Taking the Wrinkles out of the Bladder The Use of Botulinum Toxin in the Bladder

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Taking the Wrinkles out of the BladderThe Use
of Botulinum Toxin in the Bladder

• Sharon English
• Urologist
• Christchurch

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After I started botoxing I just could not stop
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Medical Uses of Botulinum Toxin

• blepharospasm pelvic pain
• strabismus
• achalasia focal dystonias
• muscle spasms
• spasticity
  wrinkles
• hyperhidrosis bladder
  overactivity
• painful bladder migraine

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Clostridium botulinum spore prior to germination
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Botulinum Toxin A (Botox)
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Mechanism of Action of Botulinum Toxin
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Mechanism of Action of Botulinum Toxin
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Regrowth of Axons
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Uses of Botulinum Toxin in Urology and Gynaecology

• neuropathic bladder conditions
• detrusor overactivity
• detrusor sphincter dysenergia
• bladder overactivity
• painful bladder syndrome
• pelvic pain
• outflow obstruction symptoms
• urinary retention

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Injecting Botulinum into the Bladder

• 100 units diluted with 10mls of normal saline
• given as 1 ml injections
• dose of 100 - 300 units
• spare the trigone

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Injecting Botulinum Toxin

• Rigid cystoscope
• using GA
• day patient
• higher doses
• more precise

• Flexible cystoscope
• using LA
• outpatient clinic
• well tolerated

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Injecting Botulinum toxin
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Flexible Cystoscopy
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Injection of Botulinum Toxinin the Bladder
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Side Effects

• Very rare
• no severe effects reported
• minor effects
• dysphagia, diplopia, blurred vision
• periheral muscle weakness
• Contraindications
• pre-existing neuromuscular conditions

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Bladder Overactivity

• Collection of Symptoms
• urgency
• urge incontinence
• frequency
• nocturia
• Very common problem especially in the elderly

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Treating Bladder Overactivity

• Treatment
• oxybutynin
• imipramine
• very expensive anticholinergics
• major surgery
• Now can offer Botulinum toxin if medications do
  not work

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Choosing the Botox Patient

• Symptoms of urgency, urge incontinence
• No UTIs
• Failed/intolerant oxybutynin
• No voiding dysfunction
• Urodynamics

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Urodynamics showing Detrusor Overactivity
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Treating Bladder Overactivitywith Botulinum Toxin

• Effects take 1-3 weeks
• Check residual if symptoms worsen
• Retention improves after 6-8 weeks
• UTIs
• Effects last 6-16 months
• Can repeat treatment

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Literature Results

• 100 units
• Urge incontinence resolved 86
• Nocturia 4 1.5
• Frequency 14 7
• Retention 4

• 200 units
• Urge incontinence resolved 50
• Nocturia
• Frequency 15 8
• Retention 37

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Repeat Treatments

• Effect on smooth muscle
• fades after 6-12 months
• axonal regeneration
• Repeat treatments results in
• same response
• antibodies to Type A very uncommon

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Neurogenic Detrusor Overactivity

• Occurs in
• spinal cord injury
• multiple sclerosis
• Parkinsons
• post-stroke

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Neurogenic Detrusor Overactivity
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Neurogenic Detrusor Overactivity

• 10 unit injections
• Use a higher dose 300 units
• Patients already self-catheterising

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Painful Bladder Syndrome

• Two studies
• one effective
• one ineffective
• Tried two patients with mixed effect
• Raises questions as to how Botulinum toxin works