Repeated Botulinum Toxin A Injections Research Articles

Impact of Urethral Sphincter Electrophysiology on Botulinum Toxin A Treatment in Women with Non-Neurogenic Dysfunctional Voiding.

Dysfunctional voiding (DV) is an abnormal urethral sphincter activity during voiding in neurologically normal individuals. Urethral sphincter botulinum toxin A (BoNT-A) injection has been used to treat DV, but the results have not been completely satisfactory. This study investigated the neurological characteristics of women with DV using the lower urinary tract electrophysiology (EP) study and the therapeutic efficacy of BoNT-A injection. In total, 48 women with DV and 16 women with normal voiding were included. Videourodynamic studies were conducted to diagnose DV before BoNT-A injection. EP studies, including urethral sphincter electromyography, bulbocavernosus reflex, and pudendal nerve conduction velocity, were conducted. Polyphasic motor unit action potentials suggestive of reinnervation were detected in 58.3% of patients with DV and 18.8% of controls (p = 0.001). Significant improvement in the corrected maximum flow rate (cQmax) was observed in patients with reinnervation at 1 and 3 months after BoNT-A injections into the urethral sphincter. Urethral sphincter denervation or reinnervation activity was commonly noted in 62.5% of women with DV. Repeated BoNT-A injections into the urethral sphincter provided effective treatment in 47.9% of patients, with mild improvement in cQmax observed in patients with urethral sphincter reinnervation. However, the improvement was not superior to those without reinnervation.

GMFCS level improvement in children with cerebral palsy treated with repeat botulinum toxin injections and intensive rehabilitation: A retrospective study.

The Gross Motor Functional Classification System (GMFCS) provides a standardized classification of motor disability in children with cerebral palsy (CP) that is typically considered longitudinally stable. Here, changes in GMFCS levels of children with CP who received repeated botulinum toxin A (BoNT-A) injections within an intensive rehabilitation approach were evaluated. This retrospective, observational study included 503 children with CP (GMFCS I-V) treated in a single university rehabilitation clinic. Individualized treatment plans and a variety of rehabilitation techniques were incorporated within an integrated model of care. Each child received≥2 repeated BoNT-A injections as well as an intensive rehabilitation program. GMFCS level following repeat treatment improved in 42.1% of the patients and worsened in 3 patients; 14.9% of children showed improvement after 1 treatment cycle, 12.3% after 2 cycles, 7.6% after 3 cycles, 3.6% after 4 cycles, and 3.8% after≥5 cycles. Type of involvement (p < 0.001), baseline GMFCS (p = 0.001), number of treatment cycles (p < 0.001) and presence of severe dystonia (p = 0.032) were significant predictors of GMFCS improvement, but age and gender were not. Children with CP may change GMFCS level when intensive rehabilitation programs are combined with repeated BoNT-A injections.

Frontiers in the Clinical Applications of Botulinum Toxin A as Treatment for Neurogenic Lower Urinary Tract Dysfunction.

Patients with neurogenic lower urinary tract dysfunction (NLUTD) experience urinary incontinence with or without difficult urination, which might promote recurrent urinary tract infection (UTI) and exacerbate upper urinary tract function. Nonetheless, appropriate bladder management has been shown to reduce urological complications and improve quality of life. In addition to pharmacological therapy and surgical intervention, botulinum toxin A (BoNT-A) has been widely utilized in NLUTD. The therapeutic efficacy of detrusor BoNT-A injections for neurogenic detrusor overactivity due to spinal cord injury (SCI), multiple sclerosis, or other central nervous system lesions, such as cerebrovascular accident, Parkinson disease, early dementia, and pediatric NLUTD due to myelomeningocele, has been well established, with repeated BoNT-A injections every 6 to 9 months being necessary to maintain its therapeutic effects. Urethral BoNT-A injection can decrease urethral sphincter resistance and facilitate efficient voiding in patients with NLUTD who wish to preserve self-voiding. Detrusor BoNT-A injection can also decrease the occurrence of autonomic dysreflexia in patients with SCI, even after failed augmentation enterocystoplasty, with additional benefits including reduced UTI episodes and preserved renal function with repeated injections. However, this treatment does have some side effects. Complete informed consent for BoNT-A injection therapy with full disclosure of its potential complications should therefore be obtained before this procedure is undertaken.

Repeated injections of botulinum toxin-A for epiphora in lacrimal drainage disorders: qualitative and quantitative assessment.

To report the outcome of repeated botulinum toxin-A (BTA) injections in the lacrimal glands in patients with epiphora. We performed retrospective chart review of patients who were injected with 2.5 units of BTA in the lacrimal gland. Epiphora and tear production were assessed by the Munk score and Schirmer-1 test, respectively, pre-injection and at 1 and 3 months post injection. Regarding repeated injections, the effects of the first were compared to those of the second and third injections. Forty-six eyes of 35 patients had an average of 2.3 injections per eye (range, 1-6). The mean Munk score significantly decreased from 3.72 to 1.87 at 1 month (p < 0.001) and 2.21 at 3 months (p < 0.001) after injection. The mean Schirmer-1 score also significantly decreased from 15.35 mm to 10.52 mm at 1 month (p < 0.001) and 12.48 mm at 3 months (p < 0.001) after injection. The mean reduction rates of Munk and Schirmer-1 scores after the second (66.1% and 29.8%, respectively) and the third injections (56.1% and 23.3%, respectively) were not significantly different from those after the first injection (63.3% and 26.1%, respectively) (p > 0.05 for each comparison). There was a significant correlation between the difficulty in exposing the lacrimal gland for injection and the risk of complication (p = 0.017). BTA injection in the lacrimal gland showed favourable outcomes; repeated injections did not compromise efficacy. BTA injection can be safely repeated for epiphora, especially in patients whose lacrimal gland can be easily exposed.

Repeated botulinum toxin injections effects on children with cerebral palsy

The main aim of this study was to show the efficiency of botulinum toxin A (BT-A) injections not only on spasticity and functional capacities but also on the quality of life in children with cerebral palsy, and to describe their long-term evolutivity profile while précising our developing country particularities. Sixty children were included in this study aged from 2 to 18 years old; who received repeated injections of BT-A (Dysport®). An evaluation was done before and after these injections. It included an evaluation of the spasticity using the Modified Ashworth Scale (MAS), the functional evaluation using the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS), an evaluation of satisfaction (Visual analogical Scale) and an evaluation of the quality of life using the Child Health Questionnaire Parent Form 50 (CHQ-PF50). The change from baseline of MAS ranged from 2.25 to 3 for the muscles of the lower limbs and ranged from 2 to 2.86 for the upper limb muscles. The average number of injection sessions was of 3.18 (1 to 6). The percentage of children improved (in GMFCS and MACS) and the average of the visual analogical satisfaction scale as well, increased from one injection to another reaching a constant level in the last two injections (P < 0.001). Our study proved the efficiency of repeated BT-A injections on the spasticity. It also revealed an improvement in both the gross function and the motor skills of children suffering from cerebral palsy. The quality of life of these children was significantly enhanced after injections.

Botulinum toxin a in upper limb spasticity management: Baseline data from the upper limb international spasticity (ULIS)–III study

ULIS-III describes real-life clinical practice in upper limb spasticity (ULS) management using licensed botulinum toxin A (BoNT-A) products and concomitant therapies. ULIS-III assesses long-term impact on patient-centred outcomes and identifies best practice strategies according to patient needs. Baseline data are presented for patients enrolled by June 2017. This longitudinal, prospective, observational, cohort study of integrated ULS management in adults ( NCT02454803 ) examines impact of repeated BoNT-A injections over 2 years. Person-centred outcomes are assessed using the Upper Limb Spasticity Index, combining individual goal setting with targeted standardised measures, using patient-selected goal areas. Injection practices and physical treatments are recorded, alongside economic and quality-of-life data. Baseline data were analysed for 975 patients across 57 sites (14 countries; 5 continents). Table 1 presents baseline characteristics; 82% of patients had spasticity post-stroke; two-thirds had received previous BoNT-A for ULS (< 5 injections, 46%; > 10 injections, 28%). Median time from diagnosis to first injection and enrolment was 1.0 and 3.4 years, respectively. Baseline muscle tone and disability measures are shown in Table 1 . Upper arm and forearm muscles were most commonly injected; 34% received concomitant BoNT-A for lower limb spasticity ( Table 2 ). Shoulder injection frequency increased since ULIS-II (e.g. pectoralis major: 34 vs. 19%). Instrumental injection guidance techniques were used in 73% of patients. Most common primary goal areas were passive function (31%) and pain (25%), showing notable changes in goal selection since ULIS-II ( Fig. 1 ). ULIS-III contributes to greater understanding of achievable treatment goals and developing practice with improved clinical reasoning, as reflected in ULIS-III baseline data. ULIS-III will improve understanding of treatment and outcomes for long-term ULS management. Final data are expected in 2019.

Time to retreatment with botulinum toxin A in upper limb spasticity management: Initial data from the Upper Limb International Spasticity (ULIS)-III study

The ongoing ULIS-III study aims to describe real-life clinical practice and assess patient-centered goal attainment with integrated upper limb spasticity (ULS) management that includes repeated botulinum toxin A (BoNT-A) injections. This interim analysis evaluates BoNT-A reinjection rates within rehabilitation management. ULIS-III is a 2-year longitudinal, prospective, observational, cohort study ( NCT02454803 ), which is expected to involve 58 centers (14 countries) and to enroll > 1000 adults with ULS receiving repeated BoNT-A injections. This analysis involved 44 centers (13 countries) and 335 patients (reflective of ULIS-III recruitment stage). Primary endpoint of ULIS-III is goal attainment, using Goal Attainment Scaling-Evaluation of Outcome for ULS to evaluate change following BoNT-A and concomitant treatments. BoNT-A preparation type, total dose, number of injections, and injection intervals will be recorded, as well as physical treatments, economic and quality-of-life data. Recruitment began January 2015. Patients with data for ≥ 2 injections ( n = 335), had a mean (SD) time between first and second injections of 154.9 (58.6), 137.8 (60.5), and 124.4 (41.0) days for abobotulinumtoxinA ( n = 203), onabotulinumtoxinA ( n = 94), and incobotulinumtoxinA ( n = 38), respectively. Of these patients, 177 received ≥ 3 injections. Mean (SD) time between second and third injection was 146.4 (48.5), 131.8 (36.9), and 116.3 (32.3) days for abobotulinumtoxinA ( n = 110), onabotulinumtoxinA ( n = 48), and incobotulinumtoxinA ( n = 19), respectively. The mean (SD) change in time between first and second injection intervals for these 177 patients was −5.8 (68.1), 2.3 (37.9), and 0.9 (23.3) days for abobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA, respectively. Initial ULIS-III injection interval data suggest differences in time to retreatment with different BoNT-A preparations. Longer injection intervals may reduce patient and carer burden. However, the clinical significance and generalizability of the findings reported here are as yet undetermined and the current sample as well as other variables may influence reinjection. Further ULIS-III data will provide additional clarity to these preliminary analyses. This is an encore of the original abstract submitted to AAPM&R 2017 (Turner-Stokes et al.).

The Experience of Treating Drooling with Repeated Botulinum Toxin Injections

Botulinum toxin A (BTX-A) injections to the salivary glands are effective in the treatment of drooling, and complications are rare. However, there are only a few previous reports on the long-term use of BTX-A injections. This study retrospectively analyzes our experience of treating drooling with repeated BTX-A injections in patients with neurodegenerative diseases. All patients who received repeated BTX-A injections to the submandibular glands at Tampere University Hospital in 2004-2013 were included in the analysis. Six patients, aged from 6 to 21 years, were included in the study, and a total of 41 bilateral BTX-A injections were administered to their submandibular glands. The average number of injections per patient was 6 (range: 3-11). The average interval between the injections was 9.8 months (range: 4-18), and 95% (39/41) of the injections were performed with good response. The complication rate of the BTX-A injections was 2.4% (1/41), since one of the patients had swallowing problems after an injection. BTX-A injections to the submandibular glands are effective and have a low morbidity rate, and repeated injections can be recommended as long-term treatment of drooling.

Intravesical Botulinum Toxin A Injections Do Not Benefit Patients with Ulcer Type Interstitial Cystitis

Background: Ulcer type and non-ulcer type interstitial cystitis/bladder pain syndromes (IC/BPS) are considered different disease entities. Thus, intravesical botulinum toxin A (BoNT-A) treatment outcomes could differ for each entity. Objectives: To evaluate and compare the treatment outcomes of BoNT-A injections for treatment of each IC/BPS type. Study Design: Prospective interventional study. Setting: Tertiary medical center affiliated with Buddhist Tzu Chi General Hospital and Tzu Chi University, Taiwan. Methods: Forty-four consecutive patients with IC/BPS for whom conventional treatments failed were prospectively enrolled in this study. Patients were classified as having ulcer (n = 10) or non-ulcer (n = 30) IC/BPS based on their previous cystoscopic findings. Intervention: All patients received 4 sets of intravesical BoNT-A injections (100 U in 40 suburothelial injections) every 6 months. The primary end-point was the global response assessment (GRA) 6 months after the fourth set of BoNT-A injections. Secondary end-points included the O’Leary-Sant score (OSS) including symptom indexes (ICSI) and problem indexes (ICPI), visual analog scale (VAS) pain score, voiding diary, and urodynamics variables. Results: After 4 sets of BoNT-A injections, 15 patients with non-ulcer IC/BPS had GRA scores ≥ 2, while the other 15 had GRA scores &lt; 2. All 10 patients with ulcer IC/BPS had GRA scores &lt; 2 at the study end-point (treatment failure). At baseline, patients with ulcer IC/BPS had significantly higher daytime frequency, nocturia, smaller functional bladder capacity, smaller voided volume, greater VAS, smaller maximal bladder capacity, and greater glomerulation grade than did patients with non-ulcer IC/BPS. After 4 sets of BoNT-A injections, patients with non-ulcer IC/BPS and GRA scores ≥ 2 or &lt; 2 all had significantly decreased ICSI, ICPI, OSS, VAS pain scores, frequency episodes, and increased functional bladder capacity. However, patients with ulcer IC/BPS showed no significant change in any clinical or urodynamic variable. After failure of repeated BoNT-A injections, all 10 patients with ulcer IC/ BPS underwent transurethral electrocauterization of their ulcers, which resulted in immediate pain relief. Limitations: Lack of a control arm in this study. Conclusion: Repeated intravesical BoNT-A injections provided effective treatment outcomes at the end-point in half of the patients with non-ulcer IC/BPS, but did not benefit any patient with ulcer type IC/BPS. Ulcer type IC/BPS should be treated as a different disease than non-ulcer IC/BPS. Institutional Review: This study was approved by the Institutional Review Board of the Tzu-chi General Hospital (TCGH 100-06). Key words: Botulinum toxin, interstitial cystitis, bladder pain syndrome, intravesical treatment, Hunner’s ulcer

Immunohistochemical evidence suggests repeated intravesical application of botulinum toxin A injections may improve treatment efficacy of interstitial cystitis/bladder pain syndrome

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A single set of botulinum toxin A (BoNT-A) injections relieves clinical symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS), but lacks long-term effect. An inadequate anti-inflammatory effect is likely to cause treatment failure. The study shows that chronic inflammation and apoptotic signalling molecules are significantly reduced after repeated intravesical BoNT-A injection in patients with IC/BPS. It also shows that repeated BoNT-A injections are necessary to achieve greater success in the treatment of IC/BPS. To investigate the mechanisms of action of botulinum toxin A (BoNT-A) treatment on interstitial cystitis/bladder pain syndrome (IC/BPS). A total of 23 women with IC/BPS who received single intravesical BoNT-A injection were studied. Among them, 11 received three repeated injections every 6 months to improve their symptoms. Bladder biopsy was obtained before each BoNT-A injection and the clinical symptoms and urodynamic variables were recorded. Immunohistochemical (IHC) staining for TUNEL and mast cell activity, and western blotting analysis of tryptase, cytokines, Bax and phospho-p38 (p-p38) were carried out. We compared the clinical results and IHC data among baseline, single or repeated BoNT-A treatments. Single BoNT-A injection improved clinical symptoms, pain score and daytime urinary frequency. Mast cell activity and apoptotic cell count did not decrease significantly, while Bax and p-p38, but not tryptase, decreased significantly after a single BoNT-A injection. The 11 patients who received three repeated BoNT-A injections had significantly lower pain scores than the remaining patients (mean [SD]: 5.80 [2.27] vs. 3.03 [2.30], P = 0), glomerulation degree (mean [SD]: 1.80 [1.06] vs. 1.20 [1.06], P = 0.026) and global response scores (mean [SD]: 0.30 [0.92] vs. 1.20 [1.06], P = 0) after treatment. Tryptase, Bax, p-p38 and apoptotic cell counts all decreased significantly. 25-kD synaptosomal-associated protein also decreased after BoNT-A treatments, which confirmed the therapeutic effect of repeated BoNT-A injections. Chronic inflammation and apoptotic signalling molecules were significantly reduced after repeated BoNT-A injections in patients with IC/BPS. The IHC improvement was associated with clinical symptom improvement. Repeated BoNT-A injections are necessary to achieve a greater success rate in the treatment of IC/BPS.

What are the long-term consequences of botulinum toxin injections in spastic cerebral palsy?

Muscle spasticity, defined as a velocity dependent resistance to stretch, is the primary impairment of spastic cerebral palsy (CP) and is neural in origin. However, spastic muscle also undergoes significant morphological and structural alterations secondary to spasticity which contribute to muscle weakness, muscle stiffness, restricted joint range of motion, and skeletal deformity. These secondary alterations can progress with age and contribute to a gradual loss of functional capacity during development, including the ability to ambulate independently. There is consensus that intra-muscular botulinum toxin A (BoNT-A) injections can be effective in the management of lower limb spasticity in children with spastic CP. BoNT-A injections can improve gait and delay and reduce the requirement for surgical interventions to treat musculoskeletal deformities when combined with conservative treatments. The study by Alhusaini et al. is one of the first that begins to address the important clinical question of how BoNT-A injections influence the secondary effects of spasticity on joint-level mechanical properties in children with spastic CP. An attractive feature of the study was that the authors assessed ankle joint stiffness and not just joint range of motion. Alhusaini et al. showed that BoNT-A has relatively minor effects on passive mechanical properties of the ankle plantar-flexor muscles at 6-weeks post injection in children with spastic CP aged 4– 10 years with high ankle joint stiffness. This study therefore does not support the efficacy of BoNT-A for treating contractures. What remains unclear at the present time is how BoNT-A might influence other structural and neuro-mechanical properties of the muscle and ⁄or tendon, especially in the longer term. For example, how does BoNT-A affect muscle size, strength, force-length-velocity behaviour, moment arms, co-activation, and tendon compliance? Of increasing concern is evidence from animal studies that intra-muscular BoNT-A injections adversely influence muscle growth in the injected muscle as well as muscles remote from the injection site. For example, Fortuna et al. recently reported up to 95% reductions in rabbit hind limb quadriceps muscle strength following 6 months of repeated BoNT-A injections, which was accompanied by up to 60% reductions in muscle mass. Reductions in strength and mass were also reported for quadriceps muscles in the contralateral limb. These findings point to the possibility that the short-term functional benefits of BoNT-A injections reported in clinical studies in spastic CP may be offset by accelerated structural weakening of muscle. This is important because children aged 2–5 years with spastic CP that have not undergone orthopaedic surgery or commenced BoNT-A injections already have significantly lower calf muscle volume relative to their typically developed peers. BoNT-A is routinely administered to children in this age group and is often repeated over many cycles. Further muscle weakening by BoNT-A would therefore be expected to adversely influence functional capacity. BoNT-A acts to weaken overactive muscles through chemical blockade of the neuromuscular junction. It might be expected that any associated muscle atrophy could contribute to observed improvements in gait following BoNT-A injections. However, during maturation in childhood and adolescence, muscles must increase in size to cope with the increased mechanical loading associated with motor function in activities such as gait. Muscle weakening from BoNT-A could therefore be beneficial in the short-term but detrimental in the longerterm because of impeded muscle growth. Aside from the study by Alhusaini et al., to our knowledge no detailed in vivo studies of the effects of BoNT-A on the active and passive mechanical properties of muscle in children with spastic CP have been conducted. In spite of the widespread use of BoNT-A injections in children with spastic CP for almost two decades, the long-term efficacy of this treatment for improving functional outcomes in children with spastic CP remain relatively unknown. In using a short-term solution we may be creating a long-term problem which could lead to increased costs of care in spastic CP. Long-term trials of the structural and neuro-mechanical responses of muscle to BoNT-A and their consequences for motor function in spastic CP are required. New developments in musculoskeletal modeling and simulation may prove fruitful in linking muscletendon adaptation with gait function in spastic CP.

Editorial Comment

Non-neurogenic detrusor overactivity or idiopathic detrusor overactivity (IDO) can pose significant challenges to the urologist. Despite multiple available modalities for conservative treatment, including antimuscarinics, biofeedback, and lifestyle changes, many patients are in need for additional, more or less, invasive treatment, like botulinum toxin A (BTX-A) injections or sacral neuromodulation. Repeated Injections of Botulinum Toxin-A for Idiopathic Detrusor OveractivityUrologyVol. 75Issue 3PreviewTo report the efficacy and safety of repeated injections of botulinum toxin-A (BTX-A) in treating idiopathic detrusor overactivity refractory to anticholinergics. Furthermore, we describe whether dose alteration in patients with poor responses or voiding dysfunction after initial treatment can improve outcomes. Full-Text PDF

Repeated Injections of Botulinum Toxin-A for Idiopathic Detrusor Overactivity

To report the efficacy and safety of repeated injections of botulinum toxin-A (BTX-A) in treating idiopathic detrusor overactivity refractory to anticholinergics. Furthermore, we describe whether dose alteration in patients with poor responses or voiding dysfunction after initial treatment can improve outcomes. A cohort of 34 patients who participated in a clinical trial was followed up and their progress reported. Twenty from this group had >1 BTX-A injection. Each patient received 200 U BTX-A initially, with subsequent injections between 100 and 300 U, administered by a trigone-sparing flexible cystoscopic technique. Efficacy was measured using voiding diaries and quality of life (QoL) assessed with Incontinence Impact Questionnaire-7 and Urogenital Distress Inventory-6 questionnaires. Urodynamic data were obtained for injections 1-3. All measurements were performed before and 3 months after injections. Twenty patients received a repeat injection and of these 9 subsequently received a third and fourth injection. Significant improvements in overactive bladder syndrome symptoms and QoL were observed after each injection as compared with baseline. Maximum cystometric capacity and bladder compliance increased with decrease in the maximum detrusor pressure during filling cystometry. When comparing overactive bladder symptoms, QoL, and urodynamic parameters 3 months after the first and last injections, no significant differences were found. Nine patients had their BTX-A dose altered, with better outcomes in 5. The commonest reported problems were difficulty in emptying the bladder and urinary tract infection. BTX-A appears to be effective and safe after repeated administration in patients with idiopathic detrusor overactivity. Certain patients will benefit from dose optimization to improve efficacy or prevent voiding dysfunction.

Therapeutic Satisfaction and Dissatisfaction in Patients With Spinal Cord Lesions and Detrusor Sphincter Dyssynergia Who Received Detrusor Botulinum Toxin A Injection

To investigate satisfaction in terms of quality-of-life (QOL) improvement among patients with spinal cord lesions and detrusor sphincter dyssynergia treated with botulinum toxin A (BoNT-A) injections to the detrusor for urinary incontinence and bladder dysfunction. A total of 50 patients with spinal cord lesion and detrusor sphincter dyssynergia were treated with BoNT-A injections (200 U) into the urinary bladder detrusor muscle. The urodynamic parameters, QOL scores, and general satisfaction with the treatment were assessed. Overall satisfactory results were perceived by 78% of patients who received detrusor BoNT-A injections. The maximal bladder capacity had increased significantly (221 +/- 107 vs 432 +/- 115 mL, P = .000), detrusor pressure decreased (43.5 +/- 21.1 vs 12.6 +/- 10.7 cm H(2)O, P = .000), and postvoid residual urine volume increased (121 +/- 107 vs 325 +/- 123 mL, P = .000) by 3 months after BoNT-A treatment. Patients had significant improvement in QOL indexes (Urogenital Distress Inventory 6-item short form 11.7 +/- 2.3 vs 4.1 +/- 2.1, P = .01; and Incontinence Impact Questionnaire, 7-item short form 16.3 +/- 3.5 vs 11.7 +/- 4.1, P = .03) after BoNT-A treatment. Decreases in incontinence grade and urgency episodes contributed the most to satisfaction, and increased difficulty in urination and the need for catheterization contributed to dissatisfaction. Of the 50 patients, 25 (50%) received repeated BoNT-A injections; 4 patients finally decided to undergo augmentation enterocystoplasty because they desired permanent corrections and did not wish to receive repeated injections. The patient satisfaction rate was 78%, and QOL improved among these patients after detrusor BoNT-A injections for urinary incontinence and bladder dysfunction.

Efficacy of repeated injections of Botulinum Toxin-A in patients with overactive bladder and idiopathic detrusor overactivity

Introduction and objective : Botulinum Toxin-A (BTX-A) is emerging as an effective second-line treatment for idiopathic detrusor overactivity (IDO). However, little is known on its longer term effects. To further validate its use, we objectively assessed the efficacy of repeated intra-detrusor injections of BTX-A in patients with IDO. Methods : 16 patients with proven IDO received repeated BTX-A injections (range 2–4, total number of injections 45). Outcome was assessed using urodynamics, voiding diaries and validated quality of life questionnaires (IIQ-7 and UDI-6) at presentation and then at 4, 12 and 24 weeks after each injection. Data were compared between the first and the last injections. Results : The mean number of weeks between the 1st and 2nd, 2nd and 3rd, and 3rd and 4th injections was 57.0, 52.3 and 33.3, respectively. After both the first and the last injections there were significant improvements in urodynamic, IIQ-7, UDI-6 and OAB symptoms compared to baseline. No significant difference was found when comparing the data 12 weeks following the first and last injection for mean cystometric capacity ( p =0.98), reflex detrusor volume ( p =0.55), detrusor compliance ( p =0.065), maximum detrusor pressure ( p =0.9), frequency ( p =0.38), urgency ( p =0.41), urge urinary incontinence ( p =0.1), UDI6 ( p =0.7) and IIQ7 ( p =0.7). Conclusion : BTX-A appears to have a sustained efficacy following repeated administration in patients with IDO. All the authors are investigators for Allegan.

Repeated botulinum toxin injection for idiopathic overactive bladder: Will chemodenervation become a long-term solution?

Botulinum toxin A (BTX-A) has emerged as a novel treatment option for idiopathic overactive bladder (OAB) refractory to antimuscarinic agents. The clinical needs of refractory OAB patients have been recently met by sacral neuromodulation and augmentation enterocystoplasty. Important features of BTX-A should include safety, efficacy, and ease of delivery during long-term repeated usage. This article reviews the role of repeated BTX-A injections in the treatment of idiopathic OAB.