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Botulinum toxin – indications still to be explored
- 1. Dr. Amita Jain Consultant Urogynaecologist Medanta Institute of Kidney & Urology Medanta -The Medicity Gurgaon, Haryana -122001, INDIA
- 2. Irreversible binding to the presynaptic membrane, producing a long-lasting paralytic effect. Action dose- and site-specific, may take 24–48 hrs to exert its effects. Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 3. Neuropathic bladder conditions ◦ Detrusor overactivity ◦ Detrusor sphincter dysenergia Bladder overactivity Painful bladder syndrome Pelvic pain Outflow obstruction symptoms Urinary retention Intradetrusor injection of BTx was approved in 2011 by FDA for neurogenic detrusor overactivity only, but the off-label use is increasingly common. Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 4. 9 ½ Years girl K/C of Langerhan’s Histocytosis ( on & off steroids) PRESENTING COMPLAINTS (March 2009) Recurrent UTI Nocturnal Enuresis Daytime incontinence Difficulty in passing urine PAST H/O Gross haematuria in 2009 (USG KUB / CECT - mild diffuse thickening of bladder wall ?Cystitis) CPE +urethral dilatation in 2010 (DMSA/ DRCG/KFT – WNL) Protenuria suggestive of ? Ig A Nephropathy/ Nephrotic Syndrome PHYSICAL EXAMINATION Normal Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 5. Micturating cystourethrogram (2010)- no reflux, no urethral obstruction MRI Spine - normal USG KUB - B/L mild HUN, persisting post void Thickened & irregular bladder wall PVR 126 cc Failed trial of antimuscarinics & alpha blockers, biofeedback and other conservative management. Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 6. Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 7. Sensation -2 cmH2O 48 cc 29 cmH2O Normal desire 70 cc 43 cmH2O Strong desire 91 cc 159 cmH2O Max cyst capacity 91 cc 158 cmH2O 180 cc 71 cc Peak flow rate 21 cc First desire Voided volume Pdet First sensation Total bladder capacity Bladder filling 3 ml/s Pdet at peak flow 8 cmH2O Average flow rate 3 ml/s Residual Urine 109 ml Opening Pdet 12 cmH2O Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 8. Refractory idiopathic detrusor overactivity with superimposed dysfunctional voiding (non-neuropathic bladdersphincter dysfunction ) Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 9. Sensation 7 cmH2O 84 cc 14 cmH2O Normal desire 88 cc 16 cmH2O Strong desire 110 cc 32 cmH2O Max cyst capacity 110 cc 33 cmH2O 110 cc 73 cc Peak flow rate 42 cc First desire Voided volume Pdet First sensation Total bladder capacity Bladder filling 6 ml/s Pdet at peak flow 33 cmH2O Average flow rate 3 ml/s Residual Urine 37 ml Opening Pdet 24 cmH2O Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 10. 48 years librarian K/C of Interstitial Cystitis Dx on Cystoscopy + bladder biopsy (2/8/10) PRESENTING COMPLAINTS (May 2011) Severe dysuria Frequent urination Feeling of incomplete emptying of bladder Poor flows PAST H/O Urethral dilatation in 2000 Failed conservative ( lifestyle & diet modification), medical management (Amitryptalline/PMSO) and Intravesical instillation therapies Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 11. Sensation 2 cmH2O 65 cc 2 cmH2O Normal desire 79 cc 2 cmH2O Strong desire 88 cc 3 cmH2O Max cyst capacity 104 cc 5 cmH2O 106 cc 55 cc Peak flow rate 59 cc First desire Voided volume Pdet First sensation Total bladder capacity Bladder filling 3 ml/s Pdet at peak flow 19 cmH2O Average flow rate 2 ml/s Residual Urine 51 ml Opening Pdet 15 cmH2O Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 12. Painful bladder Syndrome/IC (hypersensitive low capacity bladder) Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 13. Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 14. 200 units diluted with 20mls of normal saline Given as 1 ml injections at 20 different sites including trigone* Fig. 1. Injection technique for BoNT into the overactive bladder Dae Kyung Kim et al Urol Clin N Am 33 (2006) 503-510 *Kuo HC (2011) Bladder base/trigone injection is safe and as effective as bladder body injection of onabotulinumtoxinA for idiopathic detrusor overactivity refractory to antimuscarinics. Neurourol Urodyn 30:1242–1248 *Pinto R et al (2010) Trigonal injection of botulinum toxin A in patients with refractory bladder pain syndrome/interstitial cystitis. Eur Urol. Sep;58(3):360-5 Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 15. Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 16. Minor effects (Karsenty et al, 2008) ◦ ◦ ◦ ◦ ◦ most frequent injection site pain procedure-related urinary tract infection mild hematuria Increase in PVR Severe effects (Systemic) ◦ ◦ ◦ ◦ ◦ ◦ Very rare Drug reaction - rash of a flu- like illness Nausea, vomitting dysphagia, diplopia, blurred vision Mouth & respiratory weakness periheral muscle weakness Contraindications ◦ pre-existing neuromuscular conditions Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 17. Linda Brubaker et al (2012) Treatment satisfaction and goal attainment with onabotulinumtoxinA in patients with incontinence due to idiopathic OAB Int Urogynecol J 23:1017–1025 Denys P et al (2012) Efficacy and Safety of Low Doses of OnabotulinumtoxinA for the Treatment of Refractory Idiopathic Overactive Bladder: A Multicentre, Double-Blind, Randomised, Placebo-Controlled Dose-Ranging Study. Eur Urol 61:520–529 Rovner E et al (2011) Urodynamic results and clinical outcomes with intradetrusor injections of onabotulinumtoxin A in a randomized, placebocontrolled dose-finding study in idiopathic overactive bladder. Neurourol Urodyn 30:556–562 Duthie JB et al (2011) Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane Database Syst Rev (12):CD005493 Dmochowski R et al (2010) Efficacy and safety of onabotulinumtoxinA for idiopathic overactive bladder: a double-blind, placebo controlled, randomized, dose ranging trial. J Urol 184:2416–2422 Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 18. Shiu-Dong Chung et al (2012) Intravesical OnabotulinumtoxinA Injections for Refractory Painful Bladder Syndrome. Pain Physician; 15:197-202 • ISSN 1533-3159 Giannantoni A et al (2008) Botulinum A toxin intravesical injection in patients with painful bladder syndrome: 1-year followup. J Urol ; 179:1031- 1034. Giannantoni A et al(2006) Botulinum A toxin intravesical injections in the treatment of painful bladder syndrome: A pilot study. Eur Urol ; 49:704-709. Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 19. No universally accepted dose and technique. Exact targeted depth of injection remains controversial. Promising alternative option for varied indications in future. Thanks Dr Amita Jain Confidential & Proprietary Any use of material without prior permission is strictly prohibited
- 20. Medanta Institute of Kidney & Urology Dr. Amita Jain Urogynaecology Clinic 12th Floor, OPD Wing, Medanta -The Medicity Gurgaon, Haryana -122001, INDIA Tel: +91 124 4141 414 info@medanta.org www.medanta.org MOB. +91-9871136110 http://www.urogynecologistindia.in/ http://amitajainurogynaecolgist.blogspot.in/ http://www.linkedin.com/mbox?displayMBoxItem=&itemID=I225857003_75
Editor's Notes
- Localized administration produces chemical denervation by irreversible binding to the presynaptic membrane, producing a long-lasting paralytic effect. The toxin may take 24–48 h to exert its effects. After 3–6 months, the axons regenerate, thus reversing the denervation process. The toxin is dose- and site-specific. The duration of effect will vary considerably depending on how it is used.
- Detrusor external sphincter dyssynergia Detrusor hyperreflexia (neurogenic detrusor activity) Spastic conditions of the urethral rhabdosphincter (non-relaxing sphincter) Chronic prostatic pain (and pelvic floor spasticity) Interstitial cystitis, motor and sensory urge incontinence Non-fibrotic bladder outflow obstruction (including treatment of benign prostatic hyperplasia) Detrusor underactivity and acute urinary retention in women