Refractory Idiopathic Overactive Bladder Research Articles

Anatomical location and number of injection sites of intravesical OnabotulinumtoxinA for females with refractory idiopathic overactive bladder: Ascoping review.

The negative impact on quality of life and the economic-related burden to the patient and the health care system associated with idiopathic overactive bladder (iOAB) is well-documented. Intradetrusor OnabotulinumtoxinA (BTN/A) injections are a well-used treatment modality for the management of overactive detrusor refractory to medical management, with well-documented efficacy and safety profiles. There is currently no best practice guideline for the administration of BTN/A for this procedure and historically the trigone of the bladder has been excluded from the injection paradigm given the risk of vesicoureteral reflux (VUR). A scoping review methodology was employed to assess available literature to evaluate current techniques used. There is emerging literature that the inclusion of the trigone may increase the efficacy of the procedure, while maintaining a similar adverse effect profile. Similar results could also be obtained by decreasing the number of injection sites. A scoping review was completed with systematic methodology using the Preferred Systematic Reviews and Meta Analyses extension for Scoping Review checklist. The search strategy looked to evaluate BTN/A and number of injection sites and the inclusion of the trigone in female patients with iOAB. Studies with male or neurogenic bladder only were excluded. Mixed studies were included. A specialist research librarian was engaged, with supervision from a functional urologist using a combination of MeSH and natural language terms. Two investigators independently reviewed the titles and abstracts. Twelve articles were included and were published between 2005 and 2021. There was no evidence of VUR in any of the results. All but one study reported similar if not improved efficacy of trigone-inclusion. Lower number of injection sites had similar efficacy profiles to higher numbers of intradetrusor injections. Further high-quality randomized control trials of trigone inclusion and reduction of injection sites are required. It is hoped that with further exploration of intraoperative methods for BTN/A injections, the development of universally accepted guidelines may optimize management and experiences for patients with iOAB.

Safety and effectiveness of mirabegron for children and adolescents with refractory idiopathic overactive bladder for improving urinary symptoms: a systematic review.

The aim of this study was to determine the safety and effectiveness of mirabegron in children with refractory overactive bladder (OAB) for improving urinary symptoms. We conducted a search strategy in MEDLINE (OVID), EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS from inception to September 2023. We performed a systematic review of studies evaluating the effectiveness of improving urinary symptoms and the safety of mirabegron at any dose in children and adolescents with idiopathic refractory OAB. We searched the interception to September 2023. The risk of bias was assessed using the Cochrane risk of bias tool for clinical trials and the MINORS tool for non-randomized studies. We included three studies in the analysis. All of them included children and adolescents receiving mirabegron as monotherapy at different doses. Also, none of them reported a control group. Improvement and safety rates were high in every study in objective and subjective measurements. Compliance was also high in all studies. Most of the evaluated items had a low risk of bias within and across studies. Mirabegron as monotherapy appears to be a safe and effective alternative for children with refractory idiopathic OAB or those who are intolerant to antimuscarinic therapy.

Percutaneous Tibial Nerve Stimulation in the Treatment of Refractory Idiopathic Overactive Bladder Syndrome: A Retrospective Cohort Study.

Overactive bladder (OAB) is a syndrome defined as urinary urgency, accompanied by increased frequency and nocturia with or without urge incontinence, in the absence of urinary tract infection or other obvious pathology. The standard therapies are anticholinergic agents, selective beta-3 adrenoreceptor agonists, or intradetrusor injections of botulinum toxin (BTX-A). For patients with contraindications for BTX-A or drug therapies, percutaneous tibial nerve stimulation (PTNS) may be used. PTNS shows fewer side effects than anticholinergic drugs and costs less than BTX-A. The primary outcome of this study was to assess the efficacy of PTNS in women with refractory OAB. Women with refractory OAB undergoing PTNS at our tertiary referral center from 2017 to 2019 were included. The validated German Female Pelvic Floor Questionnaire and a micturition protocol were filled out before and after PTNS. PTNS was applied weekly for 12 weeks. Improvements in OAB symptoms were seen in daily micturition frequency, urgency, and urgency incontinence from pre- to post-PTNS (p < 0.006). Impairments to quality of daily life were significantly (p < 0.0002) less severe after PTNS. There was a significant reduction in daytime voiding frequency from a median of nine to five (p < 0.0001). Substantial reductions in OAB symptoms, daily micturition frequency, urgency, and urgency incontinence were found in patients with refractory OAB after PTNS.

Real-time changes in brain activity during tibial nerve stimulation for overactive bladder: Evidence from functional near-infrared spectroscopy hype scanning.

To use functional near-infrared spectroscopy (fNIRS) to identify changes in brain activity during tibial nerve stimulation (TNS) in patients with overactive bladder (OAB) responsive to therapy. Eighteen patients with refractory idiopathic OAB patients were recruited consecutively for this pilot study. At baseline, all patients completed 3 days voiding diary, Quality-of-Life score, Perception-of-Bladder-Condition, and Overactive-Bladder-Symptom score. Then 4 region-of-interest (ROI) fNIRS scans with 3 blocks were conducted for each patient. The block design was used: 60 s each for the task and rest periods and 3 to 5 repetitions of each period. A total of 360 s of data were collected. During the task period, patients used transcutaneous tibial nerve stimulation (TTNS) of 20-Hz frequency and a 0.2-millisecond pulse width and 30-milliamp stimulatory current to complete the experiment. The initial scan was obtained with a sham stimulation with an empty bladder, and a second was obtained with a verum stimulation with an empty bladder. Patients were given water till strong desire to void, and the third fNIRS scan with a verum stimulation was performed. The patients then needed to urinate since they could not tolerate the SDV condition for a long time. After a period of rest, the patients then were given water until they exhibited SDV state. The fourth scan with sham fNIRS scan in the SDV state was performed. NIRS_KIT software was used to analyze prefrontal activity, corrected by false discovery rate (FDR, p < 0.05). Statistical analyses were performed using GraphPad Prism software; p < 0.05 was considered significant. TTNS treatment was successful in 16 OAB patients and unsuccessful in 2. The 3 days voiding diary, Quality-of-Life score, Perception-of-Bladder-Condition, and Overactive-Bladder-Symptom score were significantly improved after TNS in the successfully treated group but not in the unsuccessfully treated group. The dorsolateral prefrontal cortex (DLPFC) (BA 9, Chapters 25 and 26) and the frontopolar area (FA) (BA 10, Chapters 35, 45, and 46) were significantly activated during TNS treatment with an empty bladder rather than with an SDV. Compared with the successfully treated group, the unsuccessfully treated group did not achieve statistical significance with an empty bladder and an SDV state. fNIRS confirms that TNS influences brain activity in patients with OAB who respond to therapy. That may be the central mechanism of action of TNS.

Efficacy of intravaginal electrical stimulation with different treatment frequency in women with refractory idiopathic overactive bladder

ABSTRACTObjective The aim of this study is to evaluate the effect of intravaginal electrical stimulation (IVES) therapies with different treatment frequencies (two or five days in a week) added to bladder training (BT) on incontinence-related quality of life (QoL) and clinical parameters in women with refractory idiopathic overactive bladder (OAB).Material and Methods Fifty-two women with refractory idiopathic OAB were randomized into two groups as follows: Group 1 (n:26) received BT and IVES, two times in a week, for 10 weeks and Group 2 (n:26) received BT and IVES five times in a week, for 4 weeks. IVES was performed 20 minutes in a day, a total of 20 sessions for both groups. Women were evaluated for incontinence severity (24h pad test), pelvic floor muscles strength (perineometer), 3-day voiding diary (frequency of voiding, nocturia, incontinence episodes, and the number of pads), symptom severity (OAB-V8), quality of life (IIQ-7), treatment success (positive response rate), cure/improvement rate and treatment satisfaction (Likert scale).Results There was no statistically significant differences in all parameters between the two groups at the end of the treatment. It was found that the treatment satisfaction scores, cure/improvement and positive response rates were not significantly different between two groups (p>0.05).Conclusion We concluded that the application of IVES twice a week or 5 times a week added to BT were both effective on incontinence-related QoL and clinical parameters in women with refractory idiopathic OAB. These two IVES frequencies had similar clinical efficacy and patient satisfaction with a slight difference between them; 5 times per week IVES has a shorter treatment duration.

Résultats fonctionnels et satisfaction chez 44 patients post implantation de neurostimulateur sacré type NS3 pour une hyperactivité vésicale réfractaire, d’origine idiopathique, suivi à 43 mois, série monocentrique

Sacred neuromodulation (SNM) has been used in France since 1997 for the management of non-neurogenic urinary disorders that do not respond to first-line pharmacological treatment. The aim of this study is to analyze the clinical efficacy and satisfaction of patients with refractory idiopathic overactive bladder (OAB) treated with SNM. This single-center retrospective series included 59 patients with refractory OAB of idiopathic origin and eligible for the SNM between January 2010 and December 2017. Demographic data, history of pelvic surgery, complications according to Clavien-Dindo classification, as well as revision and explantation rates were collected. All the patients included underwent a test phase. Therapeutic success for the test phase and definitive implantation was defined by≥50% improvement. Satisfaction was a secondary criteria. Of the 59 patients tested for SNM, 44 patients had a permanent implantation, of which 36 (82%) were women and 8 (12%) were men. The median age of the study was 55 years old. The median follow-up was 43 months [21,2-66,5]. All of the patients had an idiopathic refractory OAB. The median time between test and final implantation was 28 days [18-35]. The success rate for all patients tested was 60% (34/59). In patients implanted, 34 patients (77%) had clinical improvement. Adverse events had to be managed including multiple re-parameterizations (n=13), device revision (n=16), or even device implantation (n=8). The satisfaction rate was 82% (36/44). With a median follow-up of 43 months, this retrospective study on NMS shows the efficacy of second-line SNM for idiopathic OAB. This technique remains minimally invasive but with significant adverse events when informing our patients. 3.

Augmentation Cystoplasty: Fourth-Line Therapy for Refractory Idiopathic Overactive Bladder

Abstract Objective: Idiopathic overactive bladder (iOAB) refractory to conventional first-, second-, and third-line therapies is a challenging condition to manage. Fourth-line therapy, specifically...

Sacral neuromodulation vs botulinum toxin A in refractory idiopathic overactive bladder: review of cost-effectiveness evidence

Sacral neuromodulation vs botulinum toxin A in refractory idiopathic overactive bladder: review of cost-effectiveness evidence

Unilateral versus bilateral sacral neuromodulation test in the treatment of refractory idiopathic overactive bladder: A randomized controlled pilot trial.

To compare treatment success rate in terms of improvement of bladder overactivity between unilateral and bilateral sacral neuromodulation testing. A multicentric, parallel, randomized, open pilot trial (October 2012-September 2017) was conducted. Participants presented primary overactive bladder resistant to first-line treatments. Patients were excluded in case of secondary bladder, pelvic, or neurological condition. Patients were randomized between bilateral testing (n = 28) or unilateral testing (n = 27), to determine the best functional response before final implantation. The primary outcome was the rate of patients presenting at least 50% of clinical improvement at 1 month on urinary frequency, number of urge incontinence episodes or number of urinary urgency episodes. Symptom severity, implantation success rate, uroflowmetry, device tolerance, complications, and quality of life were also assessed. Fifty-five patients have been included. The rate of patients presenting at least one significant clinical improvement at month 1 was 62% in the bilateral group versus 84% in the unilateral group (P = .0891), RR = 0.74 (0.51; 1.07). There was no significant difference between bilateral and unilateral groups in terms of improvement of urinary frequency (0% and 17%; P = .1115), number of urge incontinence episodes (52% and 63%; P = .4929) or number of urinary urgency episodes (57% and 74%; P = .2411). More complications were reported in the bilateral group than in the unilateral group (9 [47%] vs 4 [16%], respectively; P = .0239). Systematic bilateral sacral neuromodulation testing before final implantation did not appear to increase success rate compared with unilateral stimulation in the treatment of overactive bladder.

A comparison of antibiotic prophylaxis regimens to decrease the risk of post-procedure urinary tract infection after onabotulinum toxin A injection.

To evaluate the risk of post-injection urinary tract infection (UTI) after onabotulinumtoxin A (BTX-A) treatment based on the timing of when antibiotic prophylaxis is started. This is a retrospective cohort study of 111 women with refractory idiopathic overactive bladder who underwent intradetrusor injection of BTX-A. Two cohorts were identified: (1) 67 women who started antibiotic prophylaxis with ciprofloxacin 1day prior to injection; (2) 44 women who received antibiotic prophylaxis with ciprofloxacin after injection only. We assessed for post-injection UTI within 90days after BTX-A. Multivariable logistic regression was performed to adjust for potential confounders. One hundred eleven women underwent BTX-A. In total, 30 (27%) had a UTI within 90days; these included 15/67 (22%) of those who started antibiotics 1day prior to injection and 15/44 (34%) of those receiving antibiotics after injection. While the unadjusted analysis showed no significant associations between timing of antibiotic administration and UTI (OR = 0.56; 95% CI = 0.24, 1.30; p = 0.18), an adjusted analysis showed the pre-procedure antibiotic group had a significant reduction in post-procedure UTI after controlling for age, history of UTI, diabetes, and urinary retention requiring catheterization (OR = 0.23; 95% CI = 0.07, 0.73; p = 0.01). Starting antibiotics 1day prior to BTX-A injection decreases the odds of post-injection UTI compared with women who use post-procedure antibiotic prophylaxis over shorter duration. Consideration should be given to beginning antibiotic prophylaxis prior to the procedure and continuing it for 4 total days to decrease the risk of UTI.

Botulinum toxin A for refractory OAB and idiopathic urinary retention: Can phenotyping improve outcome for patients: ICI‐RS 2019?

Botulinum toxin A (BTX-A) is a well-established treatment for refractory idiopathic overactive bladder (OAB). It has also been used with short-term success in treating idiopathic urinary retention. However, efficacy and complication rates are variable and predicting those likely to benefit most from treatment would enable personalization of therapy and optimization of outcomes. At the International Consultation on Incontinence-Research Society (ICI-RS) meeting in 2019 a Think Tank addressed the question of how we can improve the way we phenotype patients undergoing BTX-A treatment. The Think Tank conducted a literature review and expert consensus meeting focussing on how advances in basic science research of the mechanism of action of BTX-A, as well as assessment of psychological comorbidity, can be translated into clinical practice to improve patient selection for therapy. Idiopathic OAB and idiopathic urinary retention are heterogenous conditions encompassing several phenotypes with multiple potential pathophysiological mechanisms. Animal models have demonstrated a central nervous system mechanism of action of intravesically injected BTX-A and this has been confirmed in human functional MRI studies, but whether this tool can be used to predict outcome from treatment remains to be determined. Phenotyping based on psychological comorbidity using validated screening tools should be studied as a way to potentially optimize patient selection for therapy. Advances in basic science research into the mechanism of action of BTX-A have improved our understanding of the pathophysiology of OAB and may lead to novel ways to phenotype patients. Psychological assessment is another way in which phenotyping may be improved. Areas for further research are proposed.

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

ObjectiveTo ascertain whether a poor response and adverse events (voiding dysfunction and urinary tract infection) were predictable for first time botulinum toxin-A (BTX-A) injections in a patient cohort of refractory idiopathic overactive bladder with detrusor overactivity. MethodsPatients who received BTX-A injections for the first time between the dates of March 2004-August 2017 were analyzed in this single center study. Urogenital Distress Inventory short form (UDI-6) questionnaires were collected both preinjection and postinjection prospectively. A poor response was defined as a decrease of less than 16.7 on the UDI-6 questionnaire. Additional information was gathered from patient records in a retrospective fashion. Predictors of poor response, voiding dysfunction, and UTI were analyzed with multivariate logistic regression analysis. ResultsSeventy-four patients were analyzed. The only predictor of poor response was male gender (OR, 5.45; 95% CI 1.83-16.47; P = .002). Lower maximum urinary flow rates (OR, 0.91; 95% CI, 0.83-0.99; P = .023), male gender (OR, 5.14; 95% CI 1.41-18.72; P = .013), and hysterectomy in females (OR, 4.55; 95% CI, 1.09-18.87; P = .038) were predictors of clean intermittent self catheterisation (CISC). There was an increased risk of UTIs in patients who performed CISC (OR, 5.26; 95% CI 1.38-20.0; P = .015). ConclusionMale gender was associated with a poor response to BTX-A injections and increased risk of CISC. Lower maximum urinary flow rates and women with hysterectomies were at increased risk of requiring CISC postinjection. Performing CISC was associated with increased risk of UTI. These factors could be helpful when counselling or selecting patients.

Assessment of Anticholinergic Use After Fading of BTX-A Effects in Refractory Idiopathic Overactive Bladder: A Prospective Blinded Randomized Trial.

PurposeTo evaluate the efficacy and safety of re-treatment with anticholinergics on refractory idiopathic overactive bladder (OAB) previously treated with intravesical botulinum neurotoxin type A (BTX-A) injections.MethodsOne hundred patients were initially managed by intravesical injections of 100 IU of BTX-A. After the effects of BTX-A faded, patients were randomized into 2 groups: group A patients received solifenacin (10 mg) for 12 weeks (study group), while group B patients received placebo treatment for 12 weeks (control group), then subsequently received solifenacin (10 mg) for another 6 weeks. All patients underwent preoperative urodynamic testing. Patients were asked to complete the validated overactive bladder symptoms score (OABSS) and incontinence quality of life (I-QoL) instruments after the effects of intravesical BTX-A faded and at 12 weeks of follow-up. Univariate and multivariate analyses of the factors affecting treatment response were conducted.ResultsAt 12 weeks of follow-up, in group A, all OABSS items, including the total score, had improved significantly (P<0.0001). Group A had lower frequency and amplitude of detrusor overactivity and detrusor leak point pressure (P<0.0001, P=0.03, and P=0.01, respectively). Cystometric capacity also increased significantly (P=0.007), as did all I-QoL parameters. In a comparison of patients with failed treatment and patients with successful treatment, female sex, repeated intravesical BTX-A injections, and increased bladder capacity were statistically significant (P=0.001, P=0.0001, and P=0.002, respectively). Repeated intravesical BTX-A injections and increased bladder capacity were independent factors predicting treatment success.ConclusionsIn patients with refractory idiopathic OAB, reuse of anticholinergics could be an effective treatment option in patients after the effects of BTX-A fade. Repeated intravesical BTX-A injections and increased cystometric capacity could affect treatment response.

Treatment Response and Complications after Intradetrusor OnabotulinumtoxinA Injection in Male Patients with Idiopathic Overactive Bladder Syndrome.

We sought to assess the treatment response, complications and treatment continuation after onabotulinumtoxinA injection in male patients. We performed a retrospective study of men with refractory idiopathic overactive bladder treated with intradetrusor injection of 100 IU onabotulinumtoxinA since 2007 in our department. Patients with previous radical prostatectomy were excluded from analysis. The treatment response was assessed using a treatment benefit scale of 1-greatly improved, 2-improved, 3-not changed and 4-worse after treatment. A treatment benefit scale score of 1 or 2 was considered a treatment response. Complications were classified according to the CD (Clavien-Dindo) classification. Treatment was considered to have continued if at the last visit patients had received an onabotulinumtoxinA injection within the preceding 12 months. We performed univariate and multivariate analyses to assess factors predictive of the treatment response, complications and continuation on treatment. Of the 146 men with a mean ± SD age of 70.1 ± 13.3 years who were included in study 91 (62.3%) reported a response to treatment. A total of 24 complications (16.4%) were detected, including 19 cases (13%) of urinary retention (CD 2), 2 (1.3%) of hematuria (CD 1) and 3 (2%) of urinary infection (CD 2). Followup was more than 12 months in 128 patients, of whom 88 (68.8%) had discontinued treatment by the end of followup. A higher bladder outlet obstruction index was the only factor predicting a lower treatment response rate and a higher complication rate. Most male patients with idiopathic overactive bladder showed a treatment response after intradetrusor onabotulinumtoxinA injection. However, the majority discontinued treatment. A higher bladder outlet obstruction index was related to a lower treatment response and a higher complication rate.

Evaluation of Professional Practices in the Treatment of Refractory Idiopathic Overactive Bladder at the Dose of 50 Units (TOX50IUU)

Evaluation of Professional Practices in the Treatment of Refractory Idiopathic Overactive Bladder at the Dose of 50 Units (TOX50IUU)

Delivery of intravesical botulinum toxin A using low-energy shockwaves in the treatment of overactive bladder: A preliminary clinical study

ABSTRACTObjective: To evaluate the efficacy and safety of botulinum toxin A (BoNT-A) instillation in the bladder under the effect of low-energy shockwaves (LESWs) for the treatment of refractory idiopathic overactive bladder (OAB).Patients and methods: A preliminary clinical study was conducted, including 15 patients with refractory OAB, between September 2016 and July 2017. Intravesical instillation of 100 IU of BoNT-A was done followed by LESWs (3000 shocks over 10 min) exposure to the supra-pubic area. Patients were followed-up by urine analysis, urine culture, post-void residual urine volume (PVR), and Overactive Bladder Symptom Score (OABSS) at 1, 2 and 3 months.Results: There were statistically significant improvements in all OABSS domains and the total score after 1 and 2 months of treatment (P < 0.05). Whereas, only the nocturia domain remained significantly improved after 3 months (P = 0.02). There was no significant increase in PVR throughout the study period (P > 0.05) and none of the patients required clean intermittent catheterisation. Two, two and three patients developed urinary tract infections after 1, 2 and 3 months, respectively.Conclusion: Intravesical instillation of BoNT-A and LESWs is safe and effective method for the treatment of refractory OAB with a durable response for 2 months.Abbreviations: BoNT-A: botulinum toxin A; CIC: clean intermittent catheterisation; DO: detrusor overactivity; LESWs: low-energy shockwaves; OAB: overactive bladder; OABSS: Overactive Bladder Symptom Score; Qmax: maximum urinary flow rate; QoL: quality of life; UUI: urgency urinary incontinence

132 - Subjective and objective scales assessment after retreatment with anticholinergics post botox-faded effects in refractory idiopathic overactive bladder: A prospective single blinded randomized trial

132 - Subjective and objective scales assessment after retreatment with anticholinergics post botox-faded effects in refractory idiopathic overactive bladder: A prospective single blinded randomized trial

129 - Randomized prospective trial comparing uni- and bilateral sacral neuromodulation tests in the treatment of refractory idiopathic overactive bladder

129 - Randomized prospective trial comparing uni- and bilateral sacral neuromodulation tests in the treatment of refractory idiopathic overactive bladder

Application of methylene blue as an improvement of the injection technique of botulinum toxin A in the treatment of refractory idiopathic overactive bladder: prospective, single-blind (patient-blind), randomized trial.

IntroductionRefractory idiopathic overactive bladder (RIOAB) is a common condition with a significant negative impact on quality of life. Intravesical injection of botulinum toxin A (BTX-A) is widely used as an intervention for these cases. In the standard method the drug solution is colorless. The addition of dye such as methylene blue (MB) facilitates visualization during the procedure and may have a beneficial effect.AimTo evaluate the injection of BTX-A with the addition of methylene blue (MB) against a standard method in the treatment of RIOAB.Material and methodsIn this 1-center, single-blinded, randomized controlled trial, we recruited 80 patients with RIOAB. A total of 39 were assigned to injection into the bladder wall of 100 U BTX-A with MB (in 9.5 ml normal saline + 0.5 ml MB), and 41 were assigned to BTX-A 100 U alone (in 10 ml normal saline). Cystoscopy with a submucosal injection of the solution was performed systematically, including the bladder triangle. Participants were assessed 6 and 12 weeks after the treatment using a Likert scale and OABSS questionnaire.ResultsSignificant improvement was similar (result of 1 or 2 on the Likert scale) and was achieved in 66.7% and 69.2% after 6 weeks and in 63.9% and 64.1% after 12 weeks in the BTX-A + MB group and only-BTX-A group, respectively. There was a significant difference between the two groups (p = 0.049) in the total number of patients with complications: 2 (5.6%) vs. 9 (23.1%).ConclusionsThe addition of MB to BTX for treatment of RIOAB patients does not influence treatment efficacy, while it limits the risk of complications.

What Is the Role of Additional Pharmacotherapy and Neuromodulation in Patients with Marginal Benefit from Botulinum Toxin Injection?

Third-line therapies for patients with overactive bladder (OAB) can improve symptoms for those who have failed conservative therapies. Options include percutaneous tibial nerve stimulation (PTNS), cystoscopic injection of onabotulinumtoxinA (BTX-A), and sacral neuromodulation (SNM). This paper aims to review the current literature on the treatment of patients with idiopathic OAB who have undergone BTX-A injections and have not responded or have undesirable side effects from the therapy. There are no randomized control trials examining the role of concurrent medical therapy and BTX-A; rather, there are observational studies in the neurogenic population. Furthermore, there are two observational studies on the role of SNM in BTX-A refractory idiopathic OAB patients demonstrating its safety and efficacy. There are many options available to the patient who fails BTX-A. Further research in this specific patient population is necessary to determine why patients have suboptimal responses and to delineate the next step in treatment.