Editor,

We thank Dr. Floyd and Dr. Khadr for their interest in our work. We emphasized the Expanded Disability Status Scale (EDSS) as it is not commonly used by urologists, but is used by many neurologists and provides an excellent overall measure of the changing disability of our multiple sclerosis (MS) patients. This scale has been validated in multiple studies worldwide and has been used since 1983.

We agree with Dr. Floyd and Dr. Khadr that validated questionnaires are useful in following the urologic symptoms of MS patients. However, it should be noted that the NBSS has only been available since 2016–17 and its short form was only recently validated in 2020. Even the Short Form Qualiveen (SFQ) was not even validated until 2008 and our study population went back much earlier. We used a combination of the International Prostate Symptoms Score (IPSS) and the Bristol Female Lower Urinary Tract Questionnaire (BFLUTS) to assess lower urinary tract symptoms when we started, but agree that the NBSS or SFQ are better suited for MS patients.

All patients had baseline video-urodynamics. If patients were clinically stable on their medications, their studies were performed on medications. If there was a worsening of symptoms, repeat studies were performed on or off medications based on the individual clinical situation. These are the inherent limitations of a retrospective study and we fully recognize that a prospective study would provide more consistent data. Many of our patients came from a significant distance and received a portion of their care including urologic care locally which further convoluted data collection.

In addition, we agree that use of validated questionnaires before and after intervention will be helpful along with multidisciplinary clinics. However, our point is that patients with a worsening or high EDSS at baseline or during follow-up will be at higher risk of not only general deterioration but of urologic complications and should be followed even more carefully. These are the patients who are more likely to require more aggressive interventions to protect their upper tracts and provide social continence. And while interventions such as intravesical botulinum toxin injection or bladder augmentation and continent catheterizable stoma creation may lead to certain complications, these interventions significantly improve the quality of life of our MS patients. Again, we thank the authors for their interest and comments.


Yours sincerely,

Alejando Abello, MD, MPH

Jonathan Badin, MD

Anurag K. Das, MD, FACS