Nonmotor presentations of multiple system atrophy.

Multiple system atrophy (MSA) is a neurodegenerative disease characterized clinically by a combination of parkinsonian, cerebellar, autonomic and pyramidal features. Recent data show that the MSA clinical spectrum is wider than was originally thought, and may include various nonmotor symptoms that arise at disease onset. These symptoms include urinary disorders, erectile dysfunction in men, orthostatic hypotension, sleep disruption, stridor, and severe constipation. Neurologists and other specialists must be made aware that this relatively common neurodegenerative disease can manifest with nonmotor symptoms well before patients develop any overt motor disorder. The importance of recognizing such symptoms should not be underestimated, being crucial for understanding the disease prognosis, avoiding unnecessary tests and procedures, and planning any therapeutic intervention.