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Onabotulinum toxin for Pelvic pain Philip Toozs-Hobson Consultant Urogynaecologist Birmingham UK Declaration • I was sponsored by Allergan to travel to and attend this meeting • I work as a consultant for Allergan and Astellas • I was an author on the RELAX study • I have been involved in Allergan and Astellas sponsored trials • I undertake private practice Onabotulinum Toxin • Growing body of evidence • Mainly case reports – Relatively rare • Difficult to classify for research What can you use Botox for… • Ophthalmic – Strabismus – Blepherospasm • MSK – Corticollis – Cervical dystonia • Cosmetic • Neurological – Migraines – severe primary axillary hyperhidrosis • Urological – NDO/UDO Botox and pain • • • • • • Torticollis Vulvodynia Back pain Fibromyalgia Tennis elbow Post mastectomy pain • • • • • • TMJ pain Chronic prostatic pain Whiplash Tendonitis Premature ejaculation Anal fissures Mechanism of action Mechanism of action Facts • Botox takes min 48 hours to get flaccid paralysis • Pain relief almost instantaneous • Botox migrates up nerves BOTOX®: An innovative treatment for OAB with a dual mechanism of action1–3 BOTOX® targets both the afferent and efferent pathways Afferent pathway Efferent pathway Blocks peripheral release of neurotransmitter at presynaptic cholinergic nerve terminals Acetylcholine BOTOX® Targets both the efferent and afferent pathway Muscle contraction Reduced parasympathetic nervous system activity in response to bladder distension Treatment benefit: Detrusor muscle relaxation OAB, overactive bladder. 1. BOTOX® Summary of Product Characteristics, Allergan 2. Purves D, et al. Autonomic Regulation of the Bladder. Neuroscience. 2nd edition. 2001. 3. Apostolidis A, et al. Eur Urol 2006;49:644–50. Sensory neuropeptides and receptors Peripheral sensitisation Central sensitisation Sympathetic nervous system activity maintained as bladder fills Treatment benefit: Reduced urgency Blocks release of neurotransmitters and down regulates expression of receptors associated with sensory afferent pathway Site of action • NMJ • Autonomic ganglion • Postganglionic parasympathetic nerve ending • Postganglionic sympathetic nerve endings which use Ach Nerve interactions Nerve interactions Differential diagnosis • Vulvadynia • Atrophic vaginitis • PNE – After vaginal surgery • • • • Interstitial cystitis Visceral hypersensitivity Chronic Pelvic pain Fibromyalgia • MS • Vaginismus • Myofascial trigger points • Sacro-iliac joint pain • Psoas problems • Faccet joint problems • Referred hip pain Assessment • History – Onset – Try to differentiate cause in history • Examination – Pain mapping • Treatment – Relaxation/PFE’s Technique • Pain map with patient awake • GA 100U split doses into trigger points – Using pudendal needle • Can do in outpatients in the brave – Using blue or green needles A prospective cohort study • 12 women • dyspareunia (80 vs 28; P = 0.01) • non-significant reductions in non-menstrual pelvic pain (64 vs 37) • Pelvic floor muscles manometry showed a 37% reduction in resting pressure • Jarvis et al ANZJOG 2004 Largest review >400 patients • • • • • • • • four subgroups: BPS/IC (n = 157) CPP (n = 98), vulvodynia dyspareunia (n = 40) “other” (n = 113). complaints of voiding dysfunction (70%), dyspareunia (54%) mean PUF score of 15.9 ± 6.4 positive potassium sensitivity test in 83%. Urodynamics revealed a maximal urethral pressure of 131 cm of water and an abnormal uroflow in 80%. • benefit in all groups (50%, 67%, 73%, and 77% for vulvodynia, CPP, BPS/IC, “other”). • International Urogynecology Journal • Volume 20, Number 9 (2009), 1047-1053, Our results • Have treated around 30 patients • About a 70% response rate • Lasts at least 6 months – Side effects: urinary incontinence, retention, faecal incontinence Refractoy Myofascial trigger points Methods 31 patients (2005-10) mainly 300 U • Mean age 55 • Median pain 9.5/10 – 15 repeat injections (at median of 4 months) • 17 OPD treatment Results • 52% pain free • Median score 3/10 • Side effects – Urinary retention (3) – faecal incont (2) – Constipation/pain (3) • But improved in 15! Adelowo et al Female Pelvic Med Reconstructr surg 2013 Conclusions • Increasing understanding of Mechanisms of action of Botox • Increasing data on safety • Can be very useful with careful patient selection