Diagnosis and treatment of urinary and sexual dysfunction in hereditary TTR amyloidosis

Purpose We aimed to review the current knowledge on the epidemiology, diagnosis, and management of urinary and sexual dysfunction in patients with TTR amyloidosis (ATTR). Methods We performed a review of the literature, screening for randomized controlled trials, prospective and retrospective series, position papers, and guidelines on urinary and sexual dysfunction in ATTR patients published in PubMed and Embase. Results Lower urinary tract dysfunction is present in up to 83% of patients with ATTR. Voiding symptoms are the most common, reported in 34.8−87.5% of patients, while urinary tract infections are reported in up to 50%. Urinary incontinence is observed in 16.7−37.5% of the ATTR population, mostly due to decreased urethral resistance. Sexual dysfunction affects over 40% of ATTR patients, with erectile dysfunction and sexual arousal disorder being the most common symptoms in male and female patients, respectively. In addition to a thorough clinical examination, invasive pressure-flow urodynamic testing is a cornerstone in the assessment of ATTR lower urinary tract dysfunction. The most common finding is detrusor underactivity and intrinsic sphincter deficiency. Poor bladder compliance can also be observed in patients, due to amyloid deposits on the bladder wall. Urinary tract imaging may be of interest to rule out upper urinary tract deterioration. Given the paucity of data in the ATTR population, treatment should be tailored to the individual patient. Conclusion Urinary and sexual dysfunction are highly prevalent in ATTR patients. Comprehensive assessment and multidisciplinary management are keys to avoiding upper urinary tract damage and improving patients’ quality of life.