Urogenital dysfunctions related to autonomic failure

Multiple System Atrophy (MSA) can express itself with urogenital disorders as first signs. To evaluate the different degree of Autonomic Nervous System (ANS) involvement in the initial phase of the disease, in a group of patients with such symptoms, we investigated four subjects with urodynamic evidence of different types of vesico-urethral dysfunctions without low urinary tract obstruction and radiologically evident lesions of spinal cord. Three patients showed abnormal responses to different sympathetic and parasympathetic tests. At recruitment, however, only in two of them were polyphasic and lung duration Motor Units recorded in sphincter muscles. Later, severe orthostatic hypotension, lower motoneuron involvement, extrapyramidal-type rigidity, cerebellar dysfunction appeared. Two patients already died. One patient, who suffered from retrospermia and erectile impotence as onset symptoms associated with mild hyposensitive bladder and defective bladder neck widening, revealed a complete absence of sympathetic skin reflex limited to the lower limbs and penile region, but normal cardiovascular and pupillary responses. This condition seems to be static for 3 years and different from those associated with both the local autonomic failure affecting a limb or with chronic widespread idiopathic anhidrosis. The Authors stress that both urodynamics and ANS investigation show how diffuse autonomic involvement could be responsible of localized urogenital symptoms even in the initial phase of MSA when derangement of other systems cannot be demonstrated with clinical and electrophysiological evaluations.