Botulinum toxin now can be used to increase capacity of the neurogenic bladder and relieve incontinence
One of the most troublesome aspects of spinal cord injury (SCI) is a malfunctioning bladder.
For many spinal cord injured people this problem is worse than not being able to walk or
stand. SCI can result in a flaccid bladder or a bladder that is much too active. In the majority
of cases sphinctor control is lost and either the injured individual can not voluntarily void or
becomes incontinent. Uninary infections are frequent and recurrent with SCI. Infections can
lead to destruction of the urinary tract including the kidney, all potentially leading to sepsis
and death.
For those whose bladder is overactive incontinence is almost universal as the bladder
becomes non-compliant due to a thickened wall and loss of elasticity. Much of the excessive
tone of the bladder muscle is driven by unbalanced activity of the autonomic nervous system.
The parasympathetic arm of the autonomic nervous system causes excessive contraction of
the bladder. The neurons that innervate the bladder and cause contraction release the
neurotransmitter acetylcholine. In some respects this innervation is similar to that between
nerve and skeletal muscle. Currently the most frequently employed method of reducing the
contraction of the bladder is to take drugs that block the acetylcholine receptors on the
bladder muscle. These drugs often have unpleasant side effects including dry mouth,
problems with vision, and even change in heart rate. Unfortunately these drugs are not very
successful for a truly problematic bladder as found in many spinal cord injured individuals.
Most people are aware that the botulinum toxin (BoTox) is used to paralyze certain facial
muscles for cosmetic reasons. This toxin does not block acetylcholine receptors but instead
inhibits the release of acetylcholine from the nerve itself. This is a semi-permanent block of
neurotransmitter release that may last for up to a year more or less. Now, the FDA has
approved the use of the toxin to reduce contractions of the bladder wall. The toxin is directly
injected into a number of locations within the bladder wall. Access to the bladder is through
the urethra. This procedure has been shown to be safe and for many it provides a great deal
of relief for incontinence, and of course a great enhancement in the quality-of-life.
Press Release: August 24th, 2011, prnewswire.com
FDA Approves Botox to Treat Specific Form of Urinary Incontinence
SILVER SPRING, Md., Aug. 24, 2011 /PRNewswire-USNewswire/ — The U.S. Food and Drug
Administration today approved Botox (onabotulinumtoxinA) injection to treat urinary
incontinence in people with neurologic conditions such as spinal cord injury and multiple
sclerosis who have overactivity of the bladder.
Uninhibited urinary bladder contractions in people with some neurological conditions can lead
to an inability to store urine. Current management of this condition includes medications to
relax the bladder and use of a catheter to regularly empty the bladder.
The treatment consists of Botox being injected into the bladder resulting in relaxation of the
bladder, an increase in its storage capacity and a decrease in urinary incontinence.
“Urinary incontinence associated with neurologic conditions can be difficult to manage,” said
George Benson, deputy director, Division of Reproductive and Urologic Products. “Botox
offers another treatment option for these patients.”
Injection of the bladder with Botox is performed using cystoscopy, a procedure that allows a
doctor to visualize the interior of the bladder. Cystoscopy may require general anesthesia.
The duration of the effect of Botox on urinary incontinence in patients with bladder overactivity
associated with a neurologic condition is about nine months.
The effectiveness of Botox to treat this type of incontinence was demonstrated in two clinical
studies involving 691 patients. The patients had urinary incontinence resulting from spinal
cord injury or multiple sclerosis. Both studies showed statistically significant decreases in the
weekly frequency of incontinence episodes in the Botox group compared with placebo.
In addition to its use to improve the appearance of facial frown lines, Botox also is FDA approved
to treat chronic migraine headaches, certain kinds of muscle stiffness and
contraction, severe underarm sweating, abnormal twitch of the eyelid and a condition in which
the eyes are not properly aligned.
The most common adverse reactions observed following injection of Botox into the bladder
were urinary tract infection and urinary retention. Those who develop urinary retention after
Botox treatment may require self-catheterization to empty the bladder.
Botox is marketed in the United States by Allergan Inc., of Irvine, Calif
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