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Patients with overactive bladder syndrome suffer with urinary urgency (sudden onset of a desire to pass urine which cannot be delayed) frequency (passage of urine frequently), and may have urinary incontinence (involuntary loss of urine/leakage) or nocturia (passing urine at night frequently after having gone to sleep). If this becomes problematic it is initially treated with oral medication (anticholinergics). Unfortunately they are not always effective and often not tolerated due to their side effects. In this situation patients may endure a poor quality of life. In the past patients have been given the option of major surgery as an alternative (augmentation cystoplasty) and until recently there has been little else to offer them. Botulinum toxin is emerging as a useful alternative in this situation. Research carried out in patients with overactive bladders where the cause is neurological (ie due to damage to nerves in the spine or brain) or unknown has produced encouraging results.
You will be asked to complete a voiding diary (diary of your voiding habit over a 3 day period) and quality of life questionnaires (this will take about ten minutes to fill in) to assess severity of symptoms. In addition you will undertake routine urodynamic studies (bladder pressure studies) to assess bladder overactivity. The urodynamic studies will take approximately 45 minutes to 1 hour and will be on an outpatient basis. Some of you may have already had these tests in the past. You will be invited to our endoscopy suite at the hospital. After a dose of antibiotics and a urine test you will undergo flexible cystoscopy (camera telescope test to look into the bladder) under local anaesthetic. The urine test is looking for infection and if you are a female of child bearing age, a pregnancy test will be carried out. Antibiotics are given to minimise the chance of infection with this procedure. The cystoscopy involves passing a thin flexible fibroptic telescope into your urethra (water-pipe) and then subsequently into your bladder. We will then inject the bladder muscle in 10 to 20 different sites botulinum toxin A. You will be awake throughout the procedure and should not experience any severe pain, although certain injections may feel uncomfortable. The procedure will last 20 minutes and you will be able to go home on the same day. The effects of Botulinum toxin-A injections, tend to last for between 4-12 months but on average 8 months. If you decide to have this treatment you will be able to lead your life in the normal way. There are no lifestyle or dietary restrictions. You will still be able to take any medication you normally take every day.
The medicinal product used is Botulinum toxin A (BOTOX, ALLERGAN, Ltd). The dosage used will be 100 to 200 units initially and this will be given into the muscle of the bladder by injection through a flexible cystoscope. The dose of the toxin may be tailored to your individual need if attending for repeat injections. In these cases doses between 100-300 units will be administered.
Other treatments involve solutions put into the bladder via a catheter of medication similar to those you take orally or compounds extracted from chilli peppers. None of the above have found widespread acceptance in this field. Other options include sacral neuromodulation (stimulation of nerves at the base of your spine) and major surgery (increasing bladder capacity by putting a patch of bowel onto the bladder), which you may or may not be suitable for.
Patients may experience some discomfort during their injections in the bladder and perhaps a little blood in their urine temporarily. Flexible cystoscopy carries a very low risk of urinary tract infection, but we will minimise this risk with the use of antibiotics prior to the procedure. Side effects of botulinum toxin are very rare, but in other studies patients have experienced rash, drowsiness, or transient flu like symptoms in less than 1% of cases. As the toxin works by paralysing the bladder muscle, patients may experience difficulty emptying their bladder following botulinum toxin injections. This will be assessed at 4, 12 and 24 weeks or at anytime the patient experiences difficulty voiding or lower abdominal discomfort with a simple bladder scan in the outpatient clinic. This occurs in approximately 10-20% of cases. In such cases the bladder will need emptying by the use of a disposable catheter, inserted into the bladder and disposed following drainage of urine, usually 2-3 times per day. This procedure is known as clean intermittent self-catheterisation. This will need to be performed on a temporary basis until the effects of the toxin start to wear off. In most cases it will be necessary between 1-3 months. 100 to 200 units is well below the dose considered dangerous (1000) and since the total dose is spread out over 10-15 injections, there is no possibility that even a 'significant' dose could enter the systemic circulation (bloodstream). However, some studies have reported temporary muscle weakness in arms and legs in extremely few cases. If during your flexible cystoscopy we find an unexpected abnormality in your bladder and biopsies need to be taken to make a diagnosis, these will take priority over treatment. We will then inform you of the findings and carry out the appropriate care.
Promising results have been obtained with Botulinum toxin-A in recent studies. It is hoped that quality of life will improve and there will be reduction in incontinence episodes, urinary frequency and urinary urgency per 24 hour period. We hope that the treatment will help you. However, this cannot be guaranteed.
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