Urodynamic Evaluation in Multiple System Atrophy: A Retrospective Cohort Study

Abstract

BackgroundBackground: Urological dysfunction in patients with multiple system atrophy (MSA) is one of the main manifestations of autonomic failure. Urodynamic examination is clinically relevant since underlying pathophysiology of lower urinary tract (LUT) dysfunction can be variable. Objective Objective: Evaluation of the pathophysiology of urological symptoms and exploration of differences in urodynamic patterns of LUT dysfunction between MSA-P and MSA-C. Methods Methods: Retrospective study of patients with possible and probable MSA who were referred for urodynamic studies between 2004 and 2019. Demographic data, medical history, physical examination and urodynamic studies assessing storage and voiding dysfunction were obtained. ResultsResults: Seventy-four patients were included in this study (MSA-P 64.9% n = 48; median age 62.5 (IQR 56.8-70) years). Detrusor overactivity during filling phase was noted in 58.1% (n = 43) of the patients. In the voiding phase, detrusor sphincter dyssynergia and detrusor underactivity were observed in 24.6% (n = 17) and in 62.1% (n = 41) of the patients, respectively. A postmicturition residual volume of over 100 ml was present in 71.4% (n = 50) of the patients. Comparison of MSA subtypes showed weaker detrusor contractility in MSA-P compared to MSA-C [pdetQmax 26.2 vs. 34.4 cmH20, P = 0.04]. In 56.2% (n = 41) of patients pathophysiology of LUT dysfunction was deemed to be neurogenic and consistent with the diagnosis of MSA. In 35.6% (n = 26) urodynamic pattern suggested other urological co-morbidities. Conclusion Conclusion:Urodynamic evaluation is an important tool to analyze the pattern of LUT dysfunction in MSA. Impaired detrusor contractility was seen more in MSA-P which needs to be investigated in further studies.

Sex-related differences in the clinical presentation of multiple system atrophy

“…Compared to previous studies [ 10 , 12 , 37 , 55 ], we did not observe an association between sex and urinary incontinence or catheterization. In the general population, perineal laxity and multiparity are well-known factors that contribute to urinary incontinence in women, while prostate hypertrophy may cause urinary retention in men.…”

“…The literature on sex-related differences in the clinical presentation of MSA suggested that compared to men, women more frequently have a motor symptomatic onset and a better response to L-dopa, but overall develop greater motor disability over time and more frequently suffer from pain, depression, anxiety, sarcopenia, frailty, early falls, fractures, worse cognitive performance, and lower health-related quality of life [ 10 , 11 , 22 , 25 , 31 , 48 , 50 , 51 , 59 ]. By contrast, men were more frequently reported to have an autonomic symptomatic onset and to suffer from more widespread and severe autonomic failure, except for urinary urge incontinence and constipation, which were more common in women [ 10 , 12 , 20 , 34 , 36 , 37 , 41 , 51 , 55 , 60 , 61 ]. Higher supine BP levels as well as greater orthostatic BP falls were both associated with increased mortality in men with MSA [ 54 , 57 ].…”

“…The literature on sex-related differences in the clinical presentation of MSA primarily consisted of studies conducted following the publication of the second consensus MSA criteria [ 14 ]. Altogether, these studies indicated that women suffer from a greater motor disability and higher neuropsychiatric burden, while possibly experiencing a slight survival benefit due to initial motor onset and overall less severe autonomic failure compared to men [ 10 – 12 , 38 , 41 , 51 , 52 , 54 , 55 , 57 , 60 , 61 ]. A motor onset in MSA may positively impact women’s survival by prompting an earlier referral, diagnosis, and thus optimized care [ 10 ].…”

Underactive Bladder and Detrusor Underactivity: New Advances and Prospectives

“…The frequency of DU has been found to be increased to 62.1% in patients with MSA and 71.4% in patients with post-void residual (PVR) > 100 mL. Additionally, the strength of the detrusor in MSA-P has been found to be weaker than that of MSA-C (P det @Q max 26.2 vs. 34.4 cmH 2 O, p = 0.04) [25]. A recent systematic review found that 12% of patients with multiple sclerosis (MS) experience an atonic bladder [26].…”

Multiple system atrophy

“…The only tests needed to fulfil core clinical criteria are a postvoid bladder residual volume and a lying and standing blood pressure. However, if uncertainty remains, other investigations can help to prove autonomic involvement, for example formal urodynamics showing detrusor sphincter dyssynergia 15 or external anal sphincter electromyography showing chronic reinnervation changes in Onuf’s nucleus (however, this finding is not specific to MSA, and occurs in long-standing Parkinson’s disease, progressive supranuclear palsy and after pelvic surgery). 16 …”