Endoscopic Botulinum Toxin Injection for Refractory Enuresis Based on Urodynamic Assessment

Abstract

This study aimed to determine the urodynamic characteristics of refractory enuresis and explore whether they can be managed through differential endoscopic injection with botulinum toxin. Methods: A total of 27 patients with nonmonosymptomatic enuresis who showed no response after conservative treatment for more than 12 months were included herein. Patients then underwent videourodynamic study and received a differential endoscopic injection of botulinum toxin within the same day. Reduced capacity, detrusor overactivity, and bladder neck widening were the three major abnormal findings assessed during the filling phase, while sphincter hyperactivity was the only abnormality assessed during the emptying phase. Intravesical or intrasphincteric injection of botulinum toxin was attempted according to videourodynamic study findings. Follow-up was conducted 1, 3, 6, and 12 months after treatment. Results: The median age was 10 (7-31) years. Although 19 and 8 patients had preoperative diagnosis of overactive bladder or dysfunctional voiding, respectively, urodynamic diagnosis was different in more than half of them. Those showing detrusor overactivity benefited from intravesical botulinum toxin injection, whereas those with only sphincter hyperactivity benefited from both intravesical and intrasphincteric injections. Treatment resistance to botulinum toxin seemed to have been attributed to bladder neck widening. Time had no apparent effect on efficacy, which remained 6 months after the injection. More than 80% of the patients retained the benefits of injection after 1 year. Conclusions: Videourodynamic study was useful in identifying reasons of refractory nonmonosymptomatic enuresis and helpful in determining appropriate sites of botulinum toxin A c c e p t e d A r t i c l e 2 injection.

Urodynamic findings in children with primary refractory nocturnal enuresis: 10 years' experience of a tertiary center

“…According to a recent study, unlike MNE, lower urinary tract dysfunction and NMNE were correlated with constipation 23 . The association between MNE and constipation previously postulated in the literature may have resulted from the lack of distinction between MNE and NMNE, since the latter is frequently associated with constipation.…”

“…In Tolunay et al's study only four out of 27 patients with NMNE had normal urodynamic results (7.4%), while 16 (59.3%) had overactive detrusors 18 . According to Jung et al, more than half of their NMNE patients who had preoperative diagnoses of overactive bladder (OAB) or dysfunctional voiding had different urodynamic diagnosis 23 . Considering that the treatment of NMNE involves treating both lower urinary tract symptoms (LUTS) and enuresis, it is important to note that LUTS involves heterogeneous urodynamic abnormalities.…”

Traditional and innovative interventions in the management of enuresis

“…In severely therapy-resistant enuresis, the endoscopic injection of botulinum toxin and sacral neurostimulation have been studied as alternative treatments, even if they are not recommended as first- and second-line treatments because of the lack of evidence and randomized clinical trials. A pilot study by Jung et al including 27 patients with NME, who showed no response after conservative treatment for more than 12 months, documented an improvement of detrusor overactivity after intravesical botulinum toxin injection up to one year later, while Hoebeke et al reported positive long-term results in 70% of children after a single injection [ 81 , 82 ]. There are limited data on the effectiveness of sacral nerve stimulation in children.…”

Bibliometric and visual analysis of nocturnal enuresis from 1982 to 2022

“…At present, there are two theories about bladder function derangements. One is bladder detrusor hyperactivity, embodying some children with enuresis who can be treated with oral anticholinergic drugs or intravesical injection of botulinum toxin (70) and a great overlap between nocturnal enuresis and urgent urinary incontinence (71,72). The other is reduced bladder functional capacity (BFC) (73, 74).…”