Autonomic dysfunction: A guide for FPs
Impotence, bladder dysfunction, GI symptoms, and orthostatic hypotension can signal autonomic dysfunction. Here’s what you’ll see and how to respond.
PRACTICE RECOMMENDATIONS
› Begin a trial of an antimuscarinic if initial nonpharmacologic treatment of urge incontinence or overactive bladder is ineffective. B
› Start step-wise treatment beginning with metoclopramide A, followed by domperidone, and, finally, oral erythromycin B in patients with gastroparesis who have failed conservative measures.
› Employ step-wise pharmacologic treatment, starting with fludrocortisone, for patients with disabling symptoms of orthostatic hypotension who fail to respond to nonpharmacologic measures. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Autonomic dysreflexia: A medical emergency
Autonomic dysreflexia, a medical emergency that must be recognized immediately, is a distinct type of autonomic dysfunction seen in patients with spinal cord injury at or above the T6 level.30 It is a condition of uncontrolled sympathetic response secondary to an underlying condition such as infection, urinary retention, or rectal distention.30
Common symptoms include headache, significant hypertension, flushing of the skin, and diaphoresis above the level of injury.2 In addition, a review of systems should screen for fever, visual changes, abnormalities of the cardiovascular system, syncope, bowel and bladder symptoms, and sexual dysfunction.
Patients demonstrating autonomic dysreflexia should be placed in the upright position to produce an orthostatic decrease in BP.30 Patients should be evaluated to identify any reversible precipitants, such as urinary retention or fecal impaction. Severe attacks involving hypertensive crisis require prompt transfer to the emergency department. Sublingual nifedipine or an intravenous agent, such as hydralazine, may be used to lower BP.31
CORRESPONDENCE
Kristen Thornton, MD, 777 South Clinton Ave., Rochester, NY 14620; Kristen_Thornton@URMC.Rochester.edu
