Assessment of urodynamic and detrusor contractility variables in patients with overactive bladder syndrome treated with botulinum toxin-A: is incomplete bladder emptying predictable?

The bladder contractility and bladder outlet obstruction indices in children. Results of a global Delphi consensus study

AIMS

This Delphi study was planned to examine global expert consensus with regard to utility, accuracy, and categorization of Bladder Contractility Index (BCI), Bladder Outlet Obstruction Index (BOOI), and the related evidence. This manuscript deals with children and follows previous manuscripts reporting on adult men and women.

METHODS

Eighteen experts were invited to answer the two-round survey including three foundation questions and four survey questions. Consensus was defined as ≥75% agreement. The ordinal scale (0-10) in Round 1 was classified into "strongly agree," "agree," "neutral," "disagree," and "strongly disagree" for the final round. A systematic search for evidence was conducted for therapeutic studies that have examined outcome stratified by the indices in children.

RESULTS

Eleven experts participated in the survey with 100% completion. Consensus was not noted with regard to any of the questions. There was a general trend toward disagreement with the utility of the BCI and BOOI in children. Systematic search yielded one publication pertaining the value of the indices in predicting long-term outcome in boys treated for posterior urethral valves.

CONCLUSIONS

This global Delphi survey of experts showed a general disinclination to use numerical indices for bladder contractility and bladder outflow obstruction in children. There is very little data on the use of the BCI and BOOI indices in children. The establishment of urodynamic indices in children might help refine the treatment of functional urological disorders in children.

Evaluation of the effect of 100U of Onabotulinum toxin A on detrusor contractility in women with idiopathic OAB: A multicentre prospective study

Aims

Intradetrusor injection of Onabotulinum Toxin A (BTX‐A) is a third‐line treatment for overactive bladder (OAB). Voiding dysfunction and the need for intermittent catheterization are potential complications, consequent to bladder contractility (BC) decrement.

Primary aim: to evaluate BC variation after BTX‐A detrusor injection in women with idiopathic OAB.

Methods

A prospective multi‐institutional observational study was conducted. Medical history, bladder diary, 24‐h pad test, and invasive urodynamic parameters were recorded before and 4–6 weeks after BTX‐A 100U administration. BC was measured as Modified Projected Isovolumetric Pressure (PIP1), that is, maximum flow rate (Qmax) + detrusor pressure at Qmax (PdetQmax).

Continuous variables were expressed as median and interquartile range. We compared continuous variables using Wilcoxon test and proportions between two times with Fisher exact test.

Results

No changes in PIP1 were observed (p > 0.05) in 45 women enrolled between January 2018 and September 2019. Median age was 54.6 years. At baseline, 91.1% had urge urinary incontinence, with 4.9 ± 2.6 daily pads used and a 24‐h pad test of 205.4 ± 70.8 g. Baseline detrusor contractility was normal in all the patients.

Postoperatively, an improvement in the 24‐h pad test (p < 0.01), daily voids (p < 0.01), and nocturia (p < 0.01) occurred. Urodynamics pointed out a significant reduction of detrusor overactivity rate (p < 0.01) and an increase of median maximum cystometric capacity (p < 0.01). No difference was observed in median Qmax (p > 0.05), PdetQmax (p > 0.05), and PVR (p > 0.05). No patient needed postoperative catheterization.

Conclusions

The current series provides evidence that detrusor injection of botulinum toxin is an effective option for treating OAB, without causing voiding dysfunction and BC impairment.

Predictors of Poor Response and Adverse Events Following Botulinum Toxin A for Refractory Idiopathic Overactive Bladder: A Systematic Review

CONTEXT

Botulinum toxin A (BTX-A) injections are effective in managing refractory overactive bladder (OAB). However, some patients exhibit a poor response and/or experience adverse events (AEs) such as voiding dysfunction necessitating clean intermittent self-catheterisation (CISC) and urinary tract infections (UTIs).

OBJECTIVE

To systematically evaluate whether poor response/AEs to BTX-A for idiopathic OAB are predictable.

EVIDENCE ACQUISITION

MEDLINE, EMBASE, and Google Scholar database were searched in March 2020. Studies reporting predictive factors for poor response or AEs were included. Two reviewers independently screened articles, searched references, and extracted data. Risk of bias (Quality in Prognosis Studies [QUIPS]) and quality of evidence (Grading of Recommendations Assessment, Development and Evaluation [GRADE]) tools were utilised.

EVIDENCE SYNTHESIS

Of 1579 articles, 17 met the inclusion criteria. These were cohort studies with predominantly level 3 evidence. Factors including male gender, frailty, comorbidity, increasing age, smoking, baseline leakage episodes, and various urodynamic parameters (bladder outlet obstruction index [BOOI], high pretreatment maximum detrusor pressure, and poor bladder compliance) were proposed as predictors of nonresponse. In predicting CISC use, male gender, comorbidity, increasing age, number of vaginal deliveries, hysterectomy, and urodynamic parameters (bladder capacity, postvoid residual volume, projected isovolumetric pressure value, bladder contractility index, and BOOI) were implicated. Female gender, males with their prostates in situ, and CISC were suggested to increase UTIs after BTX-A.

CONCLUSIONS

This review has identified factors that may predict poor response/AEs following bladder BTX-A and help in counselling of patients. Overall, the quality of individual studies included was poor, limiting the certainty of evidence reported. Larger-scale, better-designed trials with uniform definitions of poor response are required to confirm these preliminary findings.

PATIENT SUMMARY

This review assessed whether we could predict poor response or side effects to bladder botulinum toxin A injections in managing overactive bladder. Many different factors based on the patient, medical conditions, previous surgery, and pretreatment investigations were identified. However, the quality of included studies was generally poor, limiting their conclusions.

Using Botulinum Toxin A for Treatment of Interstitial Cystitis/Bladder Pain Syndrome-Possible Pathomechanisms and Practical Issues

Treatment for patients with interstitial cystitis/bladder pain syndrome (IC/BPS) is always challenging for urologists. The main mechanism of the botulinum toxin A (BoNT-A) is inhibition of muscle contraction, but the indirect sensory modulation and anti-inflammatory effect in the bladder also play important roles in treating patients with IC/BPS. Although current guidelines consider BoNT-A injection to be a standard treatment, some practical issues remain debatable. Most clinical evidence of this treatment comes from retrospective uncontrolled studies, and only two randomized placebo-control studies with limited patient numbers have been published. Although 100 U BoNT-A is effective for most patients with IC/BPS, the potential efficacy of 200 U BoNT-A has not been evaluated. Both trigone and diffuse body BoNT-A injections are effective and safe for IC/BPS, although comparison studies are lacking. For IC/BPS patients with Hunner’s lesion, the efficacy of BoNT-A injection remains controversial. Most patients with IC/BPS experience symptomatic relapse at six to nine months after a BoNT-A injection, although repeated injections exhibit a persistent therapeutic effect in long-term follow-up. Further randomized placebo-controlled studies with a larger number of patients are needed to support BoNT-A as standard treatment for patients with IC/BPS.

Efficacy of botulinum toxin type A 100 Units versus 200 units for treatment of refractory idiopathic overactive bladder

Objective:

To evaluate the efficacy and safety of a single intra detrusor injection of BoNTA comparing two different doses (100 U or 200 U) in patients with idiopathic overactive bladder.

Materials and Methods:

A randomized prospective study evaluated the efficacy of BoNTA in management of refractory idiopathic overactive bladder and included 80 patients. All patients were assessed initially by taking a history, a physical examination, overactive bladder symptom score, urine analysis, routine laboratory investigations, KUB and pelviabdominal. OABSS was adjusted on all patients postoperative at 1,3,6,9 months also Urodynamic was done for all patients preoperative and postoperative at 3, 6, 9 months.

Results:

The mean age was 30.22±8.37 and 31.35±7.61 in group I and II respectively. There was no statistically difference between both groups in all parameters all over the study except at 9 months after treatment. Hematuria was observed 6 and 9 patients in group I and II respectively. Dysuria was observed in 6 and 15 patients in group I and II respectively. UTI was detected in 3 and 7 patients in group I and II respectively.

Conclusion:

A single-injection procedure of 100 U or 200 U BoNTA is an effective and safe treatment for patients with IOAB who failed anticholinergic regimens. OABSS and QoL were improved for 6 months; 100 U injections seemed to have comparable results with 200 U. There was a significant difference at month 9 towards 200 U with more incidences of adverse events.

Results of intravesical botulinum toxin A in men with idiopathic overactive bladder symptoms

Objective:

The objective of this article is to determine treatment outcomes and risk factors for urinary retention in men with idiopathic overactive bladder (OAB) symptoms treated with intravesical botulinum toxin A (BTXA).

Patients and methods:

All men undergoing intravesical BTXA treatment from 2009 to 2013 at the Royal Berkshire Hospital were identified. Pre-treatment urodynamics and outcomes of treatment were determined.

Results:

A total of 35/43 men were deemed to have idiopathic OAB. Symptomatic improvement was seen in six of 13 (46%) dry OAB and 12/22 (55%) wet OAB irrespective of proven detrusor overactivity. Catheterisation rates were dose dependent with an overall rate of 16/35 (46%). Four of nine (44%) with bladder outflow obstruction required catheterisation, as did eight of 17 (47%) without. Twelve of 25 (48%) men with a Bladder Contractility Index (BCI) ⩽120 required catheterisation, as did four of 10 (40%) with a BCI >120.

Conclusion:

BTXA is a successful treatment in males with idiopathic wet and dry OAB, irrespective of detrusor overactivity. One hundred units is an appropriate dose at which to begin treatment. Surprisingly, presence of bladder outflow obstruction and weak bladder contractility did not demonstrate an increased risk for catheterisation although further study should be conducted with larger numbers of patients.

Urinary retention rates after intravesical onabotulinumtoxinA injection for idiopathic overactive bladder in clinical practice and predictors of this outcome

AIMS

The purpose of this study was to find the rate of urinary retention in clinical practice after treatment with onabotulinumtoxinA (BTN/A) for refractory overactive bladder (OAB) symptoms and determine factors that predict this outcome.

METHODS

This is a retrospective study of BTN/A for treatment of non-neurogenic, refractory OAB symptoms. Patients were analyzed with respect to their first and second BTN/A injections. The primary outcome measure was postoperative urinary retention. Statistical significance was assessed with multivariate logistic regression.

RESULTS

Based on inclusion and exclusion criteria, the study population was 160. Mean age was 64 ± 13.2 years and 24% of the patients were men. The rate of urinary retention was 35% (n = 56). For the first BTN/A treatment, multivariate analysis revealed that preoperative PVR (post-void residual volume) (OR 1.27, 95% CI 1.13-1.43, P < 0.001) and preoperative bladder capacity (OR 1.05, 95% CI 1.01-1.08, P = 0.005) were associated with postoperative urinary retention. In patients with a preoperative PVR of ≥100 ml, 94% (n = 17) went into urinary retention. For those who underwent a second BTN/A treatment, preoperative PVR, BTN/A units injected and retention after the first BTN/A were associated with an increased rate of postoperative retention.

CONCLUSIONS

Increased preoperative PVR was associated with urinary retention. The retention rate is higher than that reported in recent clinical trials. The inclusion of patients with a preoperative PVR ≥100 ml and a lower threshold to initiate clean intermittent catheterization contributed to this high rate of retention.

Expert consensus on scientific evidence available on the use of botulinum toxin in overactive bladder

OBJECTIVES

Overactive bladder (OAB) is a pathology impairing patients' quality of life and with a high percentage of patients who are refractory to medication. In this paper, technical opinion of an «expert panel» is assessed in order to gain the most reliable professional consensus on scientific evidence available on the criteria of use of Onabotulinumtoxin A (OnabotA) in OAB.

MATERIAL AND METHODS

according to DELPHI method, 42 panelists answered a survey of 93 items divided into four strategic areas including clinical criteria and recommendations in order to improve, at different levels, the current approach to patients with OAB. The recent advances in the field, areas of controversy and their real application possibilities in the different areas of our health care system were taken into consideration.

RESULTS

Two rounds of the questionnaire were completed by all experts. In the first round, a criteria consensus was reached for 64 of 93 (68.8%) questions analyzed; in the second round the consensus reached was for 83 items evaluated (89.25%). An agreement among panelist was reached for: 1) definition, classification, detection and differential diagnosis; 2) medical treatment; 3) surgical treatment; 4) role of OnabotA in the treatment of OAB.

CONCLUSIONS

the consensus is broadly in line with the latest scientific evidence on OAB. The panelists believe that it is necessary to propose a change in the current definition of OAB and that it seems necessary to improve the screening tools too. Medical treatment of OAB must be tailored to each patient, staged and progressive. The use of OnabotA (Botox(®)) could imply therapeutic advantages with respect to other treatments, and positions itself as a safe and effective alternative to treat drug refractory OAB.

[European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence]

CONTEXT

The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.

OBJECTIVE

We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.

Botulinum toxin-A for the treatment of overactive bladder: UK contributions

Background:

Botulinum toxin-A (BoNT/A) is now established second-line management for refractory overactive bladder (OAB) and recognised in many incontinence guidelines and pathways. For those with neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis, the toxin is currently licensed in certain parts of the world, including the UK. It is an effective treatment in those in whom antimuscarinics and conservative measures have failed who have symptoms of OAB and or detrusor overactivity (DO).

Methods:

Treatment can be given in an outpatient setting and can be administered under local anaesthesia. Its efficacy lasts for between six and 12 months.

Results:

It has an acceptable safety profile with the biggest risk being urinary tract infection and difficulty emptying the bladder, necessitating clean intermittent self-catheterisation (CISC). Medium-term follow-up suggests repeated injections are also safe and efficacious.

Conclusions:

The mechanism of action of the toxin is more complicated than originally thought, and it seems likely that it affects motor and sensory nerves of the bladder. In the last 10 years much of the progress of this treatment from early experimental trials to mainstream clinical use, and a better understanding of how it works in the bladder, are as a result of research conducted in the UK. This review summarises the significant and substantial evidence for BoNT/A to treat refractory OAB from UK centres.

EAU guidelines on surgical treatment of urinary incontinence

CONTEXT

The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology.

OBJECTIVE

We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.

Bladder base/trigone injection is safe and as effective as bladder body injection of onabotulinumtoxinA for idiopathic detrusor overactivity refractory to antimuscarinics

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of onabotulinumtoxinA injections at bladder base/trigone and compare with injections at bladder body or bladder body/trigone for the treatment of idiopathic detrusor overactivity (IDO) refractory to antimuscarinics.

MATERIALS AND METHODS

A single blind, randomized, paralleled, actively controlled trial was performed in patients with urodynamically proven IDO who failed antimuscarinic therapy. Patients were randomly assigned to receive intravesical injections of 100 U of onabotulinumtoxinA into three different bladder sites. All treatments were evaluated by voiding diary variables, urgency severity score, urodynamic studies, and patient perception of bladder condition. Long-term success rates over 12 months were also determined.

RESULTS

Among the patients, 37 were randomized to injections in the bladder body, 35 into the bladder body/trigone, and 33 into the bladder base/trigone. Successful results were reported in 76 (72%) patients at 3 months: 26 (70%) in the bladder body group, 26 (74%) in the bladder body/trigone group, and 24 (73%) in the bladder base/trigone group. There were no significant differences in success rates, changes in urgency and urgency incontinence episodes, urodynamic variables, or long-term success rates among the three subgroups. The incidence of adverse events was similar among three groups. No vesicoureteral reflux was noted in all patients with or without involving trigone injection.

CONCLUSION

Intravesical onabotulinumtoxinA injection is an effective treatment for IDO regardless of the bladder injection site. Bladder base/trigone injection is as safe and effective as bladder body injections with or without trigone involvement.

Novel biomarkers for overactive bladder

Biomarkers constitute any objectively measurable indicator of a biological process. The classic biomarker used in the diagnosis of overactive bladder (OAB) has been detrusor overactivity, which is assessed urodynamically. In the search for a reliable, noninvasive alternative to urodynamics, interest has focused on genetic, imaging, and urinary factors. Along with other cytokines detectable in urine, prostaglandin E2 and nerve growth factor are indicators of low-grade inflammation. Although they correlate with OAB symptom severity, they have not been shown to have independent prognostic benefit. Imaging biomarkers have been investigated since the earliest days of video urodynamics. Despite extensive research on the ultrasonographic estimation of bladder wall thickness, further standardization of the technique is required before conclusions can be reached regarding diagnostic accuracy. Genetic factors contribute approximately half of the total risk for urgency incontinence. Functional polymorphisms of the cytochrome P450 IID6 gene significantly alter the metabolism of some commonly used anticholinergic drugs, but no genetic loci that influence risk of OAB have been definitively identified. The first genome-wide association studies for OAB are in progress, and should identify new susceptibility genes. Although current putative biomarkers correlate with OAB severity, much future work is required to assess their prognostic value, and establish their role in clinical practice.

Adverse events of intravesical botulinum toxin a injections for idiopathic detrusor overactivity: risk factors and influence on treatment outcome

BACKGROUND

Intravesical injection of botulinum toxin type A (BoNTA) provides effective treatment for detrusor overactivity and overactive bladder (OAB). However, the high rates of treatment-related adverse events (AEs) prevent its more widespread use.

OBJECTIVE

To investigate the risk factors of increasing AEs after BoNTA injection for idiopathic detrusor overactivity (IDO).

DESIGN, SETTING, AND PARTICIPANTS

This study included a total of 217 patients receiving their first intravesical BoNTA injection for refractory IDO in a tertiary university hospital from 2004 to 2009.

MEASUREMENTS

AE incidence was analyzed according to gender, age, comorbidities, prostate condition in men, OAB subtype, BoNTA dose, injection site, and baseline urodynamic parameters. Successful outcome was determined based on patient perception of improvement of bladder condition at 3 mo.

RESULTS AND LIMITATIONS

Successful outcomes were reported by 144 (66.3%) patients. By multivariable analysis, male gender (p=0.013) and baseline postvoid residual (PVR) ≥100ml (p=0.003) were independent predictors of acute urinary retention (AUR). Baseline PVR ≥100ml (p=0.007) and receiving >100 U BoNTA (p=0.029) were predictors of straining to void. The incidence of large PVR after treatment was associated with comorbidity (p=0.011). Urinary tract infection occurred more frequently in women (p=0.003) and in men with retaining prostate (p=0.008). No AUR developed after bladder base/trigonal injection. Nevertheless, the occurrence of AUR or large PVR did not affect therapeutic outcome. This study is limited by nonconsecutive enrollment of patients.

CONCLUSIONS

Male gender, baseline PVR ≥100ml, comorbidity, and BoNTA dose >100 U are risk factors for increasing incidence of AEs after intravesical BoNTA injection for IDO.

Intravesical botulinum toxin for lower urinary tract dysfunction

Botulinum neurotoxin has achieved substantial clinical benefits in neurogenic detrusor overactivity. More contentious has been its extension to management of refractory idiopathic detrusor overactivity, in which risk of impaired voiding function and consequent need for intermittent catheterisation may counteract the quality-of-life benefits of improved storage function. Several issues remain uncertain for this unlicensed treatment, and clear insights into long-term consequences are needed before it can be regarded as an established mainstream treatment.

Repeated injections of botulinum toxin-A for idiopathic detrusor overactivity

OBJECTIVES

To report the efficacy and safety of repeated injections of botulinum toxin-A (BTX-A) in treating idiopathic detrusor overactivity refractory to anticholinergics. Furthermore, we describe whether dose alteration in patients with poor responses or voiding dysfunction after initial treatment can improve outcomes.

METHODS

A cohort of 34 patients who participated in a clinical trial was followed up and their progress reported. Twenty from this group had >1 BTX-A injection. Each patient received 200 U BTX-A initially, with subsequent injections between 100 and 300 U, administered by a trigone-sparing flexible cystoscopic technique. Efficacy was measured using voiding diaries and quality of life (QoL) assessed with Incontinence Impact Questionnaire-7 and Urogenital Distress Inventory-6 questionnaires. Urodynamic data were obtained for injections 1-3. All measurements were performed before and 3 months after injections.

RESULTS

Twenty patients received a repeat injection and of these 9 subsequently received a third and fourth injection. Significant improvements in overactive bladder syndrome symptoms and QoL were observed after each injection as compared with baseline. Maximum cystometric capacity and bladder compliance increased with decrease in the maximum detrusor pressure during filling cystometry. When comparing overactive bladder symptoms, QoL, and urodynamic parameters 3 months after the first and last injections, no significant differences were found. Nine patients had their BTX-A dose altered, with better outcomes in 5. The commonest reported problems were difficulty in emptying the bladder and urinary tract infection.

CONCLUSIONS

BTX-A appears to be effective and safe after repeated administration in patients with idiopathic detrusor overactivity. Certain patients will benefit from dose optimization to improve efficacy or prevent voiding dysfunction.

Clean intermittent self-catheterization after botulinum neurotoxin type A injections: short-term effect on quality of life

OBJECTIVE

To investigate the hypothesis that the need for clean intermittent self-catheterization after botulinum neurotoxin type A injections is outweighed by the efficacy of this treatment, so that clean intermittent self-catheterization is not a burden for patients with refractory idiopathic detrusor overactivity.

METHODS

Women undergoing intradetrusor injections of 200 units botulinum neurotoxin type A for refractory idiopathic detrusor overactivity were evaluated prospectively. Clean intermittent self-catheterization was discussed with all patients and its possible need after botulinum neurotoxin type A treatment. As indicator of quality of life, lower urinary tract symptom distress and effect on daily activities were assessed using the validated Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) before and 4 weeks after receiving botulinum neurotoxin type A injections.

RESULTS

Mean age of the 65 women was 51 years, and all voided spontaneously before botulinum neurotoxin type A injections. After botulinum neurotoxin type A treatment, 28 (43%) required clean intermittent self-catheterization. Mean UDI-6 and IIQ-7 scores reduced from 61 to 33 (P<.001) and 62 to 30 (P<.001) in women performing clean intermittent self-catheterization and from 60 to 28 (P<.001) and 64 to 25 (P<.001) in those who did not, respectively. Comparison of quality of life in women performing clean intermittent self-catheterization and in those who did not revealed no significant differences before and after botulinum neurotoxin type A treatment.

CONCLUSION

Clean intermittent self-catheterization after botulinum neurotoxin type A intradetrusor injections did not impair quality of life in appropriately informed and selected women in the short term. All patients should be informed of the potential need for clean intermittent self-catheterization after botulinum neurotoxin type A injections, and a willingness to do so should be a prerequisite for this still unlicensed off-label treatment.