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.

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.

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.

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.

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