Transcript The Use of Botulinum toxin in Urology

Taking the Wrinkles out of the
Bladder
The Use of Botulinum Toxin in the
Bladder
Sharon English
Urologist
Christchurch
After I started botoxing I just could not stop
Medical Uses of Botulinum Toxin
blepharospasm
pelvic pain
strabismus
achalasia
focal dystonias
muscle spasms
spasticity
hyperhidrosis
painful bladder
wrinkles
bladder overactivity
migraine
Clostridium botulinum spore
prior to germination
Botulinum Toxin A
(Botox®)
Mechanism of Action of Botulinum
Toxin
Mechanism of Action of Botulinum
Toxin
Regrowth of Axons
Uses of Botulinum Toxin in
Urology and Gynaecology
• neuropathic bladder conditions
– detrusor overactivity
– detrusor sphincter dysenergia
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bladder overactivity
painful bladder syndrome
pelvic pain
outflow obstruction symptoms
urinary retention
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
Injecting Botulinum Toxin
• Rigid cystoscope
– using GA
– day patient
– higher doses
– more precise
• Flexible cystoscope
– using LA
– outpatient clinic
– well tolerated
Injecting Botulinum toxin
Flexible Cystoscopy
Injection of Botulinum Toxin
in the Bladder
Side Effects
• Very rare
– no severe effects reported
– minor effects
• dysphagia, diplopia, blurred vision
• periheral muscle weakness
• Contraindications
– pre-existing neuromuscular conditions
Bladder Overactivity
• Collection of Symptoms
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urgency
urge incontinence
frequency
nocturia
Very common problem especially in
the elderly
Treating Bladder Overactivity
• Treatment
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oxybutynin
imipramine
very expensive anticholinergics
major surgery
Now can offer Botulinum toxin if
medications do not work
Choosing the Botox Patient
• Symptoms of urgency, urge
incontinence
• No UTIs
• Failed/intolerant oxybutynin
• No voiding dysfunction
• Urodynamics
Urodynamics showing Detrusor
Overactivity
Treating Bladder Overactivity
with Botulinum Toxin
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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
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%
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
Neurogenic Detrusor
Overactivity
• Occurs in
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spinal cord injury
multiple sclerosis
Parkinson’s
post-stroke
Neurogenic Detrusor
Overactivity
Neurogenic Detrusor
Overactivity
• 10 unit injections
• Use a higher dose:
300 units
• Patients already selfcatheterising
Painful Bladder Syndrome
• Two studies
– one effective
– one ineffective
• Tried two patients with mixed effect
• Raises questions as to how Botulinum
toxin works