The efficacy of injection of Botulinum Toxin A into the bladder wall for the treatment of detrusor overactivity

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The efficacy of injection of Botulinum Toxin A
into the bladder wall for the treatment of
detrusor overactivity

• Soma Lahiri
• Glyn Constantine
• Good Hope Hospital, Sutton Coldfield, UK

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Overactive bladder

• Urgency with or without urge incontinence
  usually with frequency and nocturia (ICS)
• DO Urodynamic diagnosis

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Treatment

• Medical
• Anticholinergics
• Physiotherapy bladder training
• (physiotherapists and incontinence advisors)
• Surgical Management
• Botulinum Toxin A
• Sacral nerve root stimulation 60
• Augmentation cystoplasty and urinary diversion
  
• NICE Oct 2006

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Botulinum Toxin A

• Isolated in 1897 by Van Ermengem
• First used in 1980 Strabismus
• Schurch et al 2000 Neurogenic DO in pateints
  with spinal cord injury.
• Rapp et al Idiopathic overactive bladder

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Mechanism of action

• Inhibits release of Acetylcholine
• Reduced release of glutamate and substance P

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Duration of action

• Onset of action 1- 3 weeks
• Duration of action 9 -12 months
• Chemodenervation 3- 6 months
• Sahai et al 2005

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Complications

• Influenza-like syndrome
• Increased electrophysiological jitter or pareses
  in some distant muscles (transient)
• Rarely, hypersensitivity reactions

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Contraindications

• generalised disorders of muscle activity, e.g.
  myasthenia gravis
• blood clotting disorders
• pregnancy breastfeeding

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Safety in urology

• Unlicensed
• Randomised trials
• Michael et al 2009
• Brubaker et al 2008

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Our protocol

• Patient Selection
• 2 or more anticholinergics
• Refractory to treatment
• Cant tolerate the side effects
• Urodynamics showing DO
• Bladder retraining (Outpatients)
• Excluded if voiding problems and Current UTI
• Counseling
• Unlicensed
• May need long term self-catheterisation

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Our protocol

• Daycase under GA
• Prophylactic antibiotics for 3 days
• Follow up 4 weeks 6 months
• (patient led thereafter)

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Dosage and sites

• 200u Botox (Botulinum Toxin A)
• Diluent 16 mls Normal Saline
• 32 sites (0.5 mls/ site 6.25u of Botox )
• Avoiding the trigone and the ureteric openings

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Instruments

• Rigid Cystoscope (12)
• Bard Transurethral Injection system
• Injection needle 1.3cm length, 23 gauge
• Olympus system
• Injection needle 4mm length, 27 gauge

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Cost

• Day case procedure
• Botox 200 units 284
• Needle 41.57
  _______
• 325.57

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Aim

• To look at
• Improvement in symptoms
• Duration of symptom relief
• Success of repeat injections
• Complications

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Methodology

• Retrospective study
• Case note and electronic data review
• 2 hospital sites
• Good Hope Hospital, Sutton Coldfield
• Sir Robert Peel Hospital, Tamworth

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Results

• n 51
• Average age 55.4y
• (Range 31 yrs to 77 yrs)
• Average parity 2

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Results 1st injection

• Overall improvement 91
• (Quality of life)
• Daytime incontinence 80
• Frequency and urgency 75
• Nocturia 55

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Results 2nd injection

• 65 of those who had 1st injection had 2nd
  injection
• Average interval between first and second
  treatments 15.7 months
• Success rate 93
• 28 said not as good as the first
• 6 said no improvement

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ResultsTreatment 3

• 64 of those who had 2 injections had 3rd
  injection
• Average interval between the 2nd 3rd treatment
  10 months
• Success rate 75

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Complication

• Urinary tract infection 12
• Retention/ Self catheterisation 3
• Pain 2
• Lack of sensation 1

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Summary

• Improvement
• Treatment 1 91
• Treatment 2 93 Interval 15 mths.
• Treatment 3 75 Interval 10 mths.
• Complication
• UTI

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Conclusions

• Very useful alternative
• Our regime improved symptoms without causing
  retention
• As efficacy reduces with number of injections, ?
  increase the dose in repeat injections

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• Acknowledgements
• Records Department
• BICOG
• Thank you.

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Doseage Regimens described

• 200 20 sites brubaker et al 2008
• 200 300 u 40 sites schurch et al 2006
• 100 u 30 sites 26 werner et al 2006
• 300 u30 sites 10 women hajebrahimi et al

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