A Prospective, Multicenter, Double-Blind, Randomized Trial of Bladder Instillation of Liposome Formulation OnabotulinumtoxinA for Interstitial Cystitis/Bladder Pain Syndrome

Safety and efficacy of intravesical instillation of botulinum toxin-A in the treatment of interstitial cystitis/bladder pain syndrome and overactive bladder: a systematic review and meta-analysis

Background

The effectiveness and safety of the instillation of botulinum toxin A (BTX-A) remain subjects of controversy. The meta-analysis was performed to assess the efficacy and safety of a novel intravesical instillation of BTX-A for managing overactive bladder (OAB) or interstitial cystitis/bladder pain syndrome (IC/BPS).

Method

The randomized controlled trials were retrieved from PubMed, EMBASE, and the Cochrane Library databases up to 29 January 2024. The studies included in the analysis focused on the intravesical instillation of BTX-A in patients with OAB or IC/BPS. The data extraction was independently conducted by two reviewers. The random effects model was utilized for the assessment in order to compute the overall effect sizes. The heterogeneity tests and subgroup analyses were conducted.

Results

The meta-analysis and subgroup analysis did not reveal any statistically significant differences. However, the results of the meta-analysis indicated that intravesical instillation of BTX-A could reduce episodes of urgency urinary incontinence (UUI) (overall weighted mean difference [WMD] = -0.85; 95% confidence interval [CI]: -2.99 to 1.29). In subgroup analysis, an increase in void volume (VV) at 4 weeks of follow-up (WMD = -31.99; 95% CI: -70.53 to 6.54) was observed compared to that at 12 weeks (WMD = -1.73; 95% CI: -16.98 to 13.53). In contrast to the groups receiving more than 200 units of BTX-A, patients in the group receiving 200 units or fewer of BTX-A (WMD = -16.89; 95% CI: -41.14 to 7.35) exhibited a significantly greater increase in VV.

Conslusion

The intravesical instillation of BTX-A appears to be a viable administration route that may reduce UUI and VV to some extent. In terms of safety, intravesical instillation of BTX-A demonstrated a reduced risk of UTI and post-void residual compared to the placebo group.

Systematic Review registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024517877.

Bladder Pain Syndrome (BPS): A Comprehensive Review of Treatment Strategies and Management Approaches

Bladder pain Syndrome presents a multifaceted challenge in contemporary urological practice, marked by LUTS, negative behavioural, sexual, or emotional experiences, and the potential for sexual dysfunction. We meticulously explored the existing literature of conservative, non-invasive and invasive interventions, aiming to provide clinicians with a nuanced understanding of available options for comprehensive BPS management. We delve into the effectiveness and safety profiles from behavioural approaches through lifestyle changes and physical therapy, to oral or intravesical medications, until the definitive surgical treatment. The best option evaluated is the involvement of a multidisciplinary team, including urologists, urotherapists, gynaecologists, pain specialists, primary care physicians and psychologists, educating those patients regarding the condition and its chronic course and tailoring the perfect treatment for each person. Despite this, BPS remains a challenge for urologists. Indeed, our objective is to contribute to the evolving landscape of BPS management, fostering informed decision-making and personalized care for individuals grappling with this challenging condition.

A randomized-controlled pilot trial of telemedicine-delivered cognitive-behavioral therapy tailored for interstitial cystitis/bladder pain syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating urologic pain condition with few treatment advances in the past 25 years. Individuals with IC/BPS often experience significant psychological distress, which worsens symptoms and functioning. To date, there have been no large-scale, randomized controlled trials (RCTs) of comprehensive psychological interventions for IC/BPS. We conducted a 2:1 RCT of an 8-session patient-informed cognitive-behavioral therapy (CBT) intervention designed for IC/BPS for reducing pain-related symptoms and improving quality of life, delivered through telemedicine. Individuals with IC/BPS (N = 78) were randomized to receive either 8 weeks of CBT specifically designed for IC/BPS (n = 52) or an attention control condition (n = 26). Urologic symptoms (Genitourinary Pain Index, GUPI), pain-related symptoms, affective distress, and quality of life were evaluated before, immediately after, and 3 months posttreatment. Both conditions reported significant but similar reductions (P = 0.922) in the a priori primary outcome of genitourinary symptoms at posttreatment (GUPI reduction = 6.6 vs 4.8, for CBT and control, respectively) and long-term follow-up (8.1 vs 6.6, for CBT and control). However, the CBT group had significantly greater improvement in Patient Global Impression of Change (PGIC) scores and was significantly more likely to be treatment responders (PGIC ≥ 6) (37% vs 8%, P = 0.019 for CBT and control), with a large relative effect size (OR = 6.68). A subgroup analysis of CBT recipients showed that responders (PGIC 6) displayed significant reductions in genitourinary symptoms (P = 0.023), pain intensity (P = 0.027), and pain interference (P = 0.013) posttreatment. Telemedicine-delivered pain CBT for IC/BPS shows promise for improving outcomes, and this trial demonstrates the need for larger RCTs of CBT for IC/BPS.

Efficacy, Satisfaction, and Compliance: Insights from 15 Years of Botulinum Toxin Use for Female Urgency Urinary Incontinence

Urgency urinary incontinence (UUI) refractory to medical treatment poses significant challenges despite advancements. This study evaluates the efficacy of intravesical botulinum toxin for UUI and identifies factors influencing treatment outcomes. Among 368 women receiving botulinum toxin injections, 74.5% achieved a complete discontinuation of pad usage. Predictors of efficacy included lower pre-treatment pad usage and the absence of prior sling placement. Patients often required repeat injections (60.3%), with younger age and satisfaction correlating with treatment repetition. The interval between injections averaged 18 months, influenced by logistical challenges and patient preferences. Despite concerns about diminishing efficacy, subjective perceptions did not align with objective findings. Limitations include retrospective analysis and heterogeneous clinical records. In conclusion, intravesical botulinum toxin is effective for UUI, with pre-treatment pad usage and sling placement history influencing outcomes and patient characteristics influencing treatment repetition.

Promising Experimental Treatment in Animal Models and Human Studies of Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain Syndrome (IC/BPS) remains a mysterious and intricate urological disorder, presenting significant challenges to healthcare providers. Traditional guidelines for IC/BPS follow a hierarchical model based on symptom severity, advocating for conservative interventions as the initial step, followed by oral pharmacotherapy, intravesical treatments, and, in refractory cases, invasive surgical procedures. This approach embraces a multi-tiered strategy. However, the evolving understanding that IC/BPS represents a paroxysmal chronic pain syndrome, often involving extravesical manifestations and different subtypes, calls for a departure from this uniform approach. This review provides insights into recent advancements in experimental strategies in animal models and human studies. The identified therapeutic approaches fall into four categories: (i) anti-inflammation and anti-angiogenesis using monoclonal antibodies or immune modulation, (ii) regenerative medicine, including stem cell therapy, platelet-rich plasma, and low-intensity extracorporeal shock wave therapy, (iii) drug delivery systems leveraging nanotechnology, and (iv) drug delivery systems assisted by energy devices. Future investigations will require a broader range of animal models, studies on human bladder tissues, and well-designed clinical trials to establish the efficacy and safety of these therapeutic interventions.

Embracing the Versatility of Botulinum Neurotoxins in Conventional and New Therapeutic Applications

Botulinum neurotoxins (BoNTs) have been used for almost half a century in the treatment of excessive muscle contractility. BoNTs are routinely used to treat movement disorders such as cervical dystonia, spastic conditions, blepharospasm, and hyperhidrosis, as well as for cosmetic purposes. In addition to the conventional indications, the use of BoNTs to reduce pain has gained increased recognition, giving rise to an increasing number of indications in disorders associated with chronic pain. Furthermore, BoNT-derived formulations are benefiting a much wider range of patients suffering from overactive bladder, erectile dysfunction, arthropathy, neuropathic pain, and cancer. BoNTs are categorised into seven toxinotypes, two of which are in clinical use, and each toxinotype is divided into multiple subtypes. With the development of bioinformatic tools, new BoNT-like toxins have been identified in non-Clostridial organisms. In addition to the expanding indications of existing formulations, the rich variety of toxinotypes or subtypes in the wild-type BoNTs associated with new BoNT-like toxins expand the BoNT superfamily, forming the basis on which to develop new BoNT-based therapeutics as well as research tools. An overview of the diversity of the BoNT family along with their conventional therapeutic uses is presented in this review followed by the engineering and formulation opportunities opening avenues in therapy.

Lower Urinary Tract Inflammation and Infection: Key Microbiological and Immunological Aspects

The urinary system, primarily responsible for the filtration of blood and waste, is affected by several infectious and inflammatory conditions. Focusing on the lower tract, this review outlines the physiological and immune landscape of the urethra and bladder, addressing key immunological and microbiological aspects of important infectious/inflammatory conditions. The conditions addressed include urethritis, interstitial cystitis/bladder pain syndrome, urinary tract infections, and urosepsis. Key aspects of each condition are addressed, including epidemiology, pathophysiology, and clinical considerations. Finally, therapeutic options are outlined, highlighting gaps in the knowledge and novel therapeutic approaches.

Current and Emerging Pharmacological Targets and Treatments of Urinary Incontinence and Related Disorders

Overactive bladder syndrome with and without urinary incontinence and related conditions, signs, and disorders such as detrusor overactivity, neurogenic lower urinary tract dysfunction, underactive bladder, stress urinary incontinence, and nocturia are common in the general population and have a major impact on the quality of life of the affected patients and their partners. Based on the deliberations of the subcommittee on pharmacological treatments of the 7th International Consultation on Incontinence, we present a comprehensive review of established drug targets in the treatment of overactive bladder syndrome and the aforementioned related conditions and the approved drugs used in its treatment. Investigational drug targets and compounds are also reviewed. We conclude that, despite a range of available medical treatment options, a considerable medical need continues to exist. This is largely because the existing treatments are symptomatic and have limited efficacy and/or tolerability, which leads to poor long-term adherence. SIGNIFICANCE STATEMENT: Urinary incontinence and related disorders are prevalent in the general population. While many treatments have been approved, few patients stay on long-term treatment despite none of them being curative. This paper provides a comprehensive discussion of existing and emerging treatment options for various types of incontinence and related disorders.

Botulinum Toxin Therapy for Bladder Pain Syndrome/Interstitial Cystitis

Purpose of Review

Bladder pain syndrome (BPS)/interstitial cystitis (IC) can also be classified as either non-ulcerative or ulcerative, corresponding to the characteristic cystoscopic findings under hydrodistention. Promising therapeutic effects, including decreased bladder pain, have been reported from recent clinical trials using botulinum toxin A (BoNTA) for the treatment of BPS/IC. This review summarizes the current state of the literature on the underlying mechanisms of BoNTA therapy in BPS/IC as well as new forms of its application.

Recent Findings

BoNTA has its effect in the central nervous system in the afferent nerves as well as in the bladder wall. Besides the well-known effects of BoNTA in the nervous system, pain control as well as reduction of urinary urgency in BPS patients could be achieved by mast cell stabilization effecting histamine release as well as modulation of TRPV and PGE2 pathways, among other systems. In addition, new forms of BoNTA administration have focused on intravesical instillation of the drug in order to circumvent bladder wall injections. Hyperthermia, intravesical hydrogel, and lysosomes have been studied as new ways of BoNTA application in BPS/IC patients. From the available studies, bladder instillation of BoNTA in combination with EMDA is the most promising and effective novel approach.

Summary

The most promising novel application methods for BoNTA in patient with BPS/IC are bladder instillations. Future research needs to point out if bladder instillations with BoNTA with some form of bladder absorption enhancement such as hyperthermia or EMDA would be able to replace BoNTA injections in patients with BPS/IC

Liposome-Encapsulated Botulinum Toxin A in Treatment of Functional Bladder Disorders

Botulinum toxin A (BoNT-A) intravesical injections have been used to treat patients with refractory functional bladder disorders such as overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS), but the risk of adverse events and the need for repeated injections continue to prevent widespread application of this treatment. Liposomes are vesicles that comprise concentric phospholipid layers and an aqueous core; their flexible compositions enable them to adsorb and fuse with cell membranes and to deliver drugs or proteins into cells. Therefore, liposomes have been considered as promising vehicles for the less invasive delivery of BoNT-A. In previous placebo-controlled trials including patients with OAB refractory to medical treatment, it was shown that liposomal BoNT-A could significantly decrease the frequency and urgency of urination. In patients with IC/BPS, it was shown that liposomal BoNT-A could also improve bladder pain, but the therapeutic efficacy was not superior to that of the placebo. As the therapeutic mechanisms of BoNT-A include the decreased expression of nerve growth factors, P2X3 receptors, and vanilloid receptors on C-fibers, liposomal BoNT-A might play a more promising role in the treatment of bladder oversensitivity. This article features the contemporary literature regarding BoNT-A, liposomes, and liposomal BoNT-A treatment for functional bladder disorders and potential clinical applications in the future.

Broaden Horizons: The Advancement of Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating disease that induces mental stress, lower urinary symptoms, and pelvic pain, therefore resulting in a decline in quality of life. The present diagnoses and treatments still lead to unsatisfactory outcomes, and novel diagnostic and therapeutic modalities are needed. Although our understanding of the etiology and pathophysiology of IC/BPS is growing, the altered permeability of the impaired urothelium, the sensitized nerves on the bladder wall, and the chronic or intermittent sensory pain with inaccurate location, as well as pathologic angiogenesis, fibrosis, and Hunner lesions, all act as barriers to better diagnoses and treatments. This study aimed to summarize the comprehensive information on IC/BPS research, thereby promoting the progress of IC/BPS in the aspects of diagnosis, treatment, and prognosis. According to diverse international guidelines, the etiology of IC/BPS is associated with multiple factors, while the presence of Hunner lesions could largely distinguish the pathology, diagnosis, and treatment of non-Hunner lesions in IC/BPS patients. On the basis of the diagnosis of exclusion, the diverse present diagnostic and therapeutic procedures are undergoing a transition from a single approach to multimodal strategies targeting different potential phenotypes recommended by different guidelines. Investigations into the mechanisms involved in urinary symptoms, pain sensation, and bladder fibrosis indicate the pathophysiology of IC/BPS for further potential strategies, both in diagnosis and treatment. An overview of IC/BPS in terms of epidemiology, etiology, pathology, diagnosis, treatment, and fundamental research is provided with the latest evidence. On the basis of shared decision-making, a multimodal strategy of diagnosis and treatment targeting potential phenotypes for individual patients with IC/BPS would be of great benefit for the entire process of management. The complexity and emerging evidence on IC/BPS elicit more relevant studies and research and could optimize the management of IC/BPS patients.

Clinical Approach to Recurrent Voiding Dysfunction, Dysuria, and Pelvic Pain Persisting for at Least 3 Months

There are several patients with urination problems and urethral and pelvic discomfort. Usually, these patients’ symptoms are persistent and ambiguous; therefore, it is difficult to find underlying diseases associated with the patient’s symptoms. In addition, there are various conditions such as overactive bladder, cystitis, and interstitial cystitis/bladder pain syndrome (IC/BPS). Sometimes patients with other chronic disorders such as fibromyalgia, inflammatory bowel syndrome, and vulvodynia show urination problems and pelvic pain. Thus, a patient-centered approach is important to find the cause of chronic urination problems and pelvic pain. Moreover, IC/BPS should be considered during the diagnostic process because the clinical characteristics of IC/BPS are diverse. In this narrative review, we suggest an integral approach for the diagnosis and treatment of IC/ BPS.

Current Understanding of the Pathophysiology and Novel Treatments of Interstitial Cystitis/Bladder Pain Syndrome

The pathophysiology of interstitial cystitis/bladder pain syndrome (IC/BPS) is multifactorial. Identifying the clinical characteristics and cystoscopic findings of bladder-centered IC/BPS facilitates optimal treatment strategies targeting the diseased urinary bladder. Patients with Hunner’s lesion (HIC) and without Hunner’s lesion (NHIC) should be treated differently. Based on the histopathological findings, NHIC can be treated with intravesical instillation of urothelial protective agents, such as hyaluronic acid, to cover the urothelial defects. In non-responders, chronic inflammation and higher urothelial dysfunction can be treated with intravesical botulinum toxin A injection, platelet-rich plasma injection, or low-energy shock wave treatment to reduce inflammation, increase tissue regeneration, and improve the urothelial barrier. Patients with HIC should be treated with electrocauterization first; augmentation enterocystoplasty should only be used in end-stage HIC when the contracted bladder is refractory to other treatments. The antiviral agent, valacyclovir, can be used in patients with HIC, small bladder capacity, and high-grade glomerulations. In addition, behavioral modification is always recommended from the beginning of treatment. Treatment with cognitive behavioral therapy interventions in combination with bladder therapy can reduce anxiety and improve treatment outcomes. Herein, recent advances in the pathophysiology and novel treatments for IC/BPS are reviewed.

Nanotechnology as a tool to advance research and treatment of non-oncologic urogenital diseases

Nanotechnology represents an expanding area of research and innovation in almost every field of science, including Medicine, where nanomaterial-based products have been developed for diagnostic and therapeutic applications. Because of their small, nanoscale size, these materials exhibit unique physical and chemical properties that differ from those of each component when considered in bulk. In Nanomedicine, there is an increasing interest in harnessing these unique properties to engineer nanocarriers for the delivery of therapeutic agents. Nano-based drug delivery platforms have many advantages over conventional drug administration routes as this technology allows for local and transdermal applications of therapeutics that can bypass the first-pass metabolism, improves drug efficacy through encapsulation of hydrophobic drugs, and allows for a sustained and controlled release of encapsulated agents. In Urology, nano-based drug delivery platforms have been extensively investigated and implemented for cancer treatment. However, there is also great potential for use of nanotechnology to treat non-oncologic urogenital diseases. We provide an update on research that is paving the way for clinical translation of nanotechnology in the areas of erectile dysfunction (ED), overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and catheter-associated urinary tract infections (CAUTIs). Overall, preclinical and clinical studies have proven the utility of nanomaterials both as vehicles for transdermal and intravesical delivery of therapeutic agents and for urinary catheter formulation with antimicrobial agents to treat non-oncologic urogenital diseases. Although clinical translation will be dependent on overcoming regulatory challenges, it is inevitable before there is universal adoption of this technology to treat non-oncologic urogenital diseases.

Clinical Application of Botulinum Neurotoxin in Lower-Urinary-Tract Diseases and Dysfunctions: Where Are We Now and What More Can We Do?

Botulinum toxin A (Botox) had been considered a promising drug that has an effect on functional disorders of the lower urinary tract. Because Botox exhibits anti-inflammatory and antispasmodic effects, Botox injection into the bladder can decrease detrusor contractility, reduce bladder hypersensitivity, and eliminate painful sensations. Injecting Botox into the bladder outlet can relax the hyperactivity of the bladder neck, and of the urethral smooth and striated muscles. Based on these therapeutic effects, Botox has been widely applied to treat lower-urinary-tract dysfunctions (LUTDs) such as overactive bladder and neurogenic detrusor overactivity. However, this treatment has not been licensed for use in other LUTDs such as interstitial cystitis, voiding dysfunction due to benign prostatic hyperplasia in men, and dysfunctional voiding in women. Botox has also not been approved for the treatment of children with overactive bladder and dysfunctional voiding; in patients with spinal cord injuries with detrusor sphincter dyssynergia and autonomic dysreflexia; or for poorly relaxed external sphincter in non-neurogenic patients. This article reviews the current knowledge regarding Botox treatment for LUTDs and discusses the potential clinical applications of Botox, as well as work that can be conducted in the future.

Nano-BTA: A New Strategy for Intravesical Delivery of Botulinum Toxin A

Botulinum neurotoxin subtype A (BoNT-A) has been part of the urology treatment arsenal since it was first used in the treatment of detrusor-sphincter dyssynergia more than 30 years ago. BoNT-A has been recommended as an effective treatment for neurogenic detrusor overactivity and overactive bladder. However, direct intradetrusor injection of BoNT-A using cystoscopy after anesthesia may cause hematuria, pain, and infection; these adverse events have motivated urologists to find less invasive and more convenient ways to administer BoNT-A. The development of nanotechnology has led to the advancement of intravesical drug delivery. Using versatile nanocarriers to transport BoNT-A across the impermeable urothelium is a promising therapeutic option. In this review, we discuss the effectiveness and feasibility of liposomes, thermosensitive polymeric hydrogels, and hyaluronan-phosphatidylethanolamine as carriers of BoNT-A for intravesical instillation. To date, these carriers have not reached a similar efficacy as intradetrusor injections in long-term observations. Hopefully, researchers will make a breakthrough with new nanomaterials to develop clinical applications in the future.

Inhibition of U-II/UT signaling ameliorates cystitis-associated bladder hyperactivity by targeting the RhoA/Rho-kinase pathway

Urotensin II (U-II) and its receptor (UT) are involved in the pathogenesis of various diseases; however, their association with the development of cystitis has not been elucidated. The present study was designed to investigate the functional role of U-II/UT signaling in cyclophosphamide (CYP)-induced cystitis. A total of 60 female rats were randomly divided into the control and CYP-treated groups. Intraperitoneal injection of CYP successfully induced cystitis in rats of the CYP-treated group. The protein and mRNA expression levels of U-II and UT were significantly enhanced in rat bladder tissues of the CYP-treated group. Furthermore, the results of the immunofluorescence staining analysis demonstrated that CYP treatment apparently increased the expression levels of UT in the urothelium layer, detrusor smooth muscle, and bladder interstitial Cajal-like cells. The selective antagonist of UT, SB657510 (10 μm), significantly suppressed the CYP-induced increase in the spontaneous contractions of muscle strips and ameliorated the bladder hyperactivity of CYP-treated rats. Moreover, CYP treatment significantly increased the protein expression levels of Ras homolog family member (Rho) A and Rho-associated protein kinase 2 in rat bladder tissues. Following pretreatment with the Rho-kinase inhibitor Y-27632 (10 μm), the inhibitory effects of SB657510 (10 μm) on the spontaneous contractions of muscle strips were eliminated. In conclusion, the results of the present study suggested that activation of U-II/UT signaling promoted the development of cystitis-associated-bladder hyperactivity by targeting the RhoA/Rho-kinase pathway, indicating that the U-II/UT signaling could serve as a novel target for the treatment of interstitial cystitis/bladder pain syndrome.

Emerging molecular mechanisms and genetic targets for developing novel therapeutic strategies for treating bladder diseases

Bladder diseases affect millions of patients worldwide and compromise their quality of life with a substantial economic impact. The not fully understood aetiologies of bladder diseases limit the current diagnosis and therapeutic options to primarily symptomatic treatment. In addition, bladder targeted drug delivery is challenging due to its unique anatomical features and its natural physiological function of urine storage and frequent voiding. Therefore, current treatment options often fail to provide a highly effective, precisely targeted and long-lasting treatment. With the growing maturity of gene therapy, comprehensive studies are needed to provide a better understanding of the molecular mechanisms underpinning bladder diseases and help to identify novel gene therapeutic targets and biomarkers for treating bladder diseases. In this review, molecular mechanisms involved in pathology of bladder cancer, interstitial cystitis and overactive bladder syndrome are reviewed, with focus on establishing potential novel treatment options. Proposed novel therapies, including gene therapy combined with nanotechnology, localised drug delivery by nanoparticles, and probiotics, are discussed in regard to their safety profiles, efficacy, treatment lenght, precise targeting, and in comparison to conventional treatment methods.

Low-Energy Shock Wave Plus Intravesical Instillation of Botulinum Toxin A for Interstitial Cystitis/Bladder Pain Syndrome: Pathophysiology and Preliminary Result of a Novel Minimally Invasive Treatment

Low-energy shock wave (LESW) therapy is known to facilitate tissue regeneration with analgesic and anti-inflammatory effects. LESW treatment has been demonstrated to be effective in treating chronic prostatitis and pelvic pain syndrome as well as overactive bladder, and it has a potential effect on interstitial cystitis/bladder pain syndrome (IC/BPS) in humans. LESW reduces pain behavior, downregulates nerve growth factor expression, and suppresses bladder overactivity by decreasing the expression of inflammatory proteins. Previous rat IC models have shown that LESW can increase urothelial permeability, facilitate intravesical delivery of botulinum toxin A (BoNT-A), and block acetic acid-induced hyperactive bladder, suggesting that LESW might be a potential therapeutic module for relieving bladder inflammatory conditions, such as bladder oversensitivity, IC/BPS, and overactive bladder. A recent clinical trial showed that LESW monotherapy was associated with a significant reduction in pain scores and IC symptoms. BoNT-A detrusor injection or liposome-encapsulated BoNT-A instillation could also inhibit inflammation and improve IC symptoms. However, BoNT-A injection requires anesthesia and certain complications might occur. Our preliminary study using LESW plus intravesical BoNT-A instillation every week demonstrated an improvement in global response assessment without any adverse events. Moreover, an immunohistochemistry study revealed the presence of cleaved SNAP25 protein in the suburothelium of IC bladder tissue, indicating that BoNT-A could penetrate across the urothelial barrier after application of LESW. These results provide evidence for the efficacy and safety of this novel IC/BPS treatment by LESW plus BoNT-A instillation, without anesthesia, and no bladder injection. This article reviews the current evidence on LESW and LESW plus intravesical therapeutic agents on bladder disorders and the pathophysiology and pharmacological mechanism of this novel, minimally invasive treatment model for IC/BPS.

An indirect comparison meta-analysis of noninvasive intravesical instillation and intravesical injection of botulinum toxin-A in bladder disorders

BACKGROUND

Botulinum toxin type A (BTX-A) intravesical instillation and BTX-A intravesical injection are both effective treatments or overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS), but direct comparative studies of the two treatments are lacking.

METHODS

We conducted a pairs-comparison meta-analysis and an adjusted indirect comparison meta-analysis extracting published data from randomized controlled trials in literature databases from the inception of each database to Aug. 31, 2021, evaluating efficacy and safety of BTX-A intravesical instillation and BTX-A intravesical injection. We also carried out a subgroup analysis.

RESULTS

We identified 24 trials in 21 studies were included in our study, of which 18 trials in 17 studies were BTX-A intravesical injections, 6 trials in 4 studies were BTX-A intravesical instillation. Compared with the normal saline injection, BTX-A intravesical injections for patients with OAB and IC/ BPS can obviously improve the symptoms of urinary frequency, urgency episode, UI and UUI, but BTX-A significantly increased the rate of urinary retention and urinary tract infection and increased PVR (p < 0.05). Adjusted indirect comparison meta-analysis showed that BTX-A intravesical injections was more effective than BTX-A intravesical instillation (p > 0.05). Surprisingly, BTX-A intravesical instillation had fewer side effects than BTX-A intravesical injections (p < 0.05).

CONCLUSIONS

Although BTX-A intravesical injections of OAB and IC/BPS has been significantly superior the BTX-A intravesical instillation, it has major side effects, but this needs to be confirmed by more large-scale, multicenter, direct comparison randomized controlled trials.

BoNT/A in the Urinary Bladder-More to the Story than Silencing of Cholinergic Nerves

Botulinum neurotoxin (BoNT/A) is an FDA and NICE approved second-line treatment for overactive bladder (OAB) in patients either not responsive or intolerant to anti-cholinergic drugs. BoNT/A acts to weaken muscle contraction by blocking release of the neurotransmitter acetyl choline (ACh) at neuromuscular junctions. However, this biological activity does not easily explain all the observed effects in clinical and non-clinical studies. There are also conflicting reports of expression of the BoNT/A protein receptor, SV2, and intracellular target protein, SNAP-25, in the urothelium and bladder. This review presents the current evidence of BoNT/A's effect on bladder sensation, potential mechanisms by which it might exert these effects and discusses recent advances in understanding the action of BoNT in bladder tissue.

Current Status of Intravesical Therapies for Bladder Pain Syndrome (BPS): A Narrative Review of Emerging Evidence

Bladder pain syndrome (BPS) is a complex condition, which can have debilitating sequelae for patients. Many elements of BPS remain poorly understood including pathophysiology, diagnosis and treatment. Navigating patient care can therefore be challenging for the clinician. Management mandates a multidisciplinary and symptom-based approach. Intravesical treatments such as instillation therapies remain a cornerstone of most treatment algorithms and there are a range of agents that can be selected. This review offers an up-to-date evaluation of the evidence for these intravesical treatments.

Comparative safety review of current pharmacological treatments for interstitial cystitis/ bladder pain syndrome

Introduction: Interstitial cystitis (IC)/bladder pain syndrome (BPS) is a frustrating disease of chronic bladder pain associated with lower urinary tract symptoms. Although there are many proposed treatment algorithms, the uncertainty as to their etiology has a negative impact on the therapeutic outcome. Oftentimes combination therapy of drugs with different mechanisms of action will be utilized to relieve the symptoms. With the various treatment options available to patients and providers, there is an ever-growing need to implement drug efficacy as well as safety to promote best practice in use of the approved drug.Areas covered: This review will focus on guideline-based pharmacotherapies as described by the AUA and EAU, specifically oral, and intravesical therapies with the most up-to-date published literature. Pharmacotherapies targeting bladder, and/or systemic factors in the overall treatment of IC/BPS are discussed with a particular focus on efficacy and drug safety evaluation.Expert opinion: IC/BPS is a syndrome that requires bladder targeting agents to restore the urothelium barrier function and inhibit bladder hypersensitivity as well as various drugs with anti-inflammatory effects, and immune modulation effects. Current pharmacotherapies for IC/BPS have various therapeutic effects and adverse effects depending on the dose and individual response.

Novel Applications of Non-Invasive Intravesical Botulinum Toxin a Delivery in the Treatment of Functional Bladder Disorders

Although intravesical botulinum toxin type A (BoNT-A) injection for functional bladder disorders is effective, the injection-related problems-such as bladder pain and urinary tract infection-make the procedure invasive and inconvenient. Several vehicles have recently been developed to deliver BoNT-A without injection, thereby making the treatment less or non-invasive. Laboratory evidence revealed that liposome can carry BoNT-A across the uroepithelium and act on sub-urothelial nerve endings. A randomized placebo controlled study revealed that intravesical administration of liposome-encapsulated BoNT-A and TC-3 hydrogel embedded BoNT-A can improve urinary frequency, urgency, and reduce incontinence in patients with overactive bladders. A single-arm prospective study also revealed that intravesical administration of TC-3 hydrogel embedded BoNT-A can relieve bladder pain in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). We recently administered suprapubic energy shock wave (ESW) after BoNT-A intravesical administration in six patients with IC/BPS. Although pain reduction and symptom improvement were not significant, immunochemical staining showed cleaved synaptosome-associated protein 25 in the bladder after the procedure. This suggests that ESW can promote passage of BoNT-A across the uroepithelium. In conclusion, using vehicles to intra-vesically deliver BoNT-A for functional bladder disorders is promising. Further studies are necessary to confirm the efficacy and explore novel applications.

Efficacy and safety comparison of pharmacotherapies for interstitial cystitis and bladder pain syndrome: a systematic review and Bayesian network meta-analysis

INTRODUCTION AND HYPOTHESIS

The objective was to compare the clinical efficacy and safety of pharmacological interventions for interstitial cystitis and bladder pain syndrome (IC/BPS) with direct and indirect evidence from randomized trials.

METHODS

We searched PubMed, the Cochrane library, and EMBASE for randomized controlled trials (RCTs) that assessed the pharmacological therapies for IC/BPS. Primary efficacy outcomes included ICSI (O'Leary Sant Interstitial Cystitis Symptom Index), ICPI (O'Leary Sant Interstitial Cystitis Problem Index), 24-h micturition frequency, visual analog scale (VAS), and Likert score for pain. Safety outcomes are total adverse events (AEs, intravesical instillation, and others), gastrointestinal symptoms, headache, pain, and urinary symptoms. A systematic review and Bayesian network meta-analysis were performed.

RESULTS

A total of 23 RCTs with 1,871 participants were identified. The ICSI was significantly reduced in the amitriptyline group (MD = -4.9, 95% CI: -9.0 to -0.76), the cyclosporine A group (MD = -7.9, 95% CI: -13.0 to -3.0) and the certolizumab pegol group (MD = -3.6, 95% CI:-6.5 to -0.63) compared with placebo group. Moreover, for ICPI, cyclosporine A showed superior benefit compared to placebo (MD = -7.6, 95% CI: -13 to -2.3). VAS score improved significantly in cyclosporine A group than pentosan polysulfate sodium (MD = 3.09, 95% CI: 0.13 to 6.07). None of the agents revealed a significant alleviation of 24-h micturition frequency. In terms of safety outcomes, the incidence rate on urinary symptoms for botulinum toxin A was the only variate higher than chondroitin sulfate (MD = -2.02, 95% CI: -4.99 to 0.66) and placebo (MD = -1.60, 95% CI:-3.83 to 0.17). No significant difference was found among the other treatments.

CONCLUSIONS

Cyclosporine A might be superior to other pharmacological treatments in efficacy. Amitriptyline and certolizumab pegol were capable of lowering the ICSI as well.

Current standard of care in treatment of bladder pain syndrome/interstitial cystitis

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a debilitating, systemic pain syndrome with a cardinal symptom of bladder related pain with associated systemic symptoms. It is characterized by an inflammation that partially or completely destroys the mucus membrane and can extend into the muscle layer; however, the etiology and pathogenesis is still enigmatic. It has been suggested that mast cell activation, defects in the glycosaminoglycan layer, non-functional proliferation of bladder epithelial cells, neurogenic inflammation, microvascular abnormalities in the submucosal layer, autoimmunity and infectious causes may cause BPS/IC. Available treatment options include general relaxation techniques, patient education, behavioral treatments, physical therapy, multimodal pain therapy, oral (amitriptyline, cimetidine, hydroxyzine) and intravesical treatments (heparin, lidocaine, hyaluronic acid and chondroitin sulfate), hydrodistension and other more invasive treatments. Available treatments are mostly not based on a high level of evidence. Lack of understanding of disease mechanisms has resulted in lack of targeted therapies on this area and a wealth of empirical approaches with usually inadequate efficacy. The aim of this article is to review the available evidence on the pathophysiological mechanisms of BPS/IC as they relate to available treatment options.

Botulinum Toxin A: A Review of Potential Uses in Treatment of Female Urogenital and Pelvic Floor Disorders

Background: Botulinum toxin is an injectable neuromodulator that inhibits transmission between peripheral nerve endings and muscle fibers, resulting in muscle paralysis. Botulinum toxin type A is the most common form of botulinum toxin used in clinical practice.

Methods: In this review, we examine the mechanism of action, formulations, common clinical use in the genital-urinary tract, and potential clinical use in pelvic floor disorders of botulinum toxin type A.

Results: Several aspects of botulinum toxin A make it a favorable therapeutic tool, including its accessibility, its longevity, and its impermanence and reversibility of resultant chemodenervation in a relatively short and safe manner. Although botulinum toxin A has well-established efficacy in treating refractory overactive bladder and neurogenic detrusor overactivity, its use in pelvic floor disorders is still in its infancy.

Conclusion: The efficacy of botulinum toxin A for treating pelvic pain, voiding dysfunction, muscle pain and dysfunction, and certain colorectal-related pain issues shows promise but requires additional rigorous evaluation.

Biomaterial-assisted drug delivery for interstitial cystitis/bladder pain syndrome treatment

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and painful bladder condition afflicting patients with increased urinary urgency and frequency as well as incontinence. Owing to the elusive pathogenesis of IC/BPS, obtaining effective therapeutic outcomes remains challenging. Current administrational routes such as intravesical-bladder injection improve the treatment efficacy and reduce systemic side effects. However, the bladder permeability barrier hinders drug penetration into the bladder wall to meet the desired therapeutic expectation. These issues can be addressed by encapsulating drugs into biomaterials. When appropriately exploited, they would increase the drug dwelling time in the bladder, enhance the penetration of mucosa and improve the therapeutic response of IC/BPS. In this review, we first elucidate the pathogenesis and animal models of IC/BPS. Then, we highlight recent representative biomaterial-assisted drug delivery systems for IC/BPS treatment. Finally, we discuss the challenges and outlook for further developing biomaterial-based delivery systems for IC/BPS management.

Treatment of Interstitial Cystitis/Bladder Pain Syndrome: A Contemporary Review

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating condition affecting approximately 3% of the female population. IC/BPS is defined as an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than six weeks duration, in the absence of infection or other identifiable cause. This condition is known to have a profound negative impact on quality of life. There are few well-studied treatment options and no cure for this condition, which is therefore challenging to treat. The purpose of this narrative review is to summarise the contemporary literature, including the Canadian Urological Association (CUA) and American Urological Association (AUA) guidelines, on various treatment options that exist for IC/BPS, including conservative therapies, oral therapies, intravesical therapies, and more invasive surgical options. Most importantly, this review highlights the need for an individualised, multimodal approach to the treatment of IC/BPS.

Comparative effectiveness and safety of intravesical instillation treatment of interstitial cystitis/bladder pain syndrome: a systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION AND HYPOTHESIS

A large variety of agents are available for intravesical instillation treatment of interstitial cystitis/bladder pain syndrome (IC/BPS). The purpose of the study was to compare the efficacy and safety of those agents.

METHODS

PubMed, the Cochrane Library, and Embase were searched from database inception to February 2020 for randomized controlled trials. The language of publication was limited in English. Population, intervention, comparison, outcome, and study design was used to assess the eligible studies for inclusion and the Cochrane Collaboration's risk of bias tool was used to assess the methodological quality of the studies included. The primary outcome was O'Leary-Sant Interstitial Cystitis Problem Index (ICPI) and O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) improvement.

RESULTS

Eleven randomized controlled trials covering 8 agents with 902 patients were enrolled. According to the results of the ICPI and ICSI, 0.1 μM resiniferatoxin was more effective than other therapies. Combination therapy of hyaluronic acid and chondroitin sulphate ranked second in ICSI, third in ICPI, and first in the visual analog scale (VAS). Among regimens included for complication comparison, chondroitin sulphate was safer than other agents, with a probability of 78.5%.

CONCLUSIONS

Resiniferatoxin (0.1 μM) is more effective at ICPI and ICSI improvement than other agents. More well-designed randomized controlled trials with a large sample size directly comparing the efficacy and safety of those agents are in need in the future to confirm our findings.

Interventions for treating people with symptoms of bladder pain syndrome: a network meta-analysis

BACKGROUND

Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide-ranging treatment options, used alone or in combination, with limited evidence. A network meta-analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS.

OBJECTIVES

To conduct a network meta-analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS).

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible.

DATA COLLECTION AND ANALYSIS

We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random-effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta-analysis of head-to-head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories.

MAIN RESULTS

We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low-certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD -1.27, 95% CrI -3.25 to 0.71; low-certainty evidence), daytime frequency (MD -2.41, 95% CrI -6.85 to 2.05; very low-certainty evidence) or nocturia (MD 0.01, 95% CrI -2.53 to 2.50; very low-certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low-certainty evidence) or reduced pain (MD 0.42, 95% CrI -1.04 to 1.91; low-certainty evidence), frequency (MD -0.37, 95% CrI -5.00 to 3.44; very low-certainty evidence) or nocturia (MD -1.20, 95% CrI -3.62 to 1.28; very low-certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD -0.33, 95% CrI -1.71 to 1.03), frequency (MD -0.91, 95% CrI -3.24, 1.29) or nocturia (MD -0.04, 95% CrI -1.35 to 1.27). The certainty of this evidence was always very low.

AUTHORS' CONCLUSIONS

We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base.

Onabotulinumtoxin a injection with or without hydrodistension for treatment of bladder pain syndrome

INTRODUCTION

Onabotulinumtoxin A (BoNT-A) injection has been used for bladder pain syndrome (BPS) treatment with good results. Our aim was to assess the efficacy and safety of BoNT-A injection with or without hydrodistension (HD).

METHODS

Retrospective analysis of patients treated with BoNT-A injection with or without HD because of BPS between 2008 and 2014 in our department. One hundred U of Botox® was injected in the trigone and 100 U in the bladder wall. Follow-up included a VAS of pain (0-10), a patient satisfaction scale (0-10) and a treatment benefit scale (1-2: response to treatment; 3-4: non-response to treatment). Complications were classified according to the Clavien-Dindo (CD) classification. BoNT-A retreatment was offered at the patient's request. Reasons for non-retreatment request were collected. Postoperative outcomes were compared between BoNT-A and BoNT-A + HD.

RESULTS

Forty-one patients were included (39 females, 2 males), median age: 73 years (69-78.5). Reduction in VAS, postoperative VAS = 0, satisfaction with surgery and responders to treatment were significantly higher after BoNT-A + HD (n = 26) than after BoNT-A (n = 15). Eleven (26.8%) complications (CD ≤ 2) were detected, with no differences between treatment groups. Mean follow-up was 153 (± 83) months. Twelve (46.2%) patients in the BoNT-A + HD group and seven (46.7%) patients in the BoNT-A group requested retreatment. Lack of severe pain was a common reason for treatment discontinuation.

CONCLUSION

BoNT-A injection could represent a safe and effective BPS treatment. BoNT-A + HD seems to be better than BoNT-A alone for pain relief, with no significant additional morbidity.

Therapeutic Effect of Botulinum Toxin A on Sensory Bladder Disorders-From Bench to Bedside

Bladder oversensitivity arises from several different conditions involving the bladder, bladder outlet, systemic or central nervous system diseases. Increase of the bladder sensation results from activation of the sensory receptors in the urothelial cells or suburothelial tissues. Medical treatment targeting the overactive bladder (OAB) or interstitial cystitis (IC) might relieve oversensitive bladder symptoms (frequency, urgency and pain) in a portion of patients, but a certain percentage of patients still need active management. Botulinum toxin A (BoNT-A) has been demonstrated to have anti-inflammatory and antinociceptive effects in bladder sensory disorders and has been shown effective in the reduction of bladder oversensitivity and the increase of functional bladder capacity. For patients with OAB, urgency and urinary incontinence improved, while in patients with IC, bladder pain could be relieved in association with reduction of bladder oversensitivity after BoNT-A intravesical injection. Histological evidence has confirmed the therapeutic mechanism and clinical efficacy of intravesical BoNT-A injection on patients with OAB or IC. Bladder oversensitivity can also be relieved with the instillation of liposome encapsulated BoNT-A or low energy show waves (LESWs), which enable the BoNT-A molecule to penetrate into the urothelium and suburothelial space without affecting the detrusor contractility. Liposome encapsulated BoNT-A or combined LESWs and BoNT-A instillation might be future treatment alternatives for bladder oversensitivity in sensory bladder disorders.

An update on treatment options for interstitial cystitis

Interstitial cystitis or bladder pain syndrome (IC/BPS) is a chronic pelvic pain syndrome related to the urinary bladder. The ideal treatment should match as much as possible with the pathophysiologic causes of the IC/BPS, but the scarcely available evidence limits this approach, with the majority of available treatments that are primarily targeted to the control of symptoms. The treatment strategies have traditionally focused on the bladder, which is considered the primary end-organ and source of pain. Nevertheless, the growing body of evidence suggests a multifaceted nature of the disease with systemic components. In general, guidelines recommend the personalized and progressive approach, that starts from the more conservative options and then advances toward more invasive and combined treatments. The behavioral changes represent the first and most conservative steps. They can be combined with oral medications or progressively with intravesical instillation of drugs, up to more invasive techniques in a combined way. Despite the multiple available options, the optimal treatment is not easy to be found. Only further investigation on the etiopathogenetic mechanisms, taking into account the differences among subgroups, and the interaction between central and peripherical factors may allow providing a real improvement in the treatment and management of these patients.

Therapeutic Efficacy of onabotulinumtoxinA Delivered Using Various Approaches in Sensory Bladder Disorder

Cystoscopic onabotulinumtoxinA (onaBoNTA) intradetrusor injection is an efficient and durable modality for treating sensory bladder disorders. However, the inconvenience of using the cystoscopic technique and anesthesia, and the adverse effects of direct needle injection (e.g., haematuria, pain, and infections) have motivated researchers and clinicians to develop diverse injection-free procedures to improve accessibility and prevent adverse effects. However, determining suitable approaches to transfer onaBoNTA, a large molecular and hydrophilic protein, through the impermeable urothelium to reach therapeutic efficacy remains an unmet medical need. Researchers have provided potential solutions in three categories: To disrupt the barrier of the urothelium (e.g., protamine sulfate), to increase the permeability of the urothelium (e.g., electromotive drug delivery and low-energy shock wave), and to create a carrier for transportation (e.g., liposomes, thermosensitive hydrogel, and hyaluronan-phosphatidylethanolamine). Thus far, most of these novel administration techniques have not been well established in their long-term efficacy; therefore, additional clinical trials are warranted to validate the therapeutic efficacy and durability of these techniques. Finally, researchers may make progress with new combinations or biomaterials to change clinical practices in the future.

Clinical application of intravesical botulinum toxin type A for overactive bladder and interstitial cystitis

After decades of clinical and basic science research, the clinical application of botulinum toxin A (Botox) in urology has been extended to neurogenic detrusor overactivity (NDO), idiopathic detrusor overactivity, refractory overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), lower urinary tract symptoms, benign prostatic hyperplasia, and neurogenic or non-neurogenic lower urinary tract dysfunction in children. Botox selectively disrupts and modulates neurotransmission, suppresses detrusor overactivity, and modulates sensory function, inflammation, and glandular function. In addition to motor effects, Botox has been found to have sensory inhibitory effects and anti-inflammatory effects; therefore, it has been used to treat IC/BPS and OAB. Currently, Botox has been approved for the treatment of NDO and OAB. Recent clinical trials on Botox for the treatment of IC/BPS have reported promising therapeutic effects, including reduced bladder pain. Additionally, the therapeutic duration was found to be longer with repeated Botox injections than with a single injection. However, the use of Botox for IC/BPS has not been approved. This paper reviews the recent advances in intravesical Botox treatment for OAB and IC/BPS.

Botulinum Neurotoxin A Intravesical Injections in Interstitial Cystitis/Bladder Painful Syndrome: A Systematic Review with Meta-Analysis

Botulinum neurotoxin A (BoNT/A) appears to be one of the best intravesical treatments for interstitial cystitis/bladder painful syndrome (IC/BPS). We aimed to point out what the evidence is regarding the effects of BoNT/A intravesically injected in patients with IC/BPS. We performed a systematic review of all randomized controlled trials (RCTs) assessing BoNT/A for IC/BPS by using Medline, EMBASE, CINAHL, CENTRAL and MetaRegister of Controlled Trials. Standardized mean differences (SMD) were extracted from the available trials and combined in a meta-analysis applying a random effect model, including heterogeneity of effects. Twelve trials were identified. Significant benefits from BoNT/A injections were detected in: Interstitial Cystitis Symptom Index and Problem Index (ICSI, ICPI) (small to medium effect size: SMD = -0.302; p = 0.007 and -0.430, p = 0.004, respectively); Visual Analog Scale (VAS) for pain and day-time urinary frequency (medium effect size: SMD = -0.576, p < 0.0001 and -0.546, p = 0.013, respectively). A great effect size was detected for post-void residual volume (PVR, SMD = 0.728; p =0.002) although no clinically relevant in most cases. Great heterogeneity was observed in treatments' methodologies and symptoms assessment. Overall, BoNT/A intravesical injections significantly improve some of the most relevant symptoms affecting IC/BPS patients.

Temperature-responsive silk-elastinlike protein polymer enhancement of intravesical drug delivery of a therapeutic glycosaminoglycan for treatment of interstitial cystitis/painful bladder syndrome

Interstitial cystitis (IC), also known as painful bladder syndrome, is a debilitating chronic condition with many patients failing to respond to current treatment options. Rapid clearance, mucosal coating, and tight epithelium create strong natural barriers that reduce the effectiveness of many pharmacological interventions in the bladder. Intravesical drug delivery (IDD) is the administration of therapeutic compounds or devices to the urinary bladder via a urethral catheter. Previous work in improving IDD for IC has focused on the sustained delivery of analgesics within the bladder and other small molecule drugs which do not address underlying inflammation and bladder damage. Therapeutic glycosaminoglycans (GAG) function by restoring the mucosal barrier within the bladder, promoting healing responses, and preventing irritating solutes from reaching the bladder wall. There is an unmet medical need for a therapy that provides both acute relief of symptoms while alleviating underlying physiological sources of inflammation and promoting healing within the urothelium. Semi-synthetic glycosaminoglycan ethers (SAGE) are an emerging class of therapeutic GAG with intrinsic anti-inflammatory and analgesic properties. To reduce SAGE clearance and enhance its accumulation in the bladder, we developed a silk-elastinlike protein polymer (SELP) based system to enhance SAGE IDD. We evaluated in vitro release kinetics, rheological properties, impact on bladder function, pain response, and bladder inflammation and compared their effectiveness to other temperature-responsive polymers including Poloxamer 407 and poly(lactic-co-glycolic acid)-poly(ethylene glycol). SAGE delivered via SELP-enhanced intravesical delivery substantially improved SAGE accumulation in the urothelium, provided a sustained analgesic effect 24 h after administration, and reduced inflammation.

Efficacy and Safety of Noninvasive Intravesical Instillation of Onabotulinum Toxin-A for Overactive Bladder and Interstitial Cystitis/Bladder Pain Syndrome: Systematic Review and Meta-analysis

OBJECTIVE

To investigate the efficacy and safety of noninvasive intravesical instillation of onabotulinum toxin-A (OBTX-A) through systematic review and meta-analysis. Recently, several studies of noninvasive intravesical instillation of OBTX-A have been published. However, its efficacy is not well validated yet compared to well-known efficacy of minimally invasive intravesical injection of OBTX-A.

METHOD

Systematic review and meta-analysis were performed to evaluate the efficacy of noninvasive intravesical instillation of OBTX-A in patients with overactive bladder and interstitial cystitis/bladder pain syndrome by measuring outcomes such as urgency episode per 72 hours, frequency per 72 hours, urgency urinary incontinence, voided volume (VV), postvoided residual volume, maximum flow rate, and patient perception of bladder condition.

RESULT

Six trials in 4 studies that compared instillation of OBTX-A and placebo involving 248 patients (121 experimental and 127 controls) were included for final data extraction. Instillation of OBTX-A significantly increased VV, with a mean difference of 38.48 (95% confidence interval: 76.05, 0.92) compared to the placebo group. However, other outcomes showed statistically insignificant changes. Major adverse events were not reported in the group receiving intravesical instillation of OBTX-A.

CONCLUSION

Intravesical instillation of OBTX-A showed limited efficacy with improvement of VV for treatment of overactive bladder or interstitial cystitis/bladder pain syndrome. More studies are needed to overcome the efficacy of current noninvasive bladder instillation of OBTX-A regarding effective drug transport.

Modifications to Botulinum toxin A delivery in the management of detrusor overactivity recalcitrant to initial injections: a review

PURPOSE

One quarter of patients will not respond to initial intra-detrusor Botulinum toxin A (BTX) injections for detrusor overactivity. Alternative treatment options include long-term catheterization, sacral neuromodulation, urinary diversion or bladder augmentation. Some of these procedures are invasive. This review explores modifications to BTX delivery that can improve outcome.

METHODS

A search of Medline, Embase and Cochrane Library to December 2017 was performed according to Preferred Reporting Items for Systematic Review and Metaanalysis (PRISMA) guidelines. Search criteria included, dose escalation, increasing injection site number, trigone injection, switching preparation and alternative methods of BTX delivery.

RESULTS

Several modifications to BTX delivery may improve response. There is moderate evidence that increasing the dose from 100 U to 200 U results in statistically better symptom control. Trigone-including injections were associated with significantly improved patient-reported symptom scores, as well as superior results in urodynamic outcomes without risking urinary retention and vesico-ureteric reflux. Switching from onabotulinum (OTA) or abobotulinum (ATA) or vice versa may also improve response in over 50% of patients as shown in limited studies. Increasing the number of injection sites is not beneficial. Indeed, decreasing the number of injections to as low as three sites does not result in decreased clinical outcomes. Injection-free delivery is associated with lower efficacy compared to conventional intradetrusor injections.

CONCLUSION

Before contemplating alternative treatments, practitioners can try to improve on BTX delivery. Firstly, the dose can be increased to 200 U; the trigone included in the injection sites and switching brands may also be helpful.

Current Therapeutic Strategies in Clinical Urology

The field of urology encompasses all benign and malignant disorders of the urinary tract and the male genital tract. Urological disorders convey a huge economic and patient quality-of-life burden. Hospital acquired urinary tract infections, in particular, are under scrutiny as a measure of hospital quality. Given the prevalence of these pathologies, there is much progress still to be made in available therapeutic options in order to minimize side effects and provide effective care. Current drug delivery mechanisms in urological malignancy and the benign urological conditions of overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and urinary tract infection (UTI) will be reviewed herein. Both systemic and local therapies will be discussed including sustained release formulations, nanocarriers, hydrogels and other reservoir systems, as well as gene and immunotherapy. The primary focus of this review is on agents which have passed the preclinical stages of development.

Novel Applications of OnabotulinumtoxinA in Lower Urinary Tract Dysfunction

OnabotulinumtoxinA (BoNT-A) was first used to treat neurogenic lower urinary tract dysfunction (LUTD) 30 years ago. Recently, application of BoNT-A in LUTD have become more common since the approval of intravesical BoNT-A injection for patients with both overactive bladders (OAB) and neurogenic detrusor overactivity (NDO) by regulatory agencies in many countries. Although unlicensed, BoNT-A has been recommended to treat patients with interstitial cystitis/bladder pain syndrome (IC/BPS) under different guidelines. BoNT-A delivery with liposome-encapsulation and gelation hydrogel intravesical instillation provided a potentially less invasive and more convenient form of application for patients with OAB or IC/BPS. BoNT-A injections into the urethral sphincter for spinal cord injury patients with detrusor-sphincter dyssynergia have been used for a long time. New evidence revealed that it could also be applied to patients with non-neurogenic dysfunctional voiding. Previous studies and meta-analyses suggest that BoNT-A injections for patients with benign prostate hyperplasia do not have a better therapeutic effect than placebo. However, new randomized and placebo-controlled trials revealed intraprostatic BoNT-A injection is superior to placebo in specific patients. A recent trial also showed intraprostatic BoNT-A injection could significantly reduce pain in patients with chronic prostatitis. Both careful selection of patients and prudent use of urodynamic evaluation results to confirm diagnoses are essential for successful outcomes of BoNT-A treatment for LUTD.

Potential Orphan Drug Therapy of Intravesical Liposomal Onabotulinumtoxin-A for Ketamine-Induced Cystitis by Mucosal Protection and Anti-inflammation in a Rat Model

Ketamine abusers may develop ulcerative cystitis and severe lower urinary tract symptoms, which is a medical dilemma. Recently, researchers have found the endemic of ketamine-induced cystitis worldwide. The intravesical administration of liposome-encapsulated onabotulinumtoxinA (Lipotoxin) might facilitate the healing of the damaged urothelium from liposomes, and reduce the urinary symptoms by onabotulinumtoxinA-induced chemo-denervation. Using female Sprague-Dawley rats, we investigated the effects of Lipotoxin on ketamine-induced cystitis. Functional magnetic resonance imaging, metabolic cage study, and cystometry were conducted. Paraffin-embedded sections were stained. The bladder mucosa and muscle proteins were assessed through Western blotting. We observed that repeated intravesical Lipotoxin instillation could improve suburothelial hemorrhage, recover the urothelial tight junction and adhesion proteins (zonula occludens-1 and E-cadherin), ensure less substance P in the urothelium, inhibit the overexpression of inflammatory mediators (IL-6, TNF-α, nuclear NF-κB, and COX-2) in the detrusor, suppress the upregulation of the mucosal TRPV1 and detrusor M₂-mAChR, and ameliorate bladder overactivity in the ketamine-treated rats. These data reveal the mechanisms underlying the action of Lipotoxin in ketamine-induced cystitis of rats, which provide a basis of Lipotoxin for further treating ketamine-induced cystitis in humans.

The efficacy of botulinum toxin A and sacral neuromodulation in the management of interstitial cystitis (IC)/bladder pain syndrome (BPS), what do we know? ICI-RS 2017 think thank, Bristol

AIMS

This manuscript aims to address the evidence availale in the literature on the efficacy of Botulinum Toxin A (BoNT-A) and sacral neuromodulation (SNM) in patients suffering from Interstitial Cystitis (IC)/BPS and propose further research to identify mechanisms of action and establish the clinical efficacy of either therapy.

METHODS

At the International Consultation on Incontinence-Research Society (ICI-RS) in 2017, a panel of Functional Urologists and Urogynaecologists participated in a Think Tank (TT) discussing the management of IC/BPS by BoNT-A and SNM, using available data from both PubMed and Medicine literature searches.

RESULTS

The role of BoNT-A and SNM in the treatment of IC/BPS are discussed and mechanisms of actions are proposed. Despite the available randomized trial data on the effect of intravesical BoNT-A treatment on symptoms of IC/BPS, a consistent conclusion of a positive effect cannot be drawn at the moment, as the published studies are small and heterogeneous in design. There is substantive evidence for the positive effects of SNM on symptoms of IC/BPS patients however, during patient selection, it is important to distinguish the degree and the location of pain in order to tailor the best therapy to the right patients.

CONCLUSIONS

Both intravesical BoNT-A treatment and SNM have been shown to have positive effects in patients with IC/BPS. However, firm conclusions cannot yet be drawn. Patient-reported outcomes and quality of life should be assessed in addition to urinary and pain symptoms. Since current treatments mainly focus on symptomatic relief, future research should also focus on clarifying the pathogenic mechanisms involved in IC/BPS.