Botulinum-A Toxin as a Treatment of Detruosor-Sphincter Dyssynergia: A Prospective Study in 24 Spinal Cord Injury Patients

The potential and promise of using botulinum toxin in the prostate gland

Botulinum neurotoxin (BoNT) has been called the 'most poisonous poison' and a potential bioterrorist weapon. However, it is possible to use the elegant and specific activity of this toxin to treat various medical conditions. Recently, the application of BoNT was extended to prostate disorders, and we review published reports on the mechanisms of action and clinical efficacy of BoNT in the prostate. The information was gathered from Medline, abstracts from recent urological meetings, and from personal experience. BoNT has shown promising preliminary results for male lower urinary tract symptoms, and translational research suggests a novel mechanism of action of BoNT in the prostate. Importantly, the application of BoNT in the prostate is not approved by the regulatory agencies and caution should be used until larger randomized clinical studies are completed.

Simplified Bladder Botulinum-Toxin Delivery Technique Using Flexible Cystoscope and 10 Sites of Injection

Recently, the use of botulinum toxin A has been extended to patients with non-neurogenic urologic disorders such as refractory idiopathic overactive bladder. We describe a modification of our original injection technique that allows one to deliver botulinum toxin into the bladder quickly and efficiently in an office setting with reliable results and no local or systemic side effects.

Botulinum A Toxin Treatment of Urethral Sphincter Pseudodyssynergia in Patients with Cerebrovascular Accidents or Intracranial Lesions

PURPOSE

Detrusor overactivity and urethral sphincter pseudodyssynergia may develop during recovery from cerebrovascular accidents or intracranial lesions, resulting in difficulty in urination, a large amount of residual urine, and recurrent urinary tract infection. This study evaluated the effectiveness of urethral injection of botulinum A toxin in treating these patients.

METHODS

Twenty-one patients with chronic cerebrovascular accidents or intracranial lesions and difficult urination were enrolled. Patients participating in the study elected to receive either 100 units of botulinum A toxin (n = 11) or served as medically treated controls (n = 10). The urodynamic parameters and voiding efficiency after treatment were compared between the 2 groups.

RESULTS

An excellent result was obtained in 6 patients and an improved result in 4 patients, resulting in an overall success rate of 91% in the study group. Four patients with frank urinary retention before treatment resumed spontaneous voiding. The maximal effects of botulinum A toxin appeared about 2 weeks after treatment. The voiding pressure decreased (57.8 +/- 35.2 vs. 33.8 +/- 16.9 cm H2O, p = 0.005) and the maximal flow rate increased (7.2 +/- 5.9 vs. 10.3 +/- 5.2 ml/s, p = 0.005) significantly. In the control group, 4 patients (40%) had spontaneous voiding 6 months after medical treatment, whereas 6 patients remained unchanged requiring an indwelling Foley catheter (n = 2) or clean intermittent catheterization (n = 4). The symptom score and the quality of life index showed significantly greater improvement in the study group than in the control group.

CONCLUSION

This study demonstrates that urethral injection of botulinum A toxin is effective and without adverse effects in the treatment of patients with urethral sphincter pseudodyssynergia after cerebrovascular accidents or the development of intracranial lesions.

Pharmacology of the lower urinary tract

The functions of the lower urinary tract, to store and periodically release urine, are dependent on the activity of smooth and striated muscles in the urinary bladder, urethra, and external urethral sphincter. This activity is in turn controlled by neural circuits in the brain, spinal cord, and peripheral ganglia. Various neurotransmitters, including acetylcholine, norepinephrine, dopamine, serotonin, excitatory and inhibitory amino acids, adenosine triphosphate, nitric oxide, and neuropeptides, have been implicated in the neural regulation of the lower urinary tract. Injuries or diseases of the nervous system, as well as drugs and disorders of the peripheral organs, can produce voiding dysfunctions such as urinary frequency, urgency, and incontinence or inefficient voiding and urinary retention. This chapter will review recent advances in our understanding of the pathophysiology of voiding disorders and the targets for drug therapy.

Long-term analysis of suprapubic cystostomy drainage in patients with neurogenic bladder

OBJECTIVE

We assessed the roles of suprapubic cystostomy in patients with neurogenic bladder and analyzed the complications and their courses.

PATIENTS AND METHODS

We reviewed 118 patients with neurogenic bladder managed with suprapubic cystostomy. The original diseases were spinal cord injury in 90, degenerative disease of the central nervous system in 15, spina bifida in 6, cerebral palsy in 3, pontine bleeding in 1, Parkinson's disease in 1, brain tumor in 1, and dysgenesis of the external sphincter in 1. Fifty-six (62.2%) of spinal cord-injured patients demonstrated cervical damage. Renal function, urinary pH and white blood cell values were measured and evaluated after insertion. The stone-free rate after insertion was estimated by the Kaplan-Meier method.

RESULTS

Indications for cystostomy were failure of clean intermittent catheterization in 62 (52.5%) and Credé's maneuver in 2, severe urethral damage in 30 (25.4%), replacement of urethral catheter in 3, worsening of the original disease in 15 (12.7%), deterioration of the general condition in 2, mental retardation in 2, and traumatic vesical rupture in 1. Frequent complications were formation of the bladder calculi in 30 (25%) and urinary leakage through the urethra in 11 (10%). No fatal complications occurred. The stone-free rates 5 and 10 years after insertion were 77 and 64%, respectively. The urinary pH of the stone-forming group was significantly higher than that of the stone-free group. The high urinary pH group (>7.24) had a higher risk of stone formation.

CONCLUSIONS

Although continuous cystostomy drainage is not considered to be ideal management for bladder emptying, some patients with neurogenic bladder may benefit from this procedure.