Table 8

Genitourinary autonomic dysfunction

SymptomTreatment approach
Urinary storage symptomsStorage symptoms
  • Modify fluid intake, avoid caffeine, acidic juices and carbonated drinks.

  • The various antimuscarinics have roughly equal efficacy; choose based on local formulary. If needing a less-sedative option, consider Trospium MR 60 mg once daily.

  • Beta 3 agonists (eg, mirabegron) have the added benefit of improving blood pressure (useful for MSA patients) but can exacerbate supine hypertension.

  • Intravesical botulinum toxin or percutaneous tibial nerve stimulation could be considered for resistant cases.

  • Monitor postvoiding residual volume before starting medication. If this approaches 100 mL, repeat 2 weeks after starting medications to look for retention. This may require either stopping the drug or using a catheter

Voiding symptoms
  • In men aged over 60 years, consider and examine for prostate enlargement as it commonly contributes to symptoms.

  • If postvoiding residual volume is >100, consider intermittent self-catheterisation by patient/carer at least 3–4 times daily in the first instance.

  • Consider a long-term catheter in patients who cannot manage intermittent self-catheterisation.

  • Consider a suprapubic catheter early.

  • Reduce fluid intake in the 3–4 hours before bedtime.

  • An evening dosing of anticholinergic can help some patients.

  • Intranasal desmopressin can be considered If needed but requires regular monitoring of serum sodium due to its hyponatraemic adverse effects.

  • If there is a concurrent risk of nocturnal hypotension, consider a convene, bottles or pads to reduce night-time mobility.

Erectile dysfunction
  • Consider that this could be due both to autonomic dysfunction but also the psychological impact of disease, and treat accordingly.

  • Phosphodiesterase 5 inhibitors work well, but often cause hypotension, limiting their effectiveness.

  • MSA, multiple system atrophy.