www.renalandurologynews.com october 2013
Renal & Urology News 19
Botox for Urinary Incontinence Since the FDA expanded the approval of onabotulinumtoxin A (Botox) in January to include adults with overactive bladder who were not helped by anticholinergic drugs, David O. Sussman, DO, has been ready to educate urology colleagues on the appropriate use of the therapy, which he believes will become a common service. As medical director of the Kennedy Continence Center in Stratford, N.J., and Clinical Associate Professor of Urology at the University of Medicine and Dentistry of New Jersey, Dr. Sussman was an investigator in the trials leading to the approval, and remains a consultant for Botox manufacturer Allergan, Inc. You recently published a study on persons given Botox for urinary incontinence (UI) due to neurogenic detrusor overactivity (Neurourology and Urodynamics. 2013;32:242249). Is this condition covered by the FDA-approved indication for Botox?
Dr. Sussman: Yes. That was the first approval—for people who had detrusor overactivity from a neurogenic cause, such as multiple sclerosis (MS), or spinal cord injury. Now, it’s approved for people who have detrusor overactivity from other causes and have failed medication. Does that include people who have overactive bladder?
Dr. Sussman: Overactive bladder is kind of the catch-all symptom syndrome. It includes people with overactive bladder from a neurologic cause or a non-neurologic cause. The neurologic ones, which we studied first, have been the most difficult to treat, and usually fail medication. That’s where the Botox is so helpful, because it really improves the quality of life in people who, prior to this, often didn’t respond to oral medication or, if they did, [experienced] bothersome side effects.
On The Web RUN1013_QA.Sussman.indd 1
How do you expect this approval of Botox to change the paradigm of UI treatment?
Dr. Sussman: It’s still really for people who fail medications. I believe that’s still [stated] in the package insert, and I think that’s reasonable. Most people will still try oral therapy, and then once that fails, it is reasonable to consider Botox. Before [the recent Botox approval], we did use InterStim [an implanted electrical stimulator for urinary control.in both neurogenic and non-neurogenic populations. It was never really approved for the neurogenic population, but there wasn’t much else. But now, we reserve InterStim for more of the non-neurogenic population, and really use Botox for the neurogenic. Is Botox administered the same way to men and to women?
Dr. Sussman: Yes. We typically give anywhere between 20 and 30 injections into the bladder muscle in one visit. The procedure itself takes about 10 or 15 minutes. How often is this done?
Dr. Sussman: Studies have shown that for many people it’s every 10 months,
although that varies. But I think the average is going to be 6 to 10 months.
a noninvasive treatment called posterior tibial nerve stimulation, or PTNS.
What should urologists know to administer Botox effectively and safely?
And who should not receive Botox?
Dr. Sussman: Certainly there’s plenty out there in the literature now, but I think that attending a couple-of-hours seminar to understand the mechanism of action, the precautions and risks, the techniques of injection, and the ideal patient population, as well as the wrong patients, is necessary. None of it is difficult, but you should understand all of this. It’s important for providers identify the right candidates. Typically, patients in the neurogenic population often fail medications, so they are a little more straightforward [in terms of being suitable for Botox therapy]. I certainly think Botox, in the neurogenic population, is going to be the treatment of choice for failed medication. In the non-neurogenic population, again, there are those who either can’t tolerate medication or seek more efficacy from medication. Their options are going to be Botox, InterStim therapy, or
Dr. Sussman: People who have certain neuromuscular disorders, like myasthenia gravis or Lambert-Eaton syndrome. People who have poorly functioning bladders to begin with may not be good candidates. So there are people [in whom] we’d use a lot of caution, but the majority of patients would be candidates. Does Botox actually cure overactive bladder?
Dr. Sussman: Some patients get resolution of their urge incontinence. Others see a significant reduction. It’s a little hard to predict, and we let people know it’s not always going to be a cureall, but it may significantly improve their symptoms. What are the most likely side effects of Botox used for bladder control?
Dr. Sussman: The two biggest side effects are urinary tract infection and, for some people, difficulty emptying their bladders. So occasionally people require intermittent catheterization, but usually that’s a short-lived process, in the weeks-to-several-weeks range. It’s much more common in the neurogenic patients than in the non-neurogenic patients. Should Botox be discontinued in patients suffering those side effects?
Dr. Sussman: Sometimes it can just be modified with dose adjustments. What I’ll often do is adjust the dosage. In essence, patients requiring catheterization did have a good result because they’re holding their urine better. It’s just that they’re holding it too well.
It’s important for providers to identify the right candidates. —David O. Sussman, DO
Botox was approved as a treatment for urge incontinence; is approval for stress incontinence coming?
Dr. Sussman: This is not a medication that is currently being studied for stress incontinence because stress incontinence is a different mechanism, and Botox is not something that would really help that. n
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