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Neuromodulation versus neurotoxin for the treatment of refractory detrusor overactivity: for neurotoxin

Nature Clinical Practice Urology volume 5, pages 120–121 (2008)Cite this article

Overactive bladder, or detrusor overactivity (DO), is characterized by urgency with or without urge urinary incontinence (UUI), and is usually associated with increased urinary frequency and nocturia. The origin of DO can be classified as idiopathic or neurogenic, and the prevalence of DO in the adult population is estimated to be 16.5%.1 First-line therapy for UUI associated with DO is conservative in nature, and can include behavioral techniques (bladder training), physical therapies (electrical stimulation), and pharmacotherapy (antimuscarinic and anticholinergic drugs). In patients refractory to pharmacotherapy, new treatment modalities, such as neuromodulation and botulinum toxin, have shown encouraging results as alternatives to surgical intervention (e.g. augmentation and urinary diversion).

Sacral nerve modulation (SNM) has been under investigation since the early 1980's. The use of SNM is based on the premise that electrical stimulation of the pudendal nerves can modulate neural reflexes that influence bladder and pelvic floor behavior. The currently approved indications for SNM include refractory DO (US and Europe), urinary retention and bowel dysfunction (Europe). For patients with DO, the device is tested using an external stimulator for a trial period of days to weeks. The external stimulator is considered to be successful when the main incontinence symptoms improve by at least 50%; if this device is successful, a permanent stimulator is implanted, which can later be removed if necessary. A systematic review, which included data from patients with 1,827 implants, reported a >50% improvement in UUI for 80% and 67% of patients who were included in randomized controlled trials and case series, respectively.2 Incontinence episodes, leakage severity, voiding frequency and pad use were significantly reduced following implantation, and benefits were reported to persist for up to 3–5 years. Adverse effects, primarily consisting of pain at the lead or implant site, new pain (such as leg pain) and infection, were documented in 27 studies, with an overall reoperation rate of 33%. Despite the promising efficacy results with this technique, the reoperation rate is relatively high, and the full mechanism of action of SNM is incompletely understood.

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References

  1. Abrams P et al. (2003) The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 61: 37–49

    Article  Google Scholar 

  2. Brazzelli M et al. (2006) Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review. J Urol 175: 835–841

    Article  Google Scholar 

  3. Smith CP et al. (2004) Botulinum toxin A has antinociceptive effects in treating interstitial cystitis. Urology 64: 871–875

    Article  Google Scholar 

  4. Apostolidis A et al. (2006) Proposed mechanism for the efficacy of injected botulinum toxin in the treatment of human detrusor overactivity. Eur Urol 49: 644–650

    Article  CAS  Google Scholar 

  5. Schurch B et al. (2005) Botulinum toxin type A is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study. J Urol 174: 196–200

    Article  CAS  Google Scholar 

  6. Sahai A et al. (2007) Efficacy of botulinum toxin-A for treating idiopathic detrusor overactivity: results from a single center, randomized, double-blind, placebo controlled trial. J Urol 177: 2231–2236

    Article  CAS  Google Scholar 

  7. Schmid DM et al. (2006) Experience with 100 cases treated with botulinum-A toxin injections in the detrusor muscle for idiopathic overactive bladder syndrome refractory to anticholinergics. J Urol 176: 177–185

    Article  CAS  Google Scholar 

  8. Ghei M et al. (2005) Effects of botulinum toxin B on refractory detrusor overactivity: a randomized, double-blind, placebo controlled, crossover trial. J Urol 174: 1873–1877

    Article  CAS  Google Scholar 

  9. Smith CP et al. (2005) Single-institution experience in 110 patients with botulinum toxin A injection into bladder or urethra. Urology 65: 37–41

    Article  Google Scholar 

  10. Smith CP and Chancellor MB (2005) Simplified bladder botulinum-toxin delivery technique using flexible cystoscope and 10 sites of injection. J Endourol 19: 880–882

    Article  Google Scholar 

  11. Kalsi V et al. (2006) Cost-consequence analysis evaluating the use of botulinum neurotoxin-A in patients with detrusor overactivity based on clinical outcomes observed at a single UK centre. Eur Urol 49: 519–527

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. MC Smaldone is a Post-Graduate Year 4 Resident at the Department of Urology, and MB Chancellor is the Director of Neurourology and Female Urology Programs at the University of Pittsburgh Medical Center, and a Professor of Urology and Obstetric Gynecology in the McGowan Institute of Regenerative Medicine at the University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,

    Marc C Smaldone & Michael B Chancellor

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  1. Marc C Smaldone
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  2. Michael B Chancellor
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Correspondence to Marc C Smaldone.

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Competing interests

MB Chancellor is a consultant and an investigator for Allergan. MC Smaldone declared no competing interests.

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Smaldone, M., Chancellor, M. Neuromodulation versus neurotoxin for the treatment of refractory detrusor overactivity: for neurotoxin. Nat Rev Urol 5, 120–121 (2008). https://doi.org/10.1038/ncpuro1034

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