Introduction
Botulinum toxin (Botox®) is an agent that works on nerves to prevent them releasing neurotransmitters that have different effects in different parts of the body. When injected into the bladder, Botox stops nerves from releasing the neurotransmitter that is responsible for make the bladder contract, and make a patient feel like they need to go to the toilet or leak urine.
Indications
Intravesical Botox is used in the following circumstances:
- To treat overactive bladder (OAB) symptoms such as urinary urgency, urge incontinence, increased urinary frequency in those who have tried another type of medication (anticholinergics) and they don’t not work well enough or cannot be tolerated.
- To treat urinary incontinence in those with a neurological disease that causes detrusor overactivity (as proved on a urodynamic study) who still have leakage or cannot tolerate the side effects after trying an anticholinergic medication.
Preoperative Instructions
A urine test will be performed to ensure the patient does not have an active urinary tract infection, as this will require treatment prior to the procedure. Certain medications that promote bleeding such as warfarin, clopidogrel, rivaroxaban and apixaban will need to be stopped for certain period prior to the procedure to reduce the risk of significant bleeding. This procedure can still be performed if the patient is taking aspirin.
Procedure
The procedure is usually performed with the patient awake under a local anaesthetic, however it can be performed with intravenous sedation or under general anaesthetic with the patient asleep. A cystoscopy is initially performed to inspect the urethra and the bladder. Following this, Botox is then injected around the bladder (the number of injections depend on the dose used) under vision. The bladder is then emptied with a catheter and the patient is able to be discharged home.
Postoperative Instructions
The patient is typically discharged home the same day. Urinary urgency, frequency, nocturia and incontinence may all be worse in the first few days following Botox injections as the Botox takes approximately 3 to 14 days for its effects to be noticed. The patient is review at 2 weeks-time with a renal tract ultrasound to assess their symptoms and ensure they are able to empty their bladder satisfactorily.
Risks
The main side effects of intravesical Botox are:
- Urinary tract infection.
- Urinary retention (not being able to empty the bladder completely).
- Haematuria (blood in the urine).
Treatment Alternatives
Intravesical Botox is 3rd line therapy for the management of an overactive bladder. The alternative third line therapy for those who have failed conservative measures and medications is Sacral Neuromodulation.