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

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.

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.