Botulinum toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients

Abstract

Purpose: Neurogenic detrusor overactivity (NDO) is common in patients who suffer from multiple sclerosis (MS). When the usual pharmacological treatment fails, botulinum toxin type A (BTX-A) injections can be proposed. The safety and efficacy of this treatment are already well known, but only a few studies focus on its use in patients with MS. Materials and Methods: Seventy-one patients with MS underwent their first BTX-A injection for refractory NDO. They had clinical and urodynamic cystometry assessment before and three months after injection. The patients were divided in three groups according to treatment efficacy: full success (total urinary continence, no overactive detrusor), improvement, or total failure (urge incontinence and overactive detrusor). Results: 77% of the patients had clinical improvement or full success of the treatment with a reduction of their urgency and incontinence. Significant urodynamic improvement after treatment was shown on different parameters: volume at first involuntary bladder contraction (p = 0.0000001), maximum cystometric capacity (p = 0.0035), maximum detrusor pressure (p = 0.0000001). 46% of the patients were in the "full success" group. 31% of the patients had a partial improvement. 23% of the patients had no efficacy of the treatment. Duration of MS was a predictive factor of treatment failure (p = 0.015). Conclusions: Despite that a full success was obtained in 46% of the cases, BTX-A injection therapy failed to treat refractory NDO in 23% of patients suffering from MS. Duration of the disease was a predictive factor for an inefficient treatment. The injection therapy should be considered as soon as oral anticholinergic drugs fail to reduce NDO. Multiple sclerosis (MS) is a common demyelinating disease of the central nervous system. The lesions occur in different time and localization in subcortical areas, brain stem and spinal cord. The disease has varied clinical presentations (1). Bladder and urethra dysfunction are very common. Detrusor overactivity is the most common urodynamic sign. It is observed in 44% (2) to 81% (3) of patients. Detrusor sphincter dyssynergia is associated with overactive detrusor in 93% of cases (2).Detrusor overactivity is often associated with overactive bladder, defined by urgency, possibly associated with urge incontinence, daytime frequency, and nocturia (4). These symptoms significantly alter the quality of life (5). Urological complications including hydronephrosis, vesicoureteral reflux, urosepsis, and urolithiasis (6) occur in 12% of the patients who suffer from neurogenic detrusor overactivity (NDO) and MS (7). The rate NeurourologyInternational Braz J Urol

Use of botulinum toxin in individuals with neurogenic detrusor overactivity: State of the art review

“…However, those with the 300 U dose had more adverse events (AEs) (see Adverse reactions/complications section). In summary, there have been a number of excellent review articles 34,41,49,50 and clinical studies, 17,18,37,38,42,43,45,46 confirming the effectiveness of BoNT in those with NDO. Results of a number of clinical studies using BoNT/A in adults with DO due to a neurogenic cause are shown in Table 2.…”

“…47 Therefore, these authors conclude that injection therapy should be considered as soon as anticholinergic medications fail to control NDO in those with MS rather than waiting until potentially irreversible histological and neurological damage has occurred. 45 Kuo reported on a prospective study involving the impact of BoNT on NDO not only in those with SCI but also in those with chronic cerebrovascular accident (CVA). Several concepts regarding the use of BoNT in those with a CVA were learned in this study.…”

Botulinum toxin injections for treating neurogenic detrusor overactivity

“…Rufin [43] 300 U 71 *Mean MCC *Complete continence was reported in 46% of the patients. Ginsberg [39] 200/300 U 416 *MCC *The improvement in MCC and MDP during the first *MDP at the time of first involuntary detrusor contraction following treatment was better involuntary bladder than that in the placebo group (p=0.001).…”

“…In a series of 71 patients with MS, Deffontaines et al [43] administered 300 U of BTX type A injection, and they reported that urinary incontinence disappeared and that no NDO was observed in urodynamic examinations in 46% of the patients; 50% improvement was obtained in 31% of the patients, and no significant change was observed in 23% of the patients. In this series, it was mentioned that the mean maximum bladder capacity increased from 240 cc to 328 cc (p<0.001) and that the mean maximum detrusor pressure decreased from 61 cmH 2 O to 36 cmH 2 O.…”

Use of botulinum toxin in urology: a literature review

“…In addition, CIC was required in 10% of the placebo group, 35% of the 200 IU onaBoNT-A group, and 42% of the 300 IU onaBoNT-A group due to urinary retention. In a study including 71 MS patients, Deffontaines-Rafin et al (32) reported that UUI disappeared in 46% of the patients, NDO was not observed in urodynamic examinations, half-and-half improvement was achieved in 31% of cases, and a significant change was not detected in 23% of the patients, with the 300 IU onaBoNT-A injections. The mean MBC was increased from 240 cc to 328 cc (p<0.001), and the MDP was decreased from 61 cmH 2 O to 36 cmH 2 O after injections.…”