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  • Review Article
  • Published:

Current and potential urological applications of botulinum toxin A

This article has been updated

Key Points

  • Intravesical injections of botulinum toxin subtype A (BoNT-A) are approved by the US FDA for the indications of neurogenic detrusor overactivity and idiopathic overactive bladder

  • Results of phase III clinical trials have demonstrated that BoNT-A injections are superior to placebo; patients receiving BoNT-A have fewer lower urinary tract symptoms (LUTS) and a better quality of life

  • Intravesical BoNT-A injections carry a risk of adverse events (such as increased post-void residual volume, acute urinary retention and UTI); thus, informed consent must be given before treatment

  • The latest randomized control trials have failed to demonstrate any superiority of BoNT-A over placebo injections for the treatment of LUTS owing to BPH

  • Clinical trials investigating BoNT-A for the treatment of interstitial cystitis/bladder pain syndrome have shown promising therapeutic effects in reducing bladder pain, repeat injections provide therapeutic effects of a longer duration

  • Urethral BoNT-A injections decrease urethral resistance in patients with voiding dysfunction or detrusor–sphincter dyssynergia; effectiveness of BoNT-A injections in patients with non-neurogenic dysfunctional voiding or inadequate urethral relaxation is unclear

Abstract

Botulinum toxin subtype A (BoNT-A) is a potent neurotoxin that can selectively modulate neurotransmitter release from nerve endings, resulting in muscular paralysis. BoNT-A might also act on sensory nerves, and have an anti-inflammatory effect. In the first urological use of BoNT-A, injection into the urethral sphincters of patients with detrusor–sphincter dyssynergia resulted in a reduction of urethral resistance and improved voiding efficiency. Subsequently, intravesical BoNT-A injections have received regulatory approval for treatment of neurogenic detrusor overactivity owing to spinal cord lesions or multiple sclerosis, and idiopathic overactive bladder in adults. BoNT-A has also been widely used to treat patients with the off-label indications of neurogenic or non-neurogenic voiding dysfunction and male lower urinary tract symptoms owing to BPH and bladder-neck dysfunction. Other indications for which urologists have applied BoNT-A injections include interstitial cystitis/bladder pain syndrome, bladder oversensitivity and chronic pelvic pain syndrome. BoNT-A is currently delivered as an intravesical injection; however, use of liposome encapsulated formulations is also beginning to show some therapeutic potential.

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Figure 1: Effects of BoNT-A on detrusor smooth muscle contraction.
Figure 2: Effects of BoNT-A on sensory function and bladder pain.
Figure 3: Anti-inflammatory effects of BoNT-A.

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Change history

  • 18 August 2015

    In the version of this article initially published online registered trademark symbols were not included for all instances of uses of the proprietary product names Botox®, Dysport®, Xeomin® and Prosigne®. The error has been corrected for the print, HTML and PDF versions of the article.

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All authors made a substantial contribution to researching data for this article, discussions of content, and writing of this article. H.-C.K. and C.-H.L. reviewed and/or edited this manuscript before submission.

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Jiang, YH., Liao, CH. & Kuo, HC. Current and potential urological applications of botulinum toxin A. Nat Rev Urol 12, 519–533 (2015). https://doi.org/10.1038/nrurol.2015.193

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