Botulinum toxin injection: a review of injection principles and protocols

Rapp, David E.; Lucioni, Alvaro; Bales, Gregory T.

doi:10.1590/s1677-55382007000200002

Cited by 19 publications

(25 citation statements)

References 43 publications

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“…Although the injection of botulinumtoxin type A is frequently used to treat NDO, no standardisation of technique exists [9,14,15]. There are repeatedly reports of treatment failures, even in those patients, who formerly showed an excellent treatment response to botulinumtoxin [16][17][18].…”

Section: Introductionmentioning

confidence: 99%

A morphological evaluation of botulinum neurotoxin A injections into the detrusor muscle using magnetic resonance imaging

et al. 2009

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OBJECTIVES: Although botulinum neurotoxin type A (BoNT/A) intradetrusor injections are a recommended therapy for neurogenic detrusor overactivity (NDO), refractory to antimuscarinic drugs, a standardisation of injection technique is missing. Furthermore, some basic questions are still unanswered, as where the toxin solution exactly spreads after injection. Therefore, we investigated the distribution of the toxin solution after injection into the bladder wall, using magnet resonance imaging (MRI). METHODS: Six patients with NDO were recruited. Three of six patients received 300 U of BoNT/A + contrast agent distributed over 30 injection sites (group 1). The other three patients received 300 U of BoNT/A + contrast agent distributed over 10 injection sites (group 2). Immediately after injection, MRI of the pelvis was performed. The volume of the detrusor and the total volume of contrast medium inside and outside the bladder wall were calculated. RESULTS: In all patients, a small volume (mean 17.6%) was found at the lateral aspects of the bladder dome in the extraperitoneal fat tissue, whereas 82.4% of the injected volume reached the target area (detrusor). In both groups there was a similar distribution of the contrast medium in the target area. A mean of 33.3 and 25.3% of the total detrusor volume was covered in group 1 and 2, respectively. Six weeks after injection, five of six patients were continent and showed no detrusor overactivity in the urodynamic follow-up. No systemic side effects were observed. CONCLUSIONS: Our results provide morphological arguments that the currently used injection techniques are appropriate and safe.A morphological evaluation of botulinum neurotoxin A injections into the detrusor muscle using magnetic resonance Abstract ObjectivesAlthough botulinum neurotoxin type A (BoNT/A) intradetrusor injections are a recommended therapy for neurogenic detrusor overactivity (NDO), refractory to antimuscaric drugs, a standardisation of injection technique is missing. Furthermore, some basic questions are still unanswered, as where the toxin solution exactly spreads after injection. Therefore, we investigated the distribution of the toxin solution after injection into the bladder wall, using magnet resonance imaging (MRI). MethodsSix patients with NDO were recruited. 3 of 6 patients received 300 units of BoNT/A + contrast agent distributed over 30 injection sites (Group 1). The other 3 patients received 300 units of BoNT-A + contrast agent distributed over 10 injection sites (Group 2).Immediately after injection, MRI of the pelvis was performed. The volume of the detrusor and the total volume of contrast medium inside and outside the bladder wall were calculated. ResultsIn all patients, a small volume (mean 17.6%) was found at the lateral aspects of the bladder dome in the extraperitoneal fat tissue, whereas 82.4% of the injected volume reached the target area (detrusor).In both groups there was a similar distribution of the contrast medium in the target area.A mean of 33.3% and 25.3% of th...

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Section: Introductionmentioning

confidence: 99%

A morphological evaluation of botulinum neurotoxin A injections into the detrusor muscle using magnetic resonance imaging

et al. 2009

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“…Furthermore, botulinum toxin has recently been demonstrated to have inhibitory effects on additional neuronal populations (for example, sensory and autonomic) and non-neuronal tissue (for example, urothelium). 15 A number of experimental studies in rodents have provided evidence that the sensory effects of botulinum toxin might be a consequence of a suppression of afferent signalling. When injected into the bladder wall, onabotulinumtoxinA demonstrated inhibition of sensory transmitter adenosine triphosphate release, which is released following stimulation of bladder mechanoreceptors.…”

Section: Discussionmentioning

confidence: 99%

Intradetrusor versus suburothelial onabotulinumtoxinA injections for neurogenic detrusor overactivity: a pilot study

et al. 2012

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Study design: This was a multicentre, prospective, randomised study. Objectives: To compare the outcomes of intradetrusor and suburothelial onabotulinumtoxinA injections in patients with spinal cord injury and refractory neurogenic detrusor overactivity (NDO). Setting: Urology departments of two tertiary hospitals in the Czech Republic. Methods: A total of 32 spinal cord injury patients with severe NDO refractory to the standard anticholinergic treatment were randomised to receive either intradetrusor or suburothelial 300 IU onabotulinumtoxinA injections. Subjective satisfaction, bladder diary data and urodynamic data were compared in both groups before treatment and at 3 months post treatment. Results: In all, 64.3% patients in the intradetrusor group and 88.8% patients in the suburothelial group were subjectively satisfied with the treatment. There was a significant post-treatment improvement in both groups regarding the number of catheterisations over 24 h, number of incontinence episodes over 24 h, catheterised volume, cystometric capacity, volume at first involuntary detrusor contraction, maximal detrusor pressure during filling and detrusor compliance. No significant differences between the groups were observed, with the exception of improvement of detrusor compliance, which was better in the intradetrusor group. There was one adverse effect comprising transient muscle weakness that was reported by one patient in the intradetrusor group. Conclusion: Results in both groups were comparable. The authors favour suburothelial onabotulinumtoxinA injection because this method allows more precise toxin localisation. Spinal Cord (2012) 50, 904-907; doi:10.1038/sc.2012.76; published online 17 July 2012Keywords: urodynamics; neurogenic detrusor overactivity; onabotulinumtoxinA; spinal cord injury; suburothelial injection INTRODUCTION Spinal cord injuries are among the most devastating of all injuries, often having life-changing and diverse consequences. Lower urinary tract dysfunction is commonly observed as a result of a spinal cord injury. Neurogenic detrusor overactivity (NDO) is frequently associated with upper motor neuron lesion, and the subsequent increased intravesical pressure may present a potential risk by causing damage to the upper urinary tract. 1 Current standard NDO treatment comprises individualised administration of anticholinergic medication; however, this therapy is inadequate for some patients and is often associated with unacceptable adverse effects. 2 Treatment with botulinum toxin offers an accepted alternative treatment for those patients in whom anticholinergic treatment has failed.Botulinum toxin is a neurotoxin produced by anaerobic microorganisms of the Clostridium genus. Botulinum toxin acts on the peripheral nervous system where it is responsible for blockade of acetylcholine release from presynaptic nerve endings. 3 This process results in blockade of the neuromuscular transfer, with a subsequent loss of muscle cell contractility.A further effect of botulinum toxin following administra...

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“…Several review articles also address these issues. 28,34,41,49,51,[72][73][74] This will be helped with the FDA's recent approved protocol of Botox ® (onabotulinumtoxinA). However, there continue to be a number of questions.…”

Section: Future Areas Of Researchmentioning

confidence: 99%

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

Linsenmeyer

2013

The Journal of Spinal Cord Medicine

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Background: Botulinum neurotoxin (BoNT) injection into the bladder wall has been shown to be an effective alternative to anticholinergic (antimuscarinic) medications and more invasive surgery in those with multiple sclerosis and spinal cord injury with neurogenic detrusor overactivity (NDO) and urinary incontinence who are not tolerating anticholinergic medications. In August 2011, Botox ® (onabotulinumtoxinA) received Food and Drug Administration (FDA) approval for this use. Clinically, intradetrusor injection of BoNT has been found to decrease urinary incontinence and improve quality of life. Its impact on urodynamic parameters is an increase in the maximum cystometric (bladder) capacity and decrease in the maximum detrusor pressures. The most common side effects are urinary tract infections and urinary retention. There have been rare reports and a black box warning of distant spread of BoNT. BoNT has gained popularity because of its effectiveness and long duration of action, relative ease of administration, easy learning curve, reproducibility of results on repeated administration, and low incidence of complications. Objective: To discuss the structure and function, mechanisms of action, clinical and urodynamic studies, injection technique, potential beneficial and adverse effects, and potential areas of research of BoNT. Methods: Literature search focused on botulinum toxin in MEDLINE/PubMed. Search terms included botulinum toxin, neurogenic bladder, NDO, botox bladder, botox spinal cord injury, botox, FDA, botox side effects. All papers identified were English language, full-text papers. In addition, English abstracts of non-English papers were noted. The reference list of identified articles was also searched for further papers. Conclusion: Botulinum toxin is an alternative treatment for individuals with NDO who fail to tolerate anticholinergic medications. Its popularity has increased because of the literature, which has supported its effectiveness, safety, easy use and learning curve, reproducibility of results on repeated use, and recent FDA approval of Botox ® (onabotulinumtoxinA).

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Botulinum toxin injection: a review of injection principles and protocols

Cited by 19 publications

References 43 publications

A morphological evaluation of botulinum neurotoxin A injections into the detrusor muscle using magnetic resonance imaging

A morphological evaluation of botulinum neurotoxin A injections into the detrusor muscle using magnetic resonance imaging

Intradetrusor versus suburothelial onabotulinumtoxinA injections for neurogenic detrusor overactivity: a pilot study

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

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