European experience of 200 cases treated with botulinum-A toxin injections into the detrusor muscle for urinary incontinence due to neurogenic detrusor overactivity

Botulinum toxin: from life-threatening disease to novel medical therapy

Botulinum toxin A is the newest therapy for the treatment of a variety of medical disorders caused by abnormalities of muscle activity. After successful use in other medical subspecialties, the newest applications of this potent neurotoxin are within the lower urinary tract. The toxin has evolved from a cause of fatal disease into the newest neuropharmacologic medical therapy.

Botulinum injections for the treatment of bladder symptoms of multiple sclerosis

OBJECTIVE

Our objective was to demonstrate the efficacy and impact on quality of life of detrusor injections of botulinum neurotoxin type A in the treatment of bladder dysfunction in patients with multiple sclerosis.

METHODS

Forty-three patients with multiple sclerosis suffering from severe urgency incontinence were treated with detrusor injections of botulinum neurotoxin type A. Data from cystometric assessment of the bladder, voiding diaries, quality-of-life questionnaires, and procontinence medication usage were collected before treatment and 4 and 16 weeks after injection. The same data were also collected after repeat treatments.

RESULTS

Highly significant improvements (p < 0.0001) in incontinence episodes and urinary urgency, daytime frequency and nocturia, were the symptomatic reflection of the significant improvements in urodynamically demonstrated bladder function. Although 98% of patients had to perform self-catheterization after treatment, there were sustained improvements in all quality-of-life scores. The mean duration of effect was 9.7 months. Similar results were seen with repeat treatments.

INTERPRETATION

Minimally invasive injections of botulinum neurotoxin type A have been shown to be exceptionally effective in producing a prolonged improvement in urinary continence in patients with multiple sclerosis. This treatment is likely to have a major impact on future management.

Purinoceptors as therapeutic targets for lower urinary tract dysfunction

Lower urinary tract symptoms (LUTS) are present in many common urological syndromes. However, their current suboptimal management by muscarinic and alpha(1)-adrenoceptor antagonists leaves a significant opportunity for the discovery and development of superior medicines. As potential targets for such therapeutics, purinoceptors have emerged over the last two decades from investigations that have established a prominent role for ATP in the regulation of urinary bladder function under normal and pathophysiological conditions. In particular, evidence suggests that ATP signaling via P2X(1) receptors participates in the efferent control of detrusor smooth muscle excitability, and that this function may be heightened in disease and aging. ATP also appears to be involved in bladder sensation, via activation of P2X(3) and P2X(2/3) receptors on sensory afferent neurons, both within the bladder itself and possibly at central synapses. Such findings are based on results from classical pharmacological and localization studies in non-human and human tissues, knockout mice, and studies using recently identified pharmacological antagonists--some of which possess attributes that offer the potential for optimization into candidate drug molecules. Based on recent advances in this field, it is clearly possible that the development of selective antagonists for these receptors will occur that could lead to therapies offering better relief of sensory and motor symptoms for patients, while minimizing the systemic side effects that limit current medicines.

Will suburothelial injection of small dose of botulinum A toxin have similar therapeutic effects and less adverse events for refractory detrusor overactivity?

OBJECTIVES

To investigate whether suburothelial injection of different doses of botulinum A toxin (BTX-A) will have a similar therapeutic effect but fewer adverse events than 200 U BTX-A in patients with refractory detrusor overactivity.

METHODS

A total of 75 patients with detrusor overactivity refractory to anticholinergics were enrolled and randomized to receive 100, 150, or 200 U of BTX-A injected into the suburothelial space at 40 sites. Urinary incontinence was graded on a self-reported scale of 0 to 3, representing continence and mild, moderate and severe incontinence, respectively. The therapeutic effects, adverse events, and urodynamic parameters were assessed at 3 months.

RESULTS

An excellent result at 3 months was obtained in 34.8%, 36%, and 40.7% of patients treated with 100, 150, and 200 U of BTX-A, respectively. The patients who received 100 U of BTX-A had a lower incidence of a large postvoid residual urine volume (150 mL or more) than did those who received 150 or 200 U (30.4% versus 52% and 72%, respectively, P = 0.011) after treatment. The posttreatment urodynamic parameters were similar between the patients who received 150 or 200 U of BTX-A, but the changes in bladder capacity and postvoid residual urine volume were greater than those for the patients who received 100 U. The duration of therapeutic effectiveness was significantly shorter for the patients treated with 100 U compared with that for those treated with 150 or 200 U of BTX-A.

CONCLUSIONS

Suburothelial injection of 100 U of BTX-A achieved a similar rate of excellent results and had significantly fewer adverse events compared with 150 or 200 U. The dose of suburothelial BTX-A also affected the duration of therapeutic effectiveness.

Persistence of therapeutic effect after repeated injections of botulinum toxin type A to treat incontinence due to neurogenic detrusor overactivity

OBJECTIVES

To study the effect of repeated botulinum toxin type A injections into the detrusor in patients with neurogenic detrusor overactivity and incontinence to determine the safety of repeated injections, the persistence of the clinical and urodynamic treatment efficacy, and potential changes in bladder compliance.

METHODS

Seventeen patients with neurogenic detrusor overactivity who had received three or more botulinum toxin type A injections into the detrusor were studied. The clinical and urodynamic data were analyzed at baseline (before the first injection), after the first injection, and after the last repeated injection.

RESULTS

No systemic side effects were observed for the total of 91 injections. The mean number of injections per patient was 5.4 (range 3 to 9). The mean number of incontinence episodes per day decreased from 2.6 at baseline to 0 after the first injection, and remained at 0 after the last injection. The maximal cystometric bladder capacity and reflex volume increased significantly after the first and last injection compared with at baseline. The maximal detrusor pressure decreased significantly after the first and last injection compared with at baseline. No difference in compliance was found from baseline to the first or last injection.

CONCLUSIONS

Repeated injections of botulinum toxin A into the detrusor muscle are a safe and valuable treatment option for neurogenic detrusor overactivity. After repeated injections, the effect on the clinical and urodynamic parameters remained constant. Also, repeated injections did not decrease bladder compliance.

[Urological rehabilitation of spinal cord injury patients]

The urological rehabilitation of spinal cord injury patients depends on an optimal urological treatment plan and good cooperation between the patient, general practitioner, urologist, and a centre that specialises in treating spinal cord injuries. Because of medical advancements in neuro-urology, one can assume that in cases of lifelong urological care, the individual's life expectancy will be almost normal. The recognition that nonphysiological bladder storage pressure results in restricted kidney function has led to various therapeutic strategies with complementary goals, such as protection of the upper urinary tract, urinary continence, individualized bladder management.

Autonomic side effects of Botulinum toxin Type B Intravesical injections: Report of 4 cases and review of the literature

Recently, intravesical injections of Botulinum toxin type B (BT-B) have been trialled in an attempt to treat detrusor overactivity. Use of Botulinum toxin A (BT.-A), for the same in the past, has been quite successful without many reported side effects. Soon after commencing the clinical use of BT-B, a side effect profile was noticed not reported with BT-A. A total of 20 patients with refractory detrusor overactivity were included in this randomized, double blind, placebo controlled, cross over trial. As per protocol, 5000 MU (1 ml) BT-B diluted to a volume of 20 mls with normal saline were injected in 10 different sites into the detrusor, sparing the trigone. We report four cases of autonomic side effects after these injections which strongly suggest clinically relevant systemic spread of the toxin.

Refractory neurogenic detrusor overactivity

Refractory neurogenic detrusor overactivity refers to the clinical condition that is no longer manageable by anticholinergic therapy. This condition represents a formidable task to caregivers because the treatment of urinary incontinence and adequate protection of the upper urinary tract become extremely difficult. Treatment options for refractory neurogenic detrusor overactivity include detrusor injections of botulinum toxin and intravesical instillation of vanilloid compounds, mainly resiniferatoxin, or anticholinergic drugs. If these options fail, bladder augmentation or sacral anterior root stimulation offers excellent outcomes, although at much higher costs and risks to the patients.

The Case for Bladder Botulinum Toxin Application

Botulinum toxin (BoNT) has been shown to be and effective agent in suppressing detrusor overactivity due to neurogenic causes. Recently, BoNT has been extended to patients who have idiopathic detrusor overactivity. This article reviews the use of BoNT to treat disorders of neurogenic detrusor overactivity and establishes BoNT as a therapeutic modality to treat idiopathic bladder overactivity. It is important to remember that the application of BoNT in the lower urinary tract is not approved by the regulatory agencies and caution should be applied until larger randomized clinical studies are completed.

Botulinum toxin: A potential alternative to current treatment of neurogenic and idiopathic urinary incontinence due to detrusor overactivity

OBJECTIVE

To analyze and report the current data on the treatment of both neurogenic and idiopathic detrusor overactivity with Botulinum toxin.

METHODS

Literature review using Pub-Med and Medline from 1990 until June 30, 2006.

RESULTS

Case series of patients with neurogenic detrusor dysfunction (NDD) and idiopathic detrusor overactivity (IDO) range from 15 to 200 patients with follow up from 12 to 36 weeks post-treatment. Significant improvements in cystometric bladder capacity, reflex volume at first urge to void, and bladder compliance are seen in nearly all patients. Approximately 50% of NDD patients achieved urinary continence and almost all had improvement in bladder control up to 36 weeks following treatment. Patients with IDO with urgency alone or with incontinence also had urodynamic as well as symptom improvement. Approximately 75% of patients with IDO and incontinence are dry at 12 weeks post-treatment. Urgency disappears on average in two thirds of patients. Quality of life scores also shows significant improvement for all groups.

CONCLUSION

Botulinum toxin-A has emerged as a promising option for the treatment of neurogenic and refractory idiopathic detrusor overactivity. Studies to date have shown that not only is this treatment effective at decreasing urinary symptoms and incontinence, as well as improving potentially dangerous urodynamic measures, but it is also minimally invasive, reversible and safe. Questions over proper dosing and dilution, number of injection sites, and re-injection rates remain to be answered.

Successful Treatment with Intradetrusor Botulinum-A Toxin for Urethral Urinary Leakage (Catheter Bypassing) in Patients with End-Staged Multiple Sclerosis and Indwelling Suprapubic Catheters

OBJECTIVE

To present the initial results of Botulinum-A toxin (BTA) injection in patients with long-standing multiple sclerosis (MS) and urethral leakage of urine in spite of indwelling suprapubic catheters (catheter bypassing).

METHODS

Study of three patients treated with cystoscopic injection of BTA IU (Allergan). Telephone interviews were made at four- to six-week intervals. Continence status and patient satisfaction were recorded before and after treatment.

RESULTS

Patient 1 remained dry at 48 weeks post injection. Patient 2 became incontinent again after 40 weeks. The third patient was continent when interviewed at 27 weeks following injection, but died two weeks later. The patients were very satisfied with the procedure and there were no complications related to BTA.

CONCLUSIONS

Intradetrusor BTA injection is a very effective and safe treatment for intractable catheter bypassing in patients with neurogenic detrusor overactivity.

Botulinum Toxin Injections for Neurogenic and Idiopathic Detrusor Overactivity: A Critical Analysis of Results

OBJECTIVE

In recent years there has been an increasing use of the botulinum neurotoxins for the management of conditions characterised by detrusor overactivity. Early studies showed promising results in an area where few options previously existed between pharmacotherapy and surgery. This has led to an urgent need to assess the wide range of techniques and therapies available, as well as the efficacy and tolerability of the treatment. We performed a critical analysis of the numerous clinical studies for this novel treatment option in the management of neurogenic and idiopathic detrusor overactivity, with a view to directing further research and assisting urologists in the management of these conditions.

METHODS

A systematic review of the literature, as well as a search for abstracts presented to relevant peer-reviewed meetings, was performed. All articles from 1988 onwards were included, prior to which no articles describing urologic use of botulinum neurotoxins had been published, although the majority of the articles have been published since 2000.

RESULTS AND CONCLUSIONS

Although many of the studies were small, overwhelming evidence supports the efficacy, safety, and tolerability of the botulinum toxins, specifically serotype A, for the management of these conditions. Before this is accepted as a widespread treatment modality, good-quality evidence from large-scale randomised controlled trials is needed. These studies should identify not only the most appropriate patients to treat but also the best dose, administration technique, and frequency for treatment.

Management of the neurogenic bladder in the female patient

Management of the female patient with neurogenic bladder requires special considerations that are not seen with many male neurogenic bladder patients. Because of the unique challenges that certain women present, a disproportionate number of women end up with an indwelling catheter or continuously leak urine into a diaper. Other options for bladder management include intermittent catheterization and reconstruction, which, when used appropriately, can lead to significant improvements in urinary continence, quality of life, and patient independence. This article reviews the various options available today as well as several potential therapies that may be available in the future.

Evaluation and management of refractory overactive bladder

The refractory overactive bladder patient is a complex new entity for the urologic community. We present the most current review of this difficult subject matter with an emphasis on evaluation and new treatment options such as sacral neuromodulation and botulinum toxin injection. It is hoped that in this new era of medical innovation, extirpation and reconstruction of the bladder will become historic in nature and refractory therapy can be transitioned to the office and outpatient operation rooms.

Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society

Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.

Botulinum toxin and the overactive bladder

Botulinum toxin is now a treatment for many conditions. It is undergoing increasing use in several different unlicensed urological clinical situations which are outlined in this article. The article discusses the available evidence relating to its use, effectiveness and safety.

Botulinum toxin: Clinical use

Since its development for the use of blepharospasm and strabismus more than 2.5 decades ago, botulinum neurotoxin (BoNT) has become a versatile drug in various fields of medicine. It is the standard of care in different disorders such as cervical dystonia, hemifacial spasm, focal spasticity, hyperhidrosis, ophthalmological and otolaryngeal disorders. It has also found widespread use in cosmetic applications. Many other indications are currently under investigation, including gastroenterologic and urologic indications, analgesic management and migraine. This paper is an extensive review of the spectrum of BoNT clinical applications.

Neuromodulatory therapies in female pelvic medicine and reconstructive surgery: biological agents

In recent years, important improvements in the management of patients with neurogenic or non-neurogenic detrusor overactivity and urge incontinence have been brought about by the introduction of vanilloids and botulinum toxins in urology. In this review we introduce the new therapeutic options, provides basic information, and summarize the results experienced so far.

Botulinum toxin and the overactive bladder

Botulinum toxin is now a treatment for many conditions. It is undergoing increasing use in several different unlicensed urological clinical situations which are outlined in this article. The article discusses the available evidence relating to its use, effectiveness and safety.

The overactive bladder: review of current pharmacotherapy in adults. Part 2: treatment options in cases refractory to anticholinergics

In the first part of this review the potential pathophysiological factors involved in the overactive bladder were outlined, and the wide range of first-line anticholinergic pharmacotherapies available for such patients were reviewed. The second part will focus on the intravesical instillation of resiniferatoxin and injections of botulinum toxin into the bladder to treat overactive bladder and detrusor overactivity. Resiniferatoxin has been shown to increase bladder capacity and improve incontinence in patients with neurogenic and non-neurogenic detrusor overactivity. Botulinum toxin has successfully been used to treat neurogenic and idiopathic detrusor overactivity, with improvements observed in bladder capacity, decreases in detrusor pressures on filling and voiding, and increased volumes at first contraction. Further validation is required for both treatments, in the form of large randomised controlled trials, before their use can be considered routine, with particular focus on dosing required.

Botulinum toxin-type A in the treatment of drug-resistant neurogenic detrusor overactivity secondary to traumatic spinal cord injury

OBJECTIVE

To assess, in a prospective study, whether botulinum toxin-type A (BTX-A) injected into the detrusor muscle, can be used as a day-case treatment for drug-resistant neurogenic detrusor overactivity (NDO) in patients with spinal cord injury (SCI).

PATIENTS AND METHODS

BTX-A (Dysport, Ipsen, Luxembourg; 1000 units) was injected cystoscopically into the detrusor muscle of 37 patients with drug-resistant NDO and SCI, as a day-case procedure. The maximum cystometric capacity (MCC), maximum detrusor pressure (MDP), NDO, continence, and anticholinergic requirement were used as outcome variables. The International Consultation on Incontinence questionnaire (ICIQ) was used to assess the patient's quality of life before and after the BTX-A injection.

RESULTS

The mean follow-up was 7 months. The MCC increased from a mean of 259 to 522 mL, and the MDP decreased from a mean of 54 to 24 cmH2O. Incontinence and NDO were abolished in 82% and 76% patients, respectively. In all, 86% of the patients were able to stop or reduce anticholinergics, with a similar proportion of patients scoring favourably on the ICIQ. The mean duration of improvement was 9 months.

CONCLUSIONS

Injection with BTX-A is an effective day-case treatment that bridges the gap between oral and invasive surgical treatment of drug-resistant NDO in patients with SCI.

Botulinum toxin in urinary incontinence

PURPOSE OF REVIEW

In recent years, botulinum toxin has been investigated for treatment of lower urinary tract dysfunction. This review discusses recently published literature related to the role of botulinum toxin in treating incontinence, including the place for repeated treatment, the differing types of toxin available and the side effects of its use.

RECENT FINDINGS

Botulinum toxin is safe and effective in improving both urodynamic and subjective parameters. The A serotype has a longer duration of action than the B serotype and has fewer systemic side effects; hence, it is more likely to gain favour as a suitable treatment, both in patients with neurogenic detrusor overactivity and those with idiopathic detrusor overactivity. It is especially effective in reducing incontinence associated with detrusor overactivity, and repeated treatments appear safe and efficacious. A better understanding of urothelial physiology suggests that botulinum toxin not only has efferent effects but also acts on afferent pathways. The existing data as they stand at present would also suggest it to be safe in patients of all age groups.

SUMMARY

Botulinum toxin is awaiting approval for use in lower urinary tract dysfunction. Studies have been carried out in varying populations, but few have used reduction in incontinence episodes as a primary end point. The short-term and long-term efficacy and safety of botulinum toxin as a treatment modality for those with lower urinary tract dysfunction, especially for those with detrusor overactivity refractory to anticholinergics, is, however, evidenced increasingly. Further investigation is needed, specifically large randomized placebo-controlled trials, to determine the ideal conditions for the use of botulinum toxin. Some such trials are underway and we look forward to their findings with interest.

Pharmacotherapy for Neurogenic Detrusor Overactivity

Chancellor MB, Anderson RU, Boone TB: Pharmacotherapy for neurogenic detrusor overactivity. Am J Phys Med Rehabil 2006;85:536-545. Patients with neurogenic detrusor overactivity are a heterogeneous group with voiding dysfunction secondary to neurologic injury or disease. The neurogenic detrusor overactivity syndrome, which may include urinary frequency, urgency, and incontinence, frequently contributes to a loss of independence, or even institutionalization. Urodynamic assessment provides the best method of quantifying and classifying neurogenic detrusor overactivity dysfunction in patients with primary diagnoses as diverse as Parkinson's disease, cerebral palsy, multiple sclerosis, spinal cord injury, and spina bifida. For many patients, management of urinary symptoms includes pharmacotherapy with an anticholinergic agent. Several novel approaches to managing neurogenic detrusor overactivity, including intravesical instillation of anticholinergic agents, vanilloids, and neurotoxins, are being investigated. For most patients, however, flexible dosing with an anticholinergic agent, with clean intermittent catheterization when indicated, has been shown to reduce the risks of urologic complications, improve levels of continence, and enhance patient quality of life in both children and adults.

Urodynamic effect of intravesical resiniferatoxin in patients with neurogenic detrusor overactivity of spinal origin: results of a double-blind randomized placebo-controlled trial

OBJECTIVES

To access by a placebo-controlled randomized clinical trial the effect of intravesical resiniferatoxin on the urodynamic parameters of patients with neurogenic detrusor overactivity (NDO) of spinal origin.

METHODS

Twenty eight patients with spinal NDO were randomised to receive intravesically 50 nM resiniferatoxin dissolved in 10% ethanol in saline (RTX group) or only the vehicle solution (placebo group). Filling cystometries were obtained in each patient at 1 month and 1 week before and at 1 and 3 months after treatment. In a visual analog scale patients were asked to estimate the discomfort induced by treatment. Patients were also persuaded to fill a micturition chart during the 3 days preceding each cystometry.

RESULTS

The RTX and placebo groups were homogeneous in what respects the volume to first involuntary detrusor contraction (FDC, 143+/-95 ml and 115+/-58 ml, respectively, p=0.3) and maximal cystometric capacity (MCC, 189+/-99 ml and 198+/-111 ml, respectively, p=0.8). At the end of the study, mean FDC and MCC in the RTX group, 184+/-93 ml and 314+/-135 ml, respectively were significantly higher than in the placebo group, 115+/-61 ml (p=0.03) and 204+/-92 ml (p=0.02). In the visual analogue scale discomfort caused by treatment was similar. Only 10 patients in the RTX group and 6 patients in the placebo group completed adequately the micturition chart. Mean frequency and urinary incontinence decreased significantly only in the RTX group.

CONCLUSIONS

Intravesical RTX is effective in increasing bladder capacity in spinal NDO patients. Such increment might contribute to decrease urinary frequency and incontinence of these patients.

Improving the global management of the neurogenic bladder patient: part II. Future treatment strategies

BACKGROUND

Patients with neurogenic bladder represent a small fraction of the total overactive bladder population. As a consequence, development of new therapies in this area has largely focused on idiopathic urinary incontinence. The absence of data for patients with neurological disease has far-reaching implications, affecting reimbursement and physicians' willingness to prescribe therapies, and limiting access of potential valuable treatments to patients whose lives are significantly impaired by inadequately managed bladder symptoms.

SCOPE

The range of new therapies is increasing. Although many reviews of the overall safety, efficacy and mode of action of such treatments are available, there is limited information on how these treatments will best be used in clinical practice. We considered the current benefits and limitations of the various new licensed and unlicensed therapies and what role each would have in the future management of neurogenic urinary incontinence.

CONCLUSIONS

A wide range of new treatments have been investigated for the management of overactive bladder; few, however, have been evaluated extensively in neurogenic urinary incontinence. Further studies are required to determine the optimal dosing regimes and formulations for individual sub-populations of neurogenic bladder patients and to determine the cost-effectiveness of these interventions. With the current experience available, two treatment algorithms for a subset of patients with neurological disease have also been proposed, which suggest at which stage of management and in which patients individual therapies for neurogenic urinary incontinence could be used.

Efficacy of botulinum-A toxin bladder injections for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: an objective and subjective analysis

AIMS

We studied the use of botulinum-a toxin (BTX-A) injections into the bladder as an alternative approach in patients with neurogenic detrusor overactivity due to multiple sclerosis (MS) with drug-refractory overactive bladder (OAB) symptoms.

METHODS

Sixteen MS patients--11 women, 5 men; mean age 48.6 years--with refractory OAB symptoms were included in a one-center prospective study. For outcome analysis, we used a bladder diary, a complete urodynamic study, and validated questionnaires for subjective assessment. We injected 300 U of BTX-A (Botox) into the bladder and into the external sphincter muscle to reduce the probability of posttreatment urine retention.

RESULTS

There was an increase in residual volume from 81.3 +/- 23.8 to 126.3 +/- 32.9 ml after 4 weeks. In one woman, transient self-catheterization was unavoidable. Four weeks and 3 and 6 months after BTX-A injection, the significant results were as follows: daytime frequency was reduced by 29%, 44%, and 30%, respectively. Nocturia diminished by 33%, 72%, and 40%. Use of pads was be reduced by 38% after 4 weeks and by 64% after 3 months. Urodynamically, reflex volume and maximal cystometric bladder capacity increased by 73%, 77%, and 58% (at 6 months, the increase was not significant) and by 36%, 27%, and 36% (not significant). Maximal detrusor pressure decreased by 35%, 22%, and 57%. Subjective outcome indicated significant improvement of symptoms at 4 weeks and 3 months, but not at 6 months. Patient satisfaction with the therapy was very high.

CONCLUSIONS

BTX-A detrusor injections are very effective in the treatment of drug-resistant OAB symptoms in MS patients as reflected in urodynamic measurements and in patient satisfaction. Build up of residual urine remains a problem of which patients must be informed.

What is the optimum dose of type A botulinum toxin for treating neurogenic bladder overactivity?

OBJECTIVE

To assess the effects of two doses of botulinum toxin A (Dysport, Ipsen-Biotech, France; 500 and 1000 Speywood units, SU) injected into the bladder for treating incontinence due to a neurogenic overactive bladder.

PATIENTS AND METHODS

In an open-label, prospective study between October 2002 and May 2004, in two centres, we analysed the effects of successive doses of 500 and 1000 SU of Dysport, endoscopically injected into the detrusor muscle. At each step, patients (26 women and 19 men) were re-evaluated at 1 month (clinical evaluation and pressure-flow study). If there was a 'good' clinical response (complete absence of urinary leakage) the patient was observed until incontinence recurred; otherwise a further injection was administered at a higher dose.

RESULTS

The mean (sd, range) follow-up was 22 (0.75, 5-31) months; 11 of the 45 patients (24%) did not respond primarily at 1 month for both doses. The analysis of the two curves of survival with no re-injection of Dysport showed a statistically longer action at 1000 SU (P = 0.016). However, in this group there was one patient with general muscle weakness and asthenia, which could have been related to the injection.

CONCLUSIONS

The optimum dose of Dysport for incontinence secondary to a neurogenic overactive bladder is not yet defined; 1000 SU probably has a more prolonged effect than 500 SU but exposes the patient to major complications. Further studies evaluating the clinical effect of 750 SU of Dysport are necessary.

Therapy Insight: bladder dysfunction associated with multiple sclerosis

Bladder dysfunction is a common problem for patients with multiple sclerosis. The severity of symptoms often correlate with the degree of spinal cord involvement and, hence, the patient's general level of disability. The emphasis of management is now mainly medical and is increasingly offered by nonurologists. Treatments can be highly effective, relieving patients of what are otherwise very troublesome symptoms that would compound their neurological disability. This article gives an overview of the neural control of the bladder, followed by an explanation of the pathophysiology of detrusor overactivity secondary to neurological disease. A review of methods available for treating bladder dysfunction in multiple sclerosis then follows. The treatment options for this disorder are largely medical and include established first-line measures such as anticholinergics, clean intermittent self-catheterization and the use of desmopressin, as well as potential second-line agents, such as cannabinoids, intravesical vanilloids and intradetrusor botulinum neurotoxin type A. The diminishing role of surgical intervention is also discussed.

Management of bladder, prostatic and pelvic floor disorders

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. Over the years, the number of primary clinical publications has grown exponentially, and still continues to increase. It has been shown that BoNT blocks cholinergic nerve endings in the autonomic nervous system but does not block non-adrenergic non-cholinergic responses mediated by nitric oxide (NO). The present paper reviews a number of recent clinical indications for urological and pelvic floor dysfunctions, such as overactive and neurogenic bladder, non-bacterial prostatitis, benign prostatic hyperplasia, chronic anal fissure, or conditions associated to hyperactivity of the puborectalis muscle during straining. These indications provide a new promising palette of indications for future usage of BoNT in clinical practice.

Botulinum A Toxin Intravesical Injections in the Treatment of Painful Bladder Syndrome: A Pilot Study

OBJECTIVE

We evaluated the efficacy and tolerability of botulinum A toxin (BTX-A) intravesical injections in patients affected by painful bladder syndrome with increased urinary frequency, refractory to conventional treatment modalities.

METHODS

Twelve women and two men were prospectively included in the study. Under short general anaesthesia patients were given injections of 200 U of commercially available BTX-A diluted in 20 ml 0.9% NaCl. Injections were performed submucosally in the trigone and bladder floor under cystoscopic control. Voiding chart, the Visual Analog Scale (VAS) for pain, and urodynamics were performed before treatment and 1 and 3 mo afterward.

RESULTS

Overall, 12 patients (85.7%) reported subjective improvement at 1 and 3 mo follow-up. The mean VAS score was significantly reduced at 1 and 3 mo after treatment (p<0.05 for both); at the same time points daytime and nighttime urinary frequency significantly decreased (p<0.01 and p<0.05, respectively), and bladder cystometric capacity significantly increased (p<0.01). Two patients reported incomplete bladder emptying. We did not detect any systemic side effects during or after treatment.

CONCLUSIONS

The results of this pilot study indicate that BTX-A intravesical injections are effective in the short-term management of painful bladder syndrome. By modulating afferent C-fiber activity within the bladder walls, BTX-A significantly improves urodynamic parameters and reduces bladder pain and urinary frequency.

Quality of Life Changes in Patients with Neurogenic versus Idiopathic Detrusor Overactivity after Intradetrusor Injections of Botulinum Neurotoxin Type A and Correlations with Lower Urinary Tract Symptoms and Urodynamic Changes

OBJECTIVE

Little published data exist on the effect of intradetrusor botulinum neurotoxin type A (BoNT/A) on the quality of life (QOL) of patients with overactive bladder. We examined post-BoNT/A QOL changes of patients with neurogenic detrusor overactivity (NDO) in comparison to those with idiopathic detrusor overactivity (IDO), and their correlations with respective changes in lower urinary tract symptoms (LUTS) and urodynamic parameters.

METHODS

Patients with urodynamically proven intractable DO were assessed for changes in QOL 4 and 16 wk after treatment with intradetrusor BOTOX injections (NDO 300U; IDO 200U) using the short forms of the Urinary Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7). Percent changes in total QOL score were correlated to respective changes in clinical parameters recorded by bladder diaries and voiding cystometry.

RESULTS

Forty-eight treated patients (32 NDO, 16 IDO) had QOL data in at least one follow-up. Highly significant decreases (p < 0.0001) in mean +/- standard error QOL score at 4 wk were maintained at 16 wk for both the NDO and IDO subgroups. Percent improvement in QOL score was similar for NDO versus IDO at 4 (67.6 +/- 4.5 versus 70.3 +/- 7.7, p = 0.74) and 16 wk (65.2 +/- 5.5 versus 71.9 +/- 8.8, p = 0.51). Percent changes in QOL score of the whole patient group correlated with changes in 24-h micturition frequency, number of voids associated with urgency, and number of urge incontinence episodes, but not with urodynamic parameters.

CONCLUSIONS

Intradetrusor BoNT/A produces comparable, significant improvements in the QOL of patients with either NDO or IDO at least up to 16 wk after treatment. In contrast to urodynamic parameters, changes in LUTS appear to be the major determinants of improvements in the patients' QOL.

Cost-Consequence Analysis Evaluating the Use of Botulinum Neurotoxin-A in Patients with Detrusor Overactivity Based on Clinical Outcomes Observed at a Single UK Centre

OBJECTIVE(S)

This study aimed to assess the resource utilisation, health benefits and cost-effectiveness of intra-detrusor injections of botulinum neurotoxin-A (BoNT/A) in patients with overactive bladder (OAB).

METHODS

101 patients with urodynamically-proven detrusor overactivity of either neurogenic (NDO; n = 63) or idiopathic (IDO; n = 38) origin received intra-detrusor injections of 200-300 units of BoNT/A in 20-30 ml saline as part of a research protocol. Twenty-nine patients received repeat injections after 7-26 months. Symptom severity and urodynamic parameters were assessed at 0, 4 and 16 weeks. The cost of therapy was quantified based on the NHS resources used by typical patients and was used to calculate the cost-effectiveness of BoNT/A compared with standard care from the perspective of the UK NHS.

RESULTS

In an intent-to-treat analysis, 82% of patients showed a 25% or greater improvement in at least two out of five parameters (urinary frequency, urgency, urgency incontinence episodes, maximum cystometric capacity and maximum detrusor pressure) four weeks after treatment, reducing to 65% after 16 weeks. A 50% or greater improvement in the frequency of micturition, urgency or urgency incontinence was seen in 73% of patients at four weeks and 54% at 16 weeks. There were no significant differences between IDO and NDO patients in the proportion meeting these endpoints. Therapy cost pounds 826 per patient, with a cost-effectiveness ratio of pounds 617 per patient-year with > or = 25% clinical improvement.

CONCLUSION(S)

This study demonstrates that intra-detrusor BoNT/A is an effective treatment for OAB that is highly likely to be cost-effective in both idiopathic and neurogenic disease.

Disordered control of the urinary bladder after human spinal cord injury: what are the problems?

Spinal cord injury has a profound impact on the storage and voiding functions of the urinary bladder. Loss of autonomic and somatic control mechanisms leads to hypo- or hyperactivity of the bladder wall and sphincters causing problems that range from incontinence to complete loss of the capacity to empty the bladder. This chapter outlines the types of bladder dysfunction that occur after spinal cord injury, their relative prevalence and current practices used to manage the problems. With all the interventions that are available, management of bladder function often still remains a compromise, as the medications and physical interventions available may stimulate or block components of the voiding reflex, but are often not fully restorative in this effort.

Histologic features in the urinary bladder wall affected from neurogenic overactivity--a comparison of inflammation, oedema and fibrosis with and without injection of botulinum toxin type A

OBJECTIVES

To study histological features and morphological differences in bladder wall specimen from patients with and without botulinum toxin A injections and to compare those issues in responders and non-responders to the toxin therapy.

MATERIAL AND METHODS

Bladder wall specimen obtained from cystectomy in 45 patients with neurogenic overactive bladders with and without injection of botulinum toxin A into the detrusor muscle for treatment of neurogenic incontinence were evaluated concerning the histological criteria inflammation, oedema and fibrosis of the bladder wall.

RESULTS

Bladder wall specimen obtained from patients suffering from neurogenic detrusor overactivity showed important histological alterations. Generally, inflammatory infiltration, oedema and fibrosis of the bladder wall were frequently observed. When comparing specimen from patients who had received botulinum toxin injection to those from patients who had not, there was no difference concerning inflammation and oedema. However, patients who had received botulinum toxin injection showed significantly less fibrosis of the bladder wall than those who had not received the toxin injection (p<0.00073). When comparing specimen from responders and non-responders to the botulinum toxin therapy, there was no difference in inflammation. Although not significant, a trend was observed that responder to the toxin therapy had less fibrosis and oedema of the bladder wall than non-responder.

CONCLUSION

In our study injection of botulinum toxin into the detrusor muscle did not lead to increased fibrotic activity within the bladder wall, on the contrary patients with previous botulinum toxin injection revealed significant less fibrosis than patients without toxin injection.

Integrated control of lower urinary tract--clinical perspective

The neural mechanisms that determine social bladder control are reviewed, with a particular emphasis on the role played by sensation in the process. Much has been learnt about the neural control of the bladder from studying patients with neurological disease and those disorders that are known to disrupt bladder storage are described. Possible approaches to treatment of the resulting incontinence are reviewed and it is acknowledged that in the future, the optimal treatment for incontinence may be determined by its precise underlying pathophysiology in each instance, for example, suprapontine causes requiring different medication to spinal causes. Although the main emphasis of urological research and development so far has been the treatment of incontinence, effective therapy for other bladder disorders such an impaired emptying or bladder pain could have an important impact on the bladder symptoms of many patients.

Intravesikale Therapie der überaktiven Blase

INTRODUCTION

Despite recent advances in the field of anticholinergic drugs, lack of efficiency and side effects are still the main reasons for discontinuation of treatment. The introduction of botulinum A toxin was a milestone in the treatment of detrusor overactivity. The treatment, however, is invasive, the duration of the treatment effects is limited, and long-term results are not yet available. The following addresses therapeutic alternatives to local treatment of overactive bladder.

MATERIALS AND METHODS

A total of 52 patients received intravesical oxybutynin. In 16 patients, capsaicin was instilled in the bladder and 28 patients were treated with EMDA.

RESULTS

Intravesical oxybutynin was successful in 86%; the success rate of capsaicin instillation was 47%. EMDA was successful in 78%. Two transient ischemic attacks following EMDA were observed as significant side effects.

CONCLUSION

Besides botulinum A toxin, several effective treatment options are available for patients with detrusor overactivity refractory to oral anticholinergic treatment. Therefore, in each individual patient, possible risks and complications of the different treatment options should be considered thoroughly to find the optimal method in each case.

Improving the global management of the neurogenic bladder patient: part I. The complexity of patients

BACKGROUND

The management of urinary incontinence in patients with neurological disease is complex. Physicians face a multitude of challenges related to progression of the primary condition, the presence of a diversity of other related and unrelated symptoms, the safety, efficacy and tolerability issues associated with multiple therapies being required and the changing need for collaboration with other specialities.

SCOPE

Current guidelines produced by the urological communities, as well as the disease-focused organizations, aim to standardize care in their specific group of patients. A passive approach to implementation, however, means that guidelines produced are all too frequently not readily available to, read by or followed by the wider audience. In addition, each speciality has its own guidelines and a different view of the primary focus of care in neurological patients, which may lead to variations in recommendations and, subsequently, in clinical practice. A review of current urological and disease specific guidelines was made to evaluate differences between the published guidance between the specialities and within urology itself.

CONCLUSIONS

Although availability of effective therapies remains a cornerstone of neurogenic bladder treatment, consideration must also be given to the non-pharmacological and surgical issues related to the global management of this population. Improved cross-speciality interactions and development of patient-specific treatment and follow-up plans, which are in keeping with the current guidelines of each speciality involved, may serve to enhance physicians' understanding of the importance of effective urinary incontinence treatment as well as the overall management of the patient.

Therapeutic effects of suburothelial injection of botulinum a toxin for neurogenic detrusor overactivity due to chronic cerebrovascular accident and spinal cord lesions

OBJECTIVES

To investigate the therapeutic effects of suburothelial botulinum A toxin for patients with chronic cerebrovascular accident (CVA) and spinal cord lesions. Suburothelial injection of botulinum A toxin can effectively inhibit the occurrence of neurogenic detrusor overactivity.

METHODS

Twenty-four patients with neurogenic detrusor overactivity refractory to anticholinergics were enrolled and treated with 200 U of botulinum A toxin injected into the suburothelial space. The clinical effects on the lower urinary tract symptoms and urodynamic parameters were assessed.

RESULTS

Of the 24 patients enrolled in the study, 12 had CVA and 12 had suprasacral cord lesions (SCLs). After treatment, the volume of the first involuntary detrusor contraction and bladder capacity increased twofold and the postvoid residual volume fourfold for both patient groups after 1 month, decreasing slightly at 3 months. The detrusor pressure for the SCL group decreased significantly after treatment (39.1 +/- 16.6 versus 21.2 +/- 14.1, P = 0.002) relative to the CVA patients. Complete continence and improvement of incontinence grade were achieved in 1 (8.3%) and 5 (41.7%) patients with CVA and in 4 (33.3%) and 7 (58.3%) patients with SCLs. However, patients in both groups experienced an increase in voiding difficulty after treatment. The therapeutic effect declined gradually after 3 months, and all patients had experienced symptom relapse by 6 months.

CONCLUSIONS

Suburothelial botulinum A toxin at a dose of 200 U increased bladder capacity and improved the incontinence grade in 91.6% of the patients with SCL, but this was achieved for only 50% of the patients with CVA.