Gut, Bladder, and Sexual Problems in Multiple Sclerosis: A Practical Guide for Patients and Care Teams

Table of Contents

• Key Points
• Background: Why This Research Matters
• Key Points at a Glance
• Neurogenic Gastrointestinal Symptoms
• Diagnosing Constipation and Related Gut Problems
• Treating Constipation and Fecal Incontinence
• Neurogenic Urinary Symptoms
• Assessing Bladder Problems
• Treating Bladder Problems
• Neurogenic Sexual Symptoms
• Treating Sexual Problems
• Clinical Implications: What This Means for Patients
• Limitations: What the Review Could Not Prove
• Recommendations for Patients and Care Teams
• Frequently Asked Questions
• Source Information

Key Points

• Neurogenic gastrointestinal, urinary, and sexual symptoms are highly prevalent in people with MS and can substantially impair quality of life.
• These three symptom groups are closely interconnected; treating one can improve the others, so assessment should be structured and proactive.
• Constipation is the most prevalent GI symptom in MS; in one study it was found in 82% of patients at a specialist center.
• Bladder symptoms occur in up to 97% of MS patients over the disease course; clean intermittent catheterization is indicated when post-void residual is greater than 150 mL.
• Sexual dysfunction is common but often overlooked; treatments include phosphodiesterase-5 inhibitors for erectile dysfunction and lubricants for vaginal dryness.

Background: Why This Research Matters

Neurogenic gastrointestinal (GI, relating to the gut), urinary, and sexual symptoms are among the most common symptoms in multiple sclerosis. Despite how often they occur, these symptoms are frequently under-recognized and not managed appropriately. They significantly decrease the quality of life of people with MS (often abbreviated pwMS).

These three symptom groups are highly interrelated and interdependent. When left untreated, one symptom can trigger or worsen others. The reverse is also true: effective treatment of one symptom can break this cycle and produce significant benefits in the others.

The authors give a clear example of this chain. Bladder problems can affect sleep and sexual function. Sleep loss and sexual difficulties then affect cognition (thinking and memory) and mood. This leads to fatigue and reduced physical activity. Reduced activity then has secondary consequences, including increased spasticity (muscle stiffness) and constipation.

Limited time during clinical visits is often a barrier to addressing these issues. The authors suggest that screening for these symptoms with dedicated questionnaires and scheduling additional dedicated appointments may be beneficial.

The goal of this review is to translate the available evidence on neurogenic GI, urinary, and sexual symptoms in MS into a pragmatic model of care. The model is tailored to the realities of European clinical practice and to the heterogeneity (wide variation) of healthcare resources. It is designed to help neurologists and multidisciplinary teams identify needs, prioritize interventions, and optimize MS care.

Key Points at a Glance

• Neurogenic GI, urinary, and sexual symptoms are highly prevalent in people with MS and can substantially impair quality of life.
• Because limited time during clinical visits is often a barrier, screening with dedicated questionnaires and scheduling additional dedicated appointments may be beneficial.
• Constipation is the most prevalent GI symptom in MS. It is followed by fecal incontinence, delayed gastric emptying, delayed colonic transit, and accelerated gastric emptying.
• Pharmacological therapies for constipation include laxatives and prokinetics (for patients with slow colonic transit). Transanal irrigation is the treatment of choice for fecal incontinence. Biofeedback therapy is indicated in patients with dyssynergic defecation or fecal incontinence.
• Lower urinary tract symptoms in MS can be due to storage phase dysfunction or voiding phase dysfunction. Detrusor overactivity is the most common alteration in people with MS, followed by detrusor-sphincter dyssynergia, and less frequently detrusor underactivity.
• Pharmacological therapies for storage symptoms include antimuscarinics and beta3-agonists. Clean intermittent catheterization is indicated when post-void residual volume is high. Neuromodulatory options include sacral nerve modulation and percutaneous tibial nerve modulation. Pelvic floor muscle training is indicated for the prevention and treatment of all types of urinary incontinence, with preliminary data on sexual dysfunction.
• Erectile dysfunction and premature ejaculation are common sexual complaints in men with MS. Women with MS frequently experience decreased vaginal lubrication and difficulties in reaching orgasm.
• Therapeutic strategies for erectile dysfunction include phosphodiesterase-5 inhibitors, vacuum-constriction devices, and intracavernous injection of alprostadil. Dapoxetine is the only licensed drug for premature ejaculation. For women with dyspareunia (pain during sex) and/or vaginal dryness, anesthetic and water-soluble lubricants can be used. In case of postmenopausal vaginal atrophy, topical estrogen therapy is indicated. Vibrators can be useful when decreased genital sensation limits intimacy.
• The authors integrate diagnostic, therapeutic, and rehabilitative strategies across these closely interconnected domains. The authors propose a framework to help neurologists and multidisciplinary teams identify patients' needs. The framework helps teams prioritize interventions, reduce variability in care, and support MS centers. It supports MS centers in delivering more comprehensive, patient-centered management.

Neurogenic Gastrointestinal Symptoms

Neurogenic GI dysfunction in MS primarily manifests as an impairment of motor function rather than sensory or secretory function. It more commonly affects the lower GI tract (GIT).

The GIT has both extrinsic neural control (parasympathetic and sympathetic innervation) and intrinsic neural control (by the enteric nervous system, which includes the myenteric and submucosal plexuses). The vagus nerve and sacral parasympathetic nerves provide excitatory innervation to non-sphincteric GIT muscles. Sympathetic nerves (at levels T5–T10 of the spinal cord) inhibit non-sphincteric muscles and excite sphincter muscles.

Recent studies show that intrinsic myenteric neurons can be affected by MS. However, damage to the extrinsic neural control of the GIT prevails in MS and explains patients' symptoms. In particular, spinal cord lesions can interrupt supraspinal control of the sacral parasympathetic supply. Brainstem demyelinating lesions can affect gastric emptying by disrupting gastric vagal motor circuits.

Constipation is the most prevalent GI symptom in MS. A recent retrospective cohort analysis at a tertiary MS center studied GI motor function. This study identified constipation in 82% of MS patients. The study identified fecal incontinence (FI) in 33% of MS patients. It identified delayed gastric emptying in 16% of MS patients. It identified delayed colonic transit in 7% of MS patients. The study also found a previously unappreciated high prevalence of accelerated gastric emptying in 22% of patients.

The study demonstrated that GI symptoms were more prevalent across all domains than in the general population. The study also highlighted that constipation and FI are more prevalent in MS patients of older age. Constipation and FI are also more prevalent in those with spinal cord lesions. Constipation and FI are also more prevalent in those with a progressive phenotype (a form of MS with steady worsening).

According to the Rome V criteria, chronic constipation is defined by an evacuation frequency of less than 3 times per week. It is associated with hard feces, strain, a feeling of incomplete emptying or obstruction, or the need for manual maneuvers.

Constipation can also be a feature of other disorders of gut-brain interaction, particularly irritable bowel syndrome with constipation (IBS-C), and of opioid-induced constipation. Some abdominal pain can be present in patients with chronic constipation. However, pain should not be the predominant symptom, as it is in IBS.

Patients with constipation may also display anorectal disorders. These include fecal incontinence, anorectal pain, dyssynergic defecation (DD), and rectal hypo- or hyper-sensitivity. While FI only requires the presence of symptoms, a diagnosis of DD or altered rectal sensitivity requires both clinical and physiological testing data.

DD is characterized by inadequate propulsive force or paradoxical contraction (or inadequate relaxation) of the pelvic floor muscles (PFM) during defecation. Only one abnormal physiological testing result is needed for the diagnosis of DD.

Diagnosing Constipation and Related Gut Problems

The initial workup of MS patients with constipation begins with history taking. History taking helps identify secondary causes and establish the presence of red flags that can point to an underlying neoplasia (tumor).

Digital rectal examination (DRE) has a sensitivity and specificity of around 80% in detecting anal-sphincter dyssynergia. DRE is performed in the Sims position (left lateral recumbency, meaning lying on the left side).

The examination begins with visual inspection to identify structural pathology, such as hemorrhoids and anal fissures. Inspection is also performed with straining, evaluating for rectal prolapse. During inspection, it is possible to detect paradoxical contraction of the sphincter during straining rather than its normal relaxation. The examiner can appreciate increased tone of the sphincter if it is present at rest.

The examiner then asks the patient to voluntarily contract the sphincter, evaluating for an appropriate increase in tone. Next, the examiner asks the patient to perform a straining maneuver with the finger still in place. A normal response is an expulsion of the finger toward the outside.

If the finger remains in the same position, the exam is indicative of PFM weakness. If the finger is constrained, the exam points to paradoxical contraction of the sphincter (DD).

If DRE is positive for DD, the next diagnostic step is anorectal manometry. This test evaluates rectal pressure and sensitivity and anal contraction. The physiological response during defecation is an increase in rectal pressure and consensual relaxation of the anal sphincter.

Four high-resolution rectal manometry patterns can be distinguished in DD:

• Type 1: appropriate increase in rectal pressure but paradoxical contraction of the sphincter
• Type 2: no increase in rectal pressure and paradoxical contraction of the sphincter
• Type 3: rectal pressure is increased, but the sphincter is not adequately relaxed
• Type 4: no increase in rectal pressure and no relaxation of the sphincter

If high-resolution rectal manometry is not available, standard rectal manometry combined with the balloon expulsion test (BET) can identify patients with DD or altered rectal sensitivity. When rectal manometry and BET show equivocal results or discordant findings, defecography can be useful.

Treating Constipation and Fecal Incontinence

If constipation is mild, conservative treatment can be started. Caloric and liquid intake should be adequate. Only soluble fibers have a significant effect on constipation. An example is psyllium at 5–15 g per day.

A small chair can be used to elevate the feet from the ground during evacuation. The physiological gastrocolic reflex can also be exploited by trying to evacuate after meals.

Patients with spinal cord lesions who lose sacral parasympathetic control of defecation, with constipation and FI, are dependent on reflex rectal stimulation for defecation. This includes abdominal massage and perianal manual stimulation.

In cases resistant to conservative treatment, pharmacological therapy is indicated, provided that fecal impaction has been excluded or resolved. Evidence from multiple randomized controlled trials (RCTs) lasting up to 6 months supports the use of osmotic laxatives as the preferred first-line pharmacological therapy.

Macrogol is preferred over lactulose because it causes less frequent bloating. If no effect is seen after some days of laxative therapy, it is possible to perform a water enema.

In patients with concomitant abdominal pain or IBS-C, pain relief can be obtained using anti-spasmodics like peppermint oil. Patients with constipation can have normal or slow colonic transit (ST-C).

At least half of DD patients can have ST-C, which benefits from prokinetic therapy. In a real-world setting, given the limited availability and cost of colonic transit testing, an empirical trial of a prokinetic agent may be considered in patients with suspected ST-C.

Two clinical parameters can help predict ST-C based on history alone:

1. Evacuation frequency of 2 or fewer per week
2. A Bristol Stool Chart score of 1–2 (the Bristol Stool Chart is a validated stool form scale ranging from type 1, separate hard lumps, to type 7, liquid stools)

Prucalopride (2 mg per day), a highly selective agonist of the 5-HT4 receptor, has demonstrated efficacy in ST-C in phase III RCTs. No benefits have emerged with increased dosage. In older patients, or in patients with kidney damage or severe hepatic (liver) failure, the dose of 1 mg daily is preferred. Patients should be reassessed for drug efficacy after 4 weeks of therapy.

Data on intestinal secretagogues for constipation secondary to neurological disorders are limited. Options include linaclotide, lubiprostone, and plecanatide. Glycerine suppositories are an add-on option in patients with DD who cannot benefit from biofeedback therapy (BT) or do not benefit from laxatives and prokinetic therapy.

As a last resort, transanal irrigation (TAI) can be used. TAI is also the treatment of choice for FI. In ST-C patients without evidence of DD (or with DD corrected by BT), it is possible to evaluate for surgery or sacral nerve modulation (SNM). In case of rigidity and spasms of the ano-pelvic complex, oral anti-spastic therapy should be considered.

BT is indicated in patients with DD or FI, based on evidence from multiple RCTs. If rectal hyposensitivity is present, concurrent sensory training (for example, barostat-assisted sensory training) is needed.

In people with MS, cognitive dysfunction and global motor disability can impact BT efficacy and compliance. No universal BT protocol exists that establishes a needed number of sessions. Home-based and office-based BT have comparable success rates. The authors routinely perform BET at baseline and encourage patients to continue training with BET independently at home after adequate training.

Neurogenic Urinary Symptoms

Lower urinary tract symptoms (LUTS) occur in up to 97% of MS patients over the course of the disease. The median onset is 8 years after diagnosis. LUTS represent the first manifestation of MS in up to 10% of cases.

Compared with the general population, LUTS in people with MS are more frequent, occur at a younger age, and are generally more severe. LUTS can be related to storage phase dysfunction or voiding phase dysfunction.

Storage phase symptoms include:

• Frequency of micturition (needing to urinate often)
• Nocturia (waking at night to urinate)
• Urgency
• Urge incontinence

Voiding phase symptoms include:

• Hesitancy
• Straining
• Slow or interrupted flow
• Urinary retention

During bladder filling, sympathetic innervation inhibits the detrusor (the bladder muscle). Sympathetic and pudendal (somatic motor) nerves mediate contraction of the internal (smooth muscle) and external (striated muscle) urethral sphincter, respectively.

When voiding is deemed appropriate, the pontine micturition center loses the tonic inhibition of higher brain centers. The pattern of detrusor inhibition and sphincter contraction then reverses. Detrusor contraction is associated with parasympathetic stimulation and is necessary for complete bladder emptying.

Lesions at the suprapontine level predominantly cause storage symptoms (detrusor overactivity, or DO). Infrapontine suprasacral lesions can cause both storage symptoms (DO) and voiding symptoms (detrusor-sphincter dyssynergia, or DSD). Sacral or infrasacral lesions cause predominantly voiding disturbances (detrusor underactivity, or DU).

DO is the most common alteration in people with MS, followed by DSD, and less frequently DU. DO is characterized by more frequent but normal-strength detrusor contractions. Therefore, patients with suprapontine lesions usually have low post-void residuals (PVR, the amount of urine left in the bladder after urinating).

However, if DSD or DU coexist with DO, as is frequently seen in MS, PVR can be high. DSD is defined as the involuntary contraction of the external urethral sphincter concurrent with detrusor contraction during voiding. This results in incomplete bladder emptying. DU is defined as reduced strength or duration of detrusor contractions, resulting in prolonged and incomplete bladder emptying. DU usually appears only later in the course of the disease.

Patients with high PVR can develop complications. These include raised intravesical pressure (high pressure inside the bladder), leading to bladder diverticuli and trabeculations. They also include vesicoureteral reflux (VUR, backward flow of urine from the bladder toward the kidneys), leading to hydronephrosis (kidney swelling), recurrent urinary tract infections (UTIs), and renal damage.

Assessing Bladder Problems

Assessment begins with recording the patient's symptoms, reviewing a bladder diary, and performing a physical examination. The physical examination includes evaluation of structural abnormalities (such as prostate enlargement and pelvic organ prolapse), genital reflexes, and perineal sensitivity.

In patients with urinary incontinence (UI) and high disability or progressive disease, functional incontinence should be excluded. Functional incontinence means that a patient cannot reach the toilet in a timely manner.

Blood chemistry including renal function testing, urinalysis, and PVR measurements are routinely performed. Based on urinalysis results, if a UTI is suspected, urine culture is necessary and guides antibiotic treatment.

UTIs can exacerbate irritative LUTS. Therefore, antibiotic treatment is recommended in symptomatic patients. Asymptomatic bacteriuria (bacteria in the urine without symptoms) is not routinely treated. Recurrent UTIs should prompt evaluation of urological causes like bladder stones and VUR. Low-dose antibiotic prophylaxis is considered in individuals with recurrent UTIs and no identifiable causes.

PVR can be measured non-invasively with ultrasound devices. If PVR is greater than 150 mL, clean intermittent catheterization (CIC) with hydrophilic catheters is the management strategy of choice. Proper training of the patient is important in avoiding complications and improving compliance. In female patients, a mirror can be used to aid in the identification of the urethral meatus.

If manual dexterity and cognition are barriers to self-CIC, a caregiver should be trained together with the patient to help with CIC. The average CIC frequency is 4–6 per day. This frequency can be adapted based on PVR. The bladder volume at catheterization should not be greater than 400–500 mL.

If PVR is low, or in cases where CIC does not lead to sufficient benefit, symptomatic management can be started. The need for invasive urodynamic testing before treatment initiation in MS is debated. A recent RCT showed that performing a whole urodynamic study does not influence treatment choice or outcomes.

Thus, in early MS, non-invasive evaluation is probably sufficient to start therapy. Invasive studies should be reserved for patients who are refractory to first-line treatment or who have risk factors for upper urinary tract damage (UUTD).

The incidence of UUTD is low in patients with MS. A recent study assessed 325 MS patients undergoing voiding cystourethrography (VCUG). Only 5.5% had VUR, and only 3.1% showed hydronephrosis. Among MS patients with VUR, 19% had grade III–IV VUR. Hydronephrosis was observed in all grade III–IV VUR cases, whereas it was absent in patients with grade I–II VUR.

Patients with progressive MS (PMS) were more likely to have VUR compared to patients with relapsing-remitting MS (RRMS): 11.5% versus 4.1%, with a p-value of 0.04. Patients with VUR showed a mean glomerular filtration rate decrease of 29%, with no evidence of significant renal failure. Thus, patients with risk factors for UUTD should undergo VCUG to assess the presence and extent of VUR.

Treating Bladder Problems

Conservative strategies should be used in all patients. These strategies include weight loss, bladder retraining, fluid intake review, and pelvic floor muscle training (PFMT).

Bladder retraining means "voiding by the clock." The patient sets a voiding routine with increasing intervals between voidings. Fluid intake review means equally distributing fluids throughout the day.

In patients with voiding dysfunction, reflex voiding can be triggered by suprapubic tapping or thigh scratching. These maneuvers work by stimulating sacral and lumbar dermatomes. Valsalva and Credè maneuvers are not recommended because of the risk of rising intravesical pressure.

An RCT showed limited efficacy of suprapubic vibration devices. The devices produced no significant reduction in the frequency of micturition or episodes of incontinence compared to no treatment, with a p-value of 0.872.

If the patient shows nocturia or nocturnal polyuria, desmopressin can be used. This recommendation is based on evidence from prospective and retrospective studies. Caution is needed to monitor sodium, especially in elderly patients.

If the patient has storage symptoms, antimuscarinics or beta3-agonists are indicated, based on RCT evidence. Antimuscarinics block muscarinic receptors (mainly M3) in the detrusor muscle, competing with acetylcholine, and thus inhibit DO.

Highly selective M3 antimuscarinics (for example, darifenacin 7.5–15 mg once daily) or low blood-brain barrier penetrant antimuscarinics (for example, trospium 15–30 mg twice daily, fesoterodine 4–8 mg once daily) should be preferred. These options have decreased effects on cognition.

Beta3-agonists (for example, mirabegron 50 mg once daily, vibegron 75 mg once daily) selectively stimulate beta3 adrenergic receptors in the detrusor and inhibit afferent bladder signaling. Beta3-agonists do not cause the side effects reported with antimuscarinics. However, mild increases in blood pressure and, more rarely, palpitations and atrial fibrillation have been reported with mirabegron use.

In patients with overactive bladder and insufficient benefit from CIC and pharmacological treatment, additional options are considered. Neuromodulatory options include sacral nerve modulation and percutaneous tibial nerve modulation. Pelvic floor muscle training is indicated for the prevention and treatment of all types of urinary incontinence, with preliminary data on sexual dysfunction.

Neurogenic Sexual Symptoms

Sexual dysfunction is a common but often overlooked symptom in people with MS. The neurogenic control of sexual function involves multiple levels of the nervous system, and MS lesions can disrupt these pathways.

Erectile dysfunction (ED) and premature ejaculation (PE) are common sexual complaints in men with MS. Women with MS frequently experience decreased vaginal lubrication and difficulties in reaching orgasm.

The neurogenic control of sexual function includes psychogenic erections (mediated by thoraco-lumbar sympathetics at T11–L2), reflexogenic erections (mediated by sacral parasympathetics at S2–S4), and genital arousal. Detumescence (loss of erection) is also under neural control.

Treating Sexual Problems

Therapeutic strategies for erectile dysfunction include phosphodiesterase-5 inhibitors, vacuum-constriction devices, and intracavernous injection of alprostadil. Dapoxetine is the only licensed drug for premature ejaculation.

For women with dyspareunia (pain during sexual intercourse) and/or vaginal dryness, anesthetic and water-soluble lubricants can be used. In case of postmenopausal vaginal atrophy, topical estrogen therapy is indicated. Vibrators can be useful when decreased genital sensation limits intimacy.

Pelvic floor muscle training has preliminary data supporting its use for sexual dysfunction, in addition to its established role in urinary incontinence.

Clinical Implications: What This Means for Patients

This review has several important implications for patients and their care teams. The first is that GI, urinary, and sexual symptoms in MS are not separate issues. They are closely interconnected, and treating one can improve the others.

The authors emphasize that early recognition and individualized multidisciplinary treatment are essential. These approaches help prevent complications and reduce symptom burden. For example, identifying and treating constipation early may prevent fecal incontinence. Managing bladder problems may improve sleep, mood, and sexual function.

The framework proposed in this review is designed to be adaptable to different healthcare settings. This is important because healthcare resources vary widely across Europe. The framework promotes structured assessment, rehabilitation, patient education, and coordinated care.

By promoting these elements, the framework may reduce variability in management and improve patient-centered outcomes across diverse healthcare settings. The authors note that limited time during clinical visits is often a barrier. They suggest that screening for these symptoms with dedicated questionnaires and scheduling additional dedicated appointments may be beneficial.

Limitations: What the Review Could Not Prove

This article is a review, not a new clinical trial. It summarizes and interprets existing evidence rather than presenting new experimental data. Therefore, the strength of its conclusions depends on the quality of the studies it cites.

The authors acknowledge that data on some treatments are limited. For example, data on intestinal secretagogues for constipation secondary to neurological disorders are limited. The available options include linaclotide, lubiprostone, and plecanatide, but the evidence base for these drugs in MS specifically is not strong.

The need for invasive urodynamic testing before treatment initiation in MS is debated. A recent RCT showed that performing a whole urodynamic study does not influence treatment choice or outcomes. This finding supports a less invasive approach in early MS, but the debate continues.

No universal biofeedback therapy protocol exists that establishes a needed number of sessions. This lack of standardization makes it difficult to compare results across studies and centers.

The authors also note that cognitive dysfunction and global motor disability can impact biofeedback therapy efficacy and compliance in people with MS. This means that treatment success may vary depending on a patient's cognitive and physical status.

Recommendations for Patients and Care Teams

Based on this review, patients and care teams can take several practical steps. The following recommendations are drawn directly from the authors' framework.

1. Screen for GI, urinary, and sexual symptoms at every visit. Use dedicated questionnaires to identify problems early. Do not wait for patients to bring up these topics themselves.
2. Schedule dedicated appointments for these issues. Limited time during regular visits is a barrier. Additional dedicated appointments may be beneficial.
3. Assess the three domains together. Because GI, urinary, and sexual symptoms are interconnected, assessment should be structured and proactive. It should integrate symptom screening, contributing factors, and individual patient needs.
4. Start with conservative treatments. For constipation, ensure adequate caloric and liquid intake, use soluble fiber such as psyllium (5–15 g per day), and try evacuating after meals. For bladder problems, use weight loss, bladder retraining, fluid intake review, and pelvic floor muscle training.
5. Escalate treatment step by step. If conservative measures fail, move to pharmacological therapy. For constipation, osmotic laxatives are the preferred first-line pharmacological therapy. For bladder storage symptoms, antimuscarinics or beta3-agonists are indicated.
6. Consider clean intermittent catheterization when PVR is greater than 150 mL. Proper training is important to avoid complications and improve compliance. A caregiver can be trained to help if needed.
7. Address sexual dysfunction directly. For men with erectile dysfunction, options include phosphodiesterase-5 inhibitors, vacuum-constriction devices, and intracavernous injection of alprostadil. For premature ejaculation, dapoxetine is the only licensed drug. For women with vaginal dryness or pain during sex, anesthetic and water-soluble lubricants can be used. Topical estrogen therapy is indicated for postmenopausal vaginal atrophy. Vibrators can help when decreased genital sensation limits intimacy.
8. Use a multidisciplinary approach. Neurologists, urologists, gastroenterologists, rehabilitation specialists, and other team members should coordinate care. This coordination helps identify needs, prioritize interventions, and reduce variability in care.
9. Educate patients and caregivers. Patient education is a key part of the framework. Patients who understand their symptoms and treatment options can participate more actively in their care.
10. Monitor for complications. Patients with high PVR should be monitored for complications such as raised intravesical pressure, bladder diverticuli, vesicoureteral reflux, hydronephrosis, recurrent UTIs, and renal damage. Patients with risk factors for upper urinary tract damage should undergo VCUG.

Frequently Asked Questions

How common are gut, bladder, and sexual problems in multiple sclerosis?

They are very common. In one study at a specialist MS center, constipation was found in 82% of patients, fecal incontinence in 33%, delayed gastric emptying in 16%, and delayed colonic transit in 7%. Bladder symptoms occur in up to 97% of people with MS over the course of the disease, with a median onset of 8 years after diagnosis. Sexual problems are also common but often overlooked.

Are these symptoms connected, or separate?

They are closely interconnected. For example, bladder problems can affect sleep and sexual function; sleep loss and sexual difficulties then affect thinking, memory, and mood, leading to fatigue and reduced activity. Reduced activity can increase muscle stiffness and constipation. Treating one symptom can break this cycle and produce benefits in the others.

What should I expect at a visit for these symptoms?

Assessment begins with your symptom history, a bladder diary, and a physical examination. For gut symptoms, a digital rectal examination may be done. Blood tests, urinalysis, and a post-void residual measurement are routine. If a urinary tract infection is suspected, a urine culture guides antibiotic treatment. Invasive urodynamic testing is usually reserved for people who do not respond to first-line treatment or who have risk factors for upper urinary tract damage.

What does a high post-void residual mean, and what happens next?

Post-void residual (PVR) is the amount of urine left in the bladder after urinating. If PVR is greater than 150 mL, clean intermittent catheterization with hydrophilic catheters is the management strategy of choice. Proper training is important to avoid complications and improve compliance. A caregiver can be trained to help if needed. The average catheterization frequency is 4–6 per day, and the bladder volume at catheterization should not be greater than 400–500 mL.

What are the treatment options for constipation in MS?

If constipation is mild, start with conservative measures: adequate calorie and liquid intake, soluble fiber such as psyllium 5–15 g per day, a small footstool during evacuation, and trying to evacuate after meals. If these fail, osmotic laxatives are the preferred first-line pharmacological therapy; macrogol is preferred over lactulose because it causes less bloating. Prokinetics may be considered for slow colonic transit.

What treatments are available for sexual problems in MS?

For men with erectile dysfunction, options include phosphodiesterase-5 inhibitors, vacuum-constriction devices, and intracavernous injection of alprostadil. For premature ejaculation, dapoxetine is the only licensed drug. For women with pain during sex or vaginal dryness, anesthetic and water-soluble lubricants can be used. Topical estrogen therapy is indicated for postmenopausal vaginal atrophy. Vibrators can help when decreased genital sensation limits intimacy.

Can these problems be prevented from getting worse?

Early recognition and individualized multidisciplinary treatment are essential to help prevent complications and reduce symptom burden. For example, identifying and treating constipation early may prevent fecal incontinence. Managing bladder problems may improve sleep, mood, and sexual function. Screening at every visit with dedicated questionnaires and scheduling additional dedicated appointments may be beneficial, because limited time during regular visits is a barrier.

When should a patient with MS and bladder, bowel, or sexual symptoms seek a second opinion?

Seek a second opinion when these symptoms are not being screened or treated, since gut, urinary, and sexual problems are interconnected and under-recognized, and treating one can improve the others. A review is warranted if bladder problems are managed without checking post-void residual, if constipation persists on conservative measures without stepwise therapy, or if sexual dysfunction is not addressed directly. Because care varies across settings, an independent review can help confirm whether assessment and treatment follow a coordinated, multidisciplinary approach. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

Original article title: Neurogenic gastrointestinal, urinary, and sexual dysfunction in multiple sclerosis- a multidisciplinary framework for clinical practice

Authors: Giorgio Guido, Agostino Nozzolillo, Manuela Tutolo, Patrizia Giollo, Maria Assunta Rocca, and Massimo Filippi

Author affiliations: Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Urology, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy; Gastroenterology Division, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy

Publication: The Lancet Regional Health – Europe, 2026; volume 69, article 101824. Published online 2026. DOI: https://doi.org/10.1016/j.lanepe.2026.101824

Copyright: © 2026 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Multiple sclerosis; Gastrointestinal dysfunction; Urinary dysfunction; Sexual dysfunction; Pelvic floor rehabilitation; Multidisciplinary care

This patient-friendly article is based on peer-reviewed research. It is intended for educational purposes and should not replace consultation with a qualified healthcare professional. Patients should discuss their individual symptoms and treatment options with their care team.