Managing Dysautonomia in Multiple System Atrophy (MSA)

Speaker: Katie Kompoliti, MD, PhD – Professor of Neurological Sciences, Rush University Medical Center, Chicago, IL
Event: Annual All-Community Virtual MSA Conference 2025

Dysautonomia—a malfunction of the autonomic nervous system—is a defining feature of Multiple System Atrophy (MSA). The autonomic nervous system controls our body’s automatic functions, such as blood pressure, heart rate, digestion, and temperature regulation.

In this informative presentation, Dr. Katie Kompoliti explains how MSA impacts these critical systems and offers practical, actionable strategies for managing the most common autonomic symptoms.

1. Neurogenic Orthostatic Hypotension (nOH)

One of the most challenging symptoms of MSA is Neurogenic Orthostatic Hypotension (nOH). This occurs when blood pressure drops significantly (at least 20 mmHg systolic or 10 mmHg diastolic) within three minutes of standing up. Because MSA affects the central nervous system, the body fails to release enough norepinephrine to constrict blood vessels and push blood back up to the brain.

  • Common Symptoms: Dizziness, lightheadedness, blurred vision, fainting (syncope), and a characteristic “coat hanger” headache (pain in the neck and shoulders due to low blood flow to those muscles).
  • Non-Pharmacological Treatments: Discontinuing blood-pressure-lowering medications, increasing fluid (up to 2.5 liters daily) and salt intake, elevating the head of the bed by 30 degrees, and using waist-high compression stockings or abdominal binders.
  • Pharmacological Treatments: If conservative measures fail, FDA-approved medications like Midodrine and Droxidopa (Northera) can be used. Note: Patients must be monitored for supine hypertension (dangerously high blood pressure when lying down flat).

2. Bladder Dysfunction

Bladder issues are nearly universal in MSA, affecting up to 80% of patients. Early in the disease, patients typically experience an overactive bladder (urgency, frequency, and incontinence). In advanced stages, the bladder may fail to empty completely, leading to urinary retention.

  • Management Strategies: Behavioral modifications (timed voiding) and pelvic floor physical therapy.
  • Medications: Doctors must prescribe bladder medications carefully. For example, B3 adrenergic agonists like Myrbetriq (mirabegron) are often preferred for MSA patients because they do not worsen blood pressure or cause cognitive side effects, unlike some older anticholinergic drugs.
  • Advanced Care: If urinary retention becomes severe, intermittent self-catheterization or a permanent catheter may be required.

3. Gastrointestinal Issues & Constipation

MSA often causes slowed colonic transit, leading to severe constipation.

  • Management Strategies: Maintaining high hydration and fiber intake, regular exercise, and using a “Squatty Potty” to improve bowel mechanics. If needed, bulk-forming laxatives, water-secreting agents (like Miralax), or prescription motility drugs can be introduced.

4. Thermoregulation (Temperature Control)

Patients with MSA frequently lose the ability to sweat normally (anhidrosis or hypohidrosis). Sweating is the body’s primary way to dissipate heat, meaning MSA patients are at a highly increased risk for heat intolerance and heat stroke.

  • Management Strategies: It is imperative to avoid hot, humid weather, hot showers, and saunas. Patients should stay indoors during extreme heat, wear light, breathable clothing, and use rapid cooling measures (like external cooling pads or damp cloths on pulse points) if they become overheated.

5. Erectile Dysfunction

Erectile dysfunction is often one of the earliest signs of dysautonomia in men with MSA. While medications exist to treat this, Dr. Kompoliti notes that they must be used with extreme caution, as many standard erectile dysfunction drugs can dangerously lower blood pressure and exacerbate nOH.