can be managed surgically by ventrolateral thalamotomy or implanted stimulator of the type used for the treatment of Parkinson disease. Most surgical series report that about two-thirds of patients achieve a satisfactory reduction in their intention tremor (Critchley and Richardson; Geny et al). In the experience of others, the results have not been quite this reliable. In the series reported by Hooper and Whittle, only 3 of 10 MS patients who underwent thalamotomy for a severe tremor had sustained improvement. Hallett and colleagues have reported that severe postural tremor of this type can be improved by the administration of isoniazid (300 mg daily, increased by weekly increments of 300 mg to a dose of 1,200 mg daily) in combination with 100 mg of pyridoxine daily. How isoniazid produces its beneficial effects is not known, and careful monitoring of liver tests is required. Variable success may also be achieved with carbamazepine or clonazepam.
There are no valid studies to substantiate claims that have been made for the value of synthetic polypeptides other than copolymer, for hyperbaric oxygen, low-fat and gluten-free diets, or linoleate supplementation of the diet. Necessary vaccinations are usually not prohibited in patients with MS.
The importance of an understanding and sympathetic physician in the care of patients with a chronic and potentially incapacitating neurologic disease that requires choices among many medications of this kind cannot be overemphasized. The advances in available therapeutic options have transformed the prognosis for most patients with this disease. By carefully following a patient’s course clinically and with serial imaging, the clinician can balance the benefits and associated risk of available treatments in an individualized way. In this fashion, the clinician can have an impact upon a patient’s quality of life.