“Bladder-first” form of multiple system atrophy: a message from uro-neurologists

Sakakibara R1, Panicker J N2, Simeoni S2, Uchiyama T3, Yamamoto T4, Tateno F1, Aiba Y1, Kishi M1

Research Type


Abstract Category


Abstract 33
Neurogenic Bladder
Scientific Podium Short Oral Session 4
Wednesday 29th August 2018
10:45 - 10:52
Hall A
Neuropathies: Central Underactive Bladder Voiding Dysfunction Motor Dysfunction Detrusor Hypocontractility
1. Neurology, Internal Medicine, Sakura Medical Center, Toho University, 2. Uro-Neurology, the National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, 3. Continence Center, Dokkyo Medical College, 4. Neurology, Chiba University

Ryuji Sakakibara



Hypothesis / aims of study
Multiple system atrophy (MSA) is a disease which combines autonomic (postural hypotension and/or urogenital dysfunction) and motor disorders. Some patients are “bladder-first” cases, who later develop further manifestations of MSA. However, thus far such cases have been poorly recognized and characterized. We here present detailed history taking and questionnaire data in 121 patients with MSA.
Study design, materials and methods
Detailed history and questionnaire of autonomic symptoms were performed in121 MSA patients: 48 with MSA-C (cerebellar form), 17 with MSA-P (parkinsonian form), and 56 with MSA-‘Auto’ (P/C) (either cerebellar or parkinsonian form), where autonomic symptoms are the initial and main clinical feature, and mild parkinsonism, cerebellar ataxia and/or pyramidal involvement appear during the course of disease.
Among these 3 forms the difference between urinary and orthostatic symptoms was prominent in patients with MSA-C (urinary symptoms in 92%, orthostatic in 10%; p<0.01) and with MSA-P (94%, 6%; p<0.01) compared with those with MSA-‘Auto’ (100%, 82%). In MSA-‘Auto’, 40 started without gait disturbance. In this group, in patients with urinary and orthostatic symptoms (n=32), those patients who had of urinary symptoms first (n=22, 68.7%) were more common than those who had orthostatic symptoms first (n=10, 31.3%). The longest interval between urinary and gait difficulty was 7 years.
Interpretation of results
The results of the present study show that 18.2% of the MSA patients studied started with urinary symptoms alone, without any other motor/autonomic symptoms. The results are in accordance with previous cohort/case studies. Our results are clinically relevant, since such patients see urologists or physicians first, because of their urinary symptoms. In particular, men with MSA often undergo prostatic surgery after a diagnosis of prostatic hyperplasia, before the correct diagnosis is made by neurologists, often with unfavorable results. 6 For this reason, we should keep in mind that a proportion of MSA patients start with urinary symptoms alone, without any other motor/other autonomic symptoms. MSA is a more aggressive disorder than Parkinson’s disease. Surgical treatment of bladder outlet obstruction often fails in MSA patients and should be avoided; this is in contrast to Parkinson’s disease, in which prostatic surgery is not contra-indicated.13 In Parkinson’s disease, “bladder-first” cases are extremely rare.
Concluding message
18.2% of MSA patients started with urinary symptom alone. Such patients see urologists first before the correct diagnosis is made. In order to avoid unnecessary prostatic surgery, collaboration of urologists and neurologists is essential for early, correct diagnosis and management.
Figure 1
Figure 2
  1. Urinary dysfunction and orthostatic hypotension in multiple system atrophy: which is the more common and earlier manifestation? J Neurol Neurosurg Psychiatry. 2000; 68: 65-69.
  2. Lower urinary tract symptoms of neurological origin in urological practice. Clin Auton Res. 2013; 23: 67-72.
  3. First symptoms in multiple system atrophy. Clin Auton Res. 2018 Jan 8. doi: 10.1007/s10286-017-0500-0. [Epub ahead of print]
Funding None Clinical Trial No Subjects Human Ethics Committee Ethics Committee in Sakura Medical Center, Toho University Helsinki Yes Informed Consent Yes