Botox for Bladder
- Medical Community Member - October 2nd 2018
Recent findings regarding new mechanisms of action of Botox has resulted in novel indications, including as therapy for pain-related conditions. One new indication is for the treatment of urinary incontinence stemming from overactive bladder. This condition could be related to a neurologic condition (such as multiple sclerosis, Parkinson’s disease, or spinal cord injury). Patients with this condition are not able to control the contraction of bladder muscles involved in urination, and exhibit symptoms of urge urinary incontinence, urgency (strong, sudden urge to urinate), and frequency. In patients with neurologic conditions, urinary incontinence is usually due to overactivity of the detrusor, which is the smooth muscle found in the wall of the bladder. When traditional anticholinergic medications are not an option for patients or do not work for them, Botox injections present a viable alternative means of treating their bladder dysfunction.
Why use Botox for bladder?
Botox is essentially a muscle relaxant; it is composed of botulinum toxin type A, a neurotoxin isolated from the anaerobic bacterium Clostridium botulinum that acts on motor or autonomic nerve terminals to prevent the release of the neurotransmitter acetylcholine, thus producing a localized paralysis via chemical denervation. When treating bladder dysfunction, Botox is injected into the detrusor muscle where it affects the efferent pathways as described previously to stop the detrusor from contracting and thus reduce its overactivity. The effect that Botox exerts is temporary, lasting a few months before the results slowly wear off.
How much Botox is used for bladder injections?
The recommended dosage and administration differ between the two bladder dysfunction indications. For the treatment of overactive bladder, a total of 100 U (units) should be administered as five-unit injections in 20 sites across the detrusor. When treating detrusor overactivity related to a neurologic condition, administer 200 U as 1ml injections in 30 sites across the detrusor. Before administration, anesthesia may be administered to the patient via intravesical instillation of diluted local anesthetic, with or without sedation. It this is performed, the bladder must then be drained and then irrigated with sterile saline before proceeding with the Botox treatment. It is important that enough saline be present to achieve adequate visualization to perform the injections, without over-distension. Prior to injection, Botox must be reconstituted with 10ml (for 100 U of Botox) of sterile saline (for overactive bladder); or 30ml (for 200 U of Botox) of sterile saline (for detrusor overactivity associated with a neurologic condition).
How to inject Botox: for medical professionals
Prime the injection needle with 1ml of Botox to remove any air, before commencing with the injections. The solution is then injected into the detrusor muscle via a flexible or rigid cystoscope, avoiding the trigone in the process. Administration consists of either 20 injections of 0.5ml each, spaced 1cm apart and made to a depth of about 2mm into the detrusor (for overactive bladder); or 30 injections of 1ml each, spaced 1cm apart and made to a depth of about 2mm into the detrusor (for detrusor overactivity associated with a neurologic condition). The final injection should include 1ml of sterile normal saline so that all remaining Botox in the needle is administered. Once treatment is complete, the patient must be able to void (or if unable, the saline in the bladder should be drained) before they can be allowed to leave the clinic. A 30-minute post-treatment observation of the patient should be performed. The practitioner should keep the following points in mind when administering Botox to patients for bladder dysfunction: to take special care when performing the cystoscopy, to ensure that the patient has discontinued any anticoagulants they may be taking to minimize risk of bleeding, and to administer antibiotics before, during and after treatment to reduce the chances of a urinary tract infection (UTI).
Results of Botox for bladder
After treatment, many patients start to see results after 2 weeks, and should plan for repeat treatments about every six months (but no sooner than three months from the prior bladder injection). The side effects associated with Botox treatment for overactive bladder include urinary tract infection, dysuria (pain during urination), and temporary urinary retention (unable to empty the bladder spontaneously) which may require use of a self-catheter.
Can I get Botox for bladder?
There are certain patients for which Botox is not a suitable treatment; these include patients who currently have a urinary tract infection (UTI) or is not able to empty their bladder on their own (and are not routinely catheterizing). Patients who have an existing medical condition that may interfere with neuromuscular function, such as myasthenia gravis, amyotrophic lateral sclerosis, or Eaton-Lambert syndrome should also be excluded from treatment. Lastly, the practitioner should avoid treating female patients who are pregnant or breastfeeding.
In short, Botox is not just for wrinkle filling—patients who are afflicted with overactive bladder now can turn to this versatile therapeutic as a minimally invasive, safe and well-tolerated treatment option.