NEUROUROLOGY & FEMALE UROLOGY

Botulinum A toxin intravesical injection in patients with painful bladder syndrome: 1-year followup
Giannantoni A, Porena M, Costantini E, Zucchi A, Mearini L, Mearini E
Department of Urology and Andrology, University of Perugia, Policlinico Monteluce, Perugia, Italy
J Urol. 2008; 179: 1031-4

• Purpose: We evaluated the 1-year efficacy and tolerability of botulinum A toxin intravesically injected in patients with painful bladder symptoms associated with increased urinary frequency, refractory to conventional treatments.
• Materials and Methods: Three men and 12 women were prospectively included in the study. Under short general anesthesia the patients were given injections of 200 U commercially available botulinum A toxin diluted in 20 ml 0.9% NaCl. Injections were performed submucosally in the bladder trigone and lateral walls under cystoscopic guidance. A voiding chart and the visual analog scale for pain were used, and urodynamics were performed before treatment, and 1, 3, 5 and 12 months later.
• Results: Overall 13 patients (86.6%) reported subjective improvement at the 1 and 3-month followups. The mean visual analog scale score, and daytime and nighttime urinary frequency were significantly decreased (p < 0.05, < 0.01 and < 0.05, respectively). At the 5-month followup the beneficial effects persisted in 26.6% of cases but increased daytime and nighttime urinary frequency, and an increased visual analog scale score were observed compared to baseline. At 12 months after treatment pain recurred in all patients. Nine patients complained of dysuria 1 month after treatment. Dysuria persisted in 4 cases at the 3-month follow-up and in 2 at the 5-month follow-up.
• Conclusions: Intravesically injected botulinum toxin A is effective for short-term management of refractory painful bladder syndrome. The beneficial effects decreased progressively within a few months after treatment. Thus, repeat injections of the neurotoxin are required for efficacious treatment in patients with the disease.
  
  
• Editorial Comment
  The authors review their experience with Botulinum A toxin intravesical injection in patients plagued with refractory bladder pain combined with symptoms of overactive bladder (frequency, urgency, nocturia). The study noted a definitely subjective improvement at one to three months post therapy but by one year post injection, the patients had returned to their baseline. The therapy was basically well tolerated but there was a substantial number of patients (9/13) that had dysuria in addition to 20 percent of the patients needing a period of self intermittent catheterization post procedure.
  The report helps highlight the exciting use of Botulinum A toxin in urology. Though no medication is a panacea, it appears that the use of this intravesical agent may assist the urologist in treating a segment of our patient population that is among the most challenging. This report raises the question that patients with a non neurogenic type of voiding dysfunction may have a higher rate of urinary retention secondary to the Botulinum A toxin. Given this finding, it will be worthwhile for the treating physician to alert the patient that self intermittent catheterization is a distinct potential reality after this therapy. Unfortunately, even with a good response, patients will require repeat therapy to continue the beneficial effect; as noted in this paper the patients did request repeat a treatment because of the symptomatic relief they enjoyed. Given that there is a high rate of placebo effect in this patient population, enthusiasm should be tempered until a placebo controlled randomized study may be completed.

Steven P. Petrou, M.D
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu