Mutiple system atrophy (MSA) is a rare, progressive neurodegenerative disorder. The most characteristic clinical feature of MSA is autonomic dysfunction. Therefore, there may be difficulty in maintaining cardiovascular stability during general anesthesia. A 54-yr-old woman was scheduled for ureteroscopic and renoscopic laser lithotripsy because of multiple renal pelvis and upper ureteral stone. Four years ago, she was diagnosed with MSA presenting with hand tremor, orthostatic hypotension, cerebellar ataxia, and slight dysarthria. This patient had to use phenylephrine to maintain blood pressure during anesthesia. We report our experience of general anesthesia in this patient with reviewing on anesthetic management in MSA patient.