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• W2015551412 abstract "The current practice in managing overactive bladder and detrusor overactivity (DO) is based on conservative measures and antimuscarinic drugs, but a significant minority are refractory to treatment. Where the effect on quality of life is severe and the patient is willing to face risks, augmentation cystoplasty, detrusor myectomy or urinary diversion may be considered. However, there are many for whom simple measures are inadequate, but who are not in a position to proceed to major surgery. This discrepancy between the extreme ends of the treatment spectrum is a substantial drawback. Intravesical botulinum treatment has been hailed as a potential saviour in this regard. Nonetheless, it is important to remember that the procedure is as yet unlicensed. Furthermore, there is no consensus regarding optimal dosing and administration regimes. We therefore do need to maintain caution, with specific patient counselling regarding the absence of long-term evidence. The treatment was first applied in a group of neuropathic patients, who showed substantial improvements in quality of life and other measures; it is in the area of neurogenic DO that the technique is most advanced. The ease of the method and low morbidity clearly have considerable advantages. As a consequence, several small-scale uncontrolled studies extrapolated the technique into other clinical situations, including idiopathic overactive bladder, bladder pain and more. Many of these studies reported favourable outcomes and some studies point towards the usefulness of ongoing repeated injections. However, widespread adoption in a diversity of indications appears to be progressing more rapidly than the evidence to justify it. Thus, the importance of audit and governance as a crucial element in using an unlicensed procedure has to be re-emphasised. Patients should be warned of the uncertainties, including the risk of urinary retention. For patients with neurogenic DO, response rates appear to be good and the fact that many patients already use intermittent self catheterization means that concerns regarding voiding dysfunction are less of an issue in this patient group. The situation is somewhat different for idiopathic DO. In this setting few people regularly use intermittent self catheterization and the proportion of individuals at risk of requiring it represents a difficult balance in ascertaining whether quality of life has genuinely been improved. Instead, one problematic symptom (storage phase symptoms) may have simply been replaced with a symptom that potentially is worse (voiding dysfunction). The number of studies that attest to efficacy of repeated injections over the longer term is encouraging, but some individuals responding to the first set of injections do not respond on the second or subsequent treatment. Accordingly, it is not certain that all individuals can be expected to show optimal responses indefinitely. Careful thought, therefore, must be applied when considering younger patients, for whom it is rather difficult to envisage lifelong treatment. In the current health economic climate, any new treatment has to justify its introduction on the basis of efficacy and cost-effectiveness. All treatments for overactive bladder are expensive. Adding up the cost of incontinence containment products, catheters, laundry bills, drugs, social and employment costs, surgery and medical surveillance means a substantial health economic burden on society. Costs of botulinum toxin include the drug itself, the administration and the possible need to self catheterize. These can build up substantially with time as procedures are repeated, and this has to be balanced against the quality of life improvements. Even nowadays the mechanisms of action of botulinum toxin in this context are not known. In part, this reflects uncertainties about the basic science mechanisms of DO itself, and the associated sensations of urgency. Botulinum toxin inhibits efferent neuromuscular transmission from cholinergic nerves to end-organ muscles. Obviously, this can influence overactive bladder contractions. It may also explain to an extent the voiding dysfunction seen in some individuals receiving the treatment. The alternative explanation focuses on sensory traffic arising from the bladder, postulating that botulinum toxin may reduce afferent information, thereby giving the impression to the central nervous system that the bladder is less full than actually is the case. These arguments have still to be resolved and of course, it is possible that the mechanisms and the disease itself are both multifactorial. As is clear from the fascinating articles in this supplement, botulinum toxin injections into the bladder wall may come to represent a fundamental change for management of overactive bladder. Nonetheless, there is some way to go. Crucially, the technique is not licensed and major clinical trials will have to be completed before full regulatory requirements are met. Furthermore, the precise dosing requirements for optimum efficacy, balanced against manageable risk and longevity of response, have still to be determined for the various conditions. The history of the premature introduction of management techniques in the incontinence fields should be a lesson to all clinicians planning to undertake a new technique. However optimistic the preliminary case control and uncontrolled series, the wary clinician should consider the possibility of unforeseen consequences and has a burdensome responsibility to ensure that patients are fully aware of the uncertainties." @default.
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• W2015551412 date "2008-09-01" @default.
• W2015551412 modified "2023-09-27" @default.
• W2015551412 title "The current standing of intramural injection of botulinum neurotoxin in managing the overactive bladder" @default.
• W2015551412 doi "https://doi.org/10.1111/j.1464-410x.2008.07819.x" @default.
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