Urologic applications of botox

Botulinum toxin (BTX), a neurotoxin produced by the gram-positive, rod-shaped anaerobic bacterium Clostridium botulinum, was isolated in 1897 by Belgian scientist Professor Pierre Emile van Ermengem. BTX acts by blocking the release of acetylcholine at the neuromuscular junction. As a result of this chemodenervation, a temporary flaccid paralysis ensues. Different medical disciplines have taken advantage of this temporary paralysis to treat muscular hypercontraction. BTX was first approved by the US Food and Drug Administration in 1989 for use in patients with strabismus and blepharospasm. Since then, BTX has been used to treat a number of different neuromuscular disorders. Although not approved by the US Food and Drug Administration, BTX has been used successfully in urology to treat neurogenic and non-neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, motor and sensory urge, and chronic pain syndromes.

Botox in urology

Lower urinary tract dysfunction is one of the challenging problems facing urologists and patients. Several treatment trials have been introduced in the literature, but none has proven to be as effective as being a gold standard treatment for such conditions. We reviewed the literature regarding the use of botulinum toxin (BTx) type A as a current treatment of lower urinary tract conditions described below. The toxin has been shown to be safe and effective in the treatment of conditions caused by increased muscle tonicity. Indications for the urological use of BTx and future applications are also considered.

K(ATP) channel therapeutics at the bedside

The family of potassium channel openers regroups drugs that share the property of activating adenosine triphosphate-sensitive potassium (K(ATP)) channels, metabolic sensors responsible for adjusting membrane potential-dependent functions to match cellular energetic demands. K(ATP) channels, widely represented in metabolically-active tissue, are heteromultimers composed of an inwardly rectifying potassium channel pore and a regulatory sulfonylurea receptor subunit, the site of action of potassium channel opening drugs that promote channel activity by antagonizing ATP-induced pore inhibition. The activity of K(ATP) channels is critical in the cardiovascular adaptive response to stress, maintenance of neuronal electrical stability, and hormonal homeostasis. Thereby, K(ATP) channel openers have a unique therapeutic spectrum, ranging from applications in myopreservation and vasodilatation in patients with heart or vascular disease to potential clinical use as bronchodilators, bladder relaxants, islet cell protector, antiepileptics and promoters of hair growth. While the current experience in practice with potassium channel openers remains limited, multitude of ongoing investigations aims at defining the benefit of this emerging family of therapeutics in diverse disease conditions associated with metabolic distress.

Efficacy of the combination of an α1-blocker with an anticholinergic agent in the treatment of lower urinary tract symptoms associated with bladder outlet obstruction

The combination of an alpha1-blocker with an anticholinergic is a new and promising therapeutic approach for bladder outlet obstruction and detrusor overactivity. Both placebo-controlled and comparative studies have demonstrated that the addition of an anticholinergic in the conventional treatment of patients with bladder outlet obstruction is safe, as the likelihood of acute urinary retention is low. Although the pathophysiology of detrusor overactivity is unknown and most probably multifactorial, it is not expected that the voiding phase is influenced by regular doses of anticholinergics, although high doses may affect detrusor contraction. However, safety issues must be studied further. The combination of tamsulosin with propiverine or tolterodine, and of doxasosin with tolterodine has been shown to cause a significant improvement of lower urinary tract symptoms when compared with alpha1-blocker monotherapy. Indisputably, the existing literature provides clear evidence that the combination of an alpha1-blocker with an anticholinergic extends physicians ability to manage lower urinary tract symptoms caused by bladder outlet obstruction and overactive bladder syndrome.

Urinary diseases and ethnobotany among pastoral nomads in the Middle East

This article is derived from a broad, twenty-year study of ethnobotany and folk medicine among pastoral nomads in the Middle East which took place from 1984 to 2004. The article presents examples of different treatments of diseases and disorders of the urinary tract carried out by healer herbalists. The preparation of remedies includes boiling infusions, extraction of dry or fresh leaves, flowers, seeds or whole plants. Some of these plants were used both as food and as medicine, by ingesting different parts of the plants, such as leaves, flowers, fruits, and so on, either while soft, cooked or dried. Data were collected by using unstructured interviews and by observation. These plants were identified by healers, patients, and university botanists. This paper identified eighty-five plant species, which belong to thirty-six families. The most representative families are: Asteraceae (8), Brassicaceae (6), Poaceae (6), Umbelliferae (6).

Vaginal Hormone Therapy for Urogenital and Menopausal Symptoms

Reduction of ovarian steroids at menopause leads to significant changes in the urogenital tract. These changes often worsen with time, particularly in nonsmokers, affecting up to 38% of menopausal women. Urogenital symptoms that clearly respond to estrogen therapy include atrophic vaginitis, dryness, and accompanying dyspareunia. Estrogen reduces urinary tract infections in women plagued by frequent recurrence. The sensation of urgency improves with estrogen but urge incontinence improvement is similar to that with placebo. Stress incontinence does not improve with estrogen. Until recently, vaginal therapy was reserved for local symptoms. Rings make systemic vaginal therapy acceptable and even preferred by some users. Vaginal delivery, like other parenteral therapies, bypasses the gastrointestinal tract, with less anticipated impact on lipids, globulins, clotting, and fibrinolytic factors. Evidence of a lowered risk of venous thromboembolism is reviewed. Options for estrogen therapy include native, synthetic, or biologically derived estrogens delivered by cream, gel, insert (pessary), ring, or tablet. Even the lowest dose estradiol (7.5 mug daily or 25 mug twice per week) shows evidence of systemic absorption. In long-term placebo-controlled studies, bone density was better preserved and lipid profiles were more favorable. Therefore, even these low dose therapies should be opposed by occasional progestogen to prevent endometrial carcinoma. Intermittent therapy is best given for a minimum of 12 days based on laboratory data. Less frequent dosing, although preferred by patients, likely confers a slightly increased risk of hyperplasia. No combination estrogen/progestogen vaginal product is currently available. The best dose to reduce risk of endometrial pathology adequately in the lower dose therapies will be defined not only by the dose and potency of the exogenous estrogen but by the individual is body habitus and lifestyle choices.

[Goldenrod--a classical exponent in the urological phytotherapy]

Herbal remedies based on goldenrod (Solidago virgaurea L.) have been well-tried for centuries in the treatment of urinary tract diseases. Investigations in molecular pharmacology could show new mechanisms responsible for the biological effect of natural product from goldenrod extracts. The use of such herbal preparations with a rather complex action spectrum (anti-inflammatory, antimicrobial, diuretic, antispasmodic, analgesic) is especially recommended for treatment of infections and inflammations, to prevent formation of kidney stones and to help remove urinary gravel. This therapy is safe at a reasonable price and does not show drug-related side-effects.

Efficacy and safety of tamsulosin in the treatment of urological diseases

The alpha(1)-adrenoceptor antagonist, tamsulosin, is selective for alpha(1A)- and alpha(1D)- over alpha(1B)-adrenoceptors. Both placebo-controlled and comparative studies with other agents have demonstrated tamsulosin to be an effective treatment for patients with lower urinary symptoms suggestive of benign prostatic hyperplasia. Its effectiveness appears to be maintained over many years. Tamsulosin may also effectively reduce lower urinary tract symptoms in other urological diseases. A dose of tamsulosin 0.4 mg/day has a tolerability close to that of placebo and has little, if any, blood pressure lowering effects. Tolerability and lack of blood pressure lowering are maintained even in high-risk patients such as those with cardiovascular comorbidity and/or comedication. Apart from adrenoceptor subtype-selectivity, a smooth pharmacokinetic profile of its modified-release formulation and a selective accumulation in target tissues may contribute to an excellent efficacy:tolerability ratio.

Alternative use of botulinum toxin in urology

Botulinum toxin A is used in the treatment of lower urinary tract symptoms due to detrusor sphincter dysynergia and detrusor hyper-reflexia (neurogenic detrusor deficiency). The toxin acts by producing paralysis of muscle tissue and has been shown to be safe and effective in the treatment of conditions caused by increased muscle tonicity and spasticity. Here the literature is reviewed chronologically, the established and emerging indications for the urological use of botulinum toxin evaluated and future applications are also considered.

Low-dose, vaginally administered estrogens may enhance local benefits of systemic therapy in the treatment of urogenital atrophy in postmenopausal women on hormone therapy

BACKGROUND

When genital atrophy exists, systemic hormone therapy (HT) has a timing until to induce vaginal proliferation and symptomatic relieve. Thus, in order to obtain a prompt improvement, the association of local therapy acting on the genital epithelium to the systemic treatment should be considered.

OBJECTIVE

To evaluate the effects of a combined therapy consisting of vaginal estriol with transdermal 17-beta-estradiol (50 microg/day) plus medroxyprogesterone acetate (5 mg/day) per os in shortening the period of uro-genital symptoms.

SUBJECTS AND METHODS

In a randomized, double blind, controlled with placebo study, 27 women with climacteric symptoms and atrophic vaginitis were treated for 4 months with HT plus vaginal estriol 0.5 mg/day (group E) or placebo (group P). Patients use the local medication daily for the first 3 weeks and twice-weekly thereafter. Before entering in the study, patients were asked about HT and selected for inclusion. In the first visit, electible patients after written informed consent were randomized to receive HT plus local estriol or placebo. All the subjects had baseline studies, including medical history, physical examination, blood and urine analysis. In order to evaluate the effect of local treatment on urinary and genital symptoms, a score for genital, urinary and colposcopic complaints (0 minimum-100 maximum) was developed. This score and Blatt-Kuperman were recorded and performed in every control.

RESULTS

There were no differences on climacteric symptoms relief between the two groups. Additionally, the improvement in urinary symptoms at the end of the study was similar for both groups (from 16.5 +/- 6.1 to 8.5 +/- 2.4 for E group and from 15.8 +/- 7.8 to 8.8 +/- 2.7 for P group; P < 0.01 versus basal); however, those women in group E reached significant improvement on urinary complaints since the first month of treatment. Additionally, a significant difference between E and P was observed at months 2 and 3, although no differences were detected at the end of the study. Papanicolaou smear showed reactive or reparative changes and karyopyknotic index exhibited a significant increase in superficial cells in both groups and at the end of the study.

CONCLUSIONS

Adding vaginal estriol to HRT may shorten the latency period for urinary symptoms.

Management of bladder, prostatic and pelvic floor disorders with botulinum neurotoxin

Since its introduction in the late 1970s for the treatment of strabismus and blepharospasm, botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several other disorders characterized by excessive or inappropriate muscle contractions. The use of this pluripotential agent has extended to a plethora of conditions including: focal dystonia; spasticity; inappropriate contraction in most sphincters of the body such as those associated with spasmodic dysphonia, esophageal achalasia, chronic anal fissure, and vaginismus; eye movement disorders; other hyperkinetic disorders including tics and tremors; autonomic disorders such as hyperhidrosis; genitourinary disorders such as overactive and neurogenic bladder, non-bacterial prostatitis and benign prostatic hyperplasia; and aesthetically undesirable hyperfunctional facial lines. In addition, BoNT is being investigated for the control of the pain, and for the management of tension or migraine headaches and myofascial pain syndrome. BoNT injections have several advantages over drugs and surgical therapies in the management of intractable or chronic disease. Systemic pharmacologic effects are rare; permanent destruction of tissue does not occur. Graded degrees of relaxation may be achieved by varying the dose injected; most adverse effects are transient. Finally, patient acceptance is high. In this paper, clinical experience over the last years with BoNT in urological impaired patients will be illustrated. Moreover, this paper presents current data on the use of BoNT to treat pelvic floor disorders.

Role of phytotherapy in men with lower urinary tract symptoms

PURPOSE OF REVIEW

Serenoa repens extract is a popular phytotherapeutic agent in men with lower urinary tract symptoms. Although the exact mechanism of action is unknown, the agent is generally well accepted for its easy availability and good tolerability. This paper reviews the evidence of its efficacy in comparison with placebo, 5-alpha reductase inhibitor and alpha-1 adrenoreceptor antagonist.

RECENT FINDINGS

Serenoa repens extract is comparable with 5-alpha reductase (finasteride) and alpha-1 antagonist in the treatment of benign prostatic hyperplasia in terms of symptom score and peak urinary flow rate improvement, but has a lower incidence of associated sexual dysfunction. Furthermore, long-term usage (36 months) of Serenoa repens decreases the progression rate of the condition as compared with watchful waiting. In addition, the efficacies of Serenoa repens are proven in several placebo-controlled trials.

SUMMARY

Serenoa repens has proven its role in the management of benign prostatic hyperplasia and will remain as a viable first-line treatment option.

Combination Therapy with Rofecoxib and Finasteride in the Treatment of Men with Lower Urinary Tract Symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH)

PURPOSE

Cyclooxygenase-2 (COX-2) is expressed in human BPH tissue and displays either a pro-inflammatory effect or a proliferative effect on prostate cells. The aim of this study is to analyze whether combination therapy with rofecoxib, a COX-2 inhibitor, and finasteride offers an advantage compared to finasteride monotherapy in patients with BPH.

MATERIALS AND METHODS

This is a single centre unblinded trial. Forty-six consecutive men with LUTS and BPH were entered into the study and were randomized to receive rofecoxib 25mg/day plus finasteride 5mg/day (group B) versus finasteride 5mg/day alone (group A) for 24 weeks. Inclusion criteria included also a prostate size greater than 40 cc. The efficacy and safety of treatments were assessed at baseline and at week 4, 12 and 24.

RESULTS

In our population, both treatments (groups A and B) produced statistically significant improvements in total IPSS and Q(max) from baseline during follow-up, although they were very low in particular for the finasteride alone group at 4 weeks. We found that finasteride monotherapy produces very little improvement at the 1 month interval. In comparing group A with group B, a significantly higher improvement in IPSS (p=0.0001) and Q(max) (p=0.03) was obtained in group B at 4 weeks interval (% cases with IPSS reduction >4 points: group B=34.7, group A=0; % cases with Q(max) improvement >3 ml/s: group B=8.7, group A=0), whereas at week 24, the differences between the two treatments were not significant (p>0.05).

CONCLUSIONS

In our population, the advantage of the combination therapy compared to finasteride alone is significant in a short-term interval (4 weeks). It can be hypothesized that the association of rofecoxib with finasteride induces a more rapid improvement in clinical results until the effect of finasteride becomes predominant.

The relationship between erectile dysfunction and lower urinary tract symptoms: epidemiological, clinical, and basic science evidence

Lower urinary tract symptoms (LUTS) and sexual dysfunction are highly prevalent in aging men. Both conditions also are significant contributors to overall quality of life. New data have emerged to indicate potential links in epidemiological, physiologic, pathophysiologic, and treatment aspects of these two entities. There are numerous publications based on sophisticated community and clinical-based data, suggesting a strong and consistent association between LUTS and erectile dysfunction (ED). The association is supported by the consistent linear relationship of more severe LUTS with more severe ED. The link between ED and LUTS has biologic plausibility given the four leading theories of how these diseases inter-relate.

Botulinum toxin in urology: evaluation using an evidence-based medicine approach

Clinical reports documenting the beneficial effects of botulinum toxin (BTX) to treat various lower urinary tract disorders of muscle spasticity (e.g. detrusor hyperreflexia, detrusor sphincter dyssynergia) have led to its expanded application in non-neurogenic conditions such as idiopathic detrusor overactivity, detrusor underactivity and benign prostatic hyperplasia (BPH). As greater numbers of investigators report their results utilizing this agent, it becomes more important that clinicians are able to synthesize and describe the findings of current clinical studies in a meaningful way. Evidence-based medicine is a platform on which investigations concerning a particular topic can be evaluated for their levels of scientific evidence, so that rational clinical recommendations can be formulated. This review article applies evidence-based practices to the use of BTX in common urologic conditions. Appreciating the benefits as well as limitations of currently available studies will hopefully drive the development of well-controlled, randomized studies of BTX, particularly in highly prevalent conditions such as idiopathic detrusor overactivity and BPH.

Role of the newer alpha, -adrenergic-receptor antagonistsin the treatment of benign prostatic hyperplasia-related lower urinary tract symptoms

BACKGROUND

Although initially introduced for the management of hypertension, alpha(1)-adrenergic-receptor antagonists (alpha1-blockers) have become the standard of care for the medical management of benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS). However, these agents have the potential to produce orthostatic hypotension and other blood pressure-related adverse effects in normotensive patients and in those receiving concurrent treatment with other antihypertensive agents. As a result, more "uroselective," less vasoactive alpha(1)-blockers have been developed.

OBJECTIVE

This article reviews current information on the role of alpha(1)-blockers in the treatment of BPH-related LUTS. The focus is on tamsulosin and alfuzosin, newer "uroselective" agents in this class that have a decreased potential for cardiovascular adverse effects.

METHODS

Relevant articles were identified through a search of the English-language literature indexed on MEDLINE and the proceedings of scientific meetings from 1976 to 2003. The search terms were benign prostatic hyperplasia treatment, alpha(1)-adrenergic-receptor blocker, uroselectivity, lower urinary tract symptoms, complications, and cardiovascular.

RESULTS

Tamsulosin has selectivity for the a alpha(1) and alpha(1d) receptor subtypes. Alfuzosin, although not receptor subtype selective, is clinically "uroselective" and does not significantly affect vascular alpha-adrenergic receptors. Both agents are efficacious in relieving LUTS and have a decreased potential for such cardiovascular adverse effects as postural hypotension. Common adverse events with these agents include dizziness and asthenia.

CONCLUSION

Based on the available data, "uroselective" alpha(1)-blockers should be considered over older, more vasoactive agents for the medical management of LUTS, particularly in patients with BPH and hypertension.

The role of botulinum toxin in neurourology

Botulinum toxin is a presynaptic neuromuscular blocking agent that induces a selective and reversible muscle weakness of up to several months when injected intramuscularly in minute quantities. Different medical disciplines have applied the toxin to treat mainly muscular hypercontraction. For neurourologically impaired patients, the reported successful treatment of neurogenic detrusor overactivity and detrusor sphincter dyssynergia with botulinum-A toxin is a promising alternative option to conservative medication or surgery. This review of the literature presents current indications, techniques for and results of the use of botulinum toxin in neurourologically impaired patients and aims to give an insight into this new therapeutic option.