Intradetrusorial Botulinum Toxin in Patients with Multiple Sclerosis: A Neurophysiological Study

Abstract

Patients with multiple sclerosis (MS) often complain of urinary disturbances characterized by overactive bladder syndrome and difficulties in bladder emptying. The aim of the study was to investigate the pathophysiology of bladder dysfunction and the neurophysiological effects of intradetrusorial incobotulinum toxin A (BoNT/A) in patients with MS having both brain and spinal MS-related lesions. Twenty-five MS patients with neurogenic detrusor overactivity (NDO) underwent clinical evaluation and soleus Hoffmann reflex (H reflex) study during urodynamics. Of the 25 patients, 14 underwent a further session one month after intradetrusorial BoNT/A injection. Eighteen healthy subjects acted as the control. In healthy subjects, the H reflex size significantly decreased at maximum cystometric capacity (MCC), whereas in MS patients with NDO, the H reflex remained unchanged. In the patients who received intradetrusorial BoNT/A, clinical and urodynamic investigations showed that NDO improved significantly. Volumes at the first, normal and strong desire to void and MCC increased significantly. Despite its efficacy in improving bladder symptoms and in increasing volumes for first desire, normal and strong desire to void, BoNT/A left the H reflex modulation during bladder filling unchanged. In the MS patients we studied having both brain and spinal MS-related lesions, the H reflex size remained unchanged at maximum bladder filling. Since this neurophysiological pattern has been previously found in patients with spinal cord injury, we suggest that bladder dysfunction arises from the MS-related spinal lesions. BoNT/A improves bladder dysfunction by changing bladder afferent input, as shown by urodynamic findings on bladder filling sensations, but its effects on H reflex modulation remain undetectable.

Video-urodynamic Improvement of Trigonal BTX-A Injection for Patients with Poor Bladder Compliance Secondary to Spinal Cord Injury

“…We also noticed our results similar to the preview studies [6][7][8][9][10][11][12]. One study found that not one of their 24 adults with OAB refractory to anticholinergic treatment who received trigoneinjection of BTX-A developed VUR during at 6-month follow-up [6].…”

“…In the past ten years, intradetrusor injection of BTX-A was performed while avoiding the trigone to prevent VUR. To our knowledge, several studies reported satisfactory clinical results about combined detrusor-trigone BTX-A injections [6][7][8][9][10][11][12]. However, most of these studies were small and single-center experience.…”

The intravesical injection of highly purified botulinum toxin for the treatment of neurogenic detrusor overactivity

“…No significant differences were seen in the Hoffman reflex after injection. However, there were improvements in volumes at first, normal, strong desire, dyssynergic activity, and voiding diary parameters 21 .…”

“…Asafu-Adjei et al IncobotulinumtoxinA to treat neurogenic detrusor overactivity 4 © 2020 Canadian Urological Association incobotulinumtoxinA. 21 . No significant differences were seen in the Hoffman reflex after injection.…”

Sample sizes and statistical methods in interventional studies on individuals with spinal cord injury: A systematic review

“…The sizes of the groups that were compared showed large variation, due to a broad variety of design specifications (eg, different numbers of repeated measurements). Group sizes were equal in some studies, especially when paired comparisons were made, because balance is being imposed by design in this case (eg, 2 groups of size 14 each). However, in other studies, highly unbalanced scenarios were found (eg, 2 groups of sizes 6 and 10, respectively).…”