• Vol. 36 No. 1, 11–17
  • 15 January 2007

Botulinum Toxin Type A for Refractory Neurogenic Detrusor Overactivity in Spinal Cord Injured Patients in Singapore

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ABSTRACT

Introduction: Managing neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. The aims of preserving kidney function by achieving safe bladder pressures with anticholinergic medication often leave a significant proportion of patients with side effects. Botulinum toxin type A has been shown to be a promising alternative. Materials and Methods: Spinal cord injury patients who had NDO, on clean intermittent self-catheterisation, and were refractory to oral medications, were recruited. Three hundred units of botulinum toxin type A (Botox) in 30 mL NaCl solution were injected under cystoscopic guidance into the bladder. Results: Fifteen patients were recruited of whom 9 were tetraplegic and 6 were paraplegic. Eleven (73.3%) had complete injuries. There was a significant reduction in the mean number of leakages from 3.75 ± 1.79 pre-injection to 0.67 ± 1.31 and 1.5 ± 1.5 at 6 and 26 weeks post-injection, respectively (P <0.05). Seventy-five per cent, 37.5% and 50% were completely dry at 6, 26 and 39 weeks post-injection, respectively. The mean maximal catheterisable volume increased from 312.3 ± 145.6 mL pre-injection to 484.6 ± 190 mL, 422.3 ± 157.3 mL and 490.0 ± 230.4 mL at 6, 26 and 39 weeks post-injection, respectively (P <0.005). Maximum detrusor pressure decreased significantly from 66.3 ± 22.6 cmH2O to 21.2 ± 23.1 cmH2O and 33.6 ± 30.2 cmH2O at 6 and 26 weeks post-injection, respectively (P <0.05). The volume at which reflex detrusor contractions first occurred increased from 127.8 ± 57.5 mL pre-injury to 305.7 ± 130.8 mL at 6 weeks and 288.3 ± 13.0 mL at 26 weeks post-injection (P <0.05). Mean cysometric bladder capacity increased from 187.8 ± 69.2 mL to 305 ± 136.4 mL and 288.3 ± 13.0 mL at 6 and 26 weeks post- injury, respectively (P <0.05). Sixty per cent of patients were completely off medications at 6 and 26 weeks post-injection. One patient had urinary tract infection and 1 experienced autonomic dysreflexia during cystoscopy. Satisfaction levels increased from 4.3 ± 2.3 pre-injury to 7.2 ± 1.9 and 7.3 ± 2.3 at 6 weeks and 26 weeks, respectively. This also correlated with fewer leakages. Conclusion: Botulinum toxin type A injected into the detrusor is safe and efficacious for spinal cord injured patients with refractory detrusor overactivity. This effect is maintained at 26 weeks post-injection.


Managing neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. In addition to the aims of preserving kidney function by achieving safe bladder pressures so as to reduce the likelihood of upper tract deterioration, acceptable social continence and low urinary tract infection also need to be achieved. Current treatment relies on anticholinergic medication to partially block the efferent parasympathetic innervation to the detrusor to attain low bladder pressures increase storage capacity and achieve continence.

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