Management of PD and MSA, including neurogenic bladder, etc

Autonomic disturbances are common in Parkinson’s Disease (PD) and Multiple System Atrophy (MSA). Cardiovascular dysautonomia results in alterations in blood pressure and heart rate, most commonly manifesting as orthostatic hypotension. Nocturia, the most common non-motor symptom in PD may be due to an overactive bladder or nocturnal polyuria. Symptoms of an overactive bladder are common in PD, and in the early stages of MSA. Voiding dysfunction is common in PD, however urinary retention is rare. This is in contrast to MSA, where incomplete bladder emptying and urinary retention occur early in the course of disease. Concomitant to neurogenic lower urinary tract (LUT) dysfunction, co-morbidities such as prostate enlargement, medical conditions such as diabetes mellitus or heart failure, or medications such as diuretics may contribute to LUT symptoms. If LUT dysfunction is severe and predates the onset of parkinsonism, the possibility of MSA should be considered. Antimuscarinic medications remain the first line treatment for managing overactive bladder symptoms. In patients with cognitive impairment, medications which are relatively impermeable to the blood brain barrier, such as trospium chloride, or highly selective for the muscarinic receptors of the bladder, such as darifenacin, should be considered. Botulinum toxin and neuromodulation may be appropriate in select cases. Sexual dysfunction commonly occurs in PD and MSA and in MSA, may predate neurological and other autonomic dysfunction.