Frequent trips to the toilet, leakage, and wetting accidents are incidents that no adult wants to constantly live with. However, this may be caused by urinary incontinence, a condition in which urine is involuntarily voided. This issue is most common among women and the elderly, but it can also appear in younger individuals of both sexes.
After receiving the approval from the FDA in 2013, BOTOX has become one of the top treatments for urinary incontinence. This therapy contains onabotulinumtoxinA, which inhibits neuromuscular activity by blocking the transmission of acetylcholine. Generally, it relaxes muscles to prevent involuntary contraction. When injected into the muscles of the bladder walls, it works to thwart incontinence.
What is urinary incontinence?
Normally, as the bladder fills up, the bladder muscles relax while the sphincter muscles in the urethra tighten. The nerve muscles in the bladder will only send a message to the brain when the pressure is high due to the full volume of urine in the bladder. The brain reciprocates by sending a signal to the bladder for appropriate elimination behaviors at the determined time. The elimination process requires the bladder muscles to contract and relaxes the sphincter muscles in the urethra to allow the urine to pass through.
Urinary incontinence, however, provokes an urgent and frequent need to urinate as the bladder fails to store urine. The involved muscles contract involuntarily, creating high pressure in the bladder—even when the capacity is not full. As such, patients will find themselves making frequent trips to urinate and having increased leakage accidents. This tampers with their overall quality of life, reducing their comfort.
In certain cases, this ailment may occur due to detrusor overactivity caused by a neurologic condition, such as Parkinson’s disease, multiple sclerosis, or spinal cord injury. However, it may also occur in individuals with an overactive bladder disorder.
If the patient does not respond well to anticholinergic medications, Botox is the next appropriate treatment of choice. This botulinum toxin therapy inhibits the transmission of cholinergic neurotransmitters to prevent the contraction of pelvic visceral muscle cells. As the bladder muscles relax, an increased volume of urine can be stored in the bladder. This helps to reduce the activity of an overactive bladder, decrease weekly urinary leakage episodes, and increase the bladder capacity.
Botulinum toxin is sourced from Clostridium botulinum bacteria and is prepared in the form of lyophilized powder. Prior to this treatment, reconstitute each vial of Botox with sterile, preservative-free 0.9% sodium chloride injection, USP. Each reconstituted vial should be administered within 24 hours and stored in a refrigerator of 2°C–8°C. Each Botox vial is for single-use only.
To provide comfort to the patient, perform an intravesical instillation of diluted local anesthetic. Physicians may administer prophylactic antibiotics, except aminoglycosides, one to three days pretreatment, on the treatment day, and one to three days post-treatment to reduce the likelihood of urinary tract infection. Patients must discontinue anti-platelet therapy at least three days before undergoing botulinum toxin therapy.
What is the appropriate dose?
For overactive bladder, 100 Units of Botox is the recommended and maximum dose. It is injected into the detrusor muscle via a flexible or rigid cystoscope without contacting the trigone. The needle should be inserted approximately 2mm into the detrusor. Inject 0.5ml into each of the required 20 injection sites. After the injections are given, monitor the patient’s condition for 30 minutes and ask them to demonstrate their ability to void.
As for detrusor overactivity associated with a neurologic condition, the recommended dose is 200 Units of Botox per treatment. Inject the reconstituted Botox in 30 different sites of the detrusor muscle. Use 1ml of fluid per injection. Similar to overactive bladder administration, observe the patients for at least 30 minutes post-treatment.
Generally, Botox treatments last up to 3 or 4 months, but individual results may vary. The physician should monitor each individual’s progress and determine the right schedule after analyzing the first treatment cycle. The Botox treatment cycle requires at least three months of interlude between the treatments to reduce overcorrection. According to clinical trials carried out by the manufacturer Allergan, there is noticeable improvement within two weeks after the initial treatment. The patients listed in the clinical trial had an average of 32 leakage episodes in a week prior to the treatment. After six weeks of Botox therapy, they had recorded 22 fewer leakage episodes each week.
Please note that adverse effects may occur due to errors in the injection technique, the toxin spreading to other parts of the body, or incompatibility with the patient’s body. The most common side effects reported within the first 12 weeks were: UTI, blood in the urine, urinary retention, insomnia, and fatigue. Before following through with Botox treatment, discuss the possibility of using a catheter after treatment in case of urinary retention. This requires a tube insertion into the bladder for full drainage.
Physicians should also consider that botulinum toxin therapy is also not suitable for all patients. This treatment should not be administered in patients who have expressed hypersensitivity to any botulinum toxin preparation or other components in the formulation, or who have an infection at the proposed injection site. The intradetrusor injection of Botox is also contraindicated in patients with urinary tract infection or urinary retention.
The inconvenience caused by an overactive bladder can disrupt a person’s productivity and quality of life. With the help of Botox therapy, patients with this condition can have fewer leakage and runs to the toilet, regaining control over their bladder.